1. Diarrhoea and Vomiting in Children Under 5yrs
NICE clinical guideline 84
Diarrhoea and Vomiting in Children Under 5yrs
Implementing NICE guidance
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline ‘Diarrhoea and vomiting in children caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years’. This guideline has been written for all healthcare professionals who care for children with diarrhoea and vomiting caused by gastroenteritis.
The guideline is available in a number of formats, including a quick reference guide. See the end of the presentation for ordering details.
We recommend that you hand out copies of either the quick reference guide (QRG) or the ‘Assessing dehydration’ chart at your presentation so that your audience can refer to it, particularly so that reference can be made to ‘Table 1 Symptoms and signs of clinical dehydration and shock’ during the presentation of slide 7. Alternatively you may choose to use the alternative assessing dehydration slides provided which includes table 1 on the slides.
See the end of the presentation for ordering details.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. The recommendation numbers and section numbers in square brackets refer to the NICE guideline.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
2009
Dr. Jatinder Singh Jheeta, Paeds ST2

2. Background
Approx 10% of children under 5yrs present to healthcare services each year with gastroenteritis, and this puts a significant burden on health service resources.
Severe diarrhoea and vomiting can cause dehydration and shock.
There is variation in clinical practice.
NOTES FOR PRESENTERS:
Key points to raise:
This slide discusses the need for a guideline on diarrhoea and vomiting in children.
Although most children with gastroenteritis do not need to be admitted to hospital, many are treated as inpatients each year. For those children who are treated at home, many parents and carers do seek advice from healthcare professionals either remotely (for example, through NHS Direct) or in the community. Therefore the care of these children is a significant burden on healthcare service resources.
There is evidence of variation in clinical practice, which may have a major impact on the use of healthcare resources. This guideline aims to reduce this variation and make the best use of NHS resources.
Additional information:
Gastroenteritis is very common, with many children having more than one episode a year.
Parents and carers need information on how to get immediate help and follow-up from appropriate healthcare professionals in order to care for their child at home [Sections 1.7 and 1.8].
Children who are admitted as inpatients often remain in hospital for several days – thereby exposing other vulnerable hospitalised children to the illness.

3. Key priorities for implementation
Diagnosis
Assessing dehydration and shock
Fluid management
Nutritional management
Information and advice for parents and carers
NOTES FOR PRESENTERS:
The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into five areas of key priority and within these there are eight recommendations that we will consider in turn.

5. Diagnosis Perform stool MC&S if: you suspect septicaemia, or
there is blood and/or mucus in the stool, or
the child is immunocompromised.
May also consider sending stool MC&S if:
Child recently abroad, or
Persistent diarrhoea for >7days, or
Uncertainty about diagnosis of gastroenteritis
NOTES FOR PRESENTERS:
Key points to raise:
Stool culture is not usually necessary. This recommendation indicates when stool microbiological investigations should be used.
You may also consider performing stool microbiological investigations if:
the child has recently been abroad or
the diarrhoea has not improved by day 7 or
there is uncertainty about the diagnosis of gastroenteritis. [ ]
Additional information:
Suspect gastroenteritis if there is a sudden change in stool consistency to loose or watery stools, and/or a sudden onset of vomiting. [ ]
Notify and act on the advice of the public health authorities if you suspect an outbreak of gastroenteritis. [ ]
Refer to the NICE guideline for further information on:
clinical diagnosis and laboratory investigations [Section 1.1]
antibiotic therapy and other therapies [Sections 1.5 and 1.6].
Recommendation in full [ ]: as seen on slide

