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An evidence and consensus based guideline for acute diarrhoea management
  1. HARRY BAUMER, Consultant Paediatrician
  1. Derriford Hospital
  2. Plymouth, Devon, UK

    Abstract

    OBJECTIVE To develop an evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (with or without vomiting), a common problem representing 16% of all paediatric medical attenders at an accident and emergency department. Clinical assessment, investigations (biochemistry and stool culture in particular), admission, and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home.

    EVIDENCE A systematic review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendation were generated.

    CONSENSUS An anonymous, postal Delphi consensus process was used. A panel of 39 selected medical and nursing staff were asked to grade their agreement with the generated statements. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panellists' responses. Consensus was predefined as 83% of panellists agreeing with the statement.

    RECOMMENDATIONS Clinical signs useful in assessment of level of dehydration were agreed. Admission to a paediatric facility is advised for children who show signs of dehydration. For those with mild to moderate dehydration, estimated deficit is replaced over four hours with oral rehydration solution (glucose based, 200–250 mOsm/l) given “little and often”. A nasogastric tube should be used if fluid is refused and normal feeds started following rehydration. Children at high risk of dehydration should be observed to ensure at least maintenance fluid is tolerated. Management of more severe dehydration is detailed. Antidiarrhoeal medication is not indicated.

    VALIDATION The guideline has been successfully implemented and evaluated in a paediatric accident and emergency department.

    • diarrhoea
    • gastroenteritis
    • Delphi consensus
    • guideline

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    Diarrhoea is defined as a change in bowel habit for the individual child resulting in substantially more frequent and/or looser stools. Acute diarrhoea, most frequently the result of infectious intestinal disease (IID), represents a major cause of consultations in general practice. Djuretic et al estimated that each year there are 526 000 consultations in children age under 5 years with IID.1 Using 1994 population data this equates to about 1 in 6 children per year consulting their general practitioner with an episode of IID, though this figure may be an overestimate as some may attend more than once. Sixteen per cent of all paediatric medical presentations to accident and emergency departments are for children with diarrhoea, with or without vomiting.2Hospital admissions for children with gastroenteritis rose by about 6% from 1989 to 1994 and currently account for approximately 7% of all paediatric admissions in the under 5 age group.3 In 1994 hospital admission rates of 1 child in 150 under 5 years for IID were reported and the cost of inpatient care had risen from that in 1991.4 Gastroenteritis admission rates are significantly higher in young children from more deprived areas.5Children with similar severity of illness on attendance may be managed differently (unpublished data) and junior doctors make many of the initial decisions.2

    We set out to develop this guideline with the following aims: (1) to improve the process and outcome of care for children attending hospital with diarrhoea; (2) to promote consistency of care so that patients with almost identical clinical problems would be managed in the same way; and (3) to inform, educate, and improve the clinical decision making of the junior clinicians who see most of these children initially.

    Scope of the guideline

    The guideline deals with children who have diarrhoea, with or without vomiting, rather than with a defined diagnosis, as the guideline should assist clinicians in diagnosis prior to management of a particular condition.6 Children presenting with vomiting alone or with chronic diarrhoea (more than seven days duration) are not considered. We present a summary version of the full guideline (which can be obtained from the corresponding author, or theArchives of Disease in Childhood website,www.archdischild.com) to which reference should be made for clarification or further information. The authors assume that health care professionals will use general medical knowledge and clinical judgement in applying the recommendations in this document to the management of individual patients. These recommendations may not be appropriate for use in all circumstances.

    Method of development

    Recommendations made are based on statements derived from a systematic review of published literature and refined by a three round Delphi consensus development process. The literature search used the following databases: Medline (1966 to June 1998), Embase (1980 to June 1998), and Cochrane (to June 1998). The following mesh headings and text words were used: diarrh*; diarrhea infantile; diarrhea to 14 years; gastroenteritis; differential diagnosis; diagnos*; incidence; prevalence; aetiology; etiology; dehydration; patient admission; fluid therapy; intravenous; intravenous treatment; rehydration solution; administration, oral; enteral nutrition; faeces; feces; lactose intolerance; enteral; differential diagnosis. General search terms for the type of study required were also used (for example, for diagnostic procedures, the search “sensitivity and specificity or predictive value of tests or diagnostic errors or screening or diagnosis or sensitivity or specificity” was used).

    Explicit inclusion criteria were set: articles that addressed the clinical questions identified, a scientific review of the literature, and a review or clinical guideline written by a national body. Articles were excluded if opinion based. Included articles were critically appraised using a standard proforma, and recommendations were graded using a standard grading scheme (see ). The derived statements, together with the original papers referred to4 7-67 and appraisals were sent to a Delphi panel consisting of 39 medical and nursing staff who regularly manage children with diarrhoea, with or without vomiting. The final guideline based on the literature review and predefined consensus agreement (agreement by at least 83% of panelists) is in the form of an algorithm (flow diagram or decision tree) shown in fig 1. Each box is numbered, and key decision points are allocated a letter, with recommendations explained in the text. Throughout, the word “admit” is defined as follows: any admission to a paediatric facility with paediatric trained staff for observation, further investigation, and management regardless of the expected length of stay.

    Figure 1

    The final guideline. A, B, C, airway, breathing, circulation; CRP, c reactive protein; ESR, erythrocyte sedimentation rate; SPA, suprapubic aspirate; Ur, urea; Cr, creatinine; Elec, electrolytes; Bicarb, bicarbonate; Na, serum sodium (mmol/l); ORS, oral rehydration solution; NGT, nasogastric tube; IV, intravenous; IVI, intravenous infusion; CHD, congenital heart disease; U&E, urea and electrolytes.

    The guideline

    A: DIFFERENTIAL DIAGNOSIS OF CHILD PRESENTING WITH DIARRHOEA

    Statement—There are no published data on the relative probabilities of possible diagnoses in the child presenting to hospital with diarrhoea.

    A table of differential diagnoses (table 1) is shown derived from published texts18 65 (Vb, D) and consensus opinion, not intended to be comprehensive, but rather to act as an aide memoir to the clinician. (Based on Level Vb evidence and Delphi consensus, Grade D recommendation.)

    Table 1

    Broad differential diagnosis of the child presenting with acute diarrhoea (with or without vomiting). The latter diagnoses are more likely to present chronically

    It is essential that the clinician recognise any life threatening causes of diarrhoea, such as intussusception19 (Vb, D), surgical abdomen21 (Vb, D), and haemolytic uraemic syndrome20 (III, C). Features suggestive of these conditions are identified, and although these features may occur in acute gastroenteritis the likelihood of a different aetiology is increased and should be actively sought.

    Recommendation on differential diagnosis

    The following clinical features should alert the clinician to look for causes other than acute viral gastroenteritis for a child's diarrhoea with or without vomiting:

    • Abdominal pain with tenderness, with or without guarding (Vb, D)

    • Pallor, jaundice, oligo/anuria, bloody diarrhoea (III, C)

    • Systemically unwell, out of proportion to the level of dehydration (Vb, D)

    • Shock (Vb, D).

    Features are based on evidence levels shown and Delphi consensus agreement.

    B: ESTIMATION OF SEVERITY OF DEHYDRATION

    The management of gastroenteritis consists of correction of dehydration (rehydration) and maintenance of hydration. An accurate estimate of the level of dehydration is required to achieve this end.

    Statement—The severity of dehydration is most accurately assessed in terms of weight loss as a percentage of total body weight (prior to the dehydrating episode). This is the “gold standard” against which other “tests” are measured25 (I, A).

    In a prospective cohort study of children between 3 and 18 months of age in Egypt, Duggan and colleagues26 (III) found that “prolonged skinfold”, dry oral mucosa, sunken eyes, and “altered neurological status” were the best clinical signs correlating with dehydration as determined by post-rehydration weight gain. In a similarly designed study, with children under 4 years old, Mackenzie and colleagues27 (III) found “decreased skin turgor”, decreased peripheral perfusion, and deep (acidotic) breathing to be the best clinical indicators of dehydration. A urea of >6.5 mmol/l on serum blood sample and pH<7.35 on blood gas were positive investigations associated with dehydration. However the sensitivity and specificity of all these signs were low.

    In both studies mild to moderate dehydration on clinical assessment was found to represent weight loss of 3–5%. Those with severe signs (circulatory collapse) had weight loss of 9–10%. These studies correlate well with the WHO guidance on dehydration assessment.66

    Recommendation

    See table 2 for estimating level of dehydration if weight loss not available. (Level III and Delphi consensus, Grade C recommendation.)

    Table 2

    Assessment of severity of dehydration (if in doubt err by overestimating % dehydration) B

    C: BLOOD TESTS

    Statement—There is no direct evidence indicating when serum electrolytes should be measured in a child with diarrhoea.

    The indication from cohorts of children in the UK with gastroenteritis is that derangement of electrolytes is rare37 61 62 with 1% of admissions having hypernatraemia and no reports of hypokalaemia or hyponatraemia. Even when there is derangement of electrolytes in the serum, this is a result of relative losses of salts and water. There will still be a total body depletion of sodium in hypernatraemic patients.25 Oral rehydration solution (ORS) with appropriate amounts of solutes and given in the correct quantity is sufficient in itself to correct electrolyte abnormalities41 (II, B).42 It is thus unnecessary to measure electrolytes in those children who will be rehydrated with ORS. All children having intravenous rehydration should have urea and electrolytes (U&E) measured, as hypernatraemia will alter the rate at which intravenous rehydration fluids are given and further measurements of U&E should be made as rehydration progresses.25 In addition the American Academy of Pediatrics (AAP) suggest in their practice parameter40(Va, D) that electrolyte levels should be measured in moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes, and where a “doughy” feel to the skin may indicate hypernatraemia.

    Recommendation on blood tests

    The child who presents with diarrhoea, with or without vomiting, should have blood taken for urea/creatinine, electrolytes, and bicarbonate in the following circumstances:

    • Severe dehydration with circulatory compromise

    • Moderate dehydration where a “doughy” feel to the skin might indicate hypernatraemia

    • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes.

    (Based on Level Va evidence and Delphi consensus, Grade D recommendation.)

    D: MANAGEMENT OF REHYDRATION

    Following the evidence of several randomised controlled trials in the USA, Europe, and developing countries49 51 52 54 (II, B), it is acknowledged that ORS is quicker in the correction of dehydration and acidosis and safer than intravenous therapy25 40 (I, A).63 The overall failure rate of oral rehydration therapy (ORT, defined as the persistence or recurrence of signs of dehydration and other clinical indications requiring the need for intravenous rehydration) was 3.6% (95% confidence interval 1.4 to 5.8).63 Moreover the use of ORT appears to reduce the risk of seizure during correction of hypernatraemic dehydration52 (II, B).

    Recommendation in mild–moderate dehydration

    • Children who have mild–moderate dehydration secondary to acute gastroenteritis should have their deficit estimated (3–8%) and replaced with ORS (30–80 ml/kg) given “little and often” over 3–4 hours, whenever this is practically possible.25 40 44 63 (Level I and Delphi consensus, Grade A recommendation.) (An attempt was made to define “little and often” further. The literature discusses the correct administration of ORS and recommends that it be given in 5 ml aliquots every 1–2 minutes. Only if this is well tolerated with no vomiting may the size of the aliquots be increased, with decreasing frequency.25 41 42 63 64 However this regime was thought to be too labour intensive for the UK by the Delphi panelists and did not achieve consensus.) (Definition of “whenever practically possible”: this implies that the child's carer is willing and able to carry this out under supervision.)

    • Where the child's carer is not willing and able to carry this out, or when it is required overnight, rehydrate by continuous nasogastric tube infusion (preferred) or intravenous infusion. (Level Va and Delphi consensus, Grade D recommendation.)

    • Regularly assess success of rehydration (for example, two hourly). If no improvement in clinical signs of dehydration or worsening signs, consider nasogastric tube or intravenous infusion. (Level Va and Delphi consensus, Grade D recommendation.)

    E: COMPOSITION OF ORS

    In the 1970s the WHO adopted a glucose–electrolyte solution that contained 90 mmol/l of sodium for the treatment of diarrhoea. Since then there have been many controlled trials looking at the ideal concentration of electrolytes and carbohydrate in ORS. A recent multicentre trial in four developing countries found that reduced osmolarity ORS (224 mmol/l) had advantages over standard ORS (311 mmol/l) in the treatment of non-cholera diarrhoea46 (II, B). In developed countries diarrhoea tends to be isotonic (mainly rotavirus induced) and the European Society of Paediatric Gastroenterology and Nutrition (ESPGAN)44 published guidelines on the ideal composition of ORS for children of Europe. Since this publication, studies from Finland47 (II, B) and a multicentre trial46 (II, B) have confirmed that reduced osmolarity ORS is preferable in European children. See table 8 for the composition of ORS recommended and those commercially available.

    Table 8

    Composition of fluids for intravenous and oral rehydration in acute gastroenteritis

    Table A1

    Levels of evidence and grade of recommendation

    A recent meta-analysis of 13 clinical trials examining the effect of rice based ORS on total stool output and duration of diarrhoea showed that there appeared to be some benefit in those with cholera, but in those with non-cholera diarrhoea no benefit was shown48(I, A).

    Recommendation on the composition of ORS

    • ORS used for rehydration of children with acute gastroenteritis in the UK should contain: 60 mmol/l sodium, 20 mmol/l potassium, ⩾25 mmol/l chloride, and 74–111 mmol/l glucose. (Commercial solutions conforming to this include Dioralyte and Diocalm Junior.) (Level I and Delphi consensus, Grade A recommendation.)

    F: MAINTENANCE OF HYDRATION/PREVENTION OF DEHYDRATION

    The child who was not dehydrated and the child who is no longer dehydrated following rehydration should be allowed free fluids, and be encouraged to drink more than usual.25 40 Tables 3 and 4show standard methods for calculating ORS requirements. Table 5suggests when to send a stool sample to the laboratory.

    Table 3

    Calculation of oral rehydration solution requirements in the dehydrated child with acute gastroenteritis D

    Table 4

    Calculation of ORS maintenance fluid requirements F

    Table 5

    When to send a stool to the laboratory for microscopy, culture, sensitivity, and virology in acute diarrhoea

    Recommendation on maintenance fluids

    • To prevent primary dehydration or recurrence of dehydration, allow unrestricted fluids (for example, milk or water). Ensure that at least maintenance fluids are taken. (Level Va and Delphi consensus, Grade D recommendation.)

    G: REFEEDING FOLLOWING REHYDRATION

    Good evidence exists to show that children who are breast fed should continue breast feeding throughout the rehydration and maintenance phases of their therapy24 56 (III, C). In so doing they reduce the risk of dehydration, pass smaller volumes of stool, and recover quicker.

    In children with acute gastroenteritis who are formula fed, the vast majority (over 80%) can be successfully managed following rehydration with continued feeding of undiluted non-human milks55 (I, A). This is now recommended practice, including the introduction of age appropriate diets in children who are weaned.25 40 45 67

    Recommendation on refeeding (see table 6)

    • Breast feeding children should continue to breast feed through the rehydration and maintenance phases of their acute gastroenteritis illness. (Level III and Delphi consensus, Grade C recommendation.)

