Friday, September 11, 2015

Tummy bugs 101/dealing with diarrhea and Vomiting

This is an update of the post from 3/13
By far most of the tummy bugs that we see are caused by a virus. Time will generally take care of these. The typical symptoms are vomiting, loose stools and sometimes fever. Not everyone has every symptom. Vomiting without the loose stools could also indicate something else going on, like strep throat, a urinary tract infection or an ear infection. When the diarrhea comes along, it usually signals that we can narrow our attention to  some type of tummy issue. The problem with the patient losing fluids from both ends, besides being miserable, is that dehydration now becomes more of a concern.

Your main focus is to keep the patient hydrated. It is okay and even expected for them to have less of an appetite for a few days. Unless they are extremely slender,  we are not too worried if they lose a bit of weight. They will fatten right back up when this passes. Don’t stress about the food intake. Pushing food will likely just prolong things. We just need to make sure that they are getting adequate fluids.

Start by  giving  clear fluids (breast milk is also perfect if you have it.) Because we lose lots of electrolytes when we vomit or have diarrhea, it is best to replace the fluids with something that replaces the electrolytes as well. Water is not your best choice.
There are products on the market that are specially formulated for this purpose.
Pedialyte has been around for quite a while. There are pedialyte popsicles that are terrific for older kids. Regular pedialyte has always tasted a bit like soap, but they are trying to remedy that. If you can get your child to take it, consider yourself lucky. There is also  product out there called Drip Drop that tastes a little better. Coconut water is another fine choice. Consider keeping some of these products on hand so that you are prepared if a tummy bug strikes.

I don’t have any hard and fast rules. Do the best you can to get some type of fluids in them. Electrolytes are nice, but you have to do the best you can if they refuse those. See  if diluted juice, ginger ale, or colas that have lost some of the fizz are better accepted.
Whatever they are agreeing to drink, I typically wait at least  ten minutes after they have thrown up before I offer anything to eat or drink. Think of a drip irrigation system. Sometimes all you can get in there is a dropper full. That’s okay, get that fluid in, drop by drop, ice chip by ice chip. Do the best you can.

If you are breast feeding, don’t let them have too much at a time. If they overdo it they will likely keep barfing (like my medical lingo?) Please note, so that you don’t freak out, right before someone is going to vomit, it is normal for them to look quite miserable. Some kids get very pale and shaky. Some folks actually look greenish. Once they throw up, most of the time they feel a bit better and the color normalizes.

If your child has an elevated temperature as part of this illness, a tepid bath can help get the fever down. If the bath hasn’t done the trick, the fever is over 101, and your child is miserable it is worth giving some fever reducing medicine. Ibuprofen tends to be a bit harder on the stomach so I would choose acetaminophen (Tylenol) when I have an illness that includes tummy symptoms. Another advantage to the Tylenol is that it comes in suppository form, so it is more easily tolerated by a vomiting kid.  Dosage chart

If your child is running around and has good energy  I am usually  not too concerned. There is a big difference between subdued and lethargic. Some kids are well hydrated  but still feel lousy and are quieter than usual. We can call them subdued. If you have a kid with big juicy tears and lots of drool, they are probably not terribly dehydrated. The body doesn’t waste the fluid.

On the other hand, a dehydrated child is lethargic. They do not want to play. The urine is more concentrated (darker and smellier) and way less frequent. Their mouth feels dry. Their breath might be stinky (of course if they have been vomiting that is probably a given.) Their skin may be dry. Normally if you pinch up a bit of skin on the wrist, it will immediately correct itself. If someone is dry, it may remain up in the pinch for a moment.
If they are refusing fluids or can't keep down anything, you need to check in with your doctor’s office. If they are vomiting up bile ( bright green) that is another signal that their tank is really on empty and they need a little help turning things around. These are the kids that sometimes get carried into our office draped over their parent’s shoulder.

If I am giving phone advice, I am usually going to skip the office visit.  If we are concerned that you are not able to win the hydration battle then a trip to the emergency room is appropriate. Once there your child may get some IV fluids which often perk them right up.

