winter ills - bpac.org.nz · emetics, such as guaifenesin, ammonium chloride, ipecacuanha and...
TRANSCRIPT
Bronchiolitis
Cough in children
Fever in children
Acute gastroenteritis in children
Acute asthma in children: are nebulisers or spacers best?
WINTERILLS
Key Advisers
Dr Marguerite Dalton
Dr David Reith
6I BPJIIssue5
BronchiolitisMostinfantspresentingwithwheezeinthefirstyearof lifehavebronchiolitis.Mostcasesofbronchiolitisoccur
between2and5monthsofage,inairwayswithverysmallcalibre.
Bronchiolitis isusuallycausedbyRespiratorySyncytialVirus,butcanalsobecausedbyrhinovirus,adenovirus,
influenzaandparainfluenzaviruses. Itstartswith2–3daysofcoryzalsymptomsandprogressestocoughand
wheezewithfeverandtachypnoea.
Wheezesandcracklesareusuallyheardthroughoutthechest.Focalchestsignssuggestalternativediagnoses
suchaspneumoniaoraspiration.
Infantswithbronchiolitisoftengetworseforthefirst72hoursoftheirillnessandthenstarttoimprove.Symptoms
maytakeseveralweekstoresolve,withamediandurationofapproximately12days.Childrenandparentsneed
supportduringthistime.
Bronchiolitishasa1–2%mortalityrateandinfantswithhypoxaemiarelatedtosmallairwaysobstructionmayneed
treatmentwithracemicepinephrineandsteroidsinadditiontooxygen,intravenousfluidsandnasogastricfeeding.
1.
Management of bronchiolitis is mostly supportive
Interventionssuchasbronchodilators,adrenaline,steroidsandantibioticshavenotbeenshowntobebeneficialin
uncomplicatedbronchiolitis.Managementissupportivebutmayincludetheneedforoxygen,nasogastricfeeding
orintravenousfluids.Primarycarecliniciansneedtoknowthefeaturesofmoderatetoseverebronchiolitissothat
theycanmanageitappropriatelybutalsosothattheycaneducatetheparentsofchildrenwithbronchiolitisabout
recognisingdeterioratingillness.
Assessment of severity
Table 1: Assessment of severity of bronchiolitis
WINTERILLS
Mild Moderate Severe
Respiratory ratebreaths/minute
Under2months>60/min>60/min >70/min
2–12months>50/min
Chest wall indrawing None/mild Moderate Severe
Nasal flare None/mild Present Present
Grunting Absent Absent Present
Feeding Normal
Lessthanusual
Frequentlystops
Quantity>1/2normal
Notinterested
Choking
Quantity<1/2normal
History of behaviour Normal Irritable Lethargic
Any criterion in the severe category designates the child as severely ill
BPJIIssue5I7
When to refer with acute bronchiolitis
Asageneralrule refer infants earlier rather than later:ifindoubt
getspecialistadvice.
Refer all infants immediately with; severe illness (see Table 1),
progressivedehydration,wherethereisclinicalconcernabouthypoxiaora
historyofapnoea.
Refer early
Iflessthan8-weeks-oldorifbirthwassignificantlypremature(<32
weeksgestation)
Iftherehasbeenapnoeaorsignificantcomorbidity(heartandlung
disorders,immune-compromise)
Ifillnessisgettingworseafter72hoursorhomecareisuncertain
Management of bronchiolitis at home
Mostinfantswithbronchiolitiscanbesafelymanagedathome.Supportive
carepluscarefulobservationforsignsofdeteriorationarethekeys.
Supportivecaremayinclude:
Keepingthechild’senvironmentsmokefree
Keepingthechildwellhydrated
Smallfrequentfeeds
Minimalhandling
Normalsalinenasaldropsbeforefeeds
Caregiverhandwashingtopreventspreadtootherchildren
Written instructions will help caregivers to keep an eye on
feeding patterns and behaviour and to monitor for:
Respiratoryrate
Indrawing
Grunting
Nasalflare
Sleepiness
Colour
Infantswithamoderateepisodeofbronchiolitisneedtobereviewedwithin
24hoursandafirmappointment(time,place,person)helpstoensurethe
child is seen. (For an example of written instructions for caregivers see
page 23)
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Recognising severe illness in children
Behaviourandfeedingbothgo
frominterestedinfant,toinfantnot
interested
Respiratory rate
Anewbornmaybreatheupto
60breaths/min
A1-year-old:40breaths/min
A5-year-old:30breaths/min
Iftherateishigh,lookforpotential
respiratoryfailureusing2keysigns
effort,and
effectivenessofeffort
Increased effortisindicatedby
sounds
Stridorinupperairway
obstruction
Wheezeorgruntinginlower
airwaysobstruction
Accessorymuscleuseproducing
nasalflare,heavingchest,
intercostalandsubcostal
indrawing
Effectiveness of effortisindicated
bylookingatthechestmovementand
listeningtobreathsoundstojudge
ventilation:
Asilentchest
Fallingheartrate
Fallinglevelofconsciousness
Fallingrespiratoryrateinsevere
illness
areallpreterminalevents.