    • In the dehydrated child with gastroenteritis who is normally formula fed, feeds should stop during rehydration and restart as soon as the child is rehydrated (four hours). (Level I and Delphi consensus, Grade A recommendation.)

    Table 6

    Management of feeding during acute gastroenteritis G

    H: CRITERIA FOR ADMISSION OF CHILDREN WITH GASTROENTERITIS

    Statement—There are no published trials comparing outpatient with inpatient management, nor are there any recommendations made by eminent bodies.

    Recommendations for admission

    The following reached Delphi consensus agreement.

    • Children presenting to hospital with acute gastroenteritis who are severely dehydrated should be admitted to hospital.

    • Those children with mild–moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3–4 hours) and maintenance of hydration (2–3 hours).

    • Those children at high risk of dehydration on the basis of young age (infants <6 months22 23 (III, C)), high frequency of watery stools (more than eight per 24 hours22 24 (III, C)) or vomits (more than four per 24 hours22 24 (III, C)) should be observed in a hospital paediatric facility for at least 4–6 hours to ensure adequate maintenance of hydration.

    • Those children whose parents or carers are thought to be unable to manage the child's condition at home successfully should be admitted to hospital.

    (Based on Delphi consensus.)

    I: ROLE OF MEDICATION

    There is evidence from several randomised controlled trials that antidiarrhoeal and antimotility agents are not clinically beneficial in the management of acute childhood gastroenteritis, and their side effect profile is unacceptable (reviews of trials25 40(I, A)).

    Recommendation on medication (see table 7)

    • Infants and children with acute gastroenteritis should not be treated with antidiarrhoeal agents.

    Table 7

    Guide to drug treatment in acute gastroenteritis G

    (Level I and Delphi consensus, Grade A recommendation.)

    Key recommendations

    All gained consensus. The level of evidence and strength of recommendation follow each statement

    • Level of dehydration is assessed using a table modified from WHO criteria (III, C)

    • Those with no dehydration (<3%) should continue with their normal fluids at at least maintenance levels (Va, D)

    • Those with mild–moderate dehydration (3–8%) should have their deficit estimated and replaced over four hours with oral rehydration solution (glucose based and reduced osmolality, 200–250 mOsm/l) (I, A)

    • Oral rehydration solution should be given in small aliquots frequently. If vomiting persists it should be given by nasogastric tube (preferred) or intravenous rehydration commenced (I, A)

    • No routine investigations of U&E are required unless intravenous rehydration is commenced or hypernatraemia is suspected clinically (Va, D)

    • Children with mild–moderate and severe dehydration should be admitted to hospital for rehydration (consensus, D)

    • Following rehydration (four hours) normal feeds should be recommenced (I, A)

    • There is no place for antidiarrhoeal medication (I, A)

    Discussion

    This guideline for the management of the child who presents with acute diarrhoea to hospital was developed using a systematic literature review and formal consensus using a Delphi panel. It is striking that for this type of management guideline the level of published evidence on which recommendations are based is poor. During the Delphi process, 41 statements were made, of which 13% were based on level I evidence, 25% on level III, 52% on level V, and 10% on textbook recommendation or Delphi panel contributions. The final guideline consists of 34 consensus statements (83% of the total presented to the Delphi panel).

    This Delphi method of guideline development has several advantages. The use of a nationally selected panel of clinicians allows for a consensus view to be gained on those issues on which published evidence is lacking. Thus a comprehensive guideline can be produced with recommendations on all areas of management, which is likely to be acceptable and practical. It is likely to then need only simple local tailoring prior to being adopted. This method ensures that the guideline is clear on the level of evidence for each recommendation so that the clinician knows which are based on strong evidence from the literature and which on consensus.

    There are also potential weaknesses with this approach. For the areas where there is little or no good evidence in the literature the process relies on the opinion of the participating panellists. It is therefore possible to tap into collective error—the whole group managing children in a certain way based on historical practice rather than evidence. The importance of stating the level of evidence for each recommendation is again highlighted, so individual clinicians and local guideline development panels can immediately see which are based on strong evidence and which are not. The method was time consuming, with the whole process taking one year from initiating literature review to implementation of the guideline. It is therefore possible that high quality evidence is published in the intervening period which cannot be included in the recommendations at the time of publication, since it did not go through the Delphi process.

    Further research would be beneficial on many of the decision points discussed, for example: the assessment of risk of dehydration in the child in a developed country, outpatient versus inpatient management of rehydration, nasogastric versus oral rehydration, and cereal versus glucose based ORS for rehydration (and palatability) in a developed country.

    We intend to review the evidence and consensus on which this guideline is based in approximately three years from the date of its completion (May 1999).

    Acknowledgments

    The authors acknowledge Children Nationwide Medical Research Fund for their generous funding of this research, and Jeanette Taylor-Meek for effective administration of the Delphi process. The following Delphi panelists are acknowledged for contributing a great deal of time and effort: Ackland F (paediatric consultant), Arrowsmith W A (paediatric consultant), Bailey R (A&E consultant), Barker R (paediatric nurse), Bennett Britton S (paediatric consultant), Boon A W (paediatric consultant), Boyle R (paediatric specialist registrar), Cade A (paediatric specialist registrar), Carter E (paediatric consultant), Charlton C P J (paediatric consultant (gastroenterology)), Cutting W A M (paediatric consultant), Cutts J (paediatric nurse), Devane S (paediatric consultant), Edge J (paediatric consultant), Ehrhardt P (paediatric consultant), Gleeson E (A&E specialist registrar), Green C (paediatric consultant), Hewertson J (paediatric consultant), Hodges S (paediatric consultant), Huynh H (paediatric specialist registrar), Jefferson I (paediatric consultant), Jenkins H (paediatric consultant (gastroenterology)), Kershaw C (paediatric consultant), Laurent S (paediatric consultant), Lewis H M (paediatric consultant), Marcovitch H (paediatric consultant), McGovern M C (paediatric specialist registrar), McGraw M E (paediatric consultant), McLain B (paediatric consultant), Mirfattahi M M B (paediatric consultant), Puntis J (paediatric consultant (gastroenterology)), Rutter N (paediatric consultant), Sajjanhar T (paediatric consultant (A&E)), Smith R (paediatric consultant), Smith S (paediatric consultant (A&E)), Stephens S (paediatric specialist registrar), Sullivan C (paediatric consultant), Thomas S (paediatric specialist registrar), Wells L (paediatric specialist registrar).

    Appendix

    Table A1 summarises levels of evidence and grade of recommendation.

    References

    Commentary

    No doctor can hope to keep up to date with the literature across a broad spectrum of practice. National guidelines are helpful where they bring together all the evidence from research and synthesise it into a series of recommendations showing the strength of that evidence. Dr Armon and colleagues have used a formal consensus process to provide guidance, and this raises a number of important questions. It happens that there are also recent guidelines on acute diarrhoea management published by Murphy in 1998,1-1 and by the American Academy of Paediatrics (AAP) in 1996.1-2 If guidelines are to provide truly evidence based recommendations, they must be developed rigorously. How do these three guidelines measure up to the standards published by the Royal College of Paediatrics and Child Health?1-3

    They are all based on a detailed review of the literature, and two contain explicit levels of evidence for the recommendations. They were not conducted with the rigour of the systematic reviews in the Cochrane database. For example, the review of Dr Armon et al did not include textword searching, and none included hand searching through journals not covered by the electronic databases. There was no attempt to establish whether unpublished trials exist: publication bias can result when journals are more likely to publish trials with positive results. The AAP guideline was supplemented by a technical report and focused on three specific aspects of management.

    The consensus guideline of Dr Armon et alinvolved consultants from several specialties, nurses, and specialist registrars. This is important in ensuring that the perspectives of all those involved contribute to the guidance. However, with only two nurses on the panel, the Delphi process would have allowed consensus to be achieved, even when both nurses disagreed. The lack of any primary care or parental input to the process undermines the section on admission criteria, for which research evidence appears to be lacking. The assistance of parents with recent experience of managing acute diarrhoea in their children would have been most valuable in formulating written material for parents.

    The key message to emerge from all three guidelines is the safety and effectiveness of oral rehydration solutions, even in children with moderate (up to 8%) dehydration without shock. Additionally, that administration of the calculated deficit over a few hours is simple and effective. Crucial to achieving success with oral rehydration solution is the time that it takes carers to administer. All three guidelines recommend the correction of dehydration orally over a period of four hours. This would mean for some infants and children a rate of up to 80 ml/kg over four hours. However, in none of six controlled trials that I looked up,1-4-1-9 was this rate of oral administration attempted, and in only one1-7 was it achieved. Is this recommendation therefore actually consistent with the evidence, or indeed better than six or eight hours for achieving rehydration? It was rated an A grade in Dr Armon and colleagues' guideline.

    Where does this leave the UK practising paediatrician? Given the limitations of the three guidelines, there is a risk that important evidence may be missing or inadequately interpreted. We still need a well conducted evidence based guideline, involving all professional groups, primary care and parents, and based on a rigorous literature review. However, the studies that support these guidelines are compelling, and we should not wait before using a multiprofessional approach to getting oral rehydration therapy into practice at the local level. Read all three guidelines as a starting point in reviewing or developing local guidelines, but check back to the key original publications. I will leave it to you, the reader, to judge how much extra value you get from Dr Armon and colleagues' consensus statements.

    References

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    2. 1-2.
    3. 1-3.
    4. 1-4.
    5. 1-5.
    6. 1-6.
    7. 1-7.
    8. 1-8.
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    View Abstract
    • Guideline for the management of children presenting to hospital with diarrhoea, with or without vomiting

      Paediatric Accident and Emergency Research Group:

      Dr Kate Armon, Prof. Terence Stephenson, Dr Ursula Werneke, Miss Phillippa Eccleston and Dr Roderick MacFaul

       

      Dr Kate Armon. BmedSci BMBS MRCP MRCPCH DCH DRCOG

      Research Fellow, Academic Division of Child Health,

      School of Human Development,

      University of Nottingham, NG7 2UH.

      Prof. Terence Stephenson, BSc BM DM BCh FRCP FRCPCH,

      Professor of Child Health and Honorary Consultant Paediatrician,

      Academic Division of Child Health

      School of Human Development,

      University of Nottingham

      Dr Ursula Werneke, MD MSc MRCPsych

      Specialist Registrar

      Maudsley Hospital

      London SE5 8AZ

      Miss Philippa Eccleston, BSc (hons) RGN RSCN .

      Nurse Researcher,

      Academic Division of Child Health,

      School of Human Development,

      University of Nottingham.

      Dr Roderick MacFaul MB ChB FRCP FRCPCH DCH

      Consultant Paediatrician

      Pinderfields General Hospital

      Aberford Road

      Wakefield

      Correspondence to:

      Dr kate Armon

      Conflict of interest: none

      Funding: Children Nationwide Medical Research Fund

       

      Acknowledgements

        • The following Delphi panellists for contributing a great deal of time and effort:

        Ackland F (Paed. Cons.), Arrowsmith W A (Paed. Cons.), Bailey R (A&E Cons), Barker R (Paed. Nurse), Bennett Britton S (Paed. Cons.), Boon A W (Paed. Cons.), Boyle R (Paed. SpR.), Cade A (Paed. SpR.), Carter E (Paed. Cons.), Charlton C P J (Paed. Cons. (gastro)), Cutting W A M (Paed. Cons.), Cutts J (Paed. Nurse), Devane S (Paed. Cons.), Edge J (Paed. Cons.), Ehrhardt P (Paed. Cons.), Gleeson E (A&E SpR), Green C (Paed. Cons.), Hewertson J (Paed. Cons.), Hodges S(Paed. Cons.), Huynh H (Paed. SpR.), Jefferson I (Paed. Cons.), Jenkins H (Paed. Cons. (gastro)), Kershaw C (Paed. Cons.), Laurent S (Paed. Cons.), Lewis H M (Paed. Cons.), Marcovitch H (Paed. Cons.), McGovern M C (Paed. SpR.), McGraw M E (Paed. Cons.), McLain B (Paed. Cons.), Mirfattahi M M B (Paed. Cons.), Puntis J (Paed. Cons. (gastro)), Rutter N (Paed. Cons.), Sajjanhar T (Paed. Cons. (A&E)), Smith R (Paed. Cons.), Smith S (Paed. Cons. (A&E)), Stephens S (Paed. SpR.), Sullivan C (Paed. Cons.), Thomas S (Paed. SpR.), Wells L (Paed. SpR.).

        Key: Paed. = Paediatric, Cons. = Consultant, SpR = Specialist Registrar, A&E = Accident and Emergency, Gastro = Gastroenterology

        • Children Nationwide for their generous funding of this research
        • Jeanette Taylor-Meek for effective administration of the Delphi process
        • Abdominal pain with tenderness/guarding and/or bilious vomiting (?surgical)
        • Pallor, jaundice, oligoanuria, bloody stool (?HUS)
        • Systemically unwell, out of proportion to the level of dehydration (other infections, surgical, CAH etc)
        • Shock
        • Signs are ordered in each column by severity.
        • If a pre-illness accurate weight is available calculate deficit from weight loss.
        • Pinch test � Pinch skin of abdomen. Skin recoils instantly = normal, 1-2 sec = mild/moderate, >2sec = severe.
        • Children who are dehydrated are thirsty and do not normally refuse ORS.
        • Give fluid little and often. If the child is vomiting decrease volumes and increase frequency (every 5-10 minutes).
        • Where carers are not willing/able to do this under supervision (or child is asleep) then rehydrate by NGT.
        • Suitable ORS are Dioralyte, Diocalm Junior or Electrolade.
        • A history of blood +/- mucous in the stool
        • Systemically unwell, severe or prolonged diarrhoea
        • If the child is admitted to hospital (local policy)
        • A history suggestive of food poisoning
        • Recent travel abroad
        • Definition of diarrhoea
        • Differential diagnosis
        • Abdominal pain with tenderness +/- guarding (Vb,D)
        • Pallor, jaundice, oligo/anuria, bloody diarrhoea (III,C)
        • Systemically unwell, out of proportion to the level of dehydration (Vb,D)
        • Shock (Vb,D)
        • Estimation of severity of dehydration
        • Investigations (plasma)
        • Severe dehydration with circulatory compromise
        • Moderate dehydration where a �doughy� feel to the skin might indicate hypernatraemia
        • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes
        • When Intravenous rehydration is required. Severe dehydration with circulatory compromise
        • Further boluses
        • Hypernatraemic dehydration
        • Oral versus IV rehydration in the severely dehydrated child following restoration of circulating fluid volume.
        • Ward management of rehydration
        • Commercial solutions conforming to this include: dioralyte and diocalm Junior.
        • Urea and Electrolyte investigation in mild to moderate dehydration
        • Rehydration / maintenance and ongoing losses
        • Failure of ORS
        • Maintenance of hydration/ prevention of dehydration
        • Re-feeding following rehydration
        • Information
        • Admission criteria
        • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
        • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
        • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
        • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.
        • Risk of dehydration
        • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
        • More than 8 significant* diarrhoeal stools in the last 24 hours.
        • A �significant� vomit is anything more than an effortless, small volume, possett.
        • Replacement of losses in the child at risk of dehydration.
        • Criteria for admission of children with gastroenteritis
        • Literature concerning the need for stool culture
        • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
        • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
        • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
        • A history suggestive of food poisoning (no literature, Delphi consensus)
        • Recent travel abroad (Level Vb and Delphi consensus, grade D)
        • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).
        • Role of medication in gastroenteritis
        • Salmonella typhi � ciprofloxacin until sensitivities available
        • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
        • Giardia � metronidazole
        • Amoebiasis � metronidazole and Diloxanide furoate.
        • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
        • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
        • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
        • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
        • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
        • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
        • Your child�s weight today is
        • He/She needs to take in at least of fluid over a 24 hour period.
        • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
        • Stop all solid food until the vomiting has settled
        • If your baby is breast fed continue to feed on demand
        • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
        • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
        • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
        • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
        • AVOID fatty foods and sugary foods.
        • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
        • When a child is not dehydrated they may be used to supplement the child�s normal fluid.
        • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.
        • The diarrhoea has blood in it
        • Your child becomes more sleepy, lethargic or irritable than usual
        • Your child has 5 or more vomits in 24 hours
        • Your child has 9 or more loose poos in 24 hours
        • The diarrhoea continues for more than 7 days
        • Try to change the nappy as soon as it is dirty.
        • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
        • Apply barrier cream or Vaseline liberally.
        • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
        • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
        • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.

