Gastroenteritis (commonly called ‘gastro’) is an infection of the bowel that may cause diarrhoea (runny, watery bowel motions), vomiting or both. Gastroenteritis is common in children. It is easy to catch, easy to spread and often occurs in outbreaks. Vomiting usually settles within a couple of days but diarrhoea can last up to 10 days. Show What causes it?Gastroenteritis is usually caused by a virus. Many different viruses may cause gastroenteritis. Less commonly, other types of germs (bacteria or parasites) may also cause gastroenteritis. Signs and symptoms
DehydrationYoung children (especially children under six months) are at highest risk of dehydration and must be watched very carefully. If your child is in nappies, count how many wet nappies they have in a day. They should have at least half the usual number. Cool, mottled or greyish skin and drowsiness in an infant is a sign that they are very dehydrated. For older children, keep track of how frequently they pass urine and the colour. Not going to the toilet much and darker coloured urine are signs of dehydration. Your child may tell you they feel light headed or dizzy or have dry lips and mouth. What is the treatment?Preventing dehydration is the main treatment. It is very important to replace lost body fluids and ensure your child takes enough fluid to prevent becoming dehydrated. Children with more severe dehydration may need to stay in hospital to be given fluids intravenously (via a tube into a vein) or via a nasogastric tube (a tube down the nose). This helps to ‘top up’ the body fluids. Antibiotics or medications to stop diarrhoea are rarely needed and may cause harm. Some bacterial or parasitic infections may need to be treated. Your doctor will let you know if this is required for your child. Care at homeOral rehydration solutions should be given to your child at home to stop them from getting dehydrated. Give your child small sips often (as less likely to be vomited back up) using a syringe, spoon or cup. You may wish to try giving your child the fluid as an ice block. If your child is breastfed, continue to do so but offer feeds more frequently. Oral rehydration solutions (such as Gluco-lyte, Gastrolyte, HYDRAlyte, Repalyte and Pedialyte) are available from most pharmacies. They contain a balance of water, body salts and sugar and are especially designed for gastroenteritis. Follow the instructions exactly. Stronger or weaker solutions may disrupt body salt levels and harm your child. If you are having trouble getting your child to drink oral rehydration solutions, you can offer your child apple juice as long as you dilute it firstly by adding filtered or tap water to achieve a 50:50 mix. For example, for 100 mL of apple juice you need to add 100 mL of water. These fluids have a high sugar content and giving them to your child undiluted may make the diarrhoea worse. Water by itself is not recommended as it does not contain the sugars and salts your child needs. Cordial and soft drinks are not preferred.
Table of Contents
Although most cases of acute gastroenteritis require minimal medical intervention, severe dehydration and hypoglycemia may develop in cases of prolonged vomiting and diarrhea. The mainstay of treatment for mild-to-moderately dehydrated patients with acute gastroenteritis should be oral rehydration solution. Antiemetics allow for improved tolerance of oral rehydration solution, and, when used appropriately, can decrease the need for intravenous fluids and hospitalization. This issue reviews the common etiologies of acute gastroenteritis, discusses more-severe conditions that should be considered in the differential diagnosis, and provides evidence-based recommendations for management of acute gastroenteritis in patients with mild-to-moderate dehydration, severe dehydration, and hypoglycemia. Case PresentationsAn 18-month-old girl who is up-to-date on her immunizations and has no prior medical history presents with vomiting and diarrhea for the last 3 days. She initially had multiple episodes of nonbloody, nonbilious emesis that stopped yesterday. On the second day, watery, voluminous diarrhea started. Her parents estimate she has had approximately 20 episodes of diarrhea since yesterday; they cannot quantify urine output because she has had so many episodes of diarrhea. The girl does not have a fever or other symptoms. On examination, she is lying on the stretcher with her eyes closed. The girl weighs 12 kg, and her vital signs are: rectal temperature, 37.6°C (99.7°F); heart rate, 165 beats/min; blood pressure, 90/65 mm Hg; respiratory rate, 22 breaths/min; oxygen saturation, 100% on room air. Although she is crying during the examination, the girl produces no tears. Her lips are dry and her eyes appear sunken. Her abdomen is soft, with no tenderness elicited on palpation. Her capillary refill is 2 seconds. She has watery, yellow-colored stool in her diaper. Should you give this child a dose of ondansetron and attempt oral hydration or does she need intravenous hydration? Do you need to send the stool for culture? Do any laboratory studies need to be performed? A 2-year-old boy with no past medical history is brought to the ED by his parents. His mother states that his illness started with vomiting, approximately 4 episodes, that has now resolved. He has had 10 episodes of watery, nonbloody stools in the last 2 days. He is drinking well and has appropriate urine output. The boy