Gastroenteritis

An outbreak of viral gastroenteritis has been sweeping through Haiti this month and for the past 10 days, we at GLA have been feeling the effects of the epidemic, with dozens of babies, volunteers and staff coming down with diarrhoea, vomiting, headache and fever.

Gastoenteritis is one of the most common childhood illnesses world-wide. While in the developed world, symptoms are usually mild and the child recovers without any lasting effects, malnutrition and parasites make Haitian children more susceptible to severe dehydration and other life-threatening complications of diarrhoeal diseases. For this reason, the treatment of acute gastroenteritis is approached slightly differently here, than it would be in Western Europe or North America.

One major difference is that we never do blood draws on children who have diarrhoea and vomiting. In the developed world, clinical chemistry results (levels of sodium, potassium, glucose acid and bicarbonate in the blood) sometimes guide the type of fluids that are given and how quickly children are re-hydrated. These tests though, are unhelpful in here; there are no labs in our area and even if we did send a sample for analysis, it would take up to 24 hours to get the results. That is too long when you are dealing with a child who needs treatment right away.

Although we can't be certain if a child has normal, raised or lowered levels of electrolytes in their blood (all of which can occur when a child has severe gastroenteritis) , it is possible to make a reasonable guess, based on how the child looks and what their vital signs are doing. Assessments such as how moist their skin and mouth is, whether their eyes or fontanelle are sunken and how cold their hands and feet are, also indicate how dehydrated a child might be. For a more objective measure of dehydration, I weigh the children and compare their weight on the day they present to the last weight that was recorded for them. The children here are weighed once a week and this is very helpful when they get sick.

The main focus is then on making sure the child stays well hydrated by replacing fluid, salts and sugars. This is done either with an Oral rehydration solution (ORS) or with IV fluids. In over 90% of cases, we successfully rehydrate our children orally, even when the dehydration is severe. The nurses and nanny's here are very experienced in treating gastroenteritis.

If the child is vomiting, we often give anti-emetics. Although we don't usually do this in Scotland, it is routine, in Haiti, to give oral medications such as Reglan for gastroenteritis and I find that they usually work. I am in favour of this approach because anti-emetics seem not only to help the children feel better but they also make oral rehydration possible. For children who can tolerate ORS, we can then rehydrate them safely and more rapidly than we could with an IV. Typically, we are able to hydrate the children in as little as 4 hours. The majority of children who have viral illnesses are then able to tolerate small amounts of their usual milk formula or familiar foods, and this speeds their recovery.

In other cases, the child vomits persistently or is too sleepy to drink. For these children, IV fluids are usually the best option. During the current outbreak of gastroenteritis, we have had only 1 (medically fragile) child on an IV. That child returned to his nursery 48 hours later, completely recovered.

Another baby was able to drink but just didn't want to. I considered it important for this baby's recovery, to continue feeding him, and so we used a Naso-Gastric feeding tube to rehydrate him. He is now on his regular formula and he is eating well.

Since many Haitian children have or have had parasites which can cause diarrhoea, we give de-worming medications to all children with diarrhoea unless they have been treated have received treatment for intestinal parasites in the previous 6 months. Since many of the bacteria and parasites that affect Haitian children damage the gut and cause lactose intolerance (which makes the diarrhoea worse), our children are often switched to a soy formula, which they continue on for 2 weeks after the diarrhoea stops. These children are also given SMECTA, a French product that binds to the mucous lining of the gut, strengthening its defences against toxins.

We also give pre-biotics such as acidophilus, when we have them. These are proven to help reduce the duration of many diarrhoeal infections. Since most cases of gastroenteritis are viral, we usually do not start antibiotics for diarrhoea that lasts for less than a week. However, because this is Haiti, we are very aware that gastroenteritis is more likely to be caused by bacterial or protozol infections. It is routine to give medications for both types of infection at the same time. After all the children have usually been unwell for several days before they begin antibiotics and by this point, we can be reasonably sure that they need an antibiotic, and we want to make sure that what we give works as soon as possible.

In the 5 months have been here, we have nursed many children through severe gastroenteritis. I am thankful that we have been able to do that, but I am ever mindful of the children who live in impoverished communities beyond our walls. Many of these children drink contaminated water. They are malnourished and full of parasites and they have no access to medical care. For them, gastroenteritis, a condition that is both treatable and preventable can be, and all too often is, fatal.