Rotavirus

What is rotavirus?

Rotavirus is a viral infection that can cause gastroenteritis. Gastroenteritis is an infection of the gut (intestines) which usually causes vomiting and diarrhoea.

How is rotavirus spread?

Rotavirus is present in the gut of an infected person and can pass out in their diarrhoea. It is easily spread from an infected person to another by close contact. This is often because of the virus being present on the infected person's hands after they have been to the toilet. For smaller children who wear nappies, it may be spread by the hands of the person changing the infected child's nappy. Surfaces or objects touched by the infected person can also allow transmission of the virus. The virus can be passed on if the infected person prepares food. Droplets in the air that contain the virus can be breathed in, or ingested, and so rotavirus can be passed on in this way as well. Outbreaks of rotavirus that affect many people can occur - for example, in nurseries or schools.

It usually takes about 48 hours after first contact with rotavirus before symptoms develop. This period is known as the 'incubation period' for the virus.

How common is rotavirus infection and who gets it?

Rotavirus is the most common virus causing gastroenteritis in children the UK. Almost every child in the UK has a rotavirus infection before they are five years old. Rotavirus infection is most common in children between the ages of six months and two years. Around 18,000 children are thought to be admitted to hospital each year in England and Wales because of rotavirus infection. But note, most children with rotavirus infection do not need admission to hospital.

Once you have had rotavirus, your body usually becomes immune to getting it again. Therefore, it is uncommon for adults to get rotavirus because most will have had it as a child. Rotavirus infection is more common in infants and younger children than in teenagers. In the UK, rotavirus infection is seasonal. That is, the virus is more likely to be circulating (and therefore caught) during the winter season from November to April.

What are the symptoms of rotavirus infection?

The first symptoms are usually a fever and vomiting. Watery diarrhoea then follows. The severity of the diarrhoea can range from mild to severe. The diarrhoea may clear up in about three days but, in some cases, it can last for up to nine days. Your child may also have some uncomfortable stomach cramps. These may ease off after each time they pass some diarrhoea.

With vomiting and diarrhoea, there is a risk of your child becoming dehydrated. In particular, if these symptoms are severe. Dehydration is when there is a lack of fluid in the body. You should consult a doctor quickly if you suspect that your child is becoming dehydrated. Mild dehydration is common and is usually easily and quickly reversed by drinking lots of fluids. Severe dehydration can be fatal unless quickly treated because the organs of the body need a certain amount of fluid to function normally.

Symptoms of 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 lethargic.
• Symptoms of severe dehydration in children include: drowsiness, pale or mottled skin, cold hands or feet, very few wet nappies, fast (but often shallow) breathing. This is a medical emergency and immediate medical attention is needed.

Dehydration is more likely to occur in:

• Children under the age of one year (and particularly those under six months old). This is because babies don't need to lose much fluid to lose a significant proportion of their total body fluid.
• Children under the age of one year who were a low birthweight and who have not 'caught up' with their weight.
• A breastfeeding infant that has stopped feeding during their illness.
• Any child who does not drink much when they have rotavirus infection.
• Any child with severe diarrhoea and vomiting (particularly if they have passed six or more diarrhoeal stools and/or vomited three or more times in the previous 24 hours).

How is rotavirus diagnosed?

Rotavirus is usually diagnosed after a sample of your child's stool (faeces) is sent to the laboratory for testing. However, for most children who have a bout of gastroenteritis, it is not necessary to send a stool sample to be tested. This is because the treatment is usually the same for many causes of gastroenteritis in children.

So, as rotavirus is the most common cause of gastroenteritis in children, your child may well have this infection if they have an episode of diarrhoea and vomiting. But, it is usually not necessary to send a stool sample to be tested to confirm this.

When should I seek medical advice?

