Medical Care
Prehospital care
Children with acute gastroenteritis rarely require intravenous (IV) access. In those presenting with circulatory collapse due to severe dehydration or sepsis, IV access should be obtained and followed by an immediate 20-mL/kg bolus of normal saline.
Emergency department care
The American Academy of Pediatrics (AAP), the European Society of Pediatric Gastroenterology and Nutrition (ESPGAN), and the World Health Organization (WHO) 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. [2, 18, 24, 25]
One large meta-analysis of 16 trials including 1545 children with mild-to-moderate dehydration found that compared with IV rehydration, children treated with ORS had a significant reduction in length of hospital stay and fewer adverse events, including seizures and death. [26] The overall rate of ORS failure (percentage of children eventually requiring IV hydration) in studies comparing ORS with IV hydration was about 4%. [27]
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.
Minimal orno 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 nonbreastfed children).
A study of 647 children in Canada by Freedman et al 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. [28, 29]
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 parent using a teaspoon, syringe, or medicine dropper at the 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 IV rehydration, but more cost effective and with fewer adverse events. [26, 30]
Patients should be reassessed frequently by the clinician to ensure adequacy of oral intake and resolution of the various signs and symptoms of dehydration.
Severedehydration
Severe dehydration constitutes a medical emergency requiring immediate resuscitation with IV fluids. IV access should be obtained and patients should be administered a bolus of 20-30 mL/kg lactated Ringer (LR) or normal saline (NS) solution over 60 minutes. 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 tested.
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 IV rehydration.
Type of ORS
A large Cochrane meta-analysis confirmed several earlier studies showing that reduced-osmolarity ORS (osmolarity< 250 mmol/L) is associated with fewer treatment failures, lower stool output, and less frequent vomiting compared with standard-osmolarity ORS for patients with noncholera gastroenteritis. [31] Patients with cholera, however, 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. [32]
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 ORS sachets or a homemade solution of 3 g (1 tsp) salt and 18 g (6 tsp) sugar added to 1 liter of clean water.
New research suggests that polymer-based ORS, made from complex carbohydrates such as rice, wheat, or maize, may reduce stool output and length of diarrhea compared with glucose-based ORS. [33, 34] With these solutions, carbohydrates are slowly digested in the small intestine, releasing glucose to facilitate sodium uptake without adding a significant osmotic load to bowel contents. Although not widely available in the United States currently, polymer-based ORS may become the preferred solution for oral rehydration of children with diarrhea in the future.
Feeding andnutrition
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 to breast feeding 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 and foods high in simple sugars should be avoided.
For the majority of infants, clinical trials have found no benefit of lactose-free formulas over lactose-containing formulas. Similarly, highly specific diets, such as the BRAT (bananas, rice, applesauce, and toast) diet, have not been shown to improve outcomes and may provide suboptimal nutrition for the patient.
Prevention
Prophylaxis with probiotics
Some meta-analyses have suggested that probiotics improve outcomes in children with acute gastroenteritis. A large placebo-controlled study in India showed that prophylaxis with a probiotic formula of L. plantarum in healthy newborns in the first 5 days of life led to a significant reduction in the rate of sepsis and lower respiratory tract infections in the first 2 months of life. [35] However, among preschool children with acute gastroenteritis who completed another study, those who received a 5-day course of L. rhamnosus did not have better outcomes than those in the placebo group. [36] In another multicenter study of children who presented to the emergency department with gastroenteritis, a 5-day course of a probiotic with L. rhamnosus + L. helveticus did not prevent the development of moderate-to-severe gastroenteritis. [37]
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 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 |
Severe Dehydration |
Two of the following signs:
|
Some Dehydration |
Two of the following signs:
|
No Dehydration |
Not enough of the above signs to classify as some or severe dehydration |
