What is gastroenteritis?

Gastroenteritis is an infection of the intestine. The main symptoms, which may appear all together, or in different combinations, are abdominal pain, diarrhoea, and vomiting. In most cases the symptoms last for a few days, but sometimes they may last longer. The danger with gastroenteritis is dehydration, so the main treatment involves encouraging the child to drink liquids to replace lost fluids.

How common is gastroenteritis?

It is very common, and affects all ages. Bouts of gastroenteritis can occur all year round. Many children may have more than one episode a year. Mostly affected are infants who are not breastfeeding, as well as infants and toddlers in preschool.

What are the causes of gastroenteritis?

Gastroenteritis in children is most commonly caused by a virus, as well as by microorganisms such as salmonella, shigella, cambylobacter, E. coli, and by parasites such as listeria, lamblia and amoeba.

The most common cause of viral gastroenteritis is the Rota virus. Almost all children present diarrhoea from this virus at some time up until their fifth birthday. After one episode, the body acquires antibodies and immunity to this certain virus, so the Rota virus rarely attacks adults. Other viruses that cause gastroenteritis are adenoviruses and enteroviruses. They are common during the first years of life and during puberty.
Some cases of gastroenteritis involve food poisoning. Food poisoning can be caused by a spoiled or contaminated food, or under-cooked food. Food poisoning is mainly caused by bugs and not viruses (staphylococcus, salmonella, E. coli, cambylobacter). It can also be caused by parasites.

How is gastroenteritis transmitted?

Viruses are easily transmitted by an infected person through direct contact with a healthy person. The infected person often retains the virus on his hands after using the toilet.

Apart from direct contact with contaminated hands, gastroenteritis viruses can also be transmitted through contaminated surfaces and objects, like toys.

Another way of transmission is through contaminated foods, either spoiled (egg, chicken), or through foods prepared by a person carrying the bug.
Finally, microorganisms may be transmitted through contaminated water, especially in areas with poor water hygiene.

Do epidemics of gastroenteritis occur?

Yes. They are very common in areas where many people gather, like nursery schools, schools, and hospitals.

What are the symptoms of gastroenteritis?

The main symptom is diarrhoea. Diarrhoea has to do with frequency (more frequent than usual stooling), as well as with composition (loose stools, often water-like, smelly, and irritating). Some infections may cause the presence of blood or mucus in the child’s stool.

Vomiting is often completely missing from the picture. It often appears at the beginning of gastroenteritis and soon (within hours or a day) gives place to diarrhoea.

Abdominal pain is frequent. It is usually colicky (it comes and goes, it may get more intense before vomiting or diarrhea, and improves after vomiting or diarrhoea).

Tenesmus, (the child feeling the need to defecate all the time, often without passing anything, and experiencing pain in the lower part of the abdomen) is usually a warning symptom of bacterial gastroenteritis (dysentery).

There may be fever, but it is usually not high or frequent, nor persistent. In a few cases high fever, suffering, headache, and pain in the extremities co-exist.

What types of gastroenteritis exist?

Their symptoms and gravity vary. The child may present with:

– Mainly abdominal pain and vomiting for a few days

– Intense vomiting, abdominal pain, soon to be followed by diarrhoea

– Only abdominal pain and diarrhoea

– Only abdominal pain

– Extended diarrhoea for many days and/or weeks

How is the diagnosis of gastroenteritis made?

The typical symptoms of gastroenteritis usually make recognition of the disease by the parents easy. The symptoms are often mild, and improve within a few days without any treatment, apart from frequent hydration of the child.

However, in some cases, medical evaluation is needed. You should inform your doctor if you have recently traveled abroad with the child, if the child has come into contact with a person, who had, or developed similar symptoms, if the child has recently taken antibiotics, if he has recently been hospitalized, and if he has eaten any unusual or under-cooked food. These details help the doctor determine the cause of gastroenteritis.

