Vomiting Child

Question 1

Describe gastroenteritis and key points

Answer 1

• GE is a very common cause of vomiting in children but vomiting is a non-specific symptom, so ask yourself - what else could it be?
• The mother is always right – if she is worried you should be too
• Initial management is always ABC DEFG
• Choose IV fluid & rate carefully, use 0.9% saline with 5% glucose and KCL 20mmol/l for rehydration
• If your diagnosis & management are right, the child should improve

Question 2

Definition for gastroenteritis?

Answer 2

A common acute communicable intestinal infection causing vomiting, fever and diarrhoea

Question 3

Definition of acute diarrhoea?

Answer 3

3 or more loose stools / 24 hours for < 14 days

Question 4

Describe epidemiology of rotavirus gastroenteritis?

Answer 4

• Each year, in children < 5 yrs in Australia
  
  • 115,000 visit GP
  • 22,000 go to ED
  • 10,000 admitted (3,700 in NSW)
  • 1 death (may be underestimate)
• Rotavirus was responsible for 50% of gastro admissions
• First infection age 3-36 months likely most severe
• Peak in mid to late winter
• Indigenous kids x 3-5 admission, ALOS 5 v 2 days

Question 5

Causes of gastroenteritis?

Answer 5

• Viruses (70%)
  
  • Rotavirus
  • Adenovirus
    
    • Epidemics, rash maybe prominent
  • Norovirus (Calicivirus)
    
    • Epidemics - camps, schools, child care Game of Thrones (Khaleesi-virus, get it?)
  • Others
    
    • Enteroviruses
    • Parechovirus
    • Astrovirus
• Bacteria (15%)
  
  • Campylobacter
  • Salmonella
  • E.coli
    
    • enteropathogenic, enterotoxigenic
  • Others
    
    • Shigella
    • S Typhi
    • Cholera
    • Yersinia (reputation for mimicking appendicitis)
• Parasites
  
  • Giardia
  • Cryptosporidium
  • Others: entamoeba

Question 6

Describe rotavirus (pathophys, transmission, complications).

Answer 6

• RNA virus (family Reoviridae)
  
  • many serotypes/genotypes
  • immunity not life-long
  • vaccine available free since July 2007
  • 80-100% of > 3 yo have antibodies
  • incubation 1-3 days → vomiting
  • temp > 39C in 1/3
• Faecal – oral transmission
  
  • minor resp spread (?important in hospital)
• • Small bowel damage
  
  • virus penetrates cells of small bowel
    
    • villus destruction
    • takes 5-7 days to reform
  • loose watery stools, full of rotavirus
    
    • nosocomial infection very common – profuse early vomiting

Question 7

Describe human parechovirus (presentation, complications, investigation, management)

Answer 7

• Can cause acute sepsis-like syndrome with fever >38C in infants <3months, followed by erythematous rash
• Presentation + acute sepsis-like syndrome + fever
  
  • Irritability and appearing to be in pain
  • Maculopapular or erythematous rash
  • Distended abdomen, diarrhoea
  • Tachycardia
  • Tachypnoea
  • Encephalitis
  • Myoclonic jerks
  • Hepatitis
• Complications
  
  • Volvulus
  • Intussusception
  • Bowel ischaemia
• Investigation: stool culture
• Management: supportive care

Question 8

Describe campylobacter (source, clinical presentation)

Answer 8

• wide variety animal hosts, incl chicken
• abdo pain maybe prominent
• maybe difficult to find in outside labs
• findings on laparotomy
  
  • ileum inflamed, oedematous
  • mesenteric adenitis

Question 9

Describe salmonella (source, pathophys)

Answer 9

• contaminated food, summer epidemics
• mucosal invasion, colitis prominent
• white cells in stool
• prolonged excretion of salmonella
  
  • age 3 months: 27% at 8/52, 8% at 6/12
  • older kids: 7% at 8/52, 2% at 6/12

Question 10

Describe diagnosis of gastroenteritis?

Answer 10

• Diagnosis of GE in children usually made on basis of history, examination and awareness of epidemiological information
• Investigations (blood, stool, urine, other) may be needed to rule out conditions other than GE, or to inform management decisions (degree of dehydration etc)

Question 11

Factors supporting cause of gastroenteritis: viral vs bacterial?

Answer 11

• Viral / Rotavirus
  
  • Presents in autumn/winter
  • Watery diarrhoea without blood
  • +/- vomiting
  • Low grade fever
  • Anorexia
  • 90% under 5 years
• Bacteria
  
  • Blood and mucus in stool
  • +/- vomiting
  • High fever
  • May have history of recent travel
  • May be food borne
  • Haemolytic uraemic syndrome - ARF, thrombocytopaenia, microangiopathic haemolytic anaemia

Question 12

Important aspects on history for the vomiting child?

