POAC Paediatric Guideline
Diarrhoea and Vomiting caused by Gastroenteritis
EXCLUDE
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CAUTION
Child presents with
Diarrhoea and/or Vomiting
age <2 months
pre-existing conditions i.e.
diabetes, inflammatory bowel
disease, ileostomy/colostomy
acute surgical pathology i.e.
intussusception, obstructed
inguinal/femoral hernia-(see note 1)
No clinically detectable dehydration
Appears well
Alert and responsive
Normal urine output
Skin colour unchanged
Warm extremities
Eyes not sunken
Moist mucous membranes Normal
heart rate
Normal breathing pattern
Normal peripheral pulses
Normal capillary refill time
Normal skin turgor
Assess severity of illness
Clinical dehydration
Altered behaviour (eg irritable, lethargic)
Mildly decreased urine output
Skin colour unchanged
Warm extremities
Sunken eyes
Dry mucous membranes (except for ‘mouth breather')
Mild tachycardia
Mild tachypnoea
Normal peripheral pulses
Normal capillary refill time
Reduced skin turgor
Consider alternative diagnosis to gastroenteritis for:
• Abdominal pain for >24hrs
• Vomiting without diarrhoea
• Bile stained vomit- means bowel obstruction
until proven otherwise
• Bloody diarrhoea
• Signs of hypernatraemia (more lethargic than
expected from level of dehydration)
Clinical shock
Appears to be unwell or deteriorating
Decreased level of consciousness
Decreased or absent urine output
Pale or mottled skin
Cold extremities
No tears
Tachycardia
Tachypnoea
Weak peripheral pulses
Prolonged capillary refill time
Initiate POAC
Admit
Standard Primary Care
NOT ELIGIBLE FOR POAC
FUNDING
Discharge Home with advice sheet
If high risk for deterioration consider
review within 24 hours
Parents/carers should seek medical
review if :
Measure baseline weight
Rehydrate over 2-4 hours with Oral
Rehydration Solution (ORS) ...(Note 2)
• Consider Ondansetron
...(Note 3)
Note:
Vomiting is not a contraindication for ORS.
If a child vomits wait 5-10 minutes and restart
but more slowly
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Clinical review following ORS
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child appears more drowsy
than usual
there is any blood in the
diarrhoea or vomit that was
not there previously
parent/carer feels the child
is less well than when they
previously sought advise
Policy date: February 2013
Review date: August 2013
Review daily for up to 48 hours
Re weigh patient following rehydration
period
• If improving then discharge home with
advice sheet and daily review
• If worsening condition or not improving
discuss with on call paediatrician
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To
Hospital
NOTE:
If there are doubts
regarding the child’s
clinical state or social
situation then discuss
with Consultant
Paediatrician
DISCLAIMER: This management guideline has been prepared to provide general guidance with respect to a specific clinical condition. It should
be used only as an aid for clinical decision making and in conjunction with other information available. The material has been assembled by a
group of primary care practitioners and specialists in the field and adapted from the Starship Children’s Health Clinical Guideline.
POAC Paediatric Guideline
Diarrhoea and Vomiting caused by Gastroenteritis
Aim:
To enable the parent/carer to safely continue the patient care at home to reduce hospital referrals.
Note 1
Not all vomiting is gastroenteritis. Bile stained vomiting means bowel obstruction until proven
otherwise.
Surgical conditions that may present with vomiting include pyloric stenosis (typical age about 6
weeks), intussusceptions (typical age about 6-10 months), appendicitis or intestinal malrotation.
Non GI conditions that can potentially present with vomiting are: UTI, meningitis and pneumonia
Note 2
Oral Rehydration Therapy (ORT)
This is the treatment of choice for dehydration from gastroenteritis. It is safer and more effective than
IV therapy for all degrees of dehydration except shock.
Wherever possible continue breastfeeding or use expressed breast milk otherwise bubblegum
Pedialyte is the ORS of choice. This takes advantage of glucose/sodium co-transport mechanisms in
the small bowel.
Assuming not note 1, consider stat Oradispersible Ondansetron in children >12 months. Single dose
2mg (1/2 tab) in children<15kg, 4mg single dose in children >15kg.
