GASTROENTERITIS (vomiting and diarrhea)
Vomiting is the forceful emptying ("throwing up") of a large portion of the stomach's contents through the mouth. In contrast, regurgitation is the effortless spitting up of one or two mouthfuls of stomach contents (which you may often see babies less than 1 year old do).
Diarrhea is the sudden increase in the frequency and looseness of bowel movements (BMs). Mild diarrhea is the passage of a few loose or mushy BMs. Severe diarrhea is the passage of many watery BMs. The best indicator of the severity of the diarrhea is its frequency. Green bowel movements are also a sign of severe diarrhea.
The main complication is the loss of too much body fluid. Symptoms of dehydration are a dry mouth, the absence of tears, infrequent urination (for example, none in 8 hours in an infant, 12 hours in a toddler), and a darker, concentrated urine. The main goal of gastroenteritis treatment is to prevent dehydration.
Vomiting and diarrhea are usually caused by a viral infection of the lining of the intestines (gastroenteritis). Diarrhea can also be caused by bacteria or parasites. Occasionally a food allergy or drinking too much fruit juice may cause diarrhea. If your child has just one or two loose bowel movements, the cause is probably something unusual your child ate. A diet of nothing but clear fluids for more than 2 days may cause green, watery bowel movements (called "starvation stools").
Gastroenteritis usually lasts several days to a week, regardless of the type of treatment. Don't expect a quick return to solid bowel movements. Note: One loose bowel movement can mean nothing. Don't start dietary changes until your child has had several loose bowel movements.
WHAT IS DEHYDRATION
Dehydration is a condition in which the body doesn't have enough water to function properly. Your child's body can lose a lot of water if he or she has diarrhea, is vomiting, or has been exercising for a long time without having anything to drink. If water is not adequately replaced in the body, complications can include decreased activity, weakness, electrolyte imbalances, and, in cases of extreme dehydration, death.
Infants and young children are at greatest risk for dehydration. Sick children may become dehydrated if they do not want to drink because their stomach hurts or if they are very weak.
With mild dehydration, children may:
* have sticky or dry mouths
* urinate less
* be thirstier than usual.
With more severe dehydration, children often:
* have decreased alertness
* have sunken eyes
* urinate much less if at all
* lose weight.
Dehydration can be a medical emergency. Call your doctor IMMEDIATELY because your child may need intravenous (IV) fluids at the hospital if:
* Your child's activity level is greatly decreased.
* Your child is difficult to arouse.
* Your child appears limp and weak.
* Your child doesn't seem to recognize you.
HOW CAN I HELP TAKE CARE OF MY CHILD?
Encourage your child to drink. Since dehydration, no matter what the cause, involves high loss of body water, the goal is to replace it. The method used to give your child fluid may depend on the type of illness causing the dehydration. For instance, the type and rate of fluid replacement in a child who is vomiting and has diarrhea is different from fluid replacement in a child who is dehydrated from sports activity.
Mild dehydration due to illness in infants under 6 months.
Encourage, but do not force, your child to drink. If you are not breast-feeding your child, give him or her special clear liquids with electrolytes, such as Pedialyte (in France, GES 45 or Adiaril are commonly found) for 4 hours; this is for re-hydration only, and should not be continued for 1-2 days as was formerly taught. If you are breast-feeding and your baby is urinating less often than normal, offer an electrolyte solution between breast- feedings for the first 6 to 24 hours.
If your child is vomiting, give frequent small amounts of breast milk or the electrolyte fluids rather than less frequent, larger amounts. Start with 1 teaspoon to 1 tablespoon of the clear fluid every 5 minutes for infants and toddlers. If you child is over 4, you may start with 1-2 ounces every 5-10 minutes. After 4 hours without vomiting, double the amount each hour. If your child vomits using this treatment, rest the stomach completely for 30 minutes, and then start over but with smaller amounts. This one-swallow-at-a-time approach rarely fails.
If your child is not vomiting or having diarrhea, you may give age-appropriate foods along with the breast milk or electrolyte liquids.
