Children and Infants with Gastroenteritis -Acute Management

Children and Infants with Gastroenteritis -Acute Management free pdf ebook was written by AGRAH on December 31, 1969 consist of 41 page(s). The pdf file is provided by www.health.nsw.gov.au and available on pdfpedia since February 19, 2012.

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Children and Infants with Gastroenteritis -Acute Management pdf




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Children and Infants with Gastroenteritis -Acute Management - page 1
Policy Directive Department of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/ space space Children and Infants with Gastroenteritis - Acute Management space Document Number PD2010_009 Publication date 03-Feb-2010 Functional Sub group Clinical/ Patient Services - Baby and child Summary Clinical Practice Guidelines for the treatment of infants and children with gastroenteritis. Replaces Doc. No. Children and Infants with Gastroenteritis - Acute Management [PD2009_064] Author Branch Statewide Services Development Branch contact Trish Boss 9424 5706 Applies to Area Health Services/Chief Executive Governed Statutory Health Corporation, Board Governed Statutory Health Corporations, Affiliated Health Organisations - Non Declared, Affiliated Health Organisations - Declared, Public Health System Support Division, Community Health Centres, NSW Ambulance Service, Public Hospitals Audience Emergency Departments, Paediatric Units Distributed to Public Health System, Divisions of General Practice, NSW Ambulance Service, Private Hospitals and Day Procedure Centres, Tertiary Education Institutes Review date 03-Feb-2013 Policy Manual Patient Matters File No. 06/3557 Status Active Director-General space This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory for NSW Health and is a condition of subsidy for public health organisations.
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Children and Infants with Gastroenteritis -Acute Management - page 2
POLICY STATEMENT INFANTS AND CHILDREN:ACUTE MANAGEMENT OF GASTROENTERITIS PURPOSE The infants and children: acute management of gastroenteritis clinical practice guideline (attached) has been developed to provide direction to clinicians and is aimed at achieving the best possible paediatric care in all parts of the state. The clinical practice guideline was prepared for the NSW Department of Health by an expert clinical reference group under the auspice of the state wide Paediatric Clinical Practice Guideline Steering Group. MANDATORY REQUIREMENTS This policy applies to all facilities where paediatric patients are managed. It requires all Health Services to have local guidelines/protocols based on the attached clinical practice guideline in place in all hospitals and facilities likely to be required to assess or manage children with gastroenteritis. The clinical practice guideline reflects what is currently regarded as a safe and appropriate approach to the acute management of gastroenteritis in infants and children. However, as in any clinical situation there may be factors which cannot be covered by a single set of guidelines. This document should be used as a guide, rather than as a complete authoritative statement of procedures to be followed in respect of each individual presentation. It does not replace the need for the application of clinical judgement to each individual presentation. IMPLEMENTATION Chief Executives must ensure: Local protocols are developed based on the infants and children: acute management of gastroenteritis clinical practice guideline. Local protocols are in place in all hospitals and facilities likely to be required to assess or manage paediatric patients with gastroenteritis. Ensure that all staff treating paediatric patients are educated in the use of the locally developed paediatric protocols. Directors of Clinical Governance are required to inform relevant clinical staff treating paediatric patients of the revised protocols. REVISION HISTORY Version December 2004 (PD2005_238) October 2009 (PD2009_064) February 2010 (PD2010_009) Approved by Director-General Deputy Director-General Population Health Deputy Director-General Population Health Amendment notes New policy Second edition Third edition. Corrects table on page 8. ATTACHMENT 1. Infants and Children: Acute Management of Gastroenteritis – Clinical Practice Guideline. PD2010_009 Issue date: February 2010 Page 1 of 1
Children and Infants with Gastroenteritis -Acute Management - page 3
Infants and children: Acute Management of Gastroenteritis third edition CLINICAL PRACTICE GUIDELINES
Children and Infants with Gastroenteritis -Acute Management - page 4
NSW DEPARTMENT OF HEALTH 73 Miller Street North Sydney NSW 2060 Tel. (02) 9391 9000 Fax. (02) 9391 9101 www.health.nsw.gov.au This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the NSW Department of Health. NSW Department of Health 2009 SHPN: (SSD) 090178 ISBN: 978-1-74187-453-2 For further copies of this document please contact: Better Health Centre – Publications Warehouse PO Box 672 North Ryde BC, NSW 2113 Tel. (02) 9887 5450 Fax. (02) 9887 5452 Information Production and Distribution Tel. (02) 9391 9186 Fax. (02) 9391 9580 E-mail: bhc@nsccahs.nsw.gov.au Further copies of this document can be downloaded from the NSW Health website: www.health.nsw.gov.au A revision of this document is due in 2011. November 2009 - third edition
Children and Infants with Gastroenteritis -Acute Management - page 5
