Sections

Pediatric Gastroenteritis in Emergency Medicine

Sections Pediatric Gastroenteritis in Emergency Medicine
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Media Gallery
Tables
References

Follow-up

Further Outpatient Care

See the list below:

Parents should be instructed to continue providing maintenance ORS fluids at home as needed. Breastfeeding and formula feeding should be continued for infants, and children should be encouraged to return to a regular diet as rapidly as possible.
Parents should be instructed to look for the various signs of dehydration outlined above, such as change in mental status, decreased urine output, sunken eyes, absence of tears, dry mucous membranes, and slow return of abdominal skin pinch.
Parents should seek medical attention if dehydration returns, oral intake is inadequate, or if their child develops worsening abdominal pain, fever >101°F, or prolonged diarrhea lasting longer than 14 days.

Further Inpatient Care

Inpatient admission should be considered for all children with acute gastroenteritis in the following situations:

Signs of severe dehydration are present.
Caregivers are unable to manage oral rehydration or provide adequate care at home.
Substantial difficulties exist in administering ORS, such as intractable vomiting or inadequate ORS intake.
Failure of treatment occurs, such as worsening diarrhea or dehydration, despite adequate ORS intake.
Factors are present necessitating closer observation, such as young age, decreased mental status, or uncertainty of diagnosis.
Children with mild-moderate dehydration, age < 6 months, or high frequency of stools/vomits should be monitored in the emergency department for a minimum of 4-6 hours before discharge.

Deterrence/Prevention

See the list below:

The US Advisory Committee on Immunization Practices and the American Academy of Pediatrics recommend routine vaccination of US infants with rotavirus vaccine to protect against rotavirus gastroenteritis.^[18]

Patient Education

See the list below:

For patient education resources, see the Esophagus, Stomach, and Intestine Center. Also see the patient education article Gastroenteritis.

