Focus On: Current Management of Gastroenteritis in Children
By M. Tyson Pillow, MD, Evelyn Porter, MD, and Mark A. Hostetler, MD
After reading this article, the physician should be able to:
- Describe an efficient approach to the child who is dehydrated with vomiting/diarrhea.
- Choose the ideal oral rehydration fluids and techniques for children.
- Indicate when antiemetics and/or IV fluids may be effective in children.
- Identify the warning signs that necessitate further work-up and treatment.
Vomiting and diarrhea are two of the most common complaints of children presenting to the emergency department. Especially during the winter months, this complaint can overwhelm any ED.
Anxious, tired parents can further frustrate the situation by incorrectly attempting to provide hydration to their child at home. In addition, "not all that vomits is gastroenteritis." Emergency physicians must always be aware of the serious pathology lurking in the sea of vomiting children. After more serious diseases are ruled out, oral rehydration and parental education become paramount in the everyday management of this disorder.
Gastroenteritis, by definition, is an acute inflammation of the lining of the stomach and intestines, and is marked by a diarrheal component of the disease process. Vomiting alone can occur in the early stages of gastroenteritis; however, the term should generally be used only when both vomiting and diarrhea are present.
Although the combination of vomiting and diarrhea significantly narrows the differential, vomiting alone can be a much more difficult diagnostic process. The differential of vomiting includes gastrointestinal disorders (obstruction, pyloric stenosis, Meckel's diverticulum), infectious processes (pneumonia, appendicitis, sepsis, urinary tract infection), central nervous system disorders, metabolic derangements, and other less frequent causes, including toxic ingestions and trauma.
The differential is largely driven by the child's age and presentation. Remember that gastroenteritis in children younger than 3 months is rare. The typical diarrhea pattern in gastroenteritis is watery, nonbloody stool. There can be associated nausea, vomiting, fever, or mild abdominal pain. Only 10% of gastroenteritis will have bloody diarrhea, so this finding should prompt further work-up.1 In addition, any child with severe abdominal pain (or any pain in the right lower quadrant) or altered mental status deserves further work-up.
Once serious pathology has been ruled out by an appropriate physical exam and corresponding work-up, the next question to address is, "How dehydrated is this patient?"
This question is largely addressed by the physical exam rather than the history given by the parents. Ideally, we would like to know the patient's weight as compared to his or her normal weight to calculate the fluid deficit, but this is rarely available. Vital signs should be reviewed on every patient. Tachycardia may be a sign of dehydration or the result of fever. The most useful aspects of the physical exam to determine dehydration are abnormal capillary refill time, skin turgor, and respiratory rate.2
In summary, mild dehydration represents 3%-5% dehydration and the child essentially has a normal physical exam. Moderate dehydration represents 6%-9% dehydration and presents in an ill-appearing, nontoxic child with tachycardia, cool skin, decreased tears, and decreased urine output. Severe dehydration occurs at greater than 10% dehydration and causes lethargy, marked tachycardia and tachypnea, prolonged capillary refill, poor skin turgor, and minimal urine output. (See table.)
After estimation of the severity of dehydration, the next step is to calculate fluid requirements. This is easily accomplished by remembering that 1 L of fluid weighs 1 kg. Therefore, a 20-kg child who is 5% dehydrated has lost 1 kg of weight (0.05 x 20 kg = 1 kg) and has a fluid deficit of 1 L.
The next take-home point is simply stated as such: Oral rehydration therapy (ORT) is THE preferred method of rehydration in mild to moderate dehydration. In a meta-analysis of 16 studies looking at ORT, it is at least as effective, associated with fewer side effects, and results in shorter hospital stays when compared to IV hydration.3
The ideal solutions for ORT are the WHO oral rehydration solution (ORS), low-osmolality WHO ORS, Pedialyte, or Infalyte. Gatorade has a higher sugar component but is appropriate for children older than 2 years. There are several algorithms available to administer ORT, but in general, it should be started at 5 mL every 5 minutes and increased as tolerated. Ideally, the full fluid deficit should be replaced rapidly over 4 hours, as this has shown to be safe and effective.4
Vomiting is not a contraindication to ORT. In the child who remains dehydrated because of persistent vomiting, the physician may administer oral antiemetics to aid symptom control. Unlike other antiemetics in children, ondanset-ron has been proven to be safe and effective in children.5 Dosing with the oral dissolving tablet is 2 mg for infants and toddlers, 4 mg for young children, and 8 mg for older children and adolescents. The IV dose is roughly 0.15 mg/kg, up to a maximum of 8 mg.
IV therapy should be considered in the child who initially presents with severe dehydration (given in 20 mL/kg boluses until the shock resolves) or the child who fails ORT because of persistent vomiting. Traditionally, isotonic, dextrose-free fluid has been the standard; but more recent studies suggest that dextrose-containing solutions, such as D5NS or D10NS, may be better, as they help to resolve the ketonemia associated with dehydration.6 This issue is currently being explored by researchers.
