The Mundane Epidemic

The big medical news recenlty is either about Influenza (the “flu” you get a flu shot for), or measles, which has had recent national outbreaks in undervaccinated communities.  However, we’re also having a local outbreak of “stomach virus”.  Though it’s certainly a more pedestrian illness than measles or influenza, try telling that to the parents of kids who re-enact the pie-eating-contest-vomit-fest from the movie Stand By Me.

Vomiting is distressing.  It’s just plain disgusting, and many parents get nauseated themselves at the sight.  And they have to clean it up!  Nausea and vomiting are miserable for kids too- it feels lousy.  Parents often have a more profound worry- what if he won’t stop vomiting and gets dehydrated?  That’s when they come to the Emergency Department.

Most vomiting lasts only a half day or so.  However, parents often panic at the first vomit: it seems like so much!  In their disgust, they overestimate the actual volume, seeing the kid from that movie spewing gallons of blueberry smush.  Then after a few more vomits, parents worry about intake, and push too much liquid, or worse, food.  This taxes the stomach, and more yakking ensues.

However, kids do have some reserve; there’s time to work this out.  After vomiting, wait an hour for the stomach to settle.  Then start small amounts of fluids like pedialyte, sports drinks, or dilute juices.  This means just an ounce or two.  Wait a half hour, then give another few ounces.  Then another.  When those little bits are staying down, then gradually increase the volume.  Your child may start begging for more as she starts to feel better, but be strong and be patient- better to hold down a little than throw up a lot.

This method, called Oral Rehydration Therapy, is one of the greatest medical inventions.  It seems simple, but before ORT, the pediatric death rate from third world cholera and dysentery epidemics was astounding.  These are much more violent infections than their benign American counterparts, and doctors were amazed how many kids could “feed through” these illnesses without needing expensive and scarce IV treatment.

My family is fortunate that we haven’t had many stomach viruses.  One time we did we were vacationing in New Mexico, and my wife and I had gotten a babysitter to go out to dinner.  When we got back, the babysitter looked like hell, having cleaned up vomit from our two daughters. Only our son seemed unaffected.  I went to tuck him in, and there he was with the covers pulled up to his chin.  “Dad, I hate to tell you this,” he piped in his 8 year-old voice, smiling sheepishly, “but I just had diarrhea.”  In the bed.

Parents are grossed out by diarrhea, just like with the vomiting we discussed above.  It can also be accompanied by painful cramps.  And like with vomiting, parents start to worry about dehydration, particularly when they feed the kid some fluids or food, and it seems to pour right out the back end.

Kids typically absorb enough fluids to get by though, even if it seems to run right through.  In fact, the quickest way to get your child better is get them on their regular diet as soon as possible.  They won’t feel like eating much at first, so like with vomiting, start with fluids like pedialyte for babies, sports drinks or dilute juices for older kids.  No full strength fruit juice- that sugar load can act like a laxative, and make diarrhea worse.

When your child can eat, back to their regular diet.  A generation ago we were told not to give milk with diarrhea, but now the thinking is when you’re eating your regular food, including milk and yogurt, your guts get “back in balance.”  No heavy, greasy foods like fast foods though, whose fat loads can also worsen diarrhea.

The best treatment for stomach viruses is prevention. Kids contract these bugs by putting contaminated fingers in their mouths (don’t go “ew,” you do too!).  Thus they should wash their hands before eating and after using the bathroom. If your child vomits more than 12 hours, or has diarrhea for more than 4 days, call your doctor for medicine that can stop vomiting.  Unfortunately, there’s not great medicine for diarrhea.  Pepto-bismol or Imodium may slow it down some, or help with the cramps, but they’re not miracle cures.  Typically you just need to….let it pass.

Water Works

This week’s guest columnist is Dr. Meighan Anderson, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

8 year-old Ted finished his last baseball game of the season.  To celebrate, mom and dad took the family to the new burger bar in town.  Ted picked the biggest burger on the menu, his attempts to devour it leaving everyone in stitches.  Dad thought the meat looked a little too pink, but didn’t want to interrupt the good time- it was probably fine.  Later back home, Ted yells from the bathroom: “It’s coming out like water!”  Then comes the sound of vomiting.

Diarrhea and vomiting are difficult topics for parents, because they’re gross, and it’s sometimes hard for parents to know when to worry.  It’s a big mess when it happens and they just want it over!  But the real questions are- does he need to go to the doctor?  Is this a stomach virus that will get better on it’s own, or something worse?  When will it end?  When do I worry about dehydration?

