What are the management and prevention strategies for acute gastroenteritis in pediatric patients?

Acute Gastroenteritis in Children: Management and Prevention

Assessment of Dehydration Severity

The first critical step is to accurately classify dehydration severity using physical examination findings, as this determines all subsequent management decisions. 1

Clinical Classification System

• Mild dehydration (3-5% fluid deficit): Increased thirst, slightly dry mucous membranes, and minimal changes in skin turgor 1
• Moderate dehydration (6-9% fluid deficit): Loss of skin turgor with skin tenting when pinched, dry mucous membranes, sunken eyes, and decreased urine output 1, 2
• 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, 2

Most Reliable Clinical Predictors

The three most reliable predictors of significant dehydration are rapid deep breathing, prolonged skin retraction time, and decreased perfusion—these are more accurate than sunken fontanelle or absent tears. 1, 3

• Capillary refill time, abnormal skin turgor, and abnormal respiratory pattern are the most useful predictors of 5% or more dehydration 3
• Obtain accurate body weight to calculate fluid deficit and track response to therapy 1

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Rehydration Protocol by Severity

Mild Dehydration (3-5% deficit)

Administer 50 mL/kg of oral rehydration solution (ORS) over 2-4 hours using small, frequent volumes. 1, 2

• Use low-osmolarity ORS containing 50-90 mEq/L sodium 1
• Commercial formulations include Pedialyte, CeraLyte, and Enfalac Lytren 4, 1
• Give 50-100 mL of ORS after each diarrheal stool 5

Moderate Dehydration (6-9% deficit)

Administer 100 mL/kg of ORS over 2-4 hours using the same small-volume technique. 1, 2

• If the child cannot tolerate oral intake, consider nasogastric administration of ORS 4, 6
• Nasogastric rehydration is just as effective as intravenous rehydration and should be the first-line alternative when oral intake fails 6

Severe Dehydration (≥10% deficit)

This constitutes a medical emergency requiring immediate intravenous rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize. 4, 1, 2

• Administer isotonic crystalloid boluses per current fluid resuscitation guidelines 4
• Once circulation is restored, transition to ORS for the remaining deficit 2
• Malnourished infants may benefit from smaller-volume, frequent boluses of 10 mL/kg due to reduced cardiac capacity 4

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Replacement of Ongoing Losses

Continuously replace ongoing losses throughout the illness to prevent recurrent dehydration. 1

Specific Replacement Volumes

• For each watery/loose stool: 10 mL/kg of ORS 1, 2
• For each vomiting episode: 2 mL/kg of ORS 1, 2
• Infants <10 kg: 60-120 mL ORS for each diarrheal stool or vomiting episode, up to ~500 mL/day 4
• Children >10 kg: 120-240 mL ORS for each diarrheal stool or vomiting episode, up to ~1 L/day 4

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Nutritional Management During Illness

Continue feeding throughout the illness—do not "rest the bowel" as this provides no benefit and delays nutritional recovery. 1, 2

Breastfed Infants

• Continue nursing on demand without any interruption throughout the entire episode 1, 2, 5
• Breastfeeding should never be stopped during rehydration 4

Formula-Fed Infants

• Resume full-strength formula immediately upon rehydration 1, 5
• Use lactose-free or lactose-reduced formulas initially 1
• Children previously receiving lactose-containing formula can tolerate the same product in most instances 4
• Diluted formula does not confer any benefit 4

Older Children

• Resume age-appropriate normal diet immediately after rehydration 1, 2
• Offer starches, cereals, yogurt, fruits, and vegetables every 3-4 hours 2
• Avoid foods high in simple sugars and fats during acute phase 2

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Pharmacological Considerations

Antiemetics

Ondansetron may be prescribed to prevent vomiting and improve tolerance of oral rehydration solutions in children with moderate dehydration who are vomiting. 7, 3

• Children receiving ondansetron are less likely to vomit, have greater oral intake, and are less likely to require intravenous rehydration 3
• Mean Emergency Department stay is shorter with ondansetron use 3
• Very few serious side effects have been reported 3

Antimicrobials

Antimicrobial treatment should only be considered when dysentery (bloody diarrhea) or high fever is present, watery diarrhea persists >5 days, or stool cultures indicate a specific pathogen requiring treatment. 4, 2

• Obtain stool cultures for dysentery before initiating antibiotics 5
• Antimicrobials are not indicated for routine uncomplicated watery diarrhea 5

Contraindicated Medications

Antimotility drugs (loperamide) are absolutely contraindicated in all children <18 years due to risks of respiratory depression and serious cardiac adverse reactions. 2

• Anti-diarrheal agents should never be used in pediatric gastroenteritis 1

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Monitoring and Reassessment

Reassess hydration status after 2-4 hours of rehydration therapy to determine if treatment goals are being met. 2, 5

Parameters to Monitor

• Skin turgor and mucous membrane moisture 1, 5
• Mental status and perfusion 1
• Stool frequency and consistency 1, 5
• Weight changes throughout therapy 1, 5
• Urine output 7

Transition to Maintenance Phase

• If rehydrated after 2-4 hours, transition to maintenance phase with ongoing loss replacement 2
• Continue supplementing fluids with ORS to prevent further dehydration 8

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Hospitalization Criteria

Admit patients who meet any of the following criteria: 2, 5

• Severe dehydration (≥10% deficit) with signs of shock or altered mental status 2
• Inability to protect airway 5
• Ileus preventing oral intake 5
• Failed oral rehydration therapy despite adequate trial 5
• Intractable vomiting despite antiemetic use 2
• High stool output (>10 mL/kg/hour) persisting despite treatment 2

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Prevention Strategies

Three key interventions reduce the incidence of acute gastroenteritis in young children: 7

• Handwashing: Proper hand hygiene by caregivers and children 7
• Breastfeeding: Exclusive breastfeeding provides protective immunity 7
• Rotavirus vaccination: Significantly reduces rotavirus gastroenteritis incidence 7

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Common Pitfalls to Avoid

Do not rely solely on sunken fontanelle or absent tears for dehydration assessment, as these are less reliable indicators. 2

• Avoid using soft drinks, apple juice, Gatorade, or commercial beverages for rehydration due to inadequate sodium content and excessive osmolality that worsens diarrhea 4, 2
• Do not routinely order laboratory tests for mild-moderate dehydration without specific clinical indications 2
• Laboratory values like BUN or BUN/creatinine ratio show conflicting correlation with dehydration and should not be used as sole determinants 3
• Do not delay feeding after rehydration—early refeeding improves nutritional outcomes 8
• Recognize that fever, ambient temperature, and age can affect capillary refill time accuracy 1

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Key Takeaways for Nursing Practice

Oral rehydration therapy with ORS is as effective as intravenous rehydration for mild-to-moderate dehydration and should be the first-line treatment. 4, 6

• In 17 randomized controlled trials involving 1,811 children, oral rehydration was just as effective as IV rehydration for weight gain and duration of diarrhea, with shorter hospital stays (mean difference -1.2 days) 6
• Oral rehydration therapy fails in only 4% of patients 6
• Most children with mild to moderate dehydration can be managed at home with proper caregiver education 7
• Unnecessary hospitalizations increase risk of nosocomial infection and should be avoided when oral rehydration is feasible 6