Pediatric Primary Care Case Studies, 1st Ed.

Chapter 25. The Child with Vomiting and Diarrhea

Ardys M. Dunn

Victoria Winter

Vomiting and diarrhea are common phenomena in children. They often occur simultaneously, especially in the young child, and are most often associated with gastroenteritis. This case study focuses on the question of when the child with diarrhea can be managed with a telephone consultation and when he or she needs to be seen by the healthcare provider. In answering this question, we will examine the presentation of gastroenteritis in children, its epidemiology, etiology, differential diagnosis, diagnostic criteria, and treatment.

A case of gastroenteritis can be short-lived and managed with minimal intervention, or it can be the initial manifestation of a wide spectrum of acute and chronic disorders requiring more intensive therapy. The history and physical examination are essential for accurate assessment and diagnosis, and in conjunction with occasional laboratory tests, should guide care. Patient and family education on preventive measures can be effective in limiting the number of episodes of gastroenteritis in the home and the community.

Educational Objectives

1.  Identify the major etiologies of gastroenteritis in the United States.

2.  Explain the pathophysiology of the different types of diarrhea.

3.  State the factors that place the child at increased risk for hospitalization or death due to diarrhea.

4.  Determine when a healthcare provider can use telephone assessment versus inperson office assessment of the child.

5.  Describe treatment plans for acute, self-limited gastroenteritis and for severe gastroenteritis with dehydration.

  Case Presentation and Discussion

Sara’s mother is on the phone, calling about her 4-year-old daughter, who is sick with vomiting and diarrhea. “I feel ridiculous calling again, but Sara is sick. She started out with vomiting and then diarrhea, and now she is running a fever. I’ve tried everything I can think of to keep her well but this is the third time this year she has been sick. I think I need to bring her into the office. Do you think there is something seriously wrong with her that is causing all of this?”

Your office assistant informs you about this phone call. She asks what you want her to tell Sara’s mother. Do you want her to bring Sara into the office? Or is this something that can be handled on the phone?

Before you answer, the following provides some important information about gastroenteritis.

Epidemiology of Gastroenteritis

Diarrhea results in over 1 billion episodes of illness and 3–5 million deaths annually worldwide, placing it with upper respiratory tract infections as the most common infectious disease syndromes of humans. In the United States, gastroenteritis is a leading cause of morbidity and the second most common disease seen in children (Jenson & Baltimore, 2006; Lopez, Mathers, Ezzati, Jamison, & Murray, 2006; Pickering & Snyder, 2004). Most cases in this country are self-limited and require only minimal intervention aimed at dietary and fluid management. However, occasional episodes of severe, life-threatening gastroenteritis may occur, necessitating aggressive therapeutic intervention.

By definition, acute gastroenteritis is an illness of rapid onset that includes diarrhea with possible nausea, vomiting, lethargy, fever, abdominal pain, or dehydration (common in young children). Liquidity and frequency of stool are characteristic features (Jenson & Baltimore, 2006; Pickering & Snyder, 2004). Caring for a child with gastroenteritis can present a challenge to parents who must make judgments about how to keep their child hydrated during this illness, when to call or have their child seen by the pediatric primary care provider, and how to prevent this illness from occurring again or spreading to other members of the family or close contacts of the child.

Etiology of Gastroenteritis

The most common causative agents of gastroenteritis in the United States include (Pickering, Baker, Long, & McMillan, 2006):

•  Viral agents: Rotavirus, adenovirus, Norwalk, and calicivirus

•  Bacterial agents: Shigella, Salmonella, and Campylobacter jejuni

•  Parasitic agents: Giardia lamblia, Entamoeba histolytica, and Cryptosporidium

•  Agents that produce enterotoxins: S. aureus, E. coli (0157:H7), and C. difficile

Acute viral infectious gastroenteritis accounts for 70–80% of the cases of diarrhea in developed countries and results in more than 1.5 million outpatient visits and 200,000 hospitalizations in the United States each year (King, Glass, Bresee, Duggan, & Centers for Disease Control and Prevention, 2003).

Diarrhea in children can also be due to a systemic, nongastrointestinal infection; antibiotics; feeding patterns; and enzyme deficiency.

