eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Gastroenteritis: Treatment & Medication

Author: Adam Levine, MD, MPH, Assistant Professor of Emergency Medicine, Brown University Alpert School of Medicine
Coauthor(s): Karen A Santucci, MD, Fellowship Director of Pediatric Emergency Medicine, Department of Pediatrics, Assistant Professor, New Haven Children's Hospital, Yale University
Contributor Information and Disclosures

Updated: Nov 17, 2009

Treatment

Emergency Department Care

The AAP, the European Society of Pediatric Gastroenterology and Nutrition (ESPGAN), and the WHO all recommend oral rehydration solution (ORS) as the treatment of choice for children with mild-to-moderate gastroenteritis in both developed and developing countries, based on the results of dozens of randomized, controlled trials and several large meta-analyses. One large meta-analysis of 16 trials including 1545 children with mild-to-moderate dehydration found that, compared with intravenous rehydration, children treated with ORS had a significant reduction in length of hospital stay and fewer adverse events, including seizures and death.⁸ In most large trials, the rate of ORS failure (percentage of children eventually requiring intravenous hydration) was about 4%.

• Minimal or no dehydration: No immediate treatment is required. Instruction to caretakers about ORS and signs of dehydration are recommended.
• Mild-to-moderate dehydration: Children should be given 50-100 mL/kg of ORS over a 2- to 4-hour period to replace their estimated fluid deficit, with additional ORS given to replace ongoing losses (10 mL/kg body weight for each stool and 2 mL/kg body weight for each episode of emesis). After the initial rehydration phase, patients may be transitioned to maintenance fluids as described above.
  • ORS should be given slowly by the parent using a teaspoon, syringe, or medicine dropper at the rate of 5 mL every 1-2 minutes. If tolerated by the patient, the rate of ORS delivery can be increased slowly over time.
  • For patients who do not tolerate ORS by mouth due to persistent vomiting or oral ulcers, nasogastric (NG) feeding is a safe and effective alternative. Multiple large clinical trials have found NG rehydration to be as efficacious as intravenous rehydration but more cost-effective and with fewer adverse events.
  • Patients with moderate dehydration should be reassessed frequently by the clinician to ensure adequacy of oral intake and resolution of the various signs and symptoms of dehydration.
• Severe dehydration: This constitutes a medical emergency requiring immediate resuscitation with intravenous fluids.
  • IV access should be obtained and patients should be administered a bolus of 20-30 mL/kg lactated Ringer's (LR) or normal saline (NS). If pulse, perfusion, and/or mental status do not improve, a second bolus should be administered. After this, the patient should be given an infusion of 70 mL/kg LR or NS over 5 hours (for children <12 mo) or 2.5 hours (for older children). If no peripheral veins are available, an intraosseous line should be placed. Serum electrolytes, bicarbonate, urea/creatinine, and glucose levels should be obtained.
  • Once resuscitation is complete and mental status returns to normal, rehydration should continue with ORS as described above, as it has been shown to decrease the rate of hyponatremia and hypernatremia when compared with intravenous rehydration.
• Type of ORS: Two large meta-analyses confirm that reduced osmolarity ORS (osmolarity <250 mmol/L) is associated with fewer treatment failures requiring intravenous hydration, lower stool output, and less frequent vomiting compared with standard osmolarity ORS for patients with noncholera gastroenteritis.^9,10
  • Multiple preparations of reduced osmolarity ORS are available in the United States, including Pedialyte, Infalyte, and Naturalyte. Available formulations in Europe include Dioralyte and Diocalm Junior. In developing countries, clinicians can use WHO ORS or a homemade solution of 3 g (1 tsp) salt and 18 g (6 tsp) sugar added to 1 L of clean water.
  • A large meta-analysis found that patients with cholera had higher rates of hyponatremia with reduced osmolarity ORS compared with standard osmolarity ORS, without any of the added benefits seen in patients with noncholera gastroenteritis.¹¹
• Feeding and nutrition: In general, children with gastroenteritis should be returned to a normal diet as rapidly as possible. Early feeding reduces illness duration and improves nutritional outcome.
  • Breastfed infants should continue to breastfeed throughout the rehydration and maintenance phases of acute gastroenteritis.
  • Formula fed infants should restart feeding at full strength as soon as the rehydration phase is complete (ideally in 2-4 h).
  • Weaned children should restart their normal fluids and solids as soon as the rehydration phase is complete. Fatty foods and foods high in simple sugars should be avoided.
  • For most infants, clinical trials have found no benefit of lactose-free formulas over lactose-containing formulas. Similarly, highly specific diets, such as the BRAT (bananas, rice, applesauce, and toast) diet, have not been shown to improve outcomes and may provide suboptimal nutrition for the patient.

Medication

The goals of pharmacotherapy are to reduce morbidity, prevent complications, and 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. Several large studies and two recent meta-analyses have found probiotics (especially Lactobacillus GG) to be effective in reducing the duration of diarrhea in children presenting with acute gastroenteritis.^12,13

Several large studies, all conducted in developing countries, have shown zinc supplementation to be effective in reducing the duration and severity of diarrhea in children with acute gastroenteritis, as well as the likelihood of recurrence of diarrhea.¹⁴ The WHO recommends zinc supplementation (10-20 mg/d for 10-14 d) for all children younger than 5 years with acute gastroenteritis, although little data support this recommendation for children in developed countries.

Vaccines

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 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.¹⁵

Rotavirus vaccine (RotaTeq, Rotarix)

Currently, 2 orally administered live-virus vaccines are marketed in the United States.¹⁶ 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.

Antimicrobials

Since the majority of 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 be ineffective (Campylobacter), may prolong the carrier state (Salmonella), or may increase the risk of hemolytic uremic syndrome (enterohemorrhagic E coli).

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.

Although 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.

For patients with ova and parasites (O+P) confirming infection with Giardia, metronidazole (35-50 mg/kg/d divided q8h) remains the drug of choice. Nitazoxanide oral suspension (age 1-3: 100 mg q12h for 3 d, age 4-11: 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).

Antiemetics

A large, prospective, randomized, double-blind trial compared a single dose of an orally disintegrating ondansetron tablet to placebo in children presenting to an emergency department with acute gastroenteritis.¹⁷ The study found that children treated with ondansetron were less likely to vomit, had greater oral intake, were less likely to require intravenous rehydration, and had a reduced length of stay in the emergency department compared with children treated with placebo. Previous smaller studies have shown ondansetron to be similarly effective in children, although little data exist regarding the efficacy of other antiemetic drugs.

Ondansetron (Zofran)

Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally.

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