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Pediatric Gastroenteritis Workup

  • Author: Randy P Prescilla, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: May 27, 2016
 

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 (greater or less than 17) had statistically significant positive and negative likelihood ratios for detecting moderate dehydration.[16]

Clinically significant electrolyte abnormalities are rare in children with moderate dehydration. Any child being treated with intravenous fluids for severe dehydration, however, should have baseline electrolytes, bicarbonate, and urea/creatinine values tested. 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 with a recent history of antibiotic use should have stool tested for C difficile toxins. Those with a history of prolonged watery diarrhea (>14 days) or travel to an endemic area should have stool sent for ova and parasite tests.

Any child with evidence of systemic infection should have a complete workup, including CBC count 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 the 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%) (see Table 1).[2] 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 (see Table 2).

A meta-analysis of 13 separate studies looking at individual signs and symptoms of dehydration found that only abnormal capillary refill (>2 seconds), decreased skin turgor, and abnormal respiratory pattern (hyperpnea) had statistically and clinically significant positive and negative likelihood ratios for detecting dehydration in children.[16]

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.[16, 17, 18, 19, 20]

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.[18] 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 a an 8-point scale that assigns 0-2 points each to general appearance, sunken eyes, mucous membranes, and tears.[17] 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[2] (Open Table in a new window)

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 not palpable
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

Table 2: Assessment of Dehydration[21] (Open Table in a new window)

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
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Contributor Information and Disclosures
Author

Randy P Prescilla, MD Instructor in Anesthesia, Harvard Medical School; Assistant in Perioperative Anesthesia, Children's Hospital Boston

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.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

References
  1. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010 Jun 5. 375(9730):1969-87. [Medline].

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

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

  4. Hullegie S, Bruijning-Verhagen P, Uiterwaal CS, et al. First-year Daycare and Incidence of Acute Gastroenteritis. Pediatrics. 2016. 137(5):e20153356.

  5. Fischer Walker CL, Perin J, Aryee MJ, Boschi-Pinto C, Black RE. Diarrhea incidence in low- and middle-income countries in 1990 and 2010: a systematic review. BMC Public Health. 2012. 12:220. [Medline].

  6. Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis. 2003 May. 9(5):565-72. [Medline].

  7. Boschi-Pinto C, Velebit L, Shibuya K. Estimating child mortality due to diarrhoea in developing countries. Bull World Health Organ. 2008 Sep. 86(9):710-7. [Medline].

  8. 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].

  9. Tate JE, Burton AH, Boschi-Pinto C, Steele AD, Duque J, Parashar UD. 2008 estimate of worldwide rotavirus-associated mortality in children younger than 5 years before the introduction of universal rotavirus vaccination programmes: a systematic review and meta-analysis. Lancet Infect Dis. 2012 Feb. 12(2):136-41. [Medline].

  10. Cortese MM, Parashar UD,. Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2009 Feb 6. 58(RR-2):1-25. [Medline].

  11. Cortes JE, Curns AT, Tate JE, Cortese MM, Patel MM, Zhou F. Rotavirus vaccine and health care utilization for diarrhea in U.S. children. N Engl J Med. 2011 Sep 22. 365(12):1108-17. [Medline].

  12. Leshem E, Moritz RE, Curns AT, Zhou F, Tate JE, Lopman BA, et al. Rotavirus vaccines and health care utilization for diarrhea in the United States (2007-2011). Pediatrics. 2014 Jul. 134(1):15-23. [Medline].

  13. Laidman J. Rotavirus Vaccine Greatly Reduced Healthcare Use. Medscape. Available at http://www.medscape.com/viewarticle/826391. Accessed: 9/15/14.

  14. Payne DC, Vinje J, Szilagyi PG, Edwards KM, Staat MA, Weinberg GA. Norovirus and medically attended gastroenteritis in U.S. children. N Engl J Med. 2013 Mar 21. 368(12):1121-30. [Medline].

  15. Wenneras C, Erling V. Prevalence of enterotoxigenic Escherichia coli-associated diarrhoea and carrier state in the developing world. J Health Popul Nutr. 2004 Dec. 22(4):370-82. [Medline].

  16. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?. JAMA. 2004 Jun 9. 291(22):2746-54. [Medline].

  17. 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). 2010 Mar. 49(3):235-9. [Medline].

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

  19. Vega RM, Avner JR. A prospective study of the usefulness of clinical and laboratory parameters for predicting percentage of dehydration in children. Pediatr Emerg Care. 1997 Jun. 13(3):179-82. [Medline].

