WhiteCoat

Do As I Say …

Pediatricians hate treating kids for diarrhea.

The theory is that if you give children medications to slow down the diarrhea, that any infectious organism in the colon will have more time to multiply, will overgrow, and will, in turn, worsen the infection.

When children come in with diarrhea, they’re miserable, their parents are miserable, and they just want some help to feel better. Unfortunately, there’s not much on the market for treating diarrhea in children aside from probiotics or antibiotics in certain cases. Imodium elixir has dosing guidelines for kids, but many doctors shy away from recommending it. The goal is to use Oral Rehydration Therapy to get more in the mouth than comes out the other end.

Ditto for vomiting. Emetrol may help and is over the counter, but is essentially glorified sugar water. The only other medications to treat vomiting in children are prescription meds. Even the number of available prescription antiemetic medications has been narrowed considerably. Many pediatricians do not like giving children antiemetic medications unless children are dehydrated because there is a risk of “side effects” (although this study suggests otherwise, as does this Cochrane review). By the way, the “side effects” argument was the same one that pediatricians used to get most children’s cold medications taken off the market.

Here’s one About.com article on treating vomiting and diarrhea in kids.

One pediatrician on staff intermittently raises hell during medical staff meetings because emergency physicians have the gall to give children medications to treat diarrhea and vomiting. He repeatedly suggests that the ED docs “read up on” treatment of vomiting and diarrhea.

With a run on gastroenteritis in the community, this same pediatrician apparently thinks that vomiting and diarrhea of less than one day’s duration are impending emergencies. When parents are asked why what prompted them to bring their kids in for evaluation of diarrhea, they repeatedly say that they called the pediatrician and were told to go to the emergency department.

Because we aren’t supposed to give medications for vomiting or for diarrhea in children who are not dehydrated, I am now making it a habit to call the pediatrician when patients arrive – to let him know they got there and to ask what he wants me to do in the ED. I also call when the patients are discharged to let him know I have told them to follow up in the office tomorrow to make sure that they still aren’t dehydrated.

Kind of feel bad when we keep waking him up in the middle of the night for multiple patients – especially after being called by the parents as well, but through our conscientiousness, I’m hopeful that he will give the ED a better review during the next medical staff meeting.

17 Responses to “Do As I Say …”

  1. Christine says:

    We often give benadryl to kids for vomiting.

  2. 08armydoc says:

    Bahaha! In a way, I feel bad for that pediatrician, but then again, he brought it on himself!

    Tell him to put up or shut up: give you all a CME lecture on gastroenteritis in kids!

  3. WarmSocks says:

    Reading medblogs sure has opened my eyes as to what some people consider an emergency. When I was a kid, vomitting meant you needed to stay in bed, sip 7-up, and get some sleep. Diarrhea called for kaopectate or grated apple. I don’t think we ever went to any doctor for those things. Doctors were for broken bones. I give my kids gatorade. No doctor’s visits for simple illnesses; I don’t need them getting sick in the car.

  4. William the Coroner says:

    Uh, what side effects? I mean, there are side effects and there are side effects. Drowsiness that’s a side effect of Benadryl. Not to concerning. Flash pulmonary edema is a side effect of opiates. Big problem. So what side effects are they worried about?

    My patients never have side effects. I’m so blessed.

  5. California Peds says:

    As a Pediatrician – my opinion is that most vomiting and diarrhea are laundry problems, not medical problems. Unless the kid is getting dehydrated – then by all means treat the kid!!!

    • WhiteCoat says:

      I agree, but I’ve also had 4 kids and know how helpless the feeling is when your kid is sitting there puking his or her guts out and there’s nothing you can do except hold the bucket. I’d rather help them out rather than say “Oh well, looks like more laundry for you tonight.”

  6. whitecap nurse says:

    california peds – you are so right! Every episode of vomiting=1 load of laundry until your kids reach that milestone that is more important than walking or talking – making it to the bathroom to vomit!

  7. ERP says:

    I give EVERY kid down to the age of about 8 months Zofran for vomiting and have great success with it and have never had an adverse reaction. Imodium I will give to kids over 2 if the diarrhoea is severe. Generally the pediatricians (with a few annoying over-the-hill exceptions) at my hospital are happy that I just made the kid better and did not bother them in the first place.

  8. tyro says:

    I still don’t treat diarrhea but we give Zofran out pretty regularly unless under 1; to be honest, I haven’t seen that many kids under 1 with serious vomiting that isn’t concerning for pyloric stenosis or some other badness, but for the kids that are a little bigger, why not? Even if you do work them up for intussusseption (can never spell that) you should still treat them in the ED. For Pete’s sake.

  9. tyro says:

    Oh, and my favorite pediatrician referral? 8 yo girl, perfectly healthy, has a small lump over her shin 2 months after falling on a bike pedal; normal vitals, normal gait, normal exam except a painless bump, no redness, no pain. Sent for an ED hematology consult and orthopedics consult. Friday afternoon at 4:30.

  10. I admire your diligence…

  11. flightdoc says:

    Will have to remember this as I start EM residency in July…

  12. ERP says:

    When I was a resident I would sit there in disbelief when I did my peds ER rotation. In this particular ER, the peds ER treated people up to age 21. In the other hospital where I worked, the peds ER treated up to age 17. In the one where kids were defined up to age 21, they (the old Peds ER attendings) would let these 19 year olds sit there puking and crapping themselves trying to encourage PO hydration. Whatever. Give him some friggin’ meds and make him better!

  13. Don’t F with the night guy

  14. defendUSA says:

    A laundry problem is right…but!

    With four kids myself, and one who who had a rotavirus, yikes. She screamed bloody murder anytime she had to urinate or poop.
    The NP told me not to use anti-diarrhea meds but after three days I finally did, if only to give her some respite from the flaming fanny and time for the paste to work because nothing else did. She 16 months old and sick for 6 days. Diarrhea in kids sucks.

  15. defendUSA says:

    Ooops, the triple paste is what I was referring to….

  16. DreamingTree says:

    WhiteCoat, you are my hero.

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