Policy Title: Guidelines for the care and management of children with diarrhoea and vomiting These guidelines have been developed with reference to published medical literature. Wherever possible, the recommendations made are evidence based and comply with NICE Guidance for care of a child with diarrhoea and vomiting. The information contained within is supported by Partners in Paediatrics (PiP), and is also available on the stre@mline system. 1 Amendments have been made to these guidelines to reflect the updated PIP guidelines Executive Summary: Supersedes: Description of Amendment(s): This policy will impact on: The Children’s Ward, Community Children’s Nursing Team & Emergency Dept. Financial Implications: Non Known Policy Area: Children’s Services Version Number: 2 Document Reference: Effective Date: May 2013 Issued By: The Children’s Unit Review Date: April 2016 Authors: J Shippey Practice development nurse - Paediatrics Impact Assessment Date: APPROVAL RECORD Committees / Group Consultation Phase: Paediatricians, Children’s Nurses, A&E Consultant, Associate Director W&CBU, Paed Pharmacist Approval Comittee Families and Well being SQS Date April 2013 Ratified by committee/Executive director: Received for information: Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 1 Care and management of children with Diarrhoea and Vomiting Introduction Diarrhoea and vomiting caused by gastroenteritis are common in children younger than 5 years. Diarrhoea usually lasts for 5–7 days and in most children it will stop within 2 weeks. Vomiting often lasts for 1–2 days and in most children it will stop within 3 days. Diarrhoea in young children is usually caused by an infection in the gut -gastroenteritis. This guideline aims to reduce the variation in the management of diarrhoea and vomiting and is written using the Paediatric Guidelines developed by Partners in Paediatrics (PIP) (2012-2012). East Cheshire Trust is a partner organisation of PIP. The information contained within the guideline is also compliant with the guidance provided by NICE, 2009 (clinical guideline 84). For most children, their illness can be managed at home, but some children will require hospital treatment in order to rehydrate them, with parental advice in order to support them through the recovery phase. A child presenting with clinical manifestations of dehydration can be assumed to be 5% dehydrated at the outset. Key priorities / responsibilities Diagnosis – recognition and assessment Assessing dehydration and shock Investigations Stool for microbiological investigations should be performed if: septicaemia is suspected or there is blood and/or mucus in the stool or the child is immuno-compromised Fluid management Re-assessment of signs of dehydration at least every 4 hours Nutritional management Information and advice for parents and carers (see appendix) RECOGNITION AND ASSESSMENT Definition of diarrhoea Passage of loose watery stools at least three-times in 24 hr Most common cause is acute infective gastroenteritis Diarrhoea and vomiting in infants may be a sign of sepsis Symptoms and signs Sudden onset of diarrhoea (D) or vomiting (V), or both (D&V) Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 2 Fever, malaise, lethargy Abdominal cramps Loss of appetite Patient history Ask about: duration of illness frequency of stools and associated vomiting (>6 stools more likely to become dehydrated) colour of vomit (if green bilious vomit, consider obstruction) nature of stools, including presence of blood in stool feeds (fluid and food intake) urine output (number of wet nappies) contacts/exposure to infection recent travel abroad recent antibiotic use symptoms of other causes of D&V (e.g. high pyrexia, shortness of breath, severe/localised abdominal pain or tenderness, symptoms of meningitis/septicaemia) weight loss underlying problems e.g. low birth-weight, malnutrition, neuro-disability Inform public health if outbreak of gastroenteritis suspected Assessment Weight, including any previous recent weight Temperature, pulse, respiratory rate Degree of dehydration (see Table 1) and/or calculate from weight deficit Complete systemic examination to rule out other causes of D&V Children aged <1 yr are at increased risk of dehydration Calculating fluid deficit Deficit in mL = % dehydration x weight (kg) x 10 e.g. for a 10 kg child with 5% dehydration deficit is 5 x 10 x 10 = 500 mL Calculating maintenance fluids Weight (kg) <10 10–20 >20 Fluid volume 100 mL/kg/day 1000 mL + 50 mL/kg/day for each kg >10 kg 1500 mL + 20 mL/kg/day for each kg >20 kg Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 3 Table 1: Assessment of degree of dehydration Increasing severity of dehydration Clinical dehydration Clinical shock 5–10% dehydrated >10% dehydration Symptoms (remote and face-to-face assessment) No clinically detectable dehydration (<5%) Appears well Alert and responsive Normal urine output Signs (face-to-face assessment) Skin colour unchanged Warm extremities Alert and responsive Skin colour unchanged Warm extremities Eyes not sunken Moist mucous membranes (except for ‘mouth breather') Normal heart rate Normal breathing pattern