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Management of childhood gastroenteritis in the community

Perceptions of general practitioners

Jennifer E Porteous, Richard L Henry, Edward V O'Loughlin, Malcolm Ireland, J Lynn Francis and Robyn G Hankin

Electronically published Thursday 12 June 1997. Please submit comments by Thursday 10 July 1997.


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Abstract - Introduction - Methods - Analyses - Results - Discussion - Acknowledgments - References - Authors' details - Table 1 - Table 2 - Box 1 - Box 2


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Abstract

 Objective: To examine the stated practices of general practitioners (GPs) in managing childhood gastroenteritis and their perceptions about barriers to its optimal management.
Design: Cross sectional postal survey.
Setting: General practice in 1994.
Participants: All 422 urban and rural GPs practising in the Hunter Region were invited to participate. 289 (68%) responded.
Results: 97% of GPs recommended clear fluids in the management of childhood gastroenteritis, with 195 recommending oral electrolyte solution (OES). 170 GPs (59%) were assessed by an expert as managing gastroenteritis well, while an additional 33 (11%) managed gastroenteritis acceptably. 38 GPs (13%) suggested management that an expert considered inadvisable and/or potentially dangerous; and 48 (17%) provided answers that were too vague to classify. Multiple logistic regression analysis indicated that better management strategies were associated with being younger and practising in rural areas. The main barriers to effective care in gastroenteritis, as perceived by the GPs, were inadequate parenting skills (n= 131, 45%), lack of parental understanding about gastroenteritis (n= 118, 41%), other social problems (n= 67, 23%), parental anxiety (n= 57, 20%) and conflicting advice given by others (n= 42, 15%). Only 33 (11%) identified the taste of OES as a major barrier and 16 (6%) its cost.
Conclusions: Most GPs made appropriate use of dilute clear fluids and avoided prescription medication when treating childhood gastroenteritis in the community. Perceived barriers to the effective management of gastroenteritis tended to reflect parental factors.
©MJA 1997

 

Introduction

 Gastroenteritis is a common childhood condition and an important public health issue, accounting for up to 20% of all casualty presentations1 and, in New South Wales, 3%-6% of all hospital admissions in the 0 to 14 year age group.2,3 While overseas data indicate that one in ten children will suffer a significant episode of gastroenteritis in each of their first two years of life, 4,5 Australian figures suggest that medical attention may be sought for up to 50% of children under the age of four.6

The majority of children admitted to hospital with gastroenteritis see a general practitioner (GP) at least once during the course of their illness.3-5,7 Unfortunately many of these children have received antibiotics, antiemetics or antidiarrhoeal medications.3,7-10 Moreover, despite the proven efficacy of oral electrolyte solution (OES) in the ambulatory setting11,12 its usage is still low.3,7,10,13 A recent Australian study estimated that 85% of children admitted to hospital and managed with intravenous fluids could have been managed just as effectively with oral rehydration measures at the primary care level.3

Most of these studies have been hospital-based. However, the children who present to hospital with gastroenteritis may represent a very biased sub-group and the severity of their illness and the pre-hospital management is unlikely to be representative of the wider disease spectrum and treatment practices existing in the society.14 Furthermore inappropriate or suboptimal management practices observed within the community may not always be a direct result of the practitioner's advice. A substantial proportion of parents will not use oral rehydration measures even when recommended by their GP.3

We sought to address these issues by undertaking a cross-sectional study of GPs' reported management of gastroenteritis at the primary care level, and exploring those GPs' perceptions of barriers to achieving optimal care of childhood gastroenteritis in the community.  

Methods

 In the middle of 1994 (before the rotavirus epidemic), all 422 urban and rural GPs practising in the Hunter Region were forwarded a brief self-completion questionnaire together with a reply-paid envelope. Demographic details (age, sex, years since graduation), and information pertaining to the GPs' workload and practice profile (average number of patients seen per week, proportion of patients aged six years and less) were collected. GPs were presented with a case vignette of a previously well two-year-old child with mild to moderate vomiting and diarrhoea (see Box 1) and asked to describe the advice they would give the child's parent. Finally, GPs were asked to describe the nature of the barriers or difficulties they had experienced in managing childhood gastroenteritis in the community.