Important studies on the etiology of gastroenteritis reveal the following pattern:

•  A common disorder seen in the pediatric population in the emergency department (ED) is viral gastroenteritis. Rotavirus and norovirus play key roles in such viral illnesses. It is estimated that four out of five children in the United States will develop a symptomatic rotavirus gastroenteritis by age 5 years. One in seven will be seen in an ambulatory health setting, with an additional 205,000 to 272,000 ED visits due to this virus (Payne, Stockman, Gentsch, & Parashar, 2008). It is estimated that the noroviruses may be responsible for more than 235,000 clinic visits and 91,000 ED visits in children under 5 years of age living in the United States (Patel et al., 2008). With the use of the rotavirus vaccine, their numbers should decrease.

•  Extra-intestinal infections, such as otitis media, urinary tract infections, and pneumonia, can cause acute diarrhea that is mild and self-limited in nature (Berkun et al., 2008; Defilippi et al., 2008).

•  Antibiotic-associated diarrhea (AAD) occurs commonly (Turck et al., 2003) and is thought to be associated with a disruption in normal flora (Surawicz, 2003).

•  Overfeeding, especially with hyperosmolar fluids (i.e., soft drinks, apple juice, and broth) can cause diarrhea (Dennison, 1996). Limiting intake of solid foods can cause a thin, watery, green stool.

•  Lactase deficiency in the form of hypolactasia or lactase nonpersistence can cause diarrhea (Heyman & AAP Committee on Nutrition, 2006).

Pathophysiology of Vomiting and Diarrhea

Vomiting is the forceful expulsion of stomach (and sometimes duodenal) contents, often preceded by nausea. It should not be confused with regurgitation, which is the flow of undigested material from the lower esophagus and stomach without the associated forceful muscle contractions. Vomiting is a function of neuronal activity in the brainstem, specifically in the medulla oblongata of the hindbrain. The hypothalamus, stimulated by the same neuronal activity, also plays a role in vomiting. Two dynamics appear to occur leading to vomiting seen in conjunction with diarrhea: Chemosensitive receptors detect emetic agents in the bloodstream and transmit a message to the nucleus tractus solitarius (NTS) in the medulla, and vagal afferent nerves detect changes in intestinal contents and tone and send messages to the same site. The NTS is a complex of subnucleii related to gastric, laryngeal, and pharyngeal sensation; swallowing; baroreceptor function; and respiration. Neurostimulation of this center leads to the autonomic changes seen in vomiting (Hornby, 2001).

Vomiting with secretory and cytotoxic diarrhea may be due to a functional ileus seen in these conditions. As a result of the decreased intestinal tone and slowed peristalsis of a functional ileus, the intestinal lumen dilates causing abdominal pain and vomiting; gastric emptying is delayed, causing vomiting; and the patient experiences cramping due to peristaltic rushes.

Common causative factors for vomiting in infancy that are included in a differential diagnosis are congenital obstructive lesions (neonatal period), allergic reactions to formula (the first 2 months of life), pyloric stenosis, and metabolic disorders. For older children, viral or bacterial gastroenteritis or food poisoning are the more common causes of vomiting. Urinary tract infections, streptococcal pharyngitis, and otitis also are associated with vomiting. Central nervous system problems, migraine headaches, and other gastrointestinal anomalies must also be considered (Bishop, 2006).

The major pathophysiologic dynamic in diarrhea is an alteration in the balance of fluid exchange across the intestinal wall, resulting in excess fluid elimination. It is a function of a relative increase in secretion of fluid into the bowel and decrease in absorption of fluid from the small bowel. There are four main types of diarrhea commonly seen in infants and children:

1. Osmotic diarrhea: Occurs when the concentration of nutrients and electrolytes in the intestine is high enough to be osmotically active. As a result, fluid is drawn into the intestine to dilute these particles. Intestinal tissue is not typically damaged in osmotic diarrhea. Malabsorption syndromes, lactose intolerance, overfeeding, and excessive ingestion of hypertonic juices are examples of causes of osmotic diarrhea.

2. Secretory diarrhea: Occurs when bacterial enterotoxins stimulate secretion of fluids and electrolytes from small intestinal crypt cells into the intestine. Absorption by the small intestine villous cells is also inhibited. The excess fluids result in diarrhea. Common agents leading to secretory diarrhea include Aeromonas, Clostridium, E. coli, Salmonella, Shigella, Yersinia, Vibrio, and Giardia.

