What is the treatment for pediatric gastroenteritis?

Treatment of Pediatric Gastroenteritis

The cornerstone of treatment for pediatric gastroenteritis is oral rehydration therapy (ORT) using appropriate oral rehydration solutions (ORS), with continued feeding and breastfeeding throughout the illness. 1, 2

Rehydration Therapy

Assessment of Dehydration

• Mild dehydration (3-5%): Increased thirst, slightly dry mucous membranes
• Moderate dehydration (6-9%): Loss of skin turgor, tenting of skin when pinched, dry mucous membranes
• Severe dehydration (≥10%): Severe lethargy, altered consciousness, prolonged skin tenting, cool extremities, decreased capillary refill

Treatment Based on Dehydration Severity

Mild to Moderate Dehydration

• First-line treatment: Oral rehydration solution (ORS) 1, 2
  • Administer 50-100 mL/kg over 2-4 hours
  • ORS should contain:
    • Sodium: 65-90 mEq/L
    • Glucose: 75-90 mmol/L
    • Potassium: 20 mEq/L
    • Chloride: 65-80 mEq/L
    • Citrate: 10 mEq/L

Severe Dehydration

• First-line treatment: Intravenous rehydration 1, 2
  • Administer 20-30 mL/kg of isotonic fluid (normal saline or lactated Ringer's) as bolus
  • Continue until pulse, perfusion, and mental status normalize
  • Transition to ORS when the patient's condition improves

Ongoing Fluid Replacement

• Replace ongoing losses with ORS: 10 mL/kg after each loose stool 2
• Replace vomiting losses: 2 mL/kg after each episode 2

Nutritional Management

• Continue breastfeeding throughout the diarrheal episode 1, 2
• Resume age-appropriate diet during or immediately after rehydration 1
• Avoid food restriction - early refeeding decreases intestinal permeability and improves outcomes 1
• Recommended foods: Starches, cereals, yogurt, fruits, and vegetables 2
• Avoid: Foods high in simple sugars and fats 2

Medication Considerations

Antiemetics

• Ondansetron may be given to children >4 years and adolescents to facilitate ORS tolerance when vomiting is significant 1, 2
• Benefits include reduced need for hospitalization and IV rehydration 1
• Note: May increase stool volume as a side effect 1

Antimotility Agents

• Loperamide (Imodium) is contraindicated in children <18 years of age 1, 2, 3
• Associated with serious adverse events including:
  • Ileus
  • Abdominal distention
  • Lethargy
  • Deaths have been reported in children <3 years old 1

Supplemental Treatments

• Zinc supplementation reduces diarrhea duration in children 6 months to 5 years in countries with high zinc deficiency 1, 2
• Probiotics may be considered to reduce symptom severity and duration 1, 2

Special Considerations

When to Consider IV Therapy

• Failure of oral rehydration therapy 1
• Severe dehydration with shock or altered mental status 1
• Ileus or significant abdominal distention 1
• Intractable vomiting 2
• High stool output (>10 mL/kg/hour) 2

Warning Signs Requiring Medical Attention

• Worsening dehydration despite ORT
• Persistent vomiting
• Bloody diarrhea
• High fever
• Altered mental status
• Decreased urine output

Prevention Strategies

• Hand hygiene after using toilet, changing diapers, before/after food preparation, and after handling animals 1
• Rotavirus vaccination significantly reduces incidence of acute gastroenteritis in young children 1, 2
• Breastfeeding provides immunological protection 2

Common Pitfalls to Avoid

1. Using inappropriate fluids like sports drinks, juices, or sodas that have improper electrolyte compositions 2
2. Administering antimotility medications to children under 18 years 1, 2, 3
3. Restricting food during diarrheal episodes, which can worsen nutritional status 1, 2
4. Allowing dehydrated children to drink large volumes of ORS at once, which can induce vomiting 2
5. Improper mixing of ORS packets, resulting in solutions that are too concentrated or too dilute 2

The evidence strongly supports that ORT is as effective as IV therapy for mild to moderate dehydration, with fewer complications and shorter hospital stays 4. Studies show that children who can tolerate at least 20-25 mL/kg of ORS during an initial rehydration period are likely to be successfully managed with continued oral therapy 5.

Human studies: When comparing different ORS formulations, both glucose-based and rice-based solutions are effective for rehydration, though rice-based solutions may provide slightly better sodium absorption 6. The success rate of ORT is high, with studies showing that for every 25 children treated with ORT, only one will fail and require IV therapy 4.

By following these evidence-based guidelines, most cases of pediatric gastroenteritis can be effectively managed with minimal complications and improved outcomes.