Bronchiolitis

Cough in children

Fever in children

Acute gastroenteritis in children

Acute asthma in children: are nebulisers or spacers best?

WINTERILLS

Key Advisers

Dr Marguerite Dalton

Dr David Reith

6I BPJIIssue5

BronchiolitisMostinfantspresentingwithwheezeinthefirstyearof lifehavebronchiolitis.Mostcasesofbronchiolitisoccur

between2and5monthsofage,inairwayswithverysmallcalibre.

Bronchiolitis isusuallycausedbyRespiratorySyncytialVirus,butcanalsobecausedbyrhinovirus,adenovirus,

influenzaandparainfluenzaviruses. Itstartswith2–3daysofcoryzalsymptomsandprogressestocoughand

wheezewithfeverandtachypnoea.

Wheezesandcracklesareusuallyheardthroughoutthechest.Focalchestsignssuggestalternativediagnoses

suchaspneumoniaoraspiration.

Infantswithbronchiolitisoftengetworseforthefirst72hoursoftheirillnessandthenstarttoimprove.Symptoms

maytakeseveralweekstoresolve,withamediandurationofapproximately12days.Childrenandparentsneed

supportduringthistime.

Bronchiolitishasa1–2%mortalityrateandinfantswithhypoxaemiarelatedtosmallairwaysobstructionmayneed

treatmentwithracemicepinephrineandsteroidsinadditiontooxygen,intravenousfluidsandnasogastricfeeding.

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Management of bronchiolitis is mostly supportive

Interventionssuchasbronchodilators,adrenaline,steroidsandantibioticshavenotbeenshowntobebeneficialin

uncomplicatedbronchiolitis.Managementissupportivebutmayincludetheneedforoxygen,nasogastricfeeding

orintravenousfluids.Primarycarecliniciansneedtoknowthefeaturesofmoderatetoseverebronchiolitissothat

theycanmanageitappropriatelybutalsosothattheycaneducatetheparentsofchildrenwithbronchiolitisabout

recognisingdeterioratingillness.

Assessment of severity

Table 1: Assessment of severity of bronchiolitis

WINTERILLS

Mild Moderate Severe

Respiratory ratebreaths/minute

Under2months>60/min>60/min >70/min

2–12months>50/min

Chest wall indrawing None/mild Moderate Severe

Nasal flare None/mild Present Present

Grunting Absent Absent Present

Feeding Normal

Lessthanusual

Frequentlystops

Quantity>1/2normal

Notinterested

Choking

Quantity<1/2normal

History of behaviour Normal Irritable Lethargic

Any criterion in the severe category designates the child as severely ill

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When to refer with acute bronchiolitis

Asageneralrule refer infants earlier rather than later:ifindoubt

getspecialistadvice.

Refer all infants immediately with; severe illness (see Table 1),

progressivedehydration,wherethereisclinicalconcernabouthypoxiaora

historyofapnoea.

Refer early

Iflessthan8-weeks-oldorifbirthwassignificantlypremature(<32

weeksgestation)

Iftherehasbeenapnoeaorsignificantcomorbidity(heartandlung

disorders,immune-compromise)

Ifillnessisgettingworseafter72hoursorhomecareisuncertain

Management of bronchiolitis at home

Mostinfantswithbronchiolitiscanbesafelymanagedathome.Supportive

carepluscarefulobservationforsignsofdeteriorationarethekeys.

Supportivecaremayinclude:

Keepingthechild’senvironmentsmokefree

Keepingthechildwellhydrated

Smallfrequentfeeds

Minimalhandling

Normalsalinenasaldropsbeforefeeds

Caregiverhandwashingtopreventspreadtootherchildren

Written instructions will help caregivers to keep an eye on

feeding patterns and behaviour and to monitor for:

Respiratoryrate

Indrawing

Grunting

Nasalflare

Sleepiness

Colour

Infantswithamoderateepisodeofbronchiolitisneedtobereviewedwithin

24hoursandafirmappointment(time,place,person)helpstoensurethe

child is seen. (For an example of written instructions for caregivers see

page 23)

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Recognising severe illness in children

Behaviourandfeedingbothgo

frominterestedinfant,toinfantnot

interested

Respiratory rate

Anewbornmaybreatheupto

60breaths/min

A1-year-old:40breaths/min

A5-year-old:30breaths/min

Iftherateishigh,lookforpotential

respiratoryfailureusing2keysigns

effort,and

effectivenessofeffort

Increased effortisindicatedby

sounds

Stridorinupperairway

obstruction

Wheezeorgruntinginlower

airwaysobstruction

Accessorymuscleuseproducing

nasalflare,heavingchest,

intercostalandsubcostal

indrawing

Effectiveness of effortisindicated

bylookingatthechestmovementand

listeningtobreathsoundstojudge

ventilation:

Asilentchest

Fallingheartrate

Fallinglevelofconsciousness

Fallingrespiratoryrateinsevere

illness

areallpreterminalevents.

