NICE guidance on diarrhoea and vomiting in children

NICE has issued guidance on the diagnosis, assessment and management of acute diarrhoea and vomiting caused by gastroenteritis in children under five years.

According to NICE there is considerable variation in clinical practice relating to the management of gastroenteritis in children, including the advice offered to parents regarding the types of oral fluids to be given, hence the need for definitive guidance.

The guidance sets out five key priorities for implementation:

1. DIAGNOSIS

  • Perform stool microbiological investigations if:
    - you suspect septicaemia or
    - there is blood and/or mucus in the stool or
    - the child is immunocompromised

Symptoms that may indicate diagnoses other than gastroenteritis are also detailed in the guidance.

2. ASSESS DEHYDRATION AND SHOCK

  • The guidance includes a comprehensive table of symptoms and signs associated with three levels of severity of dehydration, from no clinically detectable dehydration to clinical shock. ‘Red flag’ symptoms and signs are highlighted and may help to identify children at increased risk of progression to shock.

3. FLUID MANAGEMENT

  • 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 of dehydration (see below)
    - offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration (see below)
  • In children with clinical dehydration, including hypernatraemic dehydration:
    - use low-osmolarity ORS solution (eg, Dioralyte, Electrolade)
    - give 50ml/kg for fluid deficit replacement over four hours as well as maintenance fluid
    - give the ORS solution frequently and in small amounts
    - consider supplementation with their usual fluids (eg, milk feeds or water but not fruit juices or carbonated drinks) if they refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs
    - consider giving ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently
    - monitor response to therapy by regular clinical assessment
  • Use intravenous fluid therapy for clinical dehydration if:
    - shock is suspected or confirmed
    - a child with red flag symptoms or signs shows clinical evidence of deterioration despite oral rehydration therapy
    - a child persistently vomits the ORS solution, given orally or via a nasogastric tube

The guidance also provides recommendations on choice of fluid, dosages and monitoring where intravenous fluid therapy is required for rehydration and the child is not hypernatraemic at presentation.

4. NUTRITIONAL MANAGEMENT

  • After rehydration:
    - give full-strength milk straightaway
    - reintroduce the child’s usual solid food
    - avoid giving fruit juices and carbonated drinks until the diarrhoea has stopped

5. ADVICE FOR PARENTS AND CARERS

  • Provide parents, carers and children with the following advice:
    - wash hands with soap in warm running water and dry carefully - these are the most important factors in preventing the spread of gastroenteritis
    - wash hands after going to the toilet or changing nappies and before preparing, serving or eating food
    - do not share towels used by infected children
    - do not send children to school or any other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis and for at least 48 hours after the last episode
    - do not allow children to swim in swimming pools for two weeks after the last episode of diarrhoea

Children are considered to be at increased risk of dehydration if they:

  • are younger than one year, and especially if they are younger than six months
  • were of low birth weight
  • have passed six or more diarrhoeal stools in the past 24 hours
  • have vomited three or more times in the past 24 hours
  • have not been offered or have been unable to tolerate supplementary fluids before presentation
  • have stopped breastfeeding during the illness
  • are showing signs of malnutrition

The guidance also states that antidiarrhoeals should not be given and that antibiotics should not be given routinely. Indications for antibiotic therapy are as follows:

  • Suspected or confirmed septicaemia
  • Extra-intestinal spread of bacterial infection
  • Younger than six months with salmonella gastroenteritis
  • Malnourished or immunocompromised with salmonella gastroenteritis
  • Clostridium difficile-associated pseudomembranous enterocolitis, giardiasis, dysenteric shigellosis, dysenteric amoebiasis or cholera.

To view the full guidance visit the NICE website.

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