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==Overview== | ==Overview== | ||
The hallmark of | The hallmark of acute diarrhea is the sudden onset of 3 or more stools per day, lasting less than 2 weeks. The most common symptoms of acute diarrhea include increased frequency of bowel movements, [[abdominal pain]], [[Fever|elevation of body temperature]], symptoms of fluid loss (dark or scant urine, excessive thirst, [[dizziness]], [[fatigue]]). | ||
==History and Symptoms== | ==History and Symptoms== | ||
*Acute diarrhea is usually self limiting. | *Acute diarrhea is usually self limiting. | ||
*Medical | *Medical evaluation for acute diarrhea is recommended for patients with [[fever]], mucoid or [[Dysentery|bloody diarrhea]], [[abdominal pain]] and symptoms of [[dehydration]](dizziness or light headedness, dark urine, [[fatigue]]). | ||
*Hospital admission is required for individuals who present with acute diarrhea, if there is a | *Hospital admission is required for individuals who present with acute diarrhea, if there is a medical history of [[immunosuppression]] (eg, treatment for [[Cancer|malignancy]], [[Organ transplant|transplantation]], or advanced [[HIV AIDS|HIV infection]]), with preexisting [[Intestine|bowel]] disease ([[Inflammatory bowel disease]] or [[Ischemic colitis]]) or with significant vascular or [[Circulatory system|cardiovascular]] disease. | ||
*Symptoms of | *Symptoms of acute diarrhea include loose stools (watery, bloody or mucoid), fever, [[abdominal pain]], excessive thirst, dark or scant urine, light headedness. | ||
===History=== | ===History=== | ||
*Initial evaluation of patients who present with acute diarrhea include: <ref name="pmid18666921">{{cite journal |vauthors=Greenwood Z, Black J, Weld L, O'Brien D, Leder K, Von Sonnenburg F, Pandey P, Schwartz E, Connor BA, Brown G, Freedman DO, Torresi J |title=Gastrointestinal infection among international travelers globally |journal=J Travel Med |volume=15 |issue=4 |pages=221–8 |year=2008 |pmid=18666921 |doi=10.1111/j.1708-8305.2008.00203.x |url=}}</ref> <ref name="pmid16395094">{{cite journal |vauthors=Vernacchio L, Vezina RM, Mitchell AA, Lesko SM, Plaut AG, Acheson DW |title=Diarrhea in American infants and young children in the community setting: incidence, clinical presentation and microbiology |journal=Pediatr. Infect. Dis. J. |volume=25 |issue=1 |pages=2–7 |year=2006 |pmid=16395094 |doi= |url=}}</ref> <ref name="pmid17357047">{{cite journal |vauthors=Fischer TK, Viboud C, Parashar U, Malek M, Steiner C, Glass R, Simonsen L |title=Hospitalizations and deaths from diarrhea and rotavirus among children <5 years of age in the United States, 1993-2003 |journal=J. Infect. Dis. |volume=195 |issue=8 |pages=1117–25 |year=2007 |pmid=17357047 |doi=10.1086/512863 |url=}}</ref> <ref name="pmid22675542">{{cite journal |vauthors=Talbert A, Thuo N, Karisa J, Chesaro C, Ohuma E, Ignas J, Berkley JA, Toromo C, Atkinson S, Maitland K |title=Diarrhoea complicating severe acute malnutrition in Kenyan children: a prospective descriptive study of risk factors and outcome |journal=PLoS ONE |volume=7 |issue=6 |pages=e38321 |year=2012 |pmid=22675542 |pmc=3366921 |doi=10.1371/journal.pone.0038321 |url=}}</ref> | *Initial evaluation of patients who present with acute diarrhea include:<ref name="pmid18666921">{{cite journal |vauthors=Greenwood Z, Black J, Weld L, O'Brien D, Leder K, Von Sonnenburg F, Pandey P, Schwartz E, Connor BA, Brown G, Freedman DO, Torresi J |title=Gastrointestinal infection among international travelers globally |journal=J Travel Med |volume=15 |issue=4 |pages=221–8 |year=2008 |pmid=18666921 |doi=10.1111/j.1708-8305.2008.00203.x |url=}}</ref><ref name="pmid16395094">{{cite journal |vauthors=Vernacchio L, Vezina RM, Mitchell AA, Lesko SM, Plaut AG, Acheson DW |title=Diarrhea in American infants and young children in the community setting: incidence, clinical presentation and microbiology |journal=Pediatr. Infect. Dis. J. |volume=25 |issue=1 |pages=2–7 |year=2006 |pmid=16395094 |doi= |url=}}</ref><ref