What is the management of acute gastroenteritis in children?

Management of Acute Gastroenteritis in Children

Oral rehydration therapy (ORT) using reduced-osmolarity oral rehydration solution (ORS) is the cornerstone of treatment for acute gastroenteritis in children, with intravenous fluids reserved only for severe dehydration with shock or failure of oral therapy. 1, 2

Initial Assessment of Dehydration Severity

Immediately evaluate hydration status by examining specific clinical parameters: 2, 3

• Skin turgor (normal vs. decreased/tenting)
• Mucous membranes (moist vs. dry)
• Mental status (alert vs. lethargic/irritable)
• Capillary refill time (<2 seconds vs. ≥2 seconds)
• Pulse quality and rate (normal vs. weak/rapid)
• Urine output (normal vs. decreased/absent)

Categorize dehydration severity: 1, 2

• Mild: 3-5% fluid deficit
• Moderate: 6-9% fluid deficit
• Severe: ≥10% fluid deficit with signs of shock (altered mental status, poor perfusion, weak pulse)

Rehydration Protocol Based on Severity

Mild Dehydration (3-5% deficit)

Administer 50 mL/kg of ORS over 2-4 hours. 1, 2

Moderate Dehydration (6-9% deficit)

Administer 100 mL/kg of ORS over 2-4 hours. 1, 2

Severe Dehydration (≥10% deficit)

This is a medical emergency requiring immediate intravenous rehydration: 1, 2, 3

• Administer 20 mL/kg boluses of isotonic crystalloid (lactated Ringer's or normal saline) until pulse, perfusion, and mental status normalize
• Once stabilized, transition to ORS to complete remaining fluid deficit
• Malnourished infants may benefit from smaller-volume frequent boluses of 10 mL/kg due to reduced cardiac capacity 1

Technique for Administering ORS

Critical pitfall to avoid: Do NOT allow thirsty children to drink large volumes of ORS ad libitum, as this worsens vomiting. 2, 4

For children with vomiting, use this specific approach: 2, 3

• Give 5-10 mL every 1-2 minutes using a spoon, syringe, or medicine dropper
• Gradually increase volume as tolerated
• This technique prevents overwhelming the stomach and reduces vomiting

Replacement of Ongoing Losses

After initial rehydration, replace ongoing losses throughout the illness: 1, 2, 3

• 10 mL/kg of ORS for each watery/loose stool
• 2 mL/kg of ORS for each vomiting episode
• Continue until diarrhea and vomiting resolve

Nutritional Management

Continue breastfeeding on demand throughout the entire illness without interruption. 2, 3, 4

For formula-fed infants: 2, 3

• Resume full-strength formula immediately upon rehydration
• Lactose-containing formulas are tolerated in most instances; diluted formula offers no benefit 1

For older children: 2, 3

• Resume age-appropriate diet during or immediately after rehydration
• Recommended foods: starches, cereals, yogurt, fruits, vegetables
• Avoid foods high in simple sugars and fats

Adjunctive Pharmacologic Therapy

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. 2, 3 This increases ORT success rates and reduces need for IV therapy and hospitalization. 2, 5

Antimotility Drugs (Loperamide)

Absolutely contraindicated in all children <18 years of age due to risks of respiratory depression and serious cardiac adverse reactions. 2, 3, 6 The FDA drug label specifically states loperamide is contraindicated in pediatric patients less than 2 years of age, with postmarketing cases of cardiac arrest, syncope, and respiratory depression reported. 6

Zinc Supplementation

Recommended for children 6 months to 5 years of age who reside in countries with high zinc deficiency prevalence or show signs of malnutrition, as it reduces diarrhea duration. 2, 3, 4

Probiotics

May be offered to reduce symptom severity and duration in immunocompetent children with infectious diarrhea. 2

Antibiotic Considerations

Antibiotics are not routinely indicated for acute gastroenteritis. 2 Consider antibiotics only when: 2, 4

• Dysentery (bloody diarrhea) is present
• High fever occurs
• Watery diarrhea persists >5 days
• Stool cultures indicate a treatable pathogen

Warning Signs Requiring Immediate Medical Attention

Seek immediate medical care for: 2, 4

• Bloody diarrhea (dysentery)
• Severe dehydration with shock or near-shock
• Intractable vomiting preventing successful oral rehydration
• High stool output (>10 mL/kg/hour)
• Signs of glucose malabsorption (increased stool output with ORS administration)
• Decreased urine output
• Persistent lethargy or irritability

Reassessment and Monitoring

Reassess hydration status after 2-4 hours of rehydration to determine if additional ORS is needed or if the child has improved. 2 Monitor continuously for signs of improvement or deterioration. 2, 3

Prevention

Implement these measures to reduce gastroenteritis incidence: 2, 7

• Hand hygiene after toilet use, diaper changes, before food preparation and eating
• Continue breastfeeding
• Rotavirus vaccination