Gastroenteritis+in+children_May2014+

Version control and change history Version Date from Date to Amendment 1.0 08/10/2013 5/5/2014 Original version 2.0 06/05/2014 Current Revised Version © Department for Health and Ageing, Government of South Australia. All rights reserved.

Clinical Guideline South Australian Paediatric Practice Guidelines – Gastroenteritis in Children Policy developed by: SA Child Health Clinical Network Approved SA Health Safety & Quality Strategic Governance Committee on: 8 October 2013 Next review due: 28 September 2016

Summary Clinical Practice Guideline for the management of Gastroenteritis in children

Keywords Gastroenteritis, diarrhoea, fever, vomiting, abdominal pain, hypokalaemia, hypernatraemia, ataxia, hyperreflexia, seizures, irritability, lethargy, tachycardia, urine, dysentery, drowsiness, paediatric practice guideline, clinical guideline, gastroenteritis in children

Policy history Is this a new policy? Y Does this policy amend or update an existing policy? N Does this policy replace an existing policy? N If so, which policies?

Applies to All SA Health Portfolio All Department for Health and Ageing Divisions All Health Networks CALHN, SALHN, NALHN, CHSALHN, WCHN, SAAS Other

Staff impact All Clinical, Medical, Nursing, Allied Health, Emergency, Dental, Mental Health, Pathology

PDS reference CG102

Policy

South Australian Paediatric Practice Guidelines

Gastroenteritis in children © Department of Health, Government of South Australia. All rights reserved.

Note This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of published evidence and expert opinion. Information in this statewide guideline is current at the time of publication. SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not sponsor, approve or endorse materials on such links. Health practitioners in the South Australian public health sector are expected to review specific details of each patient and professionally assess the applicability of the relevant guideline to that clinical situation. If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the patient’s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline. This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful confidential discussion. This includes:

• The use of interpreter services where necessary, • Advising consumers of their choice and ensuring informed consent is obtained, • Providing care within scope of practice, meeting all legislative requirements and

maintaining standards of professional conduct, and • Documenting all care in accordance with mandatory and local requirements

ISBN number: ISBN : 978-1-74243-614-2 Endorsed by: South Australian Paediatric Clinical Guidelines Reference Committee.

South Australian Child Health Clinical Network Last Revised: Contact: South Australian Paediatric Clinical Guidelines Reference Committee:

[email protected] Page 1 of 16

mailto:[email protected]


Gastroenteritis in children X

Table of Contents Management flowchart for gastroenteritis ...........................3 Important points ...................................................................4 Introduction ..........................................................................4 Definitions and abbreviations ..............................................4 Management summary ........................................................4 Assessment .........................................................................6 Management ........................................................................8 Medication ......................................................................... 10 APPENDICES ................................................................... 11 References ........................................................................ 15

ISBN number: ISBN : 978-1-74243-614-2 Endorsed by: South Australian Paediatric Clinical Guidelines Reference Committee. South Australian Child Health Clinical Network Last Revised: 14/04/10 Contact: South Australian Paediatric Clinical Guidelines Reference Committee:





Management flowchart for gastroenteritis

DISCHARGE Maintenance oral fluids + extra 10mL/kg per watery bowel action + reintroduce normal diet Advice sheet

HYDRATED AND TOLERATING ORAL FLUIDS (6mL/kg /hour)

STILL VOMITING OR DEHYDRATED • Admit to hospital (d/w

PED consultant/Paediatric consultant)

• Replace remaining deficit over next 4 hours

• plus maintenance • plus 2mL/kg/hr ongoing

losses

RAPID REHYDRATION • 50mL/kg total (12.5mL/kg/hr)

ORS over 4 hrs (oral or NGT) OR

• 10mL/kg/hr 0.9% sodium chloride + 5% glucose for 4 hrs

HIGH RISK • age < three months • co-existing medical

problems • psycho-social issues

LOW RISK Meets Rapid Rehydration Criteria illness present < 48 hrs child age > 6 mths no pre-existing chronic

medical condition

MODERATE 5-9%

DEGREE OF DEHYDRATION

ACUTE GASTROENTERITIS

SLOW REHYDRATION • ORS or IVT (0.9%

sodium chloride + 5% glucose)

