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Vomiting and Diarrhea: How Sick is Your Child?

Posted Aug 24 2008 1:49pm 2 Comments
CHERYL WILLS: Thank you for tuning into our webcast. I'm Cheryl Wills. If you're a parent, it's inevitable that your child will suffer diarrhea or vomiting or both at some point during their life. But how do you know when it's serious and, more so, how do you treat it?

We have two very well-informed pediatricians to discuss this topic today. Dr. Daniel Neuspiel is here. He's the associate chairman of pediatrics at Beth Israel Medical Center. Also Dr. Steven Schwartz. He is professor of pediatrics at SUNY Brooklyn. Also, he's the chairman of pediatrics at Long Island College Hospital, and he is a gastroenterologist, which will be very helpful.

So let's start off with you, Dr. Schwartz, and let's talk about diarrhea. What is diarrhea?

STEVEN SCHWARTZ, MD: That's a very good question, Cheryl. I think that what we really consider diarrhea is a change in frequency or consistency of stools from a child's normal pattern. And a child's pattern may be different from child to child. And that's one of the things that parents have to learn as their child grows up is that what's normal for one is not normal for the other.

When there's a question, I always recommend that the parents ask the pediatrician or their family doctor. But clearly, it's a change in pattern. Which may or may not be associated with other kinds of symptoms, such as fever or other problems as well.

CHERYL WILLS: Sure. And age is a major factor for parents to consider. Big difference if a six-week-old has diarrhea versus a six-year-old.

STEVEN SCHWARTZ, MD: Absolutely. In an older child who develops diarrhea, pretty well certain it could be diet-related, or there could be an intestinal infection, typically viral. In a young child -- particularly an infant under six months of age and certainly an infant under two to three months of age -- diarrhea can just be one of the symptoms of far more serious illness. And if a parent sees diarrhea in a young infant, their physician should be contacted immediately.

DANIEL NEUSPIEL, MD: I would add that, in a young infant, not only is the cause potentially different, but the consequences of diarrhea can be dramatically different. Because a young infant can lose fluids so rapidly, become dehydrated so easily compared with an older child.

CHERYL WILLS: Sure, it can be life-threatening. It's more than just a watery stool that's inconvenient for both the parent and the baby.

DANIEL NEUSPIEL, MD: That's right. And it's often managing that fluid loss and preventing serious dehydration that we mainly deal with as pediatricians.

CHERYL WILLS: In newborns, I assume it's very important to even monitor a child -- even though it may sound a little facetious -- to monitor a child's stool, because not all children have the same stool, unless a child is formula-fed, that still may be different from a breast-fed stool. Is that correct?

STEVEN SCHWARTZ, MD: Some breast-fed infants -- particularly when they get to older than a month of age -- may have one stool a week. Others will have ten stools a day. Again, they will generally develop their own pattern. And if that pattern changes, it is something at least to be looked at and considered as if it's a manifestation of a problem.

Formula-fed infants tend to have firmer -- what we call more "pasty" stools. And this is largely a consequence of the different kinds of bacterial flora that are in the bowel of breast-fed versus bottle-fed infants. And other factors as well.

CHERYL WILLS: Now before we move on with diarrhea, let's touch on vomiting. What causes vomiting?

STEVEN SCHWARTZ, MD: I want to say something. True vomiting is never really normal. Young infants will have some spitting up. It's a topic for another day, but most young infants have an element of what we call "gastroesophageal reflux." Listeners have probably heard of GR or GR, well, this is not gastroesophageal reflux disease, it's just a tendency to spit up a little bit. After feeding. That's okay.

But if a child is truly vomiting large amounts -- particularly if it's projectile or forceful -- this is always a concern.

CHERYL WILLS: I guess I considered spit-up vomiting, but there's a little difference there, right.

STEVEN SCHWARTZ, MD: We consider it different. And I think that the difference may be subtle. But I think it's important to understand that.

CHERYL WILLS: That's a very good point. Because most babies have some form of regurgitation when they eat. What other accompanying symptoms might we see with vomiting that could be serious? Fever, I assume?

STEVEN SCHWARTZ, MD: Well, the most important, potentially life-threatening situation would be if the vomitus turns greenish. That suggests that it's coming from lower down in the intestine, it may represent an obstruction.

