What key questions should pediatric resident trainees ask when evaluating a pediatric patient with gastroenteritis?

Key Questions for Pediatric Resident Trainees Evaluating Gastroenteritis

When teaching pediatric residents about gastroenteritis, focus your questioning on three critical domains: clinical assessment of dehydration severity, identification of warning signs requiring urgent intervention, and appropriate epidemiological risk stratification.

Clinical History Questions

Symptom Characterization

• When did symptoms begin and how did they start (abrupt vs. gradual onset)? 1
• What is the stool frequency and volume (number of bowel movements per day, relative quantity produced)? 1
• What are the stool characteristics (watery, bloody, mucous, purulent, greasy)? 1
• Is there associated vomiting, and if so, what is the frequency and character (bilious vs. non-bilious)? 1
• Is there fever present, and what is the temperature pattern? 1

Dehydration Assessment

• What is the child's fluid intake and urine output (decreased urination is a key sign of volume depletion)? 1, 2
• Is the child thirsty (increased thirst indicates mild dehydration)? 1
• Has there been any weight loss (acute weight change is the most accurate assessment of fluid status)? 1
• Are there signs of volume depletion including lethargy, decreased activity level, or altered mental status? 1

Critical Warning Signs to Identify

• Is the vomiting bilious (suggests possible malrotation or duodenal obstruction requiring immediate imaging)? 1
• Is the vomiting consistently forceful (consider pyloric stenosis in young infants)? 1
• Is there blood in the stool or hematemesis (indicates inflammatory or invasive pathogen)? 1
• Are there signs of severe dehydration including prolonged capillary refill (>2 seconds), cool extremities, decreased perfusion, or rapid deep breathing suggesting acidosis? 1

Physical Examination Questions

Hydration Status Assessment

• What is the child's current weight (must be obtained for accurate assessment)? 1
• What are the mucous membranes like (slightly dry in mild dehydration, very dry in moderate dehydration)? 1, 2
• What is the skin turgor (tenting and prolonged skin retraction time >2 seconds indicates moderate to severe dehydration)? 1, 2
• What is the capillary refill time (correlates well with fluid deficit; abnormal capillary refill is one of the three most useful predictors of ≥5% dehydration)? 1, 3
• What is the respiratory pattern (rapid, deep breathing suggests acidosis and is a reliable predictor of dehydration)? 1, 3
• Are there orthostatic vital sign changes (tachycardia, blood pressure changes)? 1

Excluding Other Serious Diagnoses

• Are bowel sounds present and normal (must auscultate before initiating oral therapy; absent or hypoactive sounds suggest ileus or obstruction)? 1, 4
• Is there abdominal tenderness or distension (suggests possible intra-abdominal pathology requiring imaging)? 1, 4
• Is there hepatosplenomegaly (warning sign for alternative diagnosis)? 1
• Are there signs of meningeal irritation (gastroenteritis symptoms can be the initial presentation of meningitis, sepsis, or other serious infections)? 1

Epidemiological Risk Factor Questions

Exposure History

• Has the child traveled to developing areas recently (increases risk of bacterial and parasitic pathogens)? 1
• Does the child attend daycare or have daycare contacts (common source of rotavirus and other enteric infections)? 1
• Has the child consumed unsafe foods including raw meats, eggs, shellfish, unpasteurized milk or juices? 1
• Has the child had contact with animals (farm visits, petting zoos, reptiles, or pets with diarrhea)? 1
• Are other household members or contacts ill (suggests common source outbreak)? 1

Host Risk Factors

• What is the child's age (infants <12 months are at highest risk for dehydration due to higher body surface-to-weight ratio and higher metabolic rate)? 1
• Is the child immunocompromised or on immunosuppressive medications (including those with AIDS, recent chemotherapy, or chronic steroid use)? 1
• What medications has the child taken recently (antibiotics increase risk of C. difficile; antacids alter gastric pH)? 1, 5
• Does the child have underlying medical conditions (prior gastrectomy, chronic diseases predisposing to infection)? 1

Laboratory and Testing Decision Questions

When to Order Tests

• Are there signs of severe dehydration or shock (serum electrolytes indicated to assess for abnormal sodium or potassium)? 1
• Is there bloody diarrhea with fever (stool cultures indicated for inflammatory pathogens like Shigella, Salmonella, Campylobacter)? 1
• Has the illness persisted >7 days (microbial studies warranted for prolonged symptoms)? 5
• Has the child recently received antibiotics (test for C. difficile)? 5
• Is the child immunocompromised (broader testing indicated)? 1

What NOT to Order Routinely

• Avoid routine stool cultures in mild viral gastroenteritis (not needed when viral etiology is likely and symptoms are mild)? 2
• Do not routinely order upper GI series to diagnose gastroenteritis (too brief to rule out pathologic reflux and high false-positive rate)? 1

Management Decision Questions

Rehydration Strategy

• Can the child tolerate oral fluids (oral rehydration therapy is as effective as IV for mild-moderate dehydration and should be first-line)? 1, 3, 2
• Is vomiting preventing oral intake (consider ondansetron to improve tolerance of oral rehydration)? 3, 2
• Are there signs of severe dehydration or shock (≥10% fluid deficit requires hospitalization and IV fluids)? 1, 2

Medication Considerations

• Is there bloody diarrhea (antimotility agents like loperamide are contraindicated due to risk of ileus and death)? 1
• Is antibiotic therapy indicated (only for specific bacterial pathogens like Shigella, severe Campylobacter, or C. difficile)? 1
• Should probiotics be considered (evidence supports Lactobacillus rhamnosus GG, L. reuteri, or Saccharomyces boulardii for reducing duration and severity)? 6

Common Pitfalls to Avoid

Never rely solely on sunken fontanelle or absence of tears to assess dehydration—these are less reliable than prolonged capillary refill, abnormal skin turgor, and abnormal respiratory pattern. 1, 3

Do not prescribe antimotility agents (loperamide) in children with bloody diarrhea or suspected Shiga toxin-producing E. coli—this can cause severe complications including ileus and death. 1

Do not assume all vomiting and diarrhea is simple gastroenteritis—always consider serious alternative diagnoses like meningitis, sepsis, pneumonia, urinary tract infection, appendicitis, and metabolic disorders, especially in young infants. 1

Do not withhold pain medication while awaiting diagnosis—pain control facilitates better examination without affecting diagnostic accuracy. 4

Recognize that young children (<10 years) may present with atypical features—including less architectural distortion, patchy inflammation, and rectal sparing—which should not exclude the diagnosis. 1