What is the appropriate management for a child with suspected gastroenteritis?

Management of Suspected Gastroenteritis in Children

Oral rehydration therapy is the cornerstone of management for children with suspected gastroenteritis and mild to moderate dehydration, with intravenous fluids reserved for severe cases or when oral rehydration fails. 1, 2

Assessment of Dehydration

The physical examination is the most reliable way to evaluate hydration status:

• Clinical Dehydration Scale can determine severity based on:

  • Capillary refill time (>2 seconds suggests dehydration)
  • Skin turgor
  • Respiratory pattern
  • Mental status 1, 3

• Additional assessment factors:

  • Fluid intake and output history
  • Presence and frequency of vomiting
  • Stool output (>10 mL/kg/hour is concerning)
  • Vital signs (heart rate, blood pressure)
  • Urine output (target ≥0.5 mL/kg/h) 1, 2

Management Algorithm

1. Mild Dehydration

• Home management is appropriate 2
• Oral rehydration therapy:
  • Begin with half-strength apple juice followed by child's preferred liquids
  • Alternatively, use low-osmolarity oral rehydration solutions (ORS) like Pedialyte, CeraLyte, or Enfalac Lytren 1, 2
  • ORS preparation: 3.5g NaCl, 2.5g NaHCO₃, 1.5g KCl, and 20g glucose per liter of clean water 1

2. Moderate Dehydration

• Oral rehydration solutions are recommended 1, 2
• If vomiting is problematic, consider ondansetron to improve ORS tolerance 1, 2, 3
• Nasogastric administration of ORS if child cannot tolerate oral intake or is too weak to drink adequately 1

3. Severe Dehydration (>10% dehydration or signs of shock)

• Immediate intravenous fluid resuscitation:
  • Administer 20 mL/kg isotonic crystalloid (normal saline or Ringer's lactate) rapidly
  • Can repeat to total of 40-60 mL/kg in first hour if needed
  • Prefer balanced/buffered crystalloids over 0.9% saline 1
• Continuous monitoring for signs of fluid overload:
  • Increased work of breathing
  • Rales
  • Gallop rhythm
  • Hepatomegaly 1

Nutrition During Illness

• Continue breastfeeding throughout the diarrheal episode 1
• Resume regular age-appropriate diet during or immediately after rehydration
• Early feeding reduces stool output and duration of diarrhea by approximately 50%
• Recommended foods: Bland diet including bananas, rice, applesauce, and toast (BRAT diet)
• Avoid: Foods high in simple sugars and high-fat foods 1

Medication Considerations

• Antibiotics: Generally NOT indicated for most cases of acute gastroenteritis 1, 4
  • Exceptions: infants <3 months with suspected bacterial etiology, immunocompetent patients with fever, abdominal pain, and bloody diarrhea, or recent international travelers with fever ≥38.5°C
• Ondansetron: May be used to prevent vomiting and improve ORS tolerance 1, 2, 3
• Antimotility drugs (e.g., loperamide): Should NOT be given to children under 18 years 1
• Probiotics: The American Gastroenterological Association suggests against probiotic use in children with acute infectious gastroenteritis in North America 1

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

• Hand hygiene: Proper handwashing is essential
• Rotavirus vaccination: Significantly reduces gastroenteritis-related hospitalizations 5, 1, 2
• Food and water safety measures
• Breastfeeding reduces incidence of acute gastroenteritis in young children 1, 2

Common Pitfalls to Avoid

1. Overreliance on laboratory tests: Physical examination is more reliable for assessing dehydration than laboratory values alone 2, 3
2. Underutilization of oral rehydration: Most children with dehydration can be successfully rehydrated via the oral route, yet IV fluids are often overused 1, 6
3. Inappropriate use of antibiotics: Most cases of gastroenteritis are viral and do not require antibiotics 1, 4
4. Delaying refeeding: Early reintroduction of age-appropriate diet improves outcomes 1
5. Using antimotility drugs: These are contraindicated in children under 18 years 1