name="pmid17357047">{{cite journal |vauthors=Fischer TK, Viboud C, Parashar U, Malek M, Steiner C, Glass R, Simonsen L |title=Hospitalizations and deaths from diarrhea and rotavirus among children <5 years of age in the United States, 1993-2003 |journal=J. Infect. Dis. |volume=195 |issue=8 |pages=1117–25 |year=2007 |pmid=17357047 |doi=10.1086/512863 |url=}}</ref><ref name="pmid22675542">{{cite journal |vauthors=Talbert A, Thuo N, Karisa J, Chesaro C, Ohuma E, Ignas J, Berkley JA, Toromo C, Atkinson S, Maitland K |title=Diarrhoea complicating severe acute malnutrition in Kenyan children: a prospective descriptive study of risk factors and outcome |journal=PLoS ONE |volume=7 |issue=6 |pages=e38321 |year=2012 |pmid=22675542 |pmc=3366921 |doi=10.1371/journal.pone.0038321 |url=}}</ref> | ||
**'''Duration of symptoms''' | **'''Duration of symptoms''' | ||
**'''Frequency and nature of stools:''' | **'''Frequency and nature of stools:''' | ||
***It can suggest whether the diarrhea is originating in the small or the large bowel. | ***It can suggest whether the diarrhea is originating in the small or the large [[Intestine|bowel]]. | ||
****Diarrhea of small bowel origin is typically watery, of large volume, and associated with abdominal cramping, bloating, and gas. Fever is less common and stools are mostly watery. | ****Diarrhea of [[Small intestine|small bowel]] origin is typically watery, of large volume, and associated with abdominal cramping, bloating, and gas. [[Fever]] is less common and [[Human feces|stools]] are mostly watery. | ||
****Diarrhea of large intestinal origin often presents with frequent, regular, small volume, and | ****Diarrhea of [[Large intestine|large intestinal]] origin often presents with frequent, regular, small volume, and painful [[Defecation|bowel movements]]. [[Fever]] and bloody or mucoid stools are common. | ||
**'''History of associated symptoms:''' Fever, abdominal pain, nausea and vomiting | **'''History of associated symptoms:''' [[Fever]], [[abdominal pain]], [[nausea and vomiting]] | ||
**'''Symptoms of volume depletion''' | **'''Symptoms of volume depletion:''' dark or scant urine, [[dizziness]], [[confusion]] | ||
**'''History of immunosuppression and Other bowel diseases:''' Inflammatory bowel disease, HIV, history of malignancy and transplantation | **'''History of immunosuppression and Other bowel diseases:''' [[Inflammatory bowel disease]], [[Human Immunodeficiency Virus (HIV)|HIV]], history of [[malignancy]] and [[Organ transplant|transplantation]] | ||
**'''History towards potential exposure''' | **'''History towards potential exposure:''' food history, travel history, exposure to pets | ||
***'''Travel history:''' | ***'''Travel history:''' | ||
****Travel history may be helpful in identifying a cause for diarrhea. | ****Travel history may be helpful in identifying a cause for diarrhea. | ||
****The risk of | ****The risk of travelers diarrhea is high in regions where hygienic practices and [[sanitation]] are poor. | ||
****Traveler's diarrhea risk also varies with season of the year, higher risk during warmer months and rainy seasons. | ****Traveler's diarrhea risk also varies with season of the year, higher risk during warmer months and rainy seasons. | ||
****'''Risk by geographic regions:''' | ****'''Risk by geographic regions:''' | ||
*****High risk: South and Southeast Asia, Central and western Africa, South and Central America, and Mexico | *****High risk: South and Southeast Asia, Central and western Africa, South and Central America, and Mexico | ||
*****Moderate risk: Caribbean Islands, South Africa, Central and East Asia, Eastern Europe, and the Middle East | *****Moderate risk: Caribbean Islands, South Africa, Central and East Asia, Eastern Europe, and the Middle East | ||
*****Low risk: the United States, Canada, Singapore, Japan,Northern and Western Europe, Australia and New Zealand | *****Low risk: the United States, Canada, Singapore, Japan,Northern and Western Europe, Australia and New Zealand | ||
****Common organisms that cause