Vomiting and Diarrhea

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Vomiting

and Diarrhea

Linda

S. Book,

MD

From the Department of Pediatrics, University of Utah, Primary Children’s Medical Center, Salt Lake City

ABSTRACT. Vomiting and diarrhea are frequently en-countered in pediatric patients. Dehydration, a serious consequence of both vomiting and diarrhea, results in the deaths of more than 700 children annually in the United States. With appropriate parent education, both morbid-ity and mortality can be reduced, and much ofthe anxiety about these problems can be alleviated. Parents must be educated to recognize the associated signs and symptoms that indicate serious disease and warrant notifying the

physician. Fluid therapy should be individualized, and

parents should be informed of the appropriate steps to take. Parents must make quantitative observations and keep records not only to enable the physician to assess adequate fluid balance but also to be able to demonstrate to themselves the effectiveness of the treatment. It isjust as important for the physician to reassure parents, who will have concerns about long-term nutritional or growth consequences. Pediatrics 1984;74(suppl):950-954; vomit-ing, diorrhea fluid therapy, dehydration, patient educa-tion.

Vomiting and diarrhea are frequently encoun-tered in pediatric patients, with most physicians seeing many such patients each week. More than 700 children die annually in the United States from dehydration caused by acute gastroenteritis, and many more are hospitalized.1 With appropriate par-ent education, not only can morbidity and mortality be reduced, but much anxiety about these problems can be relieved.

This article will review the information that should be transmitted to parents about vomiting and diarrhea in their child. It will define vomiting and diarrhea, determine the usual causes, delineate the observations and treatment that should be pro-vided by parents, describe the clinical course, and discuss the importance of reassuring parents about the problems of vomiting and diarrhea.

Read before the Symposium on Pediatric Patient Education: Challenge for the 80s, Dallas, Nov 29-30, 1983.

Reprint requests to (L.S.B.) Primary Children’s Medical Center, 320 12th Aye, Salt Lake City, UT 84103.

VOMITING

Vomiting is the forceful expulsion of stomach contents from the mouth or nose. Parents should be taught to distinguish it from “wet burps,” which are small amounts of food (usually less than 5 mL [1 tsp]) that many infants tend to regurgitate after feeding. Wet burps do not result in significant loss of nutrient intake and rarely cause a problem.

Causes

Some infants regurgitate amounts ofa tablespoon or more throughout the day but never empty the stomach of a large amount at any one time. This frequent regurgitation in the absence of overt ill-ness is usually due to reflux. Reflux can result from decreased tone ofthe gastroesophagealjunction and delayed gastric emptying. In most children, such episodes of regurgitation resolve by 1 year of age with conservative measures such as sitting up after feeding and raising the head of the bed for sleeping.

In addition to reflux, several problems unique to infants need to be considered, such as pyloric ste-nosis, overfeeding, improper feeding and burping techniques, and food intolerances. The toddler or older child who has vomiting as an acute symptom usually has viral gastroenteritis. Other infectious illnesses (such as otitis media), toxic ingestions, and head trauma also should be considered.

Signs and Symptoms That Indicate Serious

Illness

Vomiting can be a sign of a serious disorder. To know when to notify the pediatrician, parents should learn to recognize the associated signs and symptoms that may indicate when more than just symptomatic therapy is needed.

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change in behavior or alertness can be seen in Reye syndrome or encephalitis. Vomiting accompanied by abdominal pain could indicate appendicitis. Fol-lowing head injury, vomiting may indicate signifi-cant trauma requiring surgical intervention. Re-peated episodes of coughing and choking can be seen in gastroesophageal reflux with aspiration. Vomiting of red or black material could represent bleeding; green emesis could represent possible in-testinal obstruction. (To avoid confusing the color of the vomited material with colored food products, parents should be advised to have their child refrain from taking red or green drinks during treatment.)

Parents should be made particularly aware of the signs and symptoms of dehydration: not urinating for 12 hours, dark circles under the eyes, weakness, a sticky mouth, thirst, and, in infants, a sunken fontanel. Any of these symptoms can represent dehydration. Infants less than age 6 months may, because of decreased concentrating ability of the kidney, continue to urinate despite overt dehydra-tion.

