Acute Gastroenteritis in Children: Nursing Education Presentation
Definition and Epidemiology
Acute gastroenteritis is a diarrheal illness of rapid onset with or without vomiting, fever, or abdominal pain, typically lasting less than 7 days. 1
- Nearly every child experiences gastroenteritis by age 5 years, resulting in 179 million outpatient visits and approximately 500,000 hospitalizations annually in the United States 1
- Viruses cause the majority of cases, with norovirus (27% in hospitalized children) and rotavirus (21%) being the most common pathogens 1
- Gastroenteritis is the second most common non-traumatic cause of emergency hospitalization in children aged 1-5 years 1
Clinical Presentation
The illness typically begins with acute onset of fever and vomiting, followed 24-48 hours later by watery diarrhea. 1
- Vomiting occurs in 80-90% of infected children and usually lasts less than 24 hours 1
- Diarrhea typically consists of 10-20 bowel movements per day 1
- Symptoms generally persist 3-8 days 1
Critical caveat: Fever, vomiting, and loose stools can indicate many non-gastrointestinal illnesses including meningitis, bacterial sepsis, pneumonia, otitis media, and urinary tract infection—always perform a thorough assessment to rule out these conditions. 1
Assessment of Dehydration Severity
Physical examination is the best way to evaluate hydration status and should guide all treatment decisions. 2
Mild Dehydration (3-5% fluid deficit) 3
- Slightly decreased skin turgor
- Moist mucous membranes
- Normal mental status
- Normal vital signs
Moderate Dehydration (6-9% fluid deficit) 3
- Loss of skin turgor with tenting when pinched 4
- Dry mucous membranes 4
- Slightly decreased mental alertness
- Increased heart rate
Severe Dehydration (≥10% fluid deficit) 3
- This constitutes a medical emergency requiring immediate intervention 4
- Severe lethargy or altered consciousness 4
- Prolonged skin tenting (>2 seconds) 4
- Cool and poorly perfused extremities with decreased capillary refill 4
- Rapid, deep breathing indicating metabolic acidosis 4
Most reliable clinical predictors: Rapid deep breathing and prolonged skin retraction time are more reliably predictive than sunken fontanelle or absence of tears. 4 Acute weight change is the most accurate assessment if premorbid weight is known. 4
Treatment Algorithm
Step 1: Initial Assessment 1
- Obtain accurate body weight 1
- Auscultate for adequate bowel sounds before initiating oral therapy 1
- Categorize dehydration severity using physical examination findings 3
Step 2: Rehydration Based on Severity
No Dehydration 3
- Skip rehydration phase and begin maintenance therapy immediately 3
- Continue normal diet 3
- Replace ongoing losses with oral rehydration solution (ORS) 3
Mild Dehydration (3-5% deficit) 3
- Administer 50 mL/kg of ORS over 2-4 hours 5
- Use small volumes initially (5 mL every 1-2 minutes) with a spoon, syringe, or medicine dropper 3
- Gradually increase amount as tolerated 3
- Reassess hydration status after 2-4 hours 3
Moderate Dehydration (6-9% deficit) 3
- Administer 100 mL/kg of ORS over 2-4 hours 3, 5
- Use same small-volume technique as mild dehydration 3
- Reassess after 2-4 hours and reestimate deficit if still dehydrated 3
Severe Dehydration (≥10% deficit) 3
- Begin immediate intravenous rehydration—this is a medical emergency 3
- Administer 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 3
- May require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) 3
- Transition to oral rehydration once consciousness returns to complete remaining deficit 3
Step 3: Replace Ongoing Losses 3
- Administer 10 mL/kg of ORS for each watery or loose stool 3
- Administer 2 mL/kg of ORS for each episode of vomiting 3
- Continue replacement throughout both rehydration and maintenance phases 3
Critical Technique for Vomiting Children
A common and dangerous mistake is allowing a thirsty child to drink large volumes of ORS ad libitum, which worsens vomiting. 5
- Start with 5 mL every 1-2 minutes using a spoon or syringe 4, 5
- Gradually increase volume as tolerated without triggering vomiting 4
- This small-volume, frequent approach successfully rehydrates >90% of children with vomiting and diarrhea without antiemetic medication 4
Nutritional Management
Early refeeding is essential—do not withhold food or use restrictive diets. 4
Infants 3, 5
- Continue breastfeeding on demand throughout the entire diarrheal episode without interruption 3, 5
- Resume full-strength formula immediately upon rehydration 3, 5
- Lactose-free or lactose-reduced formulas are preferred but not mandatory 3
- True lactose intolerance (indicated by worsening diarrhea with lactose reintroduction) occurs rarely and requires temporary lactose reduction 3
