Pediatric Gastroenteritis in Emergency Medicine Treatment & Management

Updated: Apr 18, 2023
  • Author: Adam C Levine, MD, MPH; Chief Editor: Kirsten A Bechtel, MD  more...
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Approach Considerations

Experts agree that appropriate rehydration remains the most important management strategy for acute diarrhea in all populations. [33, 52, 53]  Since treatment options are dependent on dehydration status, accurately assessing and managing dehydration remains the most critical step in preventing morbidity and mortality. [54, 55, 56]  Accurate assessment of dehydration status can reduce the morbidity and mortality that results from inappropriate hydration of patients. [57]  One large meta-analysis of 16 trials including 1545 children with mild-to-moderate dehydration found that, compared with intravenous rehydration, children treated with oral rehydration solution (ORS) had a significant reduction in length of hospital stay and fewer adverse events, including seizures and death. It has been reported that for every 25 children who are started on oral rehydration therapy, one would fail and require intravenous therapy (ie, a 4% failure rate). [57]  As such, initial care in the emergency department should focus on correction of dehydration with the type and amount of fluid given reflecting the degree of dehydration in the child, as assessed using the Clinical Dehydration Scale (CDS) or DeHydration: Assessing Kids Accurately (DHAKA) Score described in the workup section.

Minimal or no dehydration

For children assessed as having minimal to no dehydration, no immediate treatment is required. Expectant management of the child can be conducted at home and parents should be provided instructions for continued oral intake. [35, 33, 52, 58]

If the child is breastfed, the mother should be encouraged to breastfeed more frequently than usual and for longer at each feed. If the child is not exclusively breastfed, then oral maintenance fluids (including clean water, soup, rice water, yogurt drink, or other culturally appropriate fluid) should be given at a rate of approximately 500 mL/day for children younger than 2 years, 1000 mL/day for children aged 2-10 years, and 2000 mL/day for children older than 10 years. Ongoing fluid losses should be replaced with 10 mL/kg body weight of additional ORS for each loose stool and 2 mL/kg body weight of additional ORS for each episode of emesis (both for breastfed and non-breastfed children). A study of 647 children in Canada by Freedman et al (2016) found that minimally dehydrated patients with mild gastroenteritis experienced fewer treatment failures when offered half-strength apple juice followed by their preferred drinks, compared with children given a standard electrolyte maintenance solution. [59]  As a result, fewer children administered apple juice required subsequent IV rehydration.

Mild-to-moderate dehydration

Children diagnosed as having mild-to-moderate dehydration should be given oral rehydration solution (ORS) and be managed in an ambulatory clinical setting. [57, 60, 61]  In fact, ORS in particular has been credited with saving more than 50 million lives over the past 50 years. [60, 61]

Over the first 2- to 4-hour period, 50-100 mL/kg of ORS should be given to children 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). ORS should be given slowly by the caregiver or parent using a teaspoon, syringe, or medicine dropper at a rate of 5 mL every 1-2 minutes. If tolerated by the patient, the rate of ORS delivery can be increased slowly over time. After the initial rehydration phase, patients may be transitioned to maintenance fluids as described above. Patients should be reassessed frequently by the clinician to ensure adequacy of oral intake and resolution of the various signs and symptoms of dehydration.

For patients who do not tolerate ORS by mouth, nasogastric (NG) feeding is a safe and effective alternative. Multiple clinical trials have found NG rehydration to be as efficacious as intravenous rehydration, but more cost-effective and with fewer adverse events and shorter hospital stay. [62]

Severe dehydration

Children with severe dehydration require immediate resuscitation with intravenous fluids (IVF) in a hospital to prevent hemodynamic compromise, organ ischemia, and death. [33, 35, 52, 58]  Intravenous 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 (children < 12 months) or 2.5 hours (older children). If no peripheral veins are available, an intraosseous line should be placed. Serum electrolytes, bicarbonate, urea/creatinine, and glucose levels should be measured. Once resuscitation is complete and severe dehydration has resolved, rehydration should continue with ORS as described above.

Type of ORS

A large CochraneDatabase of Systematic Reviews meta-analysis confirmed several earlier studies showing that reduced osmolarity ORS (osmolarity: 245 mmol/L; sodium: 75) is associated with fewer treatment failures, lower stool output, and less frequent vomiting, compared with standard osmolarity ORS for patients with noncholera gastroenteritis. [63]  However, patients with cholera appear to have 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. Nonetheless, the WHO 2005 guideline assessed that the reduced osmolarity solution appeared to be as safe and at least as effective as the standard solution for use in children with cholera. 

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 reduced osmolarity ORS sachets or a homemade solution of 3 g (1 teaspoon) salt and 18 g (6 teaspoon) sugar added to 1 liter of clean water.

A systematic Cochrane review by Gregorio et al (2016) found that polymer-based ORS, made from complex carbohydrates such as rice, wheat, or maize, shows advantages compared to glucose-based ORS with osmolarity over 310 mmol/L. Polymer-based ORS may reduce stool output in the first 24 hours and the duration of diarrhea, albeit supported by low quality of evidence. [64]  Comparisons also favored polymer-based ORS over ORS with osmolarity less than 270 mmol/L, but this analysis is underpowered according to the authors. The possible mechanism of polymer-based ORS is that carbohydrates are slowly digested in the small intestine, releasing glucose to facilitate sodium uptake without adding a significant osmotic load to bowel contents. Although currently not widely available in the United States, polymer-based ORS may become the preferred solution for oral rehydration of children with diarrhea in the future.

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 breastfeeding 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 hours). Weaned children should restart their normal fluids and solids as soon as the rehydration phase is complete. Fatty foods, foods high in simple sugars, commercial carbonated beverages, commercial fruit juices, and sweetened tea should be avoided.

There is a lack of research into the benefits of lactose-free formulas over lactose-containing formulas or the benefits of highly specific diets, such as the BRAT (bananas, rice, applesauce, and toast). Eating only a BRAT diet may provide suboptimal nutrition for patients.