6. Assessing dehydration & shock: those at increased risk…
Infants <1yr, but especially < 6 months
Infants of low birth weight
Children who have passed >6x diarrhoeal stools or vomited >3x in 24 hours
Children who have not had/not tolerated supplementary fluids
Infants who have stopped breastfeeding during the illness
Children with signs of malnutrition
NOTES FOR PRESENTERS:
Key points to raise:
This slide highlights how to recognise children at increased risk of dehydration. This is not a key recommendation, but key information in managing the care of children with diarrhoea and/or vomiting.
An ‘infant’ is a child younger than 1 year.
In the following slides we will discuss how to assess the symptoms and signs of clinical dehydration and shock [Section 1.2].
Additional information:
Suspect hypernatraemic dehydration if there are any of the following:
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma. [ ]
Recommendation in full [ ]:
The following are at increased risk of dehydration:
children younger than 1 year, especially those younger than 6 months
infants who were of low birth weight
children who have passed more than five diarrhoeal stools in the previous 24 hours
children who have vomited more than twice in the previous 24 hours
children who have not been offered or have not been able to tolerate supplementary fluids before presentation
infants who have stopped breastfeeding during the illness
children with signs of malnutrition.

7. Assessing dehydration and shock
Use the clinical signs and symptoms described in table 1 (QRG) to detect clinical dehydration and shock
Increasing severity of dehydration
No clinically detectable dehydration
Clinical dehydration
Clinical shock
Increasingly numerous and more pronounced symptoms and signs
NOTES FOR PRESENTERS:
Key points to raise:
Please refer to Table 1 on page 8 of the quick reference guide or the ‘assessing dehydration’ chart which lists ‘symptoms and signs of clinical dehydration and shock’
More numerous and more pronounced symptoms and signs of shock indicate greater severity. The guideline uses a red flag symbol to highlight symptoms and signs that may help to identify children at increased risk of progression to shock.
Additional information:
Refer to the NICE guideline for further information on:
assessing dehydration and shock (Section 1.2)
the escalation of care for children with suspected gastroenteritis (Sections 1.7)
Recommendation in full:
Use table 1 to detect clinical dehydration and shock [ NICE Guideline]

8. Signs of increasing severity of dehydration
No clinically detectable
dehydration
Clinical dehydration
Clinical shock
Alert and responsive
Altered responsiveness
Decreased level of consciousness
Skin colour unchanged
Pale or mottled skin
Warm extremities
Cold extremities
Eyes not sunken
Sunken eyes -
Moist mucous membranes
Dry mucous membranes
Normal heart rate
Tachycardia
Normal breathing pattern
Tachypnoea
Normal peripheral pulses
Weak peripheral pulses
Normal capillary refill time
Prolonged capillary refill time
Normal skin turgor
Reduced skin turgor
Normal blood pressure
Hypotension
NOTES FOR PRESENTERS:
Key points to raise:
This slide looks at the signs of dehydration and shock, which can only be identified during face-to-face assessments.
Please refer to Table 1 on page 8 of the QRG or the ‘assessing dehydration’ chart.
Additional information:
Refer to the NICE guideline for further information on:
assessing dehydration and shock [Section 1.2]
the escalation of care for children with suspected gastroenteritis [Section 1.7]
Recommendation in full [ ]:
Use table 1 to detect clinical dehydration and shock 8

9. Assessing Dehydration and Shock

10. Fluid management: children without dehydration
In children with gastroenteritis but without clinical dehydration:
continue breastfeeding and other milk feeds
encourage fluid intake
discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk
offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk.
NOTES FOR PRESENTERS:
Key points to raise:
This slide discusses fluid management in children who are not dehydrated.
Discourage the drinking of fruit juices and fizzy drinks, especially in those at increased risk of dehydration (as identified on slide 6). Fizzy drinks includes soft drinks that were fizzy but have been made flat.
Recommendation in full:
In children with gastroenteritis but without clinical dehydration:
continue breastfeeding and other milk feeds
encourage fluid intake
discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration (see )
offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration (see ). [ NICE Guideline]

