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Diarrhoea and vomiting caused by gastroenteritis in children under 5 years




                        participants was 6 years (range 0–15 years). In total, 33/278 patients developed complete HUS
                        and 4/278 developed incomplete HUS. There were three fatalities.
                        Children who reportedly vomited (29/153) were statistically significantly more likely to develop
                        HUS than those who had not vomited (8/125) (RR 3.0; 95% CI 1.4 to 6.2). Although more children
                        who  had  bloody  diarrhoea  or  fever  developed  HUS,  these  differences  were  not  statistically
                        significant (RR 2.0; 95% CI 0.5 to 7.7, and RR 1.8; 95% CI 0.8 to 4.1, respectively).
                        To investigate early predictors, the risk of HUS was evaluated according to clinical outcomes
                        measured  within  the  first  3  days  of  illness. Vomiting  remained  a  statistically  significant  risk
                        factor in this time interval (RR 1.9; 95% CI 1.0 to 3.5) and the association was modified by age.
                        Vomiting in children younger than 5.5 years was strongly associated with HUS development
                        (RR 3.5; 95% CI 1.4 to 9.4), but the association was not evident in children older than 5.5 years
                        (RR 1.0; 95% CI 0.4 to 2.4).

                        The use of medications was also analysed. In total, 50 children received a range of antibiotics
                        in the first 3 days of illness. These children were more likely to live in a household with annual
                        income over $29,000 (RR 1.7; 95% CI 1.0 to 2.8). Eight of these children went on to develop HUS
                        compared with 28/218 who did not receive antibiotics (P = 0.56). In total, 31 children received
                        antimotility agents in the first 3 days of illness. Six went on to develop HUS, compared with
                        20/234 who received no antimotility treatments (P = 0.10). There was no statistically significant
                        difference in the development of HUS in children who received adsorbant and antimotility drugs
                        compared with those who did not (P = 0.26).
                        There were no statistically significant associations between HUS development and haematocrit,
                        platelet count, blood urea nitrogen, segmented neutrophils count or band forms at presentation.
                        However, children who had a white blood cell count of over 10 500 per microlitre were at
                        increased risk of developing HUS (RR 5.2; 95% CI 1.6 to 17.0; P < 0.01), and for those with a
                        white blood cell count of over 13 000 per microlitre this risk was larger (RR 7.2; 95% CI 2.8 to
                        18.5; P < 0.01).

                        Evidence summary
                        There was consistent evidence from two studies that a raised white blood cell count in children
                        with E. coli O157:H7 was a risk factor for the subsequent development of HUS. In one study,
                        vomiting in children younger than 5.5 years was strongly associated with the risk of developing
                        HUS.  However,  there  was  conflicting  evidence  on  the  effect  of  antimicrobials.  One  study
                        reported that antimicrobial treatment was an independent risk factor for HUS but the study lacked
                        precision for this finding. The second study did not find treatment with antimicrobials or with
                        antimotility agents (with or without adsorbant agents) was associated with increased risk of HUS.

            7.9.2       Salmonella
                        One retrospective review 158  conducted in Malaysia sought to characterise the incidence, risk
                        factors and outcome of invasive non-typhoid salmonella gastroenteritis in children aged between
                        1 month and 14 years. [EL = 2+]. Participants were 131 children with positive stool cultures
                        for salmonella species but no second enteropathogen, seen in an outpatient department. Of
                        these, 67% of children were younger than 1 year. Demographic, clinical (diarrhoea, vomiting,
                        fever, hydration status), blood and stool outcome measures were recorded from case notes and
                        examined. Overall, 124 children were found to have non-invasive salmonellosis and seven had
                        invasive complications (five bacteraemia, two meningitis). Three risk factors were identified for
                        the  development  of  invasive  salmonellosis.  In  total,  45  (85%)  of  the  124  with  non-invasive
                        disease  were  younger  than  6  months  compared  with  six  of  the  seven  with  invasive  disease
                        (P  <  0.01).  Only  53  of  those  in  the  non-invasive  group  had  a  temperature  of  over  38  °C,
                        compared with all seven of the invasive group (P < 0.003). Dehydration was found in five of the
                        seven with invasive complications, but in only 25 of the 124 with non-invasive disease. One
                        infant with bacteraemia died while awaiting a blood culture result. The authors suggested that
                        empirical antibiotic treatment should be given to infants younger than 6 months who are febrile
                        and dehydrated.





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