Throughout the entire process, managing parental expectations and education are the most important aspects of the successful approach to the child with gastroenteritis.
As mentioned above, emphasize that Pedialyte, Gatorade, Infalyte, or WHO oral rehydration solutions (mixed according to package instructions) are the best solutions to use at home for rehydrating children. It is very important that parents avoid sodas and fruit juices, because they have too much sugar and may worsen diarrhea and dehydration. Pure water does not have enough sodium and may cause electrolyte disturbances that can lead to seizures.
Giving small amounts of the appropriate fluid at very frequent intervals is the best approach to successful and safe rehydration.7,8 Re-emphasize that vomiting is not a contraindication to ORT, and that refeeding should occur as soon as tolerated by the child.
Most parents know that gastroenteritis is usually caused by a viral infection and leads to vomiting and diarrhea. These symptoms can last days to weeks at a time. Although these symptoms can be problematic and stressful, once serious diseases have been ruled out, the treatment of gastroenteritis is simply rehydration.
The persistence of symptoms may be a source of anxiety for the parents, who can become frustrated with the physician because he or she hasn't "fixed" the diarrhea. Take time to explain that diarrhea and vomiting may persist even after dehydration has been treated adequately.
Finally, explain the most common signs and symptoms that should prompt parents to return to the ED. These include lethargy or severe sleepiness, no urination or wet diapers over 8 hours, severe or worsening abdominal pain, or any blood in the stool.
In summary, the child presenting with mild to moderate dehydration who tolerates ORT can be safely discharged home. If the dehydration persists because of vomiting, antiemetic therapy can be added to the regimen, or IV hydration can be attempted. After rehydration, ensure that the child can tolerate oral fluids, and discharge the patient home. If the child presents in severe dehydration or persistent dehydration despite IV hydration, then admission for observation is warranted.
Identify children who present with symptoms and history consistent with typical gastroenteritis. Initial evaluation should include a focused physical exam that includes at least an assessment of vital signs, general appearance, capillary refill, activity level, and skin turgor. Management should be based on the patient's fluid deficit and degree of dehydration.
Oral rehydration solutions should be given to these patients as an initial therapeutic treatment for mild or moderate dehydration and as soon as tolerated to all other patients. Intravenous fluid management should be reserved for severe dehydration, shock, and patients who cannot tolerate oral intake. The provider may supplement ORT with antiemetics if vomiting is preventing successful treatment.
Reassessment of the patient is necessary to ensure appropriate response to treatment and to determine if further work-up is needed. Immediate refeeding with the child's regular diet should be emphasized. Parents must be given clear, concise discharge instructions that include specifics on expectant management, continued hydration, refeeding, and warning signs.
- Cicirello HG, Glass RI. Current concepts of the epidemiology of diarrheal diseases. Semin Pediatr Infect Dis 1994; 5: 163-7.
- Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA 2004; 291(22): 2746-54.
- 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; 158(5): 483-90.
- Phin SJ, McCaskill ME, Browne GJ, et al. Clinical pathway using rapid rehydration for children with gastroenteritis. J Paediatr Child Health 2003; 39: 343-8.
- Ramsook C, Sahagun-Carreon I, Kozinetz CA, et al. A randomized clinical trial comparing oral ondansetron with placebo in children with vomiting from acute gastroenteritis. Ann Emerg Med 2002; 39(4): 397- 403.
- Levy, et al. Intravenous dextrose during outpatient rehydration in pediatric gastroenteritis. Academic Emergency Medicine 2007; 14: 324-31.
- Guarino A, Albano F, Guandalini S, et al. Oral rehydration: toward a real solution. Journal of Pediatric Gastroenterology & Nutrition 33 October 2001.Supplement 2:S2-S12.
- World Health Organization. A Manual for the Treatment of Acute Diarrhea for Use by Physicians and Other Senior Health Workers. WHO/CDC/SER 80.2 Rev.2;1990
Dr. Pillow is a third-year emergency medicine resident, chief resident of education, and a member of the section of emergency medicine at the University of Chicago Medical Center. Dr. Porter is a second-year emergency medicine resident and a member of the section of emergency medicine at the University of Chicago Medical Center. Dr. Hostetler is chief of the section of pediatric emergency medicine, medical director of the pediatric emergency department, and associate professor in the department of pediatrics at the University of Chicago Medical Center. Medical Editor Dr. Robert C. Solomon is an attending emergency physician at Trinity Health System in Steubenville, Ohio, and clinical assistant professor of emergency medicine at the West Virginia School of Osteopathic Medicine.
In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and American College of Emergency Physicians policy, contributors and editors must disclose to the program audience the existence of significant financial interests in or relationships with manufacturers of commercial products that might have a direct interest in the subject matter.
Dr. Pillow, Dr. Porter, Dr. Hostetler, and Dr. Solomon have disclosed that they have no significant relationships with or financial interests in any commercial companies that pertain to this educational activity.
"Focus On: Current Management of Gastroenteritis in Children" has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME).
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