• over 8 or 24 hours (see text)

• Admit to EECU if at WCH or paediatric ward(d/w ED or paediatric consultant)

Na+ <150

Na+ >150

MILD <5%

SEVERE >9%

RESUSCITATE URGENTLY • 0.9% sodium chloride 20mL/kg

IV/IO • Repeat until circulation stable • Check EUC, BGL, VBG • Discuss with ED/Paediatric

Consultant

Give trial of oral fluids (6mL/kg/hr) REASSESS

ADMIT TO HOSPITAL

YES NO

SLOW REHYDRATION over 48 hours






Important points > Gastroenteritis is a common infection of the gastrointestinal tract

characterised by any combination of diarrhoea, fever, vomiting and abdominal pain

> Similar symptoms may occur in other illnesses which should be considered before the diagnosis of gastroenteritis is made

> Dehydration and electrolyte abnormalities are the commonest complications requiring treatment

> Electrolyte abnormalities such as hypernatraemia (Na > 150mmol/L) and hypokalaemia are potentially dangerous and close monitoring is critical.

> Most cases of gastroenteritis can be managed using oral hydration. Enteral rehydration is preferable to intravenous (IV) hydration

> Severe dehydration can cause life-threatening shock and should be managed with 20ml/kg boluses of IV 0.9% sodium chloride

> Give careful consideration to where a child lives, and ease of access to medical attention if condition deteriorates, is required prior to discharge

Introduction > Gastroenteritis in children is a common infectious disease characterised by

any combination of diarrhoea, vomiting, fever, and abdominal pain. It is usually caused by a viral infection but may be bacterial or parasitic in origin. Outbreaks in the community are seasonal and sporadic

> Most children with gastroenteritis can be managed in the outpatient setting using oral fluids and parental education

> A small number of children become significantly dehydrated, requiring more aggressive rehydration under clinical supervision. Untreated or poorly-treated dehydration can lead to shock and death

> The risks of treatment include iatrogenic over-hydration and cerebral oedema from the use of solutions with inadequate sodium concentrations.

> Children with pre-existing conditions that make them more susceptible to dehydration or electrolyte derangement require close monitoring

> A number of potentially serious conditions which have symptoms in common with gastroenteritis and must be considered before the diagnosis of gastroenteritis is made. Warning signs of other diagnoses must be recognised and investigated (See APPENDIX 1)

Definitions and abbreviations > ORS - Oral rehydration solution

Management summary

> Establish diagnosis > Suspect gastroenteritis if there is a sudden increase in stool

frequency and a change in stool consistency to loose or watery > Early in the illness the only symptoms may be vomiting and fever.

It is important to exclude other serious conditions which may present in this way (See appendix 1)

> Ask about contacts who have a similar illness, recent travel and exposure to a potential source of enteric infection (contaminated food or water)






> In children with gastroenteritis caused by Norovirus or Rotavirus,

vomiting usually lasts for 1-2 days, and diarrhoea for 5-7 days, but stools may take some weeks to return to normal

> Assess level of dehydration > Dehydration is expressed as a percentage of pre-illness body

weight, using the assumption that 1kg of body weight approximates 1000ml water

> Clinical estimation of dehydration is imprecise, even with experienced clinicians. The following signs have been found to be the most useful: (see Table 1)

> Comparison of body weights – may be available particularly in repeat presentations

> Reduced skin turgor (prolonged time for pinched skin fold to return to normal)

> Increased capillary refill time > Abnormal respiratory pattern > Sunken eyes > Thirst > Tachycardia > Reduced urine output

> Note that in Hypernatraemic dehydration clinical estimation of

dehydration may be more difficult, Consider hypernatremia in the presence of:

> Lethargy > Irritability > A ‘doughy’ skin consistency > Ataxia, tremor > Hyperreflexia, seizures, reduced conscious level

> Clinical assessment of dehydration allows an estimate of fluid

deficit to be made which guides the amount of fluid replacement to give. Regular reassessment is important, to assess adequacy of treatment and allow for ongoing losses

> Severe dehydration may be associated with hypovolaemic shock and requires immediate fluid resuscitation using 20ml/kg 0.9% sodium chloride solution intravenously. Where the dehydration has occurred very rapidly there may be evidence of shock with a lesser degree of dehydration