Most children who have gastroenteritis (including gastroenteritis caused by rotavirus infection) have mild symptoms which will get better in a few days. The important thing is to ensure that they have plenty to drink. In many cases, you do not need to seek medical advice. However, you should seek medical advice in the following situations (or if there are any other symptoms that you are concerned about):

• If your child is under the age of six months.
• If your child has an underlying medical condition (for example, heart or kidney problems, diabetes, history of premature birth).
• If your child has a high fever.
• If you suspect dehydration is developing (see earlier).
• If your child appears drowsy or confused.
• If your child is vomiting a lot and unable to keep fluids down.
• If there is blood in their diarrhoea or vomit.
• If your child has severe abdominal pain.
• If your child has a weakened immune system because of, for example, chemotherapy treatment, long-term steroid treatment, HIV infection.
• Infections caught abroad.
• If your child has severe symptoms, or if you feel that their condition is getting worse.
• If your child's symptoms are not settling - for example, vomiting for more than 1-2 days, or diarrhoea that does not start to settle after 5-7 days.

What is the treatment of rotavirus?

There is no special medication to treat rotavirus. The aim is to make sure that your child has plenty of fluids and avoids dehydration until their immune system has the time to clear the infection. This usually takes between 4 to 6 days. Children can usually be cared for at home. Occasionally, admission to hospital is needed if symptoms are severe, or if complications develop.

Fluids to prevent dehydration

You should encourage your child to take plenty of fluids. The aim is to prevent dehydration (low body fluid). The fluid lost in their vomit and/or diarrhoea needs to be replaced. Your child should continue with their normal diet and usual drinks. In addition, they should also be encouraged to drink extra fluids. However, avoid fruit juices or fizzy drinks as these can make diarrhoea worse.

Babies under six months old are at increased risk of dehydration. You should seek medical advice if they develop gastroenteritis. Breast or bottle feeds should be encouraged as normal. You may find that your baby's demand for feeds increases. You may also be advised to give extra fluids (either water or rehydration drinks) in between feeds.

Rehydration drinks may be advised by a healthcare professional for children at increased risk of dehydration (see above for whom this may be). They are made from sachets available from pharmacies and on prescription. You should be given instructions about how much to give. Rehydration drinks provide a perfect balance of water, salts, and sugar. The small amount of sugar and salt helps water to be absorbed better from the gut into the body. Do not use home-made salt/sugar drinks, as the quantity of salt and sugar has to be exact.

If your child vomits, wait 5-10 minutes and then start giving drinks again, but more slowly (for example, a spoonful every 2-3 minutes). Use of a syringe can help in younger children who may not be able to take sips.

Note: if you suspect that your child is dehydrated, or is becoming dehydrated, you should seek medical advice urgently.

Fluids to treat dehydration

If your child is mildly dehydrated, this may be treated by giving them rehydration drinks. Your doctor or nurse will advise about how to make up the drinks and about how much to give. This can depend on the age and the weight of your child. If you are breast-feeding, you should continue with this during this time. Otherwise, don't give your child any other drinks unless the doctor or nurse has said that this is OK. It is important that your child is rehydrated before they have any solid food.

Sometimes a child may need to be admitted to hospital for treatment if they are dehydrated. Treatment in hospital usually involves giving rehydration solution via a special tube called a 'nasogastric tube'. This tube passes through your child's nose, down their throat and directly into their stomach. An alternative treatment is with intravenous fluids (fluids given directly into a vein).

Eat as normally as possible once any dehydration has been treated

Correcting any dehydration is the first priority. However, if your child is not dehydrated (most cases), or once any dehydration has been corrected, then encourage your child to have their normal diet. Do not 'starve' a child with rotavirus infection. This used to be advised but is now known to be wrong. So:

• Breast-fed babies should continue to be breast-fed if they will take it. This will usually be in addition to extra rehydration drinks (described above).
• Bottle-fed babies should be fed with their normal full-strength feeds if they will take it. Again, this will usually be in addition to extra rehydration drinks (described above).
• Older children - offer them some food every now and then. However, if he or she does not want to eat, that is fine. Drinks are the most important, and food can wait until the appetite returns.

Medication is not usually needed

You should not give medicines to stop diarrhoea to children under 12 years old. They sound attractive remedies, but are unsafe to give to children, due to possible serious complications. However, you can give paracetamol or ibuprofen to ease a high temperature or headache.

Are there any complications?