To summarize, parents should be educated to notify the pediatrician if any of the following signs or symptoms occur along with vomiting’ fever, se-vere headache, head injury, abdominal distension, abdominal pain, change in level of alertness or behavior, coughing or choking, toxic ingestion, and dehydration. The pediatrician should also be noti-fled when red, black, or green material has been vomited.

Measurements and Record-Keeping by Parents

By making certain quantitative observations and keeping precise records, parents are able to convey to the physician important information about their vomiting child. The physician can then rapidly determine whether adequate fluid balance is being maintained.

Parents should note down not only how much the child is vomiting but also how much liquid has been ingested and how frequently the child un-nates. A recording sheet like the one shown in the Figure can be used for this purpose.

Parents generally tend to overestimate the amount of emesis. It may be useful for the physician to make the following comparisons: (1) 15 mL (1 tablespoon) makes a spot on the rug or clothing

101.6 mm (4 in) in diameter, (2) a quarter cup

makes a spot 203.2 mm (8 in) in diameter, and (3) 240 mL (1 cup) saturates a 228.6 X 304.8-mm (9” x 12”) cloth diaper.

Treatment and Clinical Course

Treatment of the infant or child with acute onset ofvomiting consists of providing energy, water, and

minerals in a clear liquid. The parents should be reassured that temporary interruption of the child’s usual diet will not have significant nutritional con-sequences. Particularly for infants, who are more prone to dehydration and electrolyte abnormalities, the use of oral electrolytes (Pedialyte, Infalyte, and

Lytren) has advantages (Table 1) Jello water, apple

juice, and carbonated beverages, although adequate as energy sources, are too low in sodium, potassium, and chloride to be the exclusive fluids ingested. Parents should be discouraged from giving their child plain tea and water because of the lack of carbohydrates and electrolytes in these fluids. Use of homemade sugar-water and salt-water solutions should be discouraged because they vary too much in composition.2

Provide parents with a schedule for feeding. The vomiting child should be given no food or drink for two to four hours. Then, 15 mL (.5 oz) of liquid should be given to the vomiting infant every 20 minutes for one to two hours. For children more than 1 year old, 30 mL (1 oz) of liquid should be given every 20 minutes for one to two hours. If the vomiting stops or decreases, parents should in-crease the amount of liquid and give it every three to four hours. Parents should be informed of the minimum amount of liquid required to maintain adequate fluid balance. This figure is based on the child’s weight (Table 2).

Vomiting Diarrhea Lkine

XforEach Tune

Fluids (mLoroz)

7AM-i i AM

i i AM-3 PM

3 PM-7_PM

7PM-ii PM

i 1PM-3 AM

3AM-7_AM

Figure. Patient data sheet. Key: X = one time; XX =6

mL (‘/4 cup); XXX = 12 mL (‘/2 cup).

TABLE 1. Products Commonly Used as Clear Liquid Solutions for Treatment of Diarrhea and Vomiting

Sodium Potas- Carbo- Osmolarity

(mEq/L) sium hydrate (mosm/L)

(mEq/L) (%)

Pedialyte 30 20 50 330

Lytren 30 25 72 290

Pedialyte RS 50 20 2.5 250

Infalyte 50 20 2.5 250

Gatorade 23 10 5.9 330

Apple juice 3.5 24-32 12.0 730

Carbonated 0.5-5.0 0.1-2.0 5.3-10.6 390-750

beverages

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TABLE 2. Oral Fluid Administration

Weight of Chil d (kg)

3.2 4.5 5.9 7.7 9.1 10.8 13.6 11.8 18.1

(7lb) (lOlb) (l3lb) (l7lb) (2Olb) (24lb) (3Olb) (26th) (401b)

Amount for maintenance

mL/d 36 450 510 600 690 900 1,050 1,140 1,200

(oz/d) (12) (15) (17) (20) (23) (30) (35) (38) (40)

Amount for 5% dehydration

mL/d 510 660 810 960 1,200 1,500 1,620 1,800 2,100

(oz/d) (17) (22) (27) (32) (40) (50) (54) (60) (70)

Vomiting secondary to gastroenteritis, or intes-tinal “flu,” usually resolves in 24 to 48 hours. After 24 hours of clear liquids, parents can begin giving their child carbohydrate-containing foods such as crackers, rice, and cooked fruits. Foods high in fat content-dairy products, meats, and fried foods-should not be given yet because they may delay gastric emptying, increase nausea, and predipose the child to more vomiting. Generally, after 48 to 72 hours, a normal diet can be resumed.