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Freedman SB, Vandermeer B, Milne A, Hartling L, Pediatric Emergency Research Canada Gastroenteritis Study Group. Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis. J Pediatr. 2015 Apr. 166 (4):908-16.e1-6. [Medline].
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 Apr. 49(3):235-9. [Medline].
Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?. JAMA. 2004 Jun 9. 291 (22):2746-54. [Medline].
Granado-Villar D, Cunill-De Sautu B, Granados A. Acute gastroenteritis. Pediatr Rev. 2012 Nov. 33 (11):487-94; quiz 495. [Medline].
King CK, Glass R, Bresee JS, Duggan C, Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21. 52 (RR-16):1-16. [Medline].
[Guideline] Guarino A, Ashkenazi S, Gendrel D, Lo Vecchio A, Shamir R, Szajewska H, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr. 2014 Jul. 59 (1):132-52. [Medline].
[Guideline] World Health Organization. The treatment of diarrhea: a manual for physicians and other senior health workers. 4th revision. 2005.
Florez ID, Veroniki AA, Al Khalifah R, Yepes-Nuñez JJ, Sierra JM, Vernooij RWM, et al. Comparative effectiveness and safety of interventions for acute diarrhea and gastroenteritis in children: A systematic review and network meta-analysis. PLoS One. 2018. 13 (12):e0207701. [Medline].
Lazzerini M, Wanzira H. Oral zinc for treating diarrhoea in children. Cochrane Database Syst Rev. 2016 Dec 20. 12:CD005436. [Medline].
[Guideline] El Bcheraoui C, Mokdad AH, Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, Morozoff C, et al. Trends and Patterns of Differences in Infectious Disease Mortality Among US Counties, 1980-2014. JAMA. 2018 Mar 27. 319 (12):1248-1260. [Medline].
Keddy KH. Old and new challenges related to global burden of diarrhoea. Lancet Infect Dis. 2018 Nov. 18 (11):1163-1164. [Medline].
Gill CJ, Thea DM, Hibberd P. Diarrhoeal disease trends in the GBD 2015 study: optimism tempered by scepticism. Lancet Infect Dis. 2017 Sep. 17 (9):884-885. [Medline].
Bartsch SM, Lopman BA, Ozawa S, Hall AJ, Lee BY. Global Economic Burden of Norovirus Gastroenteritis. PLoS One. 2016. 11 (4):e0151219. [Medline]. [Full Text].
Hullegie S, Bruijning-Verhagen P, Uiterwaal CS, van der Ent CK, Smit HA, de Hoog ML. First-year Daycare and Incidence of Acute Gastroenteritis. Pediatrics. 2016 May. 137 (5):565-72. [Medline]. [Full Text].
Walker CLF, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013 Apr 20. 381 (9875):1405-1416. [Medline].
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].
Laidman J. Rotavirus Vaccine Greatly Reduced Healthcare Use. Medscape Medical News. Available at http://www.medscape.com/viewarticle/826391. June 09, 2014; Accessed: February 28, 2019.
Payne DC, Vinjé J, Szilagyi PG, Edwards KM, Staat MA, Weinberg GA, et al. Norovirus and medically attended gastroenteritis in U.S. children. N Engl J Med. 2013 Mar 21. 368 (12):1121-30. [Medline].
Waknine Y. Norovirus Is Now the Main Cause of Acute GI Problems in Kids. Medscape Medical News. Available at http://www.medscape.com/viewarticle/781459. Mar 26, 2013; Accessed: Apr 3, 2013.
Norovirus is now the leading cause of severe gastroenteritis in US children. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/media/releases/2013/p0321_norovirus_children.html. Mar 21, 2013; Accessed: Apr 3, 2013.
Dennehy PH. Acute diarrheal disease in children: epidemiology, prevention, and treatment. Infect Dis Clin North Am. 2005 Sep. 19 (3):585-602. [Medline].
Liu J, Platts-Mills JA, Juma J, et al. Use of quantitative molecular diagnostic methods to identify causes of diarrhoea in children: a reanalysis of the GEMS case-control study. Lancet. 2016 Sep 24. 388 (10051):1291-301. [Medline]. [Full Text].
Mullish BH, Williams HR. Clostridium difficile infection and antibiotic-associated diarrhoea. Clin Med (Lond). 2018 Jun. 18 (3):237-241. [Medline]. [Full Text].
D'Ostroph AR, So TY. Treatment of pediatric Clostridium difficile infection: a review on treatment efficacy and economic value. Infect Drug Resist. 2017. 10:365-375. [Medline].
Dennehy PH. Acute diarrheal disease in children: epidemiology, prevention, and treatment. Infect Dis Clin North Am. 2005 Sep. 19 (3):585-602. [Medline].
Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?. JAMA. 2004 Jun 9. 291 (22):2746-54. [Medline].
Tam RK, Wong H, Plint A, Lepage N, Filler G. Comparison of clinical and biochemical markers of dehydration with the clinical dehydration scale in children: a case comparison trial. BMC Pediatr. 2014 Jun 16. 14:149. [Medline].
Bachur RG, Callahan MJ, Monuteaux MC, Rangel SJ. Integration of ultrasound findings and a clinical score in the diagnostic evaluation of pediatric appendicitis. J Pediatr. 2015 May. 166 (5):1134-9. [Medline].
Mostbeck G, Adam EJ, Nielsen MB, Claudon M, Clevert D, Nicolau C, et al. How to diagnose acute appendicitis: ultrasound first. Insights Imaging. 2016 Apr. 7 (2):255-63. [Medline].
Mackenzie DC, Nasrin S, Atika B, Modi P, Alam NH, Levine AC. Carotid Flow Time Test Performance for the Detection of Dehydration in Children With Diarrhea. J Ultrasound Med. 2018 Jun. 37 (6):1397-1402. [Medline]. [Full Text].
Modi P, Glavis-Bloom J, Nasrin S, Guy A, Chowa EP, Dvor N, et al. Accuracy of Inferior Vena Cava Ultrasound for Predicting Dehydration in Children with Acute Diarrhea in Resource-Limited Settings. PLoS One. 2016. 11 (1):e0146859. [Medline].
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].
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].
Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, Liebmann O, et al. External validation and comparison of three pediatric clinical dehydration scales. PLoS One. 2014. 9 (5):e95739. [Medline]. [Full Text].
Levine AC, Glavis-Bloom J, Modi P, Nasrin S, Atika B, Rege S, et al. External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study. Lancet Glob Health. 2016 Oct. 4 (10):e744-51. [Medline].
Skrable K, Bilal S, Sharma R, Robertson S, Ashenafi Y, Nasrin S, et al. The Effects of Malnutrition and Diarrhea Type on the Accuracy of Clinical Signs of Dehydration in Children under Five: A Prospective Cohort Study in Bangladesh. Am J Trop Med Hyg. 2017 Nov. 97 (5):1345-1354. [Medline].
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].
Bellemare S, Hartling L, Wiebe N, Russell K, Craig WR, McConnell D, et al. 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].
Rutman L, Klein EJ, Brown JC. Clinical Pathway Produces Sustained Improvement in Acute Gastroenteritis Care. Pediatrics. 2017 Oct. 140 (4):[Medline].
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].
Rébeillé-Borgella B, Barbier C, Moussaoui R, Faisant A, Michard-Lenoir AP, Rubio A. [Nasogastric rehydration for treating children with gastroenteritis]. Arch Pediatr. 2017 Jun. 24 (6):527-533. [Medline].
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].
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].
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. CD002847. [Medline].
Murphy C, Hahn S, Volmink J. Reduced osmolarity oral rehydration solution for treating cholera. Cochrane Database Syst Rev. 2004 Oct 18. CD003754. [Medline].
Gregorio GV, Gonzales ML, Dans LF, Martinez EG. Polymer-based oral rehydration solution for treating acute watery diarrhoea. Cochrane Database Syst Rev. 2016 Dec 13. 12:CD006519. [Medline].
Szajewska H, Skórka A, Ruszczyński M, Gieruszczak-Białek D. Meta-analysis: Lactobacillus GG for treating acute gastroenteritis in children--updated analysis of randomised controlled trials. Aliment Pharmacol Ther. 2013 Sep. 38 (5):467-76. [Medline].
Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev. 2010 Nov 10. 48(3):CD003048. [Medline].
Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O'Connell KJ, et al. Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children. N Engl J Med. 2018 Nov 22. 379 (21):2002-2014. [Medline].
Lau CS, Chamberlain RS. Probiotics are effective at preventing Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Int J Gen Med. 2016. 9:27-37. [Medline].
Lazzerini M, Wanzira H. Oral zinc for treating diarrhoea in children. Cochrane Database Syst Rev. 2016 Dec 20. 12:CD005436. [Medline].
Florez ID, Veroniki AA, Al Khalifah R, Yepes-Nuñez JJ, Sierra JM, Vernooij RWM, et al. Comparative effectiveness and safety of interventions for acute diarrhea and gastroenteritis in children: A systematic review and network meta-analysis. PLoS One. 2018. 13 (12):e0207701. [Medline].
Committee on Infectious Diseases., American Academy of Pediatrics. Prevention of rotavirus disease: updated guidelines for use of rotavirus vaccine. Pediatrics. 2009 May. 123 (5):1412-20. [Medline].
Phavichitr N, Catto-Smith A. Acute gastroenteritis in children : what role for antibacterials?. Paediatr Drugs. 2003. 5 (5):279-90. [Medline].
Zollner-Schwetz I, Krause R. Therapy of acute gastroenteritis: role of antibiotics. Clin Microbiol Infect. 2015 Aug. 21 (8):744-9. [Medline].
McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018 Mar 19. 66 (7):987-994. [Medline].
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Williams P, Berkley J. Cholera Update. World Health Organization; 2017.
Marchetti F, Bonati M, Maestro A, et al. Oral Ondansetron versus Domperidone for Acute Gastroenteritis in Pediatric Emergency Departments: Multicenter Double Blind Randomized Controlled Trial. PLoS One. 2016. 11 (11):e0165441. [Medline].
Hagbom M, Novak D, Ekström M, et al. Ondansetron treatment reduces rotavirus symptoms-A randomized double-blinded placebo-controlled trial. PLoS One. 2017. 12 (10):e0186824. [Medline].
Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open. 2012. 2 (4):[Medline].
Das JK, Kumar R, Salam RA, Freedman S, Bhutta ZA. The effect of antiemetics in childhood gastroenteritis. BMC Public Health. 2013. 13 Suppl 3:S9. [Medline].
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Media Gallery