         

         

        Key words

        Diarrhoea, gastroenteritis, Delphi consensus, guideline

        Contents

         

         

         

        Page

        Quick reference guideline: Algorithm and associated tables 1-7

        4

        Abstract

        9

        Context, background information and date for review

        11

        Technical report on the guideline development process

        14

        Annotations A-S discussing evidence base for decision points in the algorithm

        16

        Associated tables 8-12

        35

        References

        40

        Implementation study

        43

        Suggested audit measures

        44

        Appendix 1. Definition of levels of evidence and grades of recommendation

        45

        Appendix 2. Parent information sheets

        46

        Appendix 3. Care pathway used in implementation

        49

        Appendix 4. Appraisal review document

        53

         

         

         

         

        Table 1: Broad differential diagnosis of the child presenting with acute diarrhoea (+/- vomiting). The latter diagnoses are more likely to present chronically.

        NB. The following features may be indicative of diagnoses other than acute viral gastroenteritis:

        • Abdominal pain with tenderness/guarding and/or bilious vomiting (?surgical)
        • Pallor, jaundice, oligoanuria, bloody stool (?HUS)
        • Systemically unwell, out of proportion to the level of dehydration (other infections, surgical, CAH etc)
        • Shock
        • Signs are ordered in each column by severity.
        • If a pre-illness accurate weight is available calculate deficit from weight loss.
        • Pinch test � Pinch skin of abdomen. Skin recoils instantly = normal, 1-2 sec = mild/moderate, >2sec = severe.
        • Children who are dehydrated are thirsty and do not normally refuse ORS.
        • Give fluid little and often. If the child is vomiting decrease volumes and increase frequency (every 5-10 minutes).
        • Where carers are not willing/able to do this under supervision (or child is asleep) then rehydrate by NGT.
        • Suitable ORS are Dioralyte, Diocalm Junior or Electrolade.
        • A history of blood +/- mucous in the stool
        • Systemically unwell, severe or prolonged diarrhoea
        • If the child is admitted to hospital (local policy)
        • A history suggestive of food poisoning
        • Recent travel abroad
        • Definition of diarrhoea
        • Differential diagnosis
        • Abdominal pain with tenderness +/- guarding (Vb,D)
        • Pallor, jaundice, oligo/anuria, bloody diarrhoea (III,C)
        • Systemically unwell, out of proportion to the level of dehydration (Vb,D)
        • Shock (Vb,D)
        • Estimation of severity of dehydration
        • Investigations (plasma)
        • Severe dehydration with circulatory compromise
        • Moderate dehydration where a �doughy� feel to the skin might indicate hypernatraemia
        • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes
        • When Intravenous rehydration is required. Severe dehydration with circulatory compromise
        • Further boluses
        • Hypernatraemic dehydration
        • Oral versus IV rehydration in the severely dehydrated child following restoration of circulating fluid volume.
        • Ward management of rehydration
        • Commercial solutions conforming to this include: dioralyte and diocalm Junior.
        • Urea and Electrolyte investigation in mild to moderate dehydration
        • Rehydration / maintenance and ongoing losses
        • Failure of ORS
        • Maintenance of hydration/ prevention of dehydration
        • Re-feeding following rehydration
        • Information
        • Admission criteria
        • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
        • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
        • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
        • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.
        • Risk of dehydration
        • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
        • More than 8 significant* diarrhoeal stools in the last 24 hours.
        • A �significant� vomit is anything more than an effortless, small volume, possett.
        • Replacement of losses in the child at risk of dehydration.
        • Criteria for admission of children with gastroenteritis
        • Literature concerning the need for stool culture
        • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
        • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
        • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
        • A history suggestive of food poisoning (no literature, Delphi consensus)
        • Recent travel abroad (Level Vb and Delphi consensus, grade D)
        • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).
        • Role of medication in gastroenteritis
        • Salmonella typhi � ciprofloxacin until sensitivities available
        • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
        • Giardia � metronidazole
        • Amoebiasis � metronidazole and Diloxanide furoate.
        • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
        • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
        • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
        • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
        • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
        • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
        • Your child�s weight today is
        • He/She needs to take in at least of fluid over a 24 hour period.
        • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
        • Stop all solid food until the vomiting has settled
        • If your baby is breast fed continue to feed on demand
        • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
        • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
        • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
        • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
        • AVOID fatty foods and sugary foods.
        • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
        • When a child is not dehydrated they may be used to supplement the child�s normal fluid.
        • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.
        • The diarrhoea has blood in it
        • Your child becomes more sleepy, lethargic or irritable than usual
        • Your child has 5 or more vomits in 24 hours
        • Your child has 9 or more loose poos in 24 hours
        • The diarrhoea continues for more than 7 days
        • Try to change the nappy as soon as it is dirty.
        • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
        • Apply barrier cream or Vaseline liberally.
        • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
        • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
        • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.

        Category

        Examples

        Infections

        Enteral: viral (commonest cause), bacterial, parasitic

        Non enteral infections (UTI, pneumonia, Otitis media)- vomiting predominates

        Surgical

        Appendicitis, Intussusception, Obstruction, Short bowel syndrome

        Systemic illness

        Endocrinopathy (Diabetes, Hyperthyroidism, Congenital Adrenal Hyperplasia, Addison�s disease, hypoparathyroidism), Immunodeficiency.

        Antibiotic associated

        Whilst taking antibiotics and rarely Pseudo-membranous colitis

        Miscellaneous

        Constipation with overflow, Toxins, Haemolytic-uraemic syndrome (HUS), Toddler diarrhoea, Child Abuse (Munchausen by proxy, sexual)

        Dietary disturbance

        Food allergy/ intolerance (Lactose, Cows milk protein), starvation stools.

        Malabsorption

        Cystic fibrosis, Coeliac disease,

        Inflammation

        Ulcerative colitis/ Crohn�s, Hirschsprung�s enterocolitis

        Idiopathic/ Psychogenic

        Irritable bowel syndrome

         

         

        Table 2: Assessment of severity of dehydration (if in doubt err by over-estimating % dehydration).

        • Signs are ordered in each column by severity.
        • If a pre-illness accurate weight is available calculate deficit from weight loss.
        • Pinch test � Pinch skin of abdomen. Skin recoils instantly = normal, 1-2 sec = mild/moderate, >2sec = severe.

         

        No dehydration

        (Less than 3% weight loss)

        Mild- Moderate dehydration

        (3-8% weight loss)

        Ordered by increasing severity

         

         

        Severe dehydration

        (>9%weight loss)

        No signs

          • Dry mucous membranes

          (be wary in the mouth breather)

           

          Increasingly marked signs from the mild-mod. group plus:

           
            • Sunken eyes

            (and minimal or no tears)

             
              • Decreased peripheral perfusion
               
                • Diminished skin turgor

                (pinch test 1-2 sec)

                 

                (cool/mottled/pale peripheries. capillary refill time>2 seconds)

                 
                  • Altered neurological status

                  (drowsiness, irritability)

                   
                  • Circulatory collapse
                   
                    • Deep (acidotic) breathing
                      

                    Table 3: Calculation of Oral Rehydration Solution (ORS) requirements in dehydration.

                      • Mild to Moderate (3% - 8%) dehydration.

                      30 to 80mls per Kg in 4 hours

                      • Severe dehydration (>9%)

                      100mls per Kg in 4 hours

                      Practical Points:

                      • Children who are dehydrated are thirsty and do not normally refuse ORS.
                      • Give fluid little and often. If the child is vomiting decrease volumes and increase frequency (every 5-10 minutes).
                      • Where carers are not willing/able to do this under supervision (or child is asleep) then rehydrate by NGT.
                      • Suitable ORS are Dioralyte, Diocalm Junior or Electrolade.

                       

                      Table 4: Calculation of maintenance requirements.

                        • 100ml per Kg per 24 hours for the first 10Kg of body weight
                          • Added to: 50ml/Kg/day for the next 10 Kg of body weight
                            • Added to: 20ml/Kg/day for remaining Kg of body weight

                            E.g. A 22Kg child has maintenance requirements of: (10x100)+(10x50)+(2x20)=1,540mls/24hours

                            Ongoing losses:

                            These requirements should be supplemented if the child has frequent or substantial watery stools or vomits.

                             

                            Table 5: When to send a stool to the lab for microscopy, culture, sensitivity and virology.

                            • A history of blood +/- mucous in the stool
                            • Systemically unwell, severe or prolonged diarrhoea
                            • If the child is admitted to hospital (local policy)
                            • A history suggestive of food poisoning
                            • Recent travel abroad
                            • Definition of diarrhoea
                            • Differential diagnosis
                            • Abdominal pain with tenderness +/- guarding (Vb,D)
                            • Pallor, jaundice, oligo/anuria, bloody diarrhoea (III,C)
                            • Systemically unwell, out of proportion to the level of dehydration (Vb,D)
                            • Shock (Vb,D)
                            • Estimation of severity of dehydration
                            • Investigations (plasma)
                            • Severe dehydration with circulatory compromise
                            • Moderate dehydration where a �doughy� feel to the skin might indicate hypernatraemia
                            • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes
                            • When Intravenous rehydration is required. Severe dehydration with circulatory compromise
                            • Further boluses
                            • Hypernatraemic dehydration
                            • Oral versus IV rehydration in the severely dehydrated child following restoration of circulating fluid volume.
                            • Ward management of rehydration
                            • Commercial solutions conforming to this include: dioralyte and diocalm Junior.
                            • Urea and Electrolyte investigation in mild to moderate dehydration
                            • Rehydration / maintenance and ongoing losses
                            • Failure of ORS
                            • Maintenance of hydration/ prevention of dehydration
                            • Re-feeding following rehydration
                            • Information
                            • Admission criteria
                            • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
                            • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
                            • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
                            • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.
                            • Risk of dehydration
                            • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
                            • More than 8 significant* diarrhoeal stools in the last 24 hours.
                            • A �significant� vomit is anything more than an effortless, small volume, possett.
                            • Replacement of losses in the child at risk of dehydration.
                            • Criteria for admission of children with gastroenteritis
                            • Literature concerning the need for stool culture
                            • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
                            • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
                            • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
                            • A history suggestive of food poisoning (no literature, Delphi consensus)
                            • Recent travel abroad (Level Vb and Delphi consensus, grade D)
                            • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).
                            • Role of medication in gastroenteritis
                            • Salmonella typhi � ciprofloxacin until sensitivities available
                            • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
                            • Giardia � metronidazole
                            • Amoebiasis � metronidazole and Diloxanide furoate.
                            • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
                            • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
                            • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
                            • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
                            • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
                            • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
                            • Your child�s weight today is
                            • He/She needs to take in at least of fluid over a 24 hour period.
                            • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
                            • Stop all solid food until the vomiting has settled
                            • If your baby is breast fed continue to feed on demand
                            • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
                            • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
                            • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
                            • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
                            • AVOID fatty foods and sugary foods.
                            • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
                            • When a child is not dehydrated they may be used to supplement the child�s normal fluid.
                            • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.
                            • The diarrhoea has blood in it
                            • Your child becomes more sleepy, lethargic or irritable than usual
                            • Your child has 5 or more vomits in 24 hours
                            • Your child has 9 or more loose poos in 24 hours
                            • The diarrhoea continues for more than 7 days
                            • Try to change the nappy as soon as it is dirty.
                            • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
                            • Apply barrier cream or Vaseline liberally.
                            • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
                            • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
                            • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.

                             

                            Table 6: Management of feeding during gastroenteritis.

                              • Breast fed

                              Continue breastfeeding throughout rehydration and maintenance phases

                                • Formula fed

                                Restart feed at full strength as soon as rehydration complete (ideally 4 hours)

                                  • Weaned children

                                  Child�s normal fluids and solids following rehydration. Avoid fatty foods or foods high in simple sugars.

                                   

                                  Table 7: Guide to drug treatment.

                                    • Antidiarrhoeals

                                    Infants and Children should not be treated with antidiarrhoeal agents.

                                      • Antibiotics

                                      Patients with invasive Salmonella typhi, Shigella, amoebiasis and Giardiasis should be treated with antibiotics. Consider in infants<6months with other salmonellas, those who are systemically unwell and the immunocompromised.

                                       

                                       

                                      Abstract

                                      Structured in the format recommended by Hayward et al for guideline reports.

                                      Objective: An evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (+/- vomiting). The guideline was developed for this common problem (18% of all paediatric medical attenders) where variation in practice occurs.

                                      Options: Assessment, investigations (biochemistry and stool culture in particular), admission and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home.

                                      Evidence: A comprehensive review of English language literature using the electronic databases Medline, Embase and Cochrane from 1966 to June 1998 was performed. Articles were selected if they addressed the specific clinical question and personal reviews were excluded. The literature was appraised, graded, and synthesised qualitatively. Statements of recommendation were made.

                                      Consensus: An anonymous, postal Delphi consensus development was used. A National panel of 39 medical and nursing staff who frequently care for these children were asked to grade their agreement with the statements generated. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panellists� responses. Consensus was defined as 83% of panellists agreeing with the statement.

                                      Recommendations: in brief. Clinical signs useful in assessment of level of dehydration are given. Admit to a paediatric facility mild-moderate and severely dehydrated children. For those with mild-moderate dehydration, estimate the deficit and replace over 4 hours with Oral Rehydration Solution (ORS, glucose based, 200-250mOsm/L) little and often. Use a naso-gastric tube where necessary. Recommence normal feeds following rehydration. Observe children at high risk of dehydration (<6 months, >8 stools/day, >4 vomits/day) and ensure at least maintenance fluid is given. Antidiarrhoeal medication is not indicated.

                                      Validation: The guideline was piloted in the form of a care pathway in a paediatric accident and emergency department. The guideline reduced inappropriate investigations and intravenous infusions. The proportions of children admitted increased in keeping with the overall increases in medical admissions.

                                       

                                       

                                      Context

                                      This policy is for the child presenting to an acute facility (accident and emergency or admissions / paediatric assessment unit) with acute diarrhoea (<7 days) with or without vomiting. Children presenting with vomiting alone or chronic diarrhoea (>7 days) are not considered.

