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Children’s health problems blogged to provide information in health issues but often with anecdotes from the GP

COUGH – WHEN TO SEE THE DOCTOR WITH YOUR CHILD

Cough is the commonest reason for preschool children to see a GP. Isolated coughing has been reported by parents in almost a third of children at any one time; the symptom can have an impact on sleep, school and activities for the child and can be anxiety provoking for parents.

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An average preschool and primary school child has 3-8 coughs or colds per year. Sometimes several coughs or colds occur one after the other. A child who lives with smokers has an increased risk of developing coughs and colds.

A cough is a reflex action to clear your airways of mucus and irritants such as dust or smoke.
Coughs may be dry or chesty and most coughs clear up within three weeks.

Cough may be broadly split in to three categories:

Acute cough = < 3 weeks

Prolonged acute cough = 3-8 weeks, slowly resolving, e.g. post-viral pertussis

Chronic cough   = Variably defined from 3-12+ weeks

Needless to say that constantly hearing your child cough especially at night is bound to cause concern. Even if the mother is happy her child is otherwise well someone else will make a comment. It may be a well meaning grandparent, a dad returning from work or a teacher who will ask whether the child has seen a doctor. I have to say when I see a child  with a cough I examine the child step by step explaining as I go along what symptoms and signs which would cause me as a doctor to be concerned. This not only makes me rule out significant causes of cough but it also reassures and educates the mother as to what important signs she should be looking for.

  • has the child lost their appetite?

  • are they playing or responding as normal?

These symptoms are most important when you are deciding if your child is unwell in that if the child is showing both of the above symptoms you must  keep a closer eye on your child so that if they go on to develop any signs listed below you can visit your GP  On many occasions I have seen a child in surgery racing around, playing happily and having eaten a good breakfast.  Be reassured a child with a cough in this situation is not needing to see a doctor.

However, If you notice any of the following associated with a cough you must bring the child to the doctor

  • has trouble breathing or is working hard to breathe

  • is breathing faster than usual

  • has a blue or dusky colour to the lips, face, or tongue

  • has a high fever (especially if your child is coughing but does NOT have a runny or stuffy nose)

  • has any fever and is younger than 3 months old

  • is an infant (3 months old or younger) who has been coughing for more than a few hours

  • makes a “whooping” sound when breathing in after coughing

  • is coughing up blood

  • has stridor (a noisy or musical sound) when breathing in

  • has wheezing when breathing out (unless your doctor already gave you an asthma action plan)

  • is weak, wingy, or irritable

  • is dehydrated; signs include dizziness, drowsiness, a dry or sticky mouth, sunken eyes, crying with little or no tears, or passing urine less often (or having fewer wet nappies)

Because most coughs are caused by viruses, doctors usually do not give antibiotics for a cough. A cough caused by a virus just needs to run its course. A viral infection can last for as long as 2 weeks. We very rarely send a child for a chest X-ray. 

Unless a cough won’t let your child sleep, cough medicines are not needed. They might help a child stop coughing, but do not treat the cause of the cough. If you do choose to use an over-the-counter (OTC) cough medicine, discuss with the pharmacist to be sure of the correct dose and to make sure it’s safe for your child.

Do not use OTC combination medicines  they have more than one medicine in them, and children can have more side effects than adults and are more likely to get an overdose of the medicine. Some cough medicines have the effect of making a child hyperactive which most parents would agree is not a desired side effect!

Cough medicines are not recommended for children under 6 years old. Meanwhile, you may want to try this homemade remedy my mother gave to us as children and remains a good remedy.

HOMEMADE COUGH MEDICINE 

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Honey, lemon and glycerine (a liquid I use in Christmas cake Royal icing to make the icing softer) is a homemade remedy for coughs provided the person  is not allergic to any of the ingredients. It is not adviseable to give to a child < 12 months. Honey is a natural antibiotic and lemon is full of cold-fighting vitamin C and glycerine is good for soothing sore throats.

It can also be bought ready mixed over the counter.

Store in the refrigerator for up to a year. For sore throats and chest congestion take one teaspoonful every few hours. (If it starts to taste so good you want to pour it over ice cream – you are probably getting better and don’t need it any more.)

¼ cup (60ml) freshly squeezed lemon juice
¼ cup (60ml) liquid honey
¼ cup (60ml) food grade glycerine

Strain the lemon juice through a fine meshed strainer. Whisk together with the honey and glycerine and pour into a glass bottle with a tight-fitting lid.

Store in the refrigerator for up to a year. For sore throats and chest congestion take one teaspoonful every few hours.

Remember to train your child to cover their cough in order to help protect  those who are vulnerable from catching an infection. 

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MEASLES CLOSE TO HOME

Watch out

                          THERE HAS BEEN AN OUTBREAK OF MEASLES IN

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If your child is not vaccinated  make an appointment as soon as possible  for a  MMR vaccination “to protect themselves, their loved ones, and the community at large.” The best protection against measles is a two dose regimen of the MMR vaccine, which is safe and more than 99% effective.

Complications of measles can include pneumonia, neurologic involvement, and death. It is well documented that about one in 1000 people with measles will develop meningitis and about one in 1000 will die. “Measles is not a trivial illness. Measles can be very serious, with devastating complications.”

A reader sent me this interesting article which gives food for thought  !!! 

https://medium.com/the-archipelago/im-autistic-and-believe-me-its-a-lot-better-than-measles-78cb039f4bea

 

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Don’t Believe In Vaccinations?

Two years ago I wrote a blog about the Measles epidemic in Swansea brought about because parents had declined to vaccinate their children. In USA there has been an outbreak of measles in 14 states and President Obama is urging parents to get their children vaccinated. At least 58 of those cases began in Disneyland in Dec. 2014, where large numbers of unvaccinated people made it easy for the virus to spread. Unvaccinated people are now being encouraged to avoid Disneyland parks altogether, lest the virus continues to spread. Last year alone the U.S. saw 644 confirmed cases of the measles, more than triple the number of cases in 2013.

   WHO            According to the WHO in November 2014

 * Measles is one of the leading causes of death among young children even though a safe and cost-effective vaccine is available.

* In 2013, there were 145 700 measles deaths globally – about 400 deaths every day or 16 deaths every hour.

* Measles vaccination resulted in a 75% drop in measles deaths between 2000 and 2013 worldwide.

* In 2013, about 84% of the world’s children received one dose of measles vaccine by their first birthday through routine health services – up from 73% in 2000.

