Page 26 - 15Diarrhoeaandvomiting

1 Scope and methodology

1.1 Introduction

When young children suddenly experience the onset of diarrhoea, with or without vomiting,
infective gastroenteritis is by far the most common explanation. A range of enteric viruses,
bacteria and protozoal pathogens may be responsible. Viral infections account for most cases
in the developed world. Gastroenteritis is very common, with many infants and young children
experiencing more than one episode in a year.
The symptoms of gastroenteritis are unpleasant and the illness has an impact on both child and
family. Vomiting causes distress and anxiety. Diarrhoea is often accompanied by abdominal pain.
Infants and young children with severe symptoms may quickly become dehydrated. Dehydration
is a serious and potentially life-threatening condition.

The management of young children with gastroenteritis involves many considerations. Depending
on the specific circumstances, care may be provided by parents or by a range of healthcare
professionals. Children may be managed in a community or a hospital setting. There is debate
and controversy regarding various aspects of clinical management. Clinical practice may have
a major impact on the use of healthcare resources. Finally, there is evidence of considerable
variation in practice in the management of children with gastroenteritis in the UK. It was for these
reasons that this NICE clinical guideline on the ‘management of acute diarrhoea and vomiting
due to gastroenteritis in children under 5’ was developed.

Gastroenteritis – the global perspective

Viewed from a global perspective, gastroenteritis in children is of enormous public health
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importance. Worldwide, approximately 1 billion people have no access to safe water and
2.6 billion people lack proper sanitation. About 10.6 million children still die every year before
reaching their fifth birthday. Overwhelmingly, these deaths occur in low-income and middle-
income countries. A global picture of the important causes of mortality in the young has emerged
from collaborative work involving WHO, UNICEF, and a group of independent technical experts
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– the Child Health Epidemiology Reference Group. Most deaths among children under 5 years
are attributable to a very small number of infectious conditions. Undernutrition increases the risk
of death from these disorders. Gastroenteritis alone is responsible for almost 20% of the deaths.
In the 1970s, there were almost 5 million childhood deaths worldwide from gastroenteritis each
year. The use of oral rehydration therapy (ORT), arguably the greatest medical discovery of the
20th century, contributed to a marked reduction in this death rate. Nevertheless, gastroenteritis
still causes between 1.6 and 2.6 million deaths in children younger than 5 years each year. 3

Efforts at further reducing the death rate continue, with strategies focusing on prevention,
nutrition and improved fluid management. Other interventions of major importance include the
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administration of zinc supplements and the use of antibiotic therapy for dysentery.
Gastroenteritis in the developed world
Deaths associated with gastroenteritis are now quite rare in developed countries. Nevertheless,
gastroenteritis remains a potentially serious illness for the individuals affected and it poses a
major burden for health services.

In the USA in the 1990s, it was estimated that childhood diarrhoea was responsible for 200 000
hospitalisations and 300 deaths in children younger than 5 years each year, and had an economic
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cost of $2 billion. Recently, a prospective observational study was undertaken in selected
areas of Belgium, France, Germany, Italy, Sweden, and the UK to determine the incidence
of gastroenteritis and of rotavirus gastroenteritis (the most common responsible pathogen) in

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