                                      The development group assumes that health care professionals will use general medical knowledge and clinical judgement in applying the recommendations in this document to the management of individual patients. These recommendations may not be appropriate for use in all circumstances.

                                      Background information

                                       

                                      Diarrhoea is defined as a change in bowel habit for the individual child resulting in substantially more frequent and/or looser stools. The UK incidence of diarrhoeal illness in children is not known, but it leads to high GP consultation rates (204/1000/year in the 0-4 age group) and hospital admissions (at least 7/1000/year <5 years old). It accounts for 16% of all paediatric medical presentations to A&E. In 1996 OPCS data for England and Wales states that there were 58 deaths from intestinal infections in children 0-15 years, accounting for 0.9% of all causes of death in this age group. This guideline was developed because gastroenteritis is common, management varies and junior doctors make many of the initial decisions.

                                      The vast majority of children have an infective cause, of which at least 80% are viral. The commonest causative organism is rotavirus, with a peak rate of infection in infants 6-12 months, and marked seasonality, peaking in Jan to March each year. The remaining 14% are predominantly campylobacter, salmonella, shigella and ecoli, in decreasing frequency. Acute infective diarrhoea is however a diagnosis of exclusion and other less common causes of diarrhoea must be considered and excluded first (see Table 1).

                                      Principles of management

                                      Morbidity and mortality are caused primarily by water and electrolyte losses in the stool. Thus the key to management is the prevention of dehydration and promotion of rehydration in those already dehydrated (see annotations K and L). This relies on an accurate estimate of the level of dehydration (Table 2). Rehydration should be done orally whenever possible and the keys to success are small amounts of Oral Rehydration Solution (ORS) frequently (Table 3).

                                       

                                      Date for review

                                      Three years from date of completed development (Jan 1999), due Jan 2002. Paediatric Accident and Emergency Research Group responsible for revisions.

                                       

                                       

                                      Technical report on guideline development

                                       

                                      Literature review

                                      A 'seed' algorithm was initially drawn up. This consisted of a flow chart detailing the decision path that the clinician might take when dealing with a child with diarrhoea. The decision points on this 'seed' algorithm were used to develop the key questions which required an answer. The questions were specified using the format described in evidence-based medicine texts , describing the patient population of interest, the problem, the intervention or test (with or without comparison) and the outcome. This set of key questions directed the literature search.

                                      The areas considered were: incidence of diarrhoea in the paediatric population; differential diagnoses of acute diarrhoea and their incidence; validity of history and examination in refining the diagnosis and determining severity; diagnostic tests required; need for admission; use of oral and intravenous rehydration in acute infective gastroenteritis; types of oral rehydration solution; patient and / or parent preferences in management. The search strategies for each question type are shown in table 8 with the clinical question type in table 9.

                                      The literature search for this guideline used the following databases: Medline (1966 to June 1998), Embase and Cochrane (to June 1998) confined to humans aged 0-16 and English language), the citations of the references found and references provided by colleagues. The following mesh headings and text words were used: diarrh*; diarrhea infantile; diarrhea to 14 years; diarrhoea; gastroenteritis; differential diagnosis; diagnos*; incidence; prevalence; aetiology; etiology; dehydration; patient admission; fluid therapy; intravenous; intravenous treatment; rehydration solution; administration, oral; enteral nutrition; faeces; feces; lactose intolerance; enteral; differential diagnosis.

                                      The references generated were limited to human, English language and child (aged 0-16). The remaining references were sifted for relevance to the clinical questions according to their titles and abstracts. They were then further sifted for inclusion and exclusion criteria. Articles with abstracts that demonstrated the following were examined: Those which addressed the specific clinical question; thorough scientific reviews of the literature; review or clinical guideline written by a national body; large, well designed clinical trial; Exclusions: Abstracts were excluded if the study was non-experimental, descriptive or opinion based.

                                      Relevant articles were appraised and abstracted using a pre-designed proforma. This was developed from epidemiological texts . The articles were assessed as to whether they met the primary and secondary guides as suggested by the evidence-based medicine group in their series of articles in the Journal of the American Medical Association. Sixty articles were of sufficient quality and relevance to be included in the literature review, based on the key clinical questions and the evidence found. Draft management statements were constructed for each step. The initial 'seed' algorithm was revised to incorporate the evidence found.

                                      Composition of the Delphi panel

                                      Members � as listed in the acknowledgments.

                                      The panellists selected were drawn from the United Kingdom, represented practice in both urban and rural settings and were clinicians who would be involved in management of a child after presentation at hospital. We did not include general practitioners, parents or patients. Ninety-six medical (consultant, registrar and SHO) and nursing staff from mixed adult/paediatric A&E departments, paediatric A&E departments, general paediatric departments (both teaching hospital and district general hospital) and specialist paediatric gastroenterology services were invited of whom 54 agreed to be included.

                                      Delphi process

                                      First round

                                      All panellists received by post: the literature review with derived management statements; a copy of all the articles cited, along with the critical appraisal abstraction sheet which included grade of evidence; a response form detailing each statement together with a 1-9 Likert scale and space for comments. The panellists were asked to rate their level of agreement with each statement as written and to comment. This first round �pack� was piloted (n=4) and revised where necessary to improve clarity and remove ambiguity. A reminder letter and a subsequent telephone call were made to non-responders. 39 panellists returned the first round response form and were included in subsequent rounds.

                                      The definition of consensus is crucial to the �consensus development� process, and should be decided before the process starts. For �nominal group consensus development� rules have been developed to assess agreement when statements have been ranked on a 9-point scale . We chose to apply this to the Delphi method since the same scale was used. One sixth of the ratings furthest from the median were removed. This is done so that outliers (who may not have understood the question, or are unique in their views) do not overly influence the results. Consensus within the panel (known as �relaxed� agreement for a nominal group) is defined as all remaining panellists� responses falling within 3 boxes of each other on the Likert scale. Consensus agreement with the statement as presented to the panel is defined as all remaining responses falling in boxes 7-9 (thus agreement both between the panel members and with the statement as given, known as �strict agreement� for a nominal group).

                                      Second and third rounds

                                      All statements that achieved �strict� consensus were removed from subsequent rounds and used for guideline construction. For statements that did not gain consensus, modified and new statements were used in the second round. After the extreme one sixth of responses were removed, the range, inter-quartile range and median of the remaining responses were reported back to the panellists, along with any comments made. Panellists were asked to re-consider the statements in the light of the responses and comments of the rest of the panel. A third round consisted of statements that had not yet achieved consensus.

                                      The guideline

                                      All statements, which had achieved �strict� consensus, were used to generate a guideline in algorithm format. Each box is numbered and annotated, referring the user to the evidence on which decisions are based. The literature review, level of evidence, grade of recommendation and consensus base of each decision point is given. The algorithm formed the basis of an integrated care pathway, which was used to pilot the guideline (described later) and to study its impact.

                                      Throughout, the word �admit� is defined as follows: �any admission to a paediatric facility with paediatric trained staff for observation, further investigation and management regardless of the expected length of stay�.

                                      The algorithm is shown at the beginning of this document and the annotations for each box follow.

                                      Annotations A-S

                                      Corresponding with letters A-S on the algorithm

                                      Summary table of the levels of evidence and grade of recommendation � fully reported in appendix 1

                                      Level

                                      Strength of evidence (Adapted from Muir Gray)

                                      Grade

                                      Grade of recommendation (Cook et al)

                                      I

                                      Strong evidence from at least one systematic review of multiple well-designed randomised controlled trials

                                      A

                                      Supported by level I evidence and therefore highly recommended.

                                      I I

                                      Strong evidence from at least one properly designed randomised controlled trial of appropriate size.

                                      B

                                      supported by level II evidence, and therefore recommended

                                      I I I

                                      Evidence from well-designed trials without randomisation, single group pre-post, cohort, time series or matched case-control studies

                                      C

                                      Supported by level III, evidence. Several potential clinical actions might be considered appropriate.

                                      IV

                                      Evidence from well-designed non-experimental studies from more than one centre or research group

                                       

                                      D

                                       

                                      Supported by level IV and V evidence. The consensus route would have to be adopted.

                                      Va

                                      Vb

                                      Opinions of respected authorities

                                      Clinical evidence, descriptive studies or reports of expert committees

                                      D

                                      D

                                       

                                      Discussion of the evidence for steps A-S on the algorithm

                                      For each of the alphabetised boxes on the algorithm the literature is discussed. A statement is then made in Italics, which was put to the Delphi panel. The level of evidence for the statement and whether it achieved consensus with the panel follows.

                                       

                                        • Definition of diarrhoea

                                        Diarrhoea is present when there is an increase in the frequency, volume or liquidity of the stool relative to the usual habit of the individual. There is a great variability in stool patterns amongst normal infants. Typically children excrete 5-10 g/Kg per day , but this can vary tremendously. Table 10 shows the range of stool pattern in normal infants. Most papers accept a working definition of diarrhoea as follows:

                                        RECOMMENDATION

                                        Diarrhoea is defined as a change in bowel habit for the individual child resulting in substantially more frequent and/or looser stools.

                                        (Based on Level Vb evidence and Delphi consensus, grade D recommendation)

                                        • Differential diagnosis

                                        Once a child has attended Accident and Emergency with a presenting complaint of diarrhoea with or without vomiting we need to know the possible differential diagnoses and the likelihood of these. Unfortunately there is very little data available to help with this clinical question. Conway et al performed a prospective hospital cohort study of patients initially thought to have acute gastro-enteritis and subsequently given other diagnoses. They included patients with vomiting alone. 1,148 were enrolled of which 59(5%) were found to have other diagnoses, which included infections other than in the GI tract, pyloric stenosis, feeding problems and cows milk protein intolerance.

                                        Fleischer in his textbook of paediatric emergency medicine (Vb,D) gives a differential diagnostic list for children presenting with diarrhoea. In the absence of published evidence a modified list of differentials was sent to the Delphi panel and consensus agreement was achieved on table 1of the algorithm.

                                        RECOMMENDATION

                                        Table 1 to aid the differential diagnosis of the child presenting with diarrhoea

                                        (Based on Level Vb evidence and Delphi consensus, grade D recommendation)

                                         

                                         

                                        With respect to life threatening causes of diarrhoea, three studies yield helpful clinical information:

                                        Macdonald and Beattie , (Vb,D) carried out a retrospective review of children with intussusception over a 10 year period. Population Incidence was found to be about 1 per 1000 in the first year of life. There were 110 children in whom 32% had diarrhoea at first presentation. 26% were shocked or dehydrated, 83% were vomiting, and 32% had bloody stool. The peak age of diagnosis was 5 months with 80% under 1. Only 42% were diagnosed correctly within 3 hours of admission.

                                        Milford et al , (III,C) reported on the clinical and epidemiological aspects of HUS in the British Isles (2987-1989), finding cases through the British Paediatric Surveillance Unit and other sources. The overall incidence in children aged 0-15 years was 0.91/100,000. The peak incidence was in the age group 1-2 years at 3.3/100,000/year. 298 children were reported over the three-year surveillance. A prodrome of diarrhoea was present in 273 (95%) of cases and in 199 it was bloody. Diagnostic features on presentation were pallor in 92%, jaundice in 35% and oligo/anuria in 38%.

                                        Reynolds , (Vb,D) looked retrospectively at children presenting with abdominal pain to the A&E department. 371 children were identified over 4 seasonally diverse months. The final diagnoses were medical in 64.4%, surgical in 6.5% and nonspecific in 29.1%. Guarding and abdominal tenderness were the two signs most strongly associated with a surgical diagnosis.

                                        RECOMMENDATION

                                        The following clinical features should alert the clinician to look for causes other than acute viral gastro-enteritis for a child�s diarrhoea +/- vomiting:

                                        • Abdominal pain with tenderness +/- guarding (Vb,D)
                                        • Pallor, jaundice, oligo/anuria, bloody diarrhoea (III,C)
                                        • Systemically unwell, out of proportion to the level of dehydration (Vb,D)
                                        • Shock (Vb,D)
                                        • Estimation of severity of dehydration
                                        • Investigations (plasma)
                                        • Severe dehydration with circulatory compromise
                                        • Moderate dehydration where a �doughy� feel to the skin might indicate hypernatraemia
                                        • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes
                                        • When Intravenous rehydration is required. Severe dehydration with circulatory compromise
                                        • Further boluses
                                        • Hypernatraemic dehydration
                                        • Oral versus IV rehydration in the severely dehydrated child following restoration of circulating fluid volume.
                                        • Ward management of rehydration
                                        • Commercial solutions conforming to this include: dioralyte and diocalm Junior.
                                        • Urea and Electrolyte investigation in mild to moderate dehydration
                                        • Rehydration / maintenance and ongoing losses
                                        • Failure of ORS
                                        • Maintenance of hydration/ prevention of dehydration
                                        • Re-feeding following rehydration
                                        • Information
                                        • Admission criteria
                                        • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
                                        • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
                                        • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
                                        • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.
                                        • Risk of dehydration
                                        • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
                                        • More than 8 significant* diarrhoeal stools in the last 24 hours.
                                        • A �significant� vomit is anything more than an effortless, small volume, possett.
                                        • Replacement of losses in the child at risk of dehydration.
                                        • Criteria for admission of children with gastroenteritis
                                        • Literature concerning the need for stool culture
                                        • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
                                        • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
                                        • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
                                        • A history suggestive of food poisoning (no literature, Delphi consensus)
                                        • Recent travel abroad (Level Vb and Delphi consensus, grade D)
                                        • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).
                                        • Role of medication in gastroenteritis
                                        • Salmonella typhi � ciprofloxacin until sensitivities available
                                        • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
                                        • Giardia � metronidazole
                                        • Amoebiasis � metronidazole and Diloxanide furoate.
                                        • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
                                        • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
                                        • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
                                        • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
                                        • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
                                        • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
                                        • Your child�s weight today is
                                        • He/She needs to take in at least of fluid over a 24 hour period.
                                        • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
                                        • Stop all solid food until the vomiting has settled
                                        • If your baby is breast fed continue to feed on demand
                                        • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
                                        • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
                                        • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
                                        • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
                                        • AVOID fatty foods and sugary foods.
                                        • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
                                        • When a child is not dehydrated they may be used to supplement the child�s normal fluid.
                                        • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.
                                        • The diarrhoea has blood in it
                                        • Your child becomes more sleepy, lethargic or irritable than usual
                                        • Your child has 5 or more vomits in 24 hours
                                        • Your child has 9 or more loose poos in 24 hours
                                        • The diarrhoea continues for more than 7 days
                                        • Try to change the nappy as soon as it is dirty.
                                        • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
                                        • Apply barrier cream or Vaseline liberally.
                                        • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
                                        • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
                                        • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.
                                        • Systemically unwell, out of proportion to the level of dehydration (Vb,D)
                                        • Shock (Vb,D)
                                        • Estimation of severity of dehydration
                                        • Investigations (plasma)
                                        • Severe dehydration with circulatory compromise
                                        • Moderate dehydration where a �doughy� feel to the skin might indicate hypernatraemia
                                        • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes
                                        • When Intravenous rehydration is required. Severe dehydration with circulatory compromise
                                        • Further boluses
                                        • Hypernatraemic dehydration
                                        • Oral versus IV rehydration in the severely dehydrated child following restoration of circulating fluid volume.
                                        • Ward management of rehydration
                                        • Commercial solutions conforming to this include: dioralyte and diocalm Junior.
                                        • Urea and Electrolyte investigation in mild to moderate dehydration
                                        • Rehydration / maintenance and ongoing losses
                                        • Failure of ORS
                                        • Maintenance of hydration/ prevention of dehydration
                                        • Re-feeding following rehydration
                                        • Information
                                        • Admission criteria
                                        • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
                                        • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
                                        • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
                                        • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.
                                        • Risk of dehydration
                                        • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
                                        • More than 8 significant* diarrhoeal stools in the last 24 hours.
                                        • A �significant� vomit is anything more than an effortless, small volume, possett.
                                        • Replacement of losses in the child at risk of dehydration.
                                        • Criteria for admission of children with gastroenteritis
                                        • Literature concerning the need for stool culture
                                        • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
                                        • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
                                        • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
                                        • A history suggestive of food poisoning (no literature, Delphi consensus)
                                        • Recent travel abroad (Level Vb and Delphi consensus, grade D)
                                        • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).
                                        • Role of medication in gastroenteritis
                                        • Salmonella typhi � ciprofloxacin until sensitivities available
                                        • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
                                        • Giardia � metronidazole
                                        • Amoebiasis � metronidazole and Diloxanide furoate.
                                        • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
                                        • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
                                        • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
                                        • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
                                        • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
                                        • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
                                        • Your child�s weight today is
                                        • He/She needs to take in at least of fluid over a 24 hour period.
                                        • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
                                        • Stop all solid food until the vomiting has settled
                                        • If your baby is breast fed continue to feed on demand
                                        • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
                                        • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
                                        • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
                                        • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
                                        • AVOID fatty foods and sugary foods.
                                        • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
                                        • When a child is not dehydrated they may be used to supplement the child�s normal fluid.
                                        • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.
                                        • The diarrhoea has blood in it
                                        • Your child becomes more sleepy, lethargic or irritable than usual
                                        • Your child has 5 or more vomits in 24 hours
                                        • Your child has 9 or more loose poos in 24 hours
                                        • The diarrhoea continues for more than 7 days
                                        • Try to change the nappy as soon as it is dirty.
                                        • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
                                        • Apply barrier cream or Vaseline liberally.
                                        • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
                                        • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
                                        • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.
                                        • Shock (Vb,D)
                                        • Estimation of severity of dehydration
                                        • Investigations (plasma)
                                        • Severe dehydration with circulatory compromise
                                        • Moderate dehydration where a �doughy� feel to the skin might indicate hypernatraemia
                                        • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes
                                        • When Intravenous rehydration is required. Severe dehydration with circulatory compromise
                                        • Further boluses
                                        • Hypernatraemic dehydration
                                        • Oral versus IV rehydration in the severely dehydrated child following restoration of circulating fluid volume.
                                        • Ward management of rehydration
                                        • Commercial solutions conforming to this include: dioralyte and diocalm Junior.
                                        • Urea and Electrolyte investigation in mild to moderate dehydration
                                        • Rehydration / maintenance and ongoing losses
                                        • Failure of ORS
                                        • Maintenance of hydration/ prevention of dehydration
                                        • Re-feeding following rehydration
                                        • Information
                                        • Admission criteria
                                        • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
                                        • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
                                        • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
                                        • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.
                                        • Risk of dehydration
                                        • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
                                        • More than 8 significant* diarrhoeal stools in the last 24 hours.
                                        • A �significant� vomit is anything more than an effortless, small volume, possett.
                                        • Replacement of losses in the child at risk of dehydration.
                                        • Criteria for admission of children with gastroenteritis
                                        • Literature concerning the need for stool culture
                                        • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
                                        • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
                                        • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
                                        • A history suggestive of food poisoning (no literature, Delphi consensus)
                                        • Recent travel abroad (Level Vb and Delphi consensus, grade D)
                                        • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).
                                        • Role of medication in gastroenteritis
                                        • Salmonella typhi � ciprofloxacin until sensitivities available
                                        • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
                                        • Giardia � metronidazole
                                        • Amoebiasis � metronidazole and Diloxanide furoate.
                                        • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
                                        • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
                                        • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
                                        • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
                                        • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
                                        • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
                                        • Your child�s weight today is
                                        • He/She needs to take in at least of fluid over a 24 hour period.
                                        • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
                                        • Stop all solid food until the vomiting has settled
                                        • If your baby is breast fed continue to feed on demand
                                        • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
                                        • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
                                        • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
                                        • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
                                        • AVOID fatty foods and sugary foods.
                                        • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
                                        • When a child is not dehydrated they may be used to supplement the child�s normal fluid.
                                        • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.
                                        • The diarrhoea has blood in it
                                        • Your child becomes more sleepy, lethargic or irritable than usual
                                        • Your child has 5 or more vomits in 24 hours
                                        • Your child has 9 or more loose poos in 24 hours
                                        • The diarrhoea continues for more than 7 days
                                        • Try to change the nappy as soon as it is dirty.
                                        • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
                                        • Apply barrier cream or Vaseline liberally.
                                        • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
                                        • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
                                        • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.

                                        (Evidence levels as shown and Delphi consensus, grade D recommendation)

                                         

                                          • Estimation of severity of dehydration

                                          Weight loss

                                          The severity of dehydration is most accurately assessed in terms of weight loss as a percentage of total body weight (prior to the dehydrating episode). An accurate weight immediately pre-illness is rarely available in the clinical situation, but if it is (for example a recent weight in the parent held record) dehydration can be estimated with some accuracy .

                                          Clinical signs

                                          In a prospective cohort study of children between 3 and 18 months of age in Egypt, Duggan (III,C) found that �prolonged skinfold�, dry oral mucosa, sunken eyes and �altered neurological status� were the best clinical signs correlating with dehydration as determined by post rehydration weight gain. In a similarly designed study, with children <4 years old, Mackenzie etal (III, C) found �decreased skin turgor�, decreased peripheral perfusion and deep (acidotic) breathing to be the best clinical signs. A urea of >6.5mmol/L on serum blood sample and pH<7.35 on blood gas were positive investigations associated with dehydration. However the sensitivity and specificity of all these signs were very low.

                                          In both studies clinical estimates of percentage dehydration greatly overestimated actual dehydration. The textbook estimation of dehydration came originally from the Medical Research Council descriptions in 1952, and was modified by Ironside in 1970, and more recently by Santosham in 1987 . The percentage weight loses on which they were based were not subject to confirmation in a clinical study. More recently two authors have looked at this. Duggan (III,C) found that those thought to be mildly dehydrated by Santosham�s scale showed weight gains of 3.6-3.9%, those moderately dehydrated showed gains of 4.9-5.3% and those severely dehydrated 9.5-9.8%.

                                          Mackenzie etal (III,C) looked only at children who were thought to be moderately dehydrated (7-10% estimated, with one of; diminished skin turgor, sunken eyes, dry mucous membranes, oliguria, recent weight loss). They found weight gains of 3.4-4.0%. These studies need repeating on larger numbers with rigorously defined clinical signs in order to confirm the findings. Nevertheless it is clear that estimation of dehydration may not be accurate.

                                          Capillary refill time >2 seconds has been proposed as a useful indicator of dehydration . This sign lacks sensitivity and specificity . Gorelick etal (II,B) showed that in healthy children the capillary refill time was abnormally prolonged following 15 minutes in a cool (air conditioned) room. However, given it�s limitations it is important to note that a child who is severely dehydrated is very unlikely to have a normal capillary refill time. Likewise a prolonged capillary refill in a child with diarrhoea should be taken as a sign of dehydration until proven otherwise .

                                          On the basis of the above studies and WHO guidelines on assessment of the dehydrated child table 2 was developed. Thus children are divided into three groups only, namely no dehydration, mild to moderate dehydration and severe dehydration. The number and severity of signs present will indicate the degree. The table was refined by the Delphi process and achieved consensus.

                                          RECOMMENDATION

                                          Table 2 for estimating level of dehydration.

                                          (Level III evidence and Delphi consensus, grade C recommendation)

                                           

                                          • Investigations (plasma)

                                          No studies have addressed this issue directly. Most episodes of dehydration caused by diarrhoea in developed countries are isonatraemic . Even when there is derangement of electrolytes in the serum, this is due to relative losses of salt and water. There will still be a total body depletion of sodium in hypernatraemic patients . It is clear from several hospital cohort studies that derangement of electrolytes in acute gastroenteritis in the UK is now rare. Table 11 summarizes three recent UK papers looking at hospital cohorts of children with GE. Approximately 1% of these admissions had hypernatraemia. None of these studies reported hypokalaemia or hyponatraemia, which are commonly found in patients dehydrated with cholera.

                                          Holliday (II, B) eloquently argues from published evidence that Oral Rehydration Solution with appropriate amounts of solutes and given in the correct quantity is sufficient in itself to correct electrolyte abnormalities (see also Meyers ). It is thus unnecessary to measure electrolytes in those children who will be rehydrated with Oral Rehydration Solution (ORS).

                                          If a child is severely dehydrated with circulatory compromise, they will need rapid Intravenous (IV) infusions to restore circulation and renal perfusion (20ml/kg boluses until circulation restored). Suitable fluids are normal saline or ringers lactate . All children having IV rehydration should have a U&E measured, as hypernatraemia will alter the rate at which IV rehydration fluids are given (discussed below). Further measurements of U&E should be made as rehydration progresses.

                                          The American Academy of Pediatrics (AAP) suggest in their practice parameter that Electrolyte levels should be measured in moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes, and in all severely dehydrated children. This is based on a consensus view (Va, D). They also state that clinicians should be aware of the clinical features of hypernatraemic dehydration, namely a doughy feel to the skin +/- irritability and fever. There is no quoted evidence on which this statement is based.

                                          RECOMMENDATION

                                          The child who presents with diarrhoea +/- vomiting should have blood taken for urea/creatinine, electrolytes and bicarbonate in the following circumstances:

                                          • Severe dehydration with circulatory compromise
                                          • Moderate dehydration where a �doughy� feel to the skin might indicate hypernatraemia
                                          • Moderately dehydrated children whose histories or physical findings are inconsistent with straightforward diarrhoeal episodes
                                          • When Intravenous rehydration is required. Severe dehydration with circulatory compromise
                                          • Further boluses
                                          • Hypernatraemic dehydration
                                          • Oral versus IV rehydration in the severely dehydrated child following restoration of circulating fluid volume.
                                          • Ward management of rehydration
                                          • Commercial solutions conforming to this include: dioralyte and diocalm Junior.
                                          • Urea and Electrolyte investigation in mild to moderate dehydration
                                          • Rehydration / maintenance and ongoing losses
                                          • Failure of ORS
                                          • Maintenance of hydration/ prevention of dehydration
                                          • Re-feeding following rehydration
                                          • Information
                                          • Admission criteria
                                          • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
                                          • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
                                          • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
                                          • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.
                                          • Risk of dehydration
                                          • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
                                          • More than 8 significant* diarrhoeal stools in the last 24 hours.
                                          • A �significant� vomit is anything more than an effortless, small volume, possett.
                                          • Replacement of losses in the child at risk of dehydration.
                                          • Criteria for admission of children with gastroenteritis
                                          • Literature concerning the need for stool culture
                                          • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
                                          • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
                                          • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
                                          • A history suggestive of food poisoning (no literature, Delphi consensus)
                                          • Recent travel abroad (Level Vb and Delphi consensus, grade D)
                                          • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).
                                          • Role of medication in gastroenteritis
                                          • Salmonella typhi � ciprofloxacin until sensitivities available
                                          • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
                                          • Giardia � metronidazole
                                          • Amoebiasis � metronidazole and Diloxanide furoate.
                                          • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
                                          • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
                                          • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
                                          • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
                                          • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
                                          • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
                                          • Your child�s weight today is
                                          • He/She needs to take in at least of fluid over a 24 hour period.
                                          • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
                                          • Stop all solid food until the vomiting has settled
                                          • If your baby is breast fed continue to feed on demand
                                          • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
                                          • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
                                          • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
                                          • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
                                          • AVOID fatty foods and sugary foods.
                                          • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
                                          • When a child is not dehydrated they may be used to supplement the child�s normal fluid.
                                          • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.
                                          • The diarrhoea has blood in it
                                          • Your child becomes more sleepy, lethargic or irritable than usual
                                          • Your child has 5 or more vomits in 24 hours
                                          • Your child has 9 or more loose poos in 24 hours
                                          • The diarrhoea continues for more than 7 days
                                          • Try to change the nappy as soon as it is dirty.
                                          • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
                                          • Apply barrier cream or Vaseline liberally.
                                          • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
                                          • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
                                          • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.

                                          All the above based on Level Vb evidence and Delphi consensus, grade D recommendation.

                                           

                                          1. IV Rehydration fluid in severe gastroenteritis

                                          If a child is severely dehydrated with circulatory compromise, they will need rapid IV infusions to restore circulation and renal perfusion (20ml/kg boluses until circulation restored). Suitable fluids are normal saline (Vb,D) or ringers lactate the compositions of which are given in Table 12. Once their circulation is stable replacement of the remaining estimated deficit can commence (details below).

                                          At the time of Delphi consensus development for this guideline there was controversy over the use of crystalloid versus colloid, which many of the Delphi panelists brought up in their comments. There was no literature on the particular issue of crystalloid versus colloid in the resuscitation of infants and children with diarrhoea. In studies in adults crystalloid is know to be as effective for rapid restoration of circulating fluid volume. Until we have more evidence for children (and this is likely to have to come from a developing country as the numbers of children presenting in shock with diarrhoea are so small in the UK) we will have to use the current literature which does not include a randomised controlled trial on crystalloid versus colloid. Sharifi , Mackenzie and Jenkins all report the use of crystalloid in severe dehydration. No studies report the use of colloid in diarrhoea.

                                          The child with dehydrating diarrhoea is different from a child with shock secondary to trauma or sepsis. The dehydrated child has lost water and salts from all body compartments. In severe dehydration the final compartment to decompensate is the intravascular one. The child will have a high haematocrit and will not have lost any plasma proteins. It thus seems reasonable from a theoretical point of view to restore what has been lost, namely water and salts.

                                          It is argued that if crystalloids are used they diffuse more readily into the interstitial and intracellular compartments. As these compartments are depleted in dehydrating diarrhoea, this seems a theoretically good thing, as long as further fluid is given to maintain intravascular volume.

                                          RECOMMENDATION

                                          Children who have severedehydration with circulatory compromise secondary to acute gastroenteritis should have their circulation restored by rapid IV infusion of normal saline or ringers lactate with a 20ml/kg bolus over one hour (faster if necessary). An experienced paediatrician should be involved early.

                                          (Based on Level I evidence and Delphi consensus, grade A recommendation)

                                          • Further boluses

                                          In severe dehydration one bolus may not be sufficient.

