What is the management of gastroenteritis in pediatric patients?

Management of Gastroenteritis in Pediatric Patients

The cornerstone of pediatric gastroenteritis management is oral rehydration therapy (ORT) with appropriate oral rehydration solution (ORS), followed by early reintroduction of normal diet, with intravenous fluids reserved only for severe dehydration or ORT failure. 1

Assessment and Classification of Dehydration

Proper assessment of dehydration severity is crucial for determining appropriate treatment:

• Mild dehydration (3-5%):

  • Clinical signs: Increased thirst, slightly dry mucous membranes
  • Management: Oral rehydration with 50 mL/kg ORS over 2-4 hours 2

• Moderate dehydration (6-9%):

  • Clinical signs: Loss of skin turgor, tenting of skin when pinched, dry mucous membranes
  • Management: Oral rehydration with 100 mL/kg ORS over 2-4 hours 2

• Severe dehydration (≥10%):

  • Clinical signs: Lethargy, altered consciousness, prolonged skin tenting, cool extremities, decreased capillary refill
  • Management: Immediate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until clinical improvement 2, 1

Rehydration Protocol

Oral Rehydration Therapy (ORT)

• Use ORS containing 65-70 mEq/L sodium, 75-90 mmol/L glucose, and 20 mEq/L potassium 1
• For vomiting children: Administer small volumes (5 mL) every minute using spoon or syringe, gradually increasing as tolerated 1
• ORT is as effective as IV therapy for mild to moderate dehydration and is associated with shorter hospital stays 3, 4
• For children refusing ORS, continuous nasogastric application is as effective as IV rehydration 3

Intravenous Rehydration

• Reserved for severe dehydration or ORT failure
• Administer 20 mL/kg boluses of isotonic crystalloid (Ringer's lactate or normal saline) until pulse, perfusion, and mental status normalize 2, 1
• May require two IV lines or alternate access sites in severe cases 2
• Once the child's consciousness returns to normal, transition to oral rehydration 2

Replacement of Ongoing Losses

• Replace each watery stool with 10 mL/kg ORS 2, 1
• Replace each episode of vomiting with 2 mL/kg ORS 2, 1
• Use low-sodium ORS (40-60 mEq/L) or standard ORS (75-90 mEq/L) with additional low-sodium fluid (water, breast milk, formula) 2

Nutritional Management

• Breastfed infants: Continue nursing on demand throughout illness 2, 1
• Formula-fed infants: Resume full-strength formula immediately after initial rehydration 2, 1
  • Consider lactose-free or lactose-reduced formulas if available
  • If unavailable, use full-strength lactose-containing formula under supervision
• Older children: Resume regular diet with emphasis on starches, cereals, yogurt, fruits, and vegetables 1
• Avoid: Foods high in simple sugars and fats 1

Medication Considerations

• Antibiotics: Not indicated for routine viral gastroenteritis 5

  • Consider only for specific bacterial causes (dysentery, severe illness) or in immunocompromised children
  • Empiric therapy with co-trimoxazole or metronidazole may be considered in severe cases while awaiting stool culture results 5

• Antidiarrheal agents: Generally not recommended for children 2, 1

  • Can cause serious side effects including opiate-induced ileus, drowsiness, and abdominal distention 2
  • May shift focus away from appropriate fluid, electrolyte, and nutritional therapy 2

Alternative Approaches

Recent evidence suggests that in minimally dehydrated children, dilute apple juice followed by preferred fluids may be an appropriate alternative to electrolyte maintenance solution, resulting in fewer treatment failures and less need for IV rehydration 6.

Monitoring and Follow-up

• Monitor hydration status frequently during rehydration
• Assess for warning signs requiring immediate medical attention:
  • Persistent vomiting
  • Bloody diarrhea
  • High fever
  • Decreased urine output
  • Lethargy or altered mental status
  • Worsening dehydration despite therapy 1

Common Pitfalls to Avoid

1. Delaying rehydration while waiting for diagnostic tests
2. Withholding food during diarrheal illness, which can worsen intestinal function 7
3. Overreliance on IV fluids when oral rehydration would be sufficient 3
4. Using inappropriate fluids (water, tea, dilute juices alone) for rehydration, which can worsen hyponatremia 1
5. Prescribing antidiarrheal medications that may cause serious side effects in children 2

By following this evidence-based approach to pediatric gastroenteritis management, clinicians can effectively prevent and treat dehydration while minimizing unnecessary interventions and hospitalizations.