The examination of the child by the doctor is important, in order to determine the degree of dehydration. Also, after examining the abdomen, the doctor will exclude surgical problems or appendicitis in doubtful cases where abdominal pain prevails.

Usually there is no need for lab tests. However, in dubious, persistent or severe cases, if the child seems extremely ill or is hospitalized, if he has recently traveled abroad, if the symptoms don’t improve, and if there is blood in the stool, or intense tenesmus, the doctor will ask for a stool examination, in order to find out if there are bacteria, viruses, and parasites.

Blood tests will be done in the hospital, and they are usually done to determine levels of electrolytes, which are affected with serious dehydration.

How long does the disease last?

Symptoms are relatively mild for most children, and they tend to improve within a few days. Diarrhoea often lasts much longer than vomiting, and it can continue for 7 days. Mild diarrhoea (smooth stool) can persist for a longer period of time (another 1-2 weeks), and it is usually an indication of temporary lactose intolerance.

Which are the complications of gastroenteritis?

1. The main complication to avoid is dehydration. Contact your doctor immediately if you are afraid that the child is becoming dehydrated. Mild dehydration is very common, and it can be easily treated with frequent replenishment of fluids orally. Severe dehydration may even be fatal, and it should be treated quickly, so that it doesn’t result in multi-organ failure. This is more likely to happen with young children, and in children with chronic diseases.

The symptoms of mild dehydration are:

• The child urinates less, his mouth becomes dryer, and he seems to be thirsty. He continues to be active, has saliva, and has some tears when he cries.
The symptoms of severe dehydration are:

• The general image of the child becomes lifeless, he is less active, lethargic, weak, he doesn’t play, he is sometimes edgy, and presents intense restlessness.
• The child doesn’t urinate, or nappies remain dry for many hours

• Glands are dry: the child has no tears when crying, no saliva, and his mouth, lips, and tongue are dry.

• The skin is pale, with poor circulation, hands and feet are cold, with persistent wrinkling when pinched.

• The child’s eyes seem sunken, and the anterior fontanelle in infants (the opening at the top of the skull) also appears sunken.

• The child has tachycardia, and rapid, shallow breathing.

Severe dehydration is an emergency situation and requires immediate medical attention. It can be accompanied by disturbance of electrolytes in the child’s blood.
Dehydration is more likely to happen to infants less than six months of age with gastroenteritis, because they can become dehydrated with a relatively low loss of fluids. It is also frequent in premature or low weight infants, in infants who don’t breastfeed during the disease, in infants who don’t drink fluids during the disease, in infants with intense and extended vomiting, and in infants with intense diarrhoea (six or more episodes in 24 hours, which lasts for longer than 1-2 days).

2. In many cases of viral gastroenteritis, the absorption capacity of the intestine is temporarily disturbed. This leads to temporary or secondary lactose intolerance, lasting from a few days up to weeks, when milk lactose cannot be completely absorbed, resulting in its remaining in the stool, and causing loose, acidic, irritating stools for an extended period of time. The child may have persistent abdominal pain, bloating, watery stools, and wind, especially after drinking milk. After a few days or weeks the absorbent surface of the intestine that was infected by gastroenteritis bounces back, and the intestine is healed. It should be noted that chronic diarrhoea (more than 2 weeks) requires detailed evaluation by a paediatrician, because it can be a sign of a chronic disease, especially if it is combined with insufficient weight gain of the child (e.g. inflammatory disease of the intestine, coeliac disease, irritable bowel syndrome etc.).

3. Other rare complications of gastroenteritis in children that deteriorate and appear increasingly more ill, are reactive arthritis, transmission of the infection (e.g. meningitis), and hemolytic uremic syndrome. When in doubt, immediate examination by a doctor is required.

What is the treatment for gastroenteritis?

The illness can usually be treated at home. Sometimes there is need for hospitalization in severe cases or complications.