diarrhea among | ****Common organisms that cause diarrhea among travelers include: | ||
*****Enterotoxigenic E.coli [[ETEC]] | *****Enterotoxigenic E.coli [[ETEC]] (leading cause) | ||
*****Shigella | *****[[Shigella]] | ||
*****Salmonella | *****[[Salmonella]] | ||
*****Campylobacter | *****[[Campylobacter]] | ||
***** | *****[[Rotavirus]] | ||
***Other organisms that are prevalent in particular parts of the world include the following: | ***Other [[Organism|organisms]] that are prevalent in particular parts of the world include the following: | ||
****Nonspecific foreign travel history: Consider Enterotoxigenic E coli [[ETEC]], Aeromonas, Giardia, Plesiomonas, Salmonella, and Shigella species | ****Nonspecific foreign travel history: Consider [[Escherichia coli enteritis|Enterotoxigenic E coli]] ([[ETEC]]), [[Aeromonas]], [[Giardia lamblia|Giardia]], [[Plesiomonas shigelloides|Plesiomonas]], [[Salmonella]], and [[Shigella]] species | ||
****Travel to Africa: Entamoeba species, Vibrio cholerae | ****Travel to Africa: [[Entamoeba]] species, [[Vibrio cholerae]] | ||
****Travel to South America and Central America: Entamoeba species, V cholerae, enterotoxigenic E coli | ****Travel to South America and Central America: [[Entamoeba|Entamoeba species]], [[Vibrio|V. cholerae]], [[Enterotoxigenic Escherichia coli|enterotoxigenic E coli]] | ||
****Travel to Asia: V cholerae | ****Travel to Asia: [[Vibrio|V. cholerae]] | ||
****Travel to Australia: Yersinia species | ****Travel to Australia: [[Yersinia|Yersinia species]] | ||
****Travel to Canada: Yersinia species | ****Travel to Canada: [[Yersinia|Yersinia species]] | ||
****Travel to Europe: Yersinia species | ****Travel to Europe: [[Yersinia|Yersinia species]] | ||
****Travel to India: Entamoeba species, V cholerae | ****Travel to India: [[Entamoeba|Entamoeba species]], [[Vibrio|V. cholerae]] | ||
****Travel to Japan: Vibrio parahaemolyticus | ****Travel to Japan: [[Vibrio parahaemolyticus]] | ||
****Travel to Mexico: Aeromonas, Entamoeba, Plesiomonas, and Yersinia species | ****Travel to Mexico: [[Aeromonas]], [[Entamoeba]], [[Plesiomonas shigelloides|Plesiomonas]], and [[Yersinia|Yersinia species]] | ||
****New Guinea: Clostridium species | ****New Guinea: [[Clostridium|Clostridium species]] | ||
**'''Day care history:''' Certain pathogens | **'''Day care history:''' Certain [[Pathogen|pathogens]] spread very quickly in daycare. | ||
***Virus: | ***[[Virus]]: | ||
**** | ****[[Rotavirus]] | ||
**** | ****[[Astrovirus]] | ||
****Calcivirus | ****Calcivirus | ||
***Bacteria: | ***[[Bacteria]]: | ||
****Campylobacter | ****[[Campylobacter]] | ||
**** | ****[[Shigella]] | ||
***Protozoa: | ***[[Protozoa]]: | ||
****Giardia | ****[[Giardia lamblia|Giardia]] | ||
****Cryptosporidium species | ****[[Cryptosporidium|Cryptosporidium species]] | ||
*'''Food history:''' | *'''Food history:''' | ||
**Intake of raw or uncooked food is a common cause of infectious diarrhea. Consumption of undercooked or raw meat or fish, unpasteurized dairy products, or certain organic vitamin preperations may suggest certain pathogens. | **Intake of raw or uncooked food is a common cause of infectious diarrhea. Consumption of undercooked or raw meat or fish, unpasteurized dairy products, or certain organic vitamin preperations may suggest certain pathogens. | ||
***Meats: C perfringens | ***Meats: [[Clostridium perfringens|C. perfringens]], [[Aeromonas]], [[Campylobacter]], and [[Salmonella]] species | ||
***Dairy food: Campylobacter | ***Dairy food: [[Campylobacter]], [[Salmonella]] species, [[Listeria monocytogenes|Listeria]] especially in pregnancy. | ||
***Eggs: Salmonella species | ***Eggs: [[Salmonella|Salmonella species]] | ||
***Seafood: Astrovirus | ***Seafood: [[Astrovirus]], [[Aeromonas]], [[Plesiomonas shigelloides|Plesiomonas]], and [[Vibrio|Vibrio species]] | ||
***Poultry: Campylobacter species | ***Poultry: [[Campylobacter|Campylobacter species]] | ||
***Oysters: Calicivirus and Plesiomonas and Vibrio species | ***Oysters: [[Caliciviridae|Calicivirus]] and [[Plesiomonas shigelloides|Plesiomonas]] and [[Vibrio|Vibrio species]] | ||
***Vegetables: Aeromonas species and C perfringens | ***Vegetables: [[Aeromonas]] species and [[Clostridium perfringens|C. perfringens]] | ||
***Ground beef: | ***Ground beef: [[Escherichia coli enteritis|EHEC]] | ||
***Pork: C perfringens, Y enterocolitica | ***Pork: [[Clostridium perfringens|C. perfringens]], [[Yersinia Enterocolitica Infection|Y. enterocolitica]] | ||
**Although it is often difficult to know which food exposure was the potential cause, the timing of onset of symptoms following exposure to the suspected food can be an important clue to find the diagnosis. | **Although it is often difficult to know which food exposure was the potential cause, the timing of onset of symptoms following exposure to the suspected food can be an important clue to find the diagnosis. | ||
***Up to 6 hrs: Ingestion of a preformed toxin produced by Staphylococcus aureus or Bacillus cereus,if nausea and vomiting were the initial symptoms. | ***Up to 6 hrs: Ingestion of a preformed toxin produced by [[Staphylococcus aureus]] or [[Bacillus cereus]], if [[Nausea and vomiting|nausea]] and [[Nausea and vomiting|vomiting]] were the initial symptoms. | ||
***Between 8 to 16 hours: suggests infection with Clostridium perfringens | ***Between 8 to 16 hours: suggests infection with [[Clostridium perfringens]] | ||
***After 16 hours: Most commonly either viral or other bacterial infection (eg, contamination of food with enterotoxigenic E.coli [[EHEC]] or other pathogens. | ***After 16 hours: Most commonly either [[Virus|viral]] or other [[Bacteria|bacterial]] infection (eg, [[Pollution|contamination]] of food with [[ETEC|enterotoxigenic E.coli]], [[EHEC]] or other pathogens). | ||
'''Water exposure''': | '''Water exposure''': | ||
*Water is the main source for organisms that cause diarrhea. | *Water is the main source for organisms that cause diarrhea. | ||
*Swimming pools have been associated with outbreaks of infection with Shigella species. | *Swimming pools have been associated with outbreaks of infection with [[Shigella]] species. | ||
*Aeromonas | *[[Aeromonas]] infection is associated with exposure to the marine environment. | ||
*Certain organisms are resistant to chlorination( | *Certain organisms are resistant to chlorination ([[Giardia lamblia|Giardia]], [[Cryptosporidium]], and [[Entamoeba]]), so exposure to contaminated water should raise the suspicion of [[infection]] with these [[Pathogen|pathogens]]. | ||
*Camping history with exposure to water sources may also suggest infection with Giardia. | *Camping history with exposure to water sources may also suggest infection with [[Giardia lamblia|Giardia]]. | ||
*'''Exposure to animals:''' | *'''Exposure to animals:''' | ||
** | **Poultry, petting zoos has been associated with [[Salmonella]] and [[Campylobacter]] infections. | ||
*'''Medical history:''' | *'''Medical history:''' | ||
**Various medical conditions can make patients prone to infections. | **Various medical conditions can make patients prone to infections. | ||
***C difficile: Hospitalization, antibiotic administration | ***C. difficile: Hospitalization, antibiotic administration | ||
***Plesiomonas species: Liver diseases or malignancy | ***Plesiomonas species: Liver diseases or malignancy | ||
***Salmonella species: Intestinal dysmotility, malnutrition, achlorhydria, hemolytic anemia (especially sickle cell disease), immunosuppression, malaria | ***Salmonella species: Intestinal dysmotility, malnutrition, achlorhydria, hemolytic anemia (especially sickle cell disease), immunosuppression, malaria | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chandrakala Yannam, MD [2]
Overview
The hallmark of acute diarrhea is the sudden onset of 3 or more stools per day, lasting less than 2 weeks. The most common symptoms of acute diarrhea include increased frequency of bowel movements, abdominal pain, elevation of body temperature, symptoms of fluid loss (dark or scant urine, excessive thirst, dizziness, fatigue).
