Pediatric Gastroenteritis Workup

  • Author: Adam Levine, MD, MPH; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Apr 7, 2010
 

Laboratory Studies

The vast majority of children presenting with acute gastroenteritis do not require serum or urine tests, as they are unlikely to be helpful in determining the degree of dehydration. In a meta-analysis of 6 studies, only serum bicarbonate (< 17) had statistically significant positive and negative likelihood ratios for detecting moderate dehydration.[8]

Clinically significant electrolyte abnormalities are rare in children with moderate dehydration. However, any child being treated with intravenous fluids for severe dehydration should have baseline electrolytes, bicarbonate, and urea/creatinine drawn. Laboratory tests are also indicated in patients with moderate dehydration whose history and physical examination are inconsistent with straightforward gastroenteritis.

Fecal leukocytes and stool culture may be helpful in children presenting with dysentery. Children older than 12 months of age with a recent history of antibiotic use should have stool tested for C difficile toxins. Those with a history of prolonged watery diarrhea (>14 d) or travel to an endemic area should have stool sent for ova and parasites.

Any child with evidence of systemic infection should have a complete workup, including CBC and blood cultures. If indicated, urine cultures, chest radiography, and/or lumbar puncture should be performed.

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Imaging Studies

Abdominal films are not indicated in the management of acute gastroenteritis. If the clinician suspects a diagnosis other than acute gastroenteritis based on history and physical examination findings, appropriate imaging modalities should be pursued.

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Other Tests

Workup of acute gastroenteritis should begin by using elements of the history and physical examination to determine level of dehydration. Both the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend using a simple dehydration scale to classify the total body water loss occurring with dehydration as minimal/none (< 3%), mild/moderate (3-9%), or severe (>10%)[2] (see Table 1 below). The World Health Organization (WHO) recommends a simpler system for use by both physicians and lay health workers, which classifies dehydration as none, some, or severe[9] (see Table 2 below).

One meta-analysis of 13 separate studies looking at individual signs and symptoms of dehydration found only abnormal capillary refill (>2 sec), decreased skin turgor, and abnormal respiratory pattern (hyperpnea) had statistically and clinically significant positive and negative likelihood ratios for detecting dehydration in children.[8]

Several studies have found that combinations of clinical signs and symptoms may have better sensitivity and specificity for detecting dehydration in children than individual signs or symptoms.[10, 11, 12, 13, 8] A study by Gorelick et al assessed the validity of a combination of 10 signs and symptoms similar to those recommended by the CDC. They found that the presence of 3 or more signs had a sensitivity of 0.87 and a specificity of 0.82 for detecting moderate dehydration.[11] The presence of 7 or more signs had a sensitivity of 0.82 and a specificity of 0.90 for detecting severe dehydration.

Parkin et al recently validated an 8-point scale that assigns 0-2 points each to general appearance, sunken eyes, mucous membranes, and tears.[10] A score of 5-8 on this scale had a positive likelihood ratio of 5.2 and a negative likelihood ratio of 0.55 for the presence of moderate/severe dehydration in children with acute gastroenteritis.

Table 1. Assessment of Dehydration* (Open Table in a new window)

Symptom or Sign No or Minimal Dehydration Mild to Moderate Dehydration Severe Dehydration
Mental statusAlertRestless, irritableLethargic, unconscious
ThirstDrinks normallyDrinks eagerlyDrinks poorly
Heart rateNormalNormal to increasedTachycardia
Quality of pulsesNormalNormal to decreasedWeak or unpalpable
BreathingNormalNormal or fastDeep
EyesNormalSlightly sunkenDeeply sunken
TearsPresentDecreasedAbsent
Mouth and tongueMoistDryParched
Skin foldInstant recoilRecoil < 2 secondsRecoil >2 seconds
Capillary refillNormalProlongedProlonged or minimal
ExtremitiesWarmCoolCold, mottled, cyanotic
Urine outputNormalDecreasedMinimal
*Adapted from King et al. MMWR Recomm Rep. 2003;52(RR-16):1-16.[2]

Table 2. Assessment of Dehydration According to the World Health Organization* (Open Table in a new window)

Severe DehydrationTwo of the following signs:



-Lethargic or unconscious



-Sunken eyes



-Not able to drink or drinking poorly



-Skin pinch goes back very slowly



Some DehydrationTwo of the following signs:



-Restless, irritable



-Sunken eyes



-Thirsty, drinks eagerly



-Skin pinch goes back slowly



No DehydrationNot enough of the above signs to classify as some or severe dehydration
*Adapted from World Health Organization.[9]
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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, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Karen A Santucci, MD  Fellowship Director of Pediatric Emergency Medicine, Department of Pediatrics, Assistant Professor, New Haven Children's Hospital, Yale University

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

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

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

References

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  2. [Guideline] King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. Nov 21 2003;52:1-16. [Medline].

