A member of the NICE guideline development group highlights the important issues from the latest evidence-based guideline for readers of Nursing Times
Over the last 18 months I have been working alongside a group of healthcare professionals and lay members to develop evidence-based recommendations for the NICE (2009) clinical guideline on diarrhoea and vomiting caused by gastroenteritis in children under five years.
Incidence of gastroenteritis
Gastroenteritis is common in young children. Every year in England 10-20% of children under five present to healthcare services with symptoms. The new guideline provides consistent advice to nurses on key issues such as fluid intake, nutritional management and preventing and managing dehydration. It also provides recommendations on advice they can give to parents and carers, and when care should be escalated – from home management through to hospital admission. By adopting the new up-to-date recommendations on managing gastroenteritis, nurses can help ensure that children’s care is consistent around the country.
Gastroenteritis should be suspected if there is a sudden change in stool consistency to loose or watery stools, and/or a sudden onset of vomiting. The guideline suggests testing stool samples if septicaemia is suspected, if there is blood or mucus in the stool, or if the child is immunocompromised. However, for the first time this key recommendation moves nurses away from the practice of routinely testing stool samples in children with gastroenteritis.
The guideline will help nurses to assess children with gastroenteritis and decide how unwell a child is so they can be followed up by the right health professional, at the right time and in the right healthcare setting. An important development of the guideline is a tool which nurses can use to identify symptoms and signs for detecting ‘no clinically detectable dehydration’, ‘clinical dehydration’ and ‘shock’ – these signs and symptoms are interpreted in the context of risk factors (red flags) for dehydration.
This guideline calls for the use of oral rehydration where possible rather than intravenous drips, which can be painful and unnecessary. By emphasising oral rehydration with low-osmolarity oral rehydration salt (ORS) solution (such as Dioralyte) as firstline treatment of dehydration and limiting intravenous fluids to selected children, the guideline will help avoid the complications and distress associated with intravenous cannulation.
Where the child is at the more severe end of the spectrum and severely dehydrated, they will most safely be managed with a drip. The guideline recommends that intravenous fluid therapy is used only if: shock is suspected or confirmed; a child with red-flag symptoms deteriorates despite oral rehydration therapy; or a child persistently vomits the ORS solution.
Gastroenteritis should be suspected if there is a sudden change in stool consistency to loose or watery stools, and/or a sudden onset of vomiting
The guideline also provides advice on nutritional management and recommends that after rehydration, full-strength milk is given straight away. Parents and carers should be advised to reintroduce the child’s usual solid food at this point but not give fruit drinks and carbonated drinks until the diarrhoea has stopped.
Information for parents
Gastroenteritis can usually be treated at home with varying levels of support and this guideline will ensure that parents are provided with good advice to help them manage the condition once they have seen a nurse or other healthcare professional. For example, parents should be given information on how to use oral hydration solutions to prevent dehydration early on, advice on how long vomiting and diarrhoea is likely to last, the best fluids and foods to give as well as the warning signs of dehydration and when to seek further medical advice.
Nurses can also provide important advice to help prevent the spread of gastroenteritis. For example, parents, carers and children should be advised of the importance of washing hands with soap (liquid if possible) in warm running water and drying them carefully. They should also advise that towels used by infected children should not be shared and hands should be washed after going to the toilet, changing nappies and before preparing, serving or eating food.
Parents I speak to every day are concerned they are receiving mixed messages about treating gastroenteritis. For example, some parents I have spoken to have heard they should give their child flat cola drinks – when the evidence shows this can make the problem far worse. I hope this guideline will help nurses to dispel the myths and give parents clear advice about what to do if their child has diarrhoea and vomiting.
By applying the guideline recommendations, nurses can play an important role in ensuring that children with gastroenteritis receive the highest standard of care, based on the best available evidence.
AUTHOR Jenny Taylor, MSc, RSCN, is advanced paediatric nurse practitioner, Calderdale and Huddersfield NHS Foundation Trust, and a member of the NICE guideline development group