Page 27 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

children younger than 5 years who received medical treatment in primary care settings, in
hospital emergency departments and as hospital inpatients. Approximately 10% of children
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younger than 5 years presented to healthcare services with gastroenteritis each year. Rotavirus
infection accounted for 28–52% of cases of gastroenteritis identified in the study. The incidence
of rotavirus gastroenteritis was 2.27–4.97 cases per 100 children. In another study looking at
cost-of-illness and conducted as part of a community surveillance study, it was estimated that the
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burden of rotavirus gastroenteritis in the UK amounted to £11.5 million each year. Recently it
was estimated that rotavirus alone was responsible for 60 000 hospitalisations and 37 deaths each
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year in the USA. A recent European study also suggested that rotavirus infection was responsible
for 72 000–77 000 hospital admissions from among the 23 million children younger than 5 years
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living in the European Union. This was associated with an estimated median cost of €1,417 per
child. The hospital admission rate for children with gastroenteritis has not declined in recent
years, and may have increased. 10

Gastroenteritis in the UK
A study from England provided an estimate of the overall rates of infectious intestinal disease
in the community and presenting to primary medical care. This involved 70 general practices
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(primary care medical practices), together serving a population of almost half a million people.
Based on prospective reporting, it appeared that about 1 in 5 people experienced symptoms
of gastroenteritis each year, but only 1 in 30 presented to their doctor. The authors estimated
that in England each year, 9.4 million cases of gastroenteritis occurred in the community and
1.5 million presented to their primary care doctor.
In infants and children, gastroenteritis is often a relatively mild illness lasting only for a few
days. Parents often manage their child’s illness at home, and in some cases they may not even
seek professional advice. However, a very large number of children do present to healthcare
professionals for advice. In the UK, parents may contact NHS Direct – a telephone-based service
providing remote assessment and advice. Parents may also seek advice from community-based
nurses or health visitors or from primary care doctors (general practitioners). Others go directly
to a hospital emergency department. In one study from the UK, diarrhoeal illness accounted for
16% of medical presentations to a major paediatric accident and emergency department. 12
Although most children with gastroenteritis do not require admission to hospital, many are treated
as inpatients each year. Once admitted they often remain in the hospital for several days. This is
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a significant burden for the health services. Admission also carries a serious a risk of spread to
other children in the hospital, some of whom may be highly vulnerable as a consequence of their
own medical conditions. 14

Developments, controversies and variation in clinical practice
The management of gastroenteritis in children is multifaceted and changing. New treatments and
management strategies are being proposed, whose roles may be controversial. New strategies
are being evaluated for ‘rapid rehydration’ with intravenous fluids. Various approaches to the
clinical assessment of dehydration severity and hence to the calculation of fluid deficits have
been proposed. A variety of new therapies, including anti-emetic and antidiarrhoeal drugs, have
been advocated for use in gastroenteritis, but there are uncertainties about the efficacy and safety
of these agents. The antisecretory agent racecadotril is not licensed for use in the UK but is used
elsewhere in Europe. Recently much interest has been expressed regarding the possible benefits
of probiotic preparations in the treatment of gastroenteritis.

Against this changing background, and despite the existence of a number of guidelines, it has long
been recognised that there is considerable variation in clinical practice. There is inconsistency in
the advice offered to parents regarding the types of oral fluids to be given. Practice still varies in
relation to the use of oral versus intravenous fluids for rehydration. Administration of fluids via a
nasogastric tube is advocated by some but others avoid this practice. The nutritional management
of infants and children during and after the episode of gastroenteritis is often inconsistent. It
seems certain that there is variation in the approach to ‘escalation of care’ from the community to
various hospital settings (day wards or inpatient management). A recent population-based study
reported significant variation in hospitalisation rates among children with rotavirus gastroenteritis
in different European countries. 15

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