A five-month-old baby presented to the surgery with a cough, runny nose, lethargy, high fever and was off his food. He was still drinking plenty of fluids and had started in a day nursery the previous week.
His mother was understandably worried about him. He was usually fit and well and other than the occasional snuffle he had never really been ill before. He had been fully vaccinated at birth and had been breast fed exclusively up to the age of four months.
The baby had initially been seen by the GP registrar who had diagnosed a non-specific viral illness causing coryzal symptoms. His examination had been unremarkable other than a pyrexia of 38.5°C. She recommended conservative treatment with paracetamol and ibuprofen to control his fever as needed.
The baby and his mother returned two days later to see me. His symptoms had not improved and she thought his cough had worsened. Again, examination of the baby was completely normal. As she was keen for her son to return to nursery so she could go back to work, I reluctantly prescribed some antibiotics for him.
Vomiting and diarrhoea
Unfortunately the baby developed vomiting and diarrhoea the day after taking the antibiotics and the mother returned with him. His oral intake had reduced a little but he was still having wet nappies, despite the diarrhoea. The antibiotics were stopped as the vomiting was thought to be a result of them.
The next day the baby’s condition had worsened — he had become lethargic and was refusing all fluids. He was still having diarrhoea which was now very watery. He was moderately dehydrated, with tachycardia, reduced urine output and a dry mouth. He was taken to the local hospital and admitted for rehydration and further investigation.
There were two other babies on the ward from the same nursery as the patient, with very similar symptoms.
He was diagnosed as having rotavirus infection and after 24 hours of IV fluids his symptoms settled and was discharged home. He returned to nursery the following week and has had no further illnesses.
Acute gastroenteritis is usually a mild self-limiting illness, but if untreated can result in morbidity and mortality secondary to water and electrolyte losses. Most cases of mild to moderate diarrhoea are self-limiting, are of short duration and do not require laboratory investigation.
All children with gastroenteritis should be assessed for dehydration (see table below).
Those with moderate or severe dehydration should be admitted.
Rotavirus is the most common cause of severe acute gastroenteritis in infants and young children; it causes half a million deaths in children under five years old worldwide each year.
Severe rotavirus gastroenteritis is actually the cause of up to 58 per cent of hospitalisations in Europe.
Rotavirus gastroenteritis is not a notifiable illness and is therefore not recorded as frequently as bacterial gastroenteritis.
Rotavirus is the most common enteric pathogen in young children, affecting boys more often than girls.
It is found more commonly in those under two years-old in the winter months.
The high infectivity of rotavirus makes it difficult to control the spread of the disease. The incubation period of rotavirus is 48 to 72 hours. Symptoms usually last from three to eight days.
Normal feeding should be restarted as soon as possible in children after gastroenteritis – there is actually no evidence that fasting will have any benefit.
There is some evidence that early feeding leads to greater weight gain after rehydration with no worsening of diarrhoea, prolongation of diarrhoea, increased vomiting, or lactose intolerance.
No drug treatments are licensed for the treatment of rotavirus. However, nitazoxanide is an antidiarrhoeal agent already licensed in the US to treat diarrhoea caused by Cryptosporidium spp and Giardia spp.
Nitazoxanide also seems to work against rotavirus. In a small randomised trial sponsored by the drug’s manufacturer, nitazoxanide halved the time it took for Egyptian children to recover after being admitted to hospital with severe rotavirus infection.
Because rotavirus is so infectious, hygiene measures to reduce spread of the disease are extremely important, especially in places where it is likely to spread quickly (nurseries and nursing homes).
People should be advised on how to prevent transmission to other family members or contacts. Recommendations include personal hygiene with hand washing, prompt disinfection of contaminated surfaces, prompt washing of soiled clothes and avoidance of food/water if there is a risk of contamination.
An oral rotavirus vaccine has been produced which has been shown to protect against 96 per cent of severe rotavirus gastroenteritis cases and prevent 100 per cent of hospitalisations due to rotavirus-induced gastroenteritis.
Reassuringly, this vaccine has no attributable risk for intussusception – a complication which was observed with a previously marketed vaccine.
Dr Newson is a GP in Solihull, West Midlands
Lessons learnt from this case
- Rotavirus often has prodromal features of upper respiratory tract infection.
- Dehydration can occur quickly in children.
- Early feeding after gastroenteritis is not detrimental.
- Rotavirus is uncommon in children over five years old.
- A new vaccine has been introduced to prevent rotavirus.
- Nitazoxanide may be licensed in the future for rotavirus.
Features associated with degree of dehydration in children
|Clinical features||Mild (< 5%)||Moderate (5-10%)||Severe (> 10%)|
|Dry mouth||Moist||Dry||Very dry|
|Extremities||Warm, good refill||Delayed refill||Mottled, poor refill|
|Tears||Normal||Normal to absent||Absent|
|Sunken eyes||Normal||Sunken||Very sunken and dry|
|Level of consciousness||Well, alert||Restless, irritable||Lethargic, unconscious (floppy)|
|Skin pinch||Goes back quickly||Goes back slowly||Considerable decrease|
|Tachycardia||Normal||Moderate increase||Major increase|
|Decreased urine output||Slight decrease||Moderate decrease||Major decrease|