1: Case vignette
A two-year-old boy, John, is brought to see you by his 26-year-old mother. The family is well known to the practice. His mother has always struck you as a sensible woman and she has two older children aged 4 and 6. The rest of the family are well. John started vomiting 24 hours previously and has had three vomits since then. In the last 12 hours he has had six loose watery stools with no blood or mucus. His urine volume is less than usual but he has passed urine twice in the past six hours. He is not clinically dehydrated. His abdomen is soft. His temperature is 37.4C and his pulse rate is 120. Physical examination is otherwise normal. What treatment/management and/or plan of action would you recommend?

Reminder letters and replacement questionnaires were sent to non-responders at two to three weekly intervals as required. The study protocol was approved by the Hunter Area Health Service and The University of Newcastle Ethics Committees.  

Analyses

 Each GP's reported management strategy was judged by a paediatric gastroenterologist (EVO) against published guidelines.1,13 It was categorised as

1. optimal (OES recommended, and all other management strategies appropriate);

2. acceptable (no mention of OES but evidence of appropriately diluted fluids with no inappropriate treatment options);

3. potentially dangerous and/or inappropriate (eg recommending the use of an antiemetic, antidiarrhoeal or antibiotic, nil by mouth, undiluted fluids or inappropriately diluted fluids such as fruit juice, cordial or half strength lemonade); and

4. too vague to be classified.

Box 2 summarises optimal management of gastroenteritis.

2: Optimal management for gastroenteritis
  • Think of an alternative diagnosis when temperature is above 39 , protracted bilious vomiting, surgical signs in the abdomen, severe abdominal pain.
  • Oral electrolyte solution (eg Gastrolyte, Repalyte) is the ideal treatment. However in a non dehydrated child diluted juice or carbonated drinks (one part to three parts water) or cordial (even more diluted) are reasonable alternatives.
  • Antiemetics and antidiarrhoeals are contraindicated and antibiotics are of use only for shigella, giardia or in septicaemic illness.
  • Breast feeding should continue with extra fluids in between and children on formulae and other diets should not be fasted for more than 24 hours.
  • Refer to hospital for intravenous fluids if child is moderately dehydrated or has protracted vomiting (in particular) and/or diarrhoea.

Data was analysed using the SAS and STATA statistical software packages. Descriptive statistics are given in terms of means ± SD if normally distributed, or medians and interquartile range (IQR) if significantly skewed. Two way analyses using Kruskal-Wallis statistics were conducted to explore the relationship between the reported management strategy with age; years since graduation; average number of hours worked per week; average number of patients seen per week; and percentage of patients seen aged six years and less. The relationship with the categorical variables gender and location of practice (urban/rural) were examined using an exact test for trend (StatXact v2, 1992, Cytel Software). Multiple logistic regression was used to assess the independent effect of each of these factors on the GP's stated management strategy after controlling for potential confounders. Statistical significance was set at the conventional p < 0.05.  

Results

Response rates and sociodemographic characteristics of respondents

Some 289 of the 422 GPs (68%) returned completed questionnaires. 243 (84%) were practising in urban Newcastle. Sixty five percent of the GPs (n= 187) were male. The mean age of respondents was 43.3 (±10.9) years). Participating GPs had graduated, on average, 18.3 (±10.2) years previously (median 16); worked 42 (±19) hours per week (median 44); saw 133 (±64) patients per week (median 130); and had 14.5% (±9.1%) of their patients aged six years or less (median 12%). No data was available for non-respondents.

Management strategies

Most GPs (n= 280,97%) recommended the use of clear fluids when treating vomiting and diarrhoea, with two thirds (n= 195) specifically mentioning OES. One hundred and forty five indicated OES should be given routinely, with the remainder suggesting it should be given "if tolerated" or "if the diarrhoea gets worse". Fifteen percent of GPs (n= 43) recommended water alone. Inappropriate and potentially dangerous advice regarding fluid replacement was given by a minority of GPs ( < 5%), with 13 suggesting half strength or full strength lemonade. The number of GPs who indicated they would prescribe antibiotics, antiemetics, and antidiarrhoeals was only one, seven and seven respectively.

Advice to modify the child's diet was frequently given. Eight percent of GPs (n= 24) suggested the child stop eating for 12-24 hours, while 18% (n= 52) recommended a bland and/or light diet. Twenty-two percent of GPs (n= 64) suggested the child should avoid milk and other dairy foods during the course of the illness.

Twenty-nine percent of GPs (n= 85) indicated they would routinely review the child's progress, usually within 12-24 hours. Many GPs (n= 120, 42%) suggested they would review the child if the parents "had concerns". Five percent of GPs (n= 14) reported that they would weigh the child, and three percent (n= 8) indicated they would obtain a stool culture.

