D

1
DV in the under 5s Dr. Victoria Lloyd GPVTS
2
DV.

• 1 to 3 illnesses per child per year lt5years
• 500 000 consultations per year lt5 years
• 16 of all hospital medical presentations
• 18000 lt5s admitted for diarrhoea yearly
• Crowley 1997 Communicable Disease report 7
• Tompkins 1999 Communicable disease and Public
  Health Report 2

3
DV. Hes been ill for a week now. Is that normal?

• Average illness lasts 8.6 days

4
DV. Hes not drunk anything today.

• How dehydrated?
• Gold standard assessment of dehydration
  weight loss.
• Mild 3, Mod 5, Severe 10
• WHO 1990
• Assess severity on basis of patients age and
  frequency of watery stools and vomiting
• no data on frequency related to outcome.

5
DV. Hes not drunk anything today.
How Dehydrated?
Duggen 1996. J Paed Gast Nutr
6
DV. What do you think has caused it?

• Viral 87
• Ferson 1996. Med J Aus
• Some unreliable pointers
• Viral - preceded by URTI.
• Bacterial - blood mucous in stool.

7
DV. What do you think has caused it?

• Antibiotic induced.
• Toddler diarrhoea.
• Other systemic infection.
• Traveler's diarrhoea.
• Intussusception, HUS, Surgical abdomen, PMC.
• Factitious.
• Chronic bowel pathology.

8
DV. Could this be food poisoning?

• V difficult to confirm food link.
• Stool culture negative in 50-66
• DOH executive summary.
• For every 1000 cases of IID, of those 160 that
  consult GP 45 have stool culture sent and 10 are
  positive. 7 need reporting to CDSC PHLS.

9
DV. Ive heard flat Coke is good.

• Pop is hyperosmolar. May cause osmolar
  diarrhoea.
• Home made salt and sugar drinks not advised.
• If mild symptoms increase in fluid intake only.
• Dioralyt, Diacalm, Rehidrat etc if dehydrated
• Am Acad Paed 1996

10
DV. How much do I use?

• Initial fluid replacement over 4 hours.
• Estimate dehydration (i.e. mild/mod 3-8
  30-80ml/Kg) given little and often
• Armon 2001. Arch Dis Chil

11
DV. But he just vomits it back?

• Keep going with small amounts and often.
• 5-10ml every 5 minutes and increase volumes once
  tolerating. V time consuming.
• Continue until rehydrated.

12
DV. What then?

• Maintenance feeds any fluids approp.
• 100ml/Kg/day first 10Kg
• 50ml/Kg/day next 10Kg
• 20ml/Kg/day for the rest
• replace ongoing losses 10ml/kg for each stool
  with extra feeds or ORF.

13
DV. Weight.

• Age 4 x2 weight in Kg.
• Age 5 20Kg 1.5L ( 200ml)
• Age 3 15Kg 1.25L ( 150ml)
• Age 1 10Kg 1L ( 100ml)

14
DV. Should I starve him?

• Early feeding i.e. After 4hours of ORF, is assoc.
  with a better outcome than waiting until
  gt24hours. Does not worsen symptoms or produce
  lactose intolerance
• Sandhu 1997. J Paed Gast Nutr
• Are bland foods better to start?
• No evidence.

15
DV. Should I stop giving him milk and yogurt?

• Malabsorption of lactose may occur for a short
  period after IID because of mucosal damage and
  lactase deficiency.In Europe continued lactose
  deficiency is uncommon.
• Meta Analysis showed lactose free diet rarely
  necessary.
• Brown 1994. Paed.
• Should not stop breast feeding.
• Who 1993.

16
DV. Is there anything you can give him?

• There is no evidence to suggest that
  anti-diarrhoeals are effective.
• BMJ 1984
• No role in IID and unacceptable SE.
• Murphy 1998
• Pepto Bismol may reduce amount of diarrhoea but
  not recommended.
• Antiemetics are not indicated.
• WHO 1993

17
DV. Should he have antibiotics?

• Most bacterial IID does not need antibiotics.
• Is indicated if Shigella.
• Is indicated if Salmonella and lt2yr or
  immunocompromised.
• Murphy 1998

18
DV. What to do and when.

• See if not improving after 48hours
• See if not settled after 10 days
• Send stool culture if above and if recent travel,
  blood /- mucous in stool, suspect food poisoning
  or systemically unwell.
• If persistent diarrhoea after reintroduction of
  feeds, evidence for lactose intolerance should be
  sought.
• Refer if

19
DV. Does he need to go to hospital?

• Severe.
• Social set up.
• Uncertain diagnosis.
• No sig. difference between oral and IV
  rehydration. Prefer IV if shocked.
• Murphy 1998. Arch Dis Chil.