Search This Blog

Saturday, July 13, 2013

Post #39 Vomiting and Diarrhea (Gastroenteritis) in Children: A Practical Guide

It certainly looks, sounds and smells awful, but vomiting and diarrhea are rarely dangerous.

Vomiting, not to be confused with spitting up, is the expulsion of food from the stomach.  Spitting up is more of a laundry problem than a medical problem, and kids who spit up do not become dehydrated.  

Diarrhea is a little harder to define, because watery stools are fairly common and most healthy individuals will experience it from time to time for reasons which do not qualify as diarrhea.

Frequent stools can be normal too, especially in breast-fed babies, who might dirty the diaper every time they feed, up to 12 times a day. It often looks watery and yellow with little remnants that look like seeds. Despite appearances, this is not diarrhea.

In general, diarrhea is a sudden increase in stool frequency, three to four times more often than usual. It has a general watery consistency, but frequency is the most important defining attribute.

No matter how copious the diarrhea, in developed countries it rarely leads to dehydration because it's easy to replenish lost fluids.

By far, the most common cause of vomiting is viral "gastroenteritis," a fancy medical term for an infection of the intestines that disrupts the normal digestive process.

While viral gastroenteritis can present with many symptoms, including headache, fever, decreased appetite, abdominal cramps and muscle aches, diarrhea and vomiting dominate. 

What to expect
In general, a child will vomit for one or two days, with three to six separate episodes of vomiting per day.  Diarrhea typically lasts much longer, from one to two weeks, with approximately six to 15 episodes per day.

Illness usually begins 12 hours to four days after exposure and lasts for three to seven days.

Viral gastroenteritis peaks in the winter; that's when 70 to 90 percent of cases are seen in the hospital.

Rotavirus Vaccine
There are many different viruses that cause various forms of gastroenteritis. Rotavirus is the most common virus and the most common cause of gastroenteritis overall.

A vaccine to combat rotavirus was introduced in 1998, but was pulled from the market in 1999 because the risk of developing a bowel obstruction was linked to the vaccine.

In 2006, two newer versions of the vaccine were introduced, RotaTeq and Rotarix. They have been proven to be safe and very effective in reducing hospitalizations, dehydration, emergency room visits, and most importantly, death.

Since the vaccine, the number of severe cases of gastroenteritis has significantly dropped and the majority of cases can now be handled at the pediatrician's office instead of the hospital.

Non-viral causes of gastroenteritis
A small percentage of gastroenteritis infections are caused by bacteria, the biggest sign of which is bloody diarrhea. 

Yet blood does not necessarily mean bacterial gastroenteritis.

With viral gastroenteritis, the skin of the anus or the lining of the intestine can become irritated and cause small amounts of bleeding.

However, if it appears the amount of blood is greater than 10 percent of the entire stool or bleeding recurs with several consecutive stools, your child needs to see the pediatrician promptly. A stool test can confirm diagnosis.

Bacterial gastroenteritis infections can become quite severe and require close monitoring, possibly in the hospital, and sometimes will benefit from antibiotic therapy.

Another cause of gastroenteritis, although infrequent, is parasites.

The most commonly seen parasitic cause of diarrhea and vomiting in the United States is Giardia Lamblia, which is most often picked up in a daycare setting. It is rarely dangerous and can be treated with antibiotics.

If your child has diarrhea that lasts longer than two weeks, a stool test will help get to the bottom of things.  Prior to the two week mark, a stool test is generally not needed.

Dangers of dehydration
Although vomiting and diarrhea can be exhausting for a parent, vomiting and diarrhea in and of themselves are not dangerous to a child.

The potential of dehydration is the greatest danger.  A simple way to understand dehydration is to think of your child's body as a box.  As long as fluids coming out of the box are replaced by fluids going into the box, your child will not become dehydrated. 

In a healthy child, fluids come out of the box through sweat, urine and stool.  During a bout of gastroenteritis, fluids will also escape via vomit and diarrhea. 

Usually, fluids can be replenished by having the child drink water and other drinks, but during a bout of gastroenteritis, it can be hard to stop those fluids from pouring back out.

When that happens, fluids can be given intravenously in the hospital. Fortunately, studies show this is rarely necessary and that oral rehydration usually works as good as an IV.

Parents might want to opt for colorless rehydration products. Anything red or purple masks more serious symptoms, such as blood in vomit or stool.

Test the waters before allowing your child to drink freely by following this simple plan:

  1. To allow stomach muscles to recuperate, do not give fluids for 30 minutes after vomiting.
  2. Give one teaspoon of Pedialyte (for children less than 1-year-old) or Gatorade (for children older than 1-year) every five minutes for 30 minutes.
  3. After 30 minutes of sipping every five minutes, wait 20-30 minutes without drinking fluids.  If they do not vomit you can allow them to begin drinking Pedialyte or Gatorade freely.
  4. If at any time they vomit again, repeat the above cycle, starting from the beginning.
  5. Advance quantity slowly as your child demonstrates tolerance to fluids.

If your child fails this cycle more than two times, call the pediatrician.

Road to recovery
If you allow a child who has vomited to drink or eat again too soon, it will likely come right back out because the stomach needs time to recover.