Twenty-four percent of GPs (n= 70) indicated they would advise the parents what to look for in terms of signs and symptoms of dehydration. Seventeen percent (n= 49) would suggest that the parents try to monitor the child's urine output, with another 11% ( n= 33) asking parents to monitor the child's total fluid balance.

Assessment of management strategies

The majority of GPs (n= 170, 60%) were regarded by an expert (EVO) as recommending optimal management. A further 11% of GPs (n= 33) gave advice that was considered acceptable and appropriate. Thirteen percent of GPs (n= 38) suggested inappropriate or potentially dangerous management, including the use of antiemetics, antidiarrhoeals, antibiotics, restricting children to nil by mouth, using inappropriately diluted fluids or adding lemonade to OES to make it taste better. The remaining GPs (n= 48, 17%) gave advice such as "give clear fluids" or "rehydrate" that was simply too vague to classify into the aforementioned categories.

Table 1 summarises the results of the two way analyses after excluding cases considered to have "vague" descriptions of management strategies (n= 48). Younger practitioners, practitioners graduating more recently and those seeing a greater proportion of children in their practice were more likely to report optimal management. Rural GPs not only saw a greater number of children with vomiting and diarrhoea per month (8 versus 10, Wilcoxon rank sum z = 3.18, P= 0.001) but were more likely to report optimal management strategies compared with their urban counterparts (87% vs 67% optimal, 15% vs 8% acceptable, 18% vs 5% inappropriate advice; standardised trend statistic = 2.48, P= 0.01). Female GPs offered more optimal and less inappropriate advice compared with male GPs (69% vs 54% optimal, 11% vs 12% acceptable, and 8% vs 16% inappropriate advice; standardised trend statistic = 2.15, P= 0.04).

1: Factors associated with reporting optimal, acceptable and poor management strategies for gastroenteritis
Strategy
"optimal"
"acceptable"
"poor"
Kruskal-Wallis P value
medianIQRmedianIQRmedianIQR(df=2)
Age (years)4035-464234-484844-5717.60.0001
Years since graduation1510-22159-202116-3014.10.001
Number of children seen each month with gastroenteritis53-1064-1053-101.2NS
Number of patients seen each week13090-17012085-150130100-1601.6NS
% of patients aged 6 years or less1310-201510-20105-157.10.03
 

 

The multiple logistic regression model controlled for gender and the average number of children seen with vomiting and diarrhoea per month (not independent predictors), and had age of the GP and location of the practice (urban/rural) as significant independent predictors of optimal management. GPs from rural areas offered optimal advice 20% more frequently than their urban colleagues, while for each additional decade of age, 9% fewer GPs offered optimal advice. The corresponding odds ratios and confidence intervals are OR 4.17 (95% CI 1.5-11.8) for location of practice, and OR 0.63 (95% CI 0.45-0.87) for age. The model was not sensitive to the inclusion or exclusion of the group whose management strategies were too vague to classify. They were not included in the aforementioned model.

Perceived barriers to optimal management as seen by GPs

Ninety-nine percent of GPs (n= 260) indicated that they had experienced difficulty with giving advice to parents about management of gastroenteritis. These are summarised in Table 2.

2: GPs perceptions of the major barriers to the effective management of childhood gastroenteritis in the community
BarrierNo of GPs%
Inadequate parenting skills13145
Inadequate parental understanding11841
Other social problems6723
Parental anxiety 5720
Conflicting advice 4215
Taste of OES3311
Cost of OES166

A number of issues contributed to "poor parental understanding". Many GPs believed that at least some of their parents had difficulty grasping the basic concepts of the disease process, and had concerns about whether those parents would recognise if their child's condition was deteriorating. GPs perceived that at least some parents expected a "quick fix", anticipating that the child's illness could be cured with antibiotics. At times parents were considered to lack basic parenting skills, and GPs were concerned about the parents' ability to comply with recommendations to give OES in the face of an uncooperative child. Some GPs were reluctant to discuss the issue of dehydration or mention the diagnosis of "gastroenteritis" because of the additional parental anxiety they felt this would cause. Working, single and/or socially disadvantaged parents were also perceived to have greater difficulty managing a sick child. A number of GPs also believed that conflicting suggestions for the child's management (usually given by well-intentioned in-laws and friends) was a major impediment to parents following their advice. Relatively few GPs appeared to consider the availability, taste or cost of OES a major barrier to its use.  