> Rehydrate or prevent dehydration > In mild or no dehydration oral administration of ORS (see

Appendix 2) is recommended using frequent, small volumes. This can be successful even in the presence of ongoing vomiting. Short, frequent breast feeds can be used for breast fed infants

> Moderate dehydration can be managed with oral or intravenous rehydration, either rapidly or over 24 hours. Choice of method will depend on a number of factors discussed below

> Infants and children with severe dehydration should be resuscitated with IV crystalloid, oxygen and close monitoring. Replacement of the fluid deficit should occur over 24 hours once the child has an adequate circulation

See APPENDIX 4 for a summary of management decisions






Assessment > Primary care / outpatient history and examination History In taking the history it is important to determine:

> Frequency and nature of vomiting and diarrhoea > Fluid intake > Urine output > Symptoms indicating diseases other than gastroenteritis (SEE APPENDIX

1). > Recent antibiotics > The presence of a similar illness in family members or close contacts > The presence of bile-stained vomiting (volvulus or obstruction) or

blood/mucous in the stool (intussusception or dysentery) should be specifically sought

Examination This should focus on detecting and quantifying the degree of dehydration (Table 1), as well as excluding other diseases Young infants usually present with non-specific symptoms and signs of illness and are more prone to developing significant dehydration rapidly. A higher level of surveillance should therefore be given to them Table 1: Clinical Estimation of Dehydration in Children with Diarrhoea and Vomiting Mild Moderate

dehydration Severe dehydration

Body Weight

<5% loss 5-9% loss >9% loss

Clinical signs

None or minimal signs

• Normal level of alertness

• Warm peripheries

• Normal drinking

• Normal pulse and respiratory rate

• Thirst • Sunken eyes

with minimal/ no tears

• Dry mucous membranes (not accurate in mouth-breather)

• Irritability or restlessness

• Mild tachycardia

• Increased capillary refill time

Signs from mild-mod. Group (more marked) plus:

• Abnormal drowsiness or lethargy

• Capillary refill >2s • Poor peripheral

perfusion • Tachycardia and

tachypnoea • “Acidotic”

breathing (deep, rapid breaths)

Pinch test for skin turgor

Normal. Skin fold retracts immediately

Slow. Skin fold visible <2s

Very slow. Skin fold visible>2s






Note: > The degree of dehydration is an estimate and should be reassessed frequently

while treatment is being given

> Clusters of signs are more accurate than one or two signs alone

Investigations Electrolyte and acid-base measurements are not routinely required and do not add to the clinical estimate of degree of dehydration Indications include:

> any child requiring intravenous therapy (IVT) > any child with severe dehydration > altered conscious state or convulsions > hypernatraemia is suspected clinically - “doughy” skin, lethargy and

irritability more than expected for degree of clinical dehydration > if there is suspicion of Haemolytic Uraemic Syndrome (bloody diarrhoea

with pallor, haematuria and poor urine output) > children with pre-existing medical conditions that predispose to electrolyte

abnormalities e.g. cystic fibrosis, renal impairment

Blood Sugar Level (point of care) Young children with gastroenteritis are susceptible to hypoglycaemia. Measure BSL in young infants, patients with large ketones in the urine and patients who are more lethargic than would be expected for their degree of dehydration. If BSL<3.0 mmol/L give 5ml/kg 10% glucose after taking blood for hypoglycaemia screen (see hypoglycaemia guideline) Complete Blood Examination may sometimes be helpful in the investigation of vomiting and fever without diarrhoea Urinalysis should be performed in every patient, if possible, to measure the level of ketones present and look for glycosuria Most cases of gastroenteritis are viral (predominantly rotavirus or norovirus) and few bacterial causes benefit from antibiotic treatment. Routine stool examination is therefore not warranted when the presentation is typical Microbiological examination of the stool may be useful in the following situations:

> bloody diarrhoea > suspected food poisoning or epidemic > prolonged (>7-10 days) diarrhoea > recent overseas travel > child in residential institution/childcare > any diagnostic uncertainty