Most of the time the ER is not necessary. Frequent but tiny amounts of fluids is a remarkably effective approach. Generally the vomiting is the first thing to ease. Once your child has started keeping down fluids, it is okay to advance the diet if they are interested in food. More often than not, we expect the stools to continue to be looser than normal for a bit longer. Trust your kids to some extent. I find that most of the time they accept foods that their bodies can handle. (Just in case, ignore the request for pepperoni pizza for a few days.)

Bland starchy foods are your best bet. I suggest a modified BRAT diet. Bananas, rice, applesauce, crackers, toast, potato, pasta, boiled chicken and watermelon are all okay.
I find that folks have a quicker time getting over this if they avoid dairy (some folks can stay on yogurt and tolerate that fine.)

In my experience, getting started with probiotics right away is the key to getting over this quickly. We need to get the gut healthy again so that it can tolerate a normal diet and the good bacteria in the probiotics is critical to this.

There are plenty of good brands out there. One of my favorites is Florajen for kids which you can get from the Noe Valley or Diamond Heights Walgreen’s.  It is kept in the back in the refrigerator, but there is no prescription needed. Baby Jarro Dophilus  (Whole Foods or health food stores) is another brand that we have had success with. If you have a trusted brand on hand, it is fine to stick with that.

One of the most common calls to our advice nurse team is when a patient seemed like they were improving and have had a bit of a relapse. This is usually caused by advancing the diet a little too quickly (especially dairy.) You may need them dairy free for a week before things return to normal. Yes, this includes cheese....

If your child is keeping food down but has loose stools, I have had great success using  the Similac expert care for Diarrhea (it used to be called Isomil DF) The Walgreen’s in Noe Valley and Diamond Heights try to keep this in stock for me. You may need to ask the pharmacist if you don’t see it on the shelves. It is ready to feed and doesn't not need to be mixed or diluted. Google shop has been another source when it is hard to find. For older kids,  I still  use this soy based formula as the base for a smoothie:
    -    Similac DF
    -    Banana
    -    Frozen yogurt (if not tolerating dairy, find a non dairy alternative)
Mix the ingredients in a blender. This smoothie is usually easily accepted, well tolerated and helps form up the stool. Watch out that it doesn’t do too good of a job and you are all stopped up.

If your baby is under 2 months old and you suspect that they have a tummy bug, we will want to monitor them closely. Young babies can get dehydrated much more easily than a larger child.

Of course it is not always easy to know what's up. Many babies spit up on a regular basis daily and normal baby poop is very liquidy. But, if you are worried, they are spitting up more than normal and have increased fussiness I will likely get them in to be seen. For a young infant,  watery/clear stool would also get my antenna up. With a dehydrated infant, the fontanel (soft spot) may appear more sunken, and they will be way sleepier or fussier than usual.  If they are nursing well, and peeing fine that is very reassuring.

If you or your child has fever, chills, bloody diarrhea and vomiting,  that could be food poisoning. The most common culprits are Salmonella, Shigella and Campylobacter.

Even though many of those illnesses are self limiting, getting seen is a good idea. We may send a stool sample to the lab to check for a bacterial stool culture. There are special containers required for this. You can get those from the office or the lab. Mom or dad, it is your job to get the poop into the specimen container (thank you for your understanding.)

If you or your child are just back from travel or camping and have awful gassy, incredibly stinky stools, we should make sure that you don’t have giardia or some other parasite.
If that is a possibility, we would send another type of stool sample to the lab that requires a different set of specialized containers. This is called an O&P (ova and parasites.) As opposed to many of the other tummy issues, these do not usually resolve without help of some medication.

Many times tummy pain is from constipation (http://nursejudynvp.blogspot.constipation)
Gas pains tend to be sharp and intermittent. Any steady abdominal pain that is lasting more than several hours should be evaluated.

With anything poop related, often defense is your best offense. Wash your hands!!!

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