History and Symptoms
- Acute diarrhea is usually self limiting.
- Medical evaluation for acute diarrhea is recommended for patients with fever, mucoid or bloody diarrhea, abdominal pain and symptoms of dehydration(dizziness or light headedness, dark urine, fatigue).
- Hospital admission is required for individuals who present with acute diarrhea, if there is a medical history of immunosuppression (eg, treatment for malignancy, transplantation, or advanced HIV infection), with preexisting bowel disease (Inflammatory bowel disease or Ischemic colitis) or with significant vascular or cardiovascular disease.
- Symptoms of acute diarrhea include loose stools (watery, bloody or mucoid), fever, abdominal pain, excessive thirst, dark or scant urine, light headedness.
History
- Initial evaluation of patients who present with acute diarrhea include:[1][2][3][4]
- Duration of symptoms
- Frequency and nature of stools:
- It can suggest whether the diarrhea is originating in the small or the large bowel.
- Diarrhea of small bowel origin is typically watery, of large volume, and associated with abdominal cramping, bloating, and gas. Fever is less common and stools are mostly watery.
- Diarrhea of large intestinal origin often presents with frequent, regular, small volume, and painful bowel movements. Fever and bloody or mucoid stools are common.
- It can suggest whether the diarrhea is originating in the small or the large bowel.
- History of associated symptoms: Fever, abdominal pain, nausea and vomiting
- Symptoms of volume depletion: dark or scant urine, dizziness, confusion
- History of immunosuppression and Other bowel diseases: Inflammatory bowel disease, HIV, history of malignancy and transplantation
- History towards potential exposure: food history, travel history, exposure to pets
- Travel history:
- Travel history may be helpful in identifying a cause for diarrhea.
- The risk of travelers diarrhea is high in regions where hygienic practices and sanitation are poor.
- Traveler's diarrhea risk also varies with season of the year, higher risk during warmer months and rainy seasons.
- Risk by geographic regions:
- High risk: South and Southeast Asia, Central and western Africa, South and Central America, and Mexico
- Moderate risk: Caribbean Islands, South Africa, Central and East Asia, Eastern Europe, and the Middle East
- Low risk: the United States, Canada, Singapore, Japan,Northern and Western Europe, Australia and New Zealand
- Common organisms that cause diarrhea among travelers include:
- Enterotoxigenic E.coli ETEC (leading cause)
- Shigella
- Salmonella
- Campylobacter
- Rotavirus
- Other organisms that are prevalent in particular parts of the world include the following:
- Nonspecific foreign travel history: Consider Enterotoxigenic E coli (ETEC), Aeromonas, Giardia, Plesiomonas, Salmonella, and Shigella species
- Travel to Africa: Entamoeba species, Vibrio cholerae
- Travel to South America and Central America: Entamoeba species, V. cholerae, enterotoxigenic E coli
- Travel to Asia: V. cholerae
- Travel to Australia: Yersinia species
- Travel to Canada: Yersinia species
- Travel to Europe: Yersinia species
- Travel to India: Entamoeba species, V. cholerae
- Travel to Japan: Vibrio parahaemolyticus
- Travel to Mexico: Aeromonas, Entamoeba, Plesiomonas, and Yersinia species
- New Guinea: Clostridium species
- Travel history:
- Day care history: Certain pathogens spread very quickly in daycare.
- Food history:
- Intake of raw or uncooked food is a common cause of infectious diarrhea. Consumption of undercooked or raw meat or fish, unpasteurized dairy products, or certain organic vitamin preperations may suggest certain pathogens.
- Meats: C. perfringens, Aeromonas, Campylobacter, and Salmonella species
- Dairy food: Campylobacter, Salmonella species, Listeria especially in pregnancy.
- Eggs: Salmonella species
- Seafood: Astrovirus, Aeromonas, Plesiomonas, and Vibrio species
- Poultry: Campylobacter species
- Oysters: Calicivirus and Plesiomonas and Vibrio species
- Vegetables: Aeromonas species and C. perfringens
- Ground beef: EHEC
- Pork: C. perfringens, Y. enterocolitica
- Although it is often difficult to know which food exposure was the potential cause, the timing of onset of symptoms following exposure to the suspected food can be an important clue to find the diagnosis.
