Norovirus in Kalamazoo

Our office received a "Health Advisory" from the Kalamazoo County Health & Community Services this week. It announces laboratory-confirmed cases of Norovirus in Kalamazoo County. Norovirus is the new, official name for viruses previously known as Norwalk viruses. Noroviruses have been responsible for relatively large outbreaks of vomiting and diarrheal illnesses on cruise ships, in schools, and in day care centers.

My factual information in this blog comes directly from that Health Advisory, and a fact sheet about Norovirus from the Michigan Department of Community Health, Communicable Disease Division, 201 Townsend Street, CVB-5th floor, Lansing, Michigan. The advice on oral rehydration is the general advice I and my colleagues at Trestlewood Pediatrics give to parents whose children are suffering from a vomiting and diarrheal illness.

Noroviruses are contagious viruses that cause stomach and intestinal illnesses in people. These kinds of illnesses are often incorrectly referred to as "stomach flu" or "flu". Actually, the correct term is gastroenteritis. Gastroenteritis has no relation to influenza (correctly termed "flu"), which is primarily a respiratory illness.

The most common symptoms of a norovirus infection are nausea, vomiting, diarrhea, and abdominal cramps. They occur 10 to 48 hours after exposure to the germ. Other symptoms can include fever, chills, headache, muscle aches, and fatigue. The symptoms last 1 to 2 days, and can be very severe for some people. Dehydration is the most worrisome problem that can result from a Norovirus infection. This would occur if the sick person cannot drink enough fluids to replace what they are losing in vomit and diarrhea.

Treating Norovirus infections means replacing fluids and waiting for the symptoms to subside. There are no antibiotics or vaccines for Norovirus. Fluid loss should be replaced with clear liquids. The best fluids, especially for children five and under, are oral rehydration solutions such as Pedialyte. Sports drinks are not a good substitute because they have too much sugar. Diluted juice or water could also be given, but preferably to an older child. Infrequently a child may need to see a doctor to determine if intravenous fluids are needed.

When orally rehydrating an infant or young child you may need to give them the oral rehydration solution in a syringe. Wait one hour after the last vomiting episode, and then syringe feed Pedialyte 1 to 2 teaspoons (5-10 ml) at a time every ten minutes for two hours. Set a timer on your stove so you can stay on track.

If vomiting starts over, wait an hour and start the oral rehydration process again. If your child tolerates 5 to 10ml every ten minutes for two hours, you can then let them have more at a time (maybe 20-30ml every 15 minutes). Continue with only clear liquids for at least half the day. If everything is going well after that you could try a little milk, or one small cracker or piece of cereal. Start over if they vomit again. Don't let your pathetic little sick child sweet talk you into giving them food or milk until you know they are tolerating the clear liquids quite well. If you introduce food or milk too soon you will set everything back by hours because it will almost certainly induce more vomiting. Crackers do NOT settle the stomach of a vomiting child. First go slowly with oral rehydration solutions such as Pedialyte. Don't let your child refuse the Pedialyte, give it to them in a syringe, as if it were medicine.

The nice thing about Pedialyte is that it can be partly absorbed from the stomach (instead of having to travel all the way to the intestine first)--so even if some of it gets vomited back up, some will still be absorbed. This is not true of sports drinks, water, or juice.

The most interesting thing about Noroviruses is how very contagious they are. They are quickly spread from person to person, by ingesting contaminated food and drink prepared by infected food preparers, by touching contaminated surfaces and then touching the mouth, or having direct contact with an infected person and then touching the mouth before washing hands. Stool and vomit from an infected person is definitely contaminated with norovirus. In some cases undercooked oysters or drinking water contaminated with sewage have been the cause of an outbreak.

If you have norovirus, you are contagious from the time you start feeling ill or nauseated until at least 3 days after recovery. The contagious period after recovery can last as long as two weeks for some people.

