Approach

Use of a treatment algorithm based on degree of dehydration is recommended.[Figure caption and citation for the preceding image starts]: Algorithm for managing acute gastroenteritis in childrenAdapted from Canadian Paediatric Society, Nutrition and Gastroenterology Committee. Oral rehydration therapy and early re-feeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006;11:527-531. Used with permission [Citation ends].com.bmj.content.model.Caption@6fe01a8d

General approach for all patients

The cornerstone of management is the use of oral rehydration therapy (ORT) with appropriate oral rehydration solutions (ORS), combined with an age-appropriate diet.[40][42] ORT is as effective as, if not better than, intravenous fluid therapy for rehydration of moderately dehydrated children.[48][49] Compared with intravenous therapy, ORT is less traumatic, cheaper, and easier to administer, and it can be given in a variety of settings, including the home.[49][50]

There are many commercially available compositions of ORS in use that have been found to be safe. Fluids containing non-physiological concentrations of glucose and electrolytes, such as carbonated drinks and sweetened fruit juices, are discouraged because they have a high carbohydrate content, very low electrolyte content, and high osmolarity.[51] Giving these hyperosmolar solutions may produce osmotic diarrhoea if given in sufficiently large quantities. Parents should also be specifically instructed not to offer plain water to children with acute gastroenteritis because the intake of water alone may lead to hyponatraemia and hypoglycaemia.

Early re-feeding has both clinical and nutritional benefits.[40][52] It induces digestive enzymes, improves absorption of nutrients, enhances enterocyte regeneration, promotes recovery of disaccharidases, decreases the intestinal permeability changes induced by infection, reduces the duration of diarrhoea, maintains growth, and improves nutritional outcomes.[51][53][54][55] Foods high in complex carbohydrates (rice, cereals, bread, wheat, and potatoes), lean meat, fruits, and vegetables are well tolerated. With the exception of a subset of children with transient secondary disaccharidase deficiency, most children with acute gastroenteritis are able to tolerate milk and lactose-containing diets. Foods high in simple sugars and fatty foods should be avoided.

Standard therapeutic recommendations

In addition to the dehydration-specific fluid replacement, patients with viral gastroenteritis should be managed as follows.

  • Daily fluid maintenance requirement is 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent 1 kg over 20 kg. This is usually supplied by the age-appropriate diet.

  • For infants who are breastfed, breastfeeding should be continued.

  • It is not necessary to dilute formula or to give lactose-free formula in re-feeding non-breastfed infants.[40][42]

  • Infants should be offered more frequent bottle or breastfeedings.

  • Children should continue to be fed an age-appropriate diet.[40][42]

Ondansetron

Use of ondansetron should be considered when vomiting interferes with ORT. Oral and single-dose ondansetron, rather than intravenous ondansetron, should be used if possible. In one randomised controlled trial (n = 194), one dose of oral ondansetron decreased the proportion of children who continued vomiting within 4 hours from 42.9% to 19.5% (95% CI 0.20 to 0.72), and also showed a decrease in the number of vomiting episodes within 4 hours (incidence rate ratio 0.51 [95% CI 0.29 to 0.88]).[56] The medication can be used for both inpatients and outpatients, but only after the patient has been clinically assessed. The medication should be used with caution in children whose diarrhoea is a major concern, as the use of medication might aggravate the diarrhoea. Clinicians must balance the confirmed benefits of antiemetic therapy against the cost and risk of adverse events in patients with gastroenteritis-related vomiting.[57][58][59][60] [ Cochrane Clinical Answers logo ]

Children with no dehydration

Treatment is aimed at providing adequate fluids to compensate for gastrointestinal losses and cover maintenance needs.

Children weighing <10 kg should receive 60 to 120 mL of ORS per episode of vomiting or diarrhoeal stool, while those weighing >10 kg should receive 120 to 240 mL of ORS per episode of vomiting or diarrhoeal stool in addition to their normal daily requirements.[42]

Standard therapeutic recommendations should be initiated.

Children with mild dehydration (<5%)

Signs of mild dehydration include: alert state; slightly decreased urine output; slightly increased thirst; slightly dry mucous membrane; slightly elevated heart rate; normal capillary refill; normal skin turgor; normal eyes; and normal anterior fontanelle.[40] Children with mild dehydration should be rehydrated with an ORS at 50 mL/kg over 4 hours.[40][42]

Ongoing losses should be replaced with ORS. Children weighing <10 kg should receive 60 to 120 mL of ORS per episode of vomiting or diarrhoeal stool, while those weighing >10 kg should receive 120 to 240 mL of ORS per episode of vomiting or diarrhoeal stool.[42]

Following rehydration, standard therapeutic recommendations should be initiated.