During respiratory failure, skin

colour changes from pink to pale, to

mottled.

Pale colour indicates vasoconstriction

and mottled indicates terminal

circulatory collapse.

Reference: Bone J. Recognising the very ill child

NZ Doctor 14 Mar 2007.

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Cough in children2.

Coughinchildrenhasdifferentcausestocoughinadultsandsymptomatictreatmentisrarelyneededor

effective.1Thesmallerairwaysarevulnerabletoinflammatorydiseasecausingswellingandobstructionby

mucoussecretions.Coughingassistsclearanceofmucous,sodonotattemptcoughsuppression.

It is reasonable to categorise childhood cough as:

Acutecough–lastinglessthantwoweeks

Persistentcough–lastingtwotofourweeks

Chroniccough–lastingoverfourweeks

Acute cough

Acute cough is usually viral

Mostacutecoughinchildrenisassociatedwithviralupperrespiratorytractinfections(URTI).Themajority

ofthese(70–80%)willresolvewithinoneweekalthough5%willpersistformorethanfourweeks.

Noover-the-counterorprescriptionmedicinesareeffective for thesymptomatic reliefofacutecough

inchildrenbut theredoesappear tobeasignificantplaceboeffect.Over-the-countercoughandcold

medicinesareasignificantcauseofmorbidity,especiallyfromaccidentaloverdose.

Itfollowsthatweshouldlookforsomethingsoothingandsafeforchildrenwithacutecough.Honeyand

lemondrinkshavestoodthetestoftimeandcanbemadeathomeatlittlecost.However,watershould

notbeboiled,firstlybecausechildrenarenotusuallyusedtohotdrinksandsecondlybecausethereis

riskofscalding.

Aspiration may be missed

Characteristicsofanacutecoughmayraisesuspicionofspecificcausessuchasthebarkingcoughof

crouportheparoxysmalcoughofpertussis.Whentherearenosymptomsofaviral infection,careful

considerationneedstobegiventoanaspirationepisode,particularlyinyoungerchildren.Aspirationmost

oftenoccurswhenanoldersiblinghasfedayoungchildunsuitablefood.

Cough soon after birth is cause for concern

Coughthatbeginsat,orwithinafewweeksofbirthalwaysraisesconcern.Congenitalcausesinclude

tracheomalacia,tracheo-oesophagealfistulaorlaryngealcleft.Coughstartingwithinafewweeksofbirth

raises theadditionalpossibilitiesofsuppurative lungdisease,aspiration,gastro-oesophageal refluxor

infectionwithchlamydia trachomatis.Coughinaneonateoftenwarrantsdiscussionwithapaediatrician.

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Chronic cough

Cough continuing beyond four weeks needs careful evaluation

Althoughanon-specificpost-viralcoughisstillthemostlikelydiagnosis,childrenwhocontinuetocoughbeyondfour

weeksneedevaluationtoexcludemorespecificcauses.Evaluationofasignificantongoingcoughincludeshistoryand

physicalexaminationwithconsiderationoftheneedforchestx-rayand,ifthechildisoldenough,spirometry.

Passiveoractivesmokingisacommoncauseofcoughinchildren.Fiftypercentofchildrenovertheageoftwoyears,

withatleasttwofamilymemberswhosmoke,havecough.

SomespecificcausessuggestedbythehistoryandexaminationaredescribedinTable2:

Table 2: Specific causes of chronic cough suggested by the history and examination

Chronic cough Specific cause of cough

Accompanying wheeze Asthmaoraspiration

Stridor Tracheomalacia,foreignbody

Moist cough, clubbing or Failure to ThriveSuppurativelungdisease,cyanoticheartdisease,cysticfibrosis,

immuneorciliarydisorders

Aspiration episodes or swallowing

difficultiesForeignbodyoraspiration

Paroxysmal cough or family members with

persistent coughPertussis

Honking cough absent during sleep Psychogenicorhabitcough

Staccato cough with or without

conjunctivitisChlamydia

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Cough from post-nasal drip, gastro-oesophageal reflux and

‘cough variant asthma’ are unusual in children

Studiesshowthatpost-nasaldripisunlikelytocausecoughinchildrenandthecoughismore

likely toberelatedtocoexistent lowerairwaypathology.Theuseofmedicationsto ‘dryup’

nasalsecretionsisthereforeunlikelytohelpthecough.