We see a lot of kids in the Emergency Department who, when they have one or two vomits or diarrheas, are rushed right in.  Then as the parent goes on about how sick their child is, the kid is dashing about the room, opening the drawers and jiggling the bed controls.  In fact, these are good signs that the child doesn’t have something bad, like a blockage, or appendicitis, or dehydration- walking, talking, and playing.  If the child is not eating, but is drinking, that’s another good sign.  Kids who make wet diapers and urinate, even if only once or twice per day, or make tears when they cry, are getting enough fluids to not worry about dehydration either.

Here’s the worrisome signs that your child needs to get seen- diarrhea with lots of blood, abdominal pain so bad they cry, and non-stop vomiting, like for hours and hours.  Finally, if kids are so lethargic that they have trouble staying awake, or even sitting up, you need to talk to a doctor.  These could be symptoms of worse things than a run-of-the-mill stomach bug, like appendicitis, blockages, severe infections, or serious dehydration.

Back to our story of Ted from above, having vomiting and diarrhea after eating undercooked hamburger.  He continued to vomit all night, into the next day, with diarrhea.  By the afternoon he’s looking like a limp dishrag- tired, pale, and sleeping a lot.  He also looks grey and sunken around the eyes.  TIme to visit the Emergency Department.

Dehydration is the most serious complication of vomiting and diarrhea.  Diarrhea alone usually doesn’t do it- if children drink and hold fluids down, dehydration is unusual.  Some parents worry that fluids are “running right through” a kid who drinks and then immediately has diarrhea.  However, kids typically absorb enough to get by.  “Feed through” diarrhea is the rule: keep it coming from the top, even if it seems to come right out the bottom.

However, if the child is also vomiting, or not drinking, dehydration is a worry.  Ted is showing us the signs- worsening fatigue, pallor and sunken eyes.  If he doesn’t make urine for 8-12 hours, that’s another clue that he needs to come in for IV fluids.

The best way to avoid dehydration is drinking clear liquids.  Fluids that contain some sugar and salt are most efficiently absorbed- sports drinks, or pedialyte for babies.  But don’t use full-strength fruit juices- they can worsen diarrhea.  To avoid vomiting, start with small amounts of fluid, to not challenge the stomach too much.  Give babies just a few ounces, older kids a half cup.  If that stays down after a half hour, give another little bit.  After a few hours where small amounts are staying down, you can give larger amounts.  Then about 6-8 hours after not vomiting, you can try bland starchy foods- rice, toast, crackers, bananas; nothing heavy like burgers, fries, or nuggets.

Your doctor can also prescribe Zofran over the phone, a medicine which can stop nausea and vomiting before it gets too far.  Antibiotics don’t help, and may worsen diarrhea.  They’re used only when tests on the stool indicate.

But if your kid is walking, smiling, and peeing, he’s not dehydrated.  Soon his body will shut off the Water Works, and the mess will finally end! 

Explosive Babies

This week’s guest columnists are Drs. Elizabeth Hunter and Alex Wolf, Family Practice residents at the University Hospital and Clinics here in Lafayette.

“Oh no, another one?” exclaimed mom as she inspected Jamie, her one year-old’s, diaper.  It was full to the brim and smelled horrendous, and this was the third since noon! It was 5:30 pm, the doctor’s office already closed. “What do I do now?”

This had never happened before.  Jamie was never sick. Mom looked up ”child with diarrhea” on the internet, tried to read the articles, but felt overwhelmed. However, Jamie, giggling and toddling around with her sippy cup, seemed to be taking it well. Mom wondered: What caused this?  Is she dehydrated?  Should I take her to the ER?

It’s a common parent scenario- your child’s pants explode and you begin to worry. Fortunately, most kids with diarrhea do well at home.  Step one, evaluate your child.  Is he playful, or at least awake and active?  Is he drinking? Is the inside of his mouth moist? If so, there’s little danger of dehydrating.

If however, she becomes progressively more sluggish through the day, starts vomiting, or begins to drink less and less, it’s time to call your doctor.  While making urine is the best sign that baby isn’t dehydrated, sometimes there’s so much watery diarrhea in the diaper that you can’t tell if there’s pee or not.  You have to go by those other signs.

Most diarrhea is caused by viruses caught from other kids, though too much fruit juice, antibiotics, or other infections can cause it too. Treating diarrhea is easy- keep the fluids coming, and food too.  If food and liquids look like their just running through baby and out the back end, keep it coming.  She will absorb enough fluids and nutrients to get by.  The slogan these days is “feed through” diarrhea.  Starchy foods are best- bananas, rice, toast.  Stay away from high sugar drinks like soda or fruit juice- these make for more acidy diarrhea, which makes diaper rashes worse.

You’re awakened in the early morning by a new sound: a gurgling from one of the kid’s bedrooms.  You rush in, flip on the light, and are greeted by the sight of a vomit-filled bed. Yuck!  While this is certainly a mess to clean up, more important worries crop up.  Is this just a stomach bug, or something worse?