Management > Minimal or no dehydration Discharge home with advice about providing adequate amounts of appropriate fluids and continuing a normal diet when tolerated. It is not necessary to pass a trial of oral rehydration under supervision. If ORS is refused dilute, unsweetened fruit juice (1:4) or cordial (1:10) can be used, but this is sub-optimal for rehydration as it has insufficient sodium. Written instructions including a guide to fluid requirements and factors which should prompt a medical review should be provided upon discharge Consider referral for a home nursing review with Royal District Nursing Service / Country Home Link tel: 1300 110 600 Patients who should be admitted for 4-6 hours or transferred to an appropriate centre for a supervised trial of oral rehydration include: > those for whom the diagnosis is uncertain > those in a high-risk group

> infants less than three months of age > patients with co-existing medical problems > patients living in geographic isolation or with limited access to medical

care > inability of caring adult to assess deterioration of child due to

tiredness/intellectual disability/mind altered state > inability to return due to lack of transport or distance > re-presentations during the same illness

> Moderate dehydration These children should be referred to a centre offering paediatric care for further assessment and management or specialist advice should be sought Decide on the method of rehydration > Rapid Rehydration Preferred method provided:

> the illness has been present for less than 48 hours, > the child is older than 6 months and > the child does not have a chronic medical condition which affects fluid

balance (e.g. chronic renal failure, some cardiac conditions) NOTE: The rapid rehydration fluid rate must not continue after 4 hours. Reassessment must occur at this time Rehydrate rapidly by giving a total volume of 50ml/kg ORS over 4 hours either orally or via NGT using a kangaroo pump for constant infusion. Do not add maintenance fluid to this volume Nasogastric tubes are generally well tolerated in children less than 4 years of age. Note that ongoing vomiting is not a contraindication to oral rehydration and that fluid can be given orally via cup, spoon or syringe IVT is more expensive and prone to more complications than NG therapy, however if oral or nasogastric fluids are not tolerated, commence IV [0.9% sodium chloride + 5% glucose]* at 10ml/kg/hr for four hours (do not add maintenance fluid to this volume). *See APPENDIX 3 for how to make up this solution






Reassess and weigh the child after this deficit volume has been given

> If the child is rehydrated and tolerates oral fluids (aim for 6mL/kg/hr) then discharge home with advice sheet and LMO follow-up. Consider referral for a home nursing review with Royal District Nursing Service / Country Home Link tel: 1300 110 600.

> If living circumstances indicate limited access to medical attention should child’s condition deteriorate, caution is recommended. Consider further observation and monitoring

> If the rapid rehydration finishes late at night and the child has improved clinically it is reasonable to continue observations and allow the child to sleep, with oral fluids commencing in the morning

> If dehydration persists the child will need overnight admission and continued rehydration. Commence maintenance fluids as ORS [or 0.9% sodium chloride + 5% glucose] (for rates see APPENDIX 3), plus fluid to correct the remaining deficit over the next 4 hours, plus 2mL/kg/hr to replace ongoing diarrhoeal losses. Reassess again once the deficit volume has been given.

> Intravenous rehydration should be considered if oral/nasogastric rehydration is not tolerated or if the child becomes dehydrated due to excessive ongoing losses despite ORT

> Slow Rehydration Patients who do not fit the criteria for rapid rehydration should be rehydrated over 24 hours. Calculate the sum of: Deficit + maintenance + ongoing losses. The fluid deficit is calculated using the formula: Give this over eight hours or more slowly in consultation with the relevant specialist unit. Ongoing losses can be estimated to be 2ml/kg/hour in acute rotavirus. ORT either orally or via NGT is preferable but I.V. [0.9% sodium chloride + 5% glucose]* may be used if ORT is not tolerated. *See APPENDIX 3 for how to make up this solution. Review the patient at 4 hours and once the rehydration volume has been given. Look particularly for:

• Weight change • Clinical signs of dehydration • Urine output • Ongoing losses & • Signs of fluid overload, such as puffy face and extremities

Once the child is rehydrated continue fluids at maintenance + ongoing losses. Potassium may be added to IV solutions once the child has passed urine and the serum potassium is known. Monitor electrolytes regularly if IV rehydration is being used Feeding may commence once oral fluids are tolerated or once the child is hungry. Full-strength milk/formula may be given to infants