A child who forcefully vomits can have a gastric problem, or can have an infection. Can have an ear infection. Can have other kinds of illnesses where vomiting is just a manifestation of that.

DANIEL NEUSPIEL, MD: I think we ought to touch on some of the serious signs of dehydration that parents ought to look out for, whether it's associated with vomiting or diarrhea or both.

CHERYL WILLS: That's where we were headed. So why don't you touch on that, doctor?

DANIEL NEUSPIEL, MD: Well, I think, again, it depends on the age of the child. But when we deal with an infant, where dehydration can be most concerning. We look early on for things like less numbers of wet diapers. Sometimes that's hard to tell these days, with the super-absorbent disposable diapers that exist. But most parents can get a rough handle on that.

Also, looking for dryness around the mouth is an important sign. A later sign, a more serious sign, might be if a baby's eyes seem sunken inside the head.

STEVEN SCHWARTZ, MD: When most infants and young children become ill, they get a little cranky, they may be a little irritable. When a child gets significantly dehydrated, the opposite tends to happen. They tend to become listless. They tend to become almost lethargic, and they may be lethargic. And that shouldn't be confused with everything's okay. If your child went from irritable to being listless, and continues to have symptoms of vomiting and diarrhea, that's a real danger sign.

CHERYL WILLS: And I think it's important -- especially for parents -- to know that you never take those for granted. Even though we toss around the term, "Oh, he has diarrhea. Oh, he's vomiting." That is something that should not be taken casually or lightly.

DANIEL NEUSPIEL, MD: That's correct. And dehydration can occur very quickly, especially in young children. And when there is vomiting with diarrhea, we usually have to pay attention to the vomiting first to -- because no matter whether the diarrhea's continuing or stopping, if the child's vomiting, then he or she is going to get dehydrated if it doesn't stop.

CHERYL WILLS: And they should always call a doctor. What do you do when a child has diarrhea or is constantly vomiting? A lot of home remedies out there for these things, you know?

STEVEN SCHWARTZ, MD: Well, again, a lot depends on age as well. I think the child less than three months of age will always be seen by the pediatrician.

Beyond that, it's really -- how well do I know the child? How reliable is the history that I'm getting? Are they sick contacts? Are there other people at home who are sick?

It's often difficult for a busy pediatrician to make a decision about when do I see a child or if I should see a child. I think the rule is, under three months of age, we're going to see most if not all.

CHERYL WILLS: So what do we do with the bigger kids who have diarrhea and vomiting? A lot of over-the-counter remedies. A lot of home remedies. Follow your gut? What should a responsible parent do?

DANIEL NEUSPIEL, MD: Well, I try to get some information when I get a call from a parent who has a child with vomiting and diarrhea. Not just the age of the child, but also the frequency of the vomiting and diarrhea. And whether the child's able to retain any liquids by mouth. And the signs of dehydration that we spoke about.

Now, if a child is continuously vomiting and not keeping down any liquids, then that child has to be seen, no matter what the age. But if the child can retain some liquids and keep from getting dehydrated, that can often be managed at home.

There are some special liquids that are available for parents to use with medical advice to help prevent dehydration, especially in infants.

CHERYL WILLS: Sure, like Pedialytes.

DANIEL NEUSPIEL, MD: Yeah, that's one brand. It's various brands of oral electrolyte solutions.

CHERYL WILLS: Right, electrolytes.

DANIEL NEUSPIEL, MD: So these are solutions that have water mixed with some chemicals that retain fluid better in their system so that they can prevent dehydration and they're more easily absorbed than some of the juices and other routine beverages.

CHERYL WILLS: What can cause diarrhea?

DANIEL NEUSPIEL, MD: The most frequent cause of diarrhea in infants is rotavirus. It's a virus that occurs all over the world. And certainly the most common cause of diarrhea in young infants in this country. And it's quite contagious. Occurs more so in the winter months.

CHERYL WILLS: Excessive fruit juice. I've heard that many times, Dr. Schwartz?

STEVEN SCHWARTZ, MD: Fruit juice, number one, is very high in sugar. And because of that, it's probably not the best liquid to give your child, anyway.

