Tummy Bug Basics
Norovirus is making the rounds. Dr Ted and I decided that this is a good time to update our tummy bug post from a couple years ago.
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 Rotavirus 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
Note: A swipe of hand sanitizer isn’t going to help all that much. It doesn’t kill these viruses. For handwashing, you need soap and water. For surfaces you need something that contains bleach.
For young babies
If your baby is under two months old and you suspect that they have a tummy bug, it is important 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.
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 only job is to make sure that they are getting adequate fluids.
Dr. Ted reminds us that children can technically go seven days without a bite of solid food before it’s medically a problem. You just need fluids with electrolytes to survive. Start by giving clear fluids (breast milk is great if you have it.) Because we lose lots of those 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 (but works if it’s all they’ll take). 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 believe 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 (Tylenol/Advil 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. That is a signal that their tank is really empty and they need help turning things around. These are the kids that are significantly low energy. It is worth remembering, however, that most doctor’s offices don’t do IVs.
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, or if they are vomiting up blood, or anything that looks like copious coffee grounds, or bile (bright green, not just yellow) 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. Dr. Ted observes that the younger the child, the longer the stools tend to remain loose. 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 can be helpful in getting over this quickly. Fermented foods are also very beneficial when they can handle them. 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 E. Coli, 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. If testing is positive, doctors are mandated to report these diseases to Centers for Public Health (so that outbreaks can be tracked). 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 with bloating, 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. The damaged intestinal walls also may lack the enzyme lactase, which typically 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.
Most of the things we discussed above can be considered acute issues. Ultimately with time or appropriate treatment they will be relegated to just a bad memory.
When you don’t find an answer and the symptoms continue to be an issue, I would no longer consider it to be acute.
Chronic intestinal issues should not be ignored. Many times general tummy pain in an otherwise healthy child 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 long has this been going on?
Do other family members seem to be impacted?
How severe are the symptoms?
Does it get better or worse with food?
Does it come and go away on its own?
If not, what did you try the may have helped?
How often are the poop? Are they hard or soft?
If you’re in the mood for it here are the poop puns
Many years ago when I was working at Noe Valley Pediatrics, Norovirus was out in force and was making headlines.
One of our patients' moms was a reporter on a local news station. She wanted to interview one of the providers about what we were seeing. I cajoled the doctors to no avail and ended up being the only one willing to be on camera.
Later that day I did a little facebook post letting folks know that they might get a glimpse of me on television.
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My facebook post took an unexpected turn.
My family can’t pass up a good opportunity to make puns and they jumped right in.
They were joined by an assortment of friends and family. The thread comes up on my facebook memories every once in a while.
If you are one of the unfortunate folks who is trying to decide between sitting on the toilet or kneeling by it or is busy cleaning up someone else’s poop or puke,I am going to attempt the challenge of giving you something to laugh about.
Judy: I had 30 seconds of fame on the local news….talking about poop
Several friends asked for the link and then the puns started to roll in
Lauren ( my oldest daughter): mom, i believe it is your doody to share this link with us
Lena (my niece):Bahahah.
Judy: well, number #1, I don't have the link yet and number# 2 Lauren, do you really want to go down that road??
Alana (youngest daughter): Awww shit. More puns?
Sandy (my partner):I almost fell off my stool!
Lena: Impressive dedication to defecation!
Alana: Now you're just talking crap, daddy
Aza( Alana’s friend) You guys…just can it
Alana: Oh come on, we’re just getting loose
Sandy: Well, this is a well formed discussion, but it does occasionally get a little loose
Emily (friend of Alana) Alana invited me to come join the potty, so I figured I’d dump everything else
Lauren: There are so many crappy puns floating around enema head, I don’t think I could flush them out if I tried
Anya (Alana’s friend): Well lookie-loo what do we have here? Do I need your permission toilet me join in the fun?
Sandy: I wish I had a pun to add to this, but I feel like I’m constipated
Anya: Well maybe you need to try some re-laxative breathing
Lauren: I just hope these puns don’t get too corny, because you know they’ll stay that way for days
Anya: Don’t make me Crohn
Lauren: You know, intestine me with your puns, you’re making me want to keep going, but for everyone’s sake we should take some time to digest what just happened on Judy’s wall. Log it away as a complete waste of time...and just stop and enjoy this video
And with that I bid you a-doo
Anya: You’re correctum, I should probably get back to anal-lizing my homework. Toot-eloo
Judy: I feel like I must apologize to the innocent original folks who commented on my status without knowing what they were in for
Anita (one of my best friends): Wow, I’m impressed by all the really good puns. I can’t seem to pinch one out myself
Aunt Millie: Well, my thoughts on this. DEPENDS on a myriad of…. SO proud of my family!
Lena: It’s a very odd thing to be proud of, but I have to agree. I may or may not be posting a screenshot of this to Reddit. And when I changed people’s names to protect the innocent, Alana may have become cousin #2…sorry
Laurie P (a friend of mine): This has got to be way more entertaining than the orig-anal airing
Sandy: Enough of this, I’m pooped
Lena: I thought I had a good pun to add here, but it seems to have been wiped from my memory
Jim (my Brother in Law): I’ve been straining all morning to come up with a pun to add to this thread, but it’s just not happening right now
Amy (my sister): I too have the urge to contribute to this pile but I’ve got nothing…besides this conversion is becoming ab-turd
Judy: I thought you were al colon it quits but these puns keep coming
Aunt Millie: Ha, this is becoming fumier and fumier, tee-hee to the French
Jeannie (an old friend from nursing school): I’d still like to see the original news clip to see if it is as funny as all of the comments
And over the years when it came back as a facebook memory it still gets a few random comments
Lena: Are we all going to start droppings in here again?
Judy: I was looking for this link to show to my Oath team, time to wipe it off
Alana: Just a reminder that this exists
Sandy: Alana, you little turd, you had to bring this up again?
Kenna sera: #1 I still never got to see the clip and #2, I’m genuinely impressed by the puns and the effort
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And there you have it. Can you think of another pun that didn’t make it to the list?
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