How to manage a 5-year-old child with acute gastroenteritis and severe gastritis?

Management of a 5-Year-Old Child with Acute Gastroenteritis and Severe Gastritis

The cornerstone of management is immediate oral rehydration therapy (ORS) using small, frequent volumes (5-10 mL every 1-2 minutes), with assessment of dehydration severity to determine if intravenous fluids are needed, followed by early refeeding with age-appropriate foods once rehydration is achieved. 1

Immediate Assessment of Dehydration Severity

The first critical step is determining the degree of dehydration through specific clinical signs:

• Mild dehydration (3-5% fluid deficit): Slightly dry mucous membranes, normal mental status, normal capillary refill 2, 1
• Moderate dehydration (6-9% fluid deficit): Dry mucous membranes, loss of skin turgor with tenting when pinched, decreased urine output 2, 1
• Severe dehydration (≥10% fluid deficit): Severe lethargy or altered consciousness, prolonged skin tenting (>2 seconds), cool and poorly perfused extremities, decreased capillary refill, rapid deep breathing indicating acidosis 2, 1

The most reliable clinical predictors are prolonged skin retraction time, abnormal capillary refill, and rapid deep breathing. 1, 3 Acute weight change is the most accurate assessment if premorbid weight is known. 1

Rehydration Protocol Based on Severity

For Mild to Moderate Dehydration (Most Likely Scenario)

Administer low-osmolarity ORS at 50-100 mL/kg over 2-4 hours (for a 5-year-old weighing approximately 18 kg, this equals 900-1800 mL total). 2, 1, 4

Critical technique to prevent vomiting:

• Start with 5-10 mL every 1-2 minutes using a spoon or syringe 2, 1
• Gradually increase volume as tolerated without triggering vomiting 1
• This approach successfully rehydrates >90% of children with vomiting and diarrhea without antiemetics 1

Replace ongoing losses continuously:

• Administer 10 mL/kg (approximately 180 mL) ORS for each watery stool 2, 1
• Administer 2 mL/kg (approximately 36 mL) for each vomiting episode 2, 1

Reassess hydration status after 2-4 hours: If still dehydrated, reestimate deficit and restart rehydration. 2, 1

For Severe Dehydration (Medical Emergency)

Initiate intravenous rehydration immediately with isotonic fluids (lactated Ringer's or normal saline) at 20 mL/kg boluses until pulse, perfusion, and mental status normalize. 2, 1, 4 This may require two IV lines or alternate access sites. 2 Once mental status returns to normal, transition to ORS for remaining deficit replacement. 2, 1

Management of Persistent Vomiting

If the child continues vomiting despite proper ORS technique:

Consider ondansetron for children >4 years old to facilitate oral rehydration when vomiting is significant. 1, 4, 5 However, at 5 years old, this child is at the lower age threshold. 6

• Ondansetron reduces vomiting episodes, improves oral intake success, and decreases need for IV hydration by approximately 33% 7, 3
• Weight-based dosing: 0.15 mg/kg of orally dissolving tablet 7
• Important caveat: Ondansetron carries warnings for potentially severe side effects, so use judiciously 8

If vomiting persists despite ondansetron and proper ORS technique, this represents failure of oral rehydration therapy and necessitates IV hydration. 1, 6

Nutritional Management

Resume age-appropriate diet immediately during or after rehydration—do not restrict foods or prolong fasting. 2, 1, 4, 6

Recommended foods:

• Starches: rice, potatoes, noodles, crackers, bananas 6
• Cereals: rice, wheat, oat 6
• Soup, yogurt, vegetables, fresh fruits 6

Foods to avoid:

• High simple sugars: soft drinks, undiluted apple juice, Jell-O, presweetened cereals (these exacerbate diarrhea through osmotic effects) 1, 6
• High-fat foods (may delay gastric empting and worsen tolerance) 6
• Caffeinated beverages: coffee, tea, caffeinated sodas, energy drinks (stimulate intestinal motility and worsen diarrhea) 1