Complications of rotavirus infection are not very common. If they do occur, they can include the following:

• Dehydration and salt (electrolyte) imbalance in the body. This is the most common complication. It occurs if the water and salts that are lost in your child's stools, or when they vomit, are not replaced by them drinking adequate fluids. If your child drinks well, then it is unlikely to occur, or is only likely to be mild and will soon recover as your child drinks.
• Lactose intolerance can sometimes occur for a period of time after rotavirus infection. It is known as 'secondary' or 'acquired' lactose intolerance. Your child's intestine (gut) lining can be damaged by the episode of gastroenteritis. This leads to lack of an enzyme called lactase that is needed to help the body digest the milk sugar lactose. Lactose intolerance leads to bloating, abdominal pain, wind and watery stools after drinking milk. The condition gets better when the infection is over and the intestinal lining heals.
• Persistent diarrhoea syndromes may rarely develop.

Preventing spread of infection to others

If your baby has rotavirus infection, be especially careful to wash your hands after changing nappies and before preparing, serving, or eating food. Ideally, use liquid soap in warm running water, but any soap is better than none. Dry your hands properly after washing. For older children, whilst they have rotavirus, the following are recommended:

• Regularly clean the toilets used with disinfectant. Also, clean the flush handle, toilet seat, sink taps, bathroom surfaces and door handles at least daily with hot water and detergent. Disposable cleaning cloths should be used (or a cloth just for toilet use).
• If a potty has to be used, wear gloves when you handle it, dispose of the contents into a toilet, then wash the potty with hot water and detergent and leave it to dry.
• Make sure your child washes their hands after going to the toilet. Ideally, they should use liquid soap in warm running water, but any soap is better than none. Dry properly after washing.
• If clothing or bedding is soiled, first remove any faeces into the toilet. Then wash in a separate wash at as high a temperature as possible.
• Don't let your child share towels and flannels.
• Don't let them help to prepare food for others.
• They should stay off school, nursery, etc, until at least 48 hours after the last episode of diarrhoea or vomiting. They should also avoid contact with other children where possible during this time.

Can rotavirus be prevented?

The advice given in the previous section is mainly aimed at preventing the spread of rotavirus infection from your child to other people. However, in general, good hygiene is essential to prevent the spread of many infections to others. Handwashing is the most important thing that you and your child can do. In particular, always wash your hands, and teach children to wash theirs:

• After going to the toilet (and after changing nappies or helping an older child to go to the toilet).
• Before preparing or touching food or drinks.
• Before eating.

If you smoke, you should also wash your hands before smoking. The simple measure of washing hands regularly and properly is known to make a big difference to the chance of developing rotavirus and other gut infections.

Immunisation against rotavirus

As mentioned earlier, rotavirus is the most common cause of gastroenteritis in children. There is an effective vaccine against rotavirus. In the UK, in February 2009, the Joint Committee on Vaccination and Immunisation (JCVI) ruled out a mass immunisation policy in the UK on the basis that it would not be cost-effective. They said "introduction of rotavirus vaccines would only become cost-effective if the vaccine prices are much less than those at which they are currently being offered." - see www.dh.gov.uk/ab/JCVI/DH_094744

However, in June 2009, the World Health Organisation (WHO) recommended that rotavirus vaccine be included in all national immunisation programmes. Therefore, the policy in the UK may change in the future.

References

• Gastroenteritis, Clinical Knowledge Summaries (September 2009)
• Diarrhoea and vomiting in children under 5, NICE Clinical Guideline (April 2009); Management of acute diarrhoea and vomiting due to gastroenteritis in children under 5
• O'Ryan M; Rotarix (RIX4414): an oral human rotavirus vaccine. Expert Rev Vaccines. 2007 Feb;6(1):11-9. [abstract]
• Jit M, Pebody R, Chen M, et al; Estimating the number of deaths with rotavirus as a cause in England and wales. Hum Vaccin. 2007 Jan-Feb;3(1):23-6. Epub 2007 Jan 18. [abstract]
• Elliott EJ; Acute gastroenteritis in children. BMJ. 2007 Jan 6;334(7583):35-40.
• Khanna R, Lakhanpaul M, Burman-Roy S, et al; Diarrhoea and vomiting caused by gastroenteritis in children under 5 years: summary of NICE guidance. BMJ. 2009 Apr 22;338:b1350. doi: 10.1136/bmj.b1350.
• HPA - Health Protection Agency. Website.