Good hand washing with SOAP AND WATER is important to prevent further spread of the virus. Infected people should not prepare food, work in nursing homes, or take care of patients while they have symptoms, and for three days after the symptoms are gone. Children may return to school and daycare when the diarrhea and vomiting is gone. Then hand washing with soap and warm water must be strictly enforced. Alcohol based hand sanitizers do NOT work against norovirus. Soap and warm water is the best way to eliminate the germ from your hands. A household chlorine bleach-based cleaner should be used to disinfect contaminated surfaces.

So, wash your hands with soap and water, disinfect your surfaces with some kind of bleach solution, don't go to work or school if you become nauseated, vomit, and/or have diarrhea, and don't return to work for three days after you are better if you have a job preparing food or taking care of patients. Don't return to school until vomiting and diarrhea have stopped, and then use careful handwashing methods with soap and water. Have some Pedialyte on hand, or know where you can get it. Stock up on medicine syringes in case you must force feed the Pedialyte. And wash your hands again.

Please call your own personal pediatrician for more specific advice for your child. My blog is meant to provide you with general information, and is not a good substitute for the personal attention your own doctor can provide.

The Michigan Department of Community Health norovirus cleaning and disinfection guidelines, as well as other information, are available at the following link. Once at the main web site, click on the icon for Health and Services, then type Norovirus into the search box.

www.michigan.gov

"Blood owies" or What do I want for my patients?

What are "blood owies"? you ask. Keep reading, I'll get to that later. What do I want for my patients and my own children? I want many things for them, so this could be a difficult question to answer. However, there is one thing I come back to, over and over. I want my patients to grow up feeling confident and in control over their bodies and minds. I want them to know that their bodies are strong and capable of fighting disease, and that they have control over the choices that help keep them healthy.

Of course parents help children BE healthy. We love them, feed them, and keep them safe. We give them a sense of right and wrong. We try to influence their choices. Most of all we love them. I believe that parents play a crucial role in helping children FEEL healthy, too.

So what does that mean, anyway? A little anecdote might help you understand what I am talking about. At my daughters' daycare the kids used to have a saying for their little cuts and scrapes that happened throughout the day. A skinned knee that didn't bleed was just an "owie", really no big deal. But a skinned knee that BLED was a "blood owie", which was very impressive to all.

I would receive tales of "blood owies" when the kids arrived home each summer day. It was a major event, as if the life force of the affected child was draining onto the ground. This kind of owie seemed to have a mystical power in my daughters' lives. Rose, our daycare provider, and my dear friend, normalized these "blood owies" for my children. She always had a hug and a band-aid ready, and she seemed to always convey to them that this was no problem, and would get better fast with that band-aid. I would look at the ravaged knee with the princess band-aid perched on top, hide a shudder and smile big at how great the owie looked now. My injured daughter would walk away feeling strong and proud of herself.

Of course most illnesses are more serious than a skinned knee! But how great would it be if we, as parents, could help our children be confident in knowing that most aches, pains, colds, flu, viruses, rashes, bug bites, etc. are common and happen to lots of people who get over them with no problem.

Preschoolers and adolescents, especially, seem to notice lots of bumps and aches all over their bodies. Don't you, too? Our children need us to explain these things to them. They don't know if these things are important, or not. "Too bad your tummy hurts, maybe you have to go potty?", or "I'm sorry to hear you have a stomachache, do you think you had too much milk? Or that you are worried about your exam?" "That happens to me sometimes, it usually just goes away after a while." "Let's try some pain reliever, and go to bed early tonight, maybe you're just tired."

But what if you miss something this way? Aren't some stomachaches and other symptoms important? Yes they are sometimes important, I'm not advocating ignoring symptoms. What I am saying is that I think the parent should be the one guiding the attitude about the illness.

The ultimate message that I want kids to receive is that their bodies and minds are amazing, strong, resilient, normal, and capable of healing. And that their parents will help them stay that way. As a pediatrician I definitely have a role in shaping this attitude, but I think parental influence is greater. Think about this. Let me know what you think.