  20. 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. 1996 Jan. 22(1):56-61. [Medline].

  21. World Health Organization. Treatment of diarrhoea: a manual for physicians and other senior health workers, 4th ed. 2005. Available at http://209.61.208.233/LinkFiles/CAH_Publications_manual_physicians.pdf. Accessed: March 26, 2013.

  22. Sandhu BK. Practical guidelines for the management of gastroenteritis in children. J Pediatr Gastroenterol Nutr. 2001 Oct. 33 Suppl 2:S36-9. [Medline].

  23. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics. 1996 Mar. 97(3):424-35. [Medline].

  24. Fonseca BK, Holdgate A, Craig JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med. 2004 May. 158(5):483-90. [Medline].

  25. Bellemare S, Hartling L, Wiebe N, Russell K, Craig WR, McConnell D. Oral rehydration versus intravenous therapy for treating dehydration due to gastroenteritis in children: a meta-analysis of randomised controlled trials. BMC Med. 2004 Apr 15. 2:11. [Medline].

  26. Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA. 2016 May 10. 315 (18):1966-74. [Medline].

  27. MacReady N. Juice, Other Drinks Can Manage Mild Gastroenteritis in Children. Medscape Medical News. Available at http://www.medscape.com/viewarticle/862764. May 03, 2016; Accessed: May 27, 2016.

  28. Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics. 2002 Apr. 109(4):566-72. [Medline].

  29. Hahn S, Kim S, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. Cochrane Database Syst Rev. 2002. (1):CD002847. [Medline].

  30. Murphy C, Hahn S, Volmink J. Reduced osmolarity oral rehydration solution for treating cholera. Cochrane Database Syst Rev. 2004. (4):CD003754. [Medline].

  31. Alam NH, Islam S, Sattar S, Monira S, Desjeux JF. Safety of rapid intravenous rehydration and comparative efficacy of 3 oral rehydration solutions in the treatment of severely malnourished children with dehydrating cholera. J Pediatr Gastroenterol Nutr. 2009 Mar. 48(3):318-27. [Medline].

  32. 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].

  33. Allen SJ, Okoko B, Martinez E, Gregorio G, Dans LF. Probiotics for treating infectious diarrhoea. Cochrane Database Syst Rev. 2004. (2):CD003048. [Medline].

  34. Szajewska H, Mrukowicz JZ. Probiotics in the treatment and prevention of acute infectious diarrhea in infants and children: a systematic review of published randomized, double-blind, placebo-controlled trials. J Pediatr Gastroenterol Nutr. 2001 Oct. 33 Suppl 2:S17-25. [Medline].

  35. Johnston BC, Ma SS, Goldenberg JZ, Thorlund K, Vandvik PO, Loeb M. Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Ann Intern Med. 2012 Dec 18. 157(12):878-88. [Medline].

  36. Lazzerini M, Ronfani L. Oral zinc for treating diarrhoea in children. Cochrane Database Syst Rev. 2012. 6:CD005436. [Medline].

  37. Ruiz-Palacios GM, Perez-Schael I, Velazquez FR, Abate H, Breuer T, Clemens SC. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. N Engl J Med. 2006 Jan 5. 354(1):11-22. [Medline].

  38. Linhares AC, Velazquez FR, Perez-Schael I, Saez-Llorens X, Abate H, Espinoza F. 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. 2008 Apr 5. 371(9619):1181-9. [Medline].

  39. 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. 2010 Jan 28. 362(4):289-98. [Medline].

  40. Richardson V, Hernandez-Pichardo J, Quintanar-Solares M, Esparza-Aguilar M, Johnson B, Gomez-Altamirano CM. Effect of rotavirus vaccination on death from childhood diarrhea in Mexico. N Engl J Med. 2010 Jan 28. 362(4):299-305. [Medline].

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

  42. Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2011. (9):CD005506. [Medline].

  43. Freedman SB, Hall M, Shah SS, Kharbanda AB, Aronson PL, Florin TA, et al. Impact of increasing ondansetron use on clinical outcomes in children with gastroenteritis. JAMA Pediatr. 2014 Apr. 168(4):321-9. [Medline].

  44. Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med. 2006 Apr 20. 354(16):1698-705. [Medline].

  45. Borowitz SM. Are antiemetics helpful in young children suffering from acute viral gastroenteritis?. Arch Dis Child. 2005 Jun. 90(6):646-8. [Medline].

 
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Table 1. Assessment of Dehydration [2]
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 not palpable
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
Table 2: Assessment of Dehydration [21]
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
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