A handout can be used to provide the following information: the amount of liquid the child should consume, the types of liquids to be used, and how to advance the diet. The handout should also in-dude a sample data sheet for recording intake and output.

Reassure parents by discussing when the patient will get better. In the case of intestinal “flu,” the vomiting generally resolves within 48 hours. Par-ents should not be concerned if the child continues to vomit occasionally during the next week, and it is usually not necessary to alter the diet if this occurs. If the child’s vomiting is secondary to an infection such as otitis media, the vomiting will decrease as the illness resolves. Some children are particularly sensitive to antibiotics and may con-tinue to regurgitate as long as the medication is given.

Forceful vomiting that fails to resolve is of con-cern in every age group. In follow-up visits the physician needs to assess weight loss or failure to gain weight adequately. The child’s growth chart can be used to illustrate to the parents adequate or inadequate growth. The parents should be told the possible reasons for their child’s vomiting, the di-agnostic plan, and the therapeutic approach. For example, an upper gastrointestinal series may be necessary to rule out pyloric stenosis, severe gastro-esophageal reflux, or duodenal ulcer. Antacids may be necessary for gastritis. It is important to express a willingness to refer the patient for specialized tests or procedures when there is no improvement.

DIARRHEA

The defmition of diarrhea as frequent, watery stools is somewhat vague and depends on one’s conception of the consistency and quantity of nor-mal bowel movements. Generally, it should not be a problem for parents to recognize that an abrupt change in their child’s habits from formed to fre-quent, watery bowel movements represents diar-rhea. However, the physician should stress, partic-ularly to parents of infants, the wide variability in stool volume, consistency, and frequency. The stool

output of infants less than age 1 year is variable; it

may reach 150 g (5 oz) per day. The stool output of infants older than 1 year may reach 200 g (7 oz) per day.3 There may be as many as 12 movements daily for the breast-fed infant.

Causes of Acute Diarrhea

In North America, the usual cause of acute diar-rhea is viral gastroenteritis. Rotavirus is one of the commonest viral pathogens, accounting for up to 80% of diarrhea in winter months.4 Parents should be informed that even though the diarrhea may be severe and accompanied by fever, viral gastroenter-itis is like the common cold. Antibiotic therapy generally will not help, and symptomatic treatment with rehydration fluids will be sufficient until the illness resolves.

Bacterial or parasitic infections can be acquired from contaminated water, infected animals, or in-fected people and may require antibiotic or anti-parasitic medication. As many as 17% of travelers to subtropical areas, even within the continental United States, have diarrhea.5 As with vomiting, diarrhea is associated with various infections, in-cluding otitis media, pneumonia, and urinary tract infections. Milk allergy is probably overdiagnosed in young infants. Its true incidence is between 0.3% and 7% of all children.#{176}’7 Appropriate education can

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Preventive

Measures

Parents should be taught how to prevent diar-rhea. Emphasize proper handwashing, particularly for care providers and children in day care facilities and crowded living conditions4 A mother should know that diarrhea may be less likely to occur in breast-fed infants.8 This information may encour-age her to continue nursing until the child is at least 6 months old; if she is not nursing now, it may encourage her to breast-feed subsequent children.

Signs and

Symptoms

That Indicate

Serious

Illness

Although diarrhea is generally mild and self-limited, certain signs and symptoms may indicate a more serious condition or a need for a specific therapy. Fever may indicate an ear on urinary tract infection requiring antibiotics. Abdominal disten-sion and pain may indicate colitis, appendicitis, or intestinal obstruction. Red or black stools suggest bleeding, pale or white stools can be seen in liver disease. As with vomiting, symptoms of dehydra-tion are important. Vomiting with diarrhea is of particular concern because the infant or child may not be able to retain the necessary fluids to prevent dehydration.