* During 2000-2013, measles vaccination prevented an estimated 15.6 million deaths making measles vaccine one of the best buys in public health.m

27 years  ago Roald Dald wrote this moving letter to encourage parents to make sure they immunise their children: the message is still pertinent today.

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Olivia, my eldest daughter, caught measles when she was seven years old. As the illness took its usual course I can remember reading to her often in bed and not feeling particularly alarmed about it.
Then one morning, when she was well on the road to recovery, I was sitting on her bed showing her how to fashion little animals out of coloured pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn’t do anything.
“Are you feeling all right?” I asked her.
“I feel all sleepy,” she said.
In an hour, she was unconscious. In 12 hours she was dead.
The measles had turned into a terrible thing called measles encephalitis and there was nothing the doctors could do to save her.
That was 24 years ago in 1962, but even now, if a child with measles happens to develop the same deadly reaction from measles as Olivia did, there would still be nothing the doctors could do to help her.
On the other hand, there is today something that parents can do to make sure that this sort of tragedy does not happen to a child of theirs. They can insist that their child is immunised against measles.
I was unable to do that for Olivia in 1962 because in those days a reliable measles vaccine had not been discovered. Today a good and safe vaccine is available to every family and all you have to do is to ask your doctor to administer it.
It is not yet generally accepted that measles can be a dangerous illness. Believe me, it is. In my opinion parents who now refuse to have their children immunised are putting the lives of those children at risk.
In America, where measles immunisation is compulsory, measles like smallpox, has been virtually wiped out.

Here in Britain, because so many parents refuse, either out of obstinacy or ignorance or fear, to allow their children to be immunised, we still have a hundred thousand cases of measles every year.
Out of those, more than 10,000 will suffer side effects of one kind or another. At least 10,000 will develop ear or chest infections. About 20 will die.
LET THAT SINK IN.
Every year around 20 children will die in Britain from measles.
So what about the risks that your children will run from being immunised?
They are almost non-existent. Listen to this. In a district of aroundu 300,000 people, there will be only one child every 250 years who will develop serious side effects from measles immunisation! That is about a million to one chance.
I should think there would be more chance of your child choking to death on a chocolate bar than of becoming seriously ill from a measles immunisation.
So what on earth are you worrying about? It really is almost a crime to allow your child to go unimmunised.
The ideal time to have it done is at 13 months, but it is never too late. All school-children who have not yet had a measles immunisation should beg their parents to arrange for them to have one as soon as possible.
Incidentally, I dedicated two of my books to Olivia, the first was ‘James and the Giant Peach’. That was when she was still alive. The second was ‘The BFG’, dedicated to her memory after she had died from measles.
You will see her name at the beginning of each of these books. And I know how happy she would be if only she could know that her death had helped to save a good deal of illness and death among other children.

***If your child has not been immunised contact your surgery to make an appointment withe practice nurse.

 
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Posted by on February 3, 2015 in Training and Advice

 

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100 days of coughing after a 100 years

Eight months ago I wrote my 100th blog about a lady who had become a centenarian and how we had celebrated her birthday and since then she has followed my blogs and I have even introduced her to TED talks which she finds most interesting!

The telephone went yesterday to inform me that she was in hospital with what in some countries is known as
the 100 days’ cough or cough of 100 days.

The red dots are Bordatella pertussis bacteria, the cause of whooping cough.

We know it as whooping cough, or Pertussis..It is a highly contagious bacterial disease caused by Bordetella pertussis.

Although, in isolation and distressed by the severe coughing fits, which often produce the namesake high-pitched “whoop” sound when air is inhaled after coughing she has been in good spirits and no doubt full of questions due to her interminable curiosity.

What causes whooping cough

The bacterium infects the lining of the airways, mainly the windpipe (trachea) and the two airways that branch off from it to the lungs (the bronchi).
When the Bordetella pertussis bacterium comes into contact with the lining of these airways, it multiplies and causes a build-up of thick mucus. It is the mucus that causes the intense bouts of coughing as your body tries to expel it.
The bacterium also causes the airways to swell up, making them narrower than usual. As a result, breathing is made difficult, which causes the ‘whoop’ sound as you gasp for breath after a bout of coughing.

How whooping cough spreads

People with whooping cough are infectious from six days after exposure to the bacterium to three weeks after the ‘whooping’ cough begins.
The Bordetella pertussis bacterium is carried in droplets of moisture in the air. When someone with whooping cough sneezes or coughs, they propel hundreds of infected droplets into the air. If the droplets are breathed in by someone else, the bacterium will infect their airways.
This is why it is highly contagious. I remember in 1979 I was working as a paediatric doctor and there had been a whooping cough vaccination scare resulting in a sharp increase in cases. It was pitiful to see the numerous admissions of babies and young children with distressing bouts of coughing. It is clear how when a vaccination is introduced how the incidence of the disease falls so rapidly but rises again if vaccination uptake declines.
Whooping cough.

Treatment
If whooping cough is diagnosed during the first three weeks (21 days) of infection, a course of antibiotics may be prescribed. This is to prevent the infection being passed on to others.
It is important to take steps to avoid spreading the infection to others, particularly babies under six months of age.
Children with whooping cough should be kept away from school or nursery for five days from the time they start taking a prescribed course of antibiotics. The same advice applies to adults returning to work.
As a precaution, household members of someone with whooping cough may also be given antibiotics and a booster shot of the vaccine.
Antibiotics will not usually be prescribed in cases where whooping cough is not diagnosed until the later stages of infection (2-3 weeks after the onset of symptoms).
By this time, the Bordetella pertussis bacterium will have gone so you will no longer be infectious. It is also very unlikely that antibiotics will improve your symptoms at this stage.
Immunisation

Children are vaccinated against whooping cough with the 5-in-1 vaccine at two, three and four months of age, and again with the 4-in-1 pre-school booster before starting school at the age of about three years and four months.

Vaccination in pregnancy
In the UK, all pregnant women are offered vaccination against whooping cough when they are 28-38 weeks pregnant. Getting vaccinated while you’re pregnant could help to protect your baby from developing whooping cough in its first few weeks of life.

The immunity you get from the vaccine will pass to your baby through the placenta and provide passive protection for them until they are old enough to be routinely vaccinated against whooping cough at two months old.

Is the whooping cough vaccine safe in pregnancy?
It’s understandable that you might have concerns about the safety of having a vaccine during pregnancy, but there’s no evidence to suggest that the whooping cough vaccine is unsafe for you or your unborn baby.