11. Recap… those at increased risk…
Infants <1yr, but especially < 6 months
Infants of low birth weight
Children who have passed >6x diarrhoeal stools or vomited >3x in 24 hours
Children who have not had/not tolerated supplementary fluids
Infants who have stopped breastfeeding during the illness
Children with signs of malnutrition
NOTES FOR PRESENTERS:
Key points to raise:
This slide highlights how to recognise children at increased risk of dehydration. This is not a key recommendation, but key information in managing the care of children with diarrhoea and/or vomiting.
An ‘infant’ is a child younger than 1 year.
In the following slides we will discuss how to assess the symptoms and signs of clinical dehydration and shock [Section 1.2].
Additional information:
Suspect hypernatraemic dehydration if there are any of the following:
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma. [ ]
Recommendation in full [ ]:
The following are at increased risk of dehydration:
children younger than 1 year, especially those younger than 6 months
infants who were of low birth weight
children who have passed more than five diarrhoeal stools in the previous 24 hours
children who have vomited more than twice in the previous 24 hours
children who have not been offered or have not been able to tolerate supplementary fluids before presentation
infants who have stopped breastfeeding during the illness
children with signs of malnutrition. 11

12. Fluid management: children with dehydration
...including hypernatraemic dehydration:
Use low-osmolarity ORS solution frequently and in small amounts.
Give 50 ml/kg for fluid deficit over 4 hours and maintenance fluid.
Consider supplementation with their usual fluids.
Consider a NG tube if they cannot drink ORS or vomit persistently
Monitor response regularly.
NOTES FOR PRESENTERS:
Key points to raise:
If children refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs (see table 1, page 8 quick reference guide) then they can be supplemented with their usual fluids including milk feeds or water, but not fruit juices or fizzy drinks.
Consider giving ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently.
Monitor the response to oral rehydration therapy by regular clinical assessment.
Additional information:
Use ORS solution to rehydrate children, including those with hypernatraemia, unless intravenous fluid therapy is indicated [ and ].
See the fluid management pathway on page 9 of the quick reference guide.
Recommendation in full [ ]:
In children with clinical dehydration, including hypernatraemic dehydration:
use low-osmolarity ORS solution (240–250 mOsm/l)1 for oral rehydration therapy
give 50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid
give the ORS solution frequently and in small amounts
consider supplementation with their usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs (see table 1, page 8 quick reference guide)
consider giving the ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently
monitor the response to oral rehydration therapy by regular clinical assessment.

13. Fluid management: when to use intravenous fluid
Use IV fluids for clinical dehydration if:
shock is suspected or confirmed
a child with red flags or clinical deterioration despite oral rehydration.
a child persistently vomits the ORS solution, given orally or via a nasogastric tube.
NOTES FOR PRESENTERS:
Key points to raise:
Red flag symptoms and signs are shown on page 8 of your quick reference guide. The red flag symbol has been used in the table to identify children at increased risk of progression to shock.
Recommendations in full [ ]:
Use intravenous fluid therapy for clinical dehydration if:
shock is suspected or confirmed
a child with red flag symptoms or signs (see table 1) shows clinical evidence of deterioration despite oral rehydration therapy
a child persistently vomits the ORS solution, given orally or via a nasogastric tube.