During respiratory failure, skin
colour changes from pink to pale, to
mottled.
Pale colour indicates vasoconstriction
and mottled indicates terminal
circulatory collapse.
Reference: Bone J. Recognising the very ill child
NZ Doctor 14 Mar 2007.
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Cough in children2.
Coughinchildrenhasdifferentcausestocoughinadultsandsymptomatictreatmentisrarelyneededor
effective.1Thesmallerairwaysarevulnerabletoinflammatorydiseasecausingswellingandobstructionby
mucoussecretions.Coughingassistsclearanceofmucous,sodonotattemptcoughsuppression.
It is reasonable to categorise childhood cough as:
Acutecough–lastinglessthantwoweeks
Persistentcough–lastingtwotofourweeks
Chroniccough–lastingoverfourweeks
Acute cough
Acute cough is usually viral
Mostacutecoughinchildrenisassociatedwithviralupperrespiratorytractinfections(URTI).Themajority
ofthese(70–80%)willresolvewithinoneweekalthough5%willpersistformorethanfourweeks.
Noover-the-counterorprescriptionmedicinesareeffective for thesymptomatic reliefofacutecough
inchildrenbut theredoesappear tobeasignificantplaceboeffect.Over-the-countercoughandcold
medicinesareasignificantcauseofmorbidity,especiallyfromaccidentaloverdose.
Itfollowsthatweshouldlookforsomethingsoothingandsafeforchildrenwithacutecough.Honeyand
lemondrinkshavestoodthetestoftimeandcanbemadeathomeatlittlecost.However,watershould
notbeboiled,firstlybecausechildrenarenotusuallyusedtohotdrinksandsecondlybecausethereis
riskofscalding.
Aspiration may be missed
Characteristicsofanacutecoughmayraisesuspicionofspecificcausessuchasthebarkingcoughof
crouportheparoxysmalcoughofpertussis.Whentherearenosymptomsofaviral infection,careful
considerationneedstobegiventoanaspirationepisode,particularlyinyoungerchildren.Aspirationmost
oftenoccurswhenanoldersiblinghasfedayoungchildunsuitablefood.
Cough soon after birth is cause for concern
Coughthatbeginsat,orwithinafewweeksofbirthalwaysraisesconcern.Congenitalcausesinclude
tracheomalacia,tracheo-oesophagealfistulaorlaryngealcleft.Coughstartingwithinafewweeksofbirth
raises theadditionalpossibilitiesofsuppurative lungdisease,aspiration,gastro-oesophageal refluxor
infectionwithchlamydia trachomatis.Coughinaneonateoftenwarrantsdiscussionwithapaediatrician.
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Chronic cough
Cough continuing beyond four weeks needs careful evaluation
Althoughanon-specificpost-viralcoughisstillthemostlikelydiagnosis,childrenwhocontinuetocoughbeyondfour
weeksneedevaluationtoexcludemorespecificcauses.Evaluationofasignificantongoingcoughincludeshistoryand
physicalexaminationwithconsiderationoftheneedforchestx-rayand,ifthechildisoldenough,spirometry.
Passiveoractivesmokingisacommoncauseofcoughinchildren.Fiftypercentofchildrenovertheageoftwoyears,
withatleasttwofamilymemberswhosmoke,havecough.
