What is the assessment and plan for a 6-year-old patient presenting with diarrhea and vomiting?

Assessment and Plan for a 6-Year-Old with Diarrhea and Vomiting

Assessment

Acute gastroenteritis is the most likely diagnosis for this 6-year-old child with diarrhea and vomiting, requiring oral rehydration therapy as the first-line treatment. 1

The assessment should focus on:

• Degree of dehydration:

  • Mild (3-5%): Increased thirst, slightly dry mucous membranes
  • Moderate (6-9%): Loss of skin turgor, dry mucous membranes
  • Severe (≥10%): Severe lethargy, altered consciousness

• Red flags requiring immediate attention:

  • Bloody diarrhea
  • Persistent vomiting
  • Signs of severe dehydration
  • Altered mental status
  • High fever (>38.5°C)
  • Symptoms persisting >5 days

Plan

1. Rehydration

• Oral Rehydration Solution (ORS) is the first-line treatment for mild to moderate dehydration 1

  • Use reduced osmolarity ORS containing 65-70 mEq/L sodium and 75-90 mmol/L glucose
  • Continue until clinical dehydration is corrected
  • For moderate dehydration, aim for approximately 25 mL/kg of ORS intake during initial rehydration 2

• If severe dehydration, shock, altered mental status, or ORS failure:

  • Initiate IV fluids with isotonic solutions (lactated Ringer's or normal saline)
  • Continue until pulse, perfusion, and mental status normalize

2. Dietary Management

• Resume age-appropriate diet during or immediately after rehydration 1

• Recommend:

  • Starches, cereals, yogurt, fruits, and vegetables
  • BRAT diet (bread, rice, applesauce, toast) may be helpful
  • Continue regular feeding as tolerated

• Avoid:

  • Foods high in simple sugars and fats
  • Lactose-containing products during acute phase
  • High-osmolar dietary supplements

3. Medication

• Antiemetics:

  • Ondansetron may be considered for children >4 years to facilitate oral rehydration, but only after adequate hydration has begun 1
  • Should not substitute for fluid and electrolyte therapy

• Antidiarrheals:

  • Loperamide is contraindicated in children under 6 years of age due to risk of respiratory depression and cardiac adverse reactions 1, 3

• Antibiotics:

  • Generally not indicated unless there is:
    • Dysentery (bloody diarrhea)
    • High fever
    • Watery diarrhea lasting >5 days
    • Specific identified pathogen requiring treatment

4. Monitoring and Follow-up

• Monitor for:

  • Improvement in hydration status
  • Decreased frequency of diarrhea and vomiting
  • Resolution of fever if present
  • Ability to tolerate oral intake

• Return precautions:

  • Worsening symptoms
  • Inability to maintain hydration
  • Development of warning signs (bloody stools, persistent vomiting, high fever)
  • Symptoms persisting >5 days

5. Prevention and Education

• Proper hand hygiene and infection control measures
• Instructions for parents on:
  • Proper preparation of ORS
  • Recognition of dehydration signs
  • When to seek immediate medical attention

Clinical Pearls

• Early reintroduction of appropriate foods is important and does not worsen diarrhea 1, 4
• Food-based ORS may reduce stool output compared to standard glucose-based solutions 5
• Children who can tolerate at least 25 mL/kg of ORS during initial rehydration have better outcomes with home management 2
• Avoid the common pitfall of unnecessarily restricting diet, which can worsen nutritional status without improving symptoms