Pertussis-containing vaccine has been used routinely in pregnant women since October 2012 and its safety has been carefully monitored by the Medicines and Healthcare Products Regulatory Agency (MHRA). The MHRA’s study of nearly 20,000 vaccinated women found no evidence of risks to pregnancy or babies.
To date, 50-60% of eligible pregnant women (over half a million) have received the whooping cough vaccine with no safety concerns being identified in the baby or mother.
Vaccination against whooping cough in pregnancy is also routinely recommended in the US and New Zealand.
The pregnancy vaccination programme has been very effective in protecting babies until they can have their first vaccine when they are two months old.
During 2012, 14 babies died from whooping cough, all of whom were born before the vaccination in pregnancy programme was introduced, and developed whooping cough before they could be vaccinated themselves. The number of infant deaths from whooping cough fell to three in 2013 – all three babies were too young to have been vaccinated themselves and none of their mothers had been vaccinated in pregnancy.

Further questions can be answered using the following link:-

http://www.nhs.uk/Conditions/Whooping-cough/Pages/Prevention.aspx

 
 

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FEVER AND COUGH IN CHILDREN – WHEN TO CALL THE DOCTOR

FEVERISH illness in children. – when to seek further advice.
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I shall always remember a cold, foggy autumn Sunday evening as a GP > 30 years ago. I was sitting by the fire, reading a good book listening to my favourite album at the time ‘Black Magic Woman’ and the phone rang as I was on call. It was a young, first time father who was a senior executive for Sony and he wanted advice as to what to give his 3 month old baby for a cough. He wondered if Benylin would be alright. No,he did not want me to come out on such a dreadful evening to their home which was in an out of the way village and not easy to find. The majority of the patients lived within 2 mile radius of the practise and I knew most of them well but this was a new family who lived the furthest distance away from the practise. The baby was sleeping well but had not been feeding so well but he shrugged that off as probably being due to the cough.
I thought to myself, ” Did I really want to leave my warm, cosy cottage or leave the book when it was just getting to the crux of the plot and after all he wasn’t demanding that I ventured out .”
However, that gut feeling told me something was not right and I needed to set eyes on this baby and it must be sooner rather than later.
It was a grim, pea-soup of an evening and I drove cautiously to the visit, following the father’s instructions to the letter and somehow managed to find the house with very little problem. The mother greeted me at the door wearing a face-mask and the father and extended family all came to the door similarly clad. I was then shown to the nursery through a house which was something out of ‘House Beautiful’ no clutter, everything perfect, decor impeccable, carpets like walking on soft foam and a bijoux nursery. As I approached the cot I viewed the baby, ashen in colour, shallow rapid breathing and barely rousable. The family looked at me expectantly in silence. How could I tell this family that their baby was life-threatill as they seemed so unaware? I spoke firmly and gently telling them of my findings. The father’s reaction was simply, “Can we go privately?”

At that time in Wales that was not an option and even getting an ambulance to take them to the local hospital was not quick and easy.

Shortly we came to a compromise that I would take the baby and mother in my Ford Popular to the nearest hospital nearly 20 miles away followed by the father in his Mercedes.
We arrived at the Hospital having prewarned them of the arrival and the baby was admitted with a diagnosis of bronchiolitis with heart failure. when I had worked as a junior paediatric doctor I had worked under the watchful eye of Sister Williams, who was always a force to be reckoned with despite being not much bigger than most of the paediatric patients.  I greeted her like a lost friend and she immediately took charge and when the parents saw our relationship it was clear that they were instantly reassured their precious child would be in good hands under the NHS.
The baby thankfully made a full recovery but what remains indelible in my mind are several aspects of this case:-

  • my momentary hesitation to visit,
  • the parents not wanting to appear over anxious,
  • these caring parents who were unable to understand the severity of their baby’s illness
  • there anxiety about their local hospital.

These factors still apply today but a combination such as this could have result in a tradegy.

A retrospective study recently carried out looked at children admitted to hospital with serious respiratory tract infections. The parents of these children were sent questionnaires after the admission and, from their replies, the authors identified factors which may have delayed earlier medical intervention and one of the reasons included ‘Problems assessing the severity of the illness’ and my other observations aswell as:-

    • The belief that their child would not be prescribed antibiotics or would be prescribed antibiotics too readily
    • The belief that their concerns would not be taken seriously
    • Feeling powerless to challenge clinical authority.

Organisational factors:

    • Perceived problems accessing healthcare services
    • Inadequate primary care triage
    • Barriers to accessing timely consultations
    • Past experience of problems accessing healthcare, leading to failure to consult
    • Perceived poor quality clinical encounter
    • Inadequate assessment and communication

It is for this reason I felt it was important to write this blog.

If you have any concerns about your child’s medical condition bring the child to the surgery and if the child is < 5years or an older child which has significant concerns they will be seen as soon as possible. If it is Out of Hours call 111 in order that your child can be seen as soon as possible at the nearest Urgent Care Centre (UCC).

  • Red flagThe following symptoms should always be treated as serious:
      • a high-pitched, weak or continuous cry
      • a lack of responsiveness, reduction in activity or increased floppiness
      • in babies, a bulging fontanelle (the soft spot on a baby’s head)
      • neck stiffness (in a child)
      • not drinking for more than eight hours (taking solid food is not as important)
      • a temperature of over 38°C for a baby less than three months old, or over 39°C for a baby aged three to six months old
      • a high temperature, but cold feet and hands
      • a high temperature coupled with quietness and listlessness
        fits, convulsions or seizures
      • turning blue, very pale, mottled or ashen
      • difficulty breathing, fast breathing, grunting while breathing, or if your child is working hard to breathe, for example, sucking their stomach in under their ribs
      • your baby or child is unusually drowsy, hard to wake up or doesn’t seem to know you
      • your child is unable to stay awake even when you wake them
      • a spotty, purple-red rash anywhere on the body (this could be a sign of meningitis)
      • repeated vomiting or bile-stained (green) vomiting

    It can be difficult to know when to call an ambulance or go to phone 111 seek a doctors advise as to where you should go. This is very important at a time when A&E departments are being replaced by Urgent Care Centres and you may need to be directed to a specialist centre.

