Latest Guidelines for Acute Gastroenteritis in Pediatrics
Oral rehydration therapy with reduced osmolarity ORS is the cornerstone of treatment for acute gastroenteritis in children, with immediate resumption of age-appropriate diet after rehydration—antimotility drugs are absolutely contraindicated in all children under 18 years of age. 1, 2
Assessment of Dehydration Severity
Clinically evaluate dehydration by examining skin turgor, mucous membranes, mental status, pulse, and capillary refill time 1, 2. Categorize dehydration into three levels:
- Mild (3-5% fluid deficit): Minimal clinical signs, child alert and responsive 1, 2
- Moderate (6-9% fluid deficit): Decreased skin turgor, dry mucous membranes, decreased urine output 1, 2
- Severe (≥10% fluid deficit): Shock or near-shock with altered mental status, poor perfusion, weak pulse 1, 2
Weight loss as a percentage of normal body weight provides the most accurate estimate of dehydration severity 3.
Rehydration Strategy by Severity
Mild Dehydration (3-5%)
Administer 50 mL/kg of ORS over 2-4 hours 1, 2. Start with small volumes (5-10 mL) every 1-2 minutes using a teaspoon, syringe, or medicine dropper, then gradually increase as tolerated 4, 2. A critical pitfall is allowing thirsty children to drink large volumes ad libitum, which worsens vomiting 2.
Moderate Dehydration (6-9%)
Administer 100 mL/kg of ORS over 2-4 hours using the same small-volume technique 1, 2. Nasogastric administration may be considered if the child cannot tolerate oral intake or refuses to drink adequately 1.
Severe Dehydration (≥10%)
This constitutes a medical emergency requiring immediate intravenous rehydration with isotonic fluids (lactated Ringer's or normal saline) in 20 mL/kg boluses until pulse, perfusion, and mental status normalize 1, 2. This may require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) 4. Once mental status normalizes, transition to oral rehydration to complete fluid replacement 2.
Reassess hydration status after 2-4 hours of rehydration therapy 4, 2.
Maintenance Phase and Ongoing Loss Replacement
After achieving rehydration, replace ongoing losses with:
Continue maintenance fluids until diarrhea and vomiting resolve 1, 2.
Nutritional Management
Continue breastfeeding on demand throughout the entire diarrheal episode without interruption 1, 2. For bottle-fed infants, resume full-strength formula immediately upon rehydration 2. Resume age-appropriate usual diet during or immediately after rehydration is completed—do not unnecessarily restrict diet or prolong fasting, which worsens nutritional status and prolongs diarrhea 1, 2.
Recommended foods include starches, cereals, yogurt, fruits, and vegetables; avoid foods high in simple sugars and fats 2.
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 1, 2. Evidence shows increased ORT success rates and reduced need for IV therapy and hospitalization 2.
Antimotility Drugs
Loperamide and other antimotility drugs are absolutely contraindicated in all children <18 years of age due to risk of serious adverse effects including respiratory depression and cardiac complications 1, 2. Avoid at any age when inflammatory diarrhea, fever, or risk of toxic megacolon exists 2.
Probiotics
Probiotic preparations may be offered to reduce symptom severity and duration in immunocompetent children with infectious or antimicrobial-associated diarrhea 1, 2.
Zinc Supplementation
Oral 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 1, 2.
Antibiotic Considerations
Antibiotics are not routinely indicated for acute gastroenteritis 2. Stool cultures are indicated for dysentery (bloody diarrhea) but not needed for typical acute watery diarrhea in immunocompetent patients 4. Consider antibiotics when:
- Dysentery is present 2
- High fever occurs 2
- Watery diarrhea persists >5 days 2
- Stool cultures indicate a treatable pathogen 2
Warning Signs Requiring Immediate Medical Attention
- Severe dehydration with shock or near-shock 2
- Bloody diarrhea (dysentery) 2
- Intractable vomiting preventing successful oral rehydration 2
- High stool output (>10 mL/kg/hour) 2
- Signs of glucose malabsorption (increased stool output with ORS administration) 2
- Decreased urine output, lethargy, or irritability 2
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 soiled items 1, 2. Use gloves and hand hygiene with soap and water or alcohol-based sanitizers in the care of children with diarrhea 1. Appropriate food safety practices prevent cross-contamination of foods or cooking surfaces 1.
Critical Pitfalls to Avoid
- Never use antimotility medications in children under 18 years, which can lead to serious adverse effects 1, 2
- Do not unnecessarily restrict diet or prolong fasting, which worsens nutritional status and prolongs diarrhea 1
- Do not fail to replace ongoing fluid losses during maintenance phase, which leads to recurrent dehydration 1
- Do not allow thirsty children to drink large volumes of ORS ad libitum, which worsens vomiting 2