Diarrhoea and vomiting Diarrhoea and vomiting caused by gastroenteritis

200 Pages·2009·3.19 MB·English

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Diarrhoea and vomiting
caused by gastroenteritis
diagnosis, assessment and management
in children younger than 5 years
National Collaborating Centre for Women’s
and Children’s Health
Commissioned by the National Institute
for Health and Clinical Excellence
April 2009
RCOG Press
Published by the RCOG Press at the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place,
Regent’s Park, London NW1 4RG
www.rcog.org.uk
Registered charity no. 213280
First published 2009
© 2009 National Collaborating Centre for Women’s and Children’s Health
No part of this publication may be reproduced, stored or transmitted in any form or by any means, without
the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance
with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries
concerning reproduction outside the terms stated here should be sent to the publisher at the UK address
printed on this page.
The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a
specific statement, that such names are exempt from the relevant laws and regulations and therefore for
general use.
While every effort has been made to ensure the accuracy of the information contained within this publication,
the publisher can give no guarantee for information about drug dosage and application thereof contained
in this book. In every individual case the respective user must check current indications and accuracy by
consulting other pharmaceutical literature and following the guidelines laid down by the manu facturers of
specific products and the relevant authorities in the country in which they are practising.
ISBN 978-1-906985-14-1
NCC-WCH Editor: Andrew Welsh
Original design: FiSH Books, London
Typesetting: Andrew Welsh
Proofreading: Katharine Timberlake (Reedmace Publishing Ltd)
Index: Jan Ross (Merrall-Ross (Wales) Ltd)
Contents
Guideline Development Group membership and acknowledgements v
Guideline Development Group v
Acknowledgements vi
Stakeholder organisations vi
Abbreviations viii
Glossary of terms ix
1 Scope and methodology 1
1.1 Introduction 1
1.2 Aim of the guideline 3
1.3 Areas within the scope of the guideline 3
1.4 Areas outside the scope of the guideline 4
1.5 For whom is the guideline intended 4
1.6 Who has developed the guideline? 5
1.7 Guideline development methodology 5
1.8 Schedule for updating the guideline 8
2 Summary of recommendations 9
2.1 Key priorities for implementation (key recommendations) 9
2.2 Summary of recommendations 11
2.3 Key priorities for research 17
2.4 Summary of research recommendations 19
2.5 Flow pathway for fluid management 19
3 Diagnosis 21
3.1 Clinical diagnosis 21
3.2 Laboratory investigations in diagnosis 27
4 Assessing dehydration and shock 38
4.1 Clinical assessment 38
4.2 Laboratory investigations for assessing dehydration 48
5 Fluid management 54
5.1 Primary prevention of dehydration 54
5.2 Treating dehydration 55
5.3 Optimal composition and administration of oral fluids 60
5.4 Intravenous fluid therapy (IVT) 66
5.5 Fluid management following rehydration 74
6 Nutritional management 76
6.1 Feeding during rehydration 76
6.2 Feeding following rehydration 78
7 Antibiotic therapy 90
7.1 Salmonella 90
7.2 Campylobacter 92
7.3 Yersinia 93
7.4 Shigella 94
7.5 Escherichia coli 95
7.6 Cryptosporidium 95
7.7 Treatment without prior identification of a pathogen 96
7.8 Traveller’s diarrhoea 98
7.9 Groups for whom antibiotic treatment may be indicated 99
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Diarrhoea and vomiting caused by gastroenteritis in children under 5 years
8 Other therapies 104
8.1 Anti-emetics 104
8.2 Antidiarrhoeal agents 109
8.3 Micronutrients and fibre 117
8.4 Alternative and complementary therapies 125
8.5 Probiotics 126
9 Escalation of care 134
10 Information and advice for parents and carers 137
10.1 Caring for a child with diarrhoea and vomiting at home 137
10.2 Preventing primary spread of diarrhoea and vomiting 138
Appendix A Cost-effectiveness of IVT versus ORT for children with dehydration 140
Appendix B Health economics of ondansetron 153
References 157
Index 163
Search strategies NICE website
Evidence tables NICE website
iv
Guideline Development
Group membership and
acknowledgements
Guideline Development Group
GDG members
Stephen Murphy GDG Chair, Senior Lecturer in Paediatrics and Child Health, Consultant
Paediatric Gastroenterologist
Ed Abrahamson Consultant in Paediatric Emergency Medicine
Richard Churchill General Practitioner and Clinical Associate Professor
Dianne Cook Children’s Community Specialist Practitioner
John Crimmins General Practitioner
Saul Faust Senior Lecturer in Paediatric Infectious Diseases/ Immunology
Alastair Hay General Practitioner
Naryndar Johal Parent/carer member
Julie Marriott Parent/carer member
Nigel Meadows Consultant Paediatric Gastroenterologist
Simon Minford Advanced Paediatric Nurse Practitioner
Robert Moy Senior Lecturer in Community Child Health
Enid Povey National Clinical Development Manager, NHS Direct
Gyanranjan Prasad Sinha Consultant Paediatrician
Jenny Taylor Advanced Paediatric Nurse Practitioner
National Collaborating Centre for Women’s and Children’s Health (NCC-WCH) staff
Monica Lakhanpaul Clinical Co-Director, NCC-WCH and Senior Lecturer, Child Health
Rajesh Khanna Senior Research Fellow
Shona Burman-Roy Research Fellow
Ana Palanca Research Fellow
Paul Jacklin Senior Health Economist
Itrat Iqbal Health Economist
Danielle Worster Information Scientist
Rosie Crossley Work Programme Coordinator
Angela Kraut Research Fellow
Sjokvist Garcia-Stewart Research Fellow
Alyson Huntley Freelance Researcher
External advisers
Craig Williams Consultant Microbiologist
Martin Richardson Consultant Paediatrician
Peer reviewer
Olivier Fontaine Medical Officer, Child and Adolescent Health and Development, World Health
Organization
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Diarrhoea and vomiting caused by gastroenteritis in children under 5 years
Acknowledgements
Additional support was received from:
• Eva Gautam-Aitken, Anna Bancsi, Martin Dougherty, Wendy Riches, Rupert Franklin and Chris Kitchen at
the NCC-WCH
• Caroline Keir at the National Institute for Health and Clinical Excellence (NICE)
• The Patient and Public Involvement Programme (PPIP) for NICE.
