eshed

Diarrhoea and/or Vomiting (Gastroenteritis) Pathway May 2015 Refr

Version South East Coast Strategic Clinical Networks
Children and Young People
Clinical Assessment / Management for Children Younger than 5 years with suspected Gastroenteritis
Management - Primary Care and Community Settings
SUSPECTED GASTROENTERITIS Do the symptoms and/or signs suggest
• Refer immediately to emergency care by 999
an immediately life threatening Yes Yes
• Alert Paediatrician-On-Call*
Patient History (high risk) illness?
presents • Stay with child whilst waiting and prepare
Assessment of Vital Signs - Temp, Heart Rate, RR, CRT
with or has • documentation
Assessment Consider any of the following as possible indicators of diagnoses other than gastroenteritis:
a history of
diarrhoea Consider differential diagnosis • Fever: Temperature of > 38°C (younger than 3 months) • Temperature of > 39°C (3 months or older) • Shortness of breath or
and / or History Hydration Antipyretics Assess tachypnoea • Altered state of consciousness • Consider a diagnosis of diabetes • Neck stiffness • Bulging fontanelle in infants •  Discuss with
vomiting 5 ml aliquots of Oral Rehydration Solution (ORS) Non blanching rash • Blood and/or mucous in stool • Bilious (green) vomit • Projectile vomiting • Vomiting alone • Head Injury •
Paediatrician-On-Call*
Severe localised abdominal pain • Abdominal distension or rebound tenderness • History/Suspicion of poisoning e.g. Carbon Monoxide
eg. Dioralyte every 5 minutes
Fruit juice / carbonated drinks should be excluded

Table 1 Clinical
Findings Green - low risk Amber - intermediate risk Red - high risk Fig 1 Children at increased risk of dehydration are those:
• Aged <1 year old (and especially the < 6 month age group)
Age Over 3 months old Under 3 months old • History of a low birth weight
• Has had six or more episodes of diarrhoea in the past 24 hours

First Draft Version: May 2011 Date of this Refreshed Version: Jan 2015 (from Nov 2013) Review Date: Jan 2017
Behaviour • Responds normally to social cues • Altered response to social cues • No response to social cues • Have vomited three times or more in the last 24 hours
• No smile • Have not taken or have not been able to tolerate fluids before
• Content / smiles presentation
• Decreased activity • Unable to rouse or if roused does not stay awake • Infants who have stopped breastfeeding during the illness
• Stays awake / awakens quickly • Irritable • Children with malnutrition
• Lethargic • Faltering growth
GMC Best Practice recommends: Record your findings

• Strong normal crying / not crying • Weak, high pitched or continuous cry
• Appears unwell • Appears ill to a healthcare professional
(See “Good Medical Practice” http://bit.ly/1DPXl2b)

Fig 2 Management of Clinical Dehydration

Skin • Normal skin colour • Normal skin colour • Pale / mottled / ashen blue • Increase oral fluid intake to 2 mls/kg every 10 mins with an oral
• Normal turgor • Warm extremities • Cold extremities rehydration solution (ORS) over 4 hours
• Warm extremities • Reduced skin turgor • Continue breast/bottle feeding, little and often
• Monitor response to ORS with parents and continue as required.
Hydration • CRT < 2 secs • CRT 2-3 secs • CRT> 3 secs • Continue ORS if ongoing losses
• Moist mucous membranes (except after a drink) • Dry mucous membranes (except for mouth breather) • Refer to Paediatrics if child is deteriorating after 2 hours and if after
• Normal urine output • History of r educed urine output • History of reduced urine output 4 hours a child is failing to respond to ORS
• Fontanelle normal
• Sunken fontanelle • Sunken fontanelle

Table 2 Normal Paediatric Values:

Respiratory • Normal breathing pattern and rate** • Normal breathing pattern and rate** • Abnormal breathing / tachypnoea**
(APLS†) Respiratory Heart Rate
• Heart rate normal • Mild tachycardia** Rate at rest: [b/min] [bpm]
Heart Rate • Severe tachycardia**
• Peripheral pulses normal • Peripheral pulses normal < 1 year 30 - 40 110 - 160
• Normal Eyes 1-2 years 25 - 35 100 - 150
Eyes • Not sunken • Sunken Eyes Sunken eyes > 2-5 years 25 - 30 95 - 140
e Sheet
Coast
South East
Strategic
g People
Clinical Networks
† Advanced Paediatric Life Support The Practical Approach Fifth Edition Advanced Life Support Group Edited by Martin Samuels; Susan Wieteska
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May 201 sion
Ver Wiley-Blackwell / 2011 BMJ Books.
years
Advice for younger than 5
of children Date / Time
advice given
Age

Child
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How is you You need
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Green Action Amber Action Urgent Action

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If your child: ated: ie. dry mouth drowsy or passin
g less urine Please ring call
ry or
seems dehydr spot on baby’s head), nt tummy pain to keep down GP surge
- dial 111

Provide Written and Verbal advice (see patient advice sheet) Refer immediately to emergency care by 999
fontanelle
(soft (poo) or consta / or is unable NHS 111

Advice from Paediatrician-On-Call* should be sought and/or a clear

in the stool breastfeeding and
has blood or
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* Please see overleaf for telephone numbers ** Please see Normal Paediatric Values in Table 2 above.
of the South

This guidance is written in This document was arrived at after careful consideration of the evidence available including but not exclusively NICE, SIGN, EBM data and NHS evidence, as applicable. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement.
the following context: The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with the patient and / or carer.
Supporting Information South East Coast Strategic Clinical Networks
Children and Young People
Dear Colleague,

I would like to introduce you to the Diarrhoea and / or Vomiting

Where can I learn more about paediatric assessment?
We also recommend signing up to the online and interactive learning
tool Spotting the Sick Child. It is free of charge. It was commissioned
by the Department of Health to support health professionals in the
assessment of the acutely sick child. It is also CPD certified.
www.spottingthesickchild.com
(Gastroenteritis) Pathway - Clinical Assessment / Management for
Children Younger than 5 years with suspected Gastroenteritis – in
Primary Care and Community Settings. This is one of a series of urgent care pathways developed by the
Children and Young People’s Network for the most common conditions requiring primary and / or acute care.
The local clinical groups who played such an important role in creating these tools, starting from 2010, have
included representatives from acute, community and primary care as well as parents, education and social
care. In particular we would also like to thank Paediatrics and Emergency Medicine colleagues for their
support in finalising these versions for circulation.