      • AmbulanceCall an ambulance for your child if they:
        • stop breathing
        • are struggling for breath (you may notice a sucking in under the ribcage)
        • are unconscious or seem unaware of what’s going on
        • won’t wake up
        • have a fit for the first time, even if they seem to recover

        imageCall 111 and a doctor will advice you where to take your child if they have any of the following:-

          • have a fever and are persistently lethargic despite taking paracetamol or ibuprofen
          • are having difficulty breathing (breathing fast or panting, or very wheezy)
          • have severe abdominal pain
          • have a cut that won’t stop bleeding or is gaping open
          • have a leg or arm injury that means they can’t use the limb
          • have swallowed a poison or tablets

        Above all, trust your instincts. You know better than anyone what your child is usually like, so you’ll know what’s different or worrying.

        When I worked as a junior paediatrician for a rather old fashioned consultant paediatrician I can hear his words echo, ” Remember , mam is always right”, and if I see any child that is always my first thought, until with the mother of father we have looked at the child together and reached the same conclusion of what the problem is and how best to manage it.

        FEVER
        Child with fever
        Fever, or pyrexia, is when the body temperature rises above normal. The average normal body temperature taken in the mouth is 37°C but anywhere between 36.5°C and 37.2°C is deemed as normal. When temperatures are measured in the axilla they can be 0.2°C to 0.3°C lower than this. Aural (tympanic) thermometers may measure the temperature as higher.

        Fever is one of the most common reasons for a child to be taken to see a doctor and is the second most common reason for a child to be admitted to hospital.

        The cause of the fever can sometimes be hard to elicit and this can be a worry for healthcare professionals. It is usually due to a viral infection that is self-limiting but it can also be a sign of serious bacterial infection, including meningitis. Early diagnosis of serious infections in general practice is difficult as incidence is low, the child may present early in the disease process and diagnostic tools are more or less limited to history and examination.

        When a child presents with a fever it is important for the health care professional to take an adequate history and for the parent or guardian to provide accurate information

        History should include asking:

      • How long has the fever been present?
      • Has the parent/carer been measuring temperature and, if so, by what method?
      • Is there a rash? If so, is it blanching or non-blanching?
      • Meningitis
      • Are there any respiratory symptoms – eg, cough, runny nose, wheeze?
      • Has the child been clutching at their ears?
      • Has there been excessive or abnormal crying?
      • Are there any new lumps or swellings?
      • Are there any limb or joint problems?
      • Is there any history of vomiting or diarrhoea? Is the vomiting bile-stained or is there any blood in the stool?
      • Has there been any recent travel abroad?
      • Has there been any contact with other people who have infective diseases?
      • Is the child feeding normally (fluids and solids as appropriate)?
      • What is the urine output? Have nappies been dry?
      • How is the child handling? Normal self/drowsy/clingy and so forth?
      • Have there been any convulsions or rigors?
      • Is there any significant past medical history/regular medication/allergy?
      • Other points to consider from the history:
      • Level of parental anxiety and instinct (they know their child best).
      • Social and family circumstances.
      • Other illnesses affecting the child or other family members. Has there been a previous serious illness or death due to febrile illness in the family?
      • Has the child been seen before in the same illness episode?

    Examination of the child
    Identify any immediately life-threatening signs on examination
    Rate of breathing:-
    Infants 60 breaths per minute at age 0-5 months
    >50 breaths per minute at age 6-12 months
    >40 breaths per minute at age older than 12 monthsLook for nasal flaring/grunting/chest indrawing.Measure the heart rate.
    More than 160 beats per minute in a child less than 12 months old
    More than 150 beats per minute in a child 12-24 months old
    More than 140 beats per minute in a child 2-4 years oldAssess the level of hydration:
    do the eyes and skin look normal? Is the mouth moist? What is the capillary refill time? Are the extremities warm or cool? Is the child feeding normally? Is the urine output reduced?
    Examine for other features:
    Rash: if there is a rash, is it blanching or non-blanching?

  • Capillary refill return
    The capillary nail refill test is a quick test done on the nail beds. It is used to monitor dehydration and the amount of blood flow to tissue.
    Pressure is applied to the nail bed until it turns white. This indicates that the blood has been forced from the tissue. It is called blanching. Once the tissue has blanched, pressure is removed.
    Normal result:If there is good blood flow to the nail bed, a pink color should return in less than 2 seconds after pressure is removed.

Assessment of the child using the National Institute for Health and Care Excellence traffic light system
NICE recommends that a traffic light system should be used to predict the risk of serious illness when the symptoms and signs have been elicited from the history and examination. Allowance should be made for individual disabilities when assessing learning-disabled children.
The following table summarises this system.
If the child has any of the symptoms or signs in the amber column, they are at intermediate risk of serious illness.
If they have any of the symptoms or signs in the red column they are at high risk of serious illness.
Children with symptoms or signs in the green column and none in the red or amber column are at low risk of serious illness.
Management of fever should be guided by the level of risk.Traffic light

Children with any red features not considered to have an immediate life-threatening illness should be seen within two hours by a healthcare professional.
Children with any amber features should be seen by a healthcare professional but the assessment of urgency of the appointment is left to the clinical judgement of the assessor.
Children with only green features can be managed at home with advice for parents and carers, including advice on when to seek further help.
Management by the non-paediatric practitioner
This includes professionals working in primary care and also those working in general accident and emergency departments.

Assessment using the traffic light system should be performed.
Children with any red features should be referred for urgent assessment by a paediatrician.
Children with any amber features in whom a specific diagnosis has not been made, should either be referred to urgent paediatric care or the carers of the child should be given a ‘safety net’, either detailing exactly when to seek further help (ie specific warning symptoms or signs) or arranging a further follow-up assessment.
Children with only green features can be managed at home with advice for parents and carers, including advice on when to seek further help.

Oral antibiotics should not be prescribed if there in no identifiable source of the fever.

Management of specific diseases:

If there is no obvious source of infection, urine should be tested in children presenting with fever.
If meningococcal disease is suspected, antibiotics should be given at the earliest opportunity.
Related blog posts
There’s no such thing as a touch of ‘flu!

Advice to parents or carers for home care of the child

Antipyretic(fever) treatment:

    • tepid sponging is not recommended.
    • Do not underdress or over-wrap children.
      Give alternating paracetamol or ibuprofen for discomfort or distress but not for the sole reason of reducing the temperature. If the child does not respond to one agent and the child’s distress persists or recurs before the next dose is due then give the child paracetamol alternating with ibuprofen at 4hourly intervals.
    • Give regular fluids: breast milk if the child is breast-fed.
    • Monitor for signs of dehydration: sunken fontanelle or eyes, dry mouth, absence of tears, poor appearance.
    • Monitor for appearance of rash: assess to ascertain if a rash is non-blanching.
    • Get up in the night to monitor the child.
    • Keep the child away from school or nursery while they have a fever and notify them.