Answer 12

• Vomiting - how frequent, bile, blood
• Stool output - number of stools, blood, mucous, watery
• Intake (compare to usual – is it at least 50%)
  
  • how much, type of fluid (e.g. water, juice, ORS)
• Urine output (compare to usual – is it at least 50%)
  
  • number of wet nappies
• Lethargy, drowsy, colour, abdo pain, rash, bruise
• Other changes
• Duration of illness
• Loss of weight (Blue Book – Personal Health Record)
• Other family members ill
• Previous illness (e.g. short gut)
• Family history (e.g. inflammatory bowel disease)
• NB: Age of child:highest risk in young infants

Question 13

Important aspects on examination for the vomiting child?

Answer 13

• Initial impression – “gestalt”
  
  • Stop. Take some time to look, listen, smell…
• Centiles
  
  • Is there a pre-existing growth problem? Use charts.
• Assess hydration
• System exam – Head to toe starting with GIT…

Question 14

Differentials for the vomiting child/gastroenteritis?

Answer 14

• Gastroenteritis: triad of fever, vomiting, diarrhoea
• Acute appendicitis
• Strangulated hernia
• Intussusception of other causes of bowel obstruction
• Urinary tract infection
• Meningitis and other types of sepsis
• Any cause of raised intracranial pressure
• Diabetic ketoacidosis
• Inborn errors of metabolism
• Inflammatory bowel disease
• Haemolytic uraemic syndrome

Question 15

What red flags are there with vomiting/when to consider another differential other than gastroenteritis?

Answer 15

• Blood in the stool or vomit
  
  • bloody stool: intussesception
  • bloody vomit: mallory weiss tear, sepsis
• Bile in vomit - bowel obstruction, intussusception, malrotation
• Vomiting but no diarrhoea - bowel obstruction, intussusception, malrotation
• Diarrhoea first, then vomiting - unusual, appendicitis, bowel obstruction
• Headache - raised ICP, meningitis, significant ear infection
• Very high fever (>39C) - other infectious causes
• Young child (esp < 3m) - other infectious causes
• Severe abdominal pain / distension - acute abdomen

Question 16

What investigations to consider with gastroenteritis/vomiting in children?

Answer 16

• In mild cases no blood or other tests are required
• In moderate to severe dehydration consider
  
  • Electrolytes, urea and creatinine, BGL
    
    • * EUC essential in any child having IV fluid
  • Full blood count
  • Stool micro, culture, virology
• If considering other aetiology
  
  • Urine micro & culture
  • Blood culture (if temp >38.5°C)
  • X-ray: AXR, CXR, ultrasound, air enea

Question 17

What is the initial management for vomiting in children/gastroenteritis?

Answer 17

• Initial management is always
  
  • A Airway
  • B Breathing
  • C Circulation
  • DEFG Don’t Ever Forget Glucose

Question 18

Describe the management algorithm for acute gastroenteritis in children

Answer 18

Question 19

Is there a benefit in having sodium and glucose in oral rehydration therapy?

Answer 19

• Yes. Effectiveness proven >30 years ago
• 1960s: intestinal water absorption mediated by active transport
  
  • sodium and glucose co-transported equi-molar ratio
  • ie when one molecule of glucose is absorbed, it takes a friend (Na)
  • – 2% - 4% glucose gives max absorption
• Co-transporter continues to function in cholera
• Does not reduce stool volume or duration of diarrhoea
• Children may continue to vomit, while having ORS

Question 20

Describe the composition of different oral rehydration solutions

Answer 20

Question 21

When to refer gastroenteritis for admission?

Answer 21

• Severe dehydration
• At risk of dehydration (age < 6mths, high frequency of watery stools or vomits, minimal oral intake, worsening symptoms)
• High risk of complications (diabetes, renal failure, poor nutrition)
• Diagnosis in doubt or surgical diagnosis considered
• Parent or carer unable to manage at home
• Unsuccessful at oral rehydration

Question 22

When do you reassess after initial management for gastroenteritis?

Answer 22

• It is expected that the child who is receiving rehydration therapy should continue to improve over the next 6 to 8 hours
• If not improving then think again or CONSULT
• If improving then COMMENCE ORAL INTAKE (ie early, with hunger)

Question 23

What are the advantages of early re-introduction of food?

Answer 23

• Early re-feeding associated with nutritional advantages
• Continue breast feeding throughout illness
• Enhance enterocyte regeneration
• Recovery of brush border membrane disaccharidases
• No advantage to re-grading feeds

Question 24

What do you NOT do with acute gastroenteritis to prevent it from becoming chronic?

Answer 24

• Restrict dietary intake
  
  • Delay feed reintroduction
  • Elimination diets
• Give high volume juices, cordials etc
  
  • Apple juice the worst culprit
• Use antibiotics
• Use antidiarrhoeals

Question 25

Is there any benefit with lactose free feeds in gastroenteritis?

Answer 25

Routine use of lactose-free feeds is not recommended. Use if reducing substances in stool and diarrhoea prolonged.

Question 26

Describe the rotavirus vaccine

Answer 26

• Rotarix (NSW, ACT)
  
  • No. of doses: 2
  • Ages: 2m, 4m
  • Vol/dose: 1mL
• Oral live attenuated vaccines
• Reduces risk of severe rotavirus GE by 85-100%, risk of any rotavirus GE by ~ 70%
• Sl increased risk of intussusception