Contents Introduction ...............................................................................................3 Summary .....................................................................................................4 Significant Changes from 2002 CPG Version ......................................................... 4 Gastroenteritis in Infancy and Childhood..................................................5 Principles of Fluid Management ............................................................................. 6 Medications ........................................................................................................... 6 Differential Diagnoses ............................................................................................ 7 Table 1: Clinical Assessment of Dehydration and Initial Treatment.......................... 8 Management Algorithm ........................................................................................ 9 Enteral Rehydration Therapy ...................................................................10 Oral Rehydration Solutions (ORS) ......................................................................... 10 Method of Giving Oral Fluids ............................................................................... 12 Discharge Criteria .............................................................................................. 12 Nasogastric Rehydration Therapy ...........................................................13 Intravenous Fluid Therapy .......................................................................15 Introductory Notes .............................................................................................. 15 Resuscitation .............................................................................................. 15 Rapid IV Rehydration ........................................................................................... 16 Standard IV Rehydration ...................................................................................... 17 Hypernatraemia Hyponatraemia .............................................................................................. 19 .............................................................................................. 19 Investigations and Observations .............................................................20 Reintroduction of Diet ......................................................................................... 21 NSW HEALTH Infants and Children — Acute Management of Gastroenteritis PAGE 1
Children and Infants with Gastroenteritis -Acute Management - page 6
References ................................................................................................22 Bibliography .............................................................................................24 Appendices .............................................................................................29 Appendix One – Glossary ..................................................................................... 29 Appendix Two – IVT Composition ....................................................................................30 Appendix Three – Parent Oral Rehydration Documentation Form ......................... 31 Appendix Four – Parent Information .................................................................... 33 Appendix Five – Resources ................................................................................... 34 Appendix Six – Significant Changes From 2002 CPG Version ............................... 35 Appendix Seven – Alternative Calculation for Maintenance Fluids ........................ 35 Appendix Eight – Working Party Members ........................................................... 36 PAGE 2 NSW HEALTH Infants and Children — Acute Management of Gastroenteritis
Children and Infants with Gastroenteritis -Acute Management - page 7
Introduction These Guidelines are aimed at achieving the best possible paediatric care in all parts of the State. The document should not be seen as a stringent set of rules to be applied without the clinical input and discretion of the managing professionals. Each patient should be individually evaluated and a decision made as to appropriate management in order to achieve the best clinical outcome. The formal definition of clinical practice guidelines comes from the National Health and Medical Research Council: ‘Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.’ should be used as a guide, rather than as a complete authoritative statement of procedures to be followed in respect of each individual presentation. It does not replace the need for the application of clinical judgment to each individual presentation. This document represents basic clinical practice guidelines for the acute management of gastroenteritis in children and infants. Further information may be required in practice; suitable widely available resources are included as Appendix Five. Each Area Health Service is responsible for ensuring that local protocols based on these guidelines are developed. Area Health Services are also responsible for ensuring that all staff treating paediatric patients are educated in the use of the locally developed paediatric guidelines and protocols. In the interests of patient care it is critical that contemporaneous, accurate and complete documentation is maintained during the course of patient management from arrival to discharge. Parental anxiety should not be discounted: it is often of significance even if the child does not appear especially unwell. (National Health and Medical Research Council ‘A Guide to the Development, implementation and evaluation of Clinical Practice Guidelines’, Endorsed 16 November 1998, available from www.nhmrc.gov.au/publications/ synopses/cp30syn.htm) It should be noted that this document reflects what is currently regarded as a safe and appropriate approach to care. However, as in any clinical situation there may be factors which cannot be covered by a single set of guidelines. This document NSW HEALTH Infants and Children — Acute Management of Gastroenteritis PAGE 3
Children and Infants with Gastroenteritis -Acute Management - page 8
