From the Guidelines
Management for a young patient with 2 days of low-grade fevers, intermittent nausea, emesis, and diarrhea should focus on supportive care and hydration, with oral rehydration solutions as the first-line therapy, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1. The patient should be encouraged to take small, frequent sips of clear fluids like water, diluted sports drinks, or oral rehydration solutions (such as Pedialyte).
- Anti-emetics like ondansetron (Zofran) 4-8mg every 8 hours as needed can help control nausea and vomiting, especially in children >4 years of age and adolescents with acute gastroenteritis associated with vomiting 1.
- For fever, acetaminophen 650mg every 6 hours or ibuprofen 400mg every 6 hours can be used.
- Solid foods should be avoided initially, then gradually reintroduced with bland foods like bananas, rice, applesauce, and toast (BRAT diet) as symptoms improve.
- Probiotics may help restore gut flora. Most viral gastroenteritis cases resolve within 3-5 days without antibiotics.
- Medical attention should be sought if symptoms persist beyond 3-4 days, if there's severe abdominal pain, high fever (>102°F), bloody stools, signs of dehydration (decreased urination, dry mouth, dizziness), or if the patient is unable to keep fluids down for 24 hours. This approach addresses the likely viral etiology while preventing dehydration, which is the main complication of gastroenteritis. It is essential to note that empiric antimicrobial therapy is not recommended for most people with acute watery diarrhea and without recent international travel, except for immunocompromised individuals or young infants who are ill-appearing 1.
From the Research
Assessment and Management
- The patient's symptoms of low-grade fevers, intermittent nausea, emesis, and diarrhea are characteristic of acute gastroenteritis 2.
- The assessment of dehydration in children is crucial, and the evidence suggests that the three most useful predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern 2.
- Laboratory data points, such as blood urea nitrogen (BUN) or BUN/creatinine ratio, may not be accurate in predicting the degree of dehydration, and their use is not routinely recommended 2.
Rehydration Therapy
- Oral or nasogastric rehydration with an oral rehydration solution is equally efficacious as intravenous (i.v.) rehydration in most cases 2, 3.
- The majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy 2.
- Ondansetron (orally or intravenously) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for i.v. hydration, and preventing the need for hospital admission in those receiving i.v. hydration 2.
Management of Fever and Nausea
- The management of fever in infants and young children requires careful evaluation, and factors such as age, poor arousability, and petechial rash may suggest serious infection 4.
- Urinary tract infections are the most common serious bacterial infection in children younger than three years, and evaluation for such infections should be performed in those with unexplained fever 4.
- Nausea and vomiting can be managed with pharmacotherapy, and newer interventions such as bioelectrical neuromodulation and behavioral therapies may also be effective 5.