> Severe dehydration These children should be referred to a centre offering paediatric care for assessment or seek specialist advice using the 13STAR (137827) number > Dehydration with shock constitutes a medical emergency

Fluid deficit in ml = % dehydration x weight in kg x 10






> Once the airway and breathing have been assessed and supported as required,

with high-flow oxygen being given, IV access should be secured

> Take blood for EUC, venous gas, and Glucose

> Consider other causes for shock and manage accordingly

> Give a fluid bolus of 20ml/kg of 0.9% sodium chloride solution. Reassess. If shock persists; repeat the fluid bolus. Once the circulation is restored commence rehydration. If there is no improvement seek specialist advice

> NB: The rehydration volume calculation should take into account fluids already given during resuscitation

> The patient should be weighed at least daily

> Electrolyte Disturbances 1.Hypernatraemic dehydration (Na > 150mmol/L) is potentially dangerous and close monitoring is critical.

> If Na > 150mmol/L speak to a specialist. Aim to replace deficit slowly (over 48 hours) to minimise risk of cerebral oedema. Admission to a unit where the patient can be closely monitored is preferable and sodium levels need to be measured 4 hourly. Fluid choice (usually 0.9% sodium chloride) and rate should be in discussion with a Paediatric specialist

> If Na <150mmol/L and intravenous rehydration is required, 0.9% sodium chloride has been shown to have less risk of lowering serum sodium levels and is recommended, particularly if serum sodium is <135mmol/L prior to rehydration

2,Hypokalaemia

Medication Avoid the use of unnecessary medication in gastroenteritis

> Antiemetics > Ondansetron in wafer or syrup form is available and has been shown

to be safe and effective for children with gastroenteritis down to 6 months of age

> There is some evidence that it can reduce admission rates and improve the success of oral rehydration. Usually only one dose is required. Ondansetron can increase the volume and frequency of diarrhoea and thus should not be used where diarrhoea is the only symptom. Conditions in appendix 1 should be excluded prior to administering Ondansetron. See APPENDIX 5 for dosage schedule

> Metoclopramide (Maxolon) and Prochlorperazine (Stemetil) are not recommended as there is a risk of extra-pyramidal side-effects and they are often ineffective in children with gastroenteritis

> Anti-diarrhoeal agents and anti-motility agents These are not recommended as their efficacy is not proven and there is a risk of adverse effects






> Antibiotics These are rarely required, even in bacterial gastroenteritis. They may be considered in young infants with high fevers in whom a bacterial cause is likely, in patients with ongoing severe symptoms due to a bacterial pathogen or inpatients who have travelled overseas recently. Consultation with a paediatrician or infectious diseases specialist is recommended

> Probiotics and Zinc These should not be given routinely. Research is ongoing in this area

APPENDICES

Appendix 1- Differential Diagnoses and Warning Signs of Serious Conditions Mimicking Gastroenteritis Vomiting alone, although a common presenting feature in early gastroenteritis is a symptom of many other illnesses. Beware- very young children or malnourished children are likely to be more severely ill or have another diagnosis. Some of the differential diagnoses to consider are: Surgical:

> intestinal obstruction (e.g. Volvulus or intussusception) > acute appendicitis > raised intracranial pressure

Medical: - > urinary tract infection > pneumonia > meningitis > sepsis > metabolic (e.g. Diabetes mellitus, urea cycle defects)

WARNING SIGNS that should be recognised and prompt further investigation include:

> Abdominal distension

> Localised abdominal tenderness or severe abdominal pain

> Bile-stained vomiting

> Fever>39°C

> Blood or mucus in stool

> Headache

> Neck stiffness

> Bulging fontanelle

> Non-blanching rash

> Shortness of breath






Appendix 2 - Oral Rehydration Solutions Fig 1: Oral Rehydration Solution Composition Name Sodium

mmol/L Potassium mmol/L

Chloride mmol/L

Citrate mmol/L

Glucose mmol/L

Osmolarity mOsm/L

Glucose-electrolyte solutions

WHO 90 20 80 10 111 311

Gastrolyte® powder

60 20 60 10 90 240

Hydralyte®

45 20 45 30 80 240

Repalyte®/ ChemmartORS®/ Restore ORS®

60 20 60 10 90 240

Pedialyte® 45 20 35 10 126 246

Rice-based solutions

Gastrolyte® R

60 20 50 10 6g pre-cooked rice/L

226

European Society of Paediatric Gastroenterology, Hepatology and Nutrition recommendation

