What are the essential points to cover when admitting pediatric patients with acute gastroenteritis?

Essential Points for Admitting Conference: Pediatric Acute Gastroenteritis

Initial Assessment and Hydration Status Evaluation

The most critical first step is accurate assessment of dehydration severity using specific clinical markers, as this determines all subsequent management decisions. 1

Dehydration Classification

• Mild dehydration (3-5% fluid deficit): Increased thirst and slightly dry mucous membranes 1
• Moderate dehydration (6-9% fluid deficit): Loss of skin turgor, skin tenting when pinched, and dry mucous membranes 1
• Severe dehydration (≥10% fluid deficit): Severe lethargy or altered consciousness, prolonged skin tenting >2 seconds, cool and poorly perfused extremities, decreased capillary refill, and rapid deep breathing indicating acidosis 1

Key Physical Examination Findings

• Obtain accurate body weight immediately and compare to premorbid weight if available, as acute weight change is the most accurate assessment of fluid deficit 1
• Auscultate for bowel sounds before initiating oral therapy—absent bowel sounds are an absolute contraindication to oral rehydration 1
• Assess capillary refill time and skin retraction time, as these are more reliably predictive of significant dehydration than sunken fontanelle or absence of tears 2
• Visual examination of stool to confirm abnormal consistency and determine presence of blood or mucus 1

Differential Diagnosis Considerations

Fever, vomiting, and loose stools can represent many non-gastrointestinal illnesses that must be ruled out before confirming gastroenteritis as the diagnosis. 1

Red Flag Conditions to Exclude

• Meningitis, bacterial sepsis, pneumonia, otitis media, and urinary tract infection can all present with gastroenteritis-like symptoms in infants and children 1
• Metabolic disorders, congestive heart failure, toxic ingestions, or trauma can present with vomiting alone 1
• Surgical abdomen: Severe abdominal pain disproportionate to examination findings requires immediate surgical consultation 2

Admission Criteria and Risk Stratification

Hospitalization is indicated for severe dehydration (≥10% deficit), failure of oral rehydration therapy, altered mental status, intractable vomiting, or significant comorbidities. 2

High-Risk Populations Requiring Lower Threshold for Admission

• Infants <3 months due to higher risk of severe dehydration and complications 2
• Immunocompromised patients (on immunosuppressive therapy, HIV-infected, transplant recipients, malignancy) due to risk of severe or prolonged illness 2
• Patients with bloody diarrhea, fever, and systemic toxicity suggesting dysentery from Salmonella, Shigella, or enterohemorrhagic E. coli, requiring monitoring for hemolytic uremic syndrome 2

Specific Clinical Presentations Mandating Admission

• Persistent tachycardia or hypotension despite initial fluid resuscitation 2
• Absent bowel sounds indicating ileus 2
• Persistent vomiting despite ondansetron trial preventing adequate oral intake 2

Rehydration Strategy

Oral rehydration solution (ORS) is first-line treatment for mild to moderate dehydration and successfully rehydrates >90% of children. 2

Oral Rehydration Protocol

• For mild dehydration (3-5% deficit): Administer low-osmolarity ORS at 50 mL/kg over 2-4 hours 2, 3
• For moderate dehydration (6-9% deficit): Administer ORS at 100 mL/kg over 2-4 hours 2, 3
• Administration technique: Use small, frequent volumes (5-10 mL every 1-2 minutes via spoon or syringe) to prevent triggering more vomiting, gradually increasing as tolerated 2
• Replace ongoing losses: 10 mL/kg ORS for each watery stool and 2 mL/kg for each vomiting episode 2
• Reassess hydration status after 2-4 hours; if still dehydrated, reestimate deficit and restart rehydration 2

Intravenous Rehydration

• For severe dehydration (≥10% deficit) or shock: Immediate IV boluses of 20 mL/kg lactated Ringer's or normal saline over 30 minutes until pulse, perfusion, and mental status normalize 2, 3
• Transition to ORS for remaining deficit once patient improves and consciousness returns 2, 3

Nasogastric Rehydration

• Consider nasogastric ORS administration for patients unable to tolerate oral intake or refusing to drink adequately 2, 3

Pharmacological Management

Antiemetic Therapy

• Ondansetron may be administered to children >4 years to facilitate oral rehydration when vomiting is significant 2, 3
• Dose: 0.15 mg/kg orally dissolving tablet or 8 mg sublingual every 4-6 hours 3, 4
• Ondansetron increases success rate of oral rehydration and minimizes need for IV therapy and hospitalization 2