Vomiting is an important protective mechanism, expelling toxins before they have a chance to harm us internally.  However, viruses often cause inappropriate vomiting. Rather than evacuating the virus, the virus uses vomiting to spread throughout the environment.  Like out of your child into her bed, potentially infecting you and your other kids.

When do you need the Emergency Department, when can you stay home?  Most kids who only have a few bouts stay hydrated.  What’s too much? Vomiting for more than 12 hours in a baby is worrisome.  For children between one and two years, 24 hours is getting too long; 48 hours for older kids.

It’s also concerning when your child stops drinking between bouts and becomes more lethargic- sleeping for longer periods and harder to arouse.  If he hasn’t urinated for more than 12 hours, it’s time to get seen.

While vomiting is usually viral and is over in a day, sometimes it’s a sign of worse trouble. If baby vomits dark green, that’s concerning for bowel obstruction, go in right away.  If she’s having bad pain, especially in the lower right side of her belly, that could be appendicitis.  If a baby under six month’s old has projectile vomiting, meaning vomit sailing clear out of the bed, that could be stomach blockage needing surgery.

Otherwise, vomiting can be treated at home.  After your child vomits, rest the stomach for an hour before letting him drink.  Then start with only small amounts of clear liquid.  Water is okay for older kids, but babies and toddlers do better with drinks like pedialyte, or low-sugar sports drinks like Gatorade G2.  Half a cup is plenty at first- if you give too much, it may push the stomach to vomit again.  You can switch to larger amounts later when the vomiting has stopped.

Don’t worry about food. Few children starve during vomiting.  Your child can go days without eating, so don’t panic when she doesn’t have an appetite- she won’t waste away within a few days!

When Vacation Follows You Home

This week’s guest columnists are Drs. Michael Johnson and Sam Defigarelli, Family Practice residents at the University Hospital and Clinics here in Lafayette.

The family returns from a cruise ship holiday in the Caribbean.  Everyone, including 10 year-old Gavin, had a blast.  He loved snorkeling, going down the waterslide on the ship, and even the exotic food at ports-of-call.  But even before the bags are unpacked at home, he says “Uh-Oh!” and runs to the bathroom, just in time for the watery explosion from below.

Traveler’s Diarrhea is a condition that develops soon after returning from trips to resource-limited countries.  Gavin has three potential whammies in his scenario.  These countries often don’t have sewage treatment, and snorkeling is a potential contact with contaminated run-off.  Cruise ships and water-parks are known risks for catching diarrhea.  And improperly prepared food could make him sick as well.

The biggest concern with diarrhea is dehydration.  Most only have a day or two of loose stools, but some also have nausea, vomiting, cramps, fever, or bloody stools.  When there’s lots of vomiting and diarrhea and worries about dehydration, kids should get seen.

Most kids only need home treatment- plenty of clear fluids like pedialyte for infants, sports drinks or dilute juices for older kids.  Avoid full strength fruit juices- these can worsen diarrhea.  For copious diarrhea, rehydration solution packets are available at pharmacies, to mix with clean water.  If kids aren’t having cramps, nausea, or vomiting, they can eat and have milk.  Bland starchy foods are best- fast food and other heavy greasy food can prolong symptoms.  We say ”feed through diarrhea;” don’t restrict food if they’re hungry!  The sooner they eat, the sooner their guts get back in balance.

You’ll want to control the spread of infection to you and your family, so that you aren’t cleaning up after multiple kids and feeling rotten yourself- a total nightmare!  Wash your hands frequently with soap and water- better than hand sanitizers.  Make sure kids aren’t touching or drinking after each other.

Prevention while traveling is even better.  Only drink from unopened bottles.  Avoid ice- it could be made with contaminated water.  Eat food served hot, and avoid salads (ingredients washed how?).  And parents, alcohol won’t reliably sterilize water or ice, so avoid having your cold one on the rocks.

Here is a different scenario than above. It’s June, the annual family reunion picnic, with all the aunts, uncles, and cousins . The grills are going and the sides have been put out: coleslaw, potato salad, macaroni salad.  There is a lot going on: pick-up football, pets running about, tables knocked over, umbrellas and chairs being set up, conversations all around.  The hamburgers are late getting on the grill and the sides have sat in the sun.  Everyone’s hungry so the burgers are a little under-done, but so what?

Any dangerous situations in this story?  It’ not the football- it’s the mayonnaise-based sides warming in the sun, incubating bacteria like Staphylococcus.  And undercooked hamburger can contain E. coli, a potentially disastrous infection.

