Managing Acute Gastroenteritis In Children

Always remember that acute gastroenteritis in children is a diagnosis of exclusion. Be especially careful about making the diagnosis in a child who only has vomiting.  Be sure to consider other serious badness like diabetic ketoacidosis or surgical abdomen.

For an outstanding and clear article on this subject please see MMWR, Managing Acute Gastroenteritis Among Children. Nov. 21, 2003, Vol. 52.

Another useful article is Acute gastroenteritis: from guidelines to real life, Clin Exp Gastroenterol. 2010; 3: 97–112. This article, the European Guidelines * cited below, and the 2013 article, Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries, all recommend consideration of po ondansetron in certain children with vomitting to increase the success rate of oral hydration therapy.

Note: In every patient with vomiting but not diarrhea, it is very important to consider other diagnoses  besides acute gastroenteritis.

The Centers for Disease Control (CDC) along with the American Academy of Pediatrics (AAP) adopted Oral Rehydration Therapy (ORT) as the therapy of choice for patients who have:

  • Mild dehydration (5-6% loss of body weight and two clinical findings assessed)
  • Moderate dehydration (7-10% loss of body weight and three clinical findings assessed)

The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS), given over a 4-6 hour time period. ORT will be initiated within the hospitals and clinics. However, the patient may be discharged prior to the completion of total rehydration. The entire guideline follows:

  1. Calculate total volume deficit:
    • Mild dehydration (<5%):
      • 50 mL/kg + 10 mL/kg additional volume for each diarrhea stool
    • Moderate dehydration (5-10%):
      • 100 mL/kg + 10 mL/kg additional volume for each diarrhea stool
  2. First hour of therapy: Administer 5 mL of ORS every two minutes for an hour
  3. If the patient vomits*, suspend ORT for 15 minutes and resume first hour of therapy.
  4. After first hour of therapy: Allow patient to rest for 15 minutes
  5. Second hour of therapy: Increase ORS amount to 6-10 mL (amount is determined by the size of the child) of ORS every two minutes for an hour**
  6. If patient tolerates total volume instruct parent to introduce normal diet for age when patient is considered rehydrated.
  7. If patient does not tolerate normal diet, continue ORS for another four to eight hours, and advance to normal diet as soon as possible.

* If vomiting persists, three or more times during first two hours of ORS attempt, consider insertion of small naso-gastric feeding tube or IV hydration. Prior to feeding tube placement, consider obtaining abdominal x-ray to evaluate for bowel obstruction or ileus as the possible cause of persistent vomiting.

**In the emergency department or outpatient clinic, consider discharging patient after completion of two to three hours of oral rehydration therapy. Instruct parent to complete ORS at home and advance to normal diet as soon as tolerated. Instruct parent to return to clinic or ED if patient not tolerating ORS at home or if condition deteriorates.

Example:

10 kg child

Calculate total volume deficit:

  • Mild dehydration (<5%): 50 mL/kg + 10 mL/kg additional volume for each diarrhea stool =

500 mL over four-hour time period + volume for stools

  • Moderate dehydration (5-10%): 100 mL/kg+10 mL/kg additional volume for each diarrhea stool =

1000 mL over four-hour time period + volume for stools

First hour of therapy:

Administer five mL of ORS every two minutes for an hour for a total of 150 mL.If the patient vomits, suspend ORT for 15 minutes and resume first hour of therapy.

After first hour of therapy:

Allow patient to rest for 15 minutes

Second hour of therapy:

Increase ORS amount to 6-10 mL (amount is determined by the size of the child) of ORS every two minutes for an hour for a total of 180 mL to 300 mL.

Continue to add 10mL/kg for each diarrhea stool to the total four-hour volume.

If patient tolerates total volume instruct parent to introduce normal diet for age when patient is considered rehydrated.

If patient does not tolerate normal diet, continue ORS for another four to eight hours, and advance to normal diet as soon as possible

ORS Example:

150 mL over first hour, rest 15 minutes,
180 mL over hour two, rest,
then 360 mL over hour three and \four.

Total volume provided over five hours is 1050 mL, if 15 min rest time used.

IV Rehydration Example:

The patient would receive two 20 mL/kg bolus over 30 minutes, followed by four hours of maintenance solution at 40 mL/hr.

Total volume provided is 560 mL of fluid. Additional time would be required to place PIV.

Sources:
MMWR, Managing Acute Gastroenteritis Among Children. Nov. 21, 2003, Vol. 52.

Practice Parameter: The Management of Acute Gastroenteritis in Young Children. Pediatrics, Vol. 97 (3), March 1996 [Please note that this guideline has been retired and the most current AAP Guideline is Managing Acute Gastroenteritis Among Children: Oral Rehydration, Maintenance, and Nutritional Therapy. Centers for Disease Control and Prevention, Pediatrics 2004;114;507.

 


These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time.

It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.

*There two recent European pediatric guidelines on acute gastroenteritis:

(1) European Society for Paediatric Gastroenterology, Hepatology, and Nutrition/European Society for Paediatric Infectious Diseases Evidence-based Guidelines for the Management of Acute Gastroenteritis in Children in Europe, Journal of Pediatric Gastroenterology and Nutrition46:S81–S184 # 2008 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

(2) 2009 Diarrhoea and Vomitting Caused by Gastroenteritis: Diagnosis, Assessment and Management in Children Under 5 Years by the (British) National Institute for Health and Clinical Excellence (NICE). 2009.

 

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