Vomiting and Diarrhea

DEFINITIONS: In describing gastrointestinal symptoms, it is important to be precise.

Vomiting implies the forceful elimination of food through the mouth.
Spitting up is where food slowly dribbles out of the mouth (cheesing up in an infant) and is often associated with gastrointestinal reflux (GER), a normal condition seen in children under 9 months, in which the valve that keeps stomach contents in the stomach has not tightened up, allowing the normal pressure in the stomach to push liquids back up and out of the mouth.
Diarrhea is defined in different ways by different people. We define it as many, very loose stools. Usually, many means more than 5-6 in a 24 hour period and loose means that it soaks into the diaper or leaks all over the place.

CAUSES OF VOMITING AND DIARRHEA: There are very few causes of both vomiting and diarrhea.

Viruses - Even when not associated with fever, viruses are the most common causes of these two symptoms. In children under 2 years old, rotavirus is the most commonly implicated virus although Norwalk virus, adenovirus, astrovirus and calcivirus are often seen as well. In older children and adults, influenza is the most common virus causing vomiting and diarrhea. Rotavirus is rarely associated with fever or cold symptoms. Adenovirus, calcivirus and influenza on the other hand, can frequently be associated with fever (as high as 105), chills, aches and pains and cold like symptoms. All are common in the late fall and winter months and occur with greatest frequency in large day care centers. Unfortunately, there is no treatment for any virus so identifying which one is affecting your child is not very helpful. How long do the symptoms last? The vomiting phase for all viruses usually lasts 1-2 days with diarrhea persisting in many cases, for up to 7-10 days.

CAUSES OF VOMITING ALONE:

Viruses - The most common cause of vomiting alone is also stomach viruses!
Bowel obstructions - Occasionally, children with appendicitis and bowel obstructions will have vomiting alone. This type of vomiting is called bilious and is green or very dark, but despite the hoopla in parenting magazines, appendicitis and other bowel obstructions are exceedingly rare (we probably see a case only 1-2 times a year)! And non-stomach virus forms of vomiting are almost never associated with fever, cold symptoms or diarrhea. Appendicitis is most commonly seen in a school aged child with vomiting, loss of appetite and right sided severe (the worst abdominal pain in your life) pain. If the child can jump up and down, he is probably okay. Hernias can also be associated with bowel obstruction but almost always the child with an incarcerated hernia where a piece of the gut has gotten stuck in the hernia, is associated with localized redness, swelling and tenderness.

CAUSES OF DIARRHEA ALONE:

Viruses - The most common cause of diarrhea alone is also a stomach virus!
Bacterial infections - If there is bloody diarrhea, especially in a child coming from a large day care, occasionally we may be dealing with bacterial infections such as Salmonella, Shigella, Yersinia or Heicobater. We rarely do anything different for children older than 3 months, but with bloody diarrhea, it is occasionally helpful to do a stool culture to prove the bacterial nature of the disease. The above 4 diseases are reportable to the Department of Health and their presence in a day care setting may be significant.
Parasites - Chronic diarrhea (defined as more than 2 weeks) may be caused by parasites such a Giardia (seen in day care contacts) or by toxin such a C. difficile (seen after recent use of certain antibiotics). If your child has had diarrhea lasting longer then 2 weeks, it may be helpful to evaluate the stool and determine the cause. Try to bring in a fresh diaper; the yield is greatly enhanced with a fresh specimen.

WHAT IS DEHYDRATION? The most common question we are asked when a child is vomiting or having diarrhea is, how can dehydration be prevented? Dehydration means the lack of water. Practically speaking however, the most accurate way of diagnosing dehydration in young children is to examine the inside of the mouth. A child who has moisture inside the lips or is drooling is usually fine. Please do not look at urine output. Because urine is often mixed with diarrheal stools and because of today’s super absorbent diapers, urine production is not a helpful sign. It is very uncommon for a child with a stomach virus to become dehydrated unless it has been accompanied by vomiting for a couple of days straight. It is especially unusual for a child with diarrhea alone to become dehydrated.

GENERAL PRINCIPLES IN THE TREATMENT OF VOMITING AND DIARRHEA:
Because the content of vomit and stool is high in salt (sodium), and high in carbohydrate (CHO), the optimal way of maintaining chemical balance in the body is to replace these losses with a solution that is close in content to the material that is being lost. In addition, sodium and water are absorbed more efficiently when moderate amounts of CHO or sugar are added, but too much CHO can actually promote diarrhea. Ideally then, we want a substance that has a CHO:sodium rationof <2:1 with CHO content of 100-150 and sodium content of 60-90. Unfortunately, most solutions used by pediatricians and parents aren’t even close to this content. Cola has a CHO of 700 and a sodium of 2; apple juice has a CHO of 690 and a sodium of 3; chick broth has no CHO and a sodium of 250 and Gatorade™ and Powerade have a CHO over 200 and a sodium of only 20.