Common pitfall: The "BRAT diet" (bananas, rice, applesauce, toast) should not be used exclusively for prolonged periods as it provides inadequate energy and protein. 2, 6

Addressing the "Severe Gastritis" Component

Since this child has both gastroenteritis and gastritis:

Consider a 2-4 week trial of extensively hydrolyzed protein or amino acid-based formula if formula-fed, as approximately 25% of children with gastritis symptoms have underlying milk protein sensitivity. 6 If symptoms improve, milk protein allergy is the likely underlying cause. 6

Proton pump inhibitors (PPIs) or H2 receptor antagonists may be considered if gastritis symptoms persist despite dietary modifications. 6

• PPIs should be dosed approximately 30 minutes before meals for optimal effectiveness 6, 9
• For a 5-year-old weighing ≥20 kg: omeprazole 20 mg once daily 9
• Important warning: Acid suppression increases risk of community-acquired pneumonia, gastroenteritis, and candidemia in young children 6
• H2 antagonists are effective but can cause tachyphylaxis within 6 weeks with long-term use 6

Do not use chronic antacid therapy due to associated risks in children. 6

Medications to Absolutely Avoid

Never administer antimotility agents (loperamide) in children under 18 years with acute diarrhea—these can cause serious side effects including ileus, drowsiness, and potentially fatal abdominal distention. 2, 1, 6

Avoid adsorbents (kaolin-pectin), antisecretory drugs, or toxin binders—they do not reduce diarrhea volume or duration and may interfere with appropriate therapy. 2, 1, 6

When to Consider Antimicrobial Therapy

Antimicrobials have limited usefulness since viral agents predominate in gastroenteritis. 2, 1, 6 Consider antimicrobial therapy only if:

• Bloody diarrhea is present (suggests Salmonella, Shigella, or enterohemorrhagic E. coli) 2, 1
• White blood cells present on methylene blue stain of stool 2
• Recent antibiotic use (suspect Clostridium difficile) 2
• Exposure to day care centers where Giardia or Shigella is prevalent 2, 6
• Immunodeficiency 2, 6

Perform stool cultures if bloody diarrhea or inflammatory markers are present. 2, 6

Red Flags Requiring Immediate Medical Attention or Hospitalization

Admit to hospital if:

• Severe dehydration (≥10% fluid deficit) or signs of shock 2, 1, 6
• Failure of oral rehydration therapy despite proper technique and ondansetron 1, 6
• Altered mental status, severe lethargy, or decreased consciousness 1, 6
• Absent bowel sounds on auscultation (absolute contraindication to oral fluids) 1
• Persistent vomiting preventing adequate oral intake 6
• Ileus 6

Seek urgent evaluation if:

• Bloody stools with fever and systemic toxicity 1
• Stool output >10 mL/kg/hour (associated with lower ORT success rates) 1
• Dramatic increase in stool output when ORS is administered with reducing substances in stool (suggests glucose malabsorption—approximately 1% incidence) 1

Monitoring During Treatment

• Reassess hydration status every 2-4 hours during rehydration phase by checking capillary refill, skin turgor, mental status, mucous membrane moisture 1
• Monitor vital signs including heart rate, blood pressure, respiratory rate 1
• Track urine output as indicator of adequate rehydration 1, 4
• Daily weights to track rehydration progress 1

Infection Control Measures

• Practice proper hand hygiene after using toilet, before eating, before and after food preparation, after handling soiled items 1, 4
• Use gloves and gowns when caring for the child with diarrhea 1, 4
• Clean and disinfect contaminated surfaces promptly 1, 4
• Separate ill child from well siblings until at least 2 days after symptom resolution 1, 4

Disposition Planning

Discharge home when:

• Tolerating oral intake adequately 1
• Producing urine 1
• Clinically rehydrated 1
• Caregiver demonstrates competence with ORS administration technique 1

Provide caregivers with:

• ORS supply to keep at home for future episodes 1
• Clear instructions on small-volume, frequent administration technique 1
• Warning signs requiring return to medical care 1