Summary Gastroenteritis is a common paediatric condition. Appropriate management attempts to avoid dehydration, but when this occurs appropriate fluid management is essential. For rehydration the enteral route is preferred, but if intravenous fluids are used then low sodium containing fluids must be avoided. For intravenous rehydration 0.9% Normal Saline (NaCl) + 2.5% Glucose is preferred. 0.9% Normal Saline (NaCl) + 5% Glucose may also be used. If rehydrating over 24 hours then 0.45% NaCl + 2.5% Glucose is an acceptable alternative. Oral rehydration solutions may be offered orally or administered nasogastrically. In cases of severe dehydration or clinical deterioration after admission or despite treatment, the Admitting Medical Officer in charge or consulting paediatrician should be notified and should personally review the patient as soon as possible. Where other medical staff act as a delegate for the Admitting Medical Officer, the hospital must have clear written protocols defining this arrangement. For hospitals employing junior medical staff: The Admitting Medical Officer MUST be notified within an hour of the decision to admit the child. Details of the physical findings and proposed fluid therapy should be discussed. Hospitals should have an internal policy that defines roles if senior registrars act as a delegate for the AMO. These Clinical Practice Guidelines should be read in conjunction with other relevant Clinical Practice Guidelines (e.g. the Recognition of a Sick Child in Emergency Departments, and Acute Management of Infants and Children with Acute Abdominal Pain). When dealing with children suspected of having gastroenteritis, it is essential that infection control measures be implemented to prevent cross-contamination and spread. PAGE 4 NSW HEALTH Infants and Children — Acute Management of Gastroenteritis
Children and Infants with Gastroenteritis -Acute Management - page 9
Gastroenteritis in Infancy and Childhood n This common acute intestinal communicable infection causes vomiting, diarrhoea and fever. It is usually viral, but sometimes bacterial or parasitic. Community outbreaks are sporadic and seasonal. A small proportion of those affected will suffer severe dehydration and electrolyte disturbance. Untreated or poorly treated dehydration may progress to shock and death. There are also risks from over-hydration and/or inappropriate electrolyte replacement, including death from cerebral oedema. Some other serious illnesses are sometimes incorrectly diagnosed as gastroenteritis. Warning signs of other diagnoses must be recognised and investigated (see page 7). n Availability of standard resuscitation intravenous fluids, including 0.9% NaCl (without added glucose) or Hartmann’s solution (without added glucose). Availability of rehydration intravenous fluids, including 0.9% NaCl + 2.5% Glucose, 0.45% NaCl + 2.5% Glucose. Intravenous paediatric giving sets with burettes, appropriate infusion pumps. Appropriate Oral Rehydration Solutions such as Gastrolyte®, Gastrolyte-R®, Repalyte®, Hydralyte® Appropriate giving sets and enteral infusion pumps (e.g. Kangaroo® pump). n n n n n n Availability of assistance when treating severely ill children n Suggested hospital requirements for management of children with gastroenteritis n 24-hour availability of nurses and medical practitioners experienced in the management of sick children. Access to 24-hour standard biochemistry for inpatient management. This may include point of care testing. The treatment of children with severe dehydration should be discussed with a paediatrician and consideration be given to transfer to a facility with a paediatric intensive care unit. For advice regarding the management of seriously ill children or to arrange their transfer to any of the children’s hospitals contact NSW Newborn and Paediatric Emergency Transport Service (NETS) Hotline number: 1300 36 2500. n n NSW HEALTH Infants and Children — Acute Management of Gastroenteritis PAGE 5
Children and Infants with Gastroenteritis -Acute Management - page 10
Calls to NETS are voice recorded and form part of the NETS medical record for the patient. n Suitable volumes should be offered: try to give about 0.5mL/kg every 5 minutes. Achieving successful oral rehydration demands constant attention and persistence, usually by parents. The principles and practice of oral replacement therapy are described on page 10. Intravenous rehydration is often a reasonable alternative for moderate dehydration (see Table 1 on page 8) and is essential where severe dehydration and/or shock are present. Children receiving fluid rehydration require regular timely reassessment. The principles and practice of intravenous replacement therapy are described on page 15. NB: Careful calculations of fluid volume and rate are required regardless of route of administration. n Principles of Fluid Management n n Infants and children with gastro- enteritis require additional fluids to prevent dehydration, or for rehydration. The enteral route is preferred for rehydration of children with mild or moderate dehydration. This is with an Oral Rehydration Solution (ORS) either by mouth or via nasogastric tube. Suitable fluids should be offered, for oral rehydration Babies who are breastfed should receive small frequent breastfeeds to ensure normal urine output. This may be supplemented with an ORS. For all other children, offer an ORS. Those requiring mixing must follow the manufacturer’s instructions. Do not add flavouring or sweet drinks to an ORS. – If an ORS is unavailable, or refused, dilute juice/lemonade (mixed as 1 part juice/lemonade with 4 parts water) can be used only if a child is not dehydrated. These are less desirable fluid options. – Do not use ‘sports drinks’ as they are not an appropriate rehydration fluid for children with gastroenteritis. – Do not use low-calorie or diet drinks. n n n n n n Medications There are no indications for using anti-motility or anti-diarrhoeal agents in the management of acute gastroenteritis in infants or children. Many antiemetic medications have a risk of significant side effects, like dystonic reactions and sedation, and should be avoided [e.g. promethazine, prochlorperazine]. Medications such as 5HT-3 receptor antagonists, such as ondansetron, may have some clinical benefit, however the evidence is not conclusive. Experienced clinicians choosing PAGE 6 NSW HEALTH Infants and Children — Acute Management of Gastroenteritis
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