Diarrhoea

If young baby — see acute assessment of unwell child

Most common complications of diarrhoea

• Dehydration — must rehydrate (replace fluids)
• Wrong balance of body chemistry (eg metabolic acidosis, low bicarbonate, low potassium)
• Lactose intolerance (gut not able to digest ‘milk-sugar’) 

Ask

• Diarrhoea — when did it start, how often, is it watery, is there blood or mucus
• Vomiting — when did it start, how often, green (bile), spurting across room (projectile)
• Drinking and eating
• What is child eating, drinking
• How much is child breastfeeding, drinking, eating
• Urine — how much urine, how many wet nappies
• Other sickness also present, contact with other sick people

Check

Assessing dehydration

• Best way to measure dehydration in children is to work out percentage of weight loss — weigh babies without clothes, small children should be weighed with minimal clothes
• Use a recent weight from child’s file notes to work out if they have lost weight — percentage of weight loss is about equal to the percentage of dehydration

• Working out percentage (%) weight loss
• % weight loss = % dehydration
• [Recent well weight – today's weight] ÷ [recent well weight] x 100
  
• Example: Weight last week was 13.5kg and weight now is 12.6kg
• (13.5 ‑ 12.6) ÷ 13.5 = 0.067, then x 100 (to make %) = 6.7%
• Child has moderate dehydration
• If recent weight not known do clinical assessment of dehydration — Table 3.23

Do — if severe dehydration

Medical emergency —Urgent medical consult

• Put in IV cannula
• If can’t get IV cannula in — put in intraosseous needle
• POC Test for electrolytes, if able
• Start IV OR Intraosseous fluids — Hartmann’s solution or normal saline
• If in shock — give 20mL/kg as a bolus
• If not in shock — give 20mL/kg/hour over 2–4 hours, depending on progress and medical advice
• Aim to correct dehydration over 4 hours
• OR Give nasogastric ORS 20mL/kg/hour over 2–4 hours depending on progress and medical advice, if can’t put in IV and child not in shock
• While waiting to send to hospital
• Check pulse, RR, capillary refill every 15 minutes
• Check BGL — if hypoglycaemia (low) may need to use rehydration solution containing glucose for maintenance
• Record amount of diarrhoea and vomiting
• Collect faeces and urine samples for pathology tests if possible

Additional reasons for medical consult

• Any of the following may mean there is another illness  
• Fever, shortness of breath, fast breathing or deep breathing
• Altered conscious state, convulsions, drowsy or unusually irritable, floppy
• Neck stiffness, bulging fontanelle
• Non-blanching rash (doesn't disappear when you press on it)
• Blood or mucus in faeces
• Bile (green) vomit
• No urine passed all day
• Severe or localised abdominal pain, swollen abdomen
• Baby with projectile vomiting (vomit spurting across room)
• It is late and you are not sure about managing child overnight

Do — if moderate dehydration

• Medical consult
• Give ORS using cup, spoon, syringe, bottle — Table 3.24
• Doses Table 3.25
• If 6 months or over and vomiting a lot — Medical consult to consider giving ondansetron wafer — doses — may help prevent need for IV rehydration
• Check progress every half hour. If not drinking ORS — use nasogastric tube
• Check at 4 hours
• How much ORS taken
• How much diarrhoea and vomiting has there been
• Weight, pulse, dehydration
• If better — weight gain, drinking well
• Send home with ORS to continue at home — 10mL/kg after every diarrhoea action. Check again in 12 hours
• If still dehydrated
• Medical consult
• Continue ORS or use IV rehydration, as for severe dehydration

Do — if mild dehydration

• Give extra fluids — Table 3.24
  
• Give ORS using a cup, spoon, syringe, bottle
• If child won’t drink ORS — give usual fluids, but not high in sugar
• Check within 12 hours OR within 6 hours if under 6 months old
  
• How much ORS have they taken
• How much diarrhoea and vomiting has there been
• Weight, pulse, dehydration
• If better — not dehydrated, weight gain, drinking well
• Send home with ORS to continue at home — 10mL/kg after every watery diarrhoea
• Review daily until diarrhoea stops
• If more dehydrated
• Treat as moderate dehydration
• Medical consult