14. Fluid management: giving intravenous fluid therapy
use isotonic solution for fluid deficit replacement and maintenance
in addition to maintenance fluid requirements, add the following amounts for fluid deficit replacement:
100ml/kg for those who were initially shocked
50ml/kg for those who were not shocked at presentation
monitor blood plasma levels at the outset and regularly, and review administration rate
consider providing intravenous potassium once the plasma potassium level is known.
NOTES FOR PRESENTERS:
Key points to raise:
Those suspected or confirmed as being in shock should receive an initial rapid intravenous fluid bolus. [ ]
These recommendations are for when the child is not hypernatraemic at presentation.
When treating children with or without shock:
junior staff may need to seek the advice of senior staff when prescribing fluids
monitor the clinical response to treatment
Blood measurements – measure plasma sodium, potassium, urea, creatinine and glucose, and alter the fluid composition or rate of administration if necessary
Additional information:
Refer to the NICE guideline for further information on intravenous fluid therapy (Section 1.3.3) including:
Use an isotonic solution – such as 0.9% sodium chloride, or 0.9% sodium chloride with 5% glucose
Start rehydration with intravenous fluid therapy when symptoms and/or signs of shock resolve after rapid intravenous infusions (see ) [ ]
Consider consulting a paediatric intensive care specialist if a child remains shocked after the second rapid intravenous infusion [ ]
Recommendations in full [ ]:
If intravenous fluid therapy is required for rehydration (and the child is not hypernatraemic at presentation):
use an isotonic solution, such as 0.9% sodium chloride, or 0.9% sodium chloride with 5% glucose, for both fluid deficit replacement and maintenance
for those who required initial rapid intravenous fluid boluses for suspected or confirmed shock,
add 100 ml/kg for fluid deficit replacement to maintenance fluid requirements, and monitor
the clinical response
for those who were not shocked at presentation, add 50 ml/kg for fluid deficit replacement to maintenance fluid requirements, and monitor the clinical response
measure plasma sodium, potassium, urea, creatinine and glucose at the outset, monitor regularly, and alter the fluid composition or rate of administration if necessary
consider providing intravenous potassium supplementation once the plasma potassium level is known.

15. Nutritional management
After rehydration:
give full-strength milk immeadiately
reintroduce the child’s usual solid food
avoid giving fruit juice and fizzy drinks until the diarrhoea has stopped.
NOTES FOR PRESENTERS:
Key points to raise:
Parents and carers may feel uncertain about when to re-introduce normal food and drink, so they should be given advice on how to care for their child after rehydration.
Additional information:
For nutrition during rehydration therapy:
continue breastfeeding
do not give solid foods in children with red flag symptoms or signs (see table 1)
do not give oral fluids other than ORS solution in children without red flag symptoms or signs (see table 1)
do not routinely give oral fluids other than ORS solution; however,
consider supplementation with the child’s usual fluids (including milk feeds or water, but not fruit juices or fizzy drinks) if they consistently refuse ORS solution.
Recommendation in full [ ]: as seen on slide

16. Myths to Dispel…
Children should not be given milk or food for the first 24hrs if they have D&V
Children should be given diluted milk rather than full strength milk if they have D&V
Children should be given flat cola or lemonade if they have D&V
Children should be given a ‘light diet’ when they are recovering from D&V

17. Information and advice: hygiene
Advise parents and carers to:
wash and carefully dry hands as this is the best way to prevent the spread of gastroenteritis
wash hands after going to the toilet or changing nappies and before preparing, serving or eating food
avoid sharing towels used by infected children.
NOTES FOR PRESENTERS:
Key points to raise:
Parents and carers should be advised to wash hands with liquid soap if possible and in warm running water.
Recommendation in full [ ]: continued on the next slide
Advise parents, carers and children that:
washing hands with soap (liquid if possible) in warm running water and careful drying is the most important factor in preventing the spread of gastroenteritis
hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food
towels used by infected children should not be shared

18. Information and advice: school, childcare and activities
Advise parents and carers to keep children away from:
School or other childcare facility
- while they have diarrhoea or vomiting caused by gastroenteritis and
for at least 48 hours after the last episode
Swimming in swimming pools for 2wks after last episode
NOTES FOR PRESENTERS:
Additional information:
Additional information on caring for a child with diarrhoea and vomiting at home are available in section 1.8 of the NICE guideline including:
Advise parents and carers that:
the usual duration of diarrhoea is 5–7 days and in most children it stops within 2 weeks
the usual duration of vomiting is 1 or 2 days and in most children it stops within 3 days
they should seek advice from a specified healthcare professional if the child’s symptoms do not resolve within these timeframes [ ]
Recommendation in full [ ]: continued from previous slide
children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis
children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting
children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea.

19. Summary… Diagnosis Assessing dehydration & shock, and using Tool
Fluid management
Nutritional management
Information and advice for parents and carers
NOTES FOR PRESENTERS:
The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into five areas of key priority and within these there are eight recommendations that we will consider in turn. 19

20. Thank you...