Dr Stephen Murphy (left) and Shona Burman-Roy outline the NICE recommendations on managing diarrhoea and vomiting caused by gastroenteritis in children under 5 years

  • Diarrhoea with or without vomiting caused by gastroenteritis is a common condition in children under the age of 5 years
  • Assessment of dehydration and shock should be performed in children with gastroenteritis
  • Fluid management varies depending on presence of clinical dehydration, including hypernatraemic dehydration
  • Fruit juices and carbonated drinks should be avoided during a gastroenteritis episode
  • Intravenous fluid therapy should be used for clinical dehydration if:
    • shock is suspected or confirmed
    • a child with red-flag symptoms or signs shows clinical evidence of deterioration in spite of oral rehydration therapy
    • a child persistently vomits oral rehydration salt solution, given orally or via a nasogastric tube
  • Nutritional management should also be considered in a child with gastroenteritis
  • Patients and parents/carers should be provided with information on how to care for a child with gastroenteritis at home, when to contact a healthcare professional, and how to prevent the spread of diarrhoea and vomiting

Sudden onset of diarrhoea in young children, with or without vomiting, is very common, with approximately 10% of children under the age of 5 years presenting to healthcare services each year.1 In the UK, viral infective gastroenteritis is the most frequent explanation, although a range of enteric bacteria and protozoal pathogens may also be responsible.2,3

Gastroenteritis is usually a mild illness lasting for only a few days. Its symptoms are unpleasant causing distress and anxiety to both child and family. Diarrhoea is often accompanied by abdominal pain, and infants and young children with severe symptoms may quickly develop dehydration: a serious and potentially life-threatening condition. Care of children with gastroenteritis may be provided by parents or by a range of healthcare professionals including primary and secondary level care staff.2,3

Need for a guideline

Although there are already a number of guidelines available on the management of gastroenteritis,4,5 considerable variation in clinical practice still exists. There is inconsistent advice regarding fluid management: parents are often unsure which oral fluids should be given, and advice on the use of oral versus intravenous fluids for rehydration varies anecdotally. Administration of fluids via a nasogastric tube is advocated by some healthcare professionals, but not by others. There is also variation in clinical assessment of dehydration severity (hence inconsistencies in the calculation of fluid deficits) and in the use of ‘rapid rehydration’ with intravenous fluids. It is widely recognised that the nutritional management of infants and children during and after the episode of gastroenteritis is often inconsistent.2,3

New controversial treatments and strategies have been proposed for both the prevention/management of dehydration and for treating the symptoms of gastroenteritis.6,7 New anti-emetic and antidiarrhoeal therapies, as well as probiotic preparations, have been advocated for use in gastroenteritis, but there are uncertainties about the efficacy and safety of these agents.2,3

Although parents often manage their child’s illness at home, a substantial number of parents/carers will ask healthcare professionals for advice (e.g. from NHS Direct, from community-based nurses/ health visitors or GPs) and some present directly at a hospital emergency department. In community settings there is variation in the way care is escalated to various hospital settings (day wards or inpatient management) for the child who may require urgent referral.

Despite most children with gastroenteritis not requiring admission to hospital, many are treated as inpatients each year and once admitted, they often remain in the hospital for several days.2,3 In one study from the UK, diarrhoeal illness accounted for 16% of medical presentations to a major paediatric accident and emergency department.8 This may have a major impact on the use of healthcare resources. In a study looking at cost-of-illness and conducted as part of a community surveillance study, it was estimated that the economic burden of rotavirus gastroenteritis in the UK amounted to £11.5 million each year.9 Admission of infected patients also carries a serious risk of spread to other children in the hospital,10 some of whom may be highly vulnerable as a consequence of their own medical conditions.

It was for these reasons that NICE Clinical Guideline CG84 Diarrhoea and vomiting in children: Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years was developed. It is intended to apply to children who present to a healthcare professional in any setting for advice on acute diarrhoea (lasting 14 days or fewer), on its own or with vomiting.2,3

The guideline is published in several formats, which are all available from the NICE website (www.nice.org.uk/CG84). The full version contains a summary of the research methodology used, results of the literature searches, the ‘translation’ of the evidence by the Guideline Development Group (GDG), and the subsequent recommendations.3 The short (NICE) version of the guideline contains the clinical and research recommendations, and the Quick Reference Guide has the clinical recommendations with care pathway for fluid management.2,11 Finally, the Understanding NICE guidance version is developed primarily for users of the NHS.12