Children with moderate dehydration (5% to 10%)

Signs of moderate dehydration include: alert state, fatigued, or irritable; decreased urine output; moderately increased thirst; dry mucous membranes; elevated heart rate; prolonged capillary refill; decreased skin turgor; sunken eyes; and sunken anterior fontanelle.[40] Children with moderate dehydration should be rehydrated with an ORS at 100 mL/kg over 4 hours.[40][42]

Ongoing losses should be replaced with ORS. Children weighing <10 kg should receive 60 to 120 mL of ORS per episode of vomiting or diarrhoeal stool, while those weighing >10 kg should receive 120 to 240 mL of ORS per episode of vomiting or diarrhoeal stool.[42]

Following rehydration, standard therapeutic recommendations should be initiated.

Children with severe dehydration (>10%)

Signs of severe dehydration include: apathetic or lethargic state; markedly decreased or absent urine output; greatly increased thirst; very dry mucous membranes; greatly elevated heart rate; prolonged or minimal capillary refill; decreased skin turgor; very sunken eyes; very sunken anterior fontanelle; cold extremities; hypotension; and coma.[40] Severe dehydration is a medical emergency necessitating immediate intravenous resuscitation and admission to hospital.

Sodium chloride 0.9% or Ringer's lactate, 20 mL/kg, should be given intravenously over 1 hour.[40][42] Vital signs should be monitored and the patient re-assessed on a regular basis. Boluses of intravenous fluid may have to be given until pulse, perfusion, and mental status return to normal.[42]

Non-osmotic stimuli of antidiuretic secretion are frequent in children with gastroenteritis.[61] Hypotonic saline solutions are inappropriate for intravenous rehydration, as non-osmotic antidiuretic hormone activity during intravenous fluid administration could lead to dilutional hyponatraemia.

ORT should be started when the child is well enough to take it. Ongoing losses should be replaced with oral or nasogastric ORS. Children weighing <10 kg should receive 60 to 120 mL of ORS per episode of vomiting or diarrhoeal stool, while those weighing >10 kg should receive 120 to 240 mL of ORS per episode of vomiting or diarrhoeal stool.[42]

Following rehydration, standard therapeutic recommendations should be initiated.

ORT not tolerated or refused

The key is to give small amounts of ORS at frequent intervals, and the volume should be gradually increased until the child can drink as desired.[43] Using a spoon or dropper for very small infants can significantly increase retention of ORS. In a child who refuses to drink, squirting the ORS into the mouth with a syringe may help.

Flavoured ORS or ORS ice-lollies, which may be more acceptable to some children, may also be tried. Flavouring ORS with either apple juice or orange juice does not improve palatability compared with commercially flavoured ORS. In addition, only very small amounts of apple juice or orange juice can be added without significantly altering the electrolyte composition and osmolarity of the ORS.[62]

If children refuse to drink by any of the above measures, nasogastric (NG) gavage should be considered before intravenous hydration is attempted. NG rehydration provides the physiological benefits of enteral rehydration and avoids the potential complications of intravenous therapy.[49][63] NG hydration is particularly useful in the emergency department where rapid correction of dehydration might prevent admission to hospital. NG hydration is also useful for patients with normal mental status who are too weak to drink adequately.[42]

Children with contraindications to the use of ORT

Contraindications to the use of ORT include protracted vomiting despite small and frequent feedings, severe dehydration with a shock-like state, impaired consciousness, paralytic ileus, and monosaccharide malabsorption.[42] Ongoing stool losses >10 mL/kg of body weight per hour is no longer considered a contraindication to ORT, as most children will still respond to ORT.

For children with contraindications to ORT, intravenous therapy should be given to replace the calculated deficit, ongoing losses, and the daily fluid maintenance requirement.

Either sodium chloride 0.9% or Ringer's lactate may be used for severe dehydration with or without shock. Sodium chloride 0.45% with 5% glucose is reserved for children with mild or moderate dehydration or for those who are not dehydrated but require compensation/maintenance fluids.

For children with mild and moderate dehydration, the deficit should be replenished in 4 hours and the rest given evenly throughout 24 hours. For children with severe dehydration, the section listed above should be referred to.

ORT and early re-feeding should be started as soon as the physical condition of the patient allows.

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