Pediatric Gastroenteritis in Emergency Medicine

Updated: Oct 31, 2016
  • Author: Adam Levine, MD, MPH; Chief Editor: Kirsten A Bechtel, MD  more...
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Overview

Practice Essentials

Though often considered a benign disease, acute gastroenteritis remains a leading cause of pediatric morbidity and mortality around the world, accounting for 520,000 deaths annually in children younger than 5 years. [1] See the video below.

Child with sunken eyes.

Viruses remain by far the most common cause of acute gastroenteritis in children, both in high-resource and low-resource settings, though several bacterial species also play an important role in acute gastroenteritis in low-resource settings. The 2 primary mechanisms responsible for acute gastroenteritis are as follows:

  • Damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to osmotic diarrhea
  • Release of toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhea

Signs and symptoms

These include the following:

  • Diarrhea
  • Vomiting
  • Increase or decrease in urinary frequency
  • Abdominal pain
  • Signs and symptoms of infection - Presence of fever, chills, myalgias, rash, rhinorrhea, sore throat, cough; these may be evidence of systemic infection or sepsis
  • Changes in appearance and behavior - Including weight loss and increased malaise, lethargy, or irritability, as well as changes in the amount and frequency of feeding and in the child’s level of thirst
  • History of recent antibiotic use - Increases the likelihood of Clostridium difficile
  • History of travel to endemic areas

Assessment of dehydration

According to the World Health Organization (WHO), a patient exhibiting 2 of the following signs can be considered to have some amount of dehydration:

  • Restless, irritable
  • Sunken eyes
  • Thirsty, drinks eagerly
  • Skin pinch goes back slowly

According to the WHO, a patient exhibiting 2 of the following signs can be considered to have severe dehydration:

  • Lethargic or unconscious
  • Sunken eyes
  • Not able to drink or drinking poorly
  • Skin pinch goes back very slowly

See Clinical Presentation for more detail.

Diagnosis

Workup in pediatric gastroenteritis can include the following:

  • Baseline electrolytes, bicarbonate, and urea/creatinine - In any child being treated with intravenous fluids for severe dehydration
  • Fecal leukocytes and stool culture - May be helpful in children presenting with dysentery
  • Stool analysis for C difficile toxins - In children older than 12 months with a recent history of antibiotic use
  • Stool analysis for ova and parasites - In patients with a history of prolonged watery diarrhea (>14 days) or travel to an endemic area
  • Complete blood count (CBC) and blood cultures - Any child with evidence of systemic infection

If indicated, urine cultures, chest radiography, and/or lumbar puncture should be performed. Several studies have found that combinations of clinical signs and symptoms may have better sensitivity and specificity for detecting dehydration in children than do individual signs or symptoms. [2, 3, 4, 5, 6]

See Workup for more detail.

Management

Oral rehydration solution

The American Academy of Pediatrics, the European Society of Pediatric Gastroenterology and Nutrition (ESPGAN), and the World Health Organization (WHO) all recommend oral rehydration solution (ORS) as the treatment of choice for children with mild to moderate gastroenteritis, including those in both high-resource and low-resource settings, based on the results of dozens of randomized, controlled trials and several large meta-analyses. [7, 8, 9]

Pharmacologic therapy

Agents used in the treatment or prevention of acute pediatric gastroenteritis include the following:

  • Probiotics - Live microbial feeding supplements commonly used in the treatment and prevention of acute diarrhea
  • Zinc - To treat diarrhea; [10] the WHO recommends zinc supplementation for all children younger than 5 years with acute gastroenteritis in low-resource settings, though little data exist to support this recommendation for children in high-resource settings
  • Metronidazole - In patients infected with C difficile and Giardia
  • Tetracycline and doxycycline - For cholera (azithromycin should be used for children younger than 8 years)
  • Vaccine - In February 2006, the US Food and Drug Administration (FDA) approved the RotaTeq vaccine for prevention of rotavirus gastroenteritis

See Treatment and Medication for more detail.

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Background

Though often considered a benign disease, acute gastroenteritis remains a leading cause of morbidity and mortality in children around the world, accounting for 520,000 deaths annually in children younger than 5 years, or roughly 10% of all child deaths worldwide. [1] Because the disease severity depends on the degree of fluid loss, accurately assessing dehydration status remains a crucial step in preventing mortality. Luckily, most cases of dehydration in children can be accurately diagnosed by a careful clinical examination and treated with simple, cost-effective measures.

See the video below depicting a child with acute gastroenteritis.

Child with slow skin pinch (reduced skin turgor).
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Pathophysiology

Adequate fluid balance in humans depends on the secretion and reabsorption of fluid and electrolytes in the intestinal tract; diarrhea occurs when intestinal fluid output overwhelms the absorptive capacity of the gastrointestinal tract. The 2 primary mechanisms responsible for acute gastroenteritis are (1) damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to an osmotic diarrhea, and (2) the release of toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhea. [11]

However, even in severe diarrhea, various sodium-coupled solute co-transport mechanisms remain intact, allowing for the efficient reabsorption of salt and water. By providing a 1:1 proportion of sodium to glucose, classic oral rehydration solution (ORS) takes advantage of a specific sodium-glucose transporter (SGLT-1) to increase the reabsorption of sodium, which leads to the passive reabsorption of water. Rice- and cereal-based ORS may also take advantage of sodium-amino acid transporters to increase reabsorption of fluid and electrolytes. [11]

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Frequency

United States

Children in the United States experience, on average, 1.3-2.3 episodes of diarrhea each year. Overall, acute gastroenteritis accounts for than 1.5 million outpatient visits, 220,000 hospitalizations, and direct costs of more than $2 billion each year in the United States alone. [12]

International

Annually, children under five experience an estimated 1.7 billion diarrheal episodes worldwide, leading to 124 million outpatient visits, 9 million hospitalizations, and 520,000 deaths. [13, 14, 15, 1]

Though the prevalence of acute gastroenteritis in children has changed little over the past 4 decades, the mortality has declined sharply, from 4.6 million in the 1970s to 3 million in the 1980s and 2.5 million in the 1990s. [16] One of the most important reasons for this decline has been the increasing international support for the use of ORS as the treatment of choice for acute diarrhea, with the proportion of diarrheal episodes treated with ORS rising from 15% in 1984 to 40% in 1993. [16]

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Epidemiology

A study by Hullegie et al investigated the effects of first-year daycare attendance on acute gastroenteritis incidence and primary care contact rate up to age 6 years. The study found that first-year daycare attendance advances the timing of acute gastroenteritis infections, resulting in increased acute gastroenteritis disease burden in the first year and relative protection thereafter. The study also added that protection against acute gastroenteritis infection persists at least up to age 6 years. [17]

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