Scope of the guidance

The NICE recommendations are based on the best available evidence wherever possible. However, much of this evidence is from developing countries and it cannot be assumed that it is applicable to a UK setting. Variation in baseline characteristics means that evidence based on absolute measures cannot be applied reliably to a developed country setting. However, even relative measures of effect need to be interpreted with a view as to whether the context is sufficiently similar: ‘Is my patient so different from those in the trial that its results cannot help me make my treatment decision?’13 The GDG applied this approach in discussing evidence for this guideline from developing country settings. Inevitably, evidence was sometimes limited or non-existent and, in such situations, recommendations were based on consensus opinion.3

The GDG specifically addressed the following issues relating to gastroenteritis:3

  • When to consider the management of acute diarrhoea and vomiting in infants and young children who were previously healthy?
  • How to identify infants and young children who are at risk of dehydration and whose condition needs immediate management?
  • How to differentiate between acute infective diarrhoea and diarrhoea due to other causes?
  • How to manage symptomatic infants and young children, including:
    • when to start rehydration?
    • what type of rehydration fluids to use?
    • what route of administration to use?
    • what additional treatment to consider?
    • appropriate feeding strategies for infants with gastroenteritis?
    • when and what investigations should be performed?
  • The threshold of referral:
    • what clinical signs or symptoms can be used to identify infants and young children who should be referred?
    • what additional factors should be taken into consideration when deciding whether or not to admit an infant or young child to hospital?
  • The information that should be given to parents and carers following initial assessment of the infant or young child by the healthcare professional, for example, regarding signs of dehydration, replacement of fluids, and feeding strategies at home.

Areas outside the scope of the guideline include children who have passed their fifth birthday, chronic diarrhoea and vomiting (lasting more than 14 days), non-gastroenteritis diarrhoea or vomiting (for example, specific food intolerances or inflammatory bowel disease), children with medical disorders that significantly alter the approach to their fluid management, such as those with cardiac or renal failure, and neonates who are admitted to the neonatal unit.2,3

Public health issues such as the contamination of food products and factors that may prevent acute diarrhoea and vomiting, for example breastfeeding, were not included, although the Department of Health guidance on the primary prevention of infection in the community was reiterated for completeness.14,15 Immunisations to prevent diarrhoea and vomiting were also not covered in the NICE guideline.2,3

Diagnosis

Gastroenteritis is the most likely diagnosis when a child presents with sudden onset of diarrhoea with or without vomiting.

Laboratory investigations
The GDG found that routine stool investigations were not warranted and recommended that these investigations should be performed if:2,3

  • the healthcare professional suspects septicaemia or
  • there is blood and/or mucus in the stool or
  • the child is immunocompromised.

The healthcare professional should also consider stool investigations if:2,3

  • the child has been abroad recently or
  • the diarrhoea has not improved by day 7 or
  • there is uncertainty about the diagnosis of gastroenteritis.

Assessment of dehydration and shock

As dehydration is the primary serious complication of gastroenteritis, healthcare professionals need to be able to recognise its presence based on clinical assessment and manage it appropriately. It is also critically important that manifestations of shock are immediately recognised. To this end, the GDG developed a table of signs and symptoms to assist with assessment of dehydration and shock (see Table 1).2,3

Table 1: Symptoms and signs of clinical dehydration and shock2,3
  Increasing severity of dehydration
arrow
  No clinically detectable dehydration Clinical dehydration Clinical shock
Symptoms (remote and face-to-face assessments) Appears well

red flag.eps Appears to be unwell or deteriorating

Alert and responsive

red flag.eps Altered responsiveness
(for example, irritable, lethargic)

Decreased level of consciousness
Normal urine output Decreased urine output
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities Warm extremities Cold extremities
Signs (face-to-face assessments) Alert and responsive

red flag.eps Altered responsiveness
(for example, irritable, lethargic)

Decreased level of consciousness
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities Warm extremities Cold extremities
Eyes not sunken

red flag.eps Sunken eyes

Moist mucous membranes (except after a drink) Dry mucous membranes
(except for ‘mouth breather’)
Normal heart rate

red flag.eps Tachycardia

Tachycardia
Normal breathing pattern

red flag.eps 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

red flag.eps Reduced skin turgor

Normal blood pressure Normal blood pressure Hypotension
(decompensated shock)

Interpret symptoms and signs taking risk factors for dehydration into account. Within the category of ‘clinical dehydration’ there is a spectrum of severity indicated by increasingly numerous and more pronounced symptoms and signs. For clinical shock, one or more of the symptoms and/or signs listed would be expected to be present. Dashes (—) indicate that these clinical features do not specifically indicate shock. Symptoms and signs with red flags (red flag.eps) may help to identify children at increased risk of progression to shock. If in doubt, manage as if there are symptoms and/or signs with red flags.

