Page 49 - 15Diarrhoeaandvomiting

Diarrhoea and vomiting caused by gastroenteritis in children under 5 years

Evidence overview

Clinical features associated with infective pathogens
In a prospective cross-sectional study from Sweden, the clinical features associated with
51
bacterial and viral gastroenteritis were compared in children (n = 393) presenting to the hospital.
The study focused on duration and frequency of symptoms, fever and abdominal pain, and
duration of hospital stay. Infection with rotavirus was characterised by sudden onset of vomiting,
a high incidence of fever and dehydration and a mean duration of diarrhoea of 5.9 days. Enteric
adenovirus was associated with longer lasting diarrhoea, with a mean of 10.8 days. Bacterial
infections were associated with abdominal pain, bloody diarrhoea, prolonged diarrhoea (mean
14.1 days), leucocytosis and a raised erythrocyte sedimentation rate (ESR). [EL = 3]
52
In the second hospital-based prospective cross-sectional study from Italy, the clinical features
at presentation were compared in 215 children with viral and bacterial gastroenteritis. Enteric
pathogens were detected in 127/215 (59%) cases with viral infections accounting for almost
80% of these (single or double viral or co-infection with bacterial pathogens) while mono-
bacterial infections were detected in the rest. No sample was positive for parasites. Vomiting
and dehydration were more frequent in children with viral gastroenteritis (P < 0.01) compared
with those without viral infection. The severity of dehydration (assessed by a 14-point severity
score) was significantly higher in children infected with either astrovirus or rotavirus group A.
Prolonged hospitalisation was also more likely to occur with rotavirus infection. [EL = 3]

53
A prospective UK study included 1148 children younger than 16 years admitted to a sub-
regional infectious disease hospital with a diagnosis of gastroenteritis over a 1 year period. Of the
admitted children, 55% (635/1148) were younger than 1 year while 5% were over 5 years of age.
Admissions were predominantly from socially disadvantaged families (62% from social classes
IV and V). At the time of admission, 8.8% (101/1148) of children were clinically dehydrated, with
1% assessed to have greater than 5% dehydration. Seventy-nine percent of children had a history
of vomiting before admission and it was more common with rotavirus infection than bacterial
pathogens (92% versus 54%; P < 0.001). Diarrhoea of bacterial, protozoal or mixed aetiology
had a higher incidence of stool containing blood and/or mucus compared with rotavirus, and
abdominal pain was more common in bacterial diarrhoea than diarrhoea of other aetiology
(P < 0.001 for both). During the hospital stay, diarrhoea persisted for longer duration in children
with bacterial, protozoal or mixed aetiology than in those with rotavirus. Fifty-two percent of
rotavirus cases settled within 48 hours of admission compared with 39% for the other group, while
16% of the rotavirus group had diarrhoea persisting beyond 96 hours of admission compared
with 31% for the other group (P < 0.05 for both comparisons). This study also gave information
on the incidence of enteric pathogens and biochemical abnormalities detected during laboratory
investigations, and that information has been included under the relevant sections. [EL = 3]
44
In a cross-sectional study from Kuwait, the duration of diarrhoea and clinical characteristics
associated with various pathogens were examined. In total, 595 children (age range under 1 year
to 12 years) admitted to the hospital with gastroenteritis were included. Two stool specimens were
collected within 18 hours of admission to determine the pathogens responsible for gastroenteritis.
Rotavirus was the most common pathogen detected, in 45% of children (34% pure isolates and
the rest in combination with bacteria), followed by salmonella in 24% of children (17% pure
isolates and 7% in combination with rotavirus). The mean duration of diarrhoea was longer
in those with salmonella (12.3 days) than in those with rotavirus (4.8 days) or other bacterial
pathogens detected alone or in combination with other infections (mean duration ranging from
6.8 to 7.9 days) (Table 3.2). Gastroenteritis with rotavirus infection had a self-limiting course with
no mortality and low morbidity and was associated with few extra-intestinal manifestations, while
salmonella infections had the highest frequency of milk intolerance (31%), malnutrition (36%),
and associated features (convulsions in 20% and septicaemia in 17%). Abdominal pain and bloody
diarrhoea were common in infections with shigella, salmonella and campylobacter. Features of
extra-intestinal invasions (such as toxic look, fever > 3 days, poor feeding, hepatosplenomegaly
and pneumonia) were seen almost exclusively in children with salmonella infections. [EL = 3]

Risk factors for persistent diarrhoea
54
A case–control study from India investigated possible risk factors for persistent diarrhoea
(>14 days). They compared 170 cases with 340 controls (aged 1–23 months) who had been

24