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Issue 9 of 2015

Gastroenteritis is the inflammation of the stomach and intestines (gut).
It is a common condition. Many children
(from birth to 12 years) have more than one episode in a year.
The severity can range from a mild, upset tummy
with mild diarrhoea for a day or two, to severe diarrhoea and
vomiting for several days or longer.
This Script is mainly for all types of diarrhoeal diseases.
CMScript Member of a medical scheme?
Know your guaranteed benefits!
Issue 9 of 2015

Causes of gastroenteritis
Infection - gastro-enteritis can be a symptom of infections
caused by many viruses, bacteria and other microbes
(germs) most of which are spread by stools (faeces) contaminated
water. Infection is more common when there is a
shortage of adequate sanitation hygiene and safe water for
drinking, cooking and cleaning. Rotavirus and Escherichia
coli are the two most common germs that cause diarrhoea
in developing countries.
Diarrhoeal disease can spread from person-to-person,
aggravated by poor personal hygiene. Food is another
major cause of diarrhoea when it is prepared or stored in
unhygienic conditions. Water can contaminate food during
irrigation. Fish and seafood from polluted water may also
contribute to the disease.
Malnutrition - Children who die from diarrhoea often suffer
from underlying malnutrition which makes them more
vulnerable to diarrhoea. Each episode of diarrhoea makes
their malnutrition even worse.
Other causes – Other non-infectious causes of gastroenteritis
include irritating foods or fluids (allergy-like reactions),
congenital (inborn) disease and stress.

Signs and symptoms
The main symptom is diarrhoea. Diarrhoea means loose or
watery stools, usually at least three times in a 24 hour period.
Blood or mucus can appear in the stools with some infections.
Vomiting is also another symptom. Crampy pains
in the tummy (abdomen) are common. Pains may ease for
a while each time some diarrhoea is passed. A high temperature
(fever), headache and aching limbs sometimes
occur. The greatest danger presented by gastroenteritis is
dehydration.
Symptoms of dehydration in children include passing little
urine; a dry mouth; a dry tongue and lips; fewer tears when
crying; sunken eyes; weakness; being irritable or lacking in
energy (lethargic). In infants a sunken fontanelle (taught in
antenatal clinics to all new mothers) is an important sign!
Symptoms of severe dehydration in children include drowsiness;
pale skin; cold hands or feet; very few wet nappies;
fast (but often shallow) breathing. Severe dehydration is
a medical emergency and immediate medical attention is
needed. Death can follow severe dehydration if body fluids
and electrolytes are not replenished, either through the
use of oral rehydration salts (ORS) solution, or through an
intravenous drip.

Diagnosis
The symptoms of gastroenteritis are usually enough to
identify the illness. Parents and caregivers should suspect
gastroenteritis if there is a sudden change in stool consistency
to loose or watery stools, and/or a sudden onset of
vomiting. It is important to find the cause as different types
of the condition respond to a variety of treatments. Health
professionals make a diagnosis based on the history provided
by parents/caregivers and physical examination. In
certain cases, stools and blood tests may be needed to establish
the cause of the gastro-enteritis.

Treatment
Oral rehydration therapy (ORT) - should be given as first
step treatment for the management of children with acute
gastroenteritis with mild to moderate dehydration. ORT is a
means of fluid replacement to treat and prevent dehydration.
The treatment is cost-effective and can be continued
at home. There are various types available in the market.
The picture below shows how to prepare ORT at home,
with water that has been boiled and then cooled:
https://flutrackers.com/forum/filedata/fetch?id=664030&d=1171765909

Nutrition and feeding - Early nutritional intervention
is important to avoid malnutrition, persistent
diarrhoea and death. At first, it may be
necessary to give smaller amounts of feeds
more frequently to avoid vomiting. The child
may initially be unable to take full feeds and may
lose weight, but the aim is to achieve full-volume
feeding within 1 - 2 days. There is no need to
dilute or otherwise modify the usual feeds, provided
that they are tolerated. Breast-fed babies
should continue to be breast-fed if they are able
to take it. Bottle-fed babies should be fed with
their normal full-strength feeds if they will take them. Fruit
juices or fizzy drinks should be avoided as these can make
diarrhoea worse.

