Diarrhoea and Vomiting in Children Under 5yrs

1. NICE clinical guideline 84 Diarrhoea and Vomiting in Children Under 5yrs Implementing NICE guidance 2009 Dr. Jatinder Singh Jheeta, Paeds ST2

2. 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.

3. Key priorities for implementation • Diagnosis • Assessing dehydration and shock • Fluid management • Nutritional management • Information and advice for parents and carers

5. Diagnosis • 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

6. Assessing dehydration & shock: those at increased risk… • Infants <1yr, but especially < 6 months • Infants oflow 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

7. Assessing dehydration and shock

9. Assessing Dehydration and Shock

10. Fluid management: children without dehydration • 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.

11. Infants <1yr, but especially < 6 months Infants oflow 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…

12. Fluid management: children with dehydration ...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.

13. Fluid management: when to use intravenous fluid 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.

14. Fluid management:giving intravenous fluid therapy • 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.

15. Nutritional management • 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.

16. 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

17. Information and advice: hygiene • 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.

18. Information and advice: school, childcare and activities • 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

19. Summary… Diagnosis Assessing dehydration & shock, and using Tool Fluid management Nutritional management Information and advice for parents and carers

20. Thank you...