Tummy Bug Basics

 

By far most of the tummy bugs that people get resolve on their own. A tincture of time will usually take care of them. The typical symptoms are stomach aches, 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, an ear infection or even appendicitis. When the diarrhea comes along, the good news is that it usually signals that we can narrow our attention to some type of gastro-intestinal issue. The bad news of course is that when the patient is losing fluids from both ends, dehydration now becomes more of a concern. I also don’t want to minimize how miserable it is when you are in the full throes of an acute GI episode and don’t know whether to sit on the toilet or kneel at it.

How do they spread?

Viruses like the Norovirus or Rotovirus are spread in a variety of ways including

• Having direct contact with an infected person
• Consuming contaminated food or water. If an infected person is involved in preparing the food, tag, you’re it
• Touching contaminated surfaces and then putting your unwashed hands in your mouth. For parents of kids who are vomiting, be careful when you are cleaning up after them. This can easily go from family member to family member

For young babies

If your baby is under two 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 or adult.

Of course it is not always easy to know what's up with the little ones. Many babies spit up on a regular basis daily. Actual vomiting will usually have a larger volume and be more forceful. Baby poop can seem pretty liquid and diarrhea-like even when everything is perfectly normal.

It may be worth checking in with a doctor if the stool is copious, watery, and clear, there has been more than one episode of vomiting in a several hour period, and they are fussier than usual.

 If they are nursing well, and peeing fine, that is very reassuring, but if they are little and you are worried, go ahead and get them checked.

How to assess hydration

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 mouths feel 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.

Kids can actually look greenish. 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.

Home treatment is usually adequate

Frequent but tiny amounts of fluids is a remarkably effective approach. If you are breastfeeding, smaller, more frequent feeding will often be much easier for the baby to keep down. It is okay and even expected for the patient to have less of an appetite for food for a few days. Unless the person is extremely slender, we are not too worried about a bit of weight loss. Most folks will gain it right back up when this passes. Don’t stress about the food intake. Pushing food will likely just aggravate the situation if they aren’t hungry. 

Your job is to make sure that they are getting adequate fluids.

Start by giving clear fluids (breast milk is great 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 is the classic brand that has been around for many years. They have significantly improved the taste over the years. It used to taste like soap.

The exercise drinks like Gatorade are another option but have more sugar than the Pedialyte. Pedialyte is one of the products that is worth keeping on hand so that you are prepared if a tummy bug strikes. It also comes in popsicle form which is great for older kids, as well as a little tube of powder that you mix yourself. 

I actually suggest that it makes a great addition to any travel emergency kit. 

I don’t have any hard and fast rules about fluid amounts. Electrolytes are the better choice, but you have to do the best you can if they simply refuse those. Try some diluted juice, coconut water, ginger ale, or colas that have lost some of the fizz. Whatever they are agreeing to drink, wait a bit after they have thrown up before offering anything. There is nothing exact about the timing. I generally try to wait 30 minutes after they vomit before giving anything. Many folks tell you to wait longer than that. But, if they are begging you for sips, go ahead and offer something.

Think of a drip irrigation system. If 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. Plus, if someone is busting your chops for a cracker, a nibble of a saltine may actually feel a bit soothing. If the worst comes to worst, and you move too fast, they will just throw up again and you will know that you need to wait a bit longer before offering the next sip or nibble.

Don’t let them guzzle. Stick with an ounce at a time. If you have a tiny tea set, or a fancy shot glass, those are fun ways to measure small amounts. You can have a star chart for the reluctant drinkers.

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

Generally, vomiting is the first thing to ease. If they remain nauseated, there is a magic pill called Zofran. This is an effective but strong medication. Most doctors would like to do a quick evaluation prior to prescribing this, to make sure they are not ignoring an underlying cause that needs treatment.

Time to get evaluated

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, not just yellow) that is another signal that their tank is really empty and they need a little help turning things around. These are the kids that are significantly low energy.

If the child is truly lethargic (can’t be roused for more than a couple seconds) and you have been attempting small amounts of fluids and failing, then a trip to the emergency room is appropriate. Once there, your child may get some IV fluids which will often perk them right up.

For adults, just google mobile IV services to see if you live in an area where that is available. If you know you simply need fluids, this is a great way to avoid a trip to the emergency room. If you don’t know what is going on, it is worth seeing an MD

Recovery and advancing the diet

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 crave the foods that their bodies can handle. If you have an outlier asking for a hotdog, follow your instincts and say no.

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). There are plenty of dairy alternatives

In my experience, getting started with probiotics right away is the key to getting over this quickly. Fermented foods are also very beneficial but not in lieu of the probiotics. 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. Jarro is usually easily available at Whole Foods and has a baby formulation.

One of the most common calls to the doctor’s office after a tummy bug is when a patient seemed like they were improving and seemed to 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. See Dr. Ted’s tidbits below for an explanation about this.

What if it isn’t a virus?

It could be bacterial. If you or your child has a fever, chills, bloody diarrhea and vomiting, that could be bacterial food poisoning. The most common culprits are Salmonella, Shigella and Campylobacter. Sometimes the symptoms might not show up for a few days, making it hard to identify the source.

Even though many of those illnesses are self limiting, getting seen is a good idea. Your doctor may send a stool sample to the lab to check for a bacterial stool culture. There are usually special containers required for this. 

It could be Parasitic.

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. Even if you haven’t been around any obvious sources, if you have a pet with loose poops, that can be an important clue. Dogs can get it from drinking nasty water and then can spread it to their humans.

Dr. Ted’s Tidbit

The intestines can take a long time to recover after an infection. It’s important to understand that vomiting or diarrhea after recovering from a tummy bug are not necessarily signs that the infection is still active. Up to one third of patients will have weeks of irritable bowel symptoms after recovering from bacterial gastroenteritis. Many symptoms after recovery from a tummy bug can be explained by understanding the physiology of the intestines. The intestines represent your largest internal organ and demand a ton of cellular energy. Often-times, the entire internal lining can be significantly damaged after a tummy bug. In the weeks it takes to repair all that lining, patients can feel unbelievably drained because of the energy required to create new cells. They also may lack the enzyme lactase, which sits in the walls of the cells that line the intestines and can be lost after infection. That may cause new symptoms of lactose intolerance, diarrhea, bloating, or even vomiting or reflux after having dairy or other large meals. If you’re experiencing symptoms after recovering from gastroenteritis, stick with Nurse Judy’s advice and eat small, easy to digest foods.

Extra discussion points

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

• While it is quite normal to lose a little bit of weight, getting a baseline and monitoring recovery is important.

• Any steady abdominal pain that is lasting more than several hours should be evaluated.

• The issues I have talked about in this post are acute. This means they are generally short lived.

Chronic intestinal issues should not be ignored. Many times general tummy pain is from constipation. Gas pains tend to be sharp and intermittent. Start keeping track. When and if you do see a doctor this data will be valuable:

• Where is the discomfort?
• How severe?
• Does it get better or worse with food?
• Did it go away on its own?
• If not, what did you try?
• How often are the poop? Are they hard or soft?