What are the essential points to discuss when admitting pediatric patients with acute gastroenteritis and varying degrees of dehydration?

Essential Points for Pediatric Acute Gastroenteritis Admission Conference

Dehydration Assessment and Classification

Begin by establishing the precise degree of dehydration using clinical examination, as this determines all subsequent management decisions. 1

Clinical Signs by Severity

Mild dehydration (3-5% fluid deficit):

• Slightly dry mucous membranes with increased thirst 2
• Normal mental status and skin turgor 3
• No decrease in urine output reported by parents 4

Moderate dehydration (6-9% fluid deficit):

• Dry mucous membranes and sunken eyes 3
• Loss of skin turgor with skin tenting when pinched 1
• Reduced urine output 3

Severe dehydration (≥10% fluid deficit):

• Severe lethargy or altered consciousness 2
• Prolonged skin tenting (>2 seconds) 2
• Cool and poorly perfused extremities with decreased capillary refill 2
• Rapid, deep breathing indicating acidosis 1

Most Reliable Clinical Predictors

The three most reliable signs are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern—these are more predictive than sunken fontanelle or absent tears. 1, 5

Laboratory Considerations

• Serum electrolytes are rarely needed but should be obtained when clinical signs suggest abnormal sodium or potassium concentrations 1
• Serum bicarbonate ≤13 mEq/L predicts failure of oral rehydration and need for hospitalization 6
• Stool cultures are indicated only for dysentery (bloody diarrhea), not routine watery diarrhea 1, 3
• Obtain accurate body weight to calculate fluid deficit and monitor response 1, 7

Rehydration Protocol by Severity

Mild Dehydration (3-5% deficit)

• Administer 50 mL/kg of ORS containing 50-90 mEq/L sodium over 2-4 hours 1, 2
• Start with small volumes (one teaspoon) using teaspoon, syringe, or medicine dropper, then gradually increase as tolerated 1
• Reassess hydration status after 2-4 hours 1

Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours using the same small-volume technique 1, 2
• Consider nasogastric administration if oral intake is not tolerated 7
• Reassess after 2-4 hours; if still dehydrated, reestimate deficit and restart rehydration 1

Severe Dehydration (≥10% deficit)

This constitutes a medical emergency requiring immediate IV rehydration. 1, 2

• Administer 20 mL/kg boluses of Ringer's lactate or normal saline IV immediately 1, 7
• Continue boluses until pulse, perfusion, and mental status normalize 1
• May require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) 1
• Once consciousness returns to normal, transition to oral rehydration for remaining deficit 1, 7

Ongoing Loss Replacement

During both rehydration and maintenance phases, continuously replace ongoing losses. 1

• Administer 10 mL/kg of ORS for each watery or loose stool 1, 7
• Administer 2 mL/kg of ORS for each vomiting episode 1, 7
• If losses can be measured accurately, give 1 mL of ORS for each gram of diarrheal stool 1, 3

Nutritional Management

Do not "rest the bowel"—continue feeding throughout illness. 2

Breastfed Infants

• Continue nursing on demand without any interruption 1, 2, 3

Bottle-fed Infants

• Resume full-strength, lactose-free or lactose-reduced formula immediately upon rehydration 1, 2
• If lactose-free formulas unavailable, use full-strength lactose-containing formula under supervision 1
• True lactose intolerance is indicated by severe diarrhea upon reintroduction of lactose, not just low stool pH (<6.0) or reducing substances (>0.5%) 1

Older Children

• Resume age-appropriate normal diet immediately after rehydration 3
• Recommended foods: starches, cereals, yogurt, fruits, and vegetables 1, 7
• Avoid foods high in simple sugars and fats 1, 7

Pharmacological Considerations

Antiemetics

• Ondansetron (oral or IV) decreases vomiting, improves oral rehydration success, and reduces need for IV hydration and hospitalization 5
• Consider ondansetron if vomiting prevents oral rehydration tolerance 2

Antibiotics

• NOT indicated for typical acute watery diarrhea 3
• Consider only when: dysentery or high fever present, watery diarrhea lasts >5 days, or stool cultures indicate specific pathogen requiring treatment 1

Contraindicated Medications

• Loperamide is absolutely contraindicated in all children <18 years due to risks of respiratory depression and serious cardiac adverse reactions 7
• Avoid cola drinks or soft drinks for rehydration—they contain inadequate sodium and excessive osmolality that worsens diarrhea 7

Admission Criteria

Hospitalize patients who:

• Have severe dehydration (≥10% deficit) or signs of shock 1, 4
• Do not respond to oral rehydration therapy plus antiemetic 4
• Have serum bicarbonate ≤13 mEq/L (predicts oral rehydration failure) 6
• Cannot tolerate oral fluids after rapid IV rehydration 6
• Have intractable vomiting despite ondansetron 7
• Have high stool output (>10 mL/kg/hour) persisting 7

Monitoring Parameters

• Reassess hydration status after 2-4 hours of rehydration therapy 1, 7
• Monitor skin turgor, mucous membrane moisture, and mental status regularly 2
• Track stool frequency and consistency 2
• Measure weight changes throughout therapy 2

Discharge Instructions for Outpatients

Instruct caregivers to return immediately if:

• Many watery stools continue 7
• Fever develops 7
• Increased thirst or sunken eyes appear 7
• Condition worsens 7
• Bloody diarrhea develops 7
• Intractable vomiting occurs 7
• High stool output persists 7

Common Pitfalls to Avoid

• Do not delay feeding or recommend "bowel rest"—early feeding is safer and more effective 3
• Do not rely solely on sunken fontanelle or absent tears for dehydration assessment 1
• Do not routinely order laboratory tests for mild-moderate dehydration without specific clinical indications 1
• Do not use hypotonic solutions for initial rehydration in severe dehydration 7
• Do not prescribe antimotility agents in children 7