SomespecificcausessuggestedbythehistoryandexaminationaredescribedinTable2:
Table 2: Specific causes of chronic cough suggested by the history and examination
Chronic cough Specific cause of cough
Accompanying wheeze Asthmaoraspiration
Stridor Tracheomalacia,foreignbody
Moist cough, clubbing or Failure to ThriveSuppurativelungdisease,cyanoticheartdisease,cysticfibrosis,
immuneorciliarydisorders
Aspiration episodes or swallowing
difficultiesForeignbodyoraspiration
Paroxysmal cough or family members with
persistent coughPertussis
Honking cough absent during sleep Psychogenicorhabitcough
Staccato cough with or without
conjunctivitisChlamydia
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Cough from post-nasal drip, gastro-oesophageal reflux and
‘cough variant asthma’ are unusual in children
Studiesshowthatpost-nasaldripisunlikelytocausecoughinchildrenandthecoughismore
likely toberelatedtocoexistent lowerairwaypathology.Theuseofmedicationsto ‘dryup’
nasalsecretionsisthereforeunlikelytohelpthecough.
Gastro-oesophagealrefluxhasbeensuggestedasacommoncauseofcoughinadultsbutthere
isnoconvincingevidencethatitisacommoncauseofcoughinchildren.
Somechildrenwith isolatedpersistentcoughwithoutwheeze receiveadiagnosisof ‘cough
variantasthma’.Howeverthereisnoevidencethatthisisreallyaformofasthma.Fewchildren
withisolatedchroniccoughhaveeosinophilicinflammation,atopyorairwayhyperresponsiveness
andtheydonotrespondtobronchodilatorsorcorticosteroids.
Cough may be the predominant feature of asthma but is usually accompanied by wheeze.
Isolated chronic cough with no apparent underlying cause is more likely to be related to a
hypersensitivecoughreflex.
Treatment of chronic cough targets the cause not the symptoms
Symptomatic treatment of chronic cough is usually not effective or appropriate. It is the
underlyingcause,whichshouldbethetargetoftherapy.
Antihistaminesareproventohavenobenefitinchroniccoughandareassociatedwithhigh
levelsofsideeffects
Coughsuppressantssuchasdextromethorphan,pholcodineandcodeinearecontraindicated
inchildren
Mentholinhalationsarenoteffectiveandareassociatedwithriskofscaldinginjuriesfrom
boilingwater
Thereisnoevidenceforeffectivenessofherbalremedies
Emetics,suchasguaifenesin,ammoniumchloride,ipecacuanhaandsquill,areusedinlow
dosesasexpectorantsbutarenoteffective
Nevertheless, the significant placebo effect of coughmedicinesmay convince parents that
oneisneeded.Asimplesoothingdemulcent,withingredientssuchashoneyandlemon,syrup
orglycerol,mayhelpreducecoughingandirritation.Itisbesttoavoidthosewithhighsugar
content.Lozengesareassociatedwithriskofchokingforchildren,especiallythoseunderthe
ageofthreeyears.
Allchildrenwithcoughwillbenefitfromasmokefreeenvironment.
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Fever in children3.
Stratification of risk for serious pathology clarifies management decisions
Risk stratification for children with fever
Practitionerswillalwayswanttoconductacarefulsearchforafocusofinfectionforanychildwithafever
andthiscanbecombinedwithassessingtheriskofseriouspathology.Urinalysisofacleancatchurine
sampleisanessentialpartofthisassessmentwhennoobviouscausesareapparent.
Search for a cause
Manage the symptoms
Feverisanappropriateresponsetoinfectionandhassomebeneficialeffects.Forexample,fevercanmake
theenvironmentlessfavourableformicroorganismstomultiplyandcertainpartsoftheimmunesystemwork
betteratslightlyhighertemperatures.However,sustainedhightemperatureaddstoinsensiblefluidlossand
riskofprogressivedehydration.
Febrileconvulsionsoccurin3–4%ofchildrenwithfever.Althoughtheyareassociatedwithfever,theyarenot
preventedbyantipyreticmedicationssuchasparacetamol.Febrileconvulsions,iftheydooccur,areusually
briskandnotlikelytocausebraindamageorlearningdisabilities.Complexfebrileseizurescanoccurand
maybeprolonged.Ifprolonged(>15minutes)theyshouldbetreatedwithrectaldiazepam.
Antipyreticmedicationsalongwithphysicalinterventions,suchascooldrinksandreducingexcessivelayers
ofclothing,canbeappropriatetomanagediscomfortwhichmaybeassociatedwithfever.
Measuring the temperature of children under five years
√Electronicthermometerinaxilla
√Chemicaldotthermometerinaxilla
√Infra-redtympanicthermometer
XOralthermometer
XRectalthermometer
XForeheadcrystalthermometer
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Table 3: High risk of serious pathology
Depending on the findings and circumstances, one or
more of the following may be appropriate:
Referralforurgentpaediatricassessment
Telephoneconsultationwithapaediatricspecialist
Firmarrangements,time/place/person,madeforafurtherreview
Writtenandverbalinstructionsonwarningsymptomsthat
mayoccurandhowtorespondtothem
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Table 4: Intermediate risk for serious pathology
Any of the above features place a child in a high-
risk category for serious pathology.
The child needs immediate admission to hospital.
In the absence of high-risk features, any of the above
features places a child at intermediate risk of serious
pathology.
Intermediate risk features
Colour Normal
Activity
Notrespondingnormallytosocialcues
Wakesonlywithprolongedstimulation
Decreasedactivity
Nosmile
Respirations
Nasalflaring:ageover12months
Age0–2months,RR>60breaths/min
Age2–12months,RR>50breaths/min
Age>12months,RR>40breaths/min
Crepitations
Hydration
Drymucousmembrane
Poorfeedingininfants
Reducedurineoutput
Other Feverfor>5days
High risk features
Colour Pale,mottled,ashenorblue
Activity
Weak,high-pitchedcontinuouscry
Diminishedlevelofconsciousness
Appearsill
Unabletorouseorifrouseddoesnotstayawake
Respirations
Grunting
RR>70breaths/min
Moderatetoseverechestindrawing
HydrationReducedskinturgor
Capillaryrefilltime>3secs
Other
Nonblanchingrash
Bulgingfontanelle
Neckstiffness
Focalneurologicalsigns
Focalseizure
Bilestainedvomiting
Swellingoflimborjoint,non-weightbearing,notusinganextremity
High temperaturesneedtobe
interpretedwithregardtoothersigns
andsymptoms,howeverT>39ºC
shouldberegardedasahighrisk
feature
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Table 6: Features of some of the serious causes of fever in children
Diagnosis to be considered Signs in conjunction with fever
Meningococcal disease
NonblanchingrashPLUSoneof:
Anilllookingchild,petechiaeorpurpura,capillaryrefilltime>3secs,meningism
Meningitis
Neckstiffness,bulgingfontanelle,decreasedlevelofconsciousness,limpness(NBNeckstiffnessandbulgingfontanellearerelativelyinsensitivesignsofmeningitis)
Herpes simplex encephalitisFocalneurologicalsigns,focalorgeneralisedseizures,decreasedlevelofconsciousness
PneumoniaIfwheezeispresentthediagnosisofpneumoniaislesslikely
Tachypnoea:Age0–2months,RR>60breaths/min
Age2–12months,RR>50breaths/min
Age>12months,RR>40breaths/min
Crepitations,nasalflaringunder12months,chestindrawing,cyanosis
Urinary tract infectionVomiting,poorfeeding,lethargy,irritability,abdominalpainortenderness,dysuriaorincreasedfrequency,offensiveurineorhaematuria
Septic arthritis Swellingofalimborjoint,notusinganextremity,non-weightbearing
Kawasaki disease(veryrare)
Fever>5daysWITHatleastfour ofthefollowing:
Rash,conjunctivitis,lymphadenopathy,crackedlips,skinpeeling
Be alert for signs of septicemia, i.e.significantfever(>38°C)PLUSlethargy(notinterested,notfeeding)and/or
significantdehydration(drymucousmembranes,poorurineoutput,capillaryreturn>2secs)and/orfastrespiratory
ratewithincreasedeffortandsignsofpooreffectivenessofeffort.
Ifachildbecomesrapidlyillorisparticularlyill,witharash,consider and exclude meningococcal disease.The
rashmaypresentasamorbilliformorsubtlepetechialrashbeforeprogressingtoapurpuricrash.
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Acute gastroenteritis in children4.
Presentation of gastroenteritis may suggest cause
Viral infections cause most gastroenteritis in
childreninNewZealand.Theyusuallyproducelow-
gradefeverandwaterydiarrhoea,withoutblood.
Rotavirus,themostfrequentviralpathogen,tends
tobeseasonal,with latewinterpeaks,andmost
frequentlyaffectschildrenbetween6monthsand
2yearsofage.Mostchildrenwillcomeincontact
with the virus and, as immunity is long lasting,
infectionisuncommoninadults.
Norovirusaffectsallages,as immunitydoesnot
lastlong.Infectiontendstooccurasoutbreaksin
institutionssuchaspreschools,childcarecentres,
hospitalsandresthomes.
Bacterialinfectionsaremorelikelytobeassociated
withhigherfeversandbloodormucusinthestool.
Theymayalsobeassociatedwithabdominalpain
orsystemiceffects,fromspreadofthebacterial
pathogensthemselvesorassociatedtoxins.
Viral infections are usually transmitted by the
faecal-oral route or by respiratory droplets
but they can linger on contaminated surfaces.
Bacterial infections are often acquired by the
ingestionofcontaminatedfoodordrinkwhichhas
not beenproperly cooked, storedor processed.
Chicken, beef, pork, seafood, ice cream and
reheatedriceareallfrequentsourcesofbacterial
gastroenteritis.
Watermaybecontaminatedwithviruses,bacteria
orprotozoa.
Most Gastroenteritis in children is viral
Therearemanycausesofacutegastroenteritisinchildren(Table
7)2butthemajorityarecausedbyrotavirusornorovirus.
Pathogens causing acute gastroenteritis in children
Viruses–approximately70%
Rotaviruses
Noroviruses
Entericadenoviruses
Caliciviruses
Astroviruses
Enteroviruses
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Bacteria–10to20%
Campylobacter jejuni
Non-typhoidSalmonellaspp.
EnteropathogenicE. coli
Shigella spp.
Yersinia enterocolitica
ShigatoxinproducingE. coli
Salmonella typhi andS. paratyphi
Vibrio cholerae
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Protozoa–lessthan10%
Cryptosporidium
Giardia lamblia
Entamoeba histolytica
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Helminths
Strongyloidesstercoralis-
Table 7: Causes of acute gastroenteritis in children
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Management involves considering four important questions
1. Is the child shocked?
Featuresofshockinachildmayinclude:
Limpness
Drowsyorcomatose
Rapid,threadypulse
Cold,blueperipheries
Hypotension
Anuria
Skin retraction and capillary refill are less
reliablesigns.
Shockisanemergencyandthechildwillneed
immediatehospitalisation.Considertheneed
forintravenousorintraosseousaccessifthere
willbeanydelayingettinghospitalcare.
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Thefollowingfour-stepapproachtothemanagementofgastroenteritisinchildrenisbasedonrecommendationsfrom
StarshipHospital3butadaptedforuseinprimarycare.
Is the child shocked?
Is it really viral gastroenteritis?
Is the child dehydrated?
Can the child be managed safely at home?
1.
2.
3.
4.
2. Is it really viral gastroenteritis?
The differential diagnosis of viral gastroenteritis is not always
easy.Sometimes in themiddleofanepidemic thediagnosiscan
bemistakenlyapplied toachildwhohasanothercause for their
symptoms.Itisworthremembering:
• Notallvomitingisgastroenteritis
• Notalldiarrhoeaisgastroenteritis
• Notallgastroenteritisisviral
Not all vomiting is gastroenteritis
Vomitingmayprecedediarrhoeainrotavirus,butisolatedvomiting
always raises suspicion of another cause. Bile stained vomiting
meansbowelobstructionuntilprovenotherwise.
Surgical conditions that may present with vomiting include:
Pyloricstenosis(typicalageabout6weeks)
Intussusception(typicalageabout6–10months)
Appendicitis
Intestinalobstruction
Other possible causes include:
Infectionssuchasurinarytractinfection,otitismedia,
pneumonia
Metabolicdiseasesuchasdiabeticketoacidosisandinborn
errorsofmetabolism
Headinjury
Poisoning
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Foradetailedexplanationofthetechnique,
equipment,indicationsetcrequiredfor
intraosseous infusionvisitthefollowing
website:http://snipurl.com/1hr9v
Intraosseous infusion
16I BPJIIssue5
Not all diarrhoea is gastroenteritis
Othercausesfordiarrhoeaneedtobe
considered.Theseinclude:
Antibioticsorothermedications
Spuriousdiarrhoeasecondaryto
constipation
Firsttimepresentationsofchronic
diarrhoea,suchascoeliacdisease
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Suspicionofbacterialgastroenteritisisanindicationforstoolculture.Campylobacter isthemostcommonformof
bacterialgastroenteritis.Antibioticsarenotindicatedforcampylobactergastroenteritisunlessthechildissystemically
unwell,astheymayprolongthediarrhoeaorcarriageoftheorganism.
Ifthechildissystemicallyunwell,erythromycinmaybeconsidered.
Not all gastroenteritis is viral
Bacterialgastroenteritishashighercomplicationratesandworse
outcomesthanviralgastroenteritis.Factorsthatmayraisesuspicion
ofbacterialgastroenteritisinclude:
Bloodormucousinthestool
Higherfevers
Systemictoxicity
Abdominalpain
Associationwithoutbreaklinkedtocontaminatedfoodsource
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3. Is the child dehydrated?
Documentedrecentweight loss isagood indicationof the levelofdehydrationbut thesemeasuresareoftennot
available.Unfortunately clinical estimatesarenot veryaccurateand thecategoriesofdehydration,whichcanbe
definedbythem,areverybroad.
4. Can the child be managed safely at home?
Children over 6 months with viral gastroenteritis of less than 24 hours duration, low-grade fever, mild levels of
dehydration,noabdominalpainandminimalsystemicsymptomscanusuallybemanagedsafelyathome.Thedecision
isoftenadifficultclinical judgementandwillbestrongly influencedbyhomecircumstancesandability toprovide
regularmedicalfollowup.
Table 8: Signs of dehydration in a child
Clinical signs of dehydration Pinch test
No dehydration Nosigns Skinfoldretractsimmediately
Dehydration
Twoormoreof:
Restlessnessorirritability
Sunkeneyes
Thirst
Deepacidoticbreathing
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Slowretractionofskinfold
–visibleforlessthan2seconds
Severe dehydration with
or without shock
Twoormoreof:
Abnormallysleepyorlethargic
Sunkeneyes
Drinkingpoorly
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Veryslowretractionofskinfold
–visibleforover2seconds
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Oral rehydration is safe and effective for most children
Oral rehydration therapy for dehydration from gastroenteritis is safer and more effective than
intravenoustherapyforalldegreesofdehydrationother thanshock.However it requiresa lotof
inputfromthechild’scaregiver.
Vomitingisnotacontraindicationtooralhydration.Mostchildrenwithgastroenteritiswhovomit,will
stillabsorbasignificantpercentageofanyfluidgivenbymouthornasogastrictube.
Fluid replacement occurs in two phases: rehydration and
maintenance
Commercial oral fluid replacement solutions, such as Plasmalyte and Pedialyte, are mixtures of
sodiumandpotassiumsalts,abase(citrateorbicarbonate)andacarbohydrate.Theyaredesigned
tocorrectdeficits inwaterandelectrolytescausedbydiarrhoea. If thechild is lethargicandthe
skinfeelsdryandinelastic,dehydrationislikelytobeassociatedwithlowsodium.Ifthechildhas
hypernatraemicdehydration,thirstisextremeandtheskinfeelsdoughy.
Breastmilk,formula,cow’smilk(ifthechildisoveroneyear),clearsouporricewaterareallsuitable.
Highlydilutedjuiceorlemonadecanbeusedifthereisnotabetteralternative,atadilutionrateof
onepartjuicetofivepartswater.Lemonadeisdilutedwithwarmwatertogetridofthebubbles.
Cola, tea, coffee or sports drinks are not suitable because of their high stimulant or sugar
content
Rehydration phase
Duringtherehydrationphase,fluidisgivenatarateof5mlperminutebyteaspoonorsyringe.The
smallvolumesdecreasetheriskofvomiting.Therate(1teaspoon/minute)iseasytocalculateand
administerforaparentsittingatthebedside.Thiscanbechangedto25mlevery5minutesonce
thechildstopsvomiting.
Thisratewillrehydrateamoderatelydehydrated1-year-oldin2to4hoursanda2-year-oldin3to
5hours.
Frequent review (at least 2 hourly) is advisable in the rehydration phase. A child who is not
rehydratingatthisrateoforalreplacementwillrequirenasogastricorintravenousfluids.
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Maintenance phase
Oncethechildisrehydrated,hydrationismaintainedby
givingmaintenancerequirementsplusadditionalfluidto
replacethefluidineveryloosestool,orthechildwillslip
backintodehydration.
Fluid requirements to maintain hydration
Table 9: Approximate fluid requirements to
maintain hydration
Drug therapy rarely needed for
gastroenteritis in children
Antibiotics
Even in bacterial gastroenteritis, antibiotics are not usually
indicated.Antibioticsmayprolongthedurationofdiarrhoea
and are best administered on the basis of a laboratory
result.
Antibiotics are required for bacterial gastroenteritis
complicated by septicaemia and for cholera, shigellosis,
amoebiasis,giardiasisandentericfever.
