Vomiting and diarrhoea in children

Question 1

What’s the definition of diarrhoea?

Answer 1

Diarrhoea = 3 or more loose stools/day

Question 2

What’s the differential diagnosis if diarrhoea last:

• less than 14 days
• more than 14 days

Answer 2

Duration of diarrhoea:

Less than 14 days

• acute gastroenteritis
• other infection
• appendicitis

More than 14 days

• persistent diarrhoea
• consider malabsorption
• check growth

Question 3

What’s the most common organism causing diarrhoea in children in:

A. developed countries

B. less developed countries

Answer 3

* Bacterial diarrhoea is less common in developed countries

• Most of the causes in developed and less developed countries are due to Rotavirus
• However, E.Coli (bacterial cause) is more common in less developed countries

Question 4

Red flags for vomiting (apperance)

Answer 4

Vomiting - red flags:

• bile
• blood
• coffee ground

Question 5

Colours of vomits and what do they indicate:

• yellow
• dark green

Answer 5

yellow -> mucous (lining of the stomach)

dark green -> bile

*some parents may say that a child is vomiting a ‘bile’ but in fact the vomit may be yellow - so confirm what colour it is

Question 6

Vomiting blood (child):

A. Common causes

B. Rare causes

Answer 6

Vomiting blood causes:

A. Common:

• Mallory Weiss tear
• foreign bodies
• swallowed blood (e.g. nose bleed)

B. Rare:

• coagulation disorder
• peptic ulcer
• varices
• viral haemorrhagic fever

*ask for travel history if appropriate - may indicate a cause of diarrhoea/vomiting

Question 7

Common causes (children) of coffee ground vomiting?

What is a coffee ground vomit result of?

Answer 7

Coffee ground vomiting

(blood has been in the stomach for a while, was oxidised)

• gastro-oesophageal reflux
• Mallory Weiss tear
• swallowed blood (e.g. nose bleed)

Question 8

What do the colours of vomit mean in terms of management?

Answer 8

Question 9

Red flags for diarrhoea in a baby/child and why

Answer 9

Diarrhoea - red flags

• bloody diarrhoea - suggestive of bacterial diarrhoea (e.g. salmonella, shigella**, E. Coli 0157, campylobacter)

*need to be seen by paediatrician

• short/ abnormal gut (children whose gut is shorter for some reasons e.g. previous surgery)

*high risk of dehydration that occurs more quickly in these children (as fluid cannot be absorbed well from their gut)

*need to see a paediatrician

Question 10

What other symptoms would you look at in a child with acute presentation of diarrhoea?

(to exclude other diagnosis)

Answer 10

• fever/ toxic appearance -> sepsis, toxic shock
• breathless -> pneumonia
• abdominal pain -> appendicitis/ intussusception (although remember that a bit of cramping abdominal pain in normal in diarrhoea - but always check for other possible causes)
• neck stiffness/bulging frontanelle and drowsiness -> meningitis
• non-blanching rash -> meningococcal septicaemia

Question 11

3 categories of dehydration

Answer 11

Dehydration - 3 categories

1. Normal hydration = people with no dehydration
2. Clinical dehydration = patients with signs of dehydration on examination
3. Shock

Question 12

Signs and symptoms of dehydration

Answer 12

Signs and symptoms of dehydration:

• altered responsiveness
• sunken eyes
• tachycardia
• tachypnoea
• reduced skin turgor

Question 13

How to assess for skin turgor?

Answer 13

Question 14

Signs of shock in a child

Answer 14

Signs of shock in children:

*may happen as a child becomes more and more dehydrated

• decreased level of consciousness
• mottled/ cold extremities
• tachycardia
• tachypnoea
• increased capillary refill time

Question 15

How and where to check for cap refill

Answer 15

Reduced cap refill: press the surface of the skin with your finger for 5 s -> then take the finger away -> it should take 2 s for the blood to return

*ideally do it on the sternum as it will give you a better picture of an acute shock (as some people have poor circulation so there may be cap refill time abnormality in the extremities)

Question 16

Management of dehydration

A. normal hydration (but at risk of dehydration)

Answer 16

Normal hydration

• continue feeds
• encourage fluid intake

Question 17

Management of dehydration

A. Clinical dehydration

B. Shock

Answer 17

Clinical dehydration

(signs and symptoms of dehydration are visible)

• give oral rehydration solution (50 ml/kg over 4 hours)
• give ORS frequently and in small amounts
• consider supplementation with usual fluids

Shock

• give IV fluids

Question 18

Mechanism of ORS

Answer 18

ORS mechanism

1. Cells in the gut have sodium-glucose linked transporter (SGLT) -> therefore if Na+ is taken by a cell from a gut lumen, with it also glucose is taken into
2. As Na+ and glucose are then pumped out into the body -> osmotic gradient is created -> H₂0 is pushed into the gut cell and then into the body

Therefore the H₂0 would be absorbed much quicker in the presence of salt and sugar (glucose and sodium) that are present in ORS

Question 19

alternatives to ORS if a child is mildly dehydrated

Answer 19

Alternatives:

*as not every child like a taste of ORS

• If a child has mild gastroenteritis and is minimally dehydrated -> initial oral hydration with diluted (half-strength) apple juice followed by child’s favourite fluids

Question 20

Diet in diarrhoea after dehydration

Answer 20

Diet in diarrhoea

After rehydration:

• give full strength milk straight away
• reintroduce child’s usual solid food
• avoid giving fizzy drinks until diarrhoea has stopped

Question 21

Why antibiotic treatment is not recommended in children with acute gastroenteritis?

Answer 21

A. Do not give antibiotics - most causes are viral-> susceptibility to other bacterial infections is increased and increased complications such as haemolytic uraemic syndrome (HUS) is possible (kidney damage due to shigella toxin causing damage to small blood vessels in the kidney and blood clots forming there -> kidney failure -> uraemia - excess urea in the blood)

*if a child has E.coli 0157 and antibiotics are given

*In HUS, Antibiotic treatment will kill the bacteria - so more toxin released = more HUS symptoms

*Therefore antibiotic treatment is not recommended and shigella toxins will clear up on their own within few days

Question 22

Why is it not recommended to give anti-emetics and anti-diarrhoeal in a child with acute gastroenteritis?

Answer 22

• Anti-emetics - not a good idea either due to side effects that are exaggerated in children (e.g. dyskinesia)
• Anti-diarrhoeals - not recommended in children; as the infectious agent will be stopped from being excreted

Question 23

• What pathogen is the most common cause of an acute diarrhoea in a child?
• what other symptoms may it present with
• typical duration of a diarrhoea
• management

Answer 23

Rotavirus

• the most common cause of acute diarrhoea in a child
• accompanied by fever and vomiting for the first 2 days
• The diarrhoea may last up to a week
• treatment is rehydration

Question 24

what are the most common causes of a chronic diarrhoea in an infant?

Answer 24

Chronic diarrhoea

Infants

• most common cause in the developed world is cows’ milk intolerance
• toddler diarrhoea: stools vary in consistency, often contain undigested food *this is physiological due to having a shorter gut - no time to absorb/digest that much
• coeliac disease
• post-gastroenteritis lactose intolerance