Pediatric Primary Care (87 page)

2.  Rarely affects ectopic sites (i.e., female genital tract, appendix, peritoneal cavity, liver, spleen).

J.  Education.

1.  Teach parent proper technique for obtaining specimen if needed.

a.  Use only clear cellophane tape. Spread buttocks early in morning, before toileting, or at night and apply tape sticky side down to perianal area.

b.  Place tape sticky side down on clear glass slide.

c.  Teach proper precautions for handling communicable specimen.

2.  Infection highly contagious and reinfection is common.

3.  Discuss strategies to avoid reinfection.

a.  Keep fingernails very short. Frequent handwashing, especially with toileting.

b.  Wash bedclothes, underwear daily; handle with precaution. Bathe daily.

c.  Discourage child from scratching anus and from placing fingers in mouth.

4.  Infections are spread only human to human. Cannot be spread by pets.

5.  Eggs are viable in environment for several days or longer.

6.  Discuss importance of second dose of medication at 2 weeks.

7.  Reassure about benign nature of the infection.

8.  Treatment side effects include abdominal pain, diarrhea.

XV. VIRAL GASTROENTERITIS

A.  Viral infection of GI tract.

B.  Etiology.

1.  Caused by several viruses, mainly:

a.  Rotavirus: highly contagious, incubation period 1-3 days. Spread by fecal-oral route. Most common viral cause.

b.  Adenovirus: second most common cause, mainly children younger than 2 years. Incubation period: 8-10 days.

c.  Norwalk group: mainly older children, adults. Main cause of viral gastroenteritis epidemics. Highly contagious, fecal-oral route. From contaminated food, water, or person to person.

2.  Osmotic diarrhea usually results from carbohydrate malabsorption, increased fluid/salts in intestines.

C.  Occurrence.

1.  Rotavirus most common cause of severe, dehydrating diarrhea in infants/ young children. Occurs mainly during winter months.

2.  Adenovirus can occur year-round, slight increase in summer months.

3.  Norwalk can occur year-round.

D.  Clinical manifestations.

1.  Watery diarrhea most common symptom. Vomiting and fever common.

2.  Rotavirus may cause severe, watery diarrhea for 5-7 days.

3.  Adenovirus diarrhea may last for 1-2 weeks with/without vomiting at onset. May be associated with low-grade fever.

4.  Norwalk may cause acute-onset vomiting, abdominal cramps, diarrhea for 1-2 days. Vomiting main symptom in children; can have fever, headache, muscle aches.

5.  Pertinent history to obtain:

a.  Onset of symptoms, sudden? Any sick contacts? Fever history?

b.  Stools: consistency, frequency, quantity, history of melena/hematochezia.

c.  Vomiting: frequency, quantity, quality. Contain bile or blood?

d.  Abdominal pain, cramping: frequency, duration, relation to stools.

e.  Complete diet and medication history.

E.  Physical findings.

1.  Weight, temperature, vital signs.

2.  Assess hydration status and level of activity.

3.  Complete physical exam with attention to abdomen (tenderness, guarding, masses) and rectal (perianal irritation, diaper rash from diarrhea).

F.  Diagnostic tests.

1.  Not usually necessary.

2.  Rotavirus/adenovirus diagnosed using commercially available kit.

3.  If dehydrated: serum electrolytes.

G.  Differential diagnosis.

1.  Parasite infection (giardia, campylobacter).

2.  Bacterial infection.

H.  Treatment.

1.  Supportive care: prevent/correct dehydration.

I.  Follow up.

1.  Return to clinic if any increased symptoms or signs of dehydration.

J.  Complications.

1.  Dehydration.

2.  Diaper rash.

K.  Education.

1.  Reassure family about self-limited nature of viral gastroenteritis.

2.  Review signs/symptoms of dehydration with family.

3.  Discuss communicability, precautions (handwashing, handling of soiled objects).

XVI. VOMITING, ACUTE

A.  Forceful expulsion of stomach contents through mouth. Highly coordinated reflex; can be symptom of disease within or outside GI tract.

B.  Etiology.

1.  Common symptom of infection such as gastroenteritis. Can also be from infection outside GI tract such as UTI, otitis media, other systemic infections.

2.  Different from regurgitation-type emesis (nonforceful), common sign of GERD.

3.  Additional etiologies vary by age:

a.  Infant: overfeeding, mechanical obstruction (pyloric stenosis, malrotation, volvulus), necrotizing enterocolitis, Hirschsprung's disease, intussusception, cow's milk protein allergy.

b.  Child: appendicitis, sinusitis, toxic ingestions, gastritis, mechanical obstruction (foreign body, malrotation).

c.  Adolescent: appendicitis, sinusitis, toxic ingestion, inflammatory bowel disease (IBD), migraine, pregnancy, bulimia.

C.  Occurrence.

1.  Common pediatric symptom.

2.  Infection is one of most common medical causes of nonbilious vomiting in first year of life, usually acute gastroenteritis.

D.  Clinical manifestations.

1.  Usually forceful, may be preceded by nausea, increased salivation, retching.

a.  Describe vomiting and symptoms preceding it.

b.  How often is child vomiting? When did it first begin?

c.  Any bile staining or hematemesis?

d.  How soon after oral intake does vomiting occur?

2.  Ask about possible associated symptoms:

a.  Fever? How is it treated? Any headache, body aches, joint pain?

b.  Describe stools; any diarrhea? Any melena or hematochezia?

c.  Is child continuing to urinate? Any dysuria or frequency?

d.  Any URI symptoms, cough, ear, throat pain? Abdominal pain?

3.  Diet history:

a.  Type, quantity of fluids, foods.

b.  History of ingestion of contaminated food?

c.  Medications/drugs or toxic ingestion history?

d.  Exposure to others with similar symptoms?

E.  Physical findings.

1.  Weight, compare with previous measurements.

2.  Temperature, vital signs.

3.  Assess level of activity; does child appear ill?

4.  Complete physical exam with attention to:

a.  Abdomen: Assess for distention, guarding, tenderness, masses.

b.  Hydration status.

c.  Rectal exam: Observe for any abnormalities, digital exam may be necessary to check for occult blood.

d.  CNS: Assess fontanel. Assess for irritability, nuchal rigidity, Brudzinski and Kernig's signs, funduscopic exam.