Paediatric Gastroenteritis

What?

A 4-year-old male presents to the Emergency Department (ED) with a 3-day history of diarrhoea. The illness began with 24-hours of vomiting, subsiding as the diarrhoea became apparent. He had been running a low-grade fever (temperature  37.8C) accompanied by episodes of lethargy.  His parents are concerned that his fluid intake is decreasing and although the number of episodes of diarrhoea appears to be reducing, they are not sure of the last time he passed urine.

A full history and careful clinical examination were undertaken following which the diagnosis of gastroenteritis with mild dehydration has been made.

So what?

In developed countries, such as the United Kingdom (UK), deaths associated with gastroenteritis (diarrhoea with or without vomiting) are now quite rare (NICE 2009). Unfortunately, as a potentially serious infection, especially for the very young (<5-years) who may be likely to require hospitalisation, it can pose a major burden for health care services (NICE 2009).

In a European prospective observational study by Van Damme et al (2007), it was determined that approximately 10% of children younger than 5-years presented to healthcare services (GP, ED etc) with gastroenteritis each year. These attendances were most commonly caused by the rotavirus pathogen (in 28–52% of cases (Van Damme et al 2007)).

Rotavirus – is a highly infectious pathogen typically affecting infants and young children, causing unpleasant bouts of diarrhoea sometimes associated with vomiting, abdominal pain (features of colic in the very young) and fever. Most children recover at home within a few days, but nearly 20% will need to seek medical attention and 10% result in hospital admission as a result of complications such as extreme dehydration (Van Damme et al 2007; NICE 2009).

Norovirus – is a self-limiting viral infection which affects all ages and requires no specific treatment. However, as with any diarrhoea and vomiting infection, dehydration is the main risk, particularly for those at the extremes of age or with significant co-morbidities (NHS 2017).

In children with gastroenteritis;

  • diarrhoea usually lasts for 5–7 days, and in most it stops within 2 weeks
  • vomiting usually lasts for 1–2 days, and in most it stops within 3 days

Consider stool microbiology if the child has;

  • recently been abroad
  • the diarrhoea has not improved by day 7
  • there is uncertainty about the diagnosis of gastroenteritis
  • you suspect septicaemia
  • there is blood and/or mucus in the stool
  • the child is immunocompromised.

Defining Dehydration

Dehydration can be mild, moderate or severe depending on how much of your body weight decreases through fluid loss. Following initial thirst the body will attempt to reduce fluid loss by reducing urine output. It is important to check if wet nappies have been noted in addition/separate to those containing diarrhoea.

 

Table 1 – Determining severity of dehydration (adapted from NICE 2009)
Not clinically detectable Clinically dehydrated

(mild/moderate)

Clinically shocked

(severe)

Alert and responsive Altered responsiveness (e.g. irritable, lethargic) Decreased level of consciousness
Skin colour unchanged Skin colour unchanged Pale or mottled skin
Warm extremities Warm extremities Cold extremities
Eyes not sunken Sunken eyes
Moist mucus membranes Dry mucus membranes
Normal Heart Rate (HR) Tachycardia Tachycardia
Normal breathing pattern Tachypnoea Tachypnoea
Normal peripheral pulses Normal peripheral pulses Weak peripheral pulses
Normal CRT (<3 seconds) Normal CRT (<3 secs) Prolonged CRT (>3secs)
Normal skin turgor Reduced skin turgor
Normal BP Normal BP Hypotension (decompensated shock)

Children at increased risk of dehydration include (Freedman et al 2016):

  • <1 year, especially those younger than 6-months
  • low birth weight babies
  • six or more diarrhoeal stools in the past 24 hours
  • vomited three times or more in the past 24 hours
  • not offered or have not been able to tolerate supplementary fluids

before presentation

  • infants who have stopped breastfeeding during the illness
  • signs of malnutrition

Treatment for Gastroenteritis

Prevention of Rotavirus infection by oral vaccine given as two doses to babies aged 8 and 12-weeks, alongside their other routine childhood vaccinations (NHS, 2017).