Stakeholder organisations
Abbott Laboratories Limited
Association for Continence Advice
Association of Medical Microbiologists
Association of Psychoanalytic Psychotherapy in the NHS
Association of the British Pharmaceuticals Industry (ABPI)
Barnsley Hospital NHS Foundation Trust
Barnsley PCT
Bedfordshire PCT
Berkshire Healthcare NHS Trust
Boehringer Ingelheim Ltd
Bolton Council
Bournemouth and Poole PCT
Bradford & Airedale PCT
Breastfeeding Network, The
British Dietetic Association
British Homeopathic Association
British National Formulary (BNF)
British Society of Paediatric Gastroenterology, Hepatology & Nutrition (BSPGHAN)
Buckinghamshire PCT
Calderdale PCT
Cardiff and Vale NHS Trust
Chelsea & Westminster Acute Trust
CIS’ters
College of Emergency Medicine
Commission for Social Care Inspection
Connecting for Health
ConvaTec
Cornwall & Isles of Scilly PCT
Department for Communities and Local Government
Department of Health
Department of Health, Social Security and Public Safety of Northern Ireland
Derbyshire Mental Health Services NHS Trust
General Chiropractic Council
General Osteopathic Council
GlaxoSmithKline UK
Good Hope Hospitals NHS Trust
Greater Manchester West Mental Health NHS Foundation Trust
Harrogate and District NHS Foundation Trust
Health and Safety Executive
Health Protection Agency
Healthcare Commission
Home Office
Infection Prevention Society
Institute of Biomedical Science
La Leche League GB
Leeds PCT
Liverpool PCT
Luton and Dunstable Hospital NHS Trust
vi
Guideline Development Group membership and acknowledgements
Meat & Livestock Commission
Medicines and Healthcare products Regulatory Agency (MHRA)
Medicines for Children Research Network (MCRN)
Mental Health Act Commission
Milton Keynes PCT
National Childbirth Trust
National Patient Safety Agency (NPSA)
National Pharmacy Association
National Public Health Service – Wales
National Treatment Agency for Substance Misuse
National Coordinating Centre for Health Technology Assessment (NCCHTA)
Neonatal & Paediatric Pharmacists Group (NPPG)
Newham University Hospital NHS Trust
NHS Clinical Knowledge Summaries Service (SCHIN)
NHS Direct
NHS Kirklees
NHS Plus
NHS Purchasing & Supply Agency
NHS Quality Improvement Scotland
Norgine
North Yorkshire and York PCT
Northwick Park and St Mark’s Hospitals NHS Trust
Nottingham University Hospitals NHS Trust
Phoenix Partnership
PERIGON Healthcare
Queen’s Medical Centre Nottingham University Hospitals NHS Trust
Royal College of General Practitioners
Royal College of Midwives
Royal College of Nursing
Royal College of Paediatrics and Child Health
Royal College of Pathologists
Royal College of Radiologists
Royal Liverpool Children’s NHS Trust
Royal Society of Medicine
SACAR
Sandwell PCT
Sanofi-Aventis
Sanofi Pasteur MSD
Scottish Intercollegiate Guidelines Network (SIGN)
Scottish Nutrition & Diet Resources Initiative
Sedgefield PCT
Sefton PCT
Sheffield PCT
Sheffield Teaching Hospitals NHS Foundation Trust
Social Care Institute for Excellence (SCIE)
South Central Ambulance Service NHS Trust
Staffordshire Ambulance HQ
University College London Hospitals (UCLH) Acute Trust
Welsh Assembly Government
Welsh Scientific Advisory Committee (WSAC)
Western Cheshire PCT
Western Health and Social Care Trust
Wiltshire PCT
Wirral Hospital Acute Trust
York NHS Foundation Trust
vviiii
Abbreviations
AROC area under receiver operating characteristic [curve]
BSS bismuth subsalicylate
BUN blood urea nitrogen
C. difficile Clostridium difficile
CI confidence interval
CRP C-reactive protein
CRT capillary refill time
DCRT digital capillary refill time
E. coli Escherichia coli
EL evidence level (level of evidence)
ELISA enzyme-linked immunosorbent assay
ESR erythrocyte sedimentation rate
ESPGHAN European Society for Paediatric Gastroenterology, Hepatology and Nutrition
GDG Guideline Development Group
HPA Health Protection Agency
HUS haemolytic uraemic syndrome
IM intramuscular
iu international unit
IV intravenous
IVT intravenous fluid therapy
LR likelihood ratio
NCC-WCH National Collaborating Centre for Women’s and Children’s Health
NHS National Health Service
NICE National Institute for Health and Clinical Excellence
NPSA National Patient Safety Agency
OR odds ratio
ORS oral rehydration salt
ORT oral rehydration therapy
PSA probabilistic sensitivity analysis
QALY quality-adjusted life year
RCT randomised controlled trial
RIV rapid intravenous hydration
RNG rapid nasogastric hydration
ROC receiver operating characteristic
RR relative risk
SD standard deviation
SMD standardised mean difference
UK United Kingdom
UNICEF United Nations Children’s Fund
USA United States of America
WHO World Health Organization
WMD weighted mean difference
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