WIREDGOV

The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Women’s and Children’s Health have today (22 April 2009) published a clinical guideline on assessing and managing diarrhoea and vomiting caused by gastroenteritis in children under the age of five. The guideline provides healthcare professionals with consistent advice on key issues such as fluid intake, nutritional management and preventing and managing dehydration. It also provides recommendations on advice to be given to parents and carers, and when care should be escalated – from home management through to hospital admission.

Between 10% and 20% (150,000 to 300,000) of children younger than 5 years in England present to healthcare services with symptoms of gastroenteritis each year. Most children get better quickly without treatment and can be looked after at home. However, severe diarrhoea and vomiting can lead to dehydration. This guideline will help healthcare professionals decide which children need further treatment so that they can be assessed by the right people at the right time.

The guideline recommends:
• In children with gastroenteritis but without clinical dehydration:
- continue breastfeeding and other milk feeds
- encourage fluid intake
- discourage the drinking of fruit juices and carbonated drinks
- offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration (e.g. Dioralyte).

• In children with clinical dehydration, including hypernatraemic dehydration:
- use low-osmolarity ORS solution for oral rehydration therapy
- give 50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid
- give 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
- monitor the response to oral rehydration therapy by regular clinical assessment.

• Use intravenous fluid therapy for clinical dehydration if:
- shock is suspected or confirmed
- a child with red flag symptoms shows clinical evidence of deterioration despite oral hydration therapy
- a child persistently vomits the ORS solution.

• If intravenous fluid therapy is required for rehydration:
- use an isotonic solution for both fluid deficit replacement and maintenance
- for those who required initial rapid intravenous fluid boluses for suspected or confirmed shock, add 100 ml/kg for fluid deficit replacement to maintenance fluid requirements, and monitor the clinical response
- for those who were not shocked at presentation, add 50ml/kg for fluid deficit replacement to maintenance fluid requirements and monitor the clinical response
- measure plasma sodium, potassium, urea, creatinine and glucose at the start, and monitor regularly
- consider intravenous potassium supplementation when the plasma potassium level is known

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

• Advise parents, carers and children that:
- washing hands with soap in warm running water and careful drying are the most important factors in preventing the spread of gastroenteritis
- hands should be washed after going to the toilet or changing nappies and before preparing, serving or eating food.

Dr Monica Lakhanpaul, Co-director National Collaborating Centre for Women’s and Children’s health and Consultant Paediatrician said: “This guideline will help all healthcare professionals to assess children with gastroenteritis and decide how sick a child is so that they can be followed up by the right people, at the right time and within the right healthcare setting. Gastroenteritis can usually be treated at home with varying levels of support and this guideline will ensure that parents are provided with good advice to help them manage the condition once they have seen a healthcare professional – for example, information on how to use oral hydration solutions to prevent dehydration early on. This guideline will save children’s lives.”

Dr Stephen Murphy, Consultant Paediatric Gastroenterologist and GDG Chair said: “This is an extremely important guideline for the many thousands of children who contract gastroenteritis each year, and their parents or carers. Most children can be looked after at home but if a child becomes dehydrated they may need to go to hospital. In this guideline we are calling for healthcare professionals to use oral rehydration solutions such as Diarolyte where possible rather than intravenous drips, which can be painful and unnecessary. Of course, where a child is at the more severe end of the spectrum and severely dehydrated, they will be most safely managed with a drip. We are also recommending that careful evaluation of the child is carried out to monitor them and ensure they are becoming rehydrated and well again.”

Dr Alastair Hay, Consultant Senior Lecturer, General Practitioner and GDG member said: “As a GP I commonly see children with gastroenteritis. It is a normal part of childhood and most of the time it is not due to a serious illness. Understandably however, it is a cause of anxiety and concern to parents and carers who have to make the difficult judgment of knowing if and when to seek medical advice. This guidance will help doctors and nurses to empower parents by giving them the information they need to optimise the care of their children. This includes advice on how long vomiting and diarrhoea is likely to last, the best fluids and foods to give as well as the warning signs of dehydration and when to seek further medical advice.”

Narynder Johal, Patient Representative and GDG member said: “As a parent to three children, I have often been very concerned when my children have had diarrhoea and vomiting and have not always received consistent advice on the how to best manage the condition. I am glad that this guideline enables parents and carers to work in partnership with healthcare professionals to look after their child. This guideline acknowledges that a parent or carer is often best at recognising when their child is ill and will ensure that our concerns are taken seriously by healthcare professionals. Often parents or carers will prefer to look after their children at home. The guideline will support them in doing this by ensuring that they are provided with advice and information if things change and this will be very reassuring.”

Simon Minford, Advanced Paediatric Nurse Practitioner and GDG member said: “Parents I speak to every day are concerned that they are receiving mixed messages about the treatment of gastroenteritis. For example, some parents I have spoken to have heard that they should give their child flat coke – when the evidence shows that this can make the problem far worse. I hope that this guideline will dispel the myths and give parents clear, evidence-based advice about what to do if their child has diarrhoea and vomiting. In this guideline we also give clear advice about how to prevent the spread of gastroenteritis by washing hands with liquid soap in clear running water and careful drying afterwards.” 

Notes for editors

1. The guidance is available at www.nice.org.uk/CG84 (from 22 April).

2. ‘Red flag’ symptoms are early warning symptoms of a condition worsening and suggest that the patient requires immediate medical attention

3. Hypernatraemic dehydration is rare but potentially fatal and occurs when babies fail to take in sufficient quantities of milk in the early days of life

About NICE

4. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

5. NICE produces guidance in three areas of health:
• public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector.
• health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS.
• clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS