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Gastroenteritis in Children: Part 2

This post is by regular contributor Naomi Cook.

Today I will look at Prevention, Treatment and the Gastro Survival Pack. I do hope that those who were suffering when I shared the part one post have recovered and bounced back to good health already.

Prevention

  • Hand-washing: Washing for one minute, rinsing for twenty seconds and drying with a paper towel has been shown to clean virus from the fingers. 1 Unfortunately it is not a guarantee against infection as the surrounding environment will most likely be contaminated in some way.1 Use the paper towel to turn off taps after washing to avoid re-contaminating yourself.
  • Toilet Lid: Close this when flushing and get your kids in the habit of doing the same to avoid aerolising infective particles which will then settle around the bathroom.
  • Gloves: Use latex gloves when handling contaminated matter 1 but still wash hands afterward.
  • Chlorine: Naturally cleaning with a cloth to produce a visibly clean surface is not enough. In addition, the cloth is also capable of transmitting the virus to further surfaces. 1 It is recommended that solid material is put into a bag, the area then cleaned with detergent, followed by a chlorine based disinfectant and hot water. 1
  • Hand Rub: Note that research states that Norovirus is unlikely to be affected by alcohol based cleaners. 1,8 Sterillium† Virugard, by Bode Chemie 10 is an antiviral hand rub that has been proven to be effective against Norovirus. 7 It is available in Europe but unfortunately not here in Australia. Without an alternative I would personally still use alcohol gel as a substitute (after hand-washing). Meanwhile I’m on a mission to find a good anti viral hand rub here; I will let you know once I find one.
  • Separate Bathrooms: If you have the luxury of having multiple bathrooms, reserve one for the gastro sufferers and keep the others for the healthy household members.

Treatment

Treat Dehydration and Electrolyte Imbalances: There are many commercially available rehydration formulations, however they may contain artificial colours and flavours. The “natural” colour “annatto 160b” can also be problematic in colour sensitive children. A homemade simple rehydration solution (however it lacks the electrolyte potassium) can be made with half a teaspoon of salt to six level teaspoons of sugar in a litre of cool boiled water. 9 A great idea would be to make ice pops/icy poles with the solution. The ice will disguise the taste by numbing the taste buds as well as adding a novelty factor. Please note that a rehydration solution that is too concentrated, or too high in sugar, will make diarrhoea worse. Fruit juices, soft and sports drinks 12 should be avoided 2 but if used, should also be diluted to half strength due to their high sugar content. 5 Diet soft drinks should be avoided as they do not contain sugar and therefore impede the absorption of salt. 5

The very young are particularly susceptible to developing severe dehydration and may need to be hospitalised for IV fluids. Watch out for signs of moderate/severe dehydration such as:

  • Decreased urine output
  • Darker urine
  • Parched mucous membranes (look in the mouth and at the tongue for dryness)5
  • Irritability/lethargy 5
  • Sunken fontanelle in infants

An example dose in the case of Mild/Moderate Dehydration

  • Initially (first four hours) 1-3 teaspoons of fluid every 10-15 minutes. 5 The dose is initially small to avoid a sudden fluid overload.
  • Then 1 teaspoon every 2-3 minutes even if the child vomits. 5
  • Breastfeeding must continue and maybe supplemented by a rehydration solution. 2
  • Formula fed babies can be given oral rehydration solution instead of their usual milk whilst they are vomiting. 13

Record: This is a great chart 11 for recording all episodes of vomiting, diarrhoea and the amount of fluids consumed. You will be thanked for bringing this chart with you to the doctor or Emergency Department if you think your child is becoming too dehydrated.

Medication: There are a range of anti-emetic (anti-vomiting) drugs that a doctor can prescribe or give as an injection. Most doctors do not readily prescribe these for children as they are much more sensitive to the side effects.  A once only dose of Zofran (Ondansetron) can help severe vomiting 3, 7 and thus facilitate rehydration. Anti-diarrhoeals are not recommended and there is a lack of research regarding their safety. 2,4 If anyone would like some information on drugs commonly used for gastro (for adults and children) please let me know in the comments below and I can email you a separate document.

Resuming a Normal Diet After the Vomiting
I don’t think it’s possible to specify “how many hours” one should wait before introducing food again. I personally think this will depend on the individual. If the child is old enough they will tell you when they are hungry and you can trial a light diet. For babies, it is more likely a bit of trial and error. The general theme in many research papers is that we shouldn’t be too restrictive nor too slow in resuming normal eating patterns as you will see below.