IN SUMMARY
When to seek further help: if the child has a fit, develops a non-blanching rash, appears less well, the parent or carer is worried, the fever lasts >5 days, the parent or carer is distressed or feels they cannot look after the child.

 
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Posted by on December 15, 2013 in Training and Advice

 

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FLU IMMUNISATION – 2013/14. – EXTENSION TO CHILDREN

After several years of acquiring good evidence from other countries the Department of Health now recommend that all children aged two to 17 are going to be offered a flu immunisation every year.
image At present, annual flu immunisation is offered only to children with underlying health problems, as well as all over 65s and anyone with long term health conditions such as heart and lung disease or diabetes.

The Chief Medical Officer for England says that even if only one in three children are immunised, hospital admissions will drop by 11,000 and 2,000 lives will be saved each year. But the full programme may not be introduced for another two years.

Although most children who suffer from influenza recover completely within a week or two, they spread the disease among the population more than any other group. Some children, of course, do get serious complications and having the immunisation will greatly reduce this risk. But the big benefit comes from increasing ‘herd immunity’ – if more children are protected, there will be a much smaller pool of susceptible children to pass on the virus, reducing its spread in the community. That means people most vulnerable to major complications (including pregnant women and grandparents) will also be protected.

Each year, the viruses that are most likely to cause flu are identified in advance and vaccines are made to match them as closely as possible. The vaccines are recommended by the World Health Organization (WHO).
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This year’s flu jab protects against:
H1N1 – the strain of flu that caused the swine flu pandemic in 2009
H3N2 – a strain of flu that can infect birds and mammals and was active in 2011
B/Wisconsin/1 – a strain of flu that was active in 2010

This will be the first non-injection flu vaccine for children – the national immunisation expert committee, the Joint Committee on Vaccination and Immunisation (JCVI), has recommended using a nasal spray for childhood immunisation. This will certainly make the procedure less uncomfortable for children, and the vaccine, called Fluenz® has now been used for several years in the USA. It has evidence from scientific trials involving 20,000 children, so we know it has a good safety record as well as being effective.

There are two elements to the children’s flu immunisation programme this year:
 a routine offer of vaccination to all two and three year olds (but not four years or older) on the 1 September 2013; and
 geographical pilots for four to ten year olds (up to and including pupils in school year 6).
Extending the flu programme to all children will involve considerable planning and work in order to obtain a high level of uptake. For this reason, the programme will be rolled out over a number of seasons and will include pilots, allowing Public Health England and NHS England time to ascertain the most effective way of implementing it.
The Department of Health has secured Fluenz® vaccine for use in 2013/14 to allow the roll-out of the programme to all two and three year olds through general practice, as well as through a small number of local geographical pilots targeted at four to ten year olds.
If you have any worries about the flu immunisation the following link may be useful

http://www.nhs.uk/Livewell/winterhealth/Pages/Flu-myths.aspx

 
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Posted by on August 23, 2013 in Training and Advice

 

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DOES THE NEW PRINCE HAVE COLIC?

Kate and William are having the necessary privacy with their baby  until even family around becomes too much and the natural feeling is to be in your own small family unit.

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I remember those early days with a newborn baby and it doesn’t matter how much you know, because you are now in a unique situation, your family unit is a one-off and whatever advice people around you give, at the end of the day it has to be appropriate to your personal situation. Nurturing a baby may be very easy or it can be unpredictably very difficult.

A crying baby is stressful and distressing to everyone and everybody has the answer!

One of the commonest reasons is infantile colic but what is this?

The definition of colic used by researchers is:
“A healthy, well-fed infant who cries for more than three hours per day, for more than three days per week, for more than three weeks
.”
We can’t explain it but talking to mothers and examining babies  we know that
imagecolic usually starts at about 2 weeks of age in a full-term infant (or later in a premature infant).
Colic almost always goes away by 3 or 4 months of age.
There is no difference in the prevalence of colic for boys and girls, whether you breastfeed or bottle feed, and whether the baby is first born or not.
Scientific studies have shown that children who had colic are no different in terms of personality, mental health, intelligence, etc., than children who never had colic.
Despite many scientific studies, no single common cause for colic has been found. Infantile colic has many different causes, and that’s why there is no one way to help it.
Many nurse, doctors, nannies have made hypotheses but nuone are well founded and I certainly it is no-ones fault!
Some of these theoretical causes:-
*Air (gas) in the intestinal tract
*Increased hormone levels that cause stomach aches or a fussy mood
*Hypersensitivity to a stimulation in the environment (sound, light, etc.)
*An intense temperament in the newborn period
*An immature nervous system
*An immature digestive system in which the intestinal muscles are often in spasm
*Digestive problems, perhaps due to intolerance of cow’s milk protein or lactose
*Reflux (heartburn due to stomach acid and milk flowing back into the oesophagus
Needless to say, if a mother or father is concerned it is reasonable to consult the Health Visitor and /or the GP in order to check if there is another reason for the excessive crying or to consider treatment for the colic.
Other reasons to be considered are:-
*An infection (for example: an ear or urinary infection)
*evidence of reflux or gastrointestinal distress
*pressure or inflammation of the brain and nervous system
*an eye problem (for example: a scratch or increased pressure)
*an abnormality of the rhythm of the heart
*a bone fracture
*a hernia
 *hair wrapped around a finger or toe
You will have advise from many sources but here are are few ideas that you may try on at a time
Different methods o sensory stimulation
*Swaddle your baby ( although with caution avoiding overheating,and caution around the hips
*Try more time in a front baby sling(the kind you wear over your chest).
*Take your baby for a ride in the car (but not when you are sleepy!).
*Put your baby in the car seat on or near the dishwasher or dryer (be careful the seat doesn’t vibrate and fall off!).
*Use “white noise” (such as static on the radio or the vacuum cleaner), classical music, or a “heartbeat tape” next to the crib.
*Try infant massage.
 *Try the baby with a dummy/ soother
*Soak baby in a warm bath.
*Try an infant swing.
*Increase or decrease the amount of stimulation in the environment.
Feeding
*Avoid eating certain foods (such as caffeine, milk, certain vegetables)
*Change the type of nipples on your baby’s bottle, use bottles with plastic liners, and wind  your baby frequently to decrease air swallowing during feedings or wind your baby less.
*If bottle feeding, try to limit milk intake, and if that doesn’t work, avoid limiting milk intake.
*If your baby is vomiting, keep him or her upright
The following are usually prescription only
*Change from one cow’s milk formula to another.
*Change from a cow’s milk formula to a soy formula.
*Change from a regular formula to a “predigested,” hypoallergenic formula.
*Add Lactase drops to the formula.
* Use of probiotics

And don’t forget your baby may just want to be put down!