Occasionally, in the diapered infant with diarrhea stools may be so watery that parents fmd it difficult to distinguish the excretion from urine. Parents may then erroneously suppose that the infant is doing well because of a presumed adequate urine output. Observing the infant with the diaper off for a period of time will usually clarify this issue.

To summarize, parents should notify their phy-sician if any of the following signs and symptoms accompany diarrhea: fever, abdominal distension, abdominal pain, severe vomiting, and dehydration. Red, black, or white stools also require attention.

Treatment

and Clinical

Course

Providing appropriate hydration/rehydration

fluids is critical in diarrhea. Losses in stool of sodium total 30 to 65 mEciJL; loss of potassium, 18 to 60 mEq/L; and loss of chloride, 26 to 55 mEg] L.9 Despite dietary changes, significant water and mineral losses tend to occur for at least 24 hours.

For infants, the most appropriate oral fluids are the commercial electrolyte solutions (Table 1). The new solutions, Infalyte and Pedialyte RS, have higher electrolyte concentrations, lower osmolari-ties, and lower glucose concentrations. They are designed particularly for the child with mild dehy-dration and may afford better water, sugar, and salt absorption in severe diarrhea.’#{176} The physician should stress to parents that although these

com-mercial solutions are more expensive than carbon-ated beverages or homemade jello water, the proper rehydrating solution for diarrhea is as important as an antibiotic medication for an ear infection. The cost is also less than for a doctor’s visit or a course of antibiotic therapy.

Jello water, juice, and carbonated beverages with carbohydrate concentrations of 10% to 15% may exceed the absorptive capacity of the intestine, resulting in efflux ofwater into the intestinal lumen and thereby increasing water and electrolyte losses. The amount an infant or child should ingest each day to prevent or treat dehydration is shown in Table 2. As with vomiting, parents should be ad-vised to keep a record of their child’s losses and liquid intake (Figure).

With the use of commercial electrolyte products, diarrhea is relieved in 24 to 48 hours. Infants should then be given formula diluted to half strength. Parents should be forewarned of the possibility of temporary intolerance to cow’s milk formula: tem-porary lactose intolerance occurs in as many as 20% of infants following diarrheal illness.” Lactose

intolerance should be suspected if stools are watery

and cause severe diaper rash when the child is fed milk or cow’s milk formula. A change to a nonlac-tose-containing soy-based formula for several weeks usually allows recovery.’2

It is important that parents have reasonable ex-pectations about stool volume and frequency during recovery. For 1 week after the onset of viral gas-troenteritis, stool output remains increased in most infants.3 As long as the approximate amount (for infants) is less than 15 g (.5 oz) per .45 kg (1 lb) of body weight per day, there should be minimal con-cern for advancing the diet. If this point is not made clear, or instructions about how to advance the diet are too vague, parents may inappropriately feed their child only clear liquids for prolonged periods.

When diarrhea is severe, both infants and older children should be encouraged to drink the oral

electrolyte solutions. For mild-to-moderate

diar-rhea, a diet of Gatorade, carbonated beverages at half strength, and starchy foods (crackers, cereal, potatoes, pretzels) is acceptable. After 24 to 48 hours, the diet can be expanded to include fruits, vegetables, eggs, and meats. The child’s intake of milk and milk products should be reduced or elim-inated for a few days to a week.

The physician should assume that parents will give their child common remedies for diarrhea un-less otherwise advised. Binding agents such as

Ka-opectate will cause stools to look more formed, but

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causing it. Medications such as paregoric, which decrease the number of stools, retard this process. In infants, paregoric has the additional disadvan-tage of decreasing stool output at the expense of retaining intestinal contents in the bowel lumen, thereby not giving parents or the physician a true picture of the losses from the infant’s body. Di-phenoxylate hydrochloride with atropine sulfate (Lomotil) is contraindicated in infants because it

contains atropine, which has been reported to be

toxic in this population.’4

An increased stool volume that persists for longer than 3 weeks or repeated failure over a week’s time to expand the diet beyond clear liquids is of concern. Because of the possibility of dehydration during the child’s diarrheal episode, parents may have become accustomed to giving the child large amounts of fluids. Parents should reduce the liquid intake to .95 L (1 qt) or less once the acute diarrheal episode has resolved, as excess fluid intake can perpetuate the loose stools.