National Institute for Health and Care Excellence (NICE) (2009) CG84. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. Quick reference guide. London: NICE. Reproduced with permission. Available from www.nice.org.uk/guidance/CG84

Fluid management

The NICE guideline recommends that in children with gastroenteritis but without clinical dehydration:2,3

  • mothers should continue breastfeeding and other milk feeds
  • healthcare professionals should encourage fluid intake but discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration
  • healthcare professionals should offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration.

In children with clinical dehydration, including hypernatraemic dehydration, healthcare professionals should:2,3

  • use low-osmolarity ORS solution (240–250 mOsm/l) for oral rehydration therapy
  • provide 50 ml/kg of ORS solution for fluid deficit replacement over 4 hours in addition to maintenance fluid
  • provide the ORS solution frequently and in small amounts
  • consider supplementation with their usual fluids (including 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 (see Table 1)
  • consider giving the ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently
  • monitor the response to oral rehydration therapy through regular clinical assessment.

Intravenous fluid therapy
Intravenous fluid therapy for clinical dehydration, which would only be provided in secondary care, should be used if:2,3

  • shock is suspected or confirmed
  • a child with red-flag symptoms or signs (see Table 1) shows clinical evidence of deterioration in spite of oral rehydration therapy
  • a child persistently vomits the ORS solution, given orally or via a nasogastric tube.

If intravenous fluid therapy is required for rehydration (and the child is not hypernatraemic at presentation) management should follow the recommendations below:2,3

  • use an isotonic solution, such as 0.9% sodium chloride, or 0.9% sodium chloride with 5% glucose, for both fluid deficit replacement and maintenance
  • for children who required initial rapid intravenous fluid boluses for suspected or confirmed shock, add 100 ml/kg of isotonic solution for fluid deficit replacement to maintenance fluid requirements, and monitor the clinical response
  • for individuals who were not shocked at presentation, add 50 ml/kg of isotonic solution for fluid deficit replacement to maintenance fluid requirements, and monitor the clinical response
  • measure plasma sodium, potassium, urea, creatinine, and glucose at the outset, monitor regularly, and alter the fluid composition or rate of administration if necessary
  • consider providing intravenous potassium supplementation once the plasma potassium level is known.

Nutritional management
Although, priority is given to fluid management or alleviation of symptoms, nutritional management is also crucial in children with gastroenteritis. After rehydration:2,3

  • give full-strength milk straight away
  • reintroduce the child’s usual solid food
  • avoid giving fruit juices and carbonated drinks until the diarrhoea has stopped.

Antibiotic and other therapies
Antibiotics should not be routinely given to children with gastroenteritis. Antidiarrhoeal medications should not be used.2,3

Information and advice for parents and carers

Caring for a child at home
Parents and carers should be informed that most children with gastroenteritis can be safely managed at home, with advice from a healthcare professional if needed. However, a healthcare professional should be contacted if symptoms of dehydration develop. Symptoms indicative of dehydration include: appearing to get more unwell, a change in level of responsiveness, decrease urine output, pale or mottled skin, or cold extremities. Advice should be tailored to the clinical situation and state of rehydration/dehydration.2,3

Advise patients and carers that:

  • the usual duration of diarrhoea is 5–7 days and in most children it stops within 2 weeks
  • the usual duration of vomiting is 1 or 2 days and in most children it stops within 3 days
  • they should seek advice from a specified healthcare professional if the child’s symptoms do not resolve within the above timescales.

Preventing spread of diarrhoea and vomiting
To prevent the primary spread of diarrhoea and vomiting, advise parents, carers, and children that:2,3

  • washing hands with soap (liquid if possible) in warm running water and careful drying is the most important factor in preventing the spread of gastroenteritis
  • hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving, or eating food
  • towels used by infected children should not be shared
  • children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis
  • children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting
  • children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea.

Changes in current practice

In the NICE guideline, an assessment strategy was aimed at simplifying the recognition and assessment of dehydration. As a consequence of this, it was possible to greatly simplify the approach to rehydration.