attends daycare, and several other children at the daycare center have the same symptoms. On examination, he is playing with his toy cars while sitting on the stretcher. His vital signs are within normal limits. He has moist oral mucosa and normal cardiac and lung examinations. His abdomen is soft, with no tenderness elicited. You diagnose him with acute gastroenteritis and inform his parents that they should continue with aggressive oral hydration. The parents ask you whether there is any medication you could prescribe that might stop his diarrhea. They also want to know if there are specific foods he should avoid. As you consider the parents' questions, you think about whether you should prescribe an antidiarrheal agent for this child? Should you recommend that the parents prescribe the traditional BRAT (bananas, rice, applesauce, toast) diet for the next few days? Are probiotics appropriate in this clinical scenario? Selected Abbreviations
IntroductionNausea, vomiting, and diarrhea are some of the most common presenting complaints of pediatric patients presenting to the emergency department (ED); and these symptoms may be associated with abdominal pain. The most common discharge diagnosis for children who present with these symptoms is acute gastroenteritis (AGE). AGE is defined as inflammation of the stomach and intestines, typically resulting from viral infection or bacterial toxins. Both vomiting AND diarrhea must be present for the diagnosis of AGE. Most cases of AGE are due to viral pathogens and are usually mild and self-limited, with no need for major medical intervention. Bacterial and parasitic infections are less common, but should be considered in the appropriate clinical context. Antibiotic-associated diarrhea and Clostridium difficile colitis are also possible etiologies of AGE symptoms. This issue of Pediatric Emergency Medicine Practice discusses various etiologies of AGE, details how to determine the level of a patient's dehydration, and reviews practice guidelines and high-quality studies that can inform the emergency clinician of the most recent and proven treatments for AGE. Critical Appraisal of the LiteratureA literature search was performed in PubMed using the search terms gastroenteritis, colitis, cows' milk protein allergy, and allergic colitis. Filters included the English language and ages birth to 18 years. No date limits were imposed. Several thousand articles were found, which were screened by title and then abstract. The Cochrane Database of Systematic Reviews and policy statements by the American Academy of Pediatrics (AAP) were also searched. One hundred-seventy articles were reviewed in full, and 119 were ultimately selected for inclusion. There are many randomized controlled trials related to pediatric AGE. The most common topics include the use of antiemetics, the ideal intravenous (IV) fluid for resuscitation, and the utility of probiotics. While many of these studies come to similar conclusions about the utility of various treatments, several involve relatively few subjects. The most recent practice guidelines published by the AAP are over 20 years old,1 but more recent studies exist. The studies by Roslund et al and Ramsook et al are robust randomized trials of oral ondansetron use in AGE.2,3 Articles evaluating probiotic use were also reviewed, such as Dinleyici et al4 and Van Niel et al,5 that evaluate Saccharomyces and Lactobacillus therapy for diarrhea, respectively. There is also a recent guideline for the treatment of AGE in children that was developed and published in 2014 by the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Pediatric Infectious Diseases.6 These recommendations were also endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Risk Management Pitfalls in Management of Pediatric Patients With Gastroenteritis3. “I didn’t find out that the patient had hypoglycemia until the electrolyte panel came back.” If you are starting IV hydration in a child that you suspect has severe dehydration, point-of-care glucose testing should be performed rather than waiting for the formal metabolic panel. Young children have low glucose reserves and can easily develop hypoglycemia when they are dehydrated. Hypoglycemia should be treated promptly. 5. “The child was slightly tachycardic but had no other signs of dehydration on examination and had only been sick for a few hours. It was late at night and the child was sleeping, so we gave IV fluids immediately.” Almost all children with mild-to-moderate dehydration due to AGE can rehydrate via the enteral route. IV placement is painful, IV fluids are more expensive, and the complication rate is higher than from enteral rehydration. 9. “She had been vomiting for the last 3 days. I just assumed that she had the AGE that everyone else was coming in with lately. It turns out she had acute pancreatitis.” Most cases of vomiting alone will be early AGE; however, there are many other serious entities that will also cause vomiting. Prolonged vomiting without diarrhea is concerning. Look carefully for signs and symptoms that might suggest other diagnoses, such as severe abdominal pain, jaundice, polyuria/polydipsia, bilious emesis, abdominal distension, etc. Tables
 ReferencesEvidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.
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What is gastroenteritis with dehydration?
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