Oral Rehydration Therapy (ORT) with electrolyte maintenance solution is widely recommended to treat and prevent dehydration in infants and young children presenting with gastroenteritis. Its efficacy in minimally dehydrated children is unproven however (Freedman et al 2016). For children who do not tolerate electrolyte-based fluids well, Freedman et al (2016) suggest dilute apple juice (followed by other preferred oral fluids) as an alternative, which was shown to result in higher rate of treatment compliance and a reduction in the need for intravenous rehydration. Although by comparison this did not significantly affecting the frequency of hospitalisation or the number of episodes of diarrhoea and vomiting experienced by those children, it was clearly shown to be a non-inferior treatment option (Freedman et al, 2016).

Hospitalised infants and children, who are not clinically shocked, could also receive ORT via nasogastric tube administration if tolerated poorly orally.

ORT Regime

Replacement of fluid and electrolytes lost through diarrhoea can be achieved by giving oral salts solutions containing sodium, potassium, and glucose or another carbohydrate such as rice starch.

ORT mmol/l
Sodium 75
Chloride 65
Glucose, anhydrous 75
Potassium 20
Citrate 10
Total osmolarity 245

Oral rehydration solutions should (WHO 2006):

  • enhance the absorption of water and electrolytes
  • replace the electrolyte deficit adequately and safely
  • contain an alkalinising agent to counter acidosis
  • be slightly hypo-osmolar (about 250 mmol/litre) to prevent the possible induction of osmotic diarrhoea
  • be simple to use in hospital and at home
  • be palatable and acceptable, especially to children
  • be readily available
  Mild dehydration Moderate dehydration
1st hour 20 mL/kg/hr 20 mL/kg/hr
6-8 hours 10 mL/kg/hr 15-20 mL/kg/hr
Reassessment at 4hrs + early re-feeding strategies

e.g. a 10Kg child would receive 20mL x 10Kg per = 200mL ORT initially given as either 16mL every 5-minutes or 32mLs every 10-minutes as tolerated.

The clinically shocked infant/child should receive resuscitation intravenous fluids at 20mLs per Kg following which replacement and maintenance fluids can be calculated to include the percentage dehydration observed (NICE 2009; APLS 2016)

Now what?

Children under the age of 5-years are likely to attend your ED with a presentation of gastroenteritis, taking a comprehensive history and performing a thorough examination should aid recognition of the dehydrated and/or the shocked child.

Only a small number of children will require hospital admission for NG or IV fluid therapy, most will be able to be managed at home with ORT and appropriate safety net advice (see red flags).

The use of dilute apple juice and then other preferred oral fluids as desired may be an appropriate alternative to electrolyte maintenance fluids in children with mild gastroenteritis and minimal dehydration (Freedman et al 2016). Breastfeeding infants should be encouraged to continue in combination with ORT (NICE 2009).

 

Shiela Pantrini

References

British Medical Journal (BMJ) Books. (2016) Advanced Paediatric Life Support (APLS) Manual (6th Edition) Manchester

Driscoll, J. (2007) Practicing clinical supervision: a reflective approach for healthcare professionals (2nd edition). Elsevier. Edinburgh.

Freedman, S.B. , Willan, A.R., Boutis, K. and Schuh, S. (2016) Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. Journal of American Medical Association 315(18):1966-74

National Health Service (NHS) Choices (2017) Diarrhoea and Vomiting (Gastroenteritis) [on-line] http://www.nhs.uk/conditions/gastroenteritis/Pages/Introduction.aspx (accessed 11/02/17)

National Institute for Health and Care Excellence. (2009) Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. National Institute for Health and Care Excellence. London.

Van Damme, P., Giaquinto, C., Huet, F., Gothefors, L. and Van der Wielen, M. (2007) Multicenter prospective study of the burden of rotavirus acute gastroenteritis in Europe, 2004–2005: the REVEAL study. Journal of Infectious Diseases 2007;195 Supplement. 1:S4–S16

World Health Organisation (WHO)(2006) Oral Rehydration salts. [on-line] http://apps.who.int/iris/bitstream/10665/69227/1/WHO_FCH_CAH_06.1.pdf?ua=1&ua=1 (accessed 11/12/17)

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