Normal peripheral pulses Normal capillary refill time Normal skin turgor Normal blood pressure Appears to be unwell or deteriorating Altered responsiveness (e.g. irritable, lethargic) Decreased urine output Skin colour unchanged – Warm extremities Altered responsiveness (e.g. irritable, lethargic) Cold extremities Decreased level of consciousness Skin colour unchanged Pale or mottled skin Warm extremities Sunken eyes Dry mucous membranes (except after a drink) Cold extremities – – Tachycardia Tachypnoea Decreased level of consciousness – Pale or mottled skin Tachycardia Tachypnoea Normal peripheral pulses Weak peripheral pulses Normal capillary refill time Prolonged capillary refill time Reduced skin turgor Normal blood pressure – Hypotension (decompensated shock) Investigations If vomiting a major feature or vomiting alone, or if baby aged <3 months: urine for MC&S If septicaemia suspected, child immunocompromised, or if stools bloody, mucous or chronic diarrhoea present, send stools for MC&S and virology If recent antibiotics, send stool for Clostridium difficile toxin If severe dehydration, possible hypernatraemic dehydration (see Hypernatraemic dehydration below) or diagnosis in doubt: FBC, U&E, chloride, glucose, blood and urine cultures. Blood gas or venous bicarbonate if decreased level of consciousness consider lumbar puncture, especially in babies IMMEDIATE TREATMENT See Flowchart – Management of acute gastroenteritis in young children (aged <4 yr) General advice to parents Adequate hydration important Encourage use of oral rehydration solution (ORS) Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 4 ‘clear fluids’ (water alone/homemade solutions of sugar and fruit) lack adequate sodium content and are inappropriate sugar, fruit juices and cola have a high osmolar load and little sodium, and can worsen diarrhoea Recommend early re-feeding with resumption of normal diet (without restriction of lactose intake) after 4 hr rehydration Do not use anti-diarrhoeal agents Anti-emetics (e.g. ondansetron melts) can be given for vomiting Continue breastfeeding throughout episode of illness, ORS can be given in addition Treatment of dehydration Admit if: patient ≥10% dehydrated failure of treatment (e.g. worsening diarrhoea and/or dehydration) other concerns (e.g. diagnosis uncertain, child aged <3 months, irritable, drowsy, potential for surgical cause) Step 1: Mild dehydration (<5%) Can be managed at home Emphasise to parents importance of adequate hydration Rehydrate orally using ORS (prescribe sachets and give clear instructions: if genuinely not tolerated, parents may substitute with diluted sugar containing juice) calculate fluid deficit and replace over 4 hr with frequent small volumes (5 mL every 1–2 min) continue to supplement with ORS for each watery stool/vomit (10 mL/kg per watery stool) Do not withhold food unless vomiting full feeding appropriate for age well tolerated with no adverse effects Step 2: Moderate dehydration (6–10%) If improving after 4 hr observation, can be managed at home provided social circumstances are appropriate/parents are happy. Otherwise, admit Calculate deficit and aim to replace with ORS 50 mL/kg oral over 4 hr Give small frequent feeds (5 mL every 1–2 min) If not tolerating oral rehydration (refuses, vomits, takes insufficient volume), use NG tube Review after 4 hr when rehydrated start a normal diet, and continue maintenance fluids and supplementary ORS for each watery stool or vomit (10 mL/kg per watery stool) if dehydration persists, continue the same regimen but replace fluid deficit with ORS over the next 4 hr if this fails, e.g. vomiting ORS, consider IV rehydration (see below) If improving move to Step 1 Step 3: Severe dehydration (>10%) – see flowchart Beware hypernatraemic dehydration. See Hypernatraemic dehydration section If child in shock, first resuscitate with sodium chloride 0.9% (20 mL/kg) and reassess If >10% dehydration, obtain IV access, especially if child drowsy Calculate deficit using recent normal weight if available If alert, rehydrate orally with ORS, replacing deficit (plus maintenance requirement) over 4 hr Use NG tube if necessary If oral/NG rehydration not possible, replace deficit with sodium chloride 0.9% with glucose 5% over 24 hr give isotonic fluid e.g. sodium chloride 0.9% or sodium chloride with glucose 5% if hypoglycaemic or at risk of hypoglycaemia use sodium chloride 0.9% with glucose 5% and potassium chloride start normal diet as soon as tolerated Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 5 continue to replace ongoing losses with ORS for each watery stool or vomit (5 mL/kg per watery stool) when improves move to Step 2 Hypernatraemic dehydration (Na >150 mmol/L) In hypernatraemic dehydration, there are fewer signs of dehydration skin feels warm and doughy, child lethargic and irritable/jittery with hypertonia and hyperreflexic. They may have seizures if in shock, resuscitate with sodium chloride 0.9% 20 mL/kg bolus if Na >170 mmol/L, contact PICU if child has passed urine, add potassium to IV fluid – initially at 10 mmol/500 mL, adjust according to blood results when available In hypernatraemic