60 20 Not <30 10 74-111 200-250

Fig 2: Composition of other Oral Fluids Sodium

mmol/L Carbohydrate mmol/L

Osmolarity mOsm/L

Apple Juice 3 690 730 Soft Drinks ~2 ~700 ~750 Sports drinks ~20 ~255 ~330






Appendix 3 – Fluid Requirements and Recommendations Maintenance Fluids 0-6months 120-140 ml/kg/day > 6months: Body Weight Fluid requirement

ml/day Fluid requirement ml/hr

First 10kg 100ml/kg 4ml/kg/hr Second 10kg + 50ml/kg +2ml/kg/hr Subsequent kg + 20ml/kg +1ml/kg/hr e.g. 25kg child: maintenance rate is 40+20+5 = 65 ml/hr Rehydration Fluids Oral Rehydration Solution 0.9% sodium chloride for resuscitation 0.9% sodium chloride for IV rehydration (with or without 5% glucose)* 0.45% sodium chloride + 5% glucose for maintenance N.B. Do not give 4% glucose + 0.18% sodium chloride or 5% glucose for rehydration * Note: 0.9% sodium chloride with 5% glucose is a commercially available solution. If unavailable: to make 0.9% sodium chloride with 5% glucose: Remove 100ml of 0.9% sodium chloride from a 1000ml bag of 0.9% sodium chloride and add 100ml of 50% glucose






Appendix 4-Management Decisions in Gastroenteritis in Children When to treat at home:

> Family able to cope > Absence of dehydration > Vomiting not interfering with fluid intake

When to consult:

> Diagnosis in doubt > Therapy in doubt > Infant under three months of age > Pre-existing disease

> Diabetes > Cyanotic heart disease > Chronic renal disease > Previous bowel resection > Malnutrition > Failure to improve

When not to treat at home

> Moderate Dehydration > Diagnosis in doubt > Family unable to cope > Deterioration > Persistent vomiting > Profuse diarrhoea

Appendix 5-Ondansetron Dosage Guidelines Ondansetron is recommended for children over 2 years of age with frequent vomiting likely to be due to gastroenteritis to assist in oral rehydration and relief of nausea. Some studies have used the medication safely for children from 6 months of age. Dose is 0.15 mg/kg as mixture If wafers are used:

> 2mg (½ wafer) for children 8-15kg > 4mg for children 15-30kg > 8mg for children >30kg

Adverse effects are unusual but studies suggest that its use may prolong the duration of diarrhoea. Ondansetron should not be used in children with prolonged QT syndrome






References Several Guideline sites were consulted for existing guidelines regarding “diarrhoea”, “vomiting” and “gastroenteritis” including: > National Guideline Clearing House http://www.guideline.gov/ > National Institute for Health and Clinical Excellence (NICE)

http://guidance.nice.org.uk/CG/published > UK NHS (http://libraries.nelh.nhs.uk/guidelinesFinder/) > National Institute of Clinical Studies http://www.nhmrc.gov.au/nics/index.htm > National Health and Medical Research Council

(http://www.nhmrc.gov.au/publications/index.htm) The following guidelines were found to be suitable for adaptation using the AGREE tool (http://www.agreecollaboration.org/pdf/agreeinstrumentfinal.pdf):

1. The Greater Eastern and Southern NSW Child Health Network Clinical Practice Guidelines for Gastroenteritis http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_009.pdf

2. The NICE guideline: Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years http://egap.evidence.nhs.uk/CG84/

The following articles were found to be relevant:

1. Harris C, Wilkinson F et al, Evidence based guideline for the management of diarrhoea with or without vomiting in children, Australian Family Physician 2008;37 (6 ) accessible at http://www.racgp.org.au/Content/NavigationMenu/Publications/AustralianFamilyPhys/2008issues/afp200806paediatricconditions/200806supplementdiarrhoea.pdf

2. DeCamp LR, Byerley JS, Doshi N et al. Use of antiemetic agents in acute gastroenteritis, a systematic review and meta-analysis. Arch Pediatr Adolesc Med. 2008;162(9):858-865