  • Continue breastfeeding 4 and give normal amounts of formula as usual. 2,4 Old advice was to dilute formula to half or quarter strength but this is not recommended any more. 4 It is not necessary to switch to a lactose free formula. 2,4
  • Continue an Age Appropriate Diet 2,4: The BRAT diet (bananas, rice, applesauce and toast) for 24 hours is commonly prescribed but has been criticised as being unnecessarily too restrictive. 4 Similarly clear fluids, fat free diets and gut rest have been criticised as being potentially harmful to recovery. 4 You can trial light, bland foods. We all know how tender we feel after vomiting so just apply commonsense to your food choices.
  • A diet very high in sugar and fat is not recommended immediately after a bout of gastro. 2
  • There may be a temporary lactose intolerance after gastro which is usually self limiting. Switching to a lactose free milk or formula for a few weeks is only recommended if the intolerance persists. 2 Similarly other food intolerances such as Cow Milk Protein Intolerance may develop. These can be managed by a temporary dietary elimination 2
  • Probiotics have been shown to decrease the duration of diarrhoea during a bout of gastro but more studies need to be conducted to determine dosage, type and frequency of administration. 2

A Gastro Survival Pack

Considering gastro seems to like to strike at unearthly hours, here are some things to put away in that bathroom cupboard so you are prepared the moment your family gets hit!

  • Re-hydration sachets (or have your own recipe handy)
  • Icy pole holders to make your own ice pops/icy poles with the hydration formula
  • Clean bucket(s)
  • Paper towels
  • Roll of disposable cloths
  • Hydration chart
  • Latex/non latex gloves
  • Roll of bin bags (double bag to prevent leaks to protect the garbage collectors)
  • Spare tissues and toilet rolls
  • Bleach/chlorine based disinfectant
  • Anti viral hand rub (or alcohol gel if nothing else)
  • Spare pyjama pants/nappies for toilet trained toddlers/preschoolers
  • Pack of moistened flushable wipes
  • Medication

Do you have any tips on how you stop the spread in your families? Can you think of anything else to add to the Gastro Survival Pack?

DISCLAIMER: The information contained in this article should NEVER be used as a substitute for the advice of a licensed physician. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please see a physician if you think you or your child are unwell. This author has no competing interests.

References

  1. Barker J, Vipondb I, Bloomfiled S (2004)  Effects of cleaning and disinfection in reducing the spread of Norovirus contamination via environmental surfaces. Journal of Hospital Infection 58, 42–49
  2. Elliot E (2007) Gastroenteritis In Children Clinical Review British Medical Journal 334:35-40
  3. Freedman S, Adler M, Seshadri R, Powell E, (2006) Oral Ondansetron for Gastroenteritis in a Pediatric Emergency Department New England Journal of Medicine 354:1698-705
  4. King C, Glass R, Bresee J, Duggan C, Ozuah P, Avner J, Stein (2003) Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003;52(RR-16):1-16
  5. London M, Ladewig P, Ball J, Bindler R (2003) Maternal and Child Nursing Care Second Edition Pretice Hall, London
  6. Ramsook C, Sahagun-Carreon I,  Kozinetz C, Moro-Sutherland D (2002) A Randomised Clinical Trial comparing Oral Ondansetron with Placebo in children with acute gastroenteritis Annals of Emergency Medicine 39:4 pp397-403
  7. Simon A, Schildgen O, Binger A, Hasan C, Bode U, Buderus S, Engelhart S, Fleischhack G (2006) Norovirus outbreak in a pediatric oncology unit Scandinavian Journal of Gastroenterology 41: 693-699
  8. Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, 2011, Centers for Disease Control and Prevention
  9. WHO position paper on Oral Rehydration Salts to reduce mortality from cholera, World Health Organisation
  10. Sterillium® Virugard, Bode
  11. Oral Fluid Intake Chart for Gastroenteritis, Hydralyte
  12. Hydralyte
  13. Gastroenteritis in Children, Westmead Children’s Hospital

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Comments

  1. Hi there,
    Do you have any tips on cleaning toys after children have been sick? Especially wooden and soft toys? (I.e. Toys that an infant would have put in their mouth and may still be contaminated)
    Thanks!

  2. Great question. This is really difficult as there is little published research on how long norovirus lives on soft surfaces. Secondly, there is even less on how to clean such surfaces! As with washing linen etc it may be best to throw soft toys in the washing machine at the highest setting you think they can withstand and then air dry them in the sun. You could consider putting them away for a while afterwards if children from outside your household will be visiting.

    With wooden toys you could follow the cleaning protocol which suggests soap detergent and then a cholrine based cleaner, but I’m guessing this would ruin them. Perhaps you could wash and dry them a few times? Now this would make an interesting study to carry out since it has real clinical relevance to us mums!

    Thanks for that “food for thought” if I come across anything published that might help us answer these questions I’ll be in touch

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