Do — if no dehydration

• Offer extra fluids
• Continue breastfeeds (more than usual) or formula (every 3 hours)
• Continue feeding with good foods
• Give ORS 10mL/kg after every watery diarrhoea
• If child won’t drink ORS — give usual fluids, but not high in sugar
• If diarrhoea or vomiting continues — review next day

Good foods

• Rice, bread, cereals, potato, banana, yoghurt, fruit, vegetables

Do not give

• Sports drinks — may increase fluid loss
• Diet soft drinks
• Food or drinks high in fat or sugar (eg chocolate, lollies, coke, other soft drinks, undiluted fruit juice, tea, other very sweet drinks)
• Antidiarrhoeal (antimotility) medicines (eg loperamide)
• Antiemetics (anti-nausea medicine) — except ondansetron

Fluids for treating dehydration

Tips for giving ORS

• ORS prevents and treats dehydration — it doesn’t stop diarrhoea
• If child vomiting a lot — start with 5mL every 1–2 minutes
• Increase amount as child tolerates it
• If over 6 months — Medical consult to consider giving ondansetron wafer — doses. May help prevent need for IV rehydration
• Consider using nasogastric tube 
• Medical consult if vomiting not improving
• Use clock or timer so parent/carer can give ORS every 5 minutes
• Record how much ORS taken
• Give with spoon, cup, syringe, bottle (avoid bottle if breastfed)
• Mix ORS sachets with chilled water (makes it taste better)
• Try ORS ice blocks — but make sure same volume given

Special situations

• If child unwell with signs of sepsis — urgent medical consult, send to hospital
• Consider systemic Shigella or Salmonella infection, especially infants less than 12 months
• Give ceftriaxone IV/IM — child 50mg/kg/dose up to 2g — doses
  
• If blood and mucus in diarrhoea — may be caused by Shigella
• Send faeces for MC&S and OCP
• If fever, malnourished, unwell — medical consult
• If evidence of strongyloides infection — see Worms
• If several linked cases of diarrhoea (eg children in daily close contact with each other, from same school class) 
• Collect faeces samples for MC&S
• Notify PHU

Persistent diarrhoea

If diarrhoea for more than 7 days — treat as persistent diarrhoea. More common in malnourished children. May be caused by 

• Long-lasting or recurrent acute infections

• Parasitic infections like Giardia or Cryptosporidium
• Gut being unable to digest some parts of milk (lactose intolerance)

Ask

• How long diarrhoea has lasted

Check

• Weight (naked)
• Signs of dehydration
• Child’s growth on growth chart — is child growing well

Do

• If dehydrated
• Give ORS
• Medical consult — send to hospital
• If growth faltering — medical consult, may need to send to hospital
• Collect faeces for MC&S and OCP on 2 occasions
• Encourage good food
• If 6 months or over — elemental zinc oral — 20mg, once a day for 14 days
  
• This is 1.8mL if using 50mg/mL zinc sulfate (50mg/mL zinc sulfate = 11.3mg/mL elemental zinc)
• Treat for Giardia
• Give metronidazole oral — child 30mg/kg/dose up to 2g — doses — once a day for 3 days
• If allergy — medical consult

Follow-up

Check on child every 2–3 days

• Examine and weigh child
• Ask about diarrhoea
• If diarrhoea continues but child well — medical consult
• If diarrhoea continues and child unwell — medical consult about sending to hospital
• Check faeces results for worms — treat if present

Prevention

Tell parents and carers how to help prevent spread of infection causing diarrhoea

• Hand washing is most important. Use soap (liquid if available) and wash hands
• After using toilet or changing nappy
• Before getting meals ready or eating
• Do not share towels or clothing
• Children should not go to school or day-care while they have diarrhoea/vomiting and should wait 24 hours after last episode to return
• Children shouldn't use swimming pools until all symptoms have gone OR for 2 weeks if they have Cryptosporidium infection