An evidence and consensus based guideline for acute diarrhoea management

Abstract

Objective-To develop an evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (with or without vomiting), a common problem representing 16% of all paediatric medical attenders at an accident and emergency department. Clinical assessment, investigations (biochemistry and stool culture in particular), admission, and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home. Evidence-A systematic review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendation were generated. Consensus-An anonymous, postal Delphi consensus process was used. A panel of 39 selected medical and nursing staV were asked to grade their agreement with the generated statements. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panellists' responses. Consensus was predefined as 83% of panellists agreeing with the statement. Recommendations-Clinical signs useful in assessment of level of dehydration were agreed. Admission to a paediatric facility is advised for children who show signs of dehydration. For those with mild to moderate dehydration, estimated deficit is replaced over four hours with oral rehydration solution (glucose based, 200-250 mOsm/l) given "little and often". A nasogastric tube should be used if fluid is refused and normal feeds started following rehydration. Children at high risk of dehydration should be observed to ensure at least maintenance fluid is tolerated. Management of more severe dehydration is detailed. Antidiarrhoeal medication is not indicated. Validation-The guideline has been successfully implemented and evaluated in a paediatric accident and emergency department. (Arch Dis Child 2001;85:132-142)

An evidence-based guideline for children presenting with acute breathing difficulty

“…We decided to make the guideline problem based13 rather than diagnosis based, unlike many other existing guidelines. This was to aid doctors with little paediatric experience to manage a patient at presentation to the hospital and the sequential approach to arriving at a diagnosis.…”

“…A guideline relating to specific diagnosis is useful only once a correct diagnosis has been made. Our guideline is one of a very few problem-based13 14 guidelines relating to the initial management of a child presenting to the hospital.…”

Question 1 Does oral ondansetron reduce vomiting and the need for intravenous fluids and hospital admission in children presenting with vomiting secondary to gastroenteritis?

“…Two systematic reviews4 5 and a Cochrane review6 were examined but excluded as all included intravenous ondansetron.…”

“…Historically, normal UK practice for the management of gastroenteritis in children without clinical signs of shock has involved the use of OFC and antipyretic medication 4 7. Despite the fact that vomiting is the major reason for failure of oral rehydration therapy,5 antiemetics have largely been considered inappropriate in paediatric patients.…”

How has research changed my practice in the last 5 years?

“…One of my favourite recent papers was the evidence- and consensus-based guidelines for acute diarrhoea management 4. I quote this often – for individual case management, for eager juniors planning an audit, and as an example of a useful, clear and (mostly) evidence-based review article to inspire would-be authors.…”