Acute Gastroenteritis Management in Paediatric Emergency Medicine

Objectives

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

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:

Consider single dose of Ondansetron if
- Children>1yr
- No signs of bowel obstruction or bilious vomiting
Consider NG tube rehydration
- If difficult IV access
- The child presents overnight and is sleeping
- Younger children
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:

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

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

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