Management of Acute Gastroenteritis in Pediatric Patients
Oral rehydration therapy (ORS) with reduced osmolarity solution is the cornerstone of treatment for acute gastroenteritis in children, with antimotility drugs contraindicated in all patients under 18 years of age. 1
Assessment of Dehydration Severity
Evaluate dehydration by examining specific clinical parameters: skin turgor, mucous membranes, mental status, pulse, and capillary refill time. 1 The most reliable signs include decreased peripheral perfusion, abnormal skin turgor, and abnormal respiratory pattern. 2
Categorize dehydration into three levels:
- Mild (3-5% fluid deficit): Minimal clinical signs 1
- Moderate (6-9% fluid deficit): Noticeable clinical signs present 1
- Severe (≥10% fluid deficit): Shock or pre-shock state 1
Weight loss as a percentage of normal body weight provides the best estimate of dehydration severity, though clinical signs typically don't appear until at least 4% body weight loss. 2
Rehydration Protocol
Mild Dehydration (3-5%)
Administer 50 ml/kg of ORS over 2-4 hours. 1 For children with vomiting, give small volumes (5-10 mL) every 1-2 minutes using a spoon or syringe, gradually increasing the amount. 1 A critical pitfall is allowing thirsty children to drink large volumes ad libitum, which worsens vomiting. 1
Moderate Dehydration (6-9%)
Administer 100 ml/kg of ORS over 2-4 hours. 1 Reassess hydration status after 2-4 hours; if dehydration persists, reassess the fluid deficit and restart rehydration. 1, 3
Severe Dehydration (≥10%)
Immediate intravenous rehydration with isotonic fluids (lactated Ringer's or normal saline) is required until pulse, perfusion, and mental status normalize. 4, 1 Once stabilized, transition to oral rehydration to complete fluid replacement. 4 IV therapy is also indicated for altered mental status, failure of ORS therapy, or ileus. 4
Maintenance and Ongoing Loss Replacement
After successful rehydration, replace ongoing losses with 10 ml/kg of ORS for each watery stool and 2 ml/kg for each vomiting episode. 1 Continue maintenance fluids until diarrhea and vomiting resolve. 4, 1
Nutritional Management
Continue breastfeeding on demand throughout the entire diarrheal episode without interruption. 4, 1, 3 For bottle-fed infants, resume full-strength formula immediately upon rehydration. 4
Resume age-appropriate usual diet during or immediately after rehydration is completed. 4, 1 Recommended foods include starches, cereals, yogurt, fruits, and vegetables; avoid foods high in simple sugars and fats. 4 The outdated practice of withholding food or using diluted formulas should be abandoned. 4
Lactose intolerance is overdiagnosed—only treat if severe diarrhea worsens upon reintroduction of lactose-containing foods, not based solely on stool pH or reducing substances. 4
Adjunctive Pharmacologic Therapy
Antiemetics
Ondansetron may be given to children >4 years of age to facilitate oral rehydration when vomiting is present, but only after adequate hydration is achieved. 4, 1 Evidence shows ondansetron increases ORT success rates and reduces need for IV therapy and hospitalization. 5, 6
Antimotility Agents
Antimotility drugs (loperamide) are absolutely contraindicated in all children <18 years of age. 4, 1 They should be avoided at any age when inflammatory diarrhea, fever, or risk of toxic megacolon exists. 4
Probiotics
Probiotic preparations may be offered to reduce symptom severity and duration in immunocompetent children with infectious diarrhea. 4
Zinc Supplementation
Zinc supplementation reduces diarrhea duration in children 6 months to 5 years of age who reside in countries with high zinc deficiency prevalence or show signs of malnutrition. 4, 1, 3
Antibiotic Considerations
Antibiotics are not routinely indicated for acute gastroenteritis. 4 Consider antibiotics only when dysentery is present, high fever occurs, watery diarrhea persists >5 days, or stool cultures indicate a treatable pathogen. 4
Warning Signs Requiring Immediate Medical Attention
- Bloody diarrhea (dysentery) 1
- Severe dehydration with shock or near-shock 1
- Intractable vomiting preventing successful oral rehydration 1
- High stool output (>10 mL/kg/hour) 1
- Signs of glucose malabsorption (increased stool output with ORS administration) 1
- Decreased urine output, lethargy, or irritability 4
Prevention and Infection Control
Hand hygiene should be performed after toilet use, diaper changes, before and after food preparation, before eating, and after handling garbage or animals. 4 Rotavirus vaccination significantly reduces gastroenteritis incidence. 7