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Pediatric Gastroenteritis in Emergency Medicine Medication

  • Author: Adam Levine, MD, MPH; Chief Editor: Kirsten A Bechtel, MD  more...
 
Updated: Jul 23, 2015
 

Medication Summary

The goals of pharmacotherapy are to reduce morbidity, to prevent complications, and for prophylaxis. Antidiarrheal (ie, kaolin-pectin) and antimotility agents (ie, loperamide) are contraindicated in the treatment of acute gastroenteritis in children because of their lack of benefit and increased risk of side effects, including ileus, drowsiness, and nausea.

Probiotics are live microbial feeding supplements commonly used in the treatment and prevention of acute diarrhea. Possible mechanisms of action include synthesis of antimicrobial substances, competition with pathogens for nutrients, modification of toxins, and stimulation of nonspecific immune responses to pathogens. Two large systematic reviews have found probiotics (especially Lactobacillus GG) to be effective in reducing the duration of diarrhea in children presenting with acute gastroenteritis.[34, 35] A recent meta-analysis found probiotics may be especially effective for the prevention of C difficile –associated diarrhea in patients receiving antibiotics.[36] As probiotic preparations vary widely, it is difficult to estimate the effectiveness of any single preparation.

A recent review of 24 published studies found zinc supplementation may be effective in reducing the duration of diarrhea in children older than 6 months in areas where zinc deficiency and moderate malnutrition is prevalent.[37] The World Health Organization (WHO) recommends zinc supplementation (10-20 mg/day for 10-14 days) for all children younger than 5 years with acute gastroenteritis, although little data exist to support this recommendation for children in developed countries.

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Vaccines

Class Summary

In February 2006, the US Food and Drug Administration (FDA) approved the RotaTeq vaccine for prevention of rotavirus gastroenteritis. The vaccine has been endorsed by the American Academy of Pediatrics (AAP).

In April 2008, the FDA approved Rotarix, another oral vaccine, for prevention of rotavirus gastroenteritis. The current recommendation is to administer 2 separate doses of Rotarix to patients aged 6-24 weeks. Rotarix was efficacious in a large study, which reported that Rotarix protected patients with severe rotavirus gastroenteritis and decreased the rate of severe diarrhea or gastroenteritis of any cause.[38] Recent large trials in both Latin America and Africa have also found Rotarix to be effective in decreasing diarrhea morbidity and mortality in children.[39, 40, 41]

Rotavirus vaccine (RotaTeq, Rotarix)

 

Currently, 2 orally administered live-virus vaccines are marketed in the United States. Each is indicated to prevent rotavirus gastroenteritis, a major cause of severe diarrhea in infants.

RotaTeq is a pentavalent vaccine that contains 5 live reassortant rotaviruses and is administered as a 3-dose regimen against G1, G2, G3, and G4 serotypes, the 4 most common rotavirus group A serotypes. It also contains attachment protein P1A (genotype P[8]).

Rotarix protects against rotavirus gastroenteritis caused by G1, G3, G4, and G9 strains and is administered as a 2-dose series in infants aged 6-24 wk.

Clinical trials reported that the vaccines prevented 74-78% of all rotavirus gastroenteritis cases, nearly all severe rotavirus gastroenteritis cases, and nearly all hospitalizations due to rotavirus.

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Antimicrobials

Class Summary

Because most cases of acute gastroenteritis in developed and developing countries are due to viruses, antibiotics are generally not indicated. Even in cases (eg, dysentery) where a bacterial pathogen is suspected, antibiotics may prolong the carrier state (Salmonella) or may increase the risk of hemolytic uremic syndrome (enterohemorrhagic E coli).[42]

In patients with positive stool assays or high clinical suspicion for C difficile, the offending antibiotic should be stopped immediately. Metronidazole (30 mg/kg/d divided qid for 7 d) can be used as a first-line agent, with oral vancomycin reserved for resistant infections.[42]

Though generally not recommended for children younger than 8 years, tetracycline (50 mg/kg/d divided qid for 3 d) and doxycycline (6 mg/kg single dose) remain the treatment of choice for cholera. Alternative treatments with good efficacy include erythromycin and ciprofloxacin.[42]

For patients with ova and parasites confirming infection with Giardia, metronidazole (35-50 mg/kg/d divided q8h) remains the drug of choice. Nitazoxanide oral suspension (aged 1-3 y: 100 mg q12h for 3 d, aged 4-11 y: 200 mg q12h for 3 d) is as effective as metronidazole and has the added benefit of treating other intestinal parasites, such as Cryptosporidium.