The professionals were all working towards four main objectives:

*GP / Clinician Priority Phonelines / Contact Numbers at Local Hospitals
Surrey and Sussex Area Hospitals
Ashford and St Peter’s Hospital NHS
Foundation Trust, Chertsey 01932 872000
Brighton and Sussex University Hospitals
NHS Trust Royal Alexandra Hospital, Brighton
01273 523230
East Sussex Healthcare NHS Trust
Conquest Hospital, Hastings 01424 755255
Eastbourne District General Hospital
01323 417400
Frimley Park Hospital NHS Foundation Trust,
Camberley 01276 604604 Bleep 100
Royal Surrey County Hospital NHS
Foundation Trust, Guildford 01483 571122
Surrey and Sussex Healthcare NHS Trust
East Surrey Hospital, Redhill 01737 231807
Western Sussex Hospitals NHS Trust St
Richards Hospital, Chichester 01243 536180/1
Worthing Hospital 01903 285060
Kent and Medway Area Hospitals
Dartford and Gravesham NHS Trust
Darent Valley Hospital / Queen Marys Hospital
Sidcup / Erith and District Hospital
01322 428100 Bleep 316 (same number applies
to both hospital sites)
East Kent Hospitals NHS Trust
Queen Elizabeth The Queen Mother Hospital,
Margate / William Harvey Hospital, Ashford
01227 783190 (same number applies to both
hospital sites)
Maidstone and Tonbridge Wells NHS Trust
01622 723011
Medway Maritime Hospital, Gillingham
01634 825000
● To promote evidence-based assessment and management of unwell children and young people. The
pathway tools aim to ensure that accurate and prompt advice is available to assist health professionals to
make safe decisions that can be taken quickly.
●  o build consistency across the Network area, so all healthcare professionals understand the pathway and
T
can assess, manage and support children, young people and their families during the episode, to the same
high standards, regardless of where they present.
To support local healthcare professionals to share learning and expertise across organisations in order to
●
drive continuous development of high quality care
● To build the confidence/resilience of parents to manage their child’s illness which should be increased
with the consistent advice offered for unwell children and young people accessing all local NHS services in
an emergency or urgent scenario.
This pathway is comprised of three elements: parental advice, a pathway for use in primary care and
community settings and a pathway for use in acute (hospital) settings. Each part has been designed to be
compatible with existing pathways in the acute sector and should be particularly valuable for use in Hospital
Emergency Departments and primary care settings.
It is an expectation that these pathways will not only provide a guide for clinicians faced with an unwell child,
but will also be used in training and disseminated across all relevant departments and team-members.
We hope you will find this a quality tool to be used within your practice. We look forward to hearing back on
how the consistency of assessment and management of these children and the overall quality of practice and
patient experience has been improved with this relatively simple but whole system initiative.

With many thanks to all those who have supported the development of our To feedback or for further information including how to obtain more copies of this document we have one
mailbox for these queries on behalf of the South East Coast Strategic Clinical Networks area
pathways including: (Kent, Surrey and Sussex). Please email: CWSCCG.cypSECpathways@nhs.net
Aaron Gain Dr Anna Mathew Dr Nelly Ninis Jeannie Baumann Lorraine Mulroney
Amanda Wood Dr Catherine Bevan Dr Oli Rahman Joanna Hodginkson Lucie Gamman May we commend it to your use.
Carole Perry Dr Debbie Pullen Dr Palla Prabhakara Joanne Farrell Matthew White Yours sincerely
Carolyn Phillips Dr Farhana Damda Dr Stuart Nicholls Karen Hearnden Melissa Hancorn
Catherine Holroyd
Chris Morris
Dr Fiona Weir
Dr Helen Milne
Dr Tim Fooks Kate Eades
Kath Evans
Nicola Mundy
Patricia Breach
The Network
Dr Tim Taylor
Christine McDermott Dr Neemisha Jain Dr Venkat Reddy Kathy Walker Rebecca C ‘Aileta
Claire O’Callaghan Dr Kamal Khoobarry Dr Vijay Iyer Katie Shedden Rosie Courtney Glossary of Terms and Abbreviations
Clare Lyons Amos Dr Kate Andrews Fiona Mackison Kim Morgan Rosie Rowlands
APLS Advanced Paediatric Life Support HR Heart Rate
Denise Matthams Dr Maggie Wearmouth Gill Cunningham Laura Robertson Susan Nicholls
Sue Pumphrey
CPD Continuous Professional Development O2 SATS Oxygen Saturation in Air
Dr Amit Bhargava Dr Mike Linney Jane Mulcahy Lois Pendlebury
Dr Ann Corkery Dr Mwape Kabole Wang Cheung
CRT Capillary Refill Time RR Respiratory Rate
Jason Gray Lois Peters
ED Hospital Emergency Department
Based on: Diarrhoea and vomiting in children under 5 2009 NICE clinical guideline 84