If you are really getting nowhere it may be you need to try

*Anti-reflux medicines, if reflux is suspected, may cut down on acid production and/or help to move the milk downstream.

*Try giving the baby some herbal tea (e.g., chamomile, mint, fennel, verbena, but NOT star anise, which can be toxic).
*Use drops such as Infacol or Windeze which sometimes work but can also make things worse
*Try giving the baby “gripe water,” but check the ingredients first. Most contain only herbs, but some from Europe may have alcohol or even phenobarbital, which, of course, you should avoid.
*Although there is limited scientific evidence to support the use of homeopathic drops for colic, some parents report they have helped their colicky baby.
NOTE: Make sure to check with your GP of Health Visitor if you are needing to use medication.
Sometimes parents think an intervention has worked,, but it may be that the colic just got better on its own. And other times, parents don’t find an intervention that works well and they just have to wait for things to improve on  their own  at 4 months or so.
Beware of magic (and expensive) “cures” that are guaranteed to work for all babies. There is no such thing!
It is very challenging to have a baby with colic and you may feel despairing, inadequate and angry because you cant solve this problem. This is not unusual and you have not failed as a parent  : it will not last forever.
If you think your anger could get out of control and you could actually harm, shake, or strike your baby, get help right away.Put your baby in a safe place, like the crib, and leave the room. See if your spouse or a friend or neighbour can be with the baby while you get some space. Phone a Health visitor and she can talk with you on the phone or call to see you. Feel reassured that the surgery are always happy to fit a baby into a slot at anytime morning or evening and in the out of hours service babies are always considered a priority.

Here are some strategies to help you more gracefully survive this tough time:
Take a break! If you’ve tried everything and your little one is still crying away, it’s perfectly fine to put him to bed and let him continue to cry for a while without you holding him.
Let others care for your baby while you do something completely frivolous for yourself in the real world. Get out of the house for a while.
Don’t guilt trip yourself about this too much. You didn’t do anything to cause your baby’s colic.
Remember that this period in your baby’s life doesn’t last forever. You will get past this difficult stage.
Don’t go it alone! Seek support and help wherever you find it.
The following charity helpline may be useful:-
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CRY-SIS is a support group for families with excessively crying, sleepless, and demanding children. Their helpline is available every day from 9 a.m. to 10 p.m. Tel: 08451 228 669. The CRY-SIS website (www.cry-sis.org.uk) also contains useful information.
The stated aims remain ‘to be efficient and effective in providing self-help and support to families with excessively crying, sleepless and demanding babies’

When to Worry About Colic

Don’t hesitate to bring your baby to the GP to be rechecked for a possible medical cause of his crying, especially if:

*The baby is not feeding well and the weight is not following the same centile line.
*He has symptoms of a possible medical problem (e.g., fever, lethargy, decreased feeding)
*You are so distressed that you are worried you could hurt him
*The colic persists for more than 5 months
 
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Posted by on August 13, 2013 in Training and Advice

 

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THE PINK DRAGON IS REVEALED

Since I have let out  the secret concerning the dragons in the garden I have been asking the Dragon experts (children < 4yrs) a little more about what they see and the general consensus is that the most visible dragons are pink, blue or purple. I was a little surprised as I had not seen any of these.

Then…..
The other evening I was sitting quietly finishing off my paperwork and there was a knock on the window – yes you are right it was Denis and who was with him but a PINK dragon. I was a bit surprised and opened the door to meet his companion. ” This is my friend Polly. I haven’t seen her for ages but she called around and asked if I knew a doctor who wasn’t frightened of Dragons and could see her and I thought you would just the doctor,”said Denis.

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“Do come in and tell me what the  problem is” I said
Polly started to cry real dragon tears, ” I have lost all my dragon scales and I can’t stop scratching as my skin is so…..oo  itchy and now none of my friends  want to play with  me except Denis”
“Oh Polly don’t be too sad  I am sure I can help you.”  I looked carefully at her skin and the worst patches were behind her knees  and elbows and in other creases including under her chin.  “Doctors  call this  eczema which is sometimes caused by allergy  but often we don’t  know why. We must try and help you but you will have to listen very carefully and do what I say:-
Firstly you will have to stop using soaps, bubble baths or anything like that.
Then I will give you some special soft Dragon cream ( an emollient  such as Ultrabase, Diprobase, Dermol , Epaderm or Cetraban ) which comes either in a big pot or a bottle with a pump. It is VERY important that you don’t put your claws in the pot because if you do you will get germs in the cream and cream with germs in will make your skin much worse especially as the skin is so cracked. It is your cream and it is only you ,Polly that can use it so, Denis you cannot share it. Perhaps you could put a sticker on pot with your name on.
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If you have a pot you can use the handle of a spoon or spatula to scoop it out and put on your skin. You will need help from your mummy to put it on the places you can’t reach. Always put the dragon cream on in the direction of tour scales( in humans the direction of the hair) and don’t rub up and down because it will make you itch more. Perhaps you can play some quiet music or watch one of your favourite videos whilst she does it just something to make you feel calm and happy.

You must put this cream over the whole body and use plenty of it and do this 3 or even 4 times a day. If you feel itchy put some more on and perhaps you can have a small tube or pot to put on by yourself.
Also you can use this as a soap and in the shower or bath.

http://www.eczema.org/uploads/BAhbBlsHOgZmIjUyMDEzLzA2LzI4LzIxXzE4XzI5XzIzNF9FbW9sbGllbnRzX0p1bmVfMjAxMy5wZGY?format=pdf. (Eczema fact sheet

The next very important thing is TAP don’t SCRATCH so that this skin doesn’t break and become very sore. To remind you I will teach you a song.
imageSing after me:

( post man pat tune)

Tap don’t scratch , tap don’t scratch,
tap don’t scratch with an Itchy feeling
all the dragons singiing
And the itch is healing
And Polly is a really happy dragon
Now I have also noticed that some of the patches are very very bad so I am going to give you some SPECIAL DRAGON CREAM (steroid cream) in a smaller tube. This cream you must use very carefully only putting on small amounts twice a day and stop when the patch looks better.
If you follow this you will find that gradually your skin will get better and be softer and back to green just like  your mummy’s and Denis’s skin.
Take this paper(prescription ) to the pharmacy and come  back next week to tell me how you are getting on. “
Then Denis and Polly turned around and hand in hand danced down the garden singing their new song………
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For more information about eczema: http://www.eczema.org/factsheets

 
 

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Have you seen the Dragons in the surgery garden?