3. Cytotoxic diarrhea: Occurs when an agent (usually viral) destroys mucosal villous cells of the small intestine. Secretory cells tend to be spared, but shortened villi lead to decreased absorption of fluids and electrolytes. Rotavirus, Norwalk virus, Cryptosporidium, and E. coli bacteria are major causes of cytotoxic diarrhea.

4. Dysenteric diarrhea: Occurs when the bowel is inflamed, damaging the mucosa and submucosa. Subsequent edema, infiltration, and bleeding compromise the ability of the intestine to absorb water, nutrients, and electrolytes. This inflammatory process can occur with bacterial infections, celiac disease, and irritable bowel syndrome, affecting the functional ability of the bowel.

Acute versus Chronic Diarrhea

Acute diarrhea is typically defined as duration of diarrheal symptoms for 5 days or less. Chronic (or persistent) diarrhea is the presence of loose or more frequent stools for more than 2 weeks (Ghishan, 2004; Pickering & Snyder, 2004). Dehydration is a major cause of morbidity and mortality in acute diarrhea, less so in chronic diarrhea. Growth retardation, both physical and cognitive, is more commonly seen with chronic diarrhea, though this is more of a problem in developing countries than in the United States (Bhutta et al., 2008).

The etiology of chronic diarrhea may be age-related, with cow’s milk protein intolerance being the most common cause in infants. However, the causes of chronic diarrhea in young children are largely uncertain and probably multiple. Mucosa damaged by an episode of acute diarrhea may be slow to heal, limiting absorption from the gut and resulting in a persistent osmotic diarrhea. Allergies or food sensitivities, dietary or nutritional deficiencies, unknown pathogens, or underlying conditions (such as enzyme deficiency, celiac disease, or an autoimmunity) may cause chronic diarrhea (Bhutta et al., 2008). One study of children with persistent diarrhea in the United States found that 59% of the stool samples sufficient for analysis contained no pathogens, and another 17.9% contained only C. difficile and E. colithat appeared unrelated to the diarrhea (Vernacchio et al., 2006). This same study found that viruses most typically associated with persistent diarrhea were rotavirus, norovirus, and sapovirus; it remains unclear what role these viruses play in chronic diarrhea in developing countries where malnutrition and other diseases complicate the presentation (Bhutta et al.; Vernacchio et al.). Protracted diarrhea also can be caused if vomiting and gastroenteritis are managed by a high-carbohydrate, low-fat, and low-protein diet (Petersen-Smith & McKenzie, 2009).

In the United States, chronic nonspecific diarrhea of childhood (CNDC), also called toddler’s diarrhea or irritable colon of infancy, is usually a benign condition, but it often leads to an outpatient medical visit and must be evaluated to determine if treatment is necessary. CNDC is a diagnosis of exclusion. The term has been in the medical literature for over 50 years, and the characteristics of the condition specified in 1966 remain valid (Kleinman, 2005). These characteristics include (Davidson & Wasserman, 1966):

•  Diarrhea typically begins between 6 and 20 months of age (> 75%); 12% of infants presented with diarrhea before 6 months of age.

•  The child is growing and developing well.

•  The first stool of the day is large and semi-formed; subsequent stools are smaller and looser.

•  Most (87%) children have diarrhea with mucous.

•  A family history of functional bowel disorders is common.

Clearly, the history and physical examination are critical to identify the condition and possible underlying causes. Laboratory and diagnostic studies are ordered as indicated. Key factors to consider in assessing and managing chronic diarrhea are:

•  In CNDC, the best treatment is reassurance and returning the child to a full, normal diet for age. In Davidson and Wasserman’s study (1966), 88% of children with CNDC cleared by 39 months of age; another 10% by 48 months of age, without growth delay.

•  Treat underlying causes if known.

•  Treat the effects of diarrhea as indicated (e.g., oral or parenteral rehydration).

•  Refer to a gastroenterologist if:

image  Newborns present with diarrhea in the first hours of life.

image  The child has abnormal or delayed growth patterns.

image  Severe illness is present.

What additional information do you need to help you make the determination about a telephone consultation versus having Sara come in for an office visit? image

Risk Factors for Hospitalization and Death Due to Gastroenteritis

Before the initiation of treatment either by telephone or in person, one must review risk factors that place a child with gastroenteritis at increased risk for hospitalization or death (Fischer et al., 2007; Ho et al., 1988). These include:

•  Age < 12 months

•  Malnutrition

•  Immunodeficiency

•  Underlying disease

•  Low socioeconomic status of the family

•  Race

•  Maternal factors:

image  Little prenatal care

image  Low level of education

image  Young

•  Poor capability of the parents to monitor and care for their child

•  Winter season

If the child in question has one or more of these risk factors, there is concern for dehydration, especially during the first 6 hours of a primary infection such as rotavirus. For a telephone assessment, the provider’s knowledge of the patient’s family is crucial in assessing the validity of the information.