Gastro-oesophagealrefluxhasbeensuggestedasacommoncauseofcoughinadultsbutthere

isnoconvincingevidencethatitisacommoncauseofcoughinchildren.

Somechildrenwith isolatedpersistentcoughwithoutwheeze receiveadiagnosisof ‘cough

variantasthma’.Howeverthereisnoevidencethatthisisreallyaformofasthma.Fewchildren

withisolatedchroniccoughhaveeosinophilicinflammation,atopyorairwayhyperresponsiveness

andtheydonotrespondtobronchodilatorsorcorticosteroids.

Cough may be the predominant feature of asthma but is usually accompanied by wheeze.

Isolated chronic cough with no apparent underlying cause is more likely to be related to a

hypersensitivecoughreflex.

Treatment of chronic cough targets the cause not the symptoms

Symptomatic treatment of chronic cough is usually not effective or appropriate. It is the

underlyingcause,whichshouldbethetargetoftherapy.

Antihistaminesareproventohavenobenefitinchroniccoughandareassociatedwithhigh

levelsofsideeffects

Coughsuppressantssuchasdextromethorphan,pholcodineandcodeinearecontraindicated

inchildren

Mentholinhalationsarenoteffectiveandareassociatedwithriskofscaldinginjuriesfrom

boilingwater

Thereisnoevidenceforeffectivenessofherbalremedies

Emetics,suchasguaifenesin,ammoniumchloride,ipecacuanhaandsquill,areusedinlow

dosesasexpectorantsbutarenoteffective

Nevertheless, the significant placebo effect of coughmedicinesmay convince parents that

oneisneeded.Asimplesoothingdemulcent,withingredientssuchashoneyandlemon,syrup

orglycerol,mayhelpreducecoughingandirritation.Itisbesttoavoidthosewithhighsugar

content.Lozengesareassociatedwithriskofchokingforchildren,especiallythoseunderthe

ageofthreeyears.

Allchildrenwithcoughwillbenefitfromasmokefreeenvironment.

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Fever in children3.

Stratification of risk for serious pathology clarifies management decisions

Risk stratification for children with fever

Practitionerswillalwayswanttoconductacarefulsearchforafocusofinfectionforanychildwithafever

andthiscanbecombinedwithassessingtheriskofseriouspathology.Urinalysisofacleancatchurine

sampleisanessentialpartofthisassessmentwhennoobviouscausesareapparent.

Search for a cause

Manage the symptoms

Feverisanappropriateresponsetoinfectionandhassomebeneficialeffects.Forexample,fevercanmake

theenvironmentlessfavourableformicroorganismstomultiplyandcertainpartsoftheimmunesystemwork

betteratslightlyhighertemperatures.However,sustainedhightemperatureaddstoinsensiblefluidlossand

riskofprogressivedehydration.

Febrileconvulsionsoccurin3–4%ofchildrenwithfever.Althoughtheyareassociatedwithfever,theyarenot

preventedbyantipyreticmedicationssuchasparacetamol.Febrileconvulsions,iftheydooccur,areusually

briskandnotlikelytocausebraindamageorlearningdisabilities.Complexfebrileseizurescanoccurand

maybeprolonged.Ifprolonged(>15minutes)theyshouldbetreatedwithrectaldiazepam.

Antipyreticmedicationsalongwithphysicalinterventions,suchascooldrinksandreducingexcessivelayers

ofclothing,canbeappropriatetomanagediscomfortwhichmaybeassociatedwithfever.

Measuring the temperature of children under five years

√Electronicthermometerinaxilla

√Chemicaldotthermometerinaxilla

√Infra-redtympanicthermometer

XOralthermometer

XRectalthermometer

XForeheadcrystalthermometer

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Table 3: High risk of serious pathology

Depending on the findings and circumstances, one or

more of the following may be appropriate:

Referralforurgentpaediatricassessment

Telephoneconsultationwithapaediatricspecialist

Firmarrangements,time/place/person,madeforafurtherreview

Writtenandverbalinstructionsonwarningsymptomsthat

mayoccurandhowtorespondtothem

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Table 4: Intermediate risk for serious pathology

Any of the above features place a child in a high-

risk category for serious pathology.