                                          RECOMMENDATION

                                          A further bolus of 20ml/kg should be given if the circulation is still compromised. If further boluses are required (>40ml/Kg) involve an anaesthetist early as intubation and ventilation should be considered

                                          (Based on Level Vb evidence and Delphi consensus, grade D recommendation)

                                          • Hypernatraemic dehydration

                                          It is acknowledged following the evidence of several randomised controlled trials in USA, Europe and developing countries that ORS is quicker in the correction of dehydration and acidosis and safer than IV therapy. Moreover the use of Oral Rehydration Therapy (ORT) appears to reduce the risk of seizure during correction of hypernatraemic dehydration, Pizarro et al(Vb,D) reported no seizures among 35 infants with hypernatraemic dehydration whose deficit was repaired with WHO-ORT over 12 hours.

                                          In the largest Randomised Controlled Trial (RCT) of IV versus ORT Sharifi et al(II,B) randomly assigned 470 children aged 1 to 18 months (without malnutrition) admitted to hospital in Tehran with severe acute GE to receive either ORS (administered initially by Naso-gastric tube (NGT)) or IV fluid. Of the 34 hypernatraemic patients in the ORT group, 2(6%) developed generalised seizures compared with 6 of 24 (25%) in the intravenous group. Similar results were found by Mackenzie (II,B) in a study in Australia, the ORS group fairing at least as well as the IV group.

                                          RECOMMENDATION

                                          The child with with hypernatraemic dehydration (Na>150mmol/L) secondary to acute gastro-enteritis should be given slow ORS, aiming to give the estimated deficit over 12 hours. Monitor electrolytes closely

                                          (Based on Level I evidence and Delphi consensus, grade A recommendation)

                                          • Oral versus IV rehydration in the severely dehydrated child following restoration of circulating fluid volume.

                                          The above literature suggests that further rehydration should be done with ORS .

                                          RECOMMENDATION

                                          Further rehydration can be done orally with ORS (given little and often) if the patient is stable and their mental state allows it.

                                          (Based on Level I evidence and Delphi consensus, grade A recommendation)

                                           

                                          • Ward management of rehydration

                                           

                                          The overriding principles of the management of gastro-enteritis are rehydration and prevention of dehydration. Several excellent systematic reviews have been published on this subject. The American Paediatric Association (I,A) and the European Society of Paediatric Gastroenterology and Nutrition (I,A) have both produced practice guidelines concerning management of children with gastro-enteritis, and their main recommendations are based on meta-analysis of good randomised controlled trials. In addition to these there is also a good systematic review published by Murphy (I,A).

                                          Composition of ORS

                                          In the 1970�s the WHO adopted a glucose-electrolyte solution for the treatment of diarrhoea that contained 90mmol/l of sodium. Since then there have been many controlled trials looking at the ideal concentration of electrolytes and carbohydrate in ORS. In developing countries rapid loses of sodium and potassium are documented, particularly with cholera, nevertheless a recent multicentre trial in 4 developing countries found that reduced osmolarity ORS (224mmol/l) had advantages over standard ORS (311mmol/l) in the treatment of non cholera diarrhoea (II,B). In developed countries diarrhoea tends to be isotonic, and therefore replacement of large quantities of sodium is not so imperative, and indeed may be harmful. Studies from Finland have confirmed that reduced osmolarity ORS is preferable in European children. European Society of Paediatric Gastroenterology And Nutritian (ESPGAN) have published guidelines on the ideal composition of ORS for children of Europe which have taken into account the results of these trials. See table 12 for the composition of ORS recommended and those commercially available.

                                          Many papers have been published looking at the different types of carbohydrate to be used in ORS. A recent meta-analysis of 13 clinical trials examining the effect of rice based ORS on total stool output and duration of diarrhoea showed that there appeared to be some benefit in those with cholera, but in those with non-cholera diarrhoea it was uncertain (I, A).

                                           

                                          RECOMMENDATION

                                          ORS used for rehydration of children with acute gastro-enteritis in the UK should contain: 60 mmol/l sodium, 20 mmol/l potassium, not<25 mmol/l chloride and between 74-111 mmol/l glucose.

                                            • Commercial solutions conforming to this include: dioralyte and diocalm Junior.

                                            (Based on Level I evidence and Delphi consensus, grade A recommendation)

                                            Practical points in the administration of ORS

                                            The authoritative reviews previously quoted state that ORS should only be used in the child who is dehydrated. It should be used for rehydration only (i.e. giving the calculated deficit over a 3-4 hour period of rehydration). It may also be used for the replacement of substantial ongoing losses in a child at high risk of dehydration. The algorithm gives some practical pointers for the administration of ORS which were derived from the AAP guideline (I,A) and modified by the Delphi Panel.

                                            RECOMMENDATION

                                            Children who have mild-moderatedehydration secondary to acute gastro-enteritis should have their deficit estimated (3% to 8%) and replaced with ORS (30-80ml/kg) given �little and often�* over 3-4 hours, whenever this is practically possibleψ .

                                            (Based on Level I evidence and Delphi consensus, grade A recommendation)

                                            *An attempt was made to define little and often further. The literature discusses the correct administration of ORS and recommends that it be given in 5ml aliquots every 1-2 minutes. Only if this is well tolerated with no vomiting the size of the aliquots may be increases with decreasing frequency. However this regime was thought to be too labor intensive for the UK by the Delphi panelists and did not achieve consensus.

                                            ψDefinition of Whenever practically possible:

                                            ψWhenever practically possible implies that the child�s carer is willing and able to carry this out under supervision. Where this is not the case (or overnight) rehydrate by continuous naso-gastric tube infusion (preferred) or IVI.

                                             

                                            Regularly assess success of rehydration (e.g. 2 hourly). If no improvement in clinical signs of dehydration or worsening signs, consider NGT or Intravenous infusion.

                                            (Above 2 statements based on Level Va evidence and Delphi consensus, grade D recommendation)

                                              • Urea and Electrolyte investigation in mild to moderate dehydration

                                              See annotation D

                                              • Rehydration / maintenance and ongoing losses

                                              Tables 3 and 4 gives the calculations required for rehydration and maintenance requirements which are well established.

                                              The literature suggests that ongoing losses should be replaced with 10ml/Kg of ORS for each loose stool and substantial vomit (I,A). However when this was put to the Delphi panel there was no consensus. An alternative of replacing estimated amounts lost was put to the panel but this also did not achieve consensus. Thus this issue had to be decided locally.

                                              • Failure of ORS

                                              See annotation I

                                              • Maintenance of hydration/ prevention of dehydration

                                              The management of the child who was not dehydrated and the child who is no longer dehydrated following rehydration is similar . It is recommended that these children be allowed free fluids, and should be encouraged to drink more than usual. Standard methods for calculating maintenance requirements are shown in Table 4 of the algorithm.

                                              RECOMMENDATION

                                              To prevent primary dehydration or recurrence of dehydration allow unrestricted fluids (eg milk or water). Ensure that at least maintenance fluids are taken .

                                              (Based on Level I evidence and Delphi consensus, grade A recommendation)

                                               

                                               

                                               

                                              • Re-feeding following rehydration

                                              Historically children were starved for the period of rehydration (often over 24 hours) and were then re-graded onto increasing strengths of milk feed. This was not based on any evidence, but thought to reduce the incidence of lactose intolerance. Many trials now suggest that rapid introduction of feeding following rehydration reduces the duration of illness and the number of loose stools, as well as improving nutrition. Brown performed a meta-analysis of the use of non-human milks in gastro-enteritis and concluded that the vast majority (over 80%) of young children with acute diarrhoea can be successfully managed with continued feeding of undiluted non-human milks (I, A). This is now recommended practice, including the introduction of age appropriate diets in children who are weaned .

                                              Good evidence exists to show that children who are breast fed should continue breast feeding throughout the rehydration and maintenance phases of their therapy (III,C). In so doing they reduce the risk of dehydration, pass smaller volumes of stool and recover quicker.

                                              RECOMMENDATION

                                              Breast feeding children should continue to breast feed through the rehydration and maintenance phases of their acute gastro-enteritis illness.

                                              (Bases on level III evidence and Delphi consensus, grade C recommndation)

                                              In the dehydrated child with gastro-enteritis who is normally formula fed, feeds should stop during rehydration and restart as soon as the child is rehydrated (4hours)

                                              (Based on level I evidence and Delphi consensus, grade A recommendation)

                                              These principles are stated in table 6 of the algorithm.

                                               

                                              • Information

                                              No evidence was found concerning the interests of other people, namely parents, carers and the children themselves in the management of acute gastroenteritis. It would be interesting to know what their views are about the use of oral rehydration therapy, intravenous infusions, naso-gastric tubes and care in hospital or at home. No evidence on which to base a statement is currently available.

                                              At a basic level, however, parents or carers should always be discharged with written information concerning the home management of diarrhoea +/- vomiting. The information sheet that we use is shown in appendix 2, and was developed from comments made by the Delphi panelists.

                                              RECOMMENDATION

                                              Parents / carers should be given an information sheet concerning the home management of diarrhoea +/- vomiting on discharge home.

                                              (No literature, Delphi consensus)

                                               

                                              • Admission criteria

                                              Despite the number of practice parameters and reviews of the literature, there are no recommendations as to when a child should be admitted to hospital. Several authors have queried the appropriateness of admission in some cases . It is clear that the child with severe dehydration must be admitted. Children with moderate dehydration and those at high risk of developing dehydration will need to be watched carefully. Those moderately dehydrated should be observed frequently by medical staff until they are fully rehydrated, and those at risk of dehydration will need to be observed for a period to ensure that they remain well hydrated (No literature evidence).

                                              In cases where there is diagnostic uncertainty children may need admission for investigation or observation of the progress of their illness.

                                              We know that there are many influences on a doctor�s decision to admit a patient other than their medical condition. Fitzgerald found that for the same severity of acute gastroenteritis, children with mothers reporting higher levels of psychological distress were more likely to be admitted. These mothers were also likely to have poor social resources. These factors influencing admission are less easy to define, but are equally important and should be incorporated into a practice guideline.

                                               

                                              RECOMMENDATION

                                              • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
                                              • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
                                              • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
                                              • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.
                                              • Risk of dehydration
                                              • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
                                              • More than 8 significant* diarrhoeal stools in the last 24 hours.
                                              • A �significant� vomit is anything more than an effortless, small volume, possett.
                                              • Replacement of losses in the child at risk of dehydration.
                                              • Criteria for admission of children with gastroenteritis
                                              • Literature concerning the need for stool culture
                                              • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
                                              • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
                                              • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
                                              • A history suggestive of food poisoning (no literature, Delphi consensus)
                                              • Recent travel abroad (Level Vb and Delphi consensus, grade D)
                                              • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).
                                              • Role of medication in gastroenteritis
                                              • Salmonella typhi � ciprofloxacin until sensitivities available
                                              • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
                                              • Giardia � metronidazole
                                              • Amoebiasis � metronidazole and Diloxanide furoate.
                                              • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
                                              • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
                                              • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
                                              • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
                                              • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
                                              • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
                                              • Your child�s weight today is
                                              • He/She needs to take in at least of fluid over a 24 hour period.
                                              • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
                                              • Stop all solid food until the vomiting has settled
                                              • If your baby is breast fed continue to feed on demand
                                              • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
                                              • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
                                              • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
                                              • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
                                              • AVOID fatty foods and sugary foods.
                                              • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
                                              • When a child is not dehydrated they may be used to supplement the child�s normal fluid.
                                              • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.
                                              • The diarrhoea has blood in it
                                              • Your child becomes more sleepy, lethargic or irritable than usual
                                              • Your child has 5 or more vomits in 24 hours
                                              • Your child has 9 or more loose poos in 24 hours
                                              • The diarrhoea continues for more than 7 days
                                              • Try to change the nappy as soon as it is dirty.
                                              • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
                                              • Apply barrier cream or Vaseline liberally.
                                              • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
                                              • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
                                              • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.
                                              • Children presenting to hospital with acute gastro-enteritis who are severely dehydrated should be admitted to hospital.
                                              • Those children with mild/moderate dehydration should be observed in a hospital paediatric facility for a period of at least 6 hours to ensure successful rehydration (3-4 hours) and maintenance of hydration (2-3 hours).
                                              • Those children at high risk of dehydration on the basis of young age, high frequency of watery stools or vomits, should be observed in a hospital paediatric facility for at least 4-6 hours to ensure adequate maintenance of hydration.
                                              • Those children whose parents or carers are thought to be unable to manage the child�s condition at home successfully should be admitted to hospital.

                                              (All the above based on level Vb evidence and Delphi consensus, grade D recommendation)

                                               

                                                • Risk of dehydration

                                                If a child is at high risk of becoming dehydrated, even though they are not dehydrated at the time of being seen in A&E they need to be managed differently to the child who is very unlikely to become dehydrated. The following factors were noted in the literature to increase the risk:

                                                Age of the child

                                                From first principles it seems reasonable that the young infant would be at higher risk of dehydration than the older child. They have increased insensible loses due to their surface area:volume ratio, they have an inherent tendency to more severe vomiting and diarrhoea, and their prime source of nutrition is milk which has a high osmotic load. This theory is born out by studies in India and Brazil. Bhattacharya etal (III,C) found a non significant trend towards the younger age groups being at more risk, Fuch etal (III,C) found a definite association, with young infants (<9 months and especially 2-3 months) at greatest risk of dehydrating diarrhoea.

                                                Severity of symptoms

                                                It seems reasonable to assume that the severity of the symptoms would affect risk of dehydration. Bhattacharya (III,C) in Calcutta performed a prospective case-control study. 379 infants<2 years old were enrolled on presentation with diarrhoea of <24 hours (defined as >3 loose stools in 24 hours). They were interviewed and assessed independently. The infants were then categorised as moderate/severe dehydration (cases) versus mild dehydration (controls), and risk factors compared. The most significant were withdrawal of breast feeding and not giving extra fluids. Additional factors were age<12months, stool frequency >8/day, vomits>2/day, vibrios in stool and malnutrition. Faruque (III,C) had very similar results in an almost identical trial design of 1,013 infants 1-35 months in Bangladesh. They found the same risk factors for dehydration as Bhattacharya (age<6 months, stool>11 per day, history of vomiting) and in addition lack of maternal education.

                                                Fuchs etal (III, C) in a case control study in Brazil found that those who were formula fed, or who had been recently weaned from the breast were at highest risk of developing moderate to severe dehydration, independent of confounding variables.

                                                Unfortunately risk factors for dehydration have not been looked at in developed countries, and the above findings may not be directly applicable to the UK. In particular vomiting>2times/day does not seem to equate with a high risk of dehydration in our clinical practice. In the UK rotavirus is very common and often causes frequent vomiting as the first sign of illness, without necessarily increasing the risk of dehydration. In view of there being no literature on risk in a developed country the Delphi panel were asked for their views on factors putting the child at greater risk.

                                                RECOMMENDATION

                                                The following factors in the history of a child presenting with diarrhoea should alert the clinician to a high risk of dehydration:

                                                • Infants <6 months (Level III and Delphi consensus, grade C recommendation)
                                                • More than 8 significant* diarrhoeal stools in the last 24 hours.

                                                *A significant stool is a discrete bowel action. Diarrhoea as defined in statement 1. Take care not to underestimate watery stools where a substantial component has been absorbed into the nappy.

                                                (Level III and Delphi consensus, grade C recommendation)

                                                More than 4 significant* vomits associated with diarrhoea in the last 24 hours.