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)

of 5

Table 1. Assessment of Dehydration*

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 impalpable
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
Adapted from King et al. MMWR Recomm Rep*. 2003;52(RR-16):1-16.^[11]

Table 2. Assessment of Dehydration According to the World Health Organization*

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
*Adapted from World Health Organization.^[7]

Clinical Dehydration Scale

General Appearance	Normal	Thirsty, restless, or irritable	Lethargic or unconscious
Eyes	Normal	Slightly sunken	Very sunken
Mucous Membranes	Moist	Dry	Very dry
Tears	Tears present	Decreased tears	Absent tears

Dehydration: Assessing Kids Accurately (DHAKA) Score

Clinical Sign	Finding	Points
General Appearance	Normal	0
	Restless/irritable	2
	Lethargic/unconscious	4
Tears	Normal	0
	Decreased	1
	Absent	2
Skin Pinch	Normal	0
	Slow	2
	Very slow	4
Respirations	Normal	0
Respirations	Deep	2

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Author

Adam C Levine, MD, MPH Associate Professor of Emergency Medicine, The Warren Alpert Medical School of Brown University

Adam C Levine, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Huy Nguyen Brown University

Disclosure: Nothing to disclose.

Karen A Santucci, MD Professor of Pediatrics (Emergency Medicine), Professor of Emergency Medicine, Medical Director, Pediatric Emergency Medicine, Section Chief, Pediatric Emergency Medicine, Yale University School of Medicine; Chief Medical Officer, Greenwich Hospital, Yale New Haven Health

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

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.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

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

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, David W Marby, MD †, to the development and writing of this article.

Sections Pediatric Gastroenteritis in Emergency Medicine
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Media Gallery
Tables
References

Pediatric Gastroenteritis in Emergency Medicine Follow-up

Further Outpatient Care

Further Inpatient Care

Deterrence/Prevention

Patient Education

References

Tables

Contributor Information and Disclosures

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