What is the treatment for viral gastroenteritis in children?

Viral Gastroenteritis in Children: Symptoms, Findings, and Treatment

Clinical Presentation

Viral gastroenteritis in children presents with fever, vomiting, and loose stools, though these symptoms can also indicate serious non-gastrointestinal illnesses including meningitis, bacterial sepsis, pneumonia, otitis media, and urinary tract infection that must be ruled out. 1

Key Symptoms

• Watery diarrhea (three or more loose or watery stools within 24 hours) 1
• Vomiting with or without diarrhea 1
• Fever 1
• Abdominal pain 2
• Anorexia 3

Disease Characteristics

• Rotavirus is the most common cause of severe gastroenteritis in infants and young children, affecting virtually all children in the first 3-5 years of life 1
• The illness is typically self-limited, resolving within a few days with virus replication restricted to the gut mucosa 4
• Severe diarrhea and dehydration occur primarily among children aged 3-35 months 1
• The spectrum ranges from mild, watery diarrhea to severe, dehydrating diarrhea with vomiting and fever 1

Physical Examination Findings

Assessment of Dehydration Status

The physical examination is the best way to evaluate hydration status, with accurate body weight being crucial. 1, 2

Mild Dehydration (3%-5% fluid deficit)

• Increased thirst 1
• Slightly dry mucous membranes 1

Moderate Dehydration (6%-9% fluid deficit)

• Loss of skin turgor 1
• Tenting of skin when pinched 1
• Dry mucous membranes 1

Severe Dehydration (≥10% fluid deficit)

• Severe lethargy or altered state of consciousness 1
• Prolonged skin tenting and skin retraction time (>2 seconds) 1
• Cool and poorly perfused extremities 1
• Decreased capillary refill 1
• Rapid, deep breathing (sign of acidosis) 1

Additional Examination Elements

• Auscultation for adequate bowel sounds before initiating oral therapy 1
• Visual examination of stool to confirm abnormal consistency and presence of blood or mucus 1
• Assessment of recent fluid intake and output history 2

Treatment

Oral rehydration therapy (ORT) is the cornerstone of treatment for viral gastroenteritis in children and is as effective as intravenous rehydration for preventing hospitalization. 4, 5

Rehydration Strategy by Severity

Mild Dehydration

• Manage at home with oral rehydration 2
• Half-strength apple juice followed by the child's preferred liquids is effective 2
• Oral rehydration solutions containing physiological concentrations of glucose and electrolytes 6

Moderate Dehydration

• Oral rehydration solutions are recommended 2
• ORT is as effective as IV therapy for children with mild-to-moderate dehydration 6, 5
• Consider ondansetron (for children over 4 years) if significant vomiting interferes with oral rehydration 4, 2

Severe Dehydration

• Hospitalization and intravenous fluids are required for children with severe dehydration (signs of shock or >10% dehydration) 4, 2
• IV therapy also indicated for children who fail oral rehydration therapy plus antiemetic 2
• For every 25 children treated with ORT, one will fail and require IV therapy 5

Nutritional Management

Early refeeding decreases intestinal permeability, reduces illness duration, and improves nutritional outcomes. 4

• Continue breastfeeding throughout the illness, as breast milk has protective effects against enteric infections 4
• Most infants can be "fed through" an episode of viral gastroenteritis 4
• Mild lactose intolerance may occur for 10-14 days following rotavirus infection, but most children completely recover 4
• A lactose-free diet may reduce diarrhea duration by an average of 18 hours in children under 5 years, though routine use is not necessary 4, 7

Medications

Antiemetics

• Ondansetron may be given to children over 4 years and adolescents with significant vomiting to facilitate oral rehydration 4, 2
• Judicious use increases success rate of ORT and minimizes need for IV therapy and hospitalization 6

Antidiarrheal Agents - DO NOT USE

• Antimotility drugs (e.g., loperamide) should NOT be given to children under 18 years with acute diarrhea 4
• These agents do not reduce diarrhea volume or duration despite theoretical benefits 1
• Side effects include opiate-induced ileus, drowsiness, and severe abdominal distention with reported deaths 1
• Reliance on antidiarrheal agents shifts focus away from appropriate fluid, electrolyte, and nutritional therapy 1

Laboratory Testing

Stool microbiological tests are not routinely needed when viral gastroenteritis is the likely diagnosis in children with mild illness. 2

• Serum electrolytes, creatinine, and glucose measurements are usually unnecessary 6
• Laboratory testing should only be considered in children with severe dehydration requiring hospitalization and IV therapy 6
• Enzyme immunoassay for rotavirus antigen detection is available but primarily useful for surveillance rather than routine clinical care 1

Prevention of Transmission

Vigorous handwashing with soap is necessary to control the spread of enteric pathogens. 4

• Staff members with symptoms should be excluded from contact with susceptible persons for at least 2 days after resolution of illness 4
• Environmental surfaces should be kept clean, with special attention to areas soiled by feces or vomitus 4
• Ill persons should be separated from well persons until at least 2 days after symptom resolution 4
• Rotavirus vaccination reduces the incidence of acute gastroenteritis in young children 2

Common Pitfalls to Avoid

• Do not routinely use antimotility agents in children, as risks outweigh benefits 1, 7
• Do not delay oral rehydration in favor of IV therapy for mild-to-moderate dehydration 5
• Do not routinely use lactose-free formulas unless diarrhea is prolonged 7
• Do not overlook serious non-gastrointestinal illnesses that can present with similar symptoms 1