Food poisoning is all too common in children.  Usually it’s just some diarrhea for a day or two and maybe some vomiting if your unlucky.  However, food poisoning with certain bacteria can have worse consequences.  Staphylococcus (a.k.a.”Staph”) often has a quick onset, within hours of ingestion, and can lead to dehydration and fatigue, especially in younger children.  There are many strains of E. coli too, the worst of which can lead to Hemolytic Uremic Syndrome, a deadly disease involving kidney failure and coma.

Treatment of these bacteria infections isn’t just giving antibiotics.  In fact, sometimes antibiotics can make the symptoms worse.  There’s no treatment besides fluids and rest, and for the really sick kids, hospitalization.  So better to prevent infections than have them!

Safe food handling is paramount.  Always cook meat thoroughly, particularly ground meat.  Be careful of your meat source- meat from a single farm, ground in the store, is much safer than meat from multiple feed lots, pre-ground and packaged when it gets to the store.  Never leave mayonnaise-containing food unrefrigerated for more than one hour.  Be sure to wash vegetables and fruits thoroughly- they might be from fields fertilized with manure that contains E. coli.

So be careful when you travel, and when you cook at home.  An ounce of prevention is worth several pounds of diarrhea, when vacation follows you home!



Running With The Runs

Today’s guest columnist is Dr. Jamie Collins, a Family Practice resident at the University Health Center here in Lafayette.

It was the start of a great day for Kevin.  It was Saturday and no school and no homework.  However, Kevin’s mom was on a mission to find a new couch for the living room and as a result, Kevin and his brothers were dragged from one furniture store to another.  At their last stop of the day, Kevin felt an uncomfortable stirring in his stomach, followed by watery sounds from below.  His mother told him to get off the couch he was sitting on, but too late. His pants erupted in a gurgling roar.

Diarrhea is one of the most common reasons children are brought to the doctor.  Children get diarrhea more often than adults.  Diarrhea is the body’s way of ridding itself of germs, and most episodes last from a few days to a week.  Diarrhea is defined as more stools than usual and more watery than usual.  The usual amount for infants is about 3 to 10 stools per day.  Breast fed infants have more and looser stool than formula-fed infants. Some infants can go 3-4 days without stooling, and that can be normal too.  Toddlers and older children usually go once or twice daily.  So if your breast-fed baby is having six watery stools per day, that’s not diarrhea, that’s normal!

The consistency and color of a child’s stool changes with age, and most color changes are normal.  Brown, yellow, green- all normal.  Diet changes can change the consistency.  Too much fruit juice makes for looser stools.  Stools that are all watery or full of mucus- that is not normal.  And white, bloody, or coal-black stools are not normal.

The most common cause of diarrhea in kids is infection from a virus, like rotavirus.  Other organisms such as salmonella or giardia, can cause diarrhea too.  Most diarrhea lasts from 3 to 14 days, and often comes with vomiting, stomach ache, headache, and fever.

The biggest concern about diarrhea is dehydration, which makes it important to keep your kid drinking.  For infants, keep the breast milk or formula coming.  It was once said that milk makes diarrhea worse.  However, it turns out that the sooner infants and children are on their milk and regular diet, the sooner they get better.  Today’s recommendation is to “feed through” diarrhea.  If it looks like what you are putting in the top is coming out the bottom, keep it coming!  Your child will absorb enough fluids and nutrients to get by.

If your baby is too ill to drink milk, then an oral hydration solution such as pedialyte or infalyte will help supply the fluids and electrolytes that are lost from diarrhea.  Older children can drink any clear liquid they like.  Popsicles are a good way to get fluids into a child who has been vomiting and needs to rehydrate slowly.

Here are things that make diarrhea worse: Drinking too much sugary fruit juice.  If your child will only drink juice when they are sick, cut the juice with half and half with water.  Antibiotics can also make diarrhea worse.  If your kid is already on an antibiotic and gets diarrhea, call your doctor to discuss whether to continue the medicine or not.  A full appetite is often the last behavior to return after an illness.  Children should be allowed to take their time returning to their normal eating.  Children usually tolerate bland, starchy foods better.

Dehydration is the most worrisome complication of diarrhea.  The signs of dehydration include dizziness and light-headedness, a dry sticky mouth, very little or no urine for a 12 to 24 hour period, no tears when crying.  If you think your child is dehydrated, call your doctor.

Parents of kids with diarrhea should avoid spreading infection.  Care with frequent hand washing and keeping sick kids out of school or daycare until the diarrhea is controlled are ways to limit the people exposed.  Hand washing is the best way to prevent the spread of diarrhea to others, and yourself!  Hand sanitizer is the next best way for disinfecting hands when a sink is not handy, but does not guard against all types of diarrhea.

I hope you’ve enjoyed all this poo-poo talk with your morning paper.  Now go wash those hands!