                                                  • A �significant� vomit is anything more than an effortless, small volume, possett.

                                                  (Level III and Delphi consensus, grade C recommendation)

                                                  The panel also considered including infants recently weaned off the breast, but felt that this did not seem relevant to our practice in a developed country. Consensus disagreement.

                                                   

                                                    • Replacement of losses in the child at risk of dehydration.

                                                    There are no trials concerning this issue, but the AAP practice parameter and Murphy�s review recommend that ongoing losses for the infant at high risk of dehydration should be replaced with 10ml/Kg of ORS for each loose stool and substantial vomit (I,A). However, the Delphi panel did not agree with this point. An alternative of replacing the estimated volume lost was put to the panel but this also did not achieve consensus. In view of the lack of consensus and no evidence in the literature either way, this issue will have to be decided at a local level.

                                                    • Criteria for admission of children with gastroenteritis

                                                    See annotation P

                                                    • Literature concerning the need for stool culture

                                                    Diagnosis & treatment

                                                    Once a diagnosis of acute gastro-enteritis has been made clinically, the question of the aetiology of the infection arises. For the individual, it would be important to know what is causing the symptoms if treatment of the infection could eliminate them. As we shall discuss later on, treatment is rarely necessary and therefore stool culture for this reason alone is not productive.

                                                    Prognosis

                                                    Some might argue that we would have a clearer idea of the prognosis if we knew the aetiology. With respect to acute risk of dehydration this does not seem to be the case. The risk of dehydration was the same for all aetiologic agents except cholera in both Faruque (III,C) and Bhattacharya�s studies (III,C). Fortunately in the UK cholera is only seen rarely in children who have travelled abroad. With respect to predicting which infections are likely to become chronic, it may be useful to know the pathogen. However when a child presents acutely it is unnecessary to make this distinction. If they present with diarrhoea lasting 5 or more days, a stool sample can be taken at this point.

                                                    In the UK a history of travelling abroad must be taken seriously. There have been two case series reported in the literature of children with malnutrition and severe chronic diarrhoea treated in UK hospitals following an extended trip abroad (Vb,D). A history of foreign travel therefore is a good reason to check a stool culture.

                                                    Implications of aetiology for Public Health

                                                    From a public health point of view it is clearly important to know which organisms in the community are causing infections, and more specifically whether there is any evidence of outbreaks of disease. With respect to food poisoning (Shigella, salmonella, campylobacter) it is important that the source of any outbreak is traced and dealt with.

                                                    Thus it is clear from the public health point of view that some stool samples should be sent for culture. However if all patients with a short spell of diarrhoea had a stool sample sent to the laboratory for culture the lab would be overwhelmed. It therefore seems reasonable to try to limit stool specimens sent to those likely to have important (bacterial or parasitic) infections.

                                                    Important historical features

                                                    DeWitt etal (III,C) looked at the value of various features of history and examination and stool screening tests in predicting whether diarrhoea was caused by a bacterial agent. They studied 200 children less than 4 years old presenting to a primary care centre in the USA with diarrhoea of less than 10 days. The best predictor on clinical grounds alone was a cluster of 3 historical variables- abrupt onset of diarrhoea, more than 4 stools per day and no vomiting before the onset of diarrhoea. This cluster had a sensitivity of 86% a specificity of 60%, PPV of 27% and NPV of 96%.

                                                    Diarrhoea which is frankly bloody is more likely to be caused by invasive bacteria than viruses. Finkelstein etal (III,C) found that in 1,035 infants under 1 year of life with diarrhoea (of which 108 (10.4%) had a bacterial cause), a history of blood in the stool was the best individual predictor of bacterial infection (sensitivity 39%, specificity 88%, PPV 30%, NPV 92%). Temperature >39° C and >10 stools per day were also useful indicators. Conway (Vb, D) looked at 1148 children <16 years with diarrhoea, in whom 153 (13%) had bacterial, protozoal or mixed pathogen aetiology. They found that the bacterial group had a statistically significant higher stool frequency of >7 per day, but the difference was of little use to the clinician (36% in bacterial group and 26% in rotavirus group, no figures given to calculate sensitivity etc). They also found that the stool more frequently contained blood or mucus (25% in the bacterial group compared with 2.8% in the viral group). In Milford�s study of HUS (III,C), 199 children (73%) had a prodrome of bloody diarrhoea, with 178 of these growing colliforms in the stool.

                                                    Based on these studies Table 5 was developed.

                                                    RECOMMENDATION concerning requirement for stool culture

                                                      • A history of blood +/- mucous in the stool (Level III and Delphi consensus, grade C)
                                                      • Systemically unwell, severe or prolonged diarrhoea (no literature, Delphi consensus)
                                                      • If the child is admitted to hospital (no literature AND noDelphi consensus, this must be decided at a local level)
                                                      • A history suggestive of food poisoning (no literature, Delphi consensus)
                                                      • Recent travel abroad (Level Vb and Delphi consensus, grade D)
                                                      • Abrupt onset of diarrhoea with more than 4 stools per day and no vomiting pre diarrhoea (Level III, BUT no Delphi consensus. To be decided at a local level).

                                                       

                                                        • Role of medication in gastroenteritis

                                                        Anti-diarrhoeal/ anti-motility agents

                                                        Several trials looking at the use of these agents have been reported. They are thoroughly reviewed in the AAP practice parameter and Murphy�s systematic review.

                                                        RECOMMENDATION

                                                        Infants and children with acute gastro-enteritis should not be treated with anti-diarrhoeal agents.

                                                        (Level 1 evidence and Delphi consensus, grade A recommendation)

                                                        Anti-microbial agents

                                                        There are several trials reported in the literature investigating the treatment of Campylobacter jejuni. Murphy reports thatone randomised controlled trial indicated that if erythromycin was started at first presentation before the results of the stool culture were available, the clinical course of the illness was shortened. Other randomised trials in which erythromycin was started after isolation of the organism showed a shortened period of bacterial excretion, but no effect on the clinical course of the illness (I,A). Trials investigating the antibiotic treatment of Yersinia enterocolitica and E coli. have not found any benefit.

                                                        Invasive Salmonella typhi (i.e. a systemic infection featuring malaise, meningismus, and fever) clearly needs treatment and sensitivities are required. For other salmonella infections there is no evidence that anti-microbials help (III, C), although they should be considered in young infants, immunocompromised children, and those who are systemically unwell. Anti-microbial treatment is however worthwhile in Shigella, Amoebiasis and Giardiasis .

                                                        RECOMMENDATION

                                                        Patients with invasive Salmonella typhi, Shigella, amoebiasis and Giardiasis should be treated with antibiotics. (Level III and Delphi consensus, grade C recommendation)

                                                        Suggested antibiotics according to the British Medical Formulary:

                                                        • Salmonella typhi � ciprofloxacin until sensitivities available
                                                        • Shigella � trimethoprim (or ciprofloxacin for trimethoprim-resistent strains)
                                                        • Giardia � metronidazole
                                                        • Amoebiasis � metronidazole and Diloxanide furoate.
                                                        • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.
                                                        • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
                                                        • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.
                                                        • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.
                                                        • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.
                                                        • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.
                                                        • Your child�s weight today is
                                                        • He/She needs to take in at least of fluid over a 24 hour period.
                                                        • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.
                                                        • Stop all solid food until the vomiting has settled
                                                        • If your baby is breast fed continue to feed on demand
                                                        • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
                                                        • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
                                                        • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
                                                        • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
                                                        • AVOID fatty foods and sugary foods.
                                                        • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
                                                        • When a child is not dehydrated they may be used to supplement the child�s normal fluid.
                                                        • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.
                                                        • The diarrhoea has blood in it
                                                        • Your child becomes more sleepy, lethargic or irritable than usual
                                                        • Your child has 5 or more vomits in 24 hours
                                                        • Your child has 9 or more loose poos in 24 hours
                                                        • The diarrhoea continues for more than 7 days
                                                        • Try to change the nappy as soon as it is dirty.
                                                        • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
                                                        • Apply barrier cream or Vaseline liberally.
                                                        • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
                                                        • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
                                                        • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.

                                                        Consider treatment of Salmonellas other than S.Typhi. in infants <6 months, those who are systemically unwell and the immunocompromised.

                                                        (Level Vb and Delphi consensus, grade D recommendation)

                                                         

                                                        Table 8. Search strategies for each type of question and inclusion criteria

                                                        Type of question

                                                        Search strategy

                                                        Inclusion criteria

                                                        Diagnostic procedure

                                                        Sensitivity and specificity or predictive value of tests or diagnostic errors or screening or diagnosis or sensitivity or specificity

                                                        Population based cohort, prospective hospital case control or cohort. If not available, retrospective cohort.

                                                        Aetiology

                                                        Risk or causality or cohort studies or case and control

                                                        Population based cohort, prospective hospital based case control or cohort, if not available, retrospective cohort.

                                                        Therapeutic intervention

                                                        Clinical trial or randomised controlled trial or research design

                                                        Randomised controlled trial, systematic review. If not available, case control or cohort study

                                                        Prognosis

                                                        prognos* or cohort studies or follow-up studies or mortality

                                                        Cohort

                                                        Qualitative

                                                        Interview or questionnaire or focus group

                                                         

                                                         

                                                        Table 9 Clinical questions and question type for the diarrhoea guideline.

                                                        Clinical question

                                                        Type of question

                                                        How do we define the child with diarrhoea?

                                                        Definition, Aetiology

                                                        What is the United Kingdom incidence of diarrhoea illness in the paediatric population, and of these what percentage comes to the A&E department

                                                        Aetiology, Prognosis

                                                        What are the differential diagnoses and incidence of these in a child presenting with diarrhoea with or without vomiting?

                                                        Diagnostic procedure, Aetiology

                                                        What symptoms are important in determining the severity of illness (risk of, or actual dehydration)?

                                                        Diagnostic procedure

                                                        What are valid and useful signs in the examination of the child with Diarrhoea +/- vomiting?

                                                        Diagnostic procedure

                                                        When is measurement of serum urea and electrolytes (and other blood tests) valuable in management?

                                                        Diagnostic procedure

                                                        What should be the management of the child with acute gastroenteritis?

                                                        Therapeutic intervention, Prognosis

                                                        When does a child with acute gastroenteritis require admission to hospital?

                                                        Therapeutic intervention, Prognosis

                                                        Are there any pharmacological agents of use in the treatment of acute gastro-enteritis?

                                                        Therapeutic intervention

                                                        What management does the parent and/or the child with acute diarrhoea +/- vomiting prefer?

                                                        Qualitative, Therapeutic intervention

                                                         

                                                         

                                                         

                                                        Table 10: Normal infant stool patterns, from Baldessano, 1991.

                                                        Age and feed type

                                                        Stool pattern

                                                        0-6 months, Breast fed

                                                        Very wide range of once every 2-3 weeks to about 12 times per day; yellow to light brown; pH=5.0

                                                        0-6 months, Formula fed

                                                        1 to 3 per day (range 1-7);yellow to brown; formed; pH=7.0

                                                        6 months � 1 year

                                                        2-3 per day (range 1-7); brown; formed

                                                        After 1 year

                                                        Formed; like adult stool

                                                         

                                                         

                                                         

                                                        Table 11: Frequency of deranged electrolytes in acute gastroenteritis in developed countries.

                                                         

                                                         

                                                        Jenkins Cohort of GE in South Wales, 1987/8, children <16years

                                                        Conway , Cohort of GE in Leeds, 1986/7, Children <16years

                                                        Ellis Cohort of GE in Manchester, 1982 (Infectious dis Unit) Infants <2years

                                                        No of cases

                                                        215

                                                        1148

                                                        447

                                                        No. (%) moderate-severe dehydration (5-10%)

                                                        15 (7%)

                                                        12 (1%)

                                                        63 (14%)

                                                        No. in whom electrolytes were measured

                                                        76 (35%)

                                                        1119 (97%)

                                                        NR

                                                        Hypernatreamia (as defined in each study in mmol/l)

                                                        Na >145

                                                        2 (<1%)

                                                        Na >149

                                                        8 (<1%)

                                                        Na>150

                                                        5 (1%)

                                                        Urea (mmol/l)

                                                        Urea >6

                                                        17 (8%)

                                                        Urea >7

                                                        86 (7%)

                                                        Urea >6

                                                        8 (1.8%)

                                                        Bicarbonate <15mmol/l

                                                        13 (6%)

                                                        NR

                                                        3 (<1%)

                                                        NR= Not reported.

                                                        Table 12: Composition of fluids for intravenous and oral rehydration.

                                                         

                                                         

                                                        Osmolality

                                                        mOsm/L

                                                        Glucose

                                                        mmol/L

                                                        Na

                                                        mmol/L

                                                        Chloride

                                                        mmol/L

                                                        Potassium

                                                        mmol/L

                                                        Base

                                                        mmol/L

                                                        Oral

                                                        ESPGAN

                                                         

                                                        200-250

                                                        74-111

                                                        60

                                                        Not<25

                                                        20

                                                        Citrate 10

                                                        Dioralyte

                                                        240

                                                        90

                                                        60

                                                        60

                                                        20

                                                        Citrate 10

                                                        Diocalm Jr

                                                        251

                                                        111

                                                        60

                                                        50

                                                        20

                                                        Citrate 10

                                                        Rehidrat

                                                        335

                                                        91*

                                                        50

                                                        50

                                                        20

                                                        Bicarb 20

                                                        Citrate 9

                                                        Electrolade

                                                        251

                                                        111

                                                        50

                                                        40

                                                        20

                                                        Bicarb 30

                                                        WHO ORS

                                                        330

                                                        111

                                                        90

                                                        80

                                                        20

                                                        Citrate 10

                                                        Intravenous

                                                        Ringers Lactate

                                                         

                                                        280

                                                         

                                                         

                                                        130

                                                         

                                                        110

                                                         

                                                        4

                                                         

                                                        Bicarb 25

                                                        0.9% saline

                                                         

                                                        308

                                                        154

                                                        154

                                                        *Glucose given with fructose 1mmol/L and sucrose 94mmol/L

                                                         

                                                         

                                                        References

                                                         

                                                         

                                                        Implementation pilot

                                                        A study was undertaken to evaluate the implementation of this guideline in a paediatric A&E on the management of the child presenting with diarrhoea, with or without vomiting.

                                                        Method: A care pathway was developed with nursing and medical staff, based on the guideline algorithm (appendix 3). This was used as the documentation for children presenting with diarrhoea, and followed the child to the ward if admitted.

                                                        The key elements of the assessment and management of the child with diarrhoea, using this guideline were used to develop a data collection form. These data were collected from the notes of children attending A&E (both GP referrals and self referrals) during a four month period in 1997 and compared with those attending during a four month period in 1999, following implementation of the care pathway. Data were compared using SPSSâ , Chi-square and Man-Whitney-U tests.

                                                        Results: 292 children attended with diarrhoea pre care pathway and 239 post. There was no difference in age, sex, or time of arrival. Numbers admitted increased from 27% to 34%. During the same period there was a 14% increase in admissions of children presenting with all other medical problems. There was no change in the numbers of children returning to A&E having been discharged.