Don’t worry I haven’t lost the plot – read on

Introduction
Many people have talked about fairies at the bottom of the garden but I want to tell you about the dragons at the bottom of the surgery garden. You may be surprised at my letting out this long guarded secret but I felt it was time to let the secret out! They are very friendly and the young dragons often play with fox cubs and cats from next door. I have to say they only come out when all the patients and infact all the staff have gone home. I hadn’t told anyone and poor Dr Livingston got such a shock when they appeared one night when she was busy working after surgery had finished. I think she thought she was back in Wales as there are so many there but they are red and talk Welsh. The dragons in the garden are green and you can easily miss them.
I first came across red dragons in Wales : they are so important that the flag of Wales (Cymru) is a red dragon!!! ( Y Ddraig Goch) and has been for many years ( 1,184 years to be precise) ever since the red dragon conquered the white dragon .

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The story as written by Nennius a monk tells how young boy visited and revealed to King Vortigern, last of the Celtic kings of Britain that he had seen two serpents, one white and one red, who had been hidden deep underground fighting with fierce shrieking until finally the red one summoned his strength and drove the white one away.
The story is then explained by the mysterious child: “the two serpents are two dragons; the red serpent is your dragon, but the white serpent is the dragon of the people who occupy several provinces and districts of Britain, even almost from sea to sea: at length, however, our people shall rise and drive away the Saxon race from beyond the sea, whence they originally came.” The King then left North Wales where this event took place and built a castle in the South (on the Welsh/English border ) it was thought to be Caerwent, in Monmouthshire now part of Gwent.

It’s interesting that in February 2003 during his enthronement at Canterbury Cathedral Archbishop Rowan Williams ( a welshman from Monmouth wore hand-woven gold silk robes bearing a gold and silver clasp that showed the white dragon of England and the red dragon of Wales to symbolise the peace between the two countries.

The red dragons are very friendly now but do tend to breathe more fire if England is playing rugby against Wales!!

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Story strictly for children ( adults can only read under child guidance)

Here’s a picture of the family in the garden. If you can’t see them because of their green colour ask a 3/4 year old because they always manage to find them and some children have seen blue and purple ones aswell!
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Introduction
The family of dragons that live in the garden are Denis(means friendly) who is 5 years of age, his mother Daphne(because she was born under the laurel tree) and father Derek ( meaning ruler) and Dolcie ( means sweet one)who is just 6 months. I don’t know how they ended up living in the surgery garden but they do have a slightly Irish accent and they are green so perhaps Liz or Mary the nurse had something to do with it!
Also Derek’s brother is called Declan…..makes you wonder!

The Day Denis Dragon couldn’t breathe fire.

One evening last week when the sun was shining I was busily working and I suddenly heard a tap at the window. At first I thought it was the cat at the door miaowing for milk but when I  looked up I saw Denis Dragon looking very sad. I thought he had probably kicked his ball over the wall whilst playing with the cat and he wanted me to get it. I opened the doors to the garden and said , “What’s the matter Denis ?”
“Dr . Bayer I can’t br….br…. breathe fire.
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It was poor Denis, he was wheezing (not the cat miaowing) and he was very breathless and no fire was coming from his mouth. That is very serious for a dragon because breathing fire is very important to heat their food and keep themselves warm and keep dangerous creatures away.
The next thing his mother Daphne was scampering up the garden and looking very worried.
“Come inside both of you and don’t worry Denis I have a special steam machine which will make you better in no time and don’t be frightened because its a bit noisy. It sounds like Thomas the Tank Engine warming up before he trundles off to see Edward and Henry along the track.” I said

We walked slowly to the back room and I listened to Denis’s chest , counted his pulse on his wrist and how fast he was breathing and put a funny machine on his finger- it pinched a bit and the lights came on and numbers started appearing and I told Denis that I was measuring his Oxygen. It wasn’t long before I had set up the steam machine (adults call it a nebuliser)by squeezing some special medicine out of a tiny plastic bottle into a into a little cup and connecting by a tube to the machine. “Are you sitting comfortably,Denis?” I said and Denis shuffled a bit and held his mummy’s claw. I put the mask over his nose and mouth (a special one as dragons have big noses) and I switched the machine on. His mummy stayed with him all the time and as the steam puffed out Denis slowly felt much better and after we stopped the machine after about 5 minutes Denis was so happy to be feeling better that he gave a huge puff of fire so much that my tea nearly boiled out of the mug!

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Here is a picture of a little boy on a nebuliser

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” Now Denis that’s not the end of story, because your mummy has told me that for a little while she has noticed that you have been getting more and more tired, the fire you have been blowing has been getting less and less and at night you have been coughing all the time . It has been worse since the trees and flowers have been in flower showering out pollen. Also she noticed that when you were racing with the cat and fox cubs that you were nearly always last and were not wanting to play with them anymore. I think you have got something called asthma.
Human being children come to the surgery with this all the time and when we give them special medicine which they have to breathe in they get better and can play happily with their friends and start running as fast as their friends again and for young dragons they can breathe fire more easily.
The breathing medicines are called inhalers, because breathing in is called inhaling and the one I will give you is a blue one: it is called Ventolin and is called a reliever because it makes you better.
You must be very senlsible and never play games squirting it in the air and you don’t have to try it out first just shake it and you will hear the liquid in it swishing about.
It is very important that you use these inhalers whenever your chest feels tight and you need to give one to your teacher in case you start wheezing in school and remember to take it with you when you go out anywhere.
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This only relieves you for a short while and at this time of the year your chest will easily get tight so I think it is a good idea to take something to prevent or stop you getting wheezy.
Guess what we can give you another inhaler to do this and what do you think it’s a called? ”
Denis thought for a while , “is it a stopper?” said Denis.
Not quite I said. Try again, I said it prevents wheezing that’s a clue.
“I know it’s a preventer” shouted out Denis nearly singeing my hair with the fire he breathed out in excitement.
You must take this in the morning before school and when you get home in the evening.
There is just one thing I must show you with before I teach you to use the inhaler. When children including dragon children try to breathe in with the inhaler it is so hard a bit like when you were a baby and it was hard to drink out of a cup so we have special thing called an aerochamber and this makes it much easier. When you use the aerochamber your breathing will be much better and mummy will be very happy to see you much better and will give an extra special bear hug.
Infact here are the instructions shown by a friendly bear. I think dragon children like teddy bears to cuddle aswell!
Click on link……
imagehttp://frx.com/pi/AeroChamberPlusFlow-VuSmall-Medium_PI.pdf

 
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Posted by on July 18, 2013 in Training and Advice

 

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Rotavirus

Immunisation against rotavirus
 
There is an effective vaccine against rotavirus. The vaccine has been used in many countries and has been shown to be safe and effective.
 
