What is the best course of management for a 9-year-old patient with a 6-day history of gastroenteritis symptoms, including nausea, vomiting, and watery diarrhea, who has been exposed to a family member with similar symptoms and has been treated with Pepto Bismol (bismuth subsalicylate)?

Management of 9-Year-Old with Prolonged Gastroenteritis

Discontinue Pepto Bismol Immediately

Bismuth subsalicylate (Pepto Bismol) should not be used in children under 12 years of age due to the risk of Reye's syndrome, particularly in the context of viral gastroenteritis. 1 The FDA labeling explicitly warns that children and teenagers who have or are recovering from flu-like symptoms should not use this product, as changes in behavior with nausea and vomiting could be early signs of Reye's syndrome, a rare but serious illness. 1

Assess Hydration Status Immediately

The priority is to evaluate this child's current hydration status using clinical signs:

• Assess skin turgor, mucous membrane moisture, mental status, capillary refill time, and vital signs 2, 3
• Categorize dehydration as mild (3-5%), moderate (6-9%), or severe (≥10%) 2, 3
• Since the child is reportedly drinking plenty and keeping fluids down, he likely has mild dehydration at most 4

Initiate Oral Rehydration Solution

For mild to moderate dehydration, oral rehydration solution (ORS) is the first-line treatment:

• Use low-osmolarity ORS formulations, not sports drinks or juices 2, 3
• Continue ORS to replace ongoing losses until diarrhea resolves 2
• The child should receive approximately 50 mL/kg over 2-4 hours if dehydration is present 3

Resume Normal Diet Immediately

Age-appropriate diet should be resumed during or immediately after rehydration:

• Early refeeding is recommended rather than fasting or restrictive diets 4, 2
• Offer starches (rice, potatoes, noodles, crackers, bananas), cereals, soup, yogurt, vegetables, and fresh fruits 5
• Avoid foods high in simple sugars (soft drinks, undiluted apple juice) as they can exacerbate diarrhea through osmotic effects 2, 3

No Antimotility Agents

Loperamide and other antimotility drugs should not be given to children under 18 years of age with acute diarrhea. 4, 3 These medications can cause serious complications including ileus, abdominal distension, lethargy, and have been associated with deaths in children under 3 years old. 4

Consider Diagnostic Testing

Given the 6-7 day duration of symptoms, consider stool testing:

• Multiplex antimicrobial testing is preferred over traditional stool cultures 6
• Test for Clostridium difficile if there has been recent antibiotic exposure 4
• Viral gastroenteritis is most likely given the family cluster and exposure history 4, 3
• Most viral gastroenteritis is self-limited and resolves within a few days 4

When to Consider Hospitalization

Reserve hospitalization for:

• Severe dehydration requiring IV fluids 2, 5
• Inability to tolerate oral fluids despite ORS attempts 5
• Altered mental status or signs of shock 3, 5
• Persistent high fever with signs of sepsis 3

Since this child is tolerating oral fluids, hospitalization is not currently indicated. 4

Antiemetic Consideration

Ondansetron may be given to children over 4 years of age to facilitate oral rehydration when vomiting is significant. 4, 3 At 9 years old, this patient qualifies if vomiting becomes problematic, though the mother reports he is currently keeping fluids down. 3

Infection Control Measures

Implement strict hygiene to prevent household transmission:

• Hand hygiene after toilet use, before eating, and after handling soiled items 4, 2
• Separate the ill child from well persons until at least 2 days after symptom resolution 3
• Clean and disinfect contaminated surfaces promptly 3
• Vigorous handwashing with soap is necessary to control spread of enteric pathogens 4

No Antibiotics Indicated

Antimicrobial therapy is not indicated for viral gastroenteritis. 2, 3 Viral agents are the predominant cause of gastroenteritis, and antibiotics provide no benefit and may cause harm. 2, 3 Consider antibiotics only if bloody diarrhea develops, suggesting bacterial infection. 4

Expected Course and Follow-Up

Most viral gastroenteritis is self-limited and resolves within a few days:

• The main risk is dehydration and electrolyte imbalance 4
• Children may manifest mild lactose intolerance for 10-14 days after rotavirus infection 4
• Approximately 9% of patients develop post-infectious irritable bowel syndrome 6
• Follow up if symptoms persist beyond 7-10 days, bloody diarrhea develops, or signs of dehydration worsen 4