What is the treatment for gastroenteritis in a 2-year-old with fever, perianal itching, and loose motions?

Treatment of Gastroenteritis in a 2-Year-Old with Fever, Perianal Itching, and Loose Motions

Oral rehydration therapy with continued feeding is the cornerstone of treatment for gastroenteritis in a 2-year-old child, while avoiding antimotility agents like loperamide which are contraindicated in children under 2 years of age. 1, 2

Rehydration Strategy

1. Oral Rehydration Therapy (ORT):

   • First-line treatment for mild to moderate dehydration 1, 3, 4
   • Administer 10 ml/kg of ORS for each loose stool and 2 ml/kg for each episode of vomiting 1
   • For severe dehydration or if child cannot tolerate oral fluids, intravenous rehydration is indicated until pulse, perfusion, and mental status normalize 1, 5

2. Assessing Dehydration:

   • Monitor hydration status through changes in weight, urine output, thirst, and physical signs 1, 4
   • Key signs: general appearance, eyes, mucous membranes, tears, capillary refill time, and vital signs 1

Nutritional Management

1. Continue Feeding:

   • Resume age-appropriate diet during or immediately after rehydration 1, 3
   • Offer food every 3-4 hours 1
   • Avoid foods high in simple sugars and fats 1
   • If breastfeeding, continue throughout the illness 1, 3

2. Special Considerations:

   • May require increased caloric intake (starting with 120 kcal/kg per day) 1
   • Consider lactose-free formulas if lactose malabsorption is suspected 1
   • Early reintroduction of usual foods has been shown to shorten illness duration 6

Pharmacological Management

1. Antiemetics:

   • Ondansetron may be prescribed if needed to prevent vomiting and improve tolerance of oral rehydration solutions 4, 7

2. Antimotility Agents:

   • AVOID loperamide in children under 2 years of age - contraindicated due to risks of respiratory depression and cardiac adverse reactions 1, 2
   • Loperamide should also be avoided in cases of bloody diarrhea, fever, or suspected inflammatory diarrhea 1, 2

3. Antibiotics:

   • Only indicated if bacterial cause is confirmed or strongly suspected 1, 7
   • First-line options based on pathogen:
     • Shigella: Azithromycin
     • Campylobacter: Azithromycin
     • Enterotoxigenic E. coli: TMP-SMX (if susceptible) or Azithromycin
     • Bacterial gastroenteritis: Third-generation cephalosporin or Azithromycin 1

4. Probiotics:

   • Consider probiotics with documented efficacy such as Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Saccharomyces boulardii 3
   • May improve intestinal microbial balance, reducing duration and severity of diarrhea 3

Infection Prevention and Control

1. Hand Hygiene:

   • Proper handwashing with soap and water after using toilet, changing diapers, before preparing food 1
   • Essential for preventing spread of infection 1, 4

2. Vaccination:

   • Rotavirus vaccination is recommended to prevent future episodes 1, 4, 7
   • Has reduced rotavirus infections by up to 90% in children 7

When to Hospitalize

• Failure to respond to oral rehydration therapy plus antiemetics 4
• Severe dehydration (signs of shock or more than 10% dehydration) 4
• Inability to maintain adequate oral intake 4, 5
• Concerning social circumstances or inability of caregivers to manage at home 4

Common Pitfalls to Avoid

• Delaying refeeding - early reintroduction of food shortens illness duration 1, 6
• Using antimotility drugs like loperamide in young children - contraindicated under age 2 1, 2
• Unnecessary stool testing in mild cases with likely viral etiology 4, 7
• Neglecting to monitor hydration status closely - young children can dehydrate rapidly 1, 4
• Forgetting to counsel on hand hygiene and infection prevention measures 1