Pediatric Gastroenteritis Treatment & Management

The American Academy of Pediatrics (AAP) states, "oral rehydration therapy is the preferred treatment of fluid and electrolytes lost by diarrhea in children with mild-to-moderate dehydration."^[3] In addition, both the AAP and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recommend rapid rehydration over 3-4 hours.^{[3, 4]} A useful method is to administer 100 mL/kg/d for the first 10 kg of body weight (BW), 50 mL/kg for the next 10 kg BW, and 20 mL/kg for each additional kg BW.

The latest CDC recommendations for managing acute gastroenteritis in children can be viewed online at Managing Acute Gastroenteritis Among Children.^[5]

• Oral rehydration therapy in the home environment

  • Several oral rehydration solutions (ORSs) and pediatric maintenance solutions are available commercially (eg, Pedialyte, Rehydralyte, Kaolectrolyte, CeraLyte, Infalyte, Equalyte).
  • A general guideline is to provide 4-8 oz for every episode of loose or watery stools until the diarrhea resolves.
  • These fluids are not recommended for rehydration: tea, juices, pop, Kool-Aid, Gatorade (or similar sport drinks), boiled rice water, or boiled skim milk.
• Rehydration therapy in healthcare settings

  • Oral rehydration is possible in a doctor's office with available space for at least 4 hours monitoring, adequately trained staff, and adequate mechanisms for billing this service. Intravenous rehydration also is feasible in these settings for mildly dehydrated patients who do not tolerate oral rehydration.
  • Provide rapid intravenous rehydration for patients with the following conditions:
    • Severe dehydration with cardiovascular involvement (ie, hypotension or shock)
    • Failure of oral rehydration because of persistent vomiting
    • High stool output (ie, usually >10 mL/kg BW/h)
    • Monosaccharide malabsorption, evidenced by the presence of glucose or reducing substances in the stool and a significant increase in the stool volume following administration of the ORS
  • Cerebral edema is the most serious potential consequence of rapidly infusing hypotonic fluids in a patient with hypernatremic dehydration.
• Medications

  • Loperamide, opiates, opiate-and-atropine combination drugs, anticholinergic drugs, and absorbents are not recommended to treat diarrhea in children. No evidence exists that these are effective, and use may lead to possible adverse events.
  • Similarly, routine use of bismuth subsalicylate and lactobacillus-containing compounds is not recommended.
  • Most authorities do not recommend routine antiemetic use for children. Clinical evidence is currently insufficient to justify the use of ondansetron or metoclopramide in children with acute viral gastroenteritis.
  • Although antibiotic treatment clearly shortens the clinical illness and duration of pathogen excretion in dysentery caused by Shigella species, routine antibiotic use provides no clear advantage to treat gastroenteritis caused by Campylobacter jejuni, Yersinia enterocolitica, E coli, and Salmonella species.
  • Antibiotic administration may be considered for very young patients with Salmonella- caused gastroenteritis, for patients who are immunocompromised, and for patients who are systemically ill.
  • Evidence suggests that antibiotic treatment of enterohemorrhagic E coli infection may increase the risk for developing hemolytic uremic syndrome.
  • Rifaximin has excellent antibacterial activity and was approved in 2004 for the treatment for traveler's diarrhea caused by noninvasive strains of E coli.

Rapidly reintroducing normal feeding is the optimal rehydration method for children who are mildly to moderately dehydrated.

For infants, the AAP, ESPGHAN, and other groups currently recommend full-strength formula. The recommended rehydration method for breastfed infants is to continue to receive mother's milk.

For older children, the usual advice is to eat bananas, rice cereals, applesauce, and toast (ie, BRAT diet). Also on the recommended list are complex carbohydrates (eg, rice, wheat, bread, cereals), lean meats, yogurt, fruits, and vegetables.