The child needs immediate admission to hospital.

In the absence of high-risk features, any of the above

features places a child at intermediate risk of serious

pathology.

Intermediate risk features

Colour Normal

Activity

Notrespondingnormallytosocialcues

Wakesonlywithprolongedstimulation

Decreasedactivity

Nosmile

Respirations

Nasalflaring:ageover12months

Age0–2months,RR>60breaths/min

Age2–12months,RR>50breaths/min

Age>12months,RR>40breaths/min

Crepitations

Hydration

Drymucousmembrane

Poorfeedingininfants

Reducedurineoutput

Other Feverfor>5days

High risk features

Colour Pale,mottled,ashenorblue

Activity

Weak,high-pitchedcontinuouscry

Diminishedlevelofconsciousness

Appearsill

Unabletorouseorifrouseddoesnotstayawake

Respirations

Grunting

RR>70breaths/min

Moderatetoseverechestindrawing

HydrationReducedskinturgor

Capillaryrefilltime>3secs

Other

Nonblanchingrash

Bulgingfontanelle

Neckstiffness

Focalneurologicalsigns

Focalseizure

Bilestainedvomiting

Swellingoflimborjoint,non-weightbearing,notusinganextremity

High temperaturesneedtobe

interpretedwithregardtoothersigns

andsymptoms,howeverT>39ºC

shouldberegardedasahighrisk

feature

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Table 6: Features of some of the serious causes of fever in children

Diagnosis to be considered Signs in conjunction with fever

Meningococcal disease

NonblanchingrashPLUSoneof:

Anilllookingchild,petechiaeorpurpura,capillaryrefilltime>3secs,meningism

Meningitis

Neckstiffness,bulgingfontanelle,decreasedlevelofconsciousness,limpness(NBNeckstiffnessandbulgingfontanellearerelativelyinsensitivesignsofmeningitis)

Herpes simplex encephalitisFocalneurologicalsigns,focalorgeneralisedseizures,decreasedlevelofconsciousness

PneumoniaIfwheezeispresentthediagnosisofpneumoniaislesslikely

Tachypnoea:Age0–2months,RR>60breaths/min

Age2–12months,RR>50breaths/min

Age>12months,RR>40breaths/min

Crepitations,nasalflaringunder12months,chestindrawing,cyanosis

Urinary tract infectionVomiting,poorfeeding,lethargy,irritability,abdominalpainortenderness,dysuriaorincreasedfrequency,offensiveurineorhaematuria

Septic arthritis Swellingofalimborjoint,notusinganextremity,non-weightbearing

Kawasaki disease(veryrare)

Fever>5daysWITHatleastfour ofthefollowing:

Rash,conjunctivitis,lymphadenopathy,crackedlips,skinpeeling

Be alert for signs of septicemia, i.e.significantfever(>38°C)PLUSlethargy(notinterested,notfeeding)and/or

significantdehydration(drymucousmembranes,poorurineoutput,capillaryreturn>2secs)and/orfastrespiratory

ratewithincreasedeffortandsignsofpooreffectivenessofeffort.

Ifachildbecomesrapidlyillorisparticularlyill,witharash,consider and exclude meningococcal disease.The

rashmaypresentasamorbilliformorsubtlepetechialrashbeforeprogressingtoapurpuricrash.

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Acute gastroenteritis in children4.

Presentation of gastroenteritis may suggest cause

Viral infections cause most gastroenteritis in

childreninNewZealand.Theyusuallyproducelow-

gradefeverandwaterydiarrhoea,withoutblood.

Rotavirus,themostfrequentviralpathogen,tends

tobeseasonal,with latewinterpeaks,andmost

frequentlyaffectschildrenbetween6monthsand

2yearsofage.Mostchildrenwillcomeincontact

with the virus and, as immunity is long lasting,

infectionisuncommoninadults.

Norovirusaffectsallages,as immunitydoesnot

lastlong.Infectiontendstooccurasoutbreaksin

institutionssuchaspreschools,childcarecentres,

hospitalsandresthomes.

Bacterialinfectionsaremorelikelytobeassociated

withhigherfeversandbloodormucusinthestool.

