What is the treatment guideline for gastroenteritis in children?

Treatment Guidelines for Gastroenteritis in Children

The cornerstone of treatment for pediatric gastroenteritis is oral rehydration therapy (ORT) using low-osmolarity oral rehydration solutions, with continued breastfeeding throughout the illness and early reintroduction of age-appropriate diet after initial rehydration. 1, 2

Assessment of Dehydration

• Dehydration severity assessment is crucial for treatment decisions:

  • Mild dehydration: <3% weight loss, minimal signs
  • Moderate dehydration: 3-9% weight loss, dry mucous membranes, decreased urine output
  • Severe dehydration: >9% weight loss, altered mental status, poor perfusion 1, 2

• Key physical examination findings:

  • Capillary refill time (abnormal if >2 seconds)
  • Mental status (alertness vs. lethargy)
  • Mucous membrane moisture
  • Tear production
  • Skin turgor 2, 3

Rehydration Therapy

Mild to Moderate Dehydration

• First-line: Oral rehydration therapy (ORT) 1, 4

  • Use low-osmolarity ORS (50-60 mEq/L sodium)
  • Dosing: 50-100 mL/kg over 3-4 hours
  • Replace ongoing losses with 10 mL/kg for each diarrheal stool or vomiting episode 1

• Nasogastric rehydration if child refuses to drink or is too weak (but has normal mental status) 1, 2

Severe Dehydration

• Intravenous rehydration required for:

  • Severe dehydration or shock
  • Altered mental status
  • Ileus
  • Failure of ORT 1, 2

• IV fluid protocol:

  • Initial: Isotonic fluids (lactated Ringer's or normal saline)
  • Continue until vital signs, perfusion, and mental status normalize
  • Then transition to ORT to complete rehydration 1

Nutritional Management

• Continue breastfeeding throughout the entire illness (strong recommendation) 1, 2

• Resume age-appropriate diet immediately after initial rehydration (within 4-6 hours) 1, 2

  • Early feeding reduces stool output and diarrhea duration by approximately 50% 2
  • Avoid foods high in simple sugars and fats 2

• For formula-fed infants: Resume full-strength formula after initial rehydration 2

• Consider temporary lactose restriction only if symptoms persist despite other interventions 2

Pharmacologic Interventions

Antiemetics

• Ondansetron may be given to children >4 years with vomiting to facilitate ORT tolerance (weak recommendation) 1, 4
  • Not a substitute for appropriate fluid therapy

Antimotility Agents

• Do not use loperamide in children <18 years with acute diarrhea (strong recommendation) 1
  • Risk of toxic megacolon in inflammatory diarrhea

Probiotics

• May be offered to reduce symptom severity and duration (weak recommendation) 1
  • Specific probiotic selection should be based on literature and manufacturer guidance

Zinc Supplementation

• Recommended for children 6 months to 5 years in countries with high zinc deficiency prevalence or with signs of malnutrition 1

Antibiotics

• Generally not indicated for uncomplicated viral gastroenteritis 2, 5
• Consider antibiotics only for:
  • Dysentery (bloody diarrhea)
  • Persistent high fever
  • Diarrhea lasting >5 days
  • Identified treatable bacterial pathogen 2

Warning Signs Requiring Immediate Attention

• Persistent vomiting preventing ORT intake
• High stool output (>10 mL/kg/hour)
• Bloody diarrhea
• Worsening dehydration despite treatment
• Lethargy or altered mental status 2

Prevention Measures

• Hand hygiene after toilet use, diaper changes, before/after food preparation, after handling garbage or soiled items 1, 2

• Infection control using gloves, gowns, and proper hand hygiene when caring for children with diarrhea 1

• Rotavirus vaccination significantly reduces gastroenteritis-related hospitalizations 2

Special Considerations

• Persistent diarrhea (>14 days) warrants evaluation for non-infectious causes (food allergies, inflammatory bowel disease) 2

• Immunocompromised children may experience severe, prolonged rotavirus diarrhea 2

• Premature infants and malnourished children are at higher risk for complications 2

• Treatment failure is more likely with higher clinical dehydration scores, abnormal capillary refill time, and higher triage urgency levels 3

By following these evidence-based guidelines, most children with gastroenteritis can be successfully managed, reducing morbidity and preventing complications from dehydration.