RECOMMENDED REHYDRATING SOLUTIONS: In most of the world, the World Heath Organization (WHO) provides a very physiological solution with CHO content of 111 and a sodium content of 90 for the optimal CHO:sodium ration of water to provide the appropriate concentration. Unfortunately, this product is not readily available locally. Fortunately, in all but the worst cases, Pedialyte (which comes fruit flavored and bubble gum flavored for better patient compliance) with a CHO of 140 and a sodium of 45 for a ration of approximately 3:1 is a reasonable alternative. For the child over 12 months with mild dehydration, Gatorade, Powerade, or Allsport is better tolerated because of taste. You can try a Pedialyte flavored popsicle mix 1 tablespoon of Jello powder with an equal amount of boiling water and add to Pedialyte to make it more palatable. Please make sure you have at least one of these solutions at home at all times so that you won’t get stuck at 12 midnight with a vomiting child and nothing to give.

HOW TO REHYDRATE

During the vomiting phase, it is best to give small amounts of rehydrating solution (ORS, Pedialyte or Gatorade) every few minutes. Small amounts mean small amounts: an ounce, a ½ ounce or even just a few sips. Build up slowly and if your child begins to vomit again, you probably went too far too fast.
Occasionally, when vomiting is in the early stages, it can be remedied by giving small sips of the thick, sugary syrup found in canned peaches or fruit cocktail (just the syrup, not the fruit) which works by coating stomach nerve endings and reducing GI irritability. The dose is 2 teaspoon 30 minutes apart for children under 2 and 1 tablespoon 30 minutes apart for older children.
Once the vomiting has passed for at least 6-8 hours, even if there is still copious diarrhea, begin solid foods concentrating especially on starchy foods such as rice, macaroni, spaghetti, pasta, bread etc. It is important to get back to a regular diet as soon as possible, because once the gut has been damaged by the virus, if you don’t provide adequate calories, you simply perpetuate the diarrhea.
The preferred beverage for children with mild diarrhea remains milk or mild based formula.
For children under a year of age with more persistent diarrhea, a formula called Isomil DF (diarrhea formula) is available. Its major advantage is that it has fiber and fiber helps bulk up the stool. (Ironically, for the same reason, it helps with constipation as well.) For children over a year, try Ensure with Fiber, a soy based adult beverage that accomplishes the same goals as Isomil DF.

AVOIDING STARVATION STOOLS: Try not to go overboard with fluid. Most parents worry about dehydration but studies show that children with diarrhea tend to get up to 2x as much liquid as they need. The more you put in, the more reabsorption from a damaged gut is necessary before it comes out. And often the child with persistently loose stools is simply getting too much liquid and not enough fat and protein for the gut to heal.

COMMON MISTAKEN FOLK WISDOMS ABOUT REHYDRATION:

Using milk makes the diarrhea worse. We used to believe that milk should be eliminated when a child is having diarrhea. It turns out that the enzyme that digests milk sugar or lactose is damaged first with most stomach viruses and so milk can theoretically worsen the diarrhea. However, providing a diet that is low in fat and protein also prolongs the diarrhea. Current thinking is that you should feed through an episode of diarrhea and that the calories, fat and protein provided by milk outweigh the possible problems associated with lactose. Only in prolonged diarrhea (>10days) do we recommend using a bulking agent like Isomil DF or Ensure with fiber. So giving 1-2 cups of milk a day as well as yogurt and cheese can actually be helpful in the long run.
It is easy to get dehydrated. Wrong! Of the 400-500 children that we see or speak to in one flu season, only 5-10 get seriously dehydrated and even then, hospitalization is rarely necessary. Although the usual toddler is taking in 24 ounces of liquid a day, he really only needs 8-10 to get by, so remember to be patient
Tea is good for diarrhea. Not usually! Herbal teas are okay, but do not have adequate amounts of sugar and sodium. Caffeinated teas may actually perpetuate the diarrhea by increasing gut motility.
Kaopectate and other gut stoppers are helpful. Actually, all they do is stop the gut from moving, allowing the virus to continue to do its damage. It is better to get the virus out of the body, even if it takes a few extra days. Unfortunately, many day care centers keep a child out of school as long as there is some loose stool. This is not really the appropriate medical approach but in such situations, you are at the mercy of the particular day care policy. In such cases, using Isomil DF or Ensure with fiber at 5-7 days will be okay. Occasionally, in a healthy appearing child, adding a tablespoon of soluble fiber (Benefiber and other generic alternatives) can help speed recovery.

Good luck and remember that vomiting and diarrhea when treated with patience and the appropriate rehydrating solution, is very messy but rarely dangerous!