Theymayalsobeassociatedwithabdominalpain

orsystemiceffects,fromspreadofthebacterial

pathogensthemselvesorassociatedtoxins.

Viral infections are usually transmitted by the

faecal-oral route or by respiratory droplets

but they can linger on contaminated surfaces.

Bacterial infections are often acquired by the

ingestionofcontaminatedfoodordrinkwhichhas

not beenproperly cooked, storedor processed.

Chicken, beef, pork, seafood, ice cream and

reheatedriceareallfrequentsourcesofbacterial

gastroenteritis.

Watermaybecontaminatedwithviruses,bacteria

orprotozoa.

Most Gastroenteritis in children is viral

Therearemanycausesofacutegastroenteritisinchildren(Table

7)2butthemajorityarecausedbyrotavirusornorovirus.

Pathogens causing acute gastroenteritis in children

Viruses–approximately70%

Rotaviruses

Noroviruses

Entericadenoviruses

Caliciviruses

Astroviruses

Enteroviruses

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Bacteria–10to20%

Campylobacter jejuni

Non-typhoidSalmonellaspp.

EnteropathogenicE. coli

Shigella spp.

Yersinia enterocolitica

ShigatoxinproducingE. coli

Salmonella typhi andS. paratyphi

Vibrio cholerae

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Protozoa–lessthan10%

Cryptosporidium

Giardia lamblia

Entamoeba histolytica

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Helminths

Strongyloidesstercoralis-

Table 7: Causes of acute gastroenteritis in children

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Management involves considering four important questions

1. Is the child shocked?

Featuresofshockinachildmayinclude:

Limpness

Drowsyorcomatose

Rapid,threadypulse

Cold,blueperipheries

Hypotension

Anuria

Skin retraction and capillary refill are less

reliablesigns.

Shockisanemergencyandthechildwillneed

immediatehospitalisation.Considertheneed

forintravenousorintraosseousaccessifthere

willbeanydelayingettinghospitalcare.

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Thefollowingfour-stepapproachtothemanagementofgastroenteritisinchildrenisbasedonrecommendationsfrom

StarshipHospital3butadaptedforuseinprimarycare.

Is the child shocked?

Is it really viral gastroenteritis?

Is the child dehydrated?

Can the child be managed safely at home?

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4.

2. Is it really viral gastroenteritis?

The differential diagnosis of viral gastroenteritis is not always

easy.Sometimes in themiddleofanepidemic thediagnosiscan

bemistakenlyapplied toachildwhohasanothercause for their

symptoms.Itisworthremembering:

• Notallvomitingisgastroenteritis

• Notalldiarrhoeaisgastroenteritis

• Notallgastroenteritisisviral

Not all vomiting is gastroenteritis

Vomitingmayprecedediarrhoeainrotavirus,butisolatedvomiting

always raises suspicion of another cause. Bile stained vomiting

meansbowelobstructionuntilprovenotherwise.

Surgical conditions that may present with vomiting include:

Pyloricstenosis(typicalageabout6weeks)

Intussusception(typicalageabout6–10months)

Appendicitis

Intestinalobstruction

Other possible causes include:

Infectionssuchasurinarytractinfection,otitismedia,

pneumonia

Metabolicdiseasesuchasdiabeticketoacidosisandinborn

errorsofmetabolism

Headinjury

Poisoning

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Foradetailedexplanationofthetechnique,

equipment,indicationsetcrequiredfor

intraosseous infusionvisitthefollowing

website:http://snipurl.com/1hr9v

Intraosseous infusion

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Not all diarrhoea is gastroenteritis

Othercausesfordiarrhoeaneedtobe

considered.Theseinclude:

Antibioticsorothermedications

Spuriousdiarrhoeasecondaryto

constipation

Firsttimepresentationsofchronic

diarrhoea,suchascoeliacdisease

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Suspicionofbacterialgastroenteritisisanindicationforstoolculture.Campylobacter isthemostcommonformof

bacterialgastroenteritis.Antibioticsarenotindicatedforcampylobactergastroenteritisunlessthechildissystemically

unwell,astheymayprolongthediarrhoeaorcarriageoftheorganism.

Ifthechildissystemicallyunwell,erythromycinmaybeconsidered.