In the UK it has now been decided to routinely vaccinate babies against rotavirus. From July 2013 babies will receive drops (by mouth) to help prevent rotavirus. These drops will be given at 2 and 3 months old. The vaccines will be given at the same time as their other routine vaccinations.
UK vaccination programme
The oral vaccine is expected to halve the number of cases of vomiting and diarrhoea caused by rotavirus and lead to 70% fewer hospital stays. 
The following sites will tell you more
 
 
 
What is rotavirus?image
Around 18,000 children are thought to be admitted to hospital each year in England and Wales because of rotavirus infection. Most children with rotavirus infection do not need admission to hospital. About 1 child in 10 who has rotavirus infection needs to be admitted to hospital.
Rotavirus is a viral infection that can cause gastroenteritis. Gastroenteritis is an infection of the gut (intestines) which usually causes symptoms of being sick (vomiting) and diarrhoea.  In most cases the infection clears within a few days, but sometimes takes longer. The main risk is a lack of fluid in the body (dehydration) and so the main treatment is to give your child lots to drink. It mainly affects young children, especially children between the ages of 6 months and 2 years.
With vomiting and diarrhoea, there is a risk of your child becoming lacking in fluid in their body (dehydrated). You should consult a doctor quickly if you suspect that your child is becoming dehydrated. Mild dehydration is common and is usually easily and quickly treated by drinking lots of fluids. Severe dehydration can be fatal unless quickly treated because the organs of the body need a certain amount of fluid to work normally.
 
Symptoms of dehydration – associated with any cause of gastroenteritis
In children symptoms include passing little urine, a dry mouth, a dry tongue and lips, fewer tears when crying, sunken eyes, weakness, being irritable or having no energy.
Symptoms also include drowsiness, pale or mottled skin, cold hands or feet, very few wet nappies, and fast (but often shallow) breathing. This is a medical emergency and immediate medical attention.
 
Fluids to prevent dehydration
You should encourage your child to drink plenty. The aim is to prevent dehydration. The fluid lost in what they bring up (their vomit) and/or their diarrhoea needs to be replaced. Your child should continue with their normal diet and usual drinks. In addition, they should also be encouraged to drink extra fluids. However, avoid fruit juices or fizzy drinks, as these can make diarrhoea worse.
If your child is mildly dehydrated, this may be treated by giving them rehydration drinks. Your doctor or nurse will advise about how to make up the drinks and about how much to give. This can depend on the age and the weight of your child. If you are breast-feeding, you should continue with this during this time. Otherwise, don’t give your child any other drinks unless the doctor or nurse has said that this is OK. It is important that your child is rehydrated before they have any solid food.
 
Babies under 6 months old are at increased risk of dehydration. You should seek medical advice if they develop gastroenteritis. Breast or bottle feeds should be encouraged as normal. You may find that your baby’s demand for feeds increases. You may also be advised to give extra fluids (either water or rehydration drinks) in between feeds.
 
Rehydration drinks may be advised by a healthcare professional for children not drinking enough or with severe diarrhoea and vomiting; especially if they have passed six or more very loose stools (faeces) or vomited three or more times in the previous 24 hours. They are made from sachets available from pharmacies and on prescription. You should be given instructions about how much to give. Rehydration drinks provide a perfect balance of water, salts, and sugar. The small amount of sugar and salt helps water to be absorbed better from the gut (intestines) into the body. Do not use home-made salt/sugar drinks, as the quantity of salt and sugar has to be exact.
 
If your child vomits, wait 5-10 minutes and then start giving drinks again, but more slowly (for example, a spoonful every 2-3 minutes). Use of a syringe can help in younger children who may not be able to take sips.
 
Note: if you suspect that your child is dehydrated, or is becoming dehydrated, you should seek medical advice urgently.
 
Sometimes a child may need to be admitted to hospital for treatment if they are dehydrated. Treatment in hospital usually involves giving rehydration solution via a special tube called a nasogastric tube. This tube passes through your child’s nose, down their throat and directly into their stomach. An alternative treatment is with fluids given directly into a vein (intravenous fluids).
 
Eat as normally as possible once any dehydration has been treated
Correcting any dehydration is the first priority. However, if your child is not dehydrated (most cases), or once any dehydration has been corrected, then encourage your child to have their normal diet. Do not ‘starve’ a child with rotavirus infection. This used to be advised but is now known to be wrong. 
 
Breast-fed babies should continue to be breast-fed if they will take it. This will usually be in addition to extra rehydration drinks (described above).
Bottle-fed babies should be fed with their normal full-strength feeds if they will take it. Again, this will usually be in addition to extra rehydration drinks (described above).
Older children – offer them some food every now and then. However, if he or she does not want to eat, that is fine. Drinks are the most important, and food can wait until the appetite returns.
Medication is not usually needed
You should not give medicines to stop diarrhoea to children under 12 years old. They are unsafe to give to children, due to possible serious complications. However, you can give paracetamol or ibuprofen to ease a high temperature (fever) or headache.
 
How is rotavirus spread?
Rotavirus is present in the gut (intestines) of an infected person and can pass out in their diarrhoea. It is easily spread from an infected person to another by close contact. This is often because the virus is on the infected person’s hands after they have been to the toilet. For smaller children who wear nappies, it may be spread by the hands of the person changing the infected child’s nappy. Surfaces or objects touched by the infected person can also allow the virus to spread. The virus can be passed on if the infected person prepares food. Outbreaks of rotavirus that affect many people can occur – for example, in nurseries or schools.
 
NB Although this is advise in a case of Rotavirus  the same advice should be followed in all cases of gastroenteritis. 
 
 

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