The child with diarrhoea and/or vomiting
The child with diarrhoea and/or vomiting
Background
•Gastroenteritis is a term used to describe the illness when children present with a vomiting and diarrhoeal illness of presumed infectious origin.
•Such illness is very common in any age, but especially in children who are younger (because they still have a naive immune system), and children who are exposed to lots of other children at home, school or indeed in hospital.
•The vast majority of gastroenteritis in children is managed by families without seeking medical intervention.
•Despite the fact that diarrhoeal illnesses are still the biggest killers of children in the developing world, only about one in every one hundred cases do children in the developed world even get admitted to hospital.
•Deaths in developed countries are extremely rare.
•Gastroenteritis can cause children to be very ill indeed but regardless of the severity of the illness, parental anxiety often runs high. I blame this on the parental instinct to feed children and to keep children well, both of which are of course frustrated by the child with diarrhoea and vomiting.
Most children who present with gastroenteritis will be essentially well. Often, the child is taking enough fluid to maintain hydration. Even when there is vomiting, children seem to manage to keep enough fluids down and compensate in other ways, such that they do cope until the illness burns out.
However, do not be too easily reassured. Those children who do run into trouble with gastroenteritis have reached the end of their ability to cope. They have moved fluid from the intracellular compartment until they have no further ability to do so, they have burnt up all their energy reserves and they have ratcheted up their cardiovascular compensatory mechanisms so that there is nowhere left to go. As a result, when they pass the point of coping, they become quite suddenly and catastrophically unwell.
Fear not though, with careful assessment and good management, success is virtually guaranteed. The odds are very much on the side of the child getting better. Your job is to help them to do this for themselves and identify the children who are not getting better, and the rare circumstance of the child who cannot get better without medical intervention.
How to assess
Although a history in the context of gastroenteritis does not have to be extensive, there are some important facts to elicit:
•How long has the child been unwell?
•Is there diarrhoea, vomiting or both? Which appeared first?
•Is the child drinking? How much do the parents think the child has had today?
•Is the child passing urine? How many times today?
•Has there been any blood or mucous in the stool? Any blood or bile in the vomit?
•Have there been any floppy or unresponsive episodes at home?
•Is anyone else unwell?
•Has there been any foreign travel?
•Look at the child’s overall health. Do they look well, a bit unwell or quite unwell?
•Note the child’s colour and facial appearance. Are they pale? Are the eyes sunken into dark sockets? Is the skin turgor normal?
•Look for wet mucous membranes. Dry lips are an unhelpful sign, especially when a child has been crying, but dry eyes and mouth are significant.
•Check the pulse, and check the capillary refill over the sternum.
•Note the respiratory rate and if breathing is normal or not.
•Listen to the heart and lungs.
•You should of course examine the abdomen, but in gastroenteritis, you should not expect to find anything significantly abnormal. Occasionally there is epigastric tenderness or other superficial (muscular) tenderness.
Examine the throat and ears, as viral infections often cause gastroenteritis and upper respiratory tract infection (URTI) at the same time.
In babies, look at the nappy area for rashes, which can be severe when there is diarrhoea.
If you happen to have a previous weight from within the past few weeks available, then it is useful to compare a re-weighing with this. Any drop in weight is mostly due to dehydration. If you work in an emergency department, make sure any child is weighed so that if they go home, this information will be available should the child come back.
Essentially, you are looking to reassure yourself that the child that you have examined is well and not significantly dehydrated or shocked. It is important to understand the difference between shock and dehydration when assessing children who have diarrhoea and vomiting. Although there is a relationship between these two physiologically abnormal states, they are different and should be managed differently.
Dehydration is the state of having a deficit of water compared to that needed for a healthy metabolism. It takes at least hours and often days to become significantly dehydrated. If more water is leaving the body than coming in, then the body will slowly transfer fluid from inside cells to keep the circulation well supplied. Dehydration is the state that occurs most commonly in children with diarrhoea and vomiting because it is an illness which undermines the body’s ability to obtain fluid or hold onto fluid. The signs of dehydration are more to do with appearance than circulation and include dry mucous membranes, reduced skin turgor and sunken eyes. Dry mucous membranes usually appear first. When sunken eyes appear, dehydration is usually more advanced.
Shock or, more correctly in this context, hypovolaemia, is the state of having insufficient circulating volume to adequately perfuse all the tissues. The circulation is compromised, leading to a fast heart rate, delayed capillary refill and eventually low blood pressure. If a child with diarrhoea and vomiting has signs of shock. it is for one of two reasons, neither of which are good news. Either the dehydration is so severe or occurring so rapidly that the child cannot compensate and fails to maintain a good circulation, or the cause of the gastroenteritis is releasing toxins which have caused a state of septic shock, which have reduced the body’s ability to maintain good tone in the blood vessels. In either case, signs of shock indicate a medical emergency.
The ‘must do’s
Any child who is sent home must be discharged with advice to return if they deteriorate.
Any child who is floppy or has an altered consciousness must have a blood sugar level checked. Children with gastroenteritis use up their sugar reserves quickly and are not replacing them, so they are particularly prone to hypoglycaemia. Hypoglycaemia must be treated with oral glucose of some description in a child who is able to swallow, or intravenous 10% dextrose (5 ml/kg bolus) in an unconscious child.
In a general practice setting, buccal glucose gel is a reasonable temporary treatment for the collapsed child with hypoglycaemia.
Pitfalls to avoid
The most common answer given by parents to questions about fluid intake and urine output is that both are completely absent. Frequently a flat response will be made by a parent despite a well looking child. Usually (but not always) the child is in fact drinking and urinating. The reason why the parent has told you that they are not doing so is because they do not want you to use a positive answer to dismiss their anxieties. The real answer would be ‘yes, but not as much as usual’; however, because the parent subconsciously needs you to take their child’s illness seriously, the answer becomes ‘no’. Because you are a good and caring doctor, you will take the parents seriously but you also need to know what is really going on. The only way to achieve this is to ask the right questions and allow no room for interpretation. The questions that get a more realistic response are: ‘When did your child last have a pee, even if it was only a little one?’ (and) ‘When did your child last have a bit to drink, even if they were sick soon afterwards?’ Try these and see if you start to get different answers.
Intravenous therapy should only be started by a doctor who is experienced in prescribing fluids for children. It would be very poor practice on any child to attach a bag of fluid to a cannula and ‘run it through’ without calculating an appropriate rate. Children can die from inappropriate fluid type or volume.
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