For most illnesses, start giving a bottle-fed baby full-strength formula again after 4 hours of the rehydration solution. If there has been diarrhea for 4-5 days, avoiding diary products for seven days (with the exception of yoghurt) is recommended (lactose-free milk, for example Diargal, is fine). It is also wise to avoid excessively sweet fluids and or fatty foods if there is prolonged diarrhea.
If your child has diarrhea only, keep giving table foods. The choice of food is important. Starchy foods are digested best. Examples of such foods are cereal (especially rice cereal), grains, bread, crackers, rice, noodles, mashed potatoes, carrots, applesauce and bananas. Pretzels or salty crackers can help meet your child's need for sodium. Lean meats, pasta and fruits are also recommended.
Mild dehydration due to illness in children over 6 months.
Encourage but do not force your child to drink. The best absorbed fruit juices are white grape and pear; apple is difficult to digest and increases the diarrhea. Clear soups, half-strength sports drinks, and Popsicles are also acceptable choices.
If your child is vomiting, he or she should drink small frequent amounts of liquid rather than large infrequent amounts. Should the above liquids not be tolerated, or should your child become more dehydrated, start to use the electrolyte fluids mentioned above. After a few hours of clear liquids, start giving your child liquids and foods with energy sources (sugar) and nutritional value. If your child has diarrhea alone, see above.
At any age, after 8 hours without vomiting, your child can gradually return to a normal diet. Older children can start with such foods as saltine crackers, white bread, bland soups like "chicken with stars," rice, and mashed potatoes. Infants can start with such foods as cereals and strained bananas. If your baby only takes formula, give 1 or 2 ounces less per feeding than usual. Usually your child can be back on a normal diet within 24 hours after recovery from vomiting.
WHAT ABOUT MEDICATIONS?
The US and European guidelines for management of gastroenteritis in children both state that anti-motility medications (loperamide, motilium) are prohibited, due to substantial side effects.
Two more recent medications, racecadotril (Tiorfan in France) and smectite (Smecta) have been gaining favor. Both guidelines suggest that, based on the few studies available, racecadotril can be used, with the caveat that more safety studies are needed in children.
Smectite is used largely in France, and the US guidelines do not address its use. The European guidelines state that it may be considered, however the studies are quite limited and more need to be performed.
Lactobacillus is a “pro-biotic” naturally occurring in yoghurt. Many studies show it diminishes the length of diarrhea by about half a day. In France, the best option is Danone’s Bio Activia. It can be also found in powder form.
MISTAKES TO AVOID
* Clear liquids should not be used alone for longer than 4-8 hours because they lack adequate calories. Your child needs normal, healthy foods to regain strength.
* Avoid highly concentrated solutions, such as boiled milk, and drinks with a lot of sugar such as colas and apple juice.
* A common error is to give as much fluid as your child wants rather than gradually increasing the amount. This almost always leads to continued vomiting.
* The most dangerous myth is that the intestine should be "put to rest."
There is no effective and safe drug for diarrhea or vomiting. Extra fluids and diet therapy work best.
Diarrhea is very contagious. Always wash your hands after changing diapers or using the toilet. This is crucial for keeping everyone in the family from getting diarrhea.
DIAPER RASH FROM DIARRHEA
The skin near your baby's anus can become irritated by the diarrhea. Wash the area near the anus after each bowel movement and then protect it with a thick layer of petroleum jelly or zinc ointment. This protection is especially needed during the night and during naps. Changing the diaper quickly after bowel movements also helps. If it worsens contact your physician.
CALL YOUR PHYSICIAN IMMEDIATELY IF:
* There are signs of dehydration (no urine in more than 8 hours, very dry mouth, no tears).
* Any blood appears in the diarrhea.
* The diarrhea is severe (more than 8 BMs in the last 8 hours).
* Your child starts acting very sick.
CALL YOUR PHYSICIAN DURING OFFICE HOURS IF:
* Mucus or pus appears in the BMs.
* Mild diarrhea lasts more than 2 weeks.