Sometimes parents are timid about reintroducing milk products and other fat-containing foods into their child’s diet. Because a diet too high in carbo-hydrate and too low in fat can also result in loose stools,’5 parents should be advised to reintroduce fat-containing foods into their child’s diet.

Most chronic diarrhea, that is, diarrhea lasting 3 weeks or more, can be accounted for by one of seven entities: milk intolerance, disacchanidase defi-ciency, celiac disease, cystic fibrosis, bacterial or parasitic infection, inflammatory bowel disease, or chronic nonspecific diarrhea. In cases of chronic diarrhea, the physician should explain to the par-ents the systematic approach to ruling out these entities.

PROVIDING REASSURANCE

In both vomiting and diarrhea, it is important that the physician provide reassurance as well as education. Parents may be frightened by the knowl-edge that these illnesses can result in dehydration. The physician should reassure parents that the body, through the kidneys, can usually compensate effectively for the salt and water losses. The par-ents’ record of their child’s diarrhea, vomiting, and liquid intake can be used to demonstrate the effec-tiveness of the therapy. Concerns about the nutri-tional consequences of the illness should be

ad-dressed. If the parents are worried that their child may not receive the adequate calories and nutrients as soon as possible after the acute illness, reassure them that 24 to 48 hours of clear liquids will not affect the child’s overall growth and development.

It is also important for the physician to provide guidelines on the duration of the vomiting or diar-rhea so that they know what to expect. An expla-nation of the circumstances that will necessitate further testing-poor weight gain, persistence of symptoms beyond a certain time, fever, and so forth-will reassure parents that their physician is prepared to deal with any deviations from normal recovery.

REFERENCES

1. Snyder J: From PedialYte to popaicles: A look at oral rehy-dration therapy used in the United States and Canada. Am J Clin Nutr 1982;35:157-161

2. Levine MM, Hughes TP, Black RE, et al: Variability of sodium and sucrose levels of simple sugar/salt oral rehydra-tion solutions prepared under optimal and field conditions.

J Pediatr 1980;97:324

3. MacLean WC, Klein GL, Lopez de Romana G, et al: Tran-sient steatorrhea following episodes ofmild diarrhea in early infancy. J Pediatr 1978;92:562

4. Pickering LK, Evans DG, DuPont HL, et al: Diarrhea caused by Shgeila, rotavirus, and Giardia in day care centers: Prospective study. J Pediatr 1981;99:51

5. Turner AC: The diarrheas of travel. Br J Hosp Med

1977;17:22

6. Gerrard JW, MacKenzie JWA, GoluboffN, et al: Cow’s milk allergy: Prevalence and manifestations in an unselected series of newborns. Acta Paediatr 1973 (suppl 2): 234 7. Eastham EJ, Walker WA: Effect of cow’s milk on the

gastrointestinal tract: A persistent dilemma for the pedia-trician. Pediatrics 1977;60:477

8. Larsen SA, Homer DR: Relation of breast vs bottlefeeding to hospitalization for gastroenteritis in a middle-class US population. J Pediatr 1978;92:417

9. Hirschhorn N: Treatment of acute diarrhea in children: Historical and physiological perspective. J Clin Nutr

1980;33:637

10. Shedi HP, Clifton JA: Solute and water absorption by the human small intestine. Nature 1963;199:1264

11. Burke V, Kerry KR, Anderson CM: Relationship of dietary lactose to refractory diarrhea in infancy. Pediatrics

1965;41:712

12. Naidoo BT, Chunterpurshael Mahyoodeen ABG, Patheu G: The use of a soy isolate based formula in the treatment of infantile diarrhea. J

mt

Med Res 1981;9:232

13. McClung HJ, Beck RD. Powers P: The effect of a Kaolin-pectin absorbent on stool losses of sodium, potassium and fat during a lactose-intolerance diarrhea in rats. J Pediatr

1980;96:769

14. Ginsberg CM: Lomotil (diphenoxylate) and atropine intox-ication. Am J Dis Child 1973;125:241

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1984;74;950

Pediatrics

Linda S. Book