Medications That Are Absolutely Contraindicated

• Loperamide is contraindicated in all children <18 years with acute diarrhea due to risk of ileus, drowsiness, and reported deaths 1, 2, 5
• Never use loperamide in bloody diarrhea regardless of age 2, 3, 5
• Avoid adsorbents (kaolin-pectin), antisecretory drugs, and toxin binders as they do not reduce diarrhea volume or duration and shift focus away from appropriate fluid and nutritional therapy 1, 2

Nutritional Management

Resume age-appropriate diet immediately during or after rehydration rather than fasting or restrictive diets. 2, 3

Feeding Guidelines

• Continue breastfeeding throughout the illness in infants 2, 3
• Early refeeding reduces severity and duration of illness 2, 4
• Offer starches, cereals, soup, yogurt, vegetables, and fresh fruits 4
• Avoid foods high in simple sugars (soft drinks, undiluted apple juice) as they can exacerbate diarrhea through osmotic effects 2
• Avoid high-fat foods and caffeinated beverages during active gastroenteritis 2

Diagnostic Workup

When to Obtain Stool Studies

• Bloody diarrhea or white blood cells on methylene blue stain suggests bacterial agent causing invasive mucosal damage and indicates stool cultures should be performed 1, 3
• Recent antibiotic use (suspect Clostridium difficile) 1
• Exposure to children in day care centers where Giardia or Shigella is prevalent 1
• Recent foreign travel 1
• Immunodeficiency, in which infectious causes should be diligently evaluated 1
• Conversely, watery diarrhea and vomiting in a child <2 years most likely represents viral gastroenteritis and does not require antimicrobial therapy or stool studies 1

Laboratory Studies

• Serum electrolytes if clinical signs suggest abnormal sodium or potassium 3
• Complete blood count to assess for anemia from blood loss and leukocytosis suggesting bacterial infection 3
• Blood culture if sepsis is suspected or patient appears toxic 2, 3
• Urinalysis with microscopy and urine culture if urinary symptoms present to rule out UTI/pyelonephritis 2

Antimicrobial Therapy Considerations

Antimicrobial agents have limited usefulness since viral agents are the predominant cause; reserve antibiotics for specific situations only. 2

Indications for Antimicrobial Therapy

• Infants <3-6 months with suspected bacterial AGE 6
• Patients with underlying disease or signs of sepsis 6
• Institutionalized patients or settings with risk of dissemination 6
• Bloody diarrhea with fever and systemic toxicity (await stool culture results unless patient appears toxic) 3

Important Caveat

• For non-Typhi Salmonella and STEC infections, targeted antibiotherapy is restricted to patients at risk of systemic infection or with prolonged diarrhea 6

Monitoring Parameters During Admission

Monitor vital signs every 2-4 hours including capillary refill, skin turgor, mental status, and mucous membrane moisture to assess for worsening dehydration. 2

Specific Monitoring

• Daily weights to track rehydration progress 2
• Urine output as indicator of adequate hydration 2
• Stool output: Output >10 mL/kg/hour is associated with lower success rates of oral rehydration, though ORT should still be attempted 2
• Signs of glucose malabsorption (approximately 1% incidence): Reducing substances in stool with dramatic increase in stool output when ORS is administered 2

Infection Control Measures

Implement strict infection control to prevent nosocomial transmission. 2

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

Discharge Planning and Family Education

Plan discharge when patient is tolerating oral intake, producing urine, clinically rehydrated, and afebrile for 24 hours. 2

Discharge Instructions

• Provide ORS supply with clear instructions on small-volume, frequent administration technique (5-10 mL every 1-2 minutes) 2, 3
• Resume age-appropriate diet immediately 2, 3
• Instruct parents to return immediately if: Child becomes irritable or lethargic, decreased urine output develops, intractable vomiting occurs, fever persists beyond 3-4 days, or increased bleeding or abdominal distension 3
• Follow up with primary care within 24-48 hours if symptoms persist 3

Common Pitfalls to Avoid

• Do not delay rehydration while awaiting diagnostic testing—initiate rehydration promptly 2, 3
• Do not use sports drinks or apple juice as primary rehydration solutions for moderate to severe dehydration; low-osmolarity ORS formulations are preferred 2, 3
• Do not unnecessarily restrict diet during or after rehydration 2, 3
• Do not administer antimotility drugs to any child or in cases of bloody diarrhea 2, 3
• Do not underestimate dehydration in infants, who are more prone to dehydration due to higher body surface-to-weight ratio, higher metabolic rate, and dependence on caregivers for fluid intake 1