3. Hartling L, Bellemare S, Wiebe N, et al. Oral versus intravenous rehydration for treatment of dehydration due to gastroenteritis in children. A Cochrane reiew. Cochrane Database of Systematic Reviews 2003(3):CD004390 http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004390/frame.html

4. Alhashimi D, Al-Hashimi H , Fedorowicz Z. Anitemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. A Cochrane review. http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD005506/frame.html

5. Diarrhoea in Children. The GUT Foundation publication, Revised in 2008 by Davidson G, Catto-Smith T and Elliott E. http://www.gut.nsw.edu.au/assets/documents/Diarrhoea%20in%20Children%20v8.pdf

6. Bellemare S, Hartling L, Wiebe N, Russell K, Craig WR, McConnell D, et al. Oral rehydration versus intravenous therapy for treating dehydration due to gastroenteritis in children: a meta-analysis of randomised controlled trials. BMC Medicine 2004;2(1):11.

7. Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics 2002;109(4):566-72

8. Dalby-Payne J, Elliott E. Gastroenteritis in Children. In: Tovey D, editor. Clinical Evidence. 13 ed. London: BMJ; 2004. p. 343-353.

9. Elliott EJ, Dalby-Payne JR. 2. Acute infectious diarrhoea and dehydration in children. Medical Journal of Australia 2004;181(10):565-70.




http://www.guideline.gov/

http://guidance.nice.org.uk/CG/published

http://libraries.nelh.nhs.uk/guidelinesFinder/

http://www.nhmrc.gov.au/nics/index.htm

http://www.nhmrc.gov.au/publications/index.htm

http://www.agreecollaboration.org/pdf/agreeinstrumentfinal.pdf

http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_009.pdf

http://egap.evidence.nhs.uk/CG84/

http://www.racgp.org.au/Content/NavigationMenu/Publications/AustralianFamilyPhys/2008issues/afp200806paediatricconditions/200806supplementdiarrhoea.pdf



http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004390/frame.html




http://www.gut.nsw.edu.au/assets/documents/Diarrhoea%20in%20Children%20v8.pdf

http://www.gut.nsw.edu.au/assets/documents/Diarrhoea%20in%20Children%20v8.pdf



10. Webb A, Starr M. Acute gastroenteritis in children. Australian Family

Physician 2005;34(4):227-31. 11. Conners GP, Barker WH, Mushlin AI, Goepp JG. Oral versus intravenous:

rehydration preferences of pediatric emergency medicine fellowship directors. Pediatric Emergency Care 2000;16(5):335-8.

12. Armon K, Stephenson T, MacFaul R, Eccleston P, Werneke U. An evidence and consensus based guideline for acute diarrhoea management. Archives of Disease in Childhood 2001;85(2):132-42

13. Ramsook C, Sahagun-Carreon I, Kozinetz CA, Moro-Sutherland D. A randomized clinical trial comparing oral ondansetron with placebo in children with vomiting from acute gastroenteritis.[see comment]. Annals of Emergency Medicine 2002;39(4):397-403.

14. Borowitz SM. Are antiemetics helpful in young children suffering from acute viral gastroenteritis? Archives of Disease in Childhood 2005;90(6):646-8.

15. Cubeddu LX, Trujillo LM, Talmaciu I, Gonzalez V, Guariguata J, Seijas J, Miller IA, Paska W. Antiemetic activity of ondansetron in acute gastroenteritis. Alimentary Pharmacology and Therapeutics 1997;11;185-191.

16. Freedman SB, Adler M, Seshadri R, Powell EC. Oral Ondansetron for Gastroenteritis in a Pediatric Emergency Department. New England Journal of Medicine 2006;354(16): 1698-1705.

17. Reeves JJ, Shannon MW, Fleisher GR. Ondansetron Decreases Vomiting Associated With Acute Gastroenteritis: A Randomized, Controlled Trial. Pediatrics 2002;109(4);e62.

18. Steiner MJ, DeWalt DA, Byerley JS. Is This Child Dehydrated? JAMA. 291(22):2746-54, 2004 Jun 9.

Information for parents Parenting and Child Health. Women’s and Children’s Health Network. Available at URL: http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=304&id=1855




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