- Up to 6 hrs: Ingestion of a preformed toxin produced by Staphylococcus aureus or Bacillus cereus, if nausea and vomiting were the initial symptoms.
- Between 8 to 16 hours: suggests infection with Clostridium perfringens
- After 16 hours: Most commonly either viral or other bacterial infection (eg, contamination of food with enterotoxigenic E.coli, EHEC or other pathogens).
- Intake of raw or uncooked food is a common cause of infectious diarrhea. Consumption of undercooked or raw meat or fish, unpasteurized dairy products, or certain organic vitamin preperations may suggest certain pathogens.
Water exposure:
- Water is the main source for organisms that cause diarrhea.
- Swimming pools have been associated with outbreaks of infection with Shigella species.
- Aeromonas infection is associated with exposure to the marine environment.
- Certain organisms are resistant to chlorination (Giardia, Cryptosporidium, and Entamoeba), so exposure to contaminated water should raise the suspicion of infection with these pathogens.
- Camping history with exposure to water sources may also suggest infection with Giardia.
- Exposure to animals:
- Poultry, petting zoos has been associated with Salmonella and Campylobacter infections.
- Medical history:
- Various medical conditions can make patients prone to infections.
- C. difficile: Hospitalization, antibiotic administration
- Plesiomonas species: Liver diseases or malignancy
- Salmonella species: Intestinal dysmotility, malnutrition, achlorhydria, hemolytic anemia (especially sickle cell disease), immunosuppression, malaria
- Rotavirus: Hospitalization
- Giardia species: Agammaglobulinemia, chronic pancreatitis, achlorhydria, cystic fibrosis
- Cryptosporidia species:Immunocompromised or immunosuppressed state
- Vibrio: Cirrhosis
- Yersinia: Hemochromatosis.
- Various medical conditions can make patients prone to infections.
- Intake of fruit or vegetable juices particularly in children.
- Lactose intolerance
- History of abdominal or gall bladder removal surgery.
- Age>50 yrs
Common Symptoms
Common symptoms of Acute diarrhea include:
- Loose stools: watery or mucoid or bloody
- Fever
- Abdominal cramps
- Abdominal pain
- Urgency to have a bowel movement
- Nausea or vomiting
- Bloating
- Symptoms of dehydration:
- Excessive thirst
- Dry mouth or tongue
- scant or no urination,dark-colored urine
- Weakness
- dizziness or lightheadedness
- Fatigue
Less Common Symptoms
Less common symptoms of Acute diarrhea include:
- Weight loss if diarrhea persists longer
- Malnutrition
- Confusion or agitation
- disorientation
- fainting
- seizures
- Abdominal guarding
- Stupor or coma
References
- ↑ Greenwood Z, Black J, Weld L, O'Brien D, Leder K, Von Sonnenburg F, Pandey P, Schwartz E, Connor BA, Brown G, Freedman DO, Torresi J (2008). "Gastrointestinal infection among international travelers globally". J Travel Med. 15 (4): 221–8. doi:10.1111/j.1708-8305.2008.00203.x. PMID 18666921.
- ↑ Vernacchio L, Vezina RM, Mitchell AA, Lesko SM, Plaut AG, Acheson DW (2006). "Diarrhea in American infants and young children in the community setting: incidence, clinical presentation and microbiology". Pediatr. Infect. Dis. J. 25 (1): 2–7. PMID 16395094.
- ↑ Fischer TK, Viboud C, Parashar U, Malek M, Steiner C, Glass R, Simonsen L (2007). "Hospitalizations and deaths from diarrhea and rotavirus among children <5 years of age in the United States, 1993-2003". J. Infect. Dis. 195 (8): 1117–25. doi:10.1086/512863. PMID 17357047.
- ↑ Talbert A, Thuo N, Karisa J, Chesaro C, Ohuma E, Ignas J, Berkley JA, Toromo C, Atkinson S, Maitland K (2012). "Diarrhoea complicating severe acute malnutrition in Kenyan children: a prospective descriptive study of risk factors and outcome". PLoS ONE. 7 (6): e38321. doi:10.1371/journal.pone.0038321. PMC 3366921. PMID 22675542.