Antidiarrhoeal and antiemetic drugs have risks of
adverse effects
Anti-diarrhoealagents,suchasloperamide,shouldbeavoided
inchildrenundertheageof12years.Theymayreducethe
durationofdiarrhoeabutadverseeffectssuchassedation,
ileusandrespiratorydepressioncanoccur.
Antiemetic medications are not recommended. They may
reducevomitingbutdonotreducetheneedfor intravenous
rehydration.Theymayinducesedation,makingoralrehydration
moredifficult.
Oral zinc may help
Oralzinctherapygivenatonsetofsymptomscanreducethe
duration and severity of acute diarrhoea but is usually not
necessary.
Lactose intolerance is usually mild and self limiting
Although lactose intolerance is common after viral
gastroenteritisitisusuallymildandself-limitinganddoesnot
requiretreatment.Ifitdoespersist,alactose-freeformulais
recommendedforfourtosixweeksbutthisisnotnecessary
asaroutineforallchildrenwithgastroenteritis.
Weight kg
Maintenance requirementsml/hour
5 20
10 40
15 50
20 60
25 70
30 75
Replacing additional fluid loss in stool
In rehydrated children whose losses are not unusually
profuse,adviseparentstogivebothmaintenancefluids
plusroughly50–100mlforeachdiarrhoealstoolfora
childundertwoyearsand100–200mlforachildover
two years. As with replacement, this volume should
begiven insmallaliquotsrather thanasasingle large
bolus.
Children who have profuse ongoing diarrhoea need to
havethediarrhoeameasuredtocalculatetheadditional
fluidreplacementrequired.
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Acute asthma in children aged 1–15 years: are nebulisers or spacers best?
Spacers and nebulisers are equally effective
Manyclinicaltrialshavefoundspacersandnebuliserstobeequallyeffectivefordeliveringhighdose
bronchodilatorsinacuteasthmaandtheyhavecomparableclinicaloutcomes.4
Spacers have the advantages of being:
Lessfrightening,especiallyforchildren
Notdependentonapowersupply
Easiertomaintain
Cheaper
ThecylindricalspacersthatareavailableonPractitionersWholesaleSupplyOrdersaresuitable.A
maskisusedforyoungchildren.Dependingontheindividualchild,theycanusuallymanagewithout
amaskoncetheyareoverthreetofiveyears.
Salbutamol isgiven through the spaceronepuff at a time, and4deepbreaths areencouraged
to takeupeachpuff.Sixpuffsshouldbegivenevery20minutesup to therecommendeddose.
Dependingonresponse,referralmaybeindicated.
Therecommendeddoseforsalbutamolinaspacerforacute severe asthmais:
SalbutamolMDI100microgrampuffs
Age<5years–6puffs
Age>5years–upto12puffs
The use of Prednisolone should also be considered. ‘Redipred’ liquid 5 mg/ml is available, the
recommendeddoseis2mg/kgoncedaily.
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Patient information on spacer use and maintenance is available from
bpacnz and can be ordered by faxing 0800 27 27 69 or visit
www.bpac.org.nz
20I BPJIIssue5
Like having aspecialist
in your cupboard
bestpractice
bestpracticeDECISION SUPPORT FOR HEALTH PROFESSIONALS
Contact: Murray Tilyard or Sarah Kennedy, bestpractice Decision Support,
Level 7, 10 George Street, PO Box 6032, Dunedinphone: 03 479 2816
email: [email protected] or [email protected]
decision support
bestpractice, the exciting new electronic
Decision Support from BPAC Inc, provides
up to date clinical support for patient
management, with a wide range of clinical
modules based on current New Zealand
guidelines and best practice.
Other features include:
•Linkages to BNF & Clinical Evidence
•Integration with your PMS
•Security model based on existing health
standards
References
LandauL.Acuteandchroniccough.
PaediatricRespiratoryReviews.2006;7s:
S64–S67.
ElliottE.Acutegastroenteritisinchildren.
BMJ.2007;334:35–40.
GastroenteritisPathwayTeam.Starship
HealthGastroenteritisClinicalGuideline.
2006Availablefrom:
http://snipurl.com/1gxmq
CatesC,CrillyJ,RoweB.Holding
chambers(spacers)versusnebulisersfor
beta-agonisttreatmentofacuteasthma.
CochraneDatabaseSystRev.2006;2:
CD000052.
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