Micronutrients - These are nutrients needed by the body
in small amounts. Zinc supplements reduce the duration
of a diarrhoea episode. There are various products in the
market. Avoid iron supplements or supplements containing
iron.

When to seek medical advice
Most children who have gastroenteritis have mild symptoms
which will get better in a few days. The important thing is to
ensure that they have plenty of liquids to drink. However
medical advice should be sought in the following situations:
• The child is under the age of 6 months
• There is an underlying medical condition (for example,
heart or kidney problems, diabetes, and history of premature
birth)
• The child has a high temperature (fever)
• Lack of fluid in the body (dehydration) is suspected or
developing
• The child appears drowsy or confused
• The child is being sick (vomiting) and unable to keep
fluids down
• There is blood in the diarrhoea or vomit
• The child has severe tummy (abdominal) pain
• Infections caught abroad or whilst visiting other countries
• The child has severe symptoms, or if you feel that their
condition is getting worse
• The symptoms are not settling (for example, vomiting
for more than 1-2 days, or diarrhoea that does not settle
after 3-4 days)
Prevention
• Full and exclusive breast-feeding on demand. It protects
against intestinal infections and prevents exposure
to environmental contamination.
• Access to safe water for drinking and food preparation,
and use of proper sanitation facilities.
• Proper hand-washing hygiene with soap and water after
toilet use, playing with pets, before food preparation
and feeding.
• Full immunisation including rotavirus vaccines. The
new rotavirus vaccines are safe and reduce the severity
of infection and prevent deaths.
Prescribed Minimum Benefits
Gastroenteritis is a Prescribed Minimum Benefit condition
under Diagnostic Treatment Pair (DTP) code 901F. The
DTP refers to gastroenteritis and colitis with life-threatening
haemorrhage (bleeding) or dehydration, regardless of
cause. The treatment component of this DTP is specified
as Medical management.

Regarding medical management, it means that the medical
scheme should pay for the diagnosis, treatment and care of
gastroenteritis according to the PMB regulation. Treatment
and care includes medication, pathology (blood tests), radiology
(abdominal x-ray and sonar) and other investigative
and monitoring services.
In case of children not admitted to the hospital, medical
management should still be funded as PMB. Payment of
PMBs from the Medical Savings Account (MSA) contravenes
Regulation 10 (6) of the Medical Schemes Act. It is
important for the treating provider to register the member
with the medical scheme for services rendered to allow
payment of health services from the correct benefit. The
members must still take the responsibility to ensure that the
form to be completed by the treating health provider is obtained
from the medical scheme. Once it is completed, the
member must ensure that the form is submitted to the medical
scheme. The medical scheme should however assist
the members with the registration process regarding PMBs.

References
Dorland, 2011. Dorland’s Illustrated Medical Dictionary, 32e
(Dorland’s Medical Dictionary). 32nd Edition. Saunders.
Steele, AD and Glass, R. 2011. Rotavirus in South Africa:
From discovery to vaccine introduction. South African Journal
Epidemiology Infect, 26(4)(Part I):184-190.
Wittenberg, DF. 2012. Management guidelines for acute
infective diarrhoea/ gastroenteritis in infants. South African
Medical Journal, 102 (2): 104 – 107.
World Health Organization. 2013. Diarrhoeal disease.
2015. [ONLINE] Available at: http://www.who.int/mediacentre/
factsheets/fs330/en/. [Accessed 7 October 2015]
Gastroenteritis in Children. Treatment and causes; information
| Patient. 2015. [ONLINE] Available at: http://patient.
info/health/gastroenteritis-in-children-leaflet. [Accessed
7 October 2015]