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Diarrhoea and vomiting in children

About

What is covered

This interactive flowchart covers the diagnosis, assessment and management of diarrhoea and vomiting in children younger than 5 years.
Diarrhoea and vomiting caused by gastroenteritis are common in children younger than 5 years. Severe diarrhoea and vomiting can lead to dehydration, which is serious, but gastroenteritis can usually be managed at home with advice from healthcare professionals. Diarrhoea usually lasts for 5–7 days and stops within 2 weeks. Vomiting usually lasts for 1–2 days and stops within 3 days. Diarrhoea and vomiting are a significant burden on health services, and clinical practice varies. This guideline aims to reduce this variation and make the best use of NHS resources.

Updates

Updates to this interactive flowchart

10 January 2017 Integrated multiplex PCR tests for identifying gastrointestinal pathogens in people with suspected gastroenteritis (xTAG Gastrointestinal Pathogen Panel, FilmArray GI Panel and Faecal Pathogens B assay) (NICE diagnostics guidance 26) added to investigation and notification.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not 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 guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing diarrhoea and vomiting caused by gastroenteritis in children under 5 in an interactive flowchart

What is covered

This interactive flowchart covers the diagnosis, assessment and management of diarrhoea and vomiting in children younger than 5 years.
Diarrhoea and vomiting caused by gastroenteritis are common in children younger than 5 years. Severe diarrhoea and vomiting can lead to dehydration, which is serious, but gastroenteritis can usually be managed at home with advice from healthcare professionals. Diarrhoea usually lasts for 5–7 days and stops within 2 weeks. Vomiting usually lasts for 1–2 days and stops within 3 days. Diarrhoea and vomiting are a significant burden on health services, and clinical practice varies. This guideline aims to reduce this variation and make the best use of NHS resources.

Updates

Updates to this interactive flowchart

10 January 2017 Integrated multiplex PCR tests for identifying gastrointestinal pathogens in people with suspected gastroenteritis (xTAG Gastrointestinal Pathogen Panel, FilmArray GI Panel and Faecal Pathogens B assay) (NICE diagnostics guidance 26) added to investigation and notification.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not 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 guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Symptoms and signs of clinical dehydration and shock

Interpret symptoms and signs taking into account risk factors for dehydration. More numerous and more pronounced symptoms and/or signs of clinical dehydration indicate greater severity. For clinical shock, one or more symptoms or signs would be present.
Red flag (*) symptoms and signs may help to identify children at increased risk of progression to shock. If in doubt, manage as if there are red flag symptoms or signs. Dashes (–) indicate that these clinical features do not specifically indicate shock.
No clinically detectable dehydration
Clinical dehydration
Clinical shock
Symptoms (remote and face-to-face assessments)
Appears well
*Appears to be unwell or deteriorating
Alert and responsive
*Altered responsiveness (for example, irritable, lethargic)
Decreased level of consciousness
Normal urine output
Decreased urine output
Skin colour unchanged
Skin colour unchanged
Pale or mottled skin
Warm extremities
Warm extremities
Cold extremities
Signs (face-to-face assessments)
Alert and responsive
*Altered responsiveness (for example, irritable, lethargic)
Decreased level of consciousness
Skin colour unchanged
Skin colour unchanged
Pale or mottled skin
Warm extremities
Warm extremities
Cold extremities
Eyes not sunken
*Sunken eyes
Moist mucous membranes (except after a drink)
Dry mucous membranes (except for 'mouth breather')
Normal heart rate
*Tachycardia
Tachycardia
Normal breathing pattern
*Tachypnoea
Tachypnoea
Normal peripheral pulses
Normal peripheral pulses
Weak peripheral pulses
Normal capillary refill time
Normal capillary refill time
Prolonged capillary refill time
Normal skin turgor
*Reduced skin turgor
Normal blood pressure
Normal blood pressure
Hypotension (indicates decompensated shock
The symptoms and signs table is also available in colour on the NICE website.

Diagnoses other than gastroenteritis

Any of the following may indicate diagnoses other than gastroenteritis:
  • temperature of 38°C or higher (younger than 3 months)
  • temperature of 39°C or higher (3 months or older)
  • shortness of breath or tachypnoea
  • altered conscious state
  • neck stiffness
  • bulging fontanelle (in infants)Infant: child younger than 1 year.
  • non-blanching rash
  • blood and/or mucus in stool
  • bilious (green) vomit
  • severe or localised abdominal pain
  • abdominal distension or rebound tenderness.

Children at increased risk of dehydration

Children younger than 1 year, especially those younger than 6 months
Infants who were of low birth weight
Children who have passed six or more diarrhoeal stools in the past 24 hours
Children who have vomited three times or more in the past 24 hours
Children who have not been offered or have not been able to tolerate supplementary fluids before presentation
Infants who have stopped breastfeeding during the illness
Children with signs of malnutrition.
  • appears well
  • has altered responsiveness – for example, is irritable or lethargic
  • has decreased urine output
  • has pale or mottled skin
  • has cold extremities.
During rehydration therapy:
  • continue breastfeeding
  • do not give solid foods
  • for children without red flag symptoms or signs (see symptoms and signs of clinical dehydration and shock or the NICE website for a colour version of the symptoms and signs table), do not routinely give oral fluids other than ORS solution; however, consider supplementing with usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they consistently refuse ORS solution
  • for children with red flag symptoms or signs (see symptoms and signs of clinical dehydration and shock or the NICE website for a colour version of the symptoms and signs table), do not give oral fluids other than ORS solution.

Glossary

intravenous fluid therapy
oral rehydration salt
oral rehydration therapy
situation in which a child is assessed by a healthcare professional who is unable to examine the child because the child is geographically remote from the assessor

Paths in this pathway

Pathway created: May 2013 Last updated: April 2017

© NICE 2017

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