Certain principles must be remembered:
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ORT is intensive. It depends on a lot of input from the child’s caregiver
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Fluid is given at a rate of 5ml per minute, by teaspoon or syringe. The small volumes decrease
the risk of vomiting. The rate (1 teaspoon/minute) is easy to calculate and administer for a
parent 25mls every 5 minutes can also be used.
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This rate of replacement is already maximal, and is not supplemented for ongoing losses. If
the child’s ongoing losses exceed an intake at this rate, the child will require nasogastric or IV
fluids and should therefore be referred to hospital.
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Hourly review is recommended
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Vomiting is not a contra-indication. Most children with gastroenteritis, who vomit, will still
absorb a significant percentage of any fluid given by mouth.
Policy date: February 2013
Review date: August 2013
POAC Paediatric Guideline
Diarrhoea and Vomiting caused by Gastroenteritis
ON CALL PAEDIATRICIAN CONTACT NUMBERS
Starship ....................................................................021 740 271
Kidz First (Middlemore) ............................................021 516 908
North Shore & Waitakere .........................................0800 244 533
POAC Funding Policy and Eligibility Criteria
It is expected that the initial assessment and management of the child with Gastroenteritis is standard primary
care and POAC is initiated when extended observation and treatment, (> 30 minutes) is required.
Please note it is POAC policy that full clinical documentation is required and must demonstrate clinical eligibility
(including initial assessment and observations undertaken throughout the episode of care).
DISCLAIMER
This management guideline has been prepared to provide general guidance with respect to a specific clinical condition. It should be
used only as an aid for clinical decision making and in conjunction with other information available.
This guideline has been developed by the POAC paediatric working group which includes the Clinical Directors from the 3 regional
DHB’s: Dr Mike Shepherd (Starship), Dr Adrian Trenholme (Kidz First, CMDHB) and Dr Tim Jelleyman (WDHB)
References:
Starship Children’s Health Clinical Guideline: Dr Raewyn Gavin / Gastroenteritis Pathway Team 2006
Childhood Gastroenteritis Guideline, Waitako DHB 2004
NICE Clinical Guideline 84: Diarrhoea and vomiting in children
Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years
Policy date: February 2013
Review date: August 2013
POAC Paediatric Guideline
Diarrhoea and Vomiting caused by Gastroenteritis
PARENT ADVICE SHEET
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Gastroenteritis (“gastro”) is a bowel infection causing diarrhoea and sometimes vomiting
Diarrhoea means runny, watery bowel motions (poo)
The diarrhoea can last up to 10 days and your child may have tummy pain or fever
Gastroenteritis is usually caused by a virus commonly called rotavirus
It affects all age groups, but is more common, and can be worse in babies and young children
The main concern is dehydration. Dehydration is the loss of fluid, due to vomiting and diarrhoea. Fluid
replacement should be given in small amounts, frequently
The younger the child, the easier it is for them to become dehydrated
Signs of dehydration include fewer wet nappies, weight loss, more tired and sleepy than usual,
sunken eyes, cold hands and feet and a dry mouth
When to seek further help
• Your child is unable to keep any fluids down or has a lot of diarrhoea (8-10 watery motions per day)
• There is any blood in the diarrhoea or vomit, or severe stomach pains occur
• Your child shows any signs of dehydration (as detailed in this sheet)
• If your child is younger than 6 months, has other health problems and is not getting better or
• If you are worried for any other reason
See your family Doctor, local Accident and Medical Clinic or Childrens Emergency Department for urgent
review
Gastro spreads very easily to others. You can help to reduce the chance of this by:
• Thorough hand washing- especially after using the toilet, changing nappies and before preparing
food. Encourage children to wash and dry their hands after using the toilet
• Thorough cleaning of toilet and bathroom areas
• Dirty soiled clothing should be washed-in hot water preferably and separately from the rest of the
family washing
• Avoid sharing food and drinks
• Keep your sick child away from friends and other children until vomiting and diarrhoea have stopped.
This includes day care, Kohanga Reo and School until the diarrhoea has stopped
MY INFORMATION
GP Phone (call if any problems): ____________________________________________________________________________
POAC Case Reference Number: ______________________________________________________________________________
Appointments: ______________________________________________________________________________________________
Policy date: February 2013
Review date: August 2013