Management of Acute Gastroenteritis in Children According to IAP Guidelines
Oral rehydration therapy with reduced osmolarity ORS is the cornerstone of management for mild to moderate dehydration, with immediate resumption of age-appropriate feeding after rehydration and strict avoidance of antimotility agents in all children. 1, 2
Assessment of Dehydration Severity
The first critical step is accurate clinical assessment of dehydration status, as this determines all subsequent management decisions 1:
Mild Dehydration (3-5% fluid deficit):
Moderate Dehydration (6-9% fluid deficit):
- Loss of skin turgor with skin tenting when pinched 3, 1
- Dry mucous membranes 3
- Decreased urine output 1
Severe Dehydration (≥10% fluid deficit):
- Severe lethargy or altered consciousness 3, 1
- Prolonged skin tenting (>2 seconds) 3, 1
- Cool, poorly perfused extremities with decreased capillary refill 3, 1
- Rapid, deep breathing indicating acidosis 3, 1
Key Clinical Pearls:
- Capillary refill time is the most reliable predictor of dehydration 1
- Rapid, deep breathing, prolonged skin retraction time, and decreased perfusion are more reliable than sunken fontanelle or absent tears 3, 1
- Obtain accurate body weight to establish baseline 3, 1
Rehydration Protocol by Severity
Severe Dehydration (≥10% deficit)
This is a medical emergency requiring immediate IV intervention: 1, 2
- Administer 20 mL/kg boluses of Ringer's lactate or normal saline IV immediately 1, 2
- Repeat boluses until pulse, perfusion, and mental status normalize 1
- Monitor continuously for improvement in vital signs 1
- Once circulation is restored, transition to ORS for the remaining fluid deficit 1
Moderate Dehydration (6-9% deficit)
- Administer 100 mL/kg of reduced osmolarity ORS (containing 50-90 mEq/L sodium) over 2-4 hours 1, 2
- If oral intake is not tolerated, consider nasogastric administration 1
- Reassess hydration status after 2-4 hours 1, 2
Mild Dehydration (3-5% deficit)
Technique for Vomiting Patients
Vomiting should not prevent oral rehydration: 2
- Give 5-10 mL of ORS every 1-2 minutes using a teaspoon, syringe, or medicine dropper 2
- This small-volume, frequent approach prevents perpetuating vomiting 2
- Consider ondansetron if vomiting prevents adequate oral intake to improve ORS tolerance 2, 4, 5, 6
Ongoing Loss Replacement
After initial rehydration, replace continuing losses: 1, 2
- Give 10 mL/kg of ORS for each watery or loose stool 1, 2
- Give 2 mL/kg of ORS for each vomiting episode 1, 2
Nutritional Management
Early feeding is critical and improves outcomes: 1, 2
For Breastfed Infants:
For Formula-Fed Infants:
- Resume full-strength, lactose-free or lactose-reduced formula immediately upon rehydration 1, 7
- True lactose intolerance is indicated only by severe diarrhea upon reintroduction, not just low stool pH or reducing substances 1
For Older Children:
- Resume age-appropriate diet immediately upon rehydration 1, 2, 7
- Include starches, cereals, yogurt, fruits, and vegetables 1
- Avoid foods high in simple sugars and fats during rehydration 1
- Offer age-appropriate foods every 3-4 hours as tolerated 7
There is no justification for "bowel rest" - do not delay feeding 1, 2
Pharmacological Management
Antimotility Agents - ABSOLUTELY CONTRAINDICATED
Antimotility drugs like loperamide are absolutely contraindicated in all children <18 years: 1, 2
- Risk of respiratory depression and serious cardiac adverse reactions 1
- Reports of severe abdominal distention, ileus, and deaths in children 3
- These agents shift focus away from appropriate fluid and nutritional therapy 3
Antiemetics
- Ondansetron may be considered if vomiting prevents adequate oral intake 2, 4, 5, 6
- Reduces rate of vomiting, improves ORS tolerance, and reduces need for IV rehydration 4, 6
- Decreases ED length of stay with minimal serious side effects 6
Antimicrobial Therapy
Empiric antibiotics are NOT recommended for uncomplicated watery diarrhea: 2
Consider antibiotics ONLY when: 1, 2
- Dysentery (bloody diarrhea) or high fever is present 1, 2
- Watery diarrhea persists for >5 days 1, 2
- Stool cultures indicate a specific pathogen requiring treatment 1, 2
- Patient is immunocompromised or has clinical features of sepsis 2
Monitoring and Reassessment
After 2-4 hours of rehydration therapy: 1, 2
- Reassess hydration status using clinical signs 1, 7
- Monitor skin turgor, mucous membrane moisture, mental status 7
- Track stool frequency and consistency 7
- Monitor weight changes and urine output 7
- If rehydrated, transition to maintenance phase with ongoing loss replacement 1
Hospitalization Criteria
- Severe dehydration (≥10% deficit) or signs of shock 1, 7
- Altered mental status or inability to protect airway 7
- Failed oral rehydration therapy despite adequate trial 1, 7
- Ileus preventing oral intake 7
- Stool output exceeding 10 mL/kg/hour 1
When to Escalate to IV Therapy
Switch from oral to intravenous isotonic fluids (Ringer's lactate or normal saline) if: 2
- Progression to severe dehydration or shock 2
- Altered mental status develops 2
- ORS therapy fails despite proper technique 2
- Stool output exceeds 10 mL/kg/hour 1, 2
Critical Pitfalls to Avoid
- Give antimotility agents (loperamide) to any pediatric patient - this is absolutely contraindicated 1, 2
- Prescribe empiric antibiotics for uncomplicated watery diarrhea 2
- Use cola drinks or soft drinks for rehydration (inadequate sodium, excessive osmolality worsens diarrhea) 1
- Delay rehydration while awaiting diagnostic test results 2
- Restrict diet during or after rehydration 2
- Rely solely on sunken fontanelle or absent tears for dehydration assessment 1
- Order routine laboratory tests for mild-moderate dehydration without specific clinical indications 1
- Use hypotonic solutions for initial rehydration in severe dehydration 1
Return Precautions
Instruct caregivers to return immediately if: 1