Gastroenteritis 8: Special Situations

Children needing high care
Abdominal distension or bile-stained vomiting
Blood in stool/dysentery
Nutritional problems
Persistent diarrhoea

The following children need high care monitoring in ward

• Persistent shock
• Altered LOC despite correction of shock
• Bile stained vomiting or marked abdominal distension
• Convulsions
• K+ <2.0 or >6 mmol/l
• Na+ <120 or >165 mmol/l
• pH <7.0 or >7.40
• pH <7.15 plus Na >150mmol/l
• pa CO2 >6.5kpa

Abdominal Distension or Bile‐Stained Vomiting

Ileus is usually a result of intestinal infection or hypokalaemia BUT surgical causes must be excluded including: malrotation, volvulus and intussusception

• Keep NBM, ivi fluids only, NGT on open drainage
• Investigations: Abdominal XRay, electrolytes
• Surgical consult if bile stained/specific concerns re obstruction

Blood In Stool/Dysentery

• Send stool MC&S
• If well: give oral Ciprofloxacin 15mg/kg twice daily
• If toxic/ill/unable to take orally give IV Ceftriaxone 50mg/kg/dose daily ivi X 3‐5days (100mg/kg/dose if can’t differentiate associated decreased level of consciousness/encephalopathy from meningitis.)
• Follow up in 3 days at local clinic to ensure recovery and mother/clinic Sister can phone in for stool culture results (Shigella dysenteriae and dysentery caused by some E. Coli can lead to haemolytic uraemic syndrome, or result in Protein Losing Enteropathy or a more protracted course.) Parents must be told to return immediately if the child’s condition changes/deteriorates

Keep differential diagnosis for blood in stools in mind especially intussusception ‐ others include inflammatory bowel disease, necrotlising enterocolitis (neonates), local lesions (e.g. anal fissure, intestinal polyps) etc.

Nutritional Problems

• SAM – follow WHO 10 steps protocol and cautious feeding. See SAM protocol.
• Under weight for age (UWFA) and/or Failure to Thrive (FTT) owing to poverty or poor nutrition practices
  ‐ Advise re Child Support Grant and refer to Nutritional Support Scheme in the community (via dietician)

Persistent diarrhoea

Persistent diarrhoea is when the child has had loose stools for > 10 days. However we intervene earlier to try to prevent the post‐enteritis syndrome/chronic diarrhoea developing.

On admission, children should continue to breastfeed or if <1 years on formula feeds, they should be put on acidified formula e.g. pellargon/melegi

This guidance is in part taken from:
WC Gastroenteritis Fam Med & Paeds Protocol 2014 
&
New Somerset Hosp Paeds Gastro Protocol 2014