CHERYL WILLS: But they love it.

STEVEN SCHWARTZ, MD: But they love it. Particularly in a child with diarrhea, the high-sugar content plus many of the juices contain certain sugars which the body poorly absorbs and can actually make diarrhea worse. So if you have an infant with gastroenteritis and you want to give them an oral solution, use one of the oral rehydration solutions, don't use fruit juice. That's really the opposite of what you should be doing.

DANIEL NEUSPIEL, MD: I'd like to add, too, that one of the common mistakes that parents make with using the oral rehydration solutions is they treat it as a medicine rather than a replacement fluid. So that commonly we'll see parents giving these solutions in combination with the child's regular diet.

CHERYL WILLS: And oral rehydration means just rehydrating a child who is dehydrated.

DANIEL NEUSPIEL, MD: Yes, or to prevent dehydration in those cases. So, really, when these solutions are used, they should be used as an entire replacement for anything else taken by mouth. And for a limited period of time, generally for just 24 hours.

STEVEN SCHWARTZ, MD: That's very important to emphasize. I have, unfortunately, seen some infants who come into the office being on one of the oral rehydration solutions for three, four days. This is not a good situation. We try to limit it to twenty-four hours, no more than 24 hours, and then reevaluate.

Many otherwise healthy children with gastroenteritis can also feed through their gastroenteritis. And do not have to have special solutions. But that should be done with the advice of a pediatrician.

CHERYL WILLS: So, again, we're not talking about medications. We're talking about over-the-counter, or things you can buy in a store, given to a child. Like electrolyte solutions. So you're saying parents should be careful when using that. That's a great point.

STEVEN SCHWARTZ, MD: There are certain medications which you can give which will absorb some of the fluid, a little bit like a sponge, that may not affect the amount of fluid that's lost in the bowel. There are certain medications that can actually change the way the bowel passes fluid through it. Instead of the fluid coming out, the fluid stays inside, in the bowel, and is not absorbed. And so you don't know where you are.

So, especially in infants, you want to stay away from antidiarrheal medications. In fact, most of these are contraindicated in children.

CHERYL WILLS: Really? What's an example of anti-diarrhea?

STEVEN SCHWARTZ, MD: Well, the oldest one is Lomotil. And Lomotil is really contraindicated in children. Imodium -- which is another one, it's commonly available -- can be used in certain situations, not during infancy. And really, your child should only receive it on a doctor's advice.

DANIEL NEUSPIEL, MD: Steve, what do you think about using medications to suppress vomiting in children?

STEVEN SCHWARTZ, MD: Most medications which actually suppress vomiting do so by sedating the child. So the child is sedated and is not taking anything orally.

CHERYL WILLS: Now, what type of medications would suppress vomiting?

STEVEN SCHWARTZ, MD: Again, these are medications which do so through sedative effects. Anti-histamines are used. Other medications are used. Phenergan is a popular one. Tigan is another popular one. Again, I never use them. I never use anti-vomiting agents, I never use anti-spasmodics.

CHERYL WILLS: What do you do -- you try to adjust it by diet?

STEVEN SCHWARTZ, MD: You're really not changing the natural course of the disease, and you're only creating potential complications.

CHERYL WILLS: So, what's the best way to treat it?

STEVEN SCHWARTZ, MD: The best way to treat it is fluids. A bland diet in an older child, with a doctor's advice. Visits to the physician if you're concerned about the child's state of dehydration. And allowing nature to run its course.

CHERYL WILLS: That's good advice, I think, for most diseases and most illnesses. Dr. Schwartz, thank you very much for joining us. As well as Dr. Neuspiel.

And thank you. The take-home message here with diarrhea and vomiting is to check with your pediatrician no matter what the age. And be careful with home remedies, sometimes they can do more harm than good. It's always good to have a professional opinion. Thank you for tuning into our webcast. I'm Cheryl Wills.

Comments (2)
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Hi, I live in Nigeria Africa and the worse place I could take my 9 year old girl would be the hospital (there are no dr. offices, etc...).  So, I am with my girl who has been throwing up everything for the last seven days.  I don't know what to do.  She won't keep anything down and I am very concerned of her hydration level.  

Do you have anything to help me? 




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