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CG84 Diarrhoea and Vomiting in Children Under 5

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CG84 Diarrhoea and Vomiting in Children Under 5 Diarrhoea and vomiting caused by gastroenteritis Diarrhoea and vomiting caused by gastroenteritis National Collaborating Centre for Women’s and Children’s Health Other NICE guidelines produced by the National Collaborating Centre for Women’s and Children’s Health include: • Antenatal care: routine care for the healthy pregnant woman • Fertility: assessment and treatment for people with fertility problems • Caesarean section • Type 1 diabetes: diagnosis and management of type 1 diabetes in children and young people • Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception • Urinary incontinence: the management of urinary incontinence in women • Heavy menstrual bleeding • Feverish illness in children: assessment and initial management in children younger than 5 years • Urinary tract infection in children: diagnosis, treatment and long-term management • Intrapartum care: care of healthy women and their babies during childbirth • Atopic eczema in children: management of atopic eczema in children from Diarrhoea and vomiting birth up to the age of 12 years • Surgical management of otitis media with effusion in children • Diabetes in pregnancy: management of diabetes and its commplications from preconception to the postnatal period caused by gastroenteritis • Induction of labour • Surgical site infection: prevention and treatment of surgical site infection Guidelines in production include: diagnosis, assessment and management • When to suspect child maltreatment • Hypertensive disorders in pregnancy • Neonatal jaundice in children younger than 5 years • Constipation in children • Bacterial meningitis and meningococcal septicaemia in children • Pregnant women with complex social factors • Autism in children and adolescents • Multiple pregnancy Enquiries regarding the above guidelines can be addressed to: National Collaborating Centre for Women’s and Children’s Health King’s Court Fourth Floor 2–16 Goodge Street London W1T 2QA [email protected] Clinical A version of this guideline for parents, carers and the public is available from the NICE website (www.nice.org.uk/CG84) or from NICE publications on 0845 003 7783; quote reference number N1845. Guideline April 2009 Published by the Royal College of Obstetricians and Gynaecologists. Clinical Guideline To purchase further copies and for a complete list of RCOG Press titles, RCOG April 2009 RCOG Press Press visit: www.rcogbookshop.com 2009 Funded to produce guidelines for the NHS by NICE Diarrhoea and vomiting caused by gastroenteritis diagnosis, assessment and management in children younger than 5 years National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Health and Clinical Excellence Evidence tables April 2009 RCOG Press Evidence tables should be read in conjunction with the full guideline. Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG www.rcog.org.uk Registered charity no. 213280 First published 2009 © 2009 National Collaborating Centre for Women’s and Children’s Health No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use. While every effort has been made to ensure the accuracy of the information contained within this publication, the publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check current indications and accuracy by consulting other pharmaceutical literature and following the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which they are practising. ISBN 978-1-906985-14-1 NCC-WCH editor: Andrew Welsh Original design: FiSH Books, London Typesetting of main guideline by Andrew Welsh Contents Abbreviations 4 3 Diagnosis 5 4 Assessing dehydration and shock 18 5 Fluid management 37 6 Nutritional management 49 7 Antibiotic therapy 71 7.1 Salmonella 71 7.2 Campylobacter 74 7.3 Yersinia 78 7.4 Shigella 80 7.6 Cryptosporidium 83 7.7 Treatment without prior identification of a pathogen 85 7.8 Traveller’s diarrhoea 90 7.9 Groups for whom antibiotic treatment may be indicated 92 7.9.1 E. coli O157:H7 92 7.9.2 Salmonella 97 8 Other therapies 100 8.1 Anti-emetics 100 8.2 Antidiarrhoeal agents 104 8.2.1 Adsorbent agents 104 8.2.1.1 Kaolin 104 8.2.1.2 Activated charcoal 105 8.2.1.3 Smectite 106 8.2.2 Antisecretory agents 108 8.2.2.1 Racecadotril 108 8.2.2.2 Bismuth subsalicylate 111 8.2.3 Antimotility