In addition to family data, the following information related to the specific illness is essential in assessing the child’s condition and determining if he or she should be seen in the office:

•  Age of child

•  Onset and duration of the illness

•  Number of diarrhea and vomiting episodes

•  Presence of blood or mucus in the stool

•  Intake of fluids—what and how much over the past 24 hours

•  Moisture on the mucus membranes

•  Fever

•  Urine frequency, amount, color, and last void

•  Activity of the child

Assessing fever and bloody stool, two features that can be present in gastroenteritis, is particularly helpful in determining the differential diagnosis and guiding the provider to make appropriate decisions regarding care (see Table 25-1).

The above information, along with the season of the year, can help guide the provider in diagnosing and treating the child. However, in order to distinguish an acute self-limited episode of gastroenteritis from a more serious disorder, additional historical information must be obtained, including:

•  Contacts with ill individuals

•  Exposures to illness or environmental contaminants such as in daycare, travel, water source, or foods

•  Previous episodes of gastroenteritis or dehydration (how many and time of last episode)

•  Medications being taken, including over-the-counter or prescription, and any complementary or alternative medications or herbal remedies

•  Prior history of other significant infections

Table 25–1 Differential Diagnosis of Gastroenteritis by Fever and Bloody Stool

image

•  Presence of concurrent infections

•  Underlying diseases

•  History of allergies

•  Family history of gastrointestinal conditions

For the child who is seen in person, the provider needs to assess and evaluate the following:

•  The infant’s or child’s level of consciousness; activity and energy level

•  Vital signs

•  Signs of dehydration

•  A careful abdominal exam looking for the presence of any localizing and/or meningeal signs

What additional questions will you need to ask when you return Sara’s mother’s phone call? image

With the information from the office triage nurse and a review of Sara’s records that indicate she is up-to-date on her immunizations, has no known allergies to medications or food, no family history of gastrointestinal conditions, and no history of recent hospitalization or serious illness, you telephone Sara’s mother. You ask her the following questions:

image  How long has Sara been sick? What started first, the vomiting or the diarrhea? She had been fine until just a few days ago. Two days ago, she threw up twice and then she had the loose stools. She had four loose stools today.

image  What do the stools look like? Any blood or mucus? They are loose greenish stools. There doesn’t seem to be any blood in them.

image  When did her fever start, what has it been, and how have you dealt with her fever? I first noticed she felt hot last night about 9 p.m. Her temperature was 100°F. I gave her some Tylenol, and it came down to normal within an hour. Her temperature this morning was 99.8°F. I haven’t given her anything for fever today, and she really doesn’t feel very warm now.

image  Is anybody in the family sick? Have you traveled anywhere recently? Has Sara eaten any new foods? Is Sara in daycare? Nobody in the family is ill. We have not gone anywhere lately. Sara’s been eating her normal diet, but we did change daycare about 2 weeks ago to a center nearer to home.

image  Has Sara been eating and drinking? How many times has Sara voided today including the time of her last urination? She had some dry cereal and milk today and some peaches for lunch, and she didn’t vomit after eating this time. She has gone to the bathroom at least three times to void, with her last voiding about 2 hours ago.

image  Has she been playing or lying around napping? She has been playing with her dolls this morning and watched one of her videos this afternoon. Do you think something else is wrong with her since she has been sick so much this year? What am I doing wrong?

You reassure Sara’s mom that she isn’t doing anything wrong, though you understand how anxious she is because Sara is sick again.

What are the possible differential diagnoses? image

Do you need to see this child, and are diagnostic tests needed at this point? image

Differential Diagnosis

Watery and/or frequent stools may be the initial manifestation of a wide spectrum of acute and chronic disorders, some of which may be life threatening in children. Of particular concern are intussusception, hemolytic uremic syndrome (HUS), pseudomembranous colitis, appendicitis, and toxic megacolon.