dehydration, aim to reduce sodium by no more than 10 mmol/L in 24 hr After initial resuscitation, give ORS: replace deficit (+ maintenance) over 48 hr – via NG if necessary Check U&E after 1 hr If ORS not tolerated or sodium drops >0.5 mmol/L/hr, start IV rehydration with sodium chloride 0.9%, replacing deficit (+ daily maintenance) over 48 hr Recheck U&E after 1–4 hr (depending on rate of drop of serum sodium and starting value) If sodium dropping by >0.5 mmol/L/hr, reduce rate by 20% Once rehydrated, start normal diet including maintenance fluids orally MANAGEMENT OF SEVERE DEHYDRATION Shock No Oral/NG tube rehydration possible Ye s Rehydrate orally or via NG tube Ye s Reasse ss Sodium chloride 0.9% 20 mL/kg No Start sodium chloride 0.9% with potassium chloride IV Measure serum sodium High (>150 mmol/L) Low/normal (<150 mmol/L) Maintenance and replacement over 48 hr Maintenance and replacement over 24 hr DISCHARGE AND FOLLOW-UP If dehydration was >5%, ensure child has taken and tolerated two breast or bottle feeds, or at least one beaker of fluid Check child has passed urine Tell parents diagnosis and advise on management and diet Explain nature of illness, signs of dehydration, and how to assess and deal with continuing D&V (explain flagged symptoms in table of dehydration) Emphasise importance of adequate hydration. If dehydration recurs will need further rehydration Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 6 If symptoms persisting, aged <1 yr or low birth weight, continue to supplement with ORS at 5 mL/kg per watery stool or vomit Do not withhold food, (especially breast milk), full feeding appropriate for age if well tolerated after initial rehydration Advise parents how to prevent transmission to other family members and contacts patient should not share towels with others hand-washing with soap and warm water after using toilet or changing nappy. Dry hands properly Exclude from school/nursery until 48 hr from last episode of diarrhoea or vomiting Exclude from swimming for 2 weeks following last episode of diarrhoea Give open access if appropriate, ensure parents aware of how to seek help if needed If diarrhoea persists for >10 days, advise to return for medical reassessment MANAGEMENT OF ACUTE GASTROENTERITIS IN YOUNG CHILDREN (AGED <4 YR) Detailed history and examination Clinician estimates % dehydration and current weight One or more of following present? >10% dehydration Signs of shock Patient drowsy Yes Hospitalise Give sodium chloride 0.9% IV bolus if shock Re-evaluate and repeat if necessary – see Management of severe dehydration Begin ORS, replacing deficit (up to 100 mL/kg) over 4 hr plus replacement of ongoing losses (oral/NG) No Is patient 6–9% dehydrated by weight loss or by clinical estimation? Yes Begin ORS, replacing deficit (up to 100 mL/kg) over 4 hr plus replacement of ongoing losses (oral/NG) No Is patient 3–5% dehydrated by weight loss or by clinical estimation? Yes Begin ORS, replacing deficit (up to 50 mL/kg) over 4 hr plus replacement of ongoing losses (oral/NG) Patient tolerating ORS No Yes No Patient with diarrhoea and <3% dehydration on clinical estimation/current weight NG rehydration Consider IV infusion Continue ORS for 4–6 hr or until rehydrated Yes Continue child’s regular diet Consider adding ORS to replace ongoing losses Continue breastfeeding Resume foods Replace ongoing losses with ORS Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 7 Audit This policy will be audited in line with the guidance produced by Partners in Paediatrics and NICE on an annual basis. The audit will be performed by a nominated paediatric unit staff member and the findings will be reported to the clinical governance group, and paediatric unit staff. Any action plans developed from this audit will be agreed by the ward manager, practice development nurse and clinical lead for paediatrics with a 6 monthly review of progress. References National Institute for Health and Clinical Excellence 2009 Diarrhoea and vomiting in children (clinical guideline 84) Partnerships in Paediatrics 2013-2015 Paediatric Guidelines – Diarrhoea and vomiting. Sherwin Rivers Printers Ltd. Stoke-onTrent Equality Analysis (Impact assessment) Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 8 Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? The guideline for the management of diarrhoea and vomiting in children Details of person responsible for completing the assessment: Name: Joanne Shippey Position: Practice Development Nurse Team/service: Children’s Ward State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) To ensure that all children with diarrhoea and vomiting receive appropriate care 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below – how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document The population of Cheshire as at the 2005 mid year figures (Cohesia Report 2008) is 684,400. Age: 17.8% (30,500) of the population in Cheshire East is over 65 compared with 15.9% nationally. This results in a high “old age” dependency ratio, i.e. low numbers of working-age people supporting a high non-working dependant older population. The percentage of “older” or “frail” old is also considerably higher, with 2.3% (8,200) persons 85 and over compared to 2.1% nationally. Cheshire East has the fastest growing older population in the North West. By 2016, the population aged 65+ will increase by 29.0% (8,845) and the population aged 85+ by 41.5% (3,403). This will have an impact on the number of patients being managed by ECT and the complexity of the health and social care issues that the older person is experiencing. In addition the staffing profile of ECT will change to include an increasing number of staff over 65 in the workforce. Race: The 2005 mid year estimate (Cohesia Report 2008) show that the majority of the population in Cheshire (94.6%) is White British, with 5.4% non White British. The Cheshire 2007-10 Local Area Agreement identified that minority ethnic communities account for around 3% of the population. Issues for BME communities include lack of knowledge of services, access to services, access to translation/interpretation, cultural differences, family values. Many people from BME communities experience poverty, poor housing and unemployment which make it difficult for them to lead healthier lives. 4180 migrant workers registered in Cheshire in 2006/07 and comparison to the midyear population estimates for Cheshire in 2005 strongly suggests that Cheshire’s migrant worker population is larger than every individual BME group other than the White-Other White group. Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 9 Gypsies and travellers – at the last count (July 2006) the highest number was recorded in the Borough of Congleton (125). 42% of gypsies and travellers report limiting long term illness compared to 18% of the settled population, with an average life expectancy 10-12 years less than settled population. 18% of gypsy and traveller mothers have experienced the death of a child compared to 1% in the settled population. Disability: There are over 10 million disabled people in Britain, of whom 5 million are over state pension age. Nearly 1 in 5 people of working age (7 million, or 18.6%) in Great Britain have a disability. Hearing loss: 1 in 4 has a hearing problem. Sight problems: There are 2 million people with sight problems in the UK. Learning disabilities: There is quite a high proportion of people with learning disabilities in the local area due to there being a number of residential homes/institutions in the area. Problems encountered can be lack of staff awareness, communication issues, information requirements. Dementia Approximately six in 100 people aged over 65 develop dementia and this rises to around 20 in 100 people aged 85 or over. Dementia affects 750,000 people in the UK. Carers Around 6 million people (11 per cent of the population aged 5+) provided unpaid care in the UK in April 2001. While 45% of carers were aged between 45 and 64, a number of the very young and very old also provided care. By 2037, it is anticipated that the number of carers will increase to 9 million. Gender On average in Cheshire, 49% of the population are male and 51% are female Transgender: No local data available, national trends show: 1/12,000 males, transgender from male to female 1/33,000 females, transgender from female to male Specific issues around access to services, specific services for men or women, and ‘single sex’ facilities. In terms of the transgender population, GIRES (Gender Identity Research and Education Society ) gives an estimate of 600 per 100,000. If these figures were applied to the Cheshire East community based on the 2005 mid year estimates, there may be around 2,100 trans people in the area. Religion/Belief In the Cheshire East area: Christian - 80% Buddhists - 0.16% Hindu - 0.15% Jewish - 0.12% Muslim - 0.36% Sikh Other religion No religion Not stated - 0.05% - 0.15% - 11.84% - 6.67% The Muslim population has the highest levels of ill health amongst faith groups – this includes higher smoking rates amongst men and higher rates of coronary heart disease and diabetes. Sexual Orientation Lesbians, gay men and bi sexual people (LGB) make up to 5-7% of the UK population (Dept of Trade and Industry, 2003). 13% of Gay men and 31% Lesbian women are parents (Morgan and Bell, First Out: Report of the findings of Beyond the Barriers national survey of LGB people) The experience and health needs of gay men and women will differ. However, both groups are likely to experience discrimination, higher levels of mental ill health and barriers to accessing health care Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 10 National Health Inequalities data shows that lesbian, gay, bisexual and transgender (LGBT) people are e 2001 census showed: significantly more likely to smoke, to have higher levels of alcohol use and to have used a range of recreational drugs than heterosexual people. They are also at greater risk of deliberate self-harm. Although most LGBT people do not experience poor mental health, research suggests that some are at higher risk of mental health disorder, suicidal behaviour and substance misuse 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) no 2.3 Does the information gathered from 