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EDUCATIONAL INSIGHTS: Pearls from a Practicing Pediatrician - “Vomiting and Diarrhea – the Dreaded ‘Stomach Flu’”

Posted: Feb 19, 2020
Comments: 0
Author: UCA Admin

Content provided by Thomas W. Tryon, MD, MBA, FAAP; UCA Pediatric Section Chair

As parents, grandparents and caregivers for children, one of the most stressful illnesses in children is what is commonly called the “stomach flu” or viral gastroenteritis.  The “stomach flu” is actually not an influenza illness at all but is caused by a multitude of different viruses and can occur at all times during the year.  Those of you who follow news stories of Norwalk Virus (or norovirus) illness that is causing cruise ships to be quarantined, would recognize this as one of the viruses we know can cause gastroenteritis.  Gastroenteritis typically involves vomiting, diarrhea and can cause fever and stomach pain.  It is very contagious.  The treatment is generally supportive care. 

However, it seems every practitioner has a canned list of recommendations to give to patients and parents about how best to treat the vomiting, what works for diarrhea, and what is the best diet to recommend for a patient with an upset stomach and vomiting.  For example, for many years the BRAT diet (bananas, rice, applesauce and toast) was what we recommended to patients.  However, is that evidence-based?  Is that truly a diet that is helpful and improves outcomes of patients suffering from a gastrointestinal illness? 

Fortunately, the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) released an updated comprehensive review of acute gastroenteritis in 2014.  Their evidence-based review has been endorsed not only by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) but also by the American Academy of Pediatrics.  The worldwide experts define acute gastroenteritis as a diarrhea illness with more than three loose or liquid stools in a 24-hour period which may be accompanied with fever or vomiting.  This acute diarrhea can typically last up to 14 days. 

Here are some of the other recommendations from the 2014 guideline:

  • Oral rehydration using a hypo-osmolar solution (such as Pedialyte) is the most important treatment and should be started as soon as possible. 
  • Breastfeeding should not be interrupted.  As an aside, as a breastfeeding advocate who is married to a lactation consultant, it is important for breastfeeding mom’s who have a baby with vomiting or diarrhea to keep breastfeeding.  What we know about breastmilk is that it is the most easily digestible fluid, it contains 50-60 prebiotics (food for the good bacteria in the gut called probiotics) and it contains the perfect blend of nutrients needed by an infant or toddler fighting off a gastrointestinal illness.  It also is chock full of mom’s immunity.  Breastfeeding moms may need to shorten the length of each breastfeeding and breastfeed more often until the infant is well.  If the baby is not feeding well, make sure to pump to keep up your milk supply for when the baby is well.
  • There is no evidence that lactose-free feedings are necessary.  This means that if an infant is receiving cow’s milk formula there is no need to switch the baby to lactose-free formula.  If a breastfeeding mom is drinking milk or eating milk-containing products, there is no reason to change that diet.   
  • The use of the BRAT diet (bananas, rice, applesauce, toast) is no longer recommended.  What research has found is that this diet is too high in carbohydrates, may contribute to more diarrhea, and does not have the needed fat or protein dietary requirements.   Instead, regular feeding (what is termed “early refeeding”) should continue with no changes in the diet, including incorporating milk in the diet.
  • Specific probiotics may provide an effective intervention for diarrhea, specifically Lactobacillus GG and Saccharomyces boulardiiLactobacillus GG is found in many over the counter products, including Culturelle for Kids.   
  • For vomiting, ondansetron, a prescription medicine, has been shown to be effective at decreasing the intensity and number of vomiting episodes as well as improving success at oral rehydration 
  • The vast majority of gastroenteritis cases can be managed in an outpatient setting and do not require hospitalization.  This includes a much lower need for intravenous (IV) fluids, if the vomiting is stopped and if oral fluids are given early and often. 

Last, the experts also have recommendations on when a child with uncomplicated gastroenteritis would need to be evaluated by a healthcare provider:

  • Any infant under two months of age with acute gastroenteritis
  • Infants or children with severe underlying disease (such as kidney disease, diabetes, heart disease, or other chronic medical conditions)
  • Severe or persistent vomiting or pea green vomiting
  • High volume diarrhea of more than eight stools a day
  • Parents perception that their child appears to be dehydrated

I would add, especially for infants and toddlers, that the child should be evaluated if there is severe cramping abdominal pain especially with the child turning pale or white with the pain episodes.  This could indicate a concerning condition called intussusception.  Also, should any of the diarrhea turn black or bloody, have mucous in it along with the child running a fever, or if the diarrhea lasts more than two weeks, it would be prudent to have the infant or child evaluated by a healthcare professional.   

Finally, vomiting and diarrhea can often be one of the most stressful conditions in an infant or child to manage as a parent.  Often parents feel that they cannot help a child with vomiting or diarrhea feel better.  When in doubt or when concerned, reaching out to the infant or child’s primary healthcare provider or seeking evaluation in your friendly urgent care is a good idea.  Most of all, make sure everyone around the child, including Dr. Mom and Dr. Dad, is practicing good hand hygiene to keep from getting sick and spreading germs to others.

Best wishes for a happy and healthy Winter, 2020 and good luck avoiding all the respiratory illnesses and acute gastroenteritis illnesses.  Spring will be here before we know it.       


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