Discussion

 This study sought to review management of child gastroenteritis from the primary care perspective. In contrast to previous reports of the pre-hospital management of gastroenteritis,3,7,9 the majority of GPs reported appropriate management of gastroenteritis in the community. Almost all GPs recommended the use of clear fluids and around two thirds specifically recommended OES. However, not all GPs provided clear instructions on the type of clear fluids they would recommend, and this is an area which may potentially be improved. Traditional "clear fluids" such as undiluted carbonated drinks, cordials and juices can be hyperosmolar and actually contraindicated in the management of gastroenteritis.15,16

A number of GPs suggested that parents withhold foods and/or provide the child with a bland or light diet until symptoms eased. Advice was also commonly given to restrict consumption of milk and other dairy foods for the duration of the illness. These restrictions are consistent with those employed by mothers in previous studies examining the home-based management of gastroenteritis.17 Recent evidence suggests that these "traditional" strategies are no longer applicable and may in fact prolong symptoms.15 Moreover, around 10% of GPs suggested management strategies that were not only inappropriate but also potentially dangerous (eg nil by mouth for 12 hours).

Only a small minority of GPs reported they would prescribe antibiotics, antiemetics or antidiarrhoeals. This is in marked contrast to earlier reports which suggested that up to 20% of children admitted to hospital for gastroenteritis had received these medications in the community.3,7,9 These studies have also given the impression that few parents are advised to take OES. A number of factors may explain these apparent differences. Firstly the present study is a survey of GPs while the earlier study was of preadmission management of hospitalised children, a small and selected subset of children with gastroenteritis seen by GPs. The hospital based studies may have introduced a selection bias so that suboptimal management practices were over represented (because these increased the likelihood of admission to hospital). Secondly, the case vignette methodology was used to standardise the clinical context in which GPs were providing advice. As a result we have information on GPs reported rather than observed management strategies. Some GPs may have presented a more idealistic view of how they would like to see themselves managing gastroenteritis in children, rather than representing their true practices under real life conditions. It is a methodological problem with all such studies that responses may reflect desirable answers rather than actual practice.

Thirdly, a selection bias may be present in terms of the GPs who participated in this study. For example, the GPs who agreed to participate may have had systematically better management strategies than those who did not. However the relatively high response rate (almost 70% of the total GP population) suggests that we are actually dealing with the stated management practices of the majority of GPs in the community.

A number of potential barriers to the optimal management of gastroenteritis were identified. It was anticipated that many GPs would cite the cost and taste of OES as major factors limiting its use. By contrast, a number of educational and social issues, such as lack of parental understanding of the disease process, society's desire for a "quick fix" with antibiotics and lack of parental skills dominated the GPs' concerns.

In conclusion, it appears that the reported management of gastroenteritis by the majority of GPs in the Hunter community is acceptable, although not necessarily optimal. Younger GPs, and those living in rural regions were more likely to provide parents with optimal advice. The major perceived barriers to the optimal management of gastroenteritis in the community were not issues such as the cost and taste of OES, but rather social issues related to parental confidence in dealing with a sick child, and parental anxiety about the nature of the condition. There appears to be an important role for a practitioner-based strategy designed not only to educate parents, but also to increase their confidence in looking after sick children in the community.  

Acknowledgments

 This study was supported by PHRDC grant No 954076. Our thanks go to the Hunter GPs who participated in this survey, and to Ms Pauline Brown, Ms Trisha Kiehne and Mrs Joan Welsh who assisted in various aspects of organising the fieldwork.  

References
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(Received 17 Sep 1996, accepted 16 May 1997)  

Authors' details

Centre for Clinical Epidemiology & Biostatistics, The University of Newcastle, Newcastle, NSW.
Jennifer E Porteous, MB BS, PhD, DipEpid(ClinEpid), FAFPHM, Lecturer in Clinical Epidemiology.
Discipline of Paediatrics, The University of Newcastle, Newcastle, NSW.
Richard L Henry, MD, FRACP, DipClinEpid, Professor of Paediatrics.
J Lynn Francis, BA, MMedStats, Professional Officer.
Robyn G Hankin, RN, Research Nurse.
The New Children's Hospital, Westmead, NSW.
Edward V O'Loughlin, MD, FRACP, Paediatric Gastroenterologist.
Discipline of General Practice, The University of Newcastle, Newcastle, NSW.
Malcolm Ireland, BApplSc, FRACGP, General Practitioner.


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