                                                        The time taken from seeing the doctor to discharge was reduced by 15 minutes from a median of 55 minutes to 40 minutes, and the total time in the department reduced by 24 minutes from median 102 to 78 minutes.

                                                        The number of children investigated for FBC and U&E fell (17 to 6, χ2 p = 0.02 and 18 to 7, p=0.02 respectively), and intravenous infusions fell (13 to 2, χ2 p=0.002). Other investigations remained the same. Documentation of symptoms, signs and management plan was improved.

                                                        Conclusion: The implementation of a care pathway for diarrhoea reduced the numbers of unnecessary investigations and unnecessary IV canulations. It also reduced the time spent in the A&E department. The proportion of attenders admitted increased in keeping with the overall increase in medical admissions. A study on the appropriateness of admission of both samples is planned.

                                                         

                                                        Audit recommendations

                                                         

                                                        The following data are valuable for monitoring compliance with guideline recommendations and auditing the impact of the guideline on clinical practice:

                                                        • Proportion of children admitted within the three levels of dehydration (none, with or without risk factors for dehydration, mild/moderate and severe) pre and post guideline implementation.

                                                        Standard � admit only those fulfilling the guideline criteria.

                                                        • Proportion of children returning to hospital (within 7 days) with the same presenting problem before and after guideline implementation.
                                                        • Proportion of children investigated by clinical chemistry and microbiology (include data on criteria for stool samples) pre and post guideline implementation. Record frequency of abnormal results.

                                                        Standard � investigate only those fulfilling guideline criteria.

                                                        • Proportion of children within each category of dehydration level who have a canula sited with or without commencement of IV rehydration, pre and post guideline implementation.

                                                        Standard � only children with severe dehydration or failed oral (including naso-gastric tube) rehydration should have a canula sited and IV rehydration commenced.

                                                        • Monitoring length of time for rehydration in dehydrated children, and duration of �starvation� prior to recommencing feeds.

                                                        Target � Aim for rehydration within four hours of admission and feeding recommenced.

                                                        • Monitoring of length of time taken to manage a child presenting with diarrhoea from consultation to admission or discharge.

                                                         

                                                         

                                                         

                                                         

                                                         

                                                        Appendix 1Article Grading

                                                        Levels of evidence, as suggested by Muir Gray1

                                                        Type

                                                        Strength of evidence

                                                        I

                                                        Strong evidence from at least one systematic review of multiple well-designed randomised controlled trials

                                                        I I

                                                        Strong evidence from at least one properly designed randomised controlled trial of appropriate size. Positive when the lower limit of the confidence interval for the effect of treatment/intervention exceeds the clinically significant benefit.

                                                        I I I

                                                        Evidence from well-designed trials without randomisation, single group pre-post, cohort, time series or matched case-control studies

                                                        IV

                                                        Evidence from well-designed non-experimental studies from more than one centre or research group

                                                        V

                                                        Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees

                                                         

                                                        Additional category to this classification, Va for opinions of respected bodies, Vb for other evidence in the level V category.

                                                        Suggested grading based on Cook2

                                                        Grade A, supported by level I evidence and therefore highly recommended.

                                                        Grade B, supported by level II evidence, and therefore recommended.

                                                        Grade C, supported by level III, evidence. Several potential clinical actions might be considered appropriate.

                                                        Grade D, supported by level IV and V evidence. The consensus route would have to be adopted.

                                                        References

                                                        1. Muir Gray J A, Evidence-Based Healthcare. 1997, first ed. London: Churchill Livingstone. 1997.

                                                        1. Cook D, Guyatt G, Laupacis A and Sackett D. Rules of Evidence and Clinical Recommendations on the Use of Antithrombotic Agents. Chest 1992: 102: 305S-311S.

                                                        Appendix 2. Parent information

                                                        Your guide to �Gastroenteritis�

                                                        Your doctor/nurse will fill in the boxes for you.

                                                        What is gastroenteritis?

                                                        Gastroenteritis is an infection in the gut, which leads to diarrhoea and/or vomiting (sickness). Diarrhoea is frequent watery poo. The infection may also give your child a temperature and tummy pain. It is usually caused by a virus, which the body clears on it�s own without treatment. The diarrhoea and vomiting may lead to dehydration (too much water lost from the body).

                                                        What do I do?

                                                        Your doctor has carefully looked for signs of dehydration and has not found any. They are therefore happy for you to take your child home. You must encourage your child to drink.

                                                        What is enough fluid?

                                                        • Your child�s weight today is

                                                        • He/She needs to take in at least of fluid over a 24 hour period.
                                                        • A teaspoon is 5mls. 1oz is 30mls. A typical beaker holds about 200 mls.

                                                        What kind of drinks should I give?

                                                        You can give any drink that your child usually has including milk. However try not to give very concentrated or sugary drinks like real fruit juices or fizzy drinks unless they are well diluted with water (4 times as much water as drink).

                                                        What if my child is vomiting?

                                                        • Stop all solid food until the vomiting has settled
                                                        • If your baby is breast fed continue to feed on demand
                                                        • If your baby is formula fed, give feeds in very small amounts (approximately 1oz(30ml)) often (every 20 minutes or so). If they continue to vomit, stop milk feeds for 4 hours and give cooled boiled water instead, little and often.
                                                        • Any other fluids that your baby or child has should be given as above (about 1oz(30ml) every 20 minutes) by bottle, spoon or cup. Do not offer a full bottle or cup as large amounts may make your child vomit again.
                                                        • As the vomiting settles you can start to offer larger amounts of fluid less often and the child�s usual solid food.
                                                        • Try rice, pasta, potatoes, toast, plain biscuits. Don�t worry if they are not hungry.
                                                        • AVOID fatty foods and sugary foods.

                                                        What about the diarrhoea?

                                                        Diarrhoea usually continues for 6-7 days. As long as your child is drinking and is improving in themselves this does not matter.

                                                        What about the temperature?

                                                        If your child has a temperature or appears to have tummy pains then give Paracetamol according to the instructions on the bottle.

                                                        What is Dioralyte/ Diocalm junior/ Electrolade?

                                                        • These are all names for salt and sugar solutions that are made up with water, to replace what is being lost. You will only be given these by your doctor if your child is dehydrated or at risk of becoming dehydrated.
                                                        • When a child is not dehydrated they may be used to supplement the child�s normal fluid.

                                                        • Try to give each time your child has a very loose poo, or large vomit. Give small amounts often. If your child does not like the taste try adding a drop of juice or sugar-free squash.

                                                        When should I ask for help or advice?

                                                        Seek advice if:

                                                        • The diarrhoea has blood in it
                                                        • Your child becomes more sleepy, lethargic or irritable than usual
                                                        • Your child has 5 or more vomits in 24 hours
                                                        • Your child has 9 or more loose poos in 24 hours
                                                        • The diarrhoea continues for more than 7 days

                                                        You could call your Health Visitor or General Practitioner

                                                        You could call the short stay unit at the Queen�s Medical Centre up to 48 hours after being on the ward

                                                        Telephone No

                                                        You could call NHS Direct

                                                        Telephone No

                                                        You could call Children�s A&E at the Queen�s Medical Centre up to 48 hours after being seen there

                                                        Telephone No

                                                         

                                                        When can my child return to school or nursery?

                                                        When the diarrhoea has settled to 2 or 3 formed poos a day they are safe to return.

                                                         

                                                        What about my baby�s sore bottom?

                                                        Frequent diarrhoea can make your baby�s bottom sore.

                                                        • Try to change the nappy as soon as it is dirty.
                                                        • Clean carefully with cotton wool and water or baby lotion (some wipes are alcohol based which can be sore on a red bottom).
                                                        • Apply barrier cream or Vaseline liberally.

                                                        How can I stop it happening again?

                                                        • Gastroenteritis is an infection that can be passed on from person to person or in contaminated food.
                                                        • Always wash hands before preparing any foods or eating and after nappy changes or going to the toilet.
                                                        • It is very important to wash and sterilise all baby bottles, teats and feeding equipment.

                                                         

                                                         

                                                         

                                                         

                                                         

                                                        Appendix 3.

                                                        Care pathway for implementation of diarrhoea guideline

                                                         

                                                        The following 3 pages show the care pathway exactly as used in the Nottingham paediatric A&E

                                                        during the implementation study

                                                        .

                                                        THE CHILD WITH DIARRHOEA+/-VOMITING

                                                        Evaluate and maintain A and B.

                                                        C. Signs of circulatory compromise go to BOX A

                                                        Please tick box when completed. Circle Y / N.

                                                        If deviations from pathway occur please record in variance table (page 2)

                                                        Complete Nursing, History and Examination for all. Then complete Box A or B or C as applies. DATE���������

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                        MEDICAL assessment: Doctor name:������������������Date/Time���������������

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                        VARIANCES

                                                        TIME

                                                        ACTIONS DEVIATING FROM PATHWAY

                                                        REASON

                                                        INITIAL

                                                            
                                                            

                                                        Appendix 4.

                                                         

                                                        Appraisal Instrument for Clinical Guidelines Version 1

                                                        Appraisal of the Paediatric A&E Research Group guideline for the management of the child presenting to hospital with diarrhoea with or without vomiting.

                                                        Appraisal performed by Dr Kate Armon

                                                        (in compliance with the RCPCH Quality of Practice Committee Report)

                                                        Dimension 1: Rigour of Development

                                                        Responsibility for guideline development

                                                        1. Is the agency responsible for the development of the guidelines clearly identified?

                                                        Yes. The Paediatric A&E Research Group, Nottingham

                                                        2. Was external funding or other support received for developing the guideline?

                                                        Yes. Charitable funding from Children Nationwide

                                                        3. If external funding or support was received, is there evidence that potential biases of the funding body were taken into account?

                                                        Yes. Children Nationwide did not influence the guideline development in any way

                                                         

                                                        Guideline development group

                                                        4. Is there a description of the individuals who were involved in the guidelines development group?

                                                        Yes. The development group is specified, and the Delphi panel are listed.

                                                        5. If so, did the group contain representatives of all key disciplines?

                                                        Yes. Those disciplines involved in the care of the child presenting to an A&E or acute paediatric department and those involved in acute management of the child on the ward were included. Patients, parents and general practitioners were not included.

                                                         

                                                        Identification and interpretation of evidence

                                                        6. Is there a description of the sources of information used to select the evidence on which the recommendations are based?

                                                        Yes. The complete Medline, Embase and Cochrane electronic databases were searched, and citations in relevant articles.

                                                        7. If so are the sources of information adequate?

                                                        Yes. Experts in the field were not contacted, but paediatric gastroenterologists included on panel.

                                                        8. Is there a description of the methods used to interpret and assess the strength of evidence?

                                                        Yes.

                                                        9. If so, is the method for rating the evidence satisfactory?

                                                        Yes. Well described method (Muir Gray)

                                                         

                                                        Formulation of recommendations

                                                        10. Is there a description of the methods used to formulate the recommendations?

                                                        Yes. Synthesis of the evidence found. Consensus development using a Delphi panel method.

                                                        11. If so, are the methods satisfactory?

                                                        Yes.

                                                        12. Is there an indication of how the views of the interested parties not on the panel were taken into account?

                                                        No. Future research plan to obtain the views of parents and carers on management.

                                                        13. Is there an explicit link between the major recommendation s and the level of supporting evidence?

                                                        Yes.

                                                         

                                                        Peer review

                                                        14. Were the guidelines independently reviewed prior to their publication/release?

                                                        Yes � Delphi process. Presented at several academic meetings and seeking publication in Archives of Diseases in Childhood.

                                                        15. If so, is explicit information given about methods and how comments were addressed?

                                                        Yes

                                                        16. Were the guidelines piloted?

                                                        Yes.

                                                        17. If the guidelines were piloted, is explicit information given about the methods used and the results adopted?

                                                        Yes. Ongoing discussion on implications of pilot.

                                                         

                                                        Updating

                                                        18. Is there a mention of a date for reviewing or updating the guidelines?

                                                        Yes.

                                                        19. Is the body responsible for the reviewing and updating clearly identified?

                                                        Yes. Paediatric A&E Research Group

                                                         

                                                        Overall assessment of the development process

                                                        20. Overall, have the potential biases of guideline development been adequately dealt with?

                                                        Yes

                                                         

                                                        Dimension 2: Context and content

                                                        21. Are the reasons for developing the guidelines clearly stated?

                                                        Yes. Common problem. Frequently managed by junior staff

                                                        22. Are the objectives of the guidelines clearly stated?

                                                        Yes. Guidance primarily on investigation and admission criteria.

                                                         

                                                        Context

                                                        23. Is there a satisfactory description of the patients to which the guidelines are meant to apply?

                                                        Yes. Children attending an acute paediatric hospital facility with the specified presenting problem.

                                                        24. Is there a description of the circumstances in which exceptions might be made in using the guideline?

                                                        Yes. Clinical judgement required in the application of the guideline is stressed.

                                                        25. Is there an explicit statement of how patients� preferences should be taken into account in applying the guideline?

                                                        Yes. It is explicitly stated that the parents views on admission should be sought.

                                                         

                                                         

                                                        Clarity

                                                        26. Do the guidelines describe the condition to be detected, treated, or prevented in unambiguous terms?

                                                        Yes.

                                                        27. Are the different possible options for the management of the condition clearly stated in the guidelines?

                                                        Yes, although recommended management derived form evidence and formal consensus is given.

                                                        28. Are the recommendations clearly presented?

                                                        Yes. Subjective opinion. Also successfully implemented by SHOs in paediatric A&E.

                                                         

                                                        Likely costs and benefits

                                                        29. Is there an adequate description of the health benefits that are likely to be gained from the recommended management?

                                                        Yes. Pilot identified likely benefits.

                                                        30. Is there an adequate description of the potential harms or risks that may occur as a result of the recommended management?

                                                        Yes. None found during the pilot stages.

                                                        31. Is there an estimate of the costs or expenditures likely to incur from the recommended management?

                                                        No.

                                                        32. Are the recommendations supported by the estimated benefits, harms and costs of intervention?

                                                        No. The guideline is intended to reduce unnecessary investigations, interventions and admissions.

                                                         

                                                        Dimension 3: Application

                                                         

                                                        Guideline dissemination and implementation

                                                        33. Does the guideline document suggest possible methods for dissemination and implementation?

                                                        Not sure. Anticipated endorsement and dissemination by the RCPCH. Availability on the Nottingham child health and PIER web sites. Implementation method using care pathway (pilot) is described.

                                                         

                                                         

                                                        Monitoring of guidelines/ clinical audit

                                                        34. Does the guideline document specific criteria for monitoring compliance?

                                                        Yes. Monitoring of investigations, admissions, management and the appropriateness of each of these.

                                                        35. Does the guideline document identify clear standards or targets?

                                                        Yes.

                                                        36. Does the guideline document define measurable outcomes that can be monitored?

                                                        Yes. Admission rates and returns within 7 days with same presenting problem.

                                                        National guidelines only

                                                        37. Does the guideline document identify key elements which need to be considered by local guideline groups?

                                                        Yes. Areas where no consensus (by the Delphi panel) was achieved are highlighted for local discussion pre-implementation.

                                                      Footnotes

                                                      • website extra

                                                        The full guideline appears on the Archives of Disease in Childhood website www.archdischild.com

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