Not all gastroenteritis is viral

Bacterialgastroenteritishashighercomplicationratesandworse

outcomesthanviralgastroenteritis.Factorsthatmayraisesuspicion

ofbacterialgastroenteritisinclude:

Bloodormucousinthestool

Higherfevers

Systemictoxicity

Abdominalpain

Associationwithoutbreaklinkedtocontaminatedfoodsource

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3. Is the child dehydrated?

Documentedrecentweight loss isagood indicationof the levelofdehydrationbut thesemeasuresareoftennot

available.Unfortunately clinical estimatesarenot veryaccurateand thecategoriesofdehydration,whichcanbe

definedbythem,areverybroad.

4. Can the child be managed safely at home?

Children over 6 months with viral gastroenteritis of less than 24 hours duration, low-grade fever, mild levels of

dehydration,noabdominalpainandminimalsystemicsymptomscanusuallybemanagedsafelyathome.Thedecision

isoftenadifficultclinical judgementandwillbestrongly influencedbyhomecircumstancesandability toprovide

regularmedicalfollowup.

Table 8: Signs of dehydration in a child

Clinical signs of dehydration Pinch test

No dehydration Nosigns Skinfoldretractsimmediately

Dehydration

Twoormoreof:

Restlessnessorirritability

Sunkeneyes

Thirst

Deepacidoticbreathing

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Slowretractionofskinfold

–visibleforlessthan2seconds

Severe dehydration with

or without shock

Twoormoreof:

Abnormallysleepyorlethargic

Sunkeneyes

Drinkingpoorly

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Veryslowretractionofskinfold

–visibleforover2seconds

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Oral rehydration is safe and effective for most children

Oral rehydration therapy for dehydration from gastroenteritis is safer and more effective than

intravenoustherapyforalldegreesofdehydrationother thanshock.However it requiresa lotof

inputfromthechild’scaregiver.

Vomitingisnotacontraindicationtooralhydration.Mostchildrenwithgastroenteritiswhovomit,will

stillabsorbasignificantpercentageofanyfluidgivenbymouthornasogastrictube.

Fluid replacement occurs in two phases: rehydration and

maintenance

Commercial oral fluid replacement solutions, such as Plasmalyte and Pedialyte, are mixtures of

sodiumandpotassiumsalts,abase(citrateorbicarbonate)andacarbohydrate.Theyaredesigned

tocorrectdeficits inwaterandelectrolytescausedbydiarrhoea. If thechild is lethargicandthe

skinfeelsdryandinelastic,dehydrationislikelytobeassociatedwithlowsodium.Ifthechildhas

hypernatraemicdehydration,thirstisextremeandtheskinfeelsdoughy.

Breastmilk,formula,cow’smilk(ifthechildisoveroneyear),clearsouporricewaterareallsuitable.

Highlydilutedjuiceorlemonadecanbeusedifthereisnotabetteralternative,atadilutionrateof

onepartjuicetofivepartswater.Lemonadeisdilutedwithwarmwatertogetridofthebubbles.

Cola, tea, coffee or sports drinks are not suitable because of their high stimulant or sugar

content

Rehydration phase

Duringtherehydrationphase,fluidisgivenatarateof5mlperminutebyteaspoonorsyringe.The

smallvolumesdecreasetheriskofvomiting.Therate(1teaspoon/minute)iseasytocalculateand

administerforaparentsittingatthebedside.Thiscanbechangedto25mlevery5minutesonce

thechildstopsvomiting.

Thisratewillrehydrateamoderatelydehydrated1-year-oldin2to4hoursanda2-year-oldin3to

5hours.

Frequent review (at least 2 hourly) is advisable in the rehydration phase. A child who is not

rehydratingatthisrateoforalreplacementwillrequirenasogastricorintravenousfluids.

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Maintenance phase

Oncethechildisrehydrated,hydrationismaintainedby

givingmaintenancerequirementsplusadditionalfluidto

replacethefluidineveryloosestool,orthechildwillslip

backintodehydration.

Fluid requirements to maintain hydration

Table 9: Approximate fluid requirements to

maintain hydration

Drug therapy rarely needed for

gastroenteritis in children

Antibiotics

Even in bacterial gastroenteritis, antibiotics are not usually

indicated.Antibioticsmayprolongthedurationofdiarrhoea

and are best administered on the basis of a laboratory

result.

Antibiotics are required for bacterial gastroenteritis

complicated by septicaemia and for cholera, shigellosis,

amoebiasis,giardiasisandentericfever.

