What are the initial admitting orders for a 2-year-old male patient, weighing 13.8kg, diagnosed with Acute Gastroenteritis (AGE) and presenting with moderate dehydration?

Admitting Orders for 2-Year-Old Male with AGE and Moderate Dehydration

Initiate oral rehydration solution (ORS) at 100 mL/kg (1,380 mL total) administered over 2-4 hours as first-line therapy for this child with moderate dehydration. 1, 2

Initial Assessment Orders

• Obtain accurate body weight to guide fluid calculations and monitor rehydration progress 1
• Vital signs every 2 hours during rehydration phase, then every 4 hours once stable 2
• Clinical hydration assessment every 2-4 hours: skin turgor, mucous membrane moisture, capillary refill time, mental status, urine output 1, 3
• Consider serum electrolytes only if clinical signs suggest abnormal sodium or potassium concentrations (e.g., altered mental status, seizures) - not routinely needed 1
• No stool cultures unless bloody diarrhea develops 1

Rehydration Phase (First 2-4 Hours)

For moderate dehydration (6-9% fluid deficit), administer 100 mL/kg ORS = 1,380 mL over 2-4 hours 1, 2

• Start with small volumes (5 mL every 5 minutes) using teaspoon, syringe, or medicine dropper, then gradually increase as tolerated 1, 2
• Use low-osmolarity ORS (total osmolarity <250 mmol/L): Pedialyte, CeraLyte, or Enfalac Lytren 1, 2
• Reassess hydration status after 2-4 hours: if rehydrated, advance to maintenance phase; if still dehydrated, re-estimate deficit and continue rehydration 1, 2
• Consider nasogastric ORS administration if child refuses oral intake or cannot tolerate adequate volumes, provided mental status is normal and no ileus present 1, 2

Replacement of Ongoing Losses (Throughout Admission)

For child >10 kg: administer 120-240 mL ORS for each diarrheal stool or vomiting episode (up to ~1 L/day) 1, 2

• Continue replacing ongoing losses until diarrhea and vomiting resolve 1, 2

Nutritional Management

• Continue age-appropriate diet during or immediately after rehydration is completed - do not restrict diet or fast 1, 2, 4, 3
• Resume regular foods as soon as rehydration phase is complete 1, 2
• If breastfed, continue breastfeeding throughout illness 1, 2, 4, 3

Pharmacological Orders

Antiemetics

• Ondansetron may be considered if vomiting is severe and interfering with oral rehydration (child is >4 years old per guidelines, but this patient is 2 years old - use clinical judgment) 1, 2, 3, 5
• Ondansetron reduces hospital admission rates and IV rehydration needs 5

Medications to AVOID

• NO antimotility drugs (loperamide) - contraindicated in children <18 years with acute diarrhea 1, 2, 4, 3
• NO adsorbents, antisecretory drugs, or toxin binders - ineffective and shift focus away from appropriate fluid therapy 1, 4
• NO antimicrobials unless specific indications develop (bloody diarrhea, immunodeficiency, specific pathogen identified) 4

Adjunctive Therapy

• Probiotics may be offered to reduce symptom severity and duration 1, 2, 4
• Zinc supplementation is not routinely indicated in developed countries unless signs of malnutrition present 1, 2

Criteria for IV Rehydration (Escalation Plan)

Switch to IV isotonic fluids (lactated Ringer's or normal saline) if: 1, 2

• Severe dehydration develops (≥10% fluid deficit)
• Altered mental status or shock
• Failure of oral rehydration therapy after adequate trial
• Ileus develops
• Persistent vomiting preventing oral intake despite antiemetic

IV bolus: 20 mL/kg over 30 minutes, repeat until pulse, perfusion, and mental status normalize 1, 3

Monitoring Parameters

• Reassess hydration status every 2-4 hours during rehydration phase 1, 2
• Monitor for hypernatremia - more common complication in rotavirus-positive AGE and associated with severe disease 6
• Monitor for hypoglycemia - metabolic disorders more common in viral AGE 6
• Watch for signs requiring IV therapy: worsening mental status, inability to tolerate oral fluids, signs of shock 2, 3

Infection Control

• Contact precautions: gloves and gowns for all patient care 1, 2, 4, 3
• Hand hygiene with soap and water (alcohol-based sanitizers less effective against some enteric pathogens) 1, 2
• Private room if available 4, 3

Discharge Criteria

• Adequate hydration restored clinically
• Tolerating oral fluids and age-appropriate diet
• Ongoing losses can be managed at home with ORS
• Caregiver education completed on ORS administration and warning signs

Common Pitfalls to Avoid

• Do not delay rehydration while awaiting diagnostic testing 4
• Do not use inappropriate fluids (apple juice, sports drinks, soft drinks) as primary rehydration - these have high osmolarity and can worsen diarrhea 1, 4
• Do not restrict diet unnecessarily during or after rehydration 4, 3
• Do not administer antimotility agents to children 1, 4