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Murphy’s recent article on management of bloody diarrhoea in children in primary care1(and indeed his interests, judging from his reference 1) appears to be orientated toward the early diagnosis and treatment of inflammatory bowel disease. Some of his recommendations, however, particularly figure1, should, therefore, be expanded so as not to be problematic for the management of infection, in general and VT+ Escherichia coli O157, in particular.

Surveillance based on a GP Sentinel Scheme in Wales showed an incidence of bloody diarrhoea of 30/100,000 in under15 year olds, 80% of which was caused by either salmonella or campylobacter infection2, which is in line with Murphy’s estimates. Recognised infection with VT+ Escherichia coli O157 is rare (1-2/100,000 per year in Wales) but early diagnosis, which, contrary to Table 2, can usually be achieved by stool culture, is important because:

1 Spread occurs readily in household3 and similar settings (such as children’s nurseries4 ) and affects primarily young children who are at high risk of developing haemolytic uraemic syndrome (HUS)5 which, as Murphy accurately points out, is “life threatening”.

2 Diagnosis is a contraindication for antibiotic therapy1 and antimotility therapy.

3 Outbreak detection is facilitated and thereby, hopefully, further cases are prevented.

The risk of household spread of VT+ Escherichia coli O157 and its serious complications, may be sufficient in certain circumstances (eg a young child in nappies with a similarly young sibling) to merit promptly admitting a child to hospital (or in some other way separating them from their siblings5) even if they are passing less than 6 bloody stools a day. Indeed, suspicion of the diagnosis, on clinical grounds such as severe abdominal pain or epidemiological grounds such as a history of contact with farm animals, even with no bloody stools (which may occur in less than 50% of cases), should lead to urgent steps to establish the diagnosis and communication with public health services so as to ensure that urgent action is taken to prevent further cases.

Roland Salmon, Meirion Evans, Brendan Mason,

Communicable Disease Surveillance Centre National Public Health Service for Wales Temple of Peace and Health, CARDIFF CF10 3NW UK

Dirk Werber, Department for Infectious Disease Epidemiology, Robert Koch Institute, BERLIN Germany

1) Murphy MS. Management of bloody diarrhoea in children in primary care. BMJ 2008;336:1010-5 2) Chalmers RM, Salmon RL. Primary care surveillance for acute bloody diarrhea, Wales. Emerg Inf Dis 2000;6:412-4. 3) Parry SM, Salmon RL. Sporadic STEC infection: secondary household transmission in Wales. Emerg Inf Dis 1998;4:657-661

4) Al-Jader L, Salmon RL, Walker AM, Williams HM, Willshaw GA, Cheasty T. Outbreak of Escherichia coli O157 in a nursery: lessons for prevention. Arch Dis Child 1999;81:60-3

5) Werber D, Mason BW, Evans MR, Salmon RL. Preventing Household Transmission of Shiga Toxin–Producing Escherichia coli O157 Infection: Promptly Separating Siblings Might Be the Key. Clin Infect Dis 2008;46:1189-96

6) Werber D, Behnke SC, Fruth A, Merle R, Menzler S, Glaser S, Kreienbrock L, et al. Shiga toxin-producing Escherichia coli infection in Germany – different risk factors for different age groups. Am J Epidemiol 2007; 165(4): 425-34

Competing interests: None declared

Competing interests: None declared

Roland L. Salmon, Consultant Epidemiologist

Meirion R. Evans, Brendan W. Mason, Dirk Werber.

National Public Health Service for Wales, Temple of Peace and Health, CARDIFF CF10 3NW

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The bacteria and parasitic are the more frequent causes of bloody diarrhea in developing countries (1). In these countries different alternatives may alter the course of this disease maybe due to different nutritional realities compared with developed countries. Sur and Bhattarcharya have established that zinc supplementation, probiotics in children may reduce severity and duration of the disease (2). Bhandari et al found in randomized clinical trial in Indian children 6 to 30 months with diarrhea that elemental zinc (10 and 20 mg) reduce the incidence of diarrhea, stool frequency, more children experimented no diarrhea episodes during follow up period. (3). These studies established the necessity of more studies about zinc supplementation in these socioeconomics contexts.

1. O'Ryan M, Prado V, Pickering LK. A millennium update on pediatric diarrheal illness in the developing world. Semin Pediatr Infect Dis. 2005;16:125-36

2. Sur D, Bhattacharya SK. Acute diarrhoeal diseases--an approach to management. J Indian Med Assoc. 2006 ;104:220-3

3. Bhandari N, Bahl R, Taneja S, Strand T, Mølbak K, Ulvik RJ. Substantial reduction in severe diarrheal morbidity by daily zinc supplementation in young north Indian children. Pediatrics. 2002;109:e86.

Competing interests: None declared

Competing interests: None declared

Cesar Augusto Guevara-Cuellar, Assistant professor

Pineda-Cañar CA

University of Valle 25360

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We read this well presented and structured article with interest. It is in an 'easy to use' format for primary care.

We were struck by the 'absence' of the hospital paediatrician in the flow chart for management of bloody diarrhoea in children.

With regards to clinical presentation, children with inflammatory bowel disease could also present with delayed puberty in both sexes or secondary amenorrhoea in girls post-menarche.

With regards to Henoch-Schonlein purpura causing overt gastro- intestinal bleeding, it is important to consider the possibility of an intussusception in these patients which could be diagnosed using ultrasonography and reduced using an air enema.

Competing interests: None declared

Competing interests: None declared

Cheri Mathews John, Consultant paediatrician

Deepa Elizabeth Mathew

Whiston hospital, Prescot L35 5DR

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Although I thought your article was a good review of the more common causes of bloody diarrhoea in children, I was somewhat troubled by the absence of any mention of general paediatrics.

As you point out, serious complications are thankfully rare, but there are some very important conditions that need to be considered. In Cumbria, with a large rural and farmaing population, we are very concerned about the possibility of E Coli 0157 and subsequent development of HUS. Hirchsprung's colitis and intussusseption again are rare, but they do happen.

An average GP will likely never see these is a career, whereas a general paediatrician in a DGH setting probably will. You are therefore neglecting a massive resource in your management plan, outlining that these children can either be managed in primary care or should see a tertiary specialist - with nothing in between.

I think you aren't considering that the majority of children with any episodes of bloody diarrhoea will be seen by general paediatricians. I would suggest that GP's managing such children tap into this resource either by admitting these children, or asking for advice. In practice, I think this is what many GP's are doing.

Competing interests: None declared

Competing interests: None declared

Glyn Jones, Consultant paediatrician

Carlisle

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