Antidiarrhoeal and antiemetic drugs have risks of

adverse effects

Anti-diarrhoealagents,suchasloperamide,shouldbeavoided

inchildrenundertheageof12years.Theymayreducethe

durationofdiarrhoeabutadverseeffectssuchassedation,

ileusandrespiratorydepressioncanoccur.

Antiemetic medications are not recommended. They may

reducevomitingbutdonotreducetheneedfor intravenous

rehydration.Theymayinducesedation,makingoralrehydration

moredifficult.

Oral zinc may help

Oralzinctherapygivenatonsetofsymptomscanreducethe

duration and severity of acute diarrhoea but is usually not

necessary.

Lactose intolerance is usually mild and self limiting

Although lactose intolerance is common after viral

gastroenteritisitisusuallymildandself-limitinganddoesnot

requiretreatment.Ifitdoespersist,alactose-freeformulais

recommendedforfourtosixweeksbutthisisnotnecessary

asaroutineforallchildrenwithgastroenteritis.

Weight kg

Maintenance requirementsml/hour

5 20

10 40

15 50

20 60

25 70

30 75

Replacing additional fluid loss in stool

In rehydrated children whose losses are not unusually

profuse,adviseparentstogivebothmaintenancefluids

plusroughly50–100mlforeachdiarrhoealstoolfora

childundertwoyearsand100–200mlforachildover

two years. As with replacement, this volume should

begiven insmallaliquotsrather thanasasingle large

bolus.

Children who have profuse ongoing diarrhoea need to

havethediarrhoeameasuredtocalculatetheadditional

fluidreplacementrequired.

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Acute asthma in children aged 1–15 years: are nebulisers or spacers best?

Spacers and nebulisers are equally effective

Manyclinicaltrialshavefoundspacersandnebuliserstobeequallyeffectivefordeliveringhighdose

bronchodilatorsinacuteasthmaandtheyhavecomparableclinicaloutcomes.4

Spacers have the advantages of being:

Lessfrightening,especiallyforchildren

Notdependentonapowersupply

Easiertomaintain

Cheaper

ThecylindricalspacersthatareavailableonPractitionersWholesaleSupplyOrdersaresuitable.A

maskisusedforyoungchildren.Dependingontheindividualchild,theycanusuallymanagewithout

amaskoncetheyareoverthreetofiveyears.

Salbutamol isgiven through the spaceronepuff at a time, and4deepbreaths areencouraged

to takeupeachpuff.Sixpuffsshouldbegivenevery20minutesup to therecommendeddose.

Dependingonresponse,referralmaybeindicated.

Therecommendeddoseforsalbutamolinaspacerforacute severe asthmais:

SalbutamolMDI100microgrampuffs

Age<5years–6puffs

Age>5years–upto12puffs

The use of Prednisolone should also be considered. ‘Redipred’ liquid 5 mg/ml is available, the

recommendeddoseis2mg/kgoncedaily.

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5.

Patient information on spacer use and maintenance is available from

bpacnz and can be ordered by faxing 0800 27 27 69 or visit

www.bpac.org.nz

20I BPJIIssue5

Like having aspecialist

in your cupboard

bestpractice

bestpracticeDECISION SUPPORT FOR HEALTH PROFESSIONALS

Contact: Murray Tilyard or Sarah Kennedy, bestpractice Decision Support,

Level 7, 10 George Street, PO Box 6032, Dunedinphone: 03 479 2816

email: sarah@bpac.org.nz or murray@bpac.org.nz

decision support

bestpractice, the exciting new electronic

Decision Support from BPAC Inc, provides

up to date clinical support for patient

management, with a wide range of clinical

modules based on current New Zealand

guidelines and best practice.

Other features include:

•Linkages to BNF & Clinical Evidence

•Integration with your PMS

•Security model based on existing health

standards

References

LandauL.Acuteandchroniccough.

PaediatricRespiratoryReviews.2006;7s:

S64–S67.

ElliottE.Acutegastroenteritisinchildren.

BMJ.2007;334:35–40.

GastroenteritisPathwayTeam.Starship

HealthGastroenteritisClinicalGuideline.

2006Availablefrom:

http://snipurl.com/1gxmq

CatesC,CrillyJ,RoweB.Holding

chambers(spacers)versusnebulisersfor

beta-agonisttreatmentofacuteasthma.

CochraneDatabaseSystRev.2006;2:

CD000052.

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