Just like muscles are sore and flaccid after a hard run, stomach and intestinal muscles are also weak after several bouts of vomiting.  This makes it difficult for the stomach and intestines to push food down as it normally would, a muscular process called peristalsis. 

As a result of the muscles being tired, food cannot progress naturally through the digestive system, so the body sends it back up again.

So, just like you would ease your leg muscles into walking after a hard run, the same must be done for a child who has been throwing up.

Refeeding advice
Most parents have heard of the BRAT diet – bananas, rice, applesauce, and toast. But the Centers for Disease Control, among other medical organizations, believe the diet is unnecessarily restrictive.

Once your child can tolerate approximately 12 ounces of fluid without vomiting, you can offer breads, pastas, crackers, soups, and bland foods such as baked chicken or baked potatoes without much seasoning or fat.  Some medical websites have a refeeding chart that is helpful, such as this one on our practice's website.

Lactose Intolerance
After a bout of gastroenteritis, some kids will experience temporary lactose intolerance.

Lactase, the enzyme that helps digest lactose (a sugar in milk), is secreted from the lining of the gut, which is stripped away when infection occurs. The lining will heal, but lactose intolerance can last a few days or even weeks or months.  It is generally short-lived.

If you notice your child is bloated or uncomfortable after eating or drinking dairy products, limit those foods, switch to lactose-free milk or try lactaid pills. The symptoms should eventually subside and your child can get back to drinking milk.

Diaper Rash
For little ones still in diapers, a bad bout of diarrhea is often accompanied by diaper rash. Even the best diaper-changing parent can't keep up with diarrhea and its potential irritation of the skin.

The rash is caused by bile acids in the stool, and although the irritation can be controlled, it probably won't improve until the diarrhea subsides.

To prevent diaper rash:

  1. Clean the bottom with a soft cloth and use gentle strokes to prevent further abrasion.
  2. Allow for adequate air-drying of the skin.  If pressed for time use a blow dryer on cool setting to dry the skin.
  3. After air-drying, apply a thick coating of a barrier cream such as Desitin, Vaseline, Vitamin A&D, etc.
  4. If the skin looks particularly irritated, a 10-minute soak in plain water without soap can help. Air-dry and apply a thick coating of diaper cream.

Occasionally, the skin becomes so broken down it becomes susceptible to bacterial and yeast infections.  If the diaper rash is progressively getting worse despite following the above advice, visit the pediatrician.

Most stomach viruses will run their course without any medications, but if your child is miserable, you can use Liquid Maalox Regular Strength Antacid Suspension to ease tummy pain.

Children 1-2yrs: 1/2 teaspoon, four times a day. Do not take more than 2 teaspoons in a 24 hour period.

Children 2-6yrs: 1 teaspoon, four times a day. Do not take more than 4 teaspoons in a 24 hour period.
Children >6yrs: 2 teaspoons, four times a day. Do not take more than 8 teaspoons in a 24 hour period.
Anti-vomiting medications, such as Zofran (generic name: Ondansetron) can be used if the oral rehydration cycle is failed twice.  Because of a small potential for side effects, it is best to use this medication as a back-up and not as the primary treatment modality.

A lot of parents ask about probiotics. Some reviews have demonstrated a benefit in reducing stool output and the duration of diarrhea.  However, the jury is still out as to how helpful they are, which ones work best, and how much exactly is needed.  

Further, there have been a few reported cases of harmful side effects.  It may be safer to use a yogurt with a high concentration of healthy bacteria until additional studies help steer recommendations on how to best utilize probiotics.

Antidiarrheal medications are almost never recommended.  If something bad is inside your intestines, it is best to let it come out.

Antibiotics are never needed for viral infections.  Even for the rarer bacterial causes of gastroenteritis, antibiotics are controversial.

Overall, try not to overreact when your child is vomiting or has diarrhea. As with most aspects of parenting and childhood, this too shall pass.


How do I know if it's a virus or something different such as food poisoning?
Food poisoning is typically short lived, lasting less than 24 hours. It's caused by a reaction to toxins generated by bacteria growing in food. The stomach will vomit up its contents until all of the toxins are expelled, after which there is a rapid recovery. Usually, a lack of diarrhea and the short burst of vomiting is what will differentiate food poisoning from a stomach virus. In most cases, treatment is not necessary.

Should I worry if I see blood in my child's vomit or stool?
More often than not, blood represents injury to the lining of the stomach, esophagus or gut. Like a knee abrasion, it will heal with time. In general, it's a good idea to touch base with the doctor if you see blood, but most cases are not dangerous.

Should vomiting or diarrhea hurt so much? My child often cries out in pain.
Vomiting and diarrhea can cause cramping and sore digestive muscles. Most pain will subside as the illness improves. Severe pain that seems to worsen in intensity and increase in frequency should be reported to a doctor.

Can I treat symptoms with OTC medications?
In general, medications are not needed as the virus will soon run its course. But use your judgment. A timely dose of anti-vomiting medication can keep the child from having to receive an IV or visit an ER, but most of the times adherence to an oral rehydration plan is all that is needed.

What if my child is desperately thirsty and asking for a drink soon after vomiting?
A small ice chip from time to time would be reasonable, but if that too is vomited, the stomach may need at least 30 minutes to rest.