Intussusception is most common in infants 6–12 months of age, but can occur later in life; the majority of cases are seen in children less than 2 years of age. Without treatment, it can be life threatening. Most children experience sudden onset of severe, intermittent, crampy abdominal pain accompanied by inconsolable crying. These episodes typically occur at 15- to 20-minute intervals. As the obstruction progresses, the attacks become more frequent and there can be bilious gastric emesis, passage of “currant jelly” stool, and a sausage-shaped mass in the right side of the abdomen. The classic triad of symptoms of pain, palpable sausage-shaped abdominal mass, and currant jelly stools are seen in less than 15% of patients with intussusception. Between episodes, the infant behaves normally, and initial symptoms can be confused with gastroenteritis.

Hemolytic uremic syndrome (HUS) should be a consideration for any child with bloody diarrhea. This illness begins 5 to 10 days after the onset of diarrhea, is sudden in onset, and is characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure (Amiriak & Amiriak, 2006). The prodromal symptoms of abdominal pain, vomiting, and diarrhea that are experienced can mimic those of ulcerative colitis, other enteric infections, and appendicitis.

Pseudomembranous colitis is a rare but serious disorder that results almost exclusively from an overgrowth of toxin-producing Clostridium difficile organisms in the bowel. It is commonly associated with antibiotic therapy and prior hospitalization of the child. The typical presentation is lower abdominal pain accompanied by watery diarrhea, low-grade fever, and leukocytosis that start during or shortly after antibiotic administration. This infection can progress to toxic megacolon and shock (Brook, 2005).

Appendicitis typically begins with diffuse abdominal pain with the following three predominant clinical features: pain in the right lower quadrant, abdominal wall rigidity, and migration of periumbilical pain to the right lower quadrant (Paulson, Kalady, & Pappas, 2003). Predictive indicators of appendicitis in preadolescent children include lower right quadrant tenderness, nausea, inability to walk, and elevated white blood cell and neutrophil counts. Diarrhea may be present in children with appendicitis but is not a useful diagnostic indicator (Colvin, Bachur, & Kharbanda, 2007).

Toxic megacolon can occur as a complication of a Shigella infection, pseudomembranous colitis, Hirschsprung disease, or inflammatory bowel disease. It is a life-threatening complication. Its clinical manifestations are fever, massively dilated colon, painful abdominal distention, and anemia with a low serum albumin level (Bishop, 2006).

In addition to these life-threatening conditions, what other conditions should you include in the differential diagnoses when a child has vomiting and diarrhea? image

The following diagnoses should also be considered:

•  Urinary tract infection

•  Other infections: otitis media, strep pharyngitis

•  Inflammatory bowel disease

•  Malabsorption: lactose intolerance, celiac disease, cystic fibrosis

•  Milk protein allergy

•  Chronic diarrhea

•  Viral gastroenteritis

•  Overfeeding

•  Excessive fluid or juice intake

•  Amoebiasis

Diagnostic Testing

Laboratory testing is not necessary in acute gastroenteritis unless one of the following is present:

•  Blood or mucus in the stools.

•  No improvement in signs and symptoms after 5–6 days.

•  Signs and symptoms of severe dehydration. Specific blood work should be done to check blood urea nitrogen (BUN), white blood cell count and differential, and electrolytes. Urine should be checked for specific gravity.

Testing for a specific virus is rarely necessary because the disease is self-limited. However, if a specific organism is suspected, the following stool tests can be performed:

•  Bacterial infection: Stool can be sent for culture (e.g., E. coli 0157:H7 if child has bloody stools).

•  Giardia: Send stool for Giardia antigen.

•  Cryptosporidium: Send stool for ova and parasite test.

•  C. difficile: Send stool for C. difficile toxins text.

Making the Diagnosis

You continue your phone conversation, telling Sara’s mom that you think Sara just has a viral infection that is causing the vomiting and diarrhea, also known as acute gastroenteritis. Some of this may be related to changing daycare centers—especially if other children are sick.

Management

The goals of treatment in diarrhea are to restore and maintain hydration and resume full bowel function as soon as possible. At the least, acute gastroenteritis is a self-limited disease that requires no intervention other than administration of oral fluids and resumption of an age-appropriate diet, as is the case with Sara. Management of more severe illness in children who present with fever and dehydration should include the following steps:

1. Restore and maintain hydration. With a diagnosis of acute gastroenteritis, initial therapy is directed at correcting any fluid deficit and electrolyte imbalance. The American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC), and World Health Organization (WHO) have established fluid replacement guidelines for children with diarrhea (AAP, 2004; King et al., 2003). All are based on the degree of dehydration or volume depletion. Severe dehydration requires immediate intervention with rapid intravenous fluid resuscitation. With mild to moderate hypovolemia, oral rehydration is preferred, and can be accomplished with oral rehydration solution (ORS) or with the use of a number of prepared commercial solutions. Inappropriate liquids are Kool-Aid, fruit juices (e.g., apple juice), sports drinks, and sodas; gelatin should also be avoided. See Table 25-2 for recommendations regarding treatment of various degrees of dehydration.

2. Resume feedings. Both the AAP and the CDC recommend the resumption of feedings of an age-appropriate diet as soon as rehydration is complete. A relatively unrestricted diet reduces the stool output and the duration of the illness (King et al., 2003). For the infant, on-demand breastfeeding should be continued without disruption when a child has diarrhea. If the infant is receiving formula, feedings should continue unchanged as tolerated. In older children, full strength cow’s milk or other nonhuman milks are usually tolerated without problems. Use of probiotics or lactose-free formulas appear to be generally unnecessary (Salazar-Lindo, Miranda-Langschwager, Campos-Sanchez, Chea-Woo, & Sack, 2004), but in a study of Thai and Asian children with genetic lactase deficiency, acute diarrhea resolved more quickly with a lactose-free formula (Simakachorn, Tongpenyai, Tongtan, & Varavithya, 2004). Foods that have high levels of fat and simple sugars are less well tolerated than complex carbohydrates, lean meats, yogurt, fruits, and vegetables (King et al., 2003). Contrary to practices from years past, fasting or “letting the bowel rest,” and exclusive use of the BRAT diet (bananas, rice, applesauce, toast) or a diet of clear liquids (like apple juice) are unusually restrictive measures and provide suboptimal nutrition for the child. The child should not fast, and the foods in the BRAT diet can be included in a normal diet as tolerated, but should not be the dietary mainstay. Toddlers and older children should eat a wide variety of healthful foods, fruits, vegetables, grains, protein, and carbohydrates as tolerated. Smaller portions, given more frequently, may be better tolerated. High-carbohydrate (especially sugared drinks and sugary foods), high-fat, and spicy foods should be avoided. Boiled milk should never be given (AAP, 2008).

Table 25–2 Rehydration Therapy

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3. Prescribe appropriate antibiotics (only if an identified bacterial agent is the cause of the diarrhea) and other medications only if indicated. Do not prescribe diphenoxylate-atropine (Lomotil) because it slows intestinal motility, can contribute to paralytic ileus, and can complicate the clinical outcome if the diarrhea is due to antibiotic administration, pseudomembranous colitis, or an enterotoxin-producing bacteria. Repetitive or incorrect dosing of diphenoxylate-atropine has also been associated with mortality in toddlers (Thomas, Pauze, & Love, 2008). Avoid use of Pepto-Bismol because it can mask symptoms of nausea and upset stomach and may interact with prescription drugs, making diagnosis and resolution of the underlying problem more difficult. Also, the active ingredient in adult preparation Pepto-Bismol, bismuth subsalicylate, has been associated with toxicity in infants (Lewis, Badillo, Schaeffer, Hagemann, & McGoodwin, 2006); the active ingredient in children’s Pepto-Bismol is calcium carbonate, which can be used cautiously in older children.

4. Administer zinc. Some studies have shown the administration of zinc to children in developing countries with diarrhea decreases the duration of the illness (King et al., 2003; Strand et al., 2002).

5. Administer parenteral fluids if signs of severe dehydration are present or if the child is at high risk for rapid dehydration. See Table 25-2 for parenteral treatment of severe dehydration. Intravenous therapy may be administered in an urgent care center or emergency department, where the child can be carefully observed. Hospitalization may be required.

6. When giving a telephone consultation, always tell the child’s care provider when to follow up with the healthcare provider. They should also be advised to seek care if severe symptoms develop or if the child’s symptoms become worse or do not resolve in a projected length of time. Identify what signs and symptoms are worrisome and require evaluation. In addition, provide a specified time frame in which the child should show signs of improvement. Tell the child’s care provider to seek assistance in an emergency department on weekends or after the clinic or office is closed if necessary.