2.1 – 2.3 indicate any negative impact as a result of this document? no 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, racial groups differently? Yes  No x Explain your response: It offers guidance for the management of diarrhoea and vomiting. All patients will have this treatment regardless of race. Any explanations to children and parents whose first language is not English will be carried out using the Trust’s interpretation and translation policy and/or the picture communications book in the ward communication aids box. _________________________________________________________________________________ ___ GENDER (INCLUDING TRANSGENDER): From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, different gender groups differently? Yes  No x Explain your response: It offers guidance for the management of diarrhoea and vomiting. All patients will have this treatment regardless of gender. DISABILITY From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, disabled people differently? Yes x No  Explain your response: Some children with disability may be more susceptible to dehydration than others depending on their underlying condition. This will be assessed on an individual basis in conjunction with their parents. If explanations are required for parents or children with hearing or visual loss, the trusts interpretation and translation policy and/or the picture communications book in the ward communications aid box will be utilised. For patients with learning disabilities, the health facilitator from CWP can be involved. _________________________________________________________________________________ ___ Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 11 AGE: From the evidence available does the policy, procedure, proposal, strategy or service, affect, or have the potential to affect, age groups differently? Yes  No x Explain your response: This guideline is only applicable to children. It offers guidance for the management of diarrhoea and vomiting for all patients on the children’s ward. Therefore it impacts on all children and young people under 16. Children with learning disability may need further information about the treatment and reasonable adjustments may need to be made in order for them to cope with the equipment use. LESBIAN, GAY, BISEXUAL: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? Yes  No x Explain your response: It offers guidance for the management of diarrhoea and vomiting. All patients will have this treatment regardless of sexual orientation ________________________________________________________________________________ RELIGION/BELIEF: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, religious belief groups differently? Yes  No x Explain your response: It offers guidance for the management of diarrhoea and vomiting. All patients will have this treatment regardless of their religion/belief _________________________________________________________________________________ ____ CARERS: From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect, carers differently? Yes  No x Explain your response: It offers guidance for the management of diarrhoea and vomiting. All patients will have this treatment regardless of whether they are a young carer. Parents and carers will be involved in explanations about treatment.________________________________________________________________________ ____ OTHER: EG Pregnant women, people in civil partnerships, human rights issues. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes  No x Explain your response: No other impacts identified _________________________________________________________________________________ _ 4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? Yes x No  b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: This guideline offers guidance for the management of diarrhoea and vomiting for all patients on the children’s ward. Therefore it impacts on all children and young people under 16. Children with learning disability may need further information about the treatment and reasonable adjustments may need to be made in order for them to cope with the equipment use. Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 12 c. If no please describe why there is considered to be no impact / significant impact on children 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? All relevant staff groups have had the opportunity to read and comment on this policy. Policy has been amended to reflect their opinions 6. Date completed: Review Date: 7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved 1. ensure all staff have been on learning This is All staff attend annually. disability awareness training covered by 2. ensure all staff are aware of Paediatrics communications box and contents the Essentials which all staff attend annually 8. Approval – At this point, you should forward the template to the Trust Equality and Diversity Lead [email protected] Approved by Trust Equality and Diversity Lead: Date: 15.1.13 Care and management of children with Diarrhoea and Vomiting – Paediatrics. East Cheshire NHS Trust J Shippey Practice development nurse. April 2013 Review March 2016 13