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!

Vomiting

DODGING VOMIT
I have gotten pretty good at dodging vomit over my years as a pediatrician. It only takes once or twice really to learn, after you have been hit.
“Gastroenteritis”, also called “stomach viruses,” “stomach flu,” or “rotavirus” is one of the most common kid illnesses.
You catch the virus (or occasionally bacteria)
from other people’s dirty hands or from food contaminated with the virus. In a day or two the virus “brews” inside you and you start with the vomiting and diarrhea, sometimes fever and headache. Usually the vomiting only lasts half a day or so, then you have four or five or more days of diarrhea.
Dehydration is the main way children get into serious trouble. Dehydration is when the body does not have enough water to provide good blood volume. The body’s organs begin to starve for lack of fluids, nutrients, and oxygen. Your kidneys try to hold on to what fluids you have, and you stop making urine. The signs of dehydration then become more obvious as your organs- your brain, your blood, your kidneys- sicken. You get sleepy and harder to arouse, you begin to breathe shallow and fast, your skin gets pale and grayish.
Most vomiting can be taken care of at home. If a child vomits, simply wait an hour or two for the stomach to settle down. Then start giving only clear fluids like sports drinks or pedialyte. Pedialyte is the very best to give for babies. If the child vomits again, relax. Wait another hour or two and try a small amount of fluid again. It usually takes a good eight to twelve hours for a child to really start to get dehydrated. When in doubt, call your doctor.
If your child has stopped vomiting and is taking clear fluids for six or so hours, then you can restart small amounts of bland food. If the child vomits then, stop for an hour or two and restart the small amounts of clear liquid.
If your child only has diarrhea, but is drinking ok, they typically won’t have dehydration. Children tend to absorb enough fluids even with lots of diarrhea. Keep the fluids coming. Also, science has shown that the sooner a child is back on their regular diet, the sooner the diarrhea goes away. So as soon as your child can take food, give it and keep it coming. Even if it looks if it is going “right through,” keep the food coming- your child again will absorb enough to get by.