Metronidazole (Flagyl)

 

Recommended as the treatment of choice for mild-to-moderate cases of C difficile colitis. Provides effective therapy, with reported response rates from 95-100%. In vitro activity is bactericidal and dose dependent. Standard dosing has been shown to promote fecal concentrations capable of a 99.99% reduction of C difficile. Metronidazole IV may be administered to those patients who cannot tolerate PO medications because of its potential to accumulate in the inflamed colon. IV route is not as effective as PO.

Nitazoxanide (Alinia)

 

Inhibits growth of C parvum sporozoites and oocysts and G lamblia trophozoites. Elicits antiprotozoal activity by interference with the pyruvate: ferredoxin oxidoreductase (PFOR) enzyme-dependent electron transfer reaction, which is essential to anaerobic energy metabolism. Available as an oral suspension (20 mg/mL).

Tetracycline (Sumycin)

 

Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Treatment of choice for cholera. Not recommended for children younger than 8 years.

Doxycycline (Bio-Tab, Doryx, Doxy)

 

Broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.

Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Treatment of choice for cholera. Not recommended for children younger than 8 years.

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Antiemetics

Class Summary

A review of 7 randomized, controlled trials in children found that oral ondansetron reduced vomiting and the need for intravenous (IV) rehydration and hospital admission, IV ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate suppository reduced the duration of vomiting.[43, 18]

A previous large, prospective, randomized, double-blind trial compared a single dose of an orally disintegrating ondansetron tablet with placebo in children presenting to an emergency department with acute gastroenteritis.[44] This study also found that children treated with ondansetron were less likely to vomit and that they had greater oral intake, were less likely to require IV rehydration, and had a reduced length of stay in the emergency department compared with children treated with placebo.

Several smaller studies have also demonstrated ondansetron to be effective in children.[43, 45]

Ondansetron (Zofran)

 

Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally. Off-label indication for pediatrics.

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Contributor Information and Disclosures
Author

Adam Levine, MD, MPH Assistant Professor of Emergency Medicine, Brown University Alpert School of Medicine

Adam Levine, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Karen A Santucci, MD, MD 

Karen A Santucci, MD, MD is a member of the following medical societies: Alpha Omega Alpha, Academic Pediatric Association, American Academy of Pediatrics, Sigma Xi, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

James Li, MD Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, David W Marby, MD †, to the development and writing of this article.

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Child with sunken eyes.
Child with slow skin pinch (reduced skin turgor).
Child with absent tears.
Child with lethargy/poor general appearance.
Child with hyperpnea (deep, acidotic breathing)
Table 1. Assessment of Dehydration*
Symptom or Sign No or Minimal Dehydration Mild to Moderate Dehydration Severe Dehydration
Mental status Alert Restless, irritable Lethargic, unconscious
Thirst Drinks normally Drinks eagerly Drinks poorly
Heart rate Normal Normal to increased Tachycardia
Quality of pulses Normal Normal to decreased Weak or unpalpable
Breathing Normal Normal or fast Deep
Eyes Normal Slightly sunken Deeply sunken
Tears Present Decreased Absent
Mouth and tongue Moist Dry Parched
Skin fold Instant recoil Recoil < 2 seconds Recoil >2 seconds
Capillary refill Normal Prolonged Prolonged or minimal
Extremities Warm Cool Cold, mottled, cyanotic
Urine output Normal Decreased Minimal
*Adapted from King et al. MMWR Recomm Rep. 2003;52(RR-16):1-16.[15]
Table 2. Assessment of Dehydration According to the World Health Organization*
Severe Dehydration Two of the following signs:



-Lethargic or unconscious



-Sunken eyes



-Not able to drink or drinking poorly



-Skin pinch goes back very slowly



Some Dehydration Two of the following signs:



-Restless, irritable



-Sunken eyes



-Thirsty, drinks eagerly



-Skin pinch goes back slowly



No Dehydration Not enough of the above signs to classify as some or severe dehydration
*Adapted from World Health Organization.[10]
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