  3. Dennehy PH. Acute diarrheal disease in children: epidemiology, prevention, and treatment. Infect Dis Clin North Am. Sep 2005;19(3):585-602. [Medline].

  4. Kosek M, Bern C, Guerrant RL. The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. Bull World Health Organ. 2003;81(3):197-204. [Medline].

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  6. [Guideline] Cortese MM, Parashar UD. Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Feb 6 2009;58:1-25. [Medline]. [Full Text].

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  9. World Health Organization. The treatment of diarrhoea: a manual for physicians and other senior health workers -- 4th revision. 2005.

  10. Parkin PC, Macarthur C, Khambalia A, Goldman RD, Friedman JN. Clinical and laboratory assessment of dehydration severity in children with acute gastroenteritis. Clin Pediatr (Phila). Apr 2010;49(3):235-9. [Medline].

  11. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. May 1997;99(5):E6. [Medline].

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  13. Duggan C, Refat M, Hashem M, Wolff M, Fayad I, Santosham M. How valid are clinical signs of dehydration in infants?. J Pediatr Gastroenterol Nutr. Jan 1996;22(1):56-61. [Medline].

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  22. Gregorio GV, Gonzales ML, Dans LF, Martinez EG. Polymer-based oral rehydration solution for treating acute watery diarrhoea. Cochrane Database Syst Rev. 2009;(2):CD006519. [Medline].

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  25. Patro B, Golicki D, Szajewska H. Meta-analysis: zinc supplementation for acute gastroenteritis in children. Aliment Pharmacol Ther. Sep 15 2008;28(6):713-23. [Medline].

  26. Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. Jan 5 2006;354(1):11-22. [Medline].

  27. Linhares AC, Velazquez FR, Perez-Schael I, et al. Efficacy and safety of an oral live attenuated human rotavirus vaccine against rotavirus gastroenteritis during the first 2 years of life in Latin American infants: a randomised, double-blind, placebo-controlled phase III study. Lancet. Apr 5 2008;371(9619):1181-9. [Medline].

  28. Madhi SA, Cunliffe NA, Steele D, Witte D, Kirsten M, Louw C. Effect of human rotavirus vaccine on severe diarrhea in African infants. N Engl J Med. Jan 28 2010;362(4):289-98. [Medline].

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  30. Phavichitr N, Catto-Smith A. Acute gastroenteritis in children : what role for antibacterials?. Paediatr Drugs. 2003;5(5):279-90. [Medline].

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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 statusAlertRestless, irritableLethargic, unconscious
ThirstDrinks normallyDrinks eagerlyDrinks poorly
Heart rateNormalNormal to increasedTachycardia
Quality of pulsesNormalNormal to decreasedWeak or unpalpable
BreathingNormalNormal or fastDeep
EyesNormalSlightly sunkenDeeply sunken
TearsPresentDecreasedAbsent
Mouth and tongueMoistDryParched
Skin foldInstant recoilRecoil < 2 secondsRecoil >2 seconds
Capillary refillNormalProlongedProlonged or minimal
ExtremitiesWarmCoolCold, mottled, cyanotic
Urine outputNormalDecreasedMinimal
*Adapted from King et al. MMWR Recomm Rep. 2003;52(RR-16):1-16.[2]
Table 2. Assessment of Dehydration According to the World Health Organization*
Severe DehydrationTwo of the following signs:



-Lethargic or unconscious



-Sunken eyes



-Not able to drink or drinking poorly



-Skin pinch goes back very slowly



Some DehydrationTwo of the following signs:



-Restless, irritable



-Sunken eyes



-Thirsty, drinks eagerly



-Skin pinch goes back slowly



No DehydrationNot enough of the above signs to classify as some or severe dehydration
*Adapted from World Health Organization.[9]
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