agents 114 8.2.3.1 Loperamide 114 8.3 Micronutrients and fibre 116 8.3.1 Zinc 116 8.3.2 Vitamin A 121 8.3.3 Glutamine 123 8.3.4 Folic acid 124 8.3.5 Fibre 125 8.4 Alternative and complementary therapies 111 Homeopathy 127 8.5 Probiotics 129 Systematic reviews 129 Randomised controlled trials 136 References 142 Abbreviations AROC area under receiver operating characteristic [curve] BSS bismuth subsalicylate BUN blood urea nitrogen C. difficile Clostridium difficile CI confidence interval CRP C-reactive protein CRT capillary refill time DCRT digital capillary refill time E. coli Escherichia coli EL evidence level (level of evidence) ELISA enzyme-linked immunosorbent assay ESR erythrocyte sedimentation rate ESPGHAN European Society for Paediatric Gastroenterology, Hepatology and Nutrition GDG Guideline Development Group HPA Health Protection Agency HUS haemolytic uraemic syndrome IM intramuscular iu international unit IV intravenous IVT intravenous fluid therapy LR likelihood ratio NCC-WCH National Collaborating Centre for Women’s and Children’s Health NHS National Health Service NICE National Institute for Health and Clinical Excellence NPSA National Patient Safety Agency OR odds ratio ORS oral rehydration salt ORT oral rehydration therapy PSA probabilistic sensitivity analysis QALY quality-adjusted life year RCT randomised controlled trial RIV rapid intravenous hydration RNG rapid nasogastric hydration ROC receiver operating characteristic RR relative risk SD standard deviation SMD standardised mean difference UK United Kingdom UNICEF United Nations Children’s Fund USA United States of America WHO World Health Organization WMD weighted mean difference 4 3 Diagnosis Bibliographic Study type and Number of Patient Intervention and Follow-up and Effect size Study summary Reviewer comments information evidence level patients characteristics comparison outcome measures Khuffash FA; Sethi SK; Study Type: 595 children. 5 Children aged from Intervention: Clinical Follow-up period: Mean Duration Gastroenteritis due to rotavirus Shaltout AA; Cross-sectional children with under 1 year to 12 features of Clinical progress Frequency of clinical follows a benign course both in Aeromonas years gastroenteritis during hospitalisation the developing and developed characteristics by Rotavirus 4.8 days hydrophilia were and after discharge world 1988 44 Evidence level: 3 presence of aetiological pathogen excluded from the was recorded Salmonellae 12.3 days gastroenteritis Duration of comparison E. Coli 6.8 days hospitalised gastroenteritis by Although the overall number of because of the Kuwait aetiological agent Campylobacter 7.4 days small number. Outcome Measures: participants is large, some of Duration of diarrhoea Shigellae 7.9 days the groups have small numbers of children. Comparison: Rotavirus & Salmonella 12.9 days Comparisons of Rotavirus & others 7.4 days Because of the higher incidence of bacterial pathogens, the duration of diarrhoea No pathogen 5.6 days are made between cases seem to have longer children with Overall mean 7.4 days durations. gastroenteritis due to different aetiological Mortality 0.7% (all from salmonella agents group) Uhnoo I; Olding- Study Type: 416 children (228 Children below 15 Intervention: Clinical Clinical features of Rotavirus vs. Adenovirus vs. Clinical features of Stenkvist E; Kreuger A; Cross-sectional boys and 188 years of age with features of children in relation to Bacteria gastroenteritis with rotavirus, girls) acute gastroenteritis gastroenteritis enteropathogens enteric adenoviruses and who attended the detected in stool bacteria each exhibit patterns 1986 51 Evidence level: 3 Frequency of clinical features (%) Department of that could guide the Paediatrics. Comparison: experienced clinician to a Comparisons of Mean duration of Sweden Diarrhoea: 98 vs. 97 vs. 100 presumptive diagnosis symptoms and signs of diarrhoea (in days) in Mean age 24.9 rotavirus infections relation to pathogens Diarrhoea > 10 times daily: 21 vs. months with those of 22 vs. 36 Median age 15 adenovirus, bacterial, Vomiting: 87 vs. 78 vs. 43 months mixed and non-specific Vomiting > 5 times daily: 37 vs. 7 infections. vs. 9 Fever: 84 vs. 44 vs. 69 Abdominal pain: 18 vs. 25 vs. 50 Blood present in stools: 1 vs. 3 vs. 41 Mucus present in stools: 17 vs. 19 vs. 26 5 Diarrhoea and vomiting caused by gastroenteritis in children
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