Prehospital Care
Children with acute gastroenteritis rarely require intravenous access. In those presenting with circulatory collapse due to severe dehydration or sepsis, intravenous access should be obtained and followed by an immediate 20 mL/kg bolus of normal saline.
Emergency Department Care
The American Academy of Pediatrics (2012), the European Society of Pediatric Gastroenterology (2014) and Nutrition (ESPGAN), the Center for Disease Control (CDC) (2003), and the World Health Organization (2004) all recommend oral rehydration solution (ORS) as the treatment of choice for children with mild-to-moderate gastroenteritis in both developed and developing countries, based on the results of dozens of randomized, controlled trials and several large meta-analyses. [5, 6, 7, 8]
One large meta-analysis of 16 trials including 1545 children with mild-to-moderate dehydration found that, compared with intravenous rehydration, children treated with ORS had a significant reduction in length of hospital stay and fewer adverse events, including seizures and death. [40] It has been reported that for every 25 children who are started on oral rehydration therapy, one would fail and require intravenous therapy (i.e. 4% failure rate). [41]
Initial care in the emergency department should focus on correction of dehydration. The type and amount of fluid given should reflect the degree of dehydration in the child.
A study reported sustained improvement in acute gastroenteritis care as a result of a clinical care pathway that emphasizes oral rehydration therapy and ondansetron for children with acute gastroenteritis. A decrease in the percentage of patients receiving IV fluids was reported from 48% to 26% after initiation of the pathway and later with addition of ondansetron. The study also reported a decrease from 247 to 172 minutes in average emergency department length of stay for discharged patients with acute gastroenteritis. [42]
Minimal or no dehydration
No immediate treatment is required. 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.
In addition, 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 patients with mild gastroenteritis and minimal dehydration experienced fewer treatment failures when offered half-strength apple juice followed by their preferred drinks compared with children given a standard electrolyte maintenance solution. As a result, fewer children administered apple juice required subsequent IV rehydration. [43]
Mild-to-moderate dehydration
Children should be given 50-100 mL/kg of ORS over a 2- to 4-hour period 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). After the initial rehydration phase, patients may be transitioned to maintenance fluids as described above.
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.
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. [44, 45, 46] . Therefore, ORS and NG are recommended as first-line treatment options before IV administration for mild-to-moderate dehydration.
Patients should be reassessed frequently by the clinician to ensure adequacy of oral intake and resolution of the various signs and symptoms of dehydration.
Severe dehydration
Severe dehydration constitutes a medical emergency requiring immediate resuscitation with intravenous fluids. 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 sent.
Once resuscitation is complete and mental status returns to normal, rehydration should continue with ORS as described above, as it has been shown to decrease the rate of hyponatremia and hypernatremia when compared with intravenous rehydration.
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. [47] 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. [48] 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. [8]
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. [49] Polymer-based ORS may reduce stool output in the first 24 hours and the duration of diarrhoea, albeit supported by low quality of evidence. Comparisons also favoured 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 h). 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 solely BRAT may provide suboptimal nutrition for patients.
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Child with sunken eyes.
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Child with slow skin pinch (reduced skin turgor).
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Child with absent tears.
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Child with lethargy/poor general appearance.
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Child with hyperpnea (deep, acidotic breathing)
Tables
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. [6] |
|||
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] |
|
| 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 |
| 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 |
| Deep | 2 |