7. Follow up. Follow up with a telephone call to check on the child’s progress.

Sara’s mom asks what she can do about her being sick. You tell her that one of the most important measures she, Sara, and the other members of her family can do is simple handwashing with soap and water. Everyone needs to do this after using the bathroom and before eating any food. You recommend that she also check with the head of the daycare to see how they are cleaning the toys and equipment at the center. Proper cleaning of supplies and equipment will help keep all of the children healthy.

You tell her to make sure Sara continues to eat and drink as much as she is comfortable with. She shouldn’t give her juice, soda, or any sweetened drinks, and she should avoid fatty foods like chips, french fries, or ice cream; fried foods like chicken nuggets; or any sweets like candy or cookies. She may want to eat smaller portions, more frequently, rather than three meals a day. Her mother should try giving her foods like fresh fruits, cooked vegetables, cereal, bread, rice, pasta, yogurt, and some lean meats like chicken. The foods she has eaten today are the right ones and should help her recover quicker.

The diarrhea should stop in a day or so. If it continues for a total of 6 days, she should call you back because you will want to see Sara. She should also call back if her fever is higher than 101 degrees or if she is acting unusual, more “tired” or “weird.” If she seems worse, won’t eat or drink, or only voids once or twice a day, she should call right away so that you can see her as an urgent visit.

Sara’s mother asks how she can keep her from getting sick all the time. What will you tell her? image

You tell her that children Sara’s age often have minor illnesses, especially if they are around other children. Once she is back to her normal self, the best way to keep Sara healthy is to make sure she gets the rest she needs and that she eats a variety of healthy foods—fruits, vegetables, breads, grains, and protein like milk, cheese, yogurt, nuts, and meat. She doesn’t have to eat all of these every day, but she should provide her with good foods. Sara should avoid fried foods and fatty foods like french fries and chips, and avoid sugary drinks and soda. She should also limit the amount of juice Sara drinks to about 8 ounces a day. She should limit sweets too, but it’s fine if she has a cookie, ice cream, or sweet once every day or two. Finally, she should make sure Sara and everyone else in the family washes their hands often.

Key Points from This Case

1. History is essential for accurate diagnosis of gastroenteritis.

2. Viral enteritis is the most common cause of gastroenteritis in children.

3. Telephone consultation may be appropriate for the management of many cases of acute, self-limited gastroenteritis, but close follow-up is critical to assess outcome.

4. Risk factors for dehydration must be considered in making decisions about assessment and treatment.

5. Oral rehydration following diarrhea and vomiting promotes more rapid healing than parenteral therapy alone.

6. Parenteral therapy may be appropriate for children at high risk for dehydration and/or children with severe dehydration; resume oral rehydration as soon as possible.

7. A normal diet should be resumed as soon as possible after replacement fluids have been administered.

8. Handwashing and healthful diets are key factors in preventing gastroenteritis in children. Patient, parent, and community education should emphasize these factors.

REFERENCES

American Academy of Pediatrics. (2004). Statement of endorsement: managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. Pediatrics, 114(2), 507.

American Academy of Pediatrics. (2008). Diarrhea, vomiting, and water loss (dehydration). Retrieved December 12, 2008, from http://patiented.aap.org/AtoZIndex.aspx?letter=D

Amiriak, I., & Amiriak, B. (2006). Haemolytic uraemic syndrome: an overview. Nephrology, 11(3), 213–218.

Berkun, Y., Nir-Paz, R., Ami, A. B., Klar, A., Deutsch, E., & Hurvitz, H. (2008). Acute otitis media in the first two months of life: characteristics and diagnostic difficulties. Archives of Disease in Childhood, 93(8), 690–694.

Bhutta, Z. A., Nelson, E. A., Lee, W. S., Tarr, P. I., Zablah, R., Phua, K. B., et al. (2008). Recent advances and evidence gaps in persistent diarrhea. Journal of Pediatric Gastroenterology and Nutrition, 47(2), 260–265.

Bishop, W. P. (2006). The digestive system. In R. M. Kliegman, K. J. Marcdante, H. B. Jenson, & R. E. Behrman (Eds.), Nelson essentials of pediatrics (5th ed., pp. 579–624). Philadelphia: Elsevier Saunders.

Brook, I. (2005). Pseudomembranous colitis in children. Journal of Gastroenterology and Hepatology, 20(2), 182–186.

Colvin, J. M., Bachur, R., & Kharbanda, A. (2007). The presentation of appendicitis in preadolescent children. Pediatric Emergency Care, 23, 849–855.

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