Older Children 3, 5
- Resume age-appropriate usual diet during or immediately after rehydration 3, 5
- Recommended foods: starches, cereals, yogurt, fruits, and vegetables 3, 5
- Avoid foods high in simple sugars (soft drinks, undiluted apple juice) and high-fat foods 3, 4, 5
- Avoid caffeinated beverages as they worsen diarrhea through stimulation of intestinal motility 4
Pharmacological Management
What NOT to Use
Antimotility agents (loperamide) are absolutely contraindicated in all children under 18 years of age. 4, 5 Serious adverse events including ileus and deaths have been reported. 5
Antibiotics are not routinely indicated as viral agents cause the majority of cases. 3, 4
Adsorbents, antisecretory drugs, and toxin binders should be avoided as they do not reduce diarrhea volume or duration. 4, 5
Metoclopramide should never be used in gastroenteritis—it is counterproductive as it accelerates gastrointestinal transit. 4
What MAY Be Used
Ondansetron may be given to children >4 years of age to facilitate oral rehydration when vomiting is significant, but only after adequate hydration is achieved. 4, 5 Evidence shows increased oral rehydration success rates and reduced need for IV therapy. 5
Probiotics may reduce symptom severity and duration in immunocompetent children. 4, 5
Zinc supplementation reduces diarrhea duration in children 6 months to 5 years of age in areas with high zinc deficiency prevalence or in children with signs of malnutrition. 4, 5
When to Consider Antibiotics 3, 4
- Dysentery (bloody diarrhea) with fever and systemic toxicity
- High fever present
- Watery diarrhea lasting >5 days
- Stool cultures indicate a treatable pathogen
Red Flags Requiring Immediate Medical Attention
Severe dehydration signs (≥10% fluid deficit): 4
- Severe lethargy or altered consciousness
- Prolonged skin tenting (>2 seconds)
- Cool extremities with poor perfusion
- Rapid, deep breathing
Other critical red flags: 4, 5
- Bloody stools with fever and systemic toxicity (may indicate Salmonella, Shigella, or enterohemorrhagic E. coli)
- Persistent vomiting despite small-volume ORS administration
- Absent bowel sounds (absolute contraindication to oral rehydration)
- Failure to improve after initial 2-4 hour rehydration attempt
Warning signs for moderate concern: 4, 5
- Decreased urine output
- Lethargy or irritability
- Stool output >10 mL/kg/hour (associated with lower oral rehydration success rates)
Hospitalization Criteria
- Severe dehydration (≥10% fluid deficit)
- Signs of shock
- Failure of oral rehydration therapy
- Altered mental status
- Intractable vomiting despite antiemetics
- Significant comorbidities
Lower threshold for admission: 4, 1
- Infants <3 months (higher risk of severe dehydration and complications)
- Immunocompromised patients (risk of severe or prolonged illness)
Infection Control Measures
Hand hygiene is the most critical prevention measure. 4, 1, 5
When to perform hand hygiene: 4, 1, 5
- After using toilet or changing diapers
- Before and after food preparation
- Before eating
- After handling soiled items or garbage
- Use gloves and gowns when caring for children with diarrhea
- Clean and disinfect contaminated surfaces promptly
- Separate ill children from well children until at least 2 days after symptom resolution
Monitoring During Treatment
Reassess hydration status after 2-4 hours of rehydration therapy. 3, 5
Monitor every 2-4 hours: 4
- Vital signs
- Capillary refill
- Skin turgor
- Mental status
- Mucous membrane moisture
Track daily weights to monitor rehydration progress. 4
Plan discharge when: 4
- Tolerating oral intake
- Producing urine
- Clinically rehydrated
- Afebrile for 24 hours (if bacterial infection confirmed)
Prevention Strategies
Rotavirus vaccination is the most effective prevention measure. 1 Two FDA-licensed vaccines are recommended by the Advisory Committee on Immunization Practices: RotaTeq (RV5) and Rotarix (RV1). 1
Breastfeeding reduces the incidence of acute gastroenteritis in young children. 2
Proper hand hygiene and infection control measures prevent transmission. 4, 1, 2
Key Nursing Takeaways
Oral rehydration solution is the cornerstone of treatment for mild to moderate dehydration—it is as effective as IV rehydration for preventing hospitalization. 4, 1, 2
The small-volume, frequent technique is critical for success in vomiting children—5 mL every 1-2 minutes prevents triggering more vomiting. 4, 5
Early refeeding improves outcomes—do not withhold food or use restrictive diets. 4, 5
Never use antimotility agents in children—they are contraindicated and dangerous. 4, 5
Physical examination is the best assessment tool—learn to recognize the signs of severe dehydration that require immediate intervention. 4, 1, 2