Encourage the child to drink lots of fluids. The aim is to prevent dehydration. Each quantity of liquid that is lost through vomiting or diarrhea should be replenished.

Preferred liquids are special electrolytic solutions and water. Electrolytic solutions have the right proportion of electrolytes, soda, salt, and sugars in order to replenish liquid losses. Avoid sugary liquids and fruit juice as much as possible. Regarding milk, the child should continue to breastfeed. If the child is not breastfeeding, continue to offer milk if the child asks for it, especially to infants who depend on it exclusively or almost exclusively.

Give liquids frequently and in small quantities. If the child vomits, wait for 5-10 minutes for him to calm down, and then begin fluid administration again, slowly and frequently (spoonfuls every few minutes, or with a syringe).

If in doubt about the degree of dehydration, contact your doctor.

In the case of exclusively breastfed infants less than 6 months old, continue breastfeeding the child by offering the breast more frequently.

Food and solid foods are of secondary importance, and parents should primarily encourage fluid intake for hydration. Neutral foods that can be given during persistent diarrhoea are simple soups, cereals with complex carbohydrates (bread, rice, pasta), chicken, banana, yogurt.

As soon as there is improvement and the child is hydrated, give the child its normal diet according to his appetite.

Keep breastfeeding if the child wants to, and can.

Don’t impose interruption of fluids and/or food on children with gastroenteritis.

Don’t dilute powdered milk more than indicated; keep giving it normally, in a smaller quantity and more often.

Don’t force the child to eat if he has no appetite; liquid replenishment is what the child needs for a few hours or days.

Don’t avoid solid food if the child wants it, and can eat it.

Medication to stop diarrhoea is forbidden in children under 12 years old. It is not safe, and may have severe side-effects.

You can give paracetamol for high fever, abdominal pain, or headache.
In some cases of bacterial gastroenteritis (after taking a stool sample), certain antibiotics may be required, depending on the type of the infection.
Probiotics help restore the normal flora (normal bacteria) of the intestine. The doctor may recommend them in serious, relapsing, or persistent cases.

When to worry

Contact your doctor if:

• Your child is under 6 months old

• Your child suffers from a chronic disease (renal, cardiac, diabetes, prematurity)

• Your child seems to be dehydrating

• Your child persistently refuses to drink liquids

• Your child has persistent high fever

• Your child seems dizzy or confused

• Your child vomits persistently or frequently, and cannot keep liquids down

• You find blood in the child’s stool or vomit

• Your child seems to have severe abdominal pain

• The symptoms in general seem severe to you, or you feel that the condition is deteriorating. Indicative, if vomiting persists for more than 24 hours, or diarrhoea has not improved after 3-4 days.

Prevention of transmission of gastroenteritis to other people

Frequent and thorough washing of hands, especially after nappy changes, and before the preparation and serving of food, will significantly prevent transmission to other members of the family. For older children with gastroenteritis, thorough cleaning of the toilet bowl and handles with disinfectant and warm water after use. Children should wash their hands after using the toilet. Avoid the use of common towels. Children should not go to school or nursery school for at least 48 hours after the last episode of vomiting or diarrhoea, and should avoid contact with other children as much as possible.

How can gastroenteritis be avoided?

The most important prevention measure is washing of the hands. Teach children to always wash their hands after using the toilet from an early age, also before they touch food, after playing with sand or soil, and after playing with pets.
Breastfeeding acts protectively. Babies who breast feed are less likely to catch gastroenteritis, or get severe gastroenteritis, than babies who drink formula.

Foods should always be as fresh as possible, properly cooked, and stored correctly.

The vaccine against the Rota virus has not yet been included in the recommended vaccination programme in Greece, but it is widely used in countries of the developed and developing world. In 2009 the World Health Organization published a recommendation for universal use of this vaccine in national vaccination programs. It is effective, and protects against a virus that causes many episodes of gastroenteritis.

Stelios Papaventsis MRCPCH DCH IBCLC 2011

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