Previous guidance has been reported to be difficult to implement.16 This may be partly owing to practical impediments to implementing recommendations in the real world (e.g. professional or parental perceptions or views). The GDG responsible for the NICE guideline recommendations included parents with personal experience of caring for ill children, and doctors and nurses working in the community, and in primary, secondary, and tertiary healthcare settings who were able to address these previous limitations.5

Summary

The NICE guideline was focused on providing advice on the recognition of dehydration and its effective treatment. A crucial objective in implementation of the guideline recommendations is the provision of advice on the management of children in home settings—an area of practice involving GPs and other members of the primary care team.

NICE implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 84 on Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. They are now available to download from the NICE website: www.nice.org.uk

Costing tools

Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.

Slide set

The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. This information does not supersede or replace the guidance itself.

Audit support

Audit support has been developed to support the implementation of the NICE guideline on diarrhoea and vomiting in children. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools.

References

  1. Van Damme P, Giaquinto C, Huet F et al. Multicenter prospective study of the burden of rotavirus acute gastroenteritis in Europe, 2004–2005: the REVEAL study. J Infect Dis 2007; 195 (Suppl 1): S4–S16.
  2. National Institute for Health and Care Excellence. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. Clinical Guideline 84. London: NICE, 2009. Available at: www.nice.org.uk/CG84
  3. National Collaborating Centre for Women’s and Children’s Health. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. Clinical Guideline. London: NCCWCH, 2009. Available at: www.nice.org.uk/guidance/CG84
  4. Armon K, Stephenson T, MacFaul R et al. An evidence and consensus based guideline for acute diarrhoea management. Arch Dis Child 2001; 85 (2):132–142.
  5. Sandhu B; European Society of Pediatric Gastroenterology, Hepatology and Nutrition Working Group on Acute Diarrhoea. Practical guidelines for the management of gastroenteritis in children. J Pediatr Gastroenterol Nutr 2001; 33 (Suppl 2): S36–39.
  6. World Health Organization. The treatment of diarrhoea: a manual for physicians and other senior health workers. 4th edn. Geneva: WHO, 2005.
  7. World Health Organization. Diarrhoea treatment guidelines for clinical based healthcare workers. Geneva: WHO, 2005.
  8. Armon K, Stephenson T, Gabriel V et al. Determining the common medical presenting problems to an accident and emergency department. Arch Dis Child 2001; 84 (5): 390–392.
  9. Lorgelly P, Joshi D, Iturriza Gomara M et al. Infantile gastroenteritis in the community: a cost-of-illness study. Epidemiol Infect 2008; 136 (1): 34–43.
  10. Lopman B, Reacher M, Vipond I et al. Epidemiology and cost of nosocomial gastroenteritis, Avon, England, 2002–2003. Emerging Infect Dis 2004; 10 (10): 1827–1834.
  11. National Institute for Health and Care Excellence. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. Clinical Guideline 84. Quick Reference Guide. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG84
  12. National Institute for Health and Care Excellence. Understanding NICE guidance—Diarrhoea and vomiting in children. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG84
  13. Sackett D, Richardson W, Rosenberg W, Haynes R. Evidence-based medicine. How to practice and teach EBM. London: Churchill Livingstone, 1997.
  14. Health Protection Agency. Guidance on infection control in schools and other child care settings. London: HPA, 2006. Available at: www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947358374
  15. PHLS Advisory Committee on gastrointestinal infections. Preventing person-to-person spread following gastrointestinal infections: guidelines for public health physicians and environmental health officers. Commun Dis Public Health 2004; 7 (4): 362–384.
  16. Szajewska H, Hoekstra J, Sandhu B. Management of acute gastroenteritis in Europe and the impact of the new recommendations: a multicenter study. The Working Group on acute diarrhoea of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2000; 30 (5): 522–527. G

 

  • The NICE guideline can help to differentiate between children who need to be assessed face-to-face or referred to hospital
  • Commissioners should ensure all primary care clinical staff and urgent-care providers are aware of the guideline and use it in their practice
  • The recommendations could be built into contracts with key providers (e.g. out-of-hours providers, walk-in centres, GP practices)
  • Compliance with these guidelines could be monitored by performing audits of patients referred to local accident and emergency departments
  • Paediatric attendances and admissions are rising in most places—proper adherence to these guidelines could mitigate the impact and cost of avoidable attendances
  • Costs of accident and emergency attendance = £87 for standard attendance (2010–2011 tariff)
  • Paediatric admission = £3434
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