What is the treatment for pediatric gastroenteritis?

Treatment of Pediatric Gastroenteritis

Oral rehydration therapy (ORT) with low-osmolarity oral rehydration solutions is the first-line treatment for pediatric gastroenteritis, with intravenous fluids reserved only for severe dehydration, shock, altered mental status, or failure of oral therapy. 1

Assessment of Dehydration

The physical examination is the best way to evaluate hydration status in children with gastroenteritis:

• Mild dehydration: Alert, normal heart rate, normal skin turgor, moist mucous membranes
• Moderate dehydration: Irritable/lethargic, tachycardia, decreased skin turgor, dry mucous membranes
• Severe dehydration: Altered mental status, tachycardia with weak pulses, significantly decreased skin turgor, very dry mucous membranes

The most useful predictors of significant dehydration (≥5%) are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern 2.

Rehydration Approach

Mild to Moderate Dehydration

• First-line: Oral rehydration with low-osmolarity ORS 1, 3
• Administer 50-100 mL/kg over 3-4 hours
• If child cannot tolerate oral intake or is too weak to drink, consider nasogastric administration 1
• Commercial ORS options include Pedialyte, CeraLyte, and Enfalac Lytren 1
• Half-strength apple juice followed by preferred liquids can be as effective as commercial ORS for mild dehydration 4

Severe Dehydration

• Intravenous fluids with isotonic solutions (lactated Ringer's or normal saline) 1
• Initial bolus of 20 mL/kg, repeated if necessary
• Transition to oral rehydration once the child is stabilized 1

Managing Vomiting

• Ondansetron may be used to prevent vomiting and improve ORS tolerance 1, 4, 2
• Benefits include:
  • Decreased vomiting episodes
  • Improved oral intake
  • Reduced need for IV therapy
  • Shorter emergency department stays 2

Nutritional Management

• Continue breastfeeding throughout the diarrheal episode 1
• Resume regular age-appropriate diet during or immediately after rehydration 1
• Early feeding reduces stool output and duration of diarrhea by approximately 50% compared to gradual reintroduction of food 1
• A bland diet (BRAT: bananas, rice, applesauce, toast) is recommended 1
• Avoid foods high in simple sugars and high-fat foods 1

Medication Considerations

• Antibiotics are generally NOT indicated for most cases of acute gastroenteritis in children 1
• Antimotility drugs (loperamide) should NOT be given to children under 18 years with acute diarrhea 1
• Probiotics are not recommended for children with acute infectious gastroenteritis in North America (conditional recommendation, moderate quality evidence) 1

Monitoring and Follow-up

• Monitor urine output (target ≥0.5 mL/kg/h)
• Track vital signs, especially blood pressure and heart rate
• Monitor for warning signs requiring immediate medical attention:
  • Persistent vomiting preventing ORS intake
  • High stool output (>10 mL/kg/hour)
  • Bloody diarrhea
  • Worsening dehydration despite treatment
  • Lethargy or altered mental status 1

Prevention

• Proper hand hygiene and infection control measures
• Rotavirus vaccination significantly reduces gastroenteritis-related hospitalizations 1, 5
• Several norovirus vaccines are currently in clinical trials 5

Common Pitfalls to Avoid

1. Overreliance on IV fluids: ORT is as effective as IV therapy for mild to moderate dehydration and has fewer complications 3, 4
2. Unnecessary laboratory testing: Serum electrolytes are usually not necessary except in severe dehydration 5
3. Delaying feeding: Early reintroduction of food improves outcomes 1
4. Inappropriate use of antibiotics: Most cases are viral and do not require antimicrobial therapy 1
5. Using antimotility agents: These are contraindicated in children under 18 years 1