Gastroenteritis in children (management)

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Objectives

This guideline has been written to assist and standardise the management of gastroenteritis in children. 

Scope

This guideline should be followed by all healthcare professionals that are involved in the management of children with gastroenteritis. 

Diagnosis
  • Consider a diagnosis of Gastroenteritis if:
    • Sudden onset of vomiting
    • Change to loose/watery stools
    • Recent contact with person suffering from diarrhoea/vomiting

  • Other diagnoses must ALWAYS be considered and excluded by a thorough history and examination. BEWARE of children who present only with vomiting. Be particularly cautious in children with:
    • Pyrexia
      • >38 under 3 months old
      • >39 over 3 month and older
    • Tachypnoea
    • Altered conscious level
    • Stiff neck, bulging fontanelle, non-blanching rash
    • Blood/mucus in stool
    • Severe/localised abdominal pain,
    • Abdominal distension, rebound tenderness.
    • Bilious vomiting is a red flag. Ask parents if the vomit is green (like Fairy Liquid). All children should be discussed with the Surgical Team.

  • If return visit compare weight with first presentation
Management

Not clinically dehydrated

Clinically dehydrated

Clinically shocked

Well, alert and responsive

Irritable, lethargic Decreased consciousness

Normal skin colour, warm extremities

Decreased urine output Cold extremities, pale/mottled skin

Moist mucous membranes

Sunken eyes, dry mucous membranes ↑RR ↑HR ↑capillary refill time

Normal observations

↑RR ↑HR ↓skin turgour ↓BP

Discharge with advice

Further period of observation IV access, bloods (include U&E, Glucose) cap or venous gas

Continue BF/milk feeds

ORT 50mls/kg/4 hours (see table below)

IVF bolus 20ml/kg 0.9% saline

Encourage supplementary fluids

Continue breast feeds

Repeat if necessary

Avoid fruit juice/fizzy drinks

Diluting juice ok

Consider normal fluids if refusing ORT emphasise that these should contain sugar (e.g. apple juice) Involve PICU if 3rd bolus needed

ORT if high risk*

Monitor progress  
 

If irritable or lethargic check a BM. If <3.4 give dextrose gel

 

 

*High risk:

Under 1 year old and/or low birth weight 
>6 stools and/or >3 vomits in past 24 hours 
No supplementary fluids, not breast-feeding, looks malnourished 

 

Clinically dehydrated and continues to vomit:

  1. Consider single dose of Ondansetron if
    • Children>1yr
    • No signs of bowel obstruction or bilious vomiting 

  2. Consider NG tube rehydration
    • If difficult IV access
    • The child presents overnight and is sleeping
    • Younger children

  3. If deteriorating
    • IV access and bloods (incl U&E/Glucose/VBG +/- blood ketones)
    • IV fluids (see below)
Hyper/Hyponatraemia

Children with abnormal Sodium can be difficult to identify. They may:

  • Not necessarily be shocked
  • Have hypo/hyperreflexia
  • Lethargy/ decreased conscious level/seizures
  • Doughy skin

Seek senior help. These patients must have controlled correction of their IV fluids and U&Es monitored frequently. Refer to separate guidance on Hyper/Hyponatraemia

Investigations
  • Bloods 
    • Are indicated if IV fluids are required
  • Stool microscopy with culture to bacteriology and virology
    • Septicaemia
    • Blood/mucus in stool
    • Immunocompromised
    • Consider if recent travel, diarrhoea >7 days, uncertain diagnosis, or multiple attendances
Target for Oral Rehydration Therapy
Weight (kg) 5 min volume of ORS 
0-5 5 mls
5-10 10 mls
10-20 20 mls
20-30 30 mls
>30 30 mls

 

Nasogastric Rehydration Therapy (4 hours)
Weight (kg) Normal hourly rate (mls/hr) 
25ml/kg/hour
Slow hourly rate (ml/hr)* 
4 - 40
6 150 60
8 200 80
10 250 100
12 300 120
14 350 140
16 400 160
18 450 180
20 500 200

*Children <6months or with co-morbidities or with severe abdominal pain

IV Fluid Management
After Rehydration
After rehydration:
  • Start milk, introduce solids
  • Avoid fruit juice/fizzy drinks until diarrhoea stops

 

Editorial Information

Last reviewed: 19 June 2017

Next review: 19 June 2020

Author(s): Fiona Russell

Approved By: Paediatric Clinical Effectiveness & Risk Committee