What is the management for a patient with Acute Gastroenteritis (AGE) and moderate dehydration?

Management of Acute Gastroenteritis with Moderate Dehydration

For patients with moderate dehydration due to acute gastroenteritis, oral rehydration solution (ORS) should be administered at a dose of 100 mL/kg over 2-4 hours as the first-line therapy. 1

Assessment of Dehydration

• Moderate dehydration (6-9% fluid deficit) is characterized by decreased skin turgor, dry mucous membranes, sunken eyes, decreased urine output, and altered mental status 1
• Physical examination is the best way to evaluate hydration status, with clinical scales helping determine severity 2

Rehydration Protocol for Moderate Dehydration

• Administer reduced osmolarity ORS (total osmolarity <250 mmol/L) at 100 mL/kg over 2-4 hours 1, 3
• Use small volumes initially (e.g., one teaspoon) and gradually increase as tolerated 1
• Nasogastric administration of ORS may be considered for patients who cannot tolerate oral intake or refuse to drink adequately 1
• Commercially available ORS formulations include Pedialyte, CeraLyte, and Enfalac Lytren 1
• Popular beverages like apple juice, Gatorade, and commercial soft drinks should NOT be used for rehydration 1

Replacement of Ongoing Losses

• Replace ongoing stool losses with ORS:
  • For children <10 kg: 60-120 mL ORS for each diarrheal stool or vomiting episode (up to ~500 mL/day) 1
  • For children >10 kg: 120-240 mL ORS for each diarrheal stool or vomiting episode (up to ~1 L/day) 1
  • For adolescents and adults: Ad libitum, up to ~2 L/day 1
• Continue replacement as long as diarrhea or vomiting persists 1

Nutritional Management

• Human milk feeding should be continued in infants and children throughout the diarrheal episode 1, 3
• Resume age-appropriate usual diet during or immediately after the rehydration process is completed 1, 3
• Food should not be withheld during the illness 3

Adjunctive Therapies

• Antiemetics (ondansetron) may be considered for children >4 years of age to facilitate oral rehydration if vomiting is severe 1, 3
• Antimotility drugs (loperamide) should NOT be given to children <18 years of age with acute diarrhea 1, 3
• Probiotic preparations (particularly Lactobacillus GG and Saccharomyces boulardii) may be offered to reduce symptom severity and duration 1, 4
• Zinc supplementation may be beneficial for children 6 months to 5 years of age in areas with high prevalence of zinc deficiency 1

Indications for Intravenous Therapy

• Intravenous fluids are indicated when:
  • Patient has severe dehydration (≥10% fluid deficit) 1
  • Patient has shock or altered mental status 1
  • Oral rehydration therapy fails 1
  • Patient has ileus 1
  • Patient has ketonemia and cannot tolerate oral rehydration 1
• Isotonic fluids (lactated Ringer's or normal saline) should be used for IV rehydration 1

Prevention of Transmission

• Hand hygiene should be performed after using the toilet, changing diapers, before and after preparing food, and after handling potentially contaminated items 1
• Infection control measures including gloves, gowns, and proper hand hygiene should be followed when caring for patients with diarrhea 1

Follow-up and Reassessment

• After 2-4 hours of rehydration therapy, reassess hydration status 1
• If the patient is rehydrated, progress to maintenance therapy 1
• If still dehydrated, reestimate fluid deficit and continue rehydration therapy 1
• Seek immediate medical attention if the child becomes unable to tolerate oral fluids, signs of dehydration worsen, diarrhea becomes bloody, or fever increases significantly 3