Principles of management of child with gastroenteritis

Majority of gastroenteritis cases in children are self limiting and rarely require treatment (1).

Prevention of dehydration is the main goal in the treatment of gastroenteritis:

• in a child with minimal or no dehydration – encourage to continue his or her usual diet plus drink adequate fluids
  • several studies have reported that a child's regular diet reduces the duration of diarrhoea.
• early fluid replacement with an oral rehydration solution (ORS) can be carried out at home and may prevent severe dehydration in a child
  • a commercially available ORS product can be used as soon as diarrhoea develops
  • clear liquids, such as water, sodas, chicken broth, and apple juice, should not be used instead of ORS because they are hyperosmolar and do not adequately replace potassium, bicarbonate, and sodium.
    • an adult ORS should not used in children (2)

NICE have issued guidance regarding the management of gastroenteritis in children. The main points in the guidance have been summarised:

• fluid management
  • in children with gastroenteritis but without clinical dehydration:
    • continue breastfeeding and other milk feeds
    • encourage fluid intake
    • discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration
    • oral rehydration salt (ORS) solution should be offered as supplemental fluid to those at increased risk of dehydration
  • in children with clinical dehydration, including hypernatraemic dehydration:
    • use low-osmolarity ORS solution (240-250 mOsm/l) for oral rehydration therapy
      • 50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid
      • ORS solution should be given frequently and in small amounts
      • clinician should consider supplementation with their usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs
      • if child is unable to drink it or if they vomit persistently consider giving the ORS solution via a nasogastric tube
      • response to oral rehydration therapy should be monitored by regular clinical assessment
  • intravenous fluid therapy for clinical dehydration should be used if:
    • shock is suspected or confirmed a child
    • child shows clinical evidence of deterioration despite oral rehydration therapy
    • child persistently vomits the ORS solution (given orally or via a nasogastric tube)
    • if intravenous fluid therapy is required for rehydration (and the child is not hypernatraemic at presentation):
      • an isotonic solution, such as 0.9% sodium chloride, or 0.9% sodium chloride with 5% glucose, should be used - for both fluid deficit replacement and maintenance
      • for those who required initial rapid intravenous fluid boluses for suspected or confirmed shock, add 100 ml/kg for fluid deficit replacement to maintenance fluid requirements, and monitor the clinical response
      • for those who were not shocked at presentation, add 50 ml/kg for fluid deficit replacement to maintenance fluid requirements, and monitor the clinical response
      • plasma sodium, potassium, urea, creatinine and glucose
        • should be measured at the outset, monitor regularly, and alter the fluid composition or rate of administration if necessary
        • the clinician should consider providing intravenous potassium supplementation once the plasma potassium level is known
• nutritional management
  • during rehydration therapy:
    • continue breastfeeding
    • do not give solid foods
    • in children with red flag symptoms or signs, do not give oral fluids other than ORS solution
    • in children without red flag symptoms or signs, do not routinely give oral fluids other than ORS solution; however, consider supplementation with the child's usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they consistently refuse ORS solution.
  • after rehydration:
    • advised to give full-strength milk straight away
    • the child's usual solid food should be reintroduced
    • it is advised to avoid giving fruit juices and carbonated drinks until the diarrhoea has stopped
• antibiotic therapy
  • antibiotics should not be routinely given to children with gastroenteritis
  • antibiotic treatment is indicated to all children:
    • if suspected or confirmed septicaemia OR
    • if extra-intestinal spread of bacterial infection OR
    • if younger than 6 months with salmonella gastroenteritis OR
    • if child is malnourished or immunocompromised with salmonella gastroenteritis OR
    • if child has Clostridium difficile-associated pseudomembranous enterocolitis, giardiasis, dysenteric shigellosis, dysenteric amoebiasis or cholera
    • specialist advice should be sought about possible antibiotic therpay for children who have recently been abroad
• antidiarrhoeal medications
  • should not be used in children with diarrhoea
• advice for parents and carers
  • parents, carers and children that :
    • most important factor in preventing the spread of gastroenteritis is washing hands with soap (liquid if possible) in warm running water and careful drying
      • hands should be washed in order to prevent spread of infection. Specific situations include:
        • after going to the toilet (children)
        • after changing nappies (parents/carers)
        • before preparing, serving or eating food
    • do not share towels used by infected children
    • children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis
      • children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting
    • swimming
      • children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea

Probiotics

• given as an adjunct to ORS , has shown to reduce the duration and intensity of symptoms of gastroenteritis (4).

Notes:

• there is evidence that in children with acute gastroenteritis and mild or moderate dehydration who have failed an oral rehydration challenge, oral ondansetron can reduce the need for intravenous hydration (5)

Reference:

• (1) Granado-Villar D et al. Acute gastroenteritis. Pediatr Rev. 2012;33(11):487-94; quiz 495
• (2) Churgay CA, Aftab Z. Gastroenteritis in children: Part 1. Diagnosis. Am Fam Physician. 2012;85(11):1059-62.
• (3) NICE (April 2009). Diarrhoea and vomiting in children.
• (4) Guarino A et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr. 2014;59(1):132-52
• (5) Roslund G et al. The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial. Ann Emerg Med. 2008 Jul;52(1):22-29.e6.