Gastroenteritis in Children

Family Medicine & Pharmacy Podcast

Billy looked at the following guidelines to summarize the approach to a child with gastroenteritis:

UK NICE Guideline: Diarrhoea and vomiting in children under 5 (Issued: April 2009) http://guidance.nice.org.uk/cg84

CPS Guideline: Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis (Posted: Nov 1, 2006) http://www.cps.ca/documents/position/oral-rehydration-therapy

History:

• onset of diarrhea and/or vomiting (gastro is sudden in onset)
• duration of vomiting and diarrhea (diarrhea 5-7 days, max 2 weeks; vomiting 1-2 days, max 3 days)
• sick contact
• pathogen exposure
• travel history

History suggestive of increased risk of dehydration:

• young age (esp <6mo)
• low birth weight infants
• >5 diarrhea in 24h
• >2 vomiting in 24h
• no oral intake
• signs of malnutrition

Think about differential diagnosis if:

• fever >38 in children younger than 3 months
• fever >39 in children older than 3 months (fever workup required)
• shortness of breath or tachypnoea
• altered conscious state
• neck stiffness
• bulging fontanelle in infants
• non-blanching rash
• blood and/or mucus in stool
• bilious (green) vomit
• severe or localised abdominal pain
• abdominal distension or rebound tenderness.

SSx of dehydration and shock

Table 1 in NICE

Increasing severity of dehydration
	No clinically detectable dehydration	Clinical dehydration	Clinical shock
Symptoms (remote and face-to-face assessments)	Appears well	Red flag Appears to be unwell or deteriorating	–
	Alert and responsive	Red flag Altered responsiveness (for example, irritable, lethargic)	Decreased level of consciousness
	Normal urine output	Decreased urine output	–
	Skin colour unchanged	Skin colour unchanged	Pale or mottled skin
	Warm extremities	Warm extremities	Cold extremities
Signs (face-to-face assessments)	Eyes not sunken	Red flag Sunken eyes	–
	Moist mucous membranes (except after a drink)	Dry mucous membranes (except for ‘mouth breather’)	–
	Normal heart rate	Red flag Tachycardia	Tachycardia
	Normal breathing pattern	Red flag Tachypnoea	Tachypnoea
	Normal peripheral pulses	Normal peripheral pulses	Weak peripheral pulses
	Normal capillary refill time	Normal capillary refill time	Prolonged capillary refill time
	Normal skin turgor	Red flag Reduced skin turgor	–
	Normal blood pressure	Normal blood pressure	Hypotension (decompensated shock)

Table 2 in CPS

TABLE 2 Clinical assessment of degree of dehydration *
Mild (under 5%)	Moderate (5-10%)	Severe (over 10%)
Slightly decreased urine output Slightly increased thirst Slightly dry mucous membrane Slightly elevated heart rate	Decreased urine output Moderately increased thirst Dry mucous membrane Elevated heart rate Decreased skin turgor Sunken eyes Sunken anterior fontanelle	Markedly decreased or absent urine output Greatly increased thirst Very dry mucous membrane Greatly elevated heart rate Decreased skin turgor Very sunken eyes Very sunken anterior fontanelles Lethargy Cold extremities Hypotension Coma
*Some of these signs may not be present

SSx of hypernatremic dehydration:

• jittery
• increased muscle tone
• hyperreflexia
• convulsions
• drowsiness or coma

Labs:

• No routine blood work
• Serum sodium, potassium, urea, creatinine, glucose if IV fluids or signs of hypernatremia
• Blood gas if shock suspected

Stool culture if:

• blood and/or mucus in stool
• immunocompromized
• septicemia suspected
• travel history
• diarrhea not improved by day 7
• uncertainty about diagnosis of gastroenteritis

Blood culture if antibiotic started

Watch for HUS in E. coli O157:H7

Treatment:

Figure 1 in CPS

No 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 (see 1.2.1.2)
• offer ORS solution as supplemental fluid to those at increased risk of dehydration (see 1.2.1.2).

Dehydration

ORT

• Contraindications
  • IVF indicated (shock, deterioration, persistent vomiting despite NG tube)
  • paralytic ileus
  • monosaccharide malabsorption
• use low-osmolarity ORS solution (240–250 mOsm/l)[5] (eg Pedialyte, Gastrolyte in Canada) for oral rehydration therapy
• give 50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid
• give the ORS solution frequently and in small amounts
• 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 (see table 1)
• plain water discouraged by CPS
• consider giving the ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently
• monitor the response to oral rehydration therapy by regular clinical assessment

IVF

• indications:
  • Shock
  • a child with red flag symptoms or signs (see table 1) shows clinical evidence of deterioration despite oral rehydration therapy
  • a child persistently vomits the ORS solution, given orally or via a nasogastric tube.
• Initial bolus
  • 20mL/kg of NS, then another one if still shocked
  • If no response to 2 boluses, consider other causes of shock. Consult PICU.
• IVF therapy
  • Use NS or D5NS
  • If shocked: add 100mL/kg for fluid deficit to maintenance
  • If no shocked: add 50mL/kg for fluid deficit to maintenance
  • Early oral rehydration recommended. Switch to ORT as early as tolerated.
• IVF in Hypernatremic dehydration
  • Urgent consult to specialist
  • Use NS or D5NS still
  • replace slowly over 48 hours, aiming at reducing serum sodium at a rate of less than 0.5mmol/L per hour

Maintenance after rehydration

• Encourage breastfeeding, milk, and fluids
• Consider giving 5mL/kg of ORS after each large watery stool
• If dehydration recurs, restart ORT

Antibiotic indications:

• suspected or confirmed septicaemia
• extra-intestinal spread of bacterial infection
• younger than 6 months with salmonella gastroenteritis
• patient malnourished or immunocompromised with salmonella gastroenteritis
• Clostridium difficile-associated pseudomembranous enterocolitis
• giardiasis
• dysenteric shigellosis
• dysenteric amoebiasis
• cholera

Do not use antidiarrhoeal medications.

Home care

Red flags for dehydration (seek medical attention):

• appearing to get more unwell
• changing responsiveness (for example, irritability, lethargy)
• decreased urine output
• pale or mottled skin
• cold extremities

Also seek medical attention if length of illness beyond the usual course:

• diarrhoea: 5–7 days and in most children it stops within 2 weeks
• vomiting: 1 or 2 days and in most children it stops within 3 days

If not dehydrated:

• to continue usual feeds, including breast or other milk feeds
• to encourage the child to drink plenty of fluids
• to discourage the drinking of fruit juices and carbonated drinks
• plain water also discouraged by CPS
• to offer ORS solution as supplemental fluid

with clinical dehydration:

• that rehydration is usually possible with ORS solution
• premixed ORS preferred due to risk of error (CPS)
• to give 50 ml/kg of ORS solution for rehydration plus maintenance volume over a 4-hour period
• to give this amount of ORS solution in small amounts, frequently
• to seek advice if the child refuses to drink the ORS solution or vomits persistently
• to continue breastfeeding as well as giving the ORS solution
• not to give other oral fluids unless advised
• not to give solid foods.

after rehydration:

• drink plenty of their usual fluids, including milk feeds if these were stopped
• avoid fruit juices and carbonated drinks until the diarrhoea has stopped
• reintroduce the child’s usual diet
• give 5 ml/kg ORS solution after each large watery stool if you consider that the child is at increased risk of dehydration

Disease prevention

• washing hands with soap (liquid if possible) in warm running water and careful drying are the most important factors in preventing the spread of gastroenteritis
• hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food
• towels used by infected children should not be shared
• 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
• children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea.

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