Diarrhoea and Vomiting in Children Under 5yrs

Implementing NICE guidance

2009

NICE clinical guideline 84

Dr. Jatinder Singh Jheeta, Paeds ST2

Background• Approx 10% of children under 5yrs present to

healthcare services each year with gastroenteritis, and this puts a significant burden on health service resources.

• Severe diarrhoea and vomiting can cause dehydration and shock.

• There is variation in clinical practice.

Key priorities for implementation

• Diagnosis

• Assessing dehydration and shock

• Fluid management

• Nutritional management

• Information and advice for parents and carers

Perform stool MC&S if:

• you suspect septicaemia, or• there is blood and/or mucus in the stool, or• the child is immunocompromised.

May also consider sending stool MC&S if:• Child recently abroad, or• Persistent diarrhoea for >7days, or• Uncertainty about diagnosis of gastroenteritis

Diagnosis

• Infants <1yr, but especially < 6 months

• Infants of low birth weight

• Children who have passed >6x diarrhoeal stools or vomited >3x in 24 hours

• Children who have not had/not tolerated supplementary fluids

• Infants who have stopped breastfeeding during the illness

• Children with signs of malnutrition

Assessing dehydration & shock: those at increased risk…

Assessing dehydration and shock

Use the clinical signs and symptoms described in table 1 (QRG) to detect clinical dehydration and

shock

Increasing severity of dehydrationNo clinically detectable dehydration

Clinical dehydration Clinical shock

Increasingly numerous and more pronounced symptoms and signs

Signs of increasing severity of dehydrationNo clinically detectabledehydration

Clinical dehydration Clinical shock

Alert and responsive Altered responsiveness

Decreased level of consciousness

Skin colour unchanged Skin colour unchanged Pale or mottled skin

Warm extremities Warm extremities Cold extremitiesEyes not sunken Sunken eyes -Moist mucous membranes

Dry mucous membranes -

Normal heart rate Tachycardia TachycardiaNormal breathing pattern

Tachypnoea Tachypnoea

Normal peripheral pulses

Normal peripheral pulses

Weak peripheral pulses

Normal capillary refill time

Normal capillary refill time

Prolonged capillary refill time

Normal skin turgor Reduced skin turgor -Normal blood pressure Normal blood pressure Hypotension

Assessing Dehydration and Shock

In children with gastroenteritis but without clinical dehydration:•continue breastfeeding and other milk feeds•encourage fluid intake •discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk

•offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk.

Fluid management: children without dehydration

• Infants <1yr, but especially < 6 months

• Infants of low birth weight

• Children who have passed >6x diarrhoeal stools or vomited >3x in 24 hours

• Children who have not had/not tolerated supplementary fluids

• Infants who have stopped breastfeeding during the illness

• Children with signs of malnutrition

Recap… those at increased risk…

...including hypernatraemic dehydration:

• Use low-osmolarity ORS solution frequently and in small amounts.

• Give 50 ml/kg for fluid deficit over 4 hours and maintenance fluid.

• Consider supplementation with their usual fluids.

• Consider a NG tube if they cannot drink ORS or vomit persistently

• Monitor response regularly.

Fluid management: children with dehydration

Use IV fluids for clinical dehydration if:

• shock is suspected or confirmed

• a child with red flags or clinical deterioration despite oral rehydration.

• a child persistently vomits the ORS solution, given orally or via a nasogastric tube.

Fluid management: when to use intravenous fluid

• use isotonic solution for fluid deficit replacement and maintenance

• in addition to maintenance fluid requirements, add the following amounts for fluid deficit replacement:

­ 100ml/kg for those who were initially shocked­ 50ml/kg for those who were not shocked at presentation

• monitor blood plasma levels at the outset and regularly, and review administration rate

• consider providing intravenous potassium once the plasma potassium level is known.

Fluid management:giving intravenous fluid therapy

After rehydration:

•give full-strength milk immeadiately

•reintroduce the child’s usual solid food

•avoid giving fruit juice and fizzy drinks until the diarrhoea has stopped.

Nutritional management

Myths to Dispel…• Children should not be given milk or food for the first

24hrs if they have D&V

• Children should be given diluted milk rather than full strength milk if they have D&V

• Children should be given flat cola or lemonade if they have D&V

• Children should be given a ‘light diet’ when they are recovering from D&V

Advise parents and carers to:

• wash and carefully dry hands as this is the best way to prevent the spread of gastroenteritis

•wash hands after going to the toilet or changing nappies and before preparing, serving or eating food

•avoid sharing towels used by infected children.

Information and advice: hygiene

Advise parents and carers to keep children away from:

• School or other childcare facility - while they have diarrhoea or vomiting caused by

gastroenteritis and - for at least 48 hours after the last episode

• Swimming in swimming pools for 2wks after last episode

Information and advice: school, childcare and activities

Summary…

• Diagnosis

• Assessing dehydration & shock, and using Tool

• Fluid management

• Nutritional management

• Information and advice for parents and carers

Thank you...