Read before the Bureau of Pediatrics, I.H.A., JUNE 18, 1948.
Epidemic diarrhea of the newborn is a clinical syndrome generally limited to the first month of life. It is characterized by marked contagiousness, high morbidity and mortality rates. In a clinical pattern manifestations include frequent water stools, rapid weight loss, prostration, dehydration, and acidosis. At the autopsies there are no characteristic pathologic findings.
The etiology is obscure. We know of no definite causative agent as none has been identified. The latest investigations have led us to believe that a virus may be the etiologic factor. This syndrome seems to come in epidemics which have followed or have occurred during outbreaks of influenza among adults and older children. There may be a possible relationship, but this has not been proved. It is noteworthy that nurses who are in constant contact with infected infants have never contracted the infection.
This syndrome occurs as often among breast-fed as among bottle-fed infants, and is equally severe among the private patients as the ward patients. I have seen it at various seasons of the year. Up to the present time epidemics have only been reported from the north temperate zone. The newborn infant seems to have little, if any, immunity against the disease-the premature or undernourished infant is especially predisposed to it. I believe the severity of the illness varies from epidemic to epidemic and also from patient to patient in the same epidemic.
The symptoms of this syndrome seem to run quite a stereotyped course. The incubation period is very short, a matter of a couple of days. During the stage of invasion the infant refuses to nurse, usually does not gain or actually loses weight, and becomes restless or fretful. Occasional vomiting is a symptom and abdominal distension may develop. The temperature runs a course from 97F. to 100F. Many of the severe cases never develop a temperature over normal. The most remarkable symptoms are related to the character, frequency, and manner of expulsion of the stools. The stools are watery, yellow in color or green acid in reaction.
They contain no mucous or pus, and rarely a streak of blood. The stools are frequent and often expelled explosively. The noisy, rapid expulsion of a large, watery stool is so characteristic that it can be considered almost pathognomonic of this condition. The restlessness become more marked. It may be so marked and so persistent that traumatic ulcers may be produced on the knees and on the heels from the infants constant rubbing of them against the bed linen. The cry is short and feeble.
The loss of weight is progressive and continuous. Dehydration is marked. The infant becomes drowsy and coma may supervene. Acidosis with carbon dioxide determination as low as 15 volumes percent may occur during the stage of invasion and during the stage to toxicity. These infants who develop acidosis-hyperapnoea is frequently not presents; there is hemoconcentration with an elevation of proteins, nonprotein nitrogen and blood chlorides; albumin and casts are found in the urine. The clinical course varies markedly from few days to several weeks. The complications may include otitis media, bronchopneumonia, and septicemia.
The diagnosis of this diarrhea during the newborn period is usually established when one or more infants have diarrhea in the same ward and one of them becomes critically ill or dies. We all know that during the immediate neonatal period the character and number of the stools for a normal infant may vary considerably, and we are very frequently able to pick out the tangible causes.
Deviations in the bowels habit may occur from overfeeding and from improper artificial feeding, but I feel certain that a provisional diagnosis of epidemic diarrhea in the newborn may be made whenever two or more infants have otherwise an insignificant diarrhea with sudden weight loss. The prognosis in these cases must always be guarded. There has been a very high mortality rate. As far as I can investigate I feel that the fatality rate is 43 percent in the epidemics. The future progress of all the infants that have survived epidemic diarrhea as a rule is uneventful.
Prophylaxis is of the greatest importance and applies both to the prevention of the initial infection and the prevention of infection of other infants. This is primarily a hospital disease but care of the nursery and the nursing care are not within the scope of this paper.
Active treatment is much the same as that of any of the diarrheal disturbances that occur during infancy. The orthodox school has laid out a complete plan of treatment which consists of an initial starvation period with only glucose in saline solution by mouth. Parenteral fluids are given by the subcutaneous and intravenous routes for the state of acidosis. Ascorbic acid and thiamine chloride are used. Solution of the amino acids are especially valuable to avoid protein depletion. Their direct therapy, as I have observed it, belongs in the sulfonamide field. Blood and plasma transfusions are considered necessary adjuncts in the therapy to avoid the depletion of serum protein and to correct anemia. In the hospital blood carbon dioxide determinations are repeated whenever there is an exaggeration of any of the symptoms.