A Review on the Management of Acute Gastroenteritis in Children

7/27/2019 A Review on the Management of Acute Gastroenteritis in Children

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Hong Kong Journal of Emergency Medicine

A review on the management of acute gastroenteritis in children

KC Shek , P Ng , CY Hung , KK Lam , CL Lau , WM Ching ,

CW Kam

Acute gastroenteritis represents a frequent cause of morbidity among children in Hong Kong. Despite the

large number of potential etiologic agents, principles of management of gastroenteritis are uniform and

aim to prevent the two major complications dehydration and malnutrition. A review of the literature was

performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on

recommendations were generated. Current evidence emphasises the use of oral rehydration and the early

reintroduction of age-appropriate foods. Apart from these two, important aspects of management reviewed

included laboratory investigations, role of anti-diarrhoeal agents, and use of anti-microbial agents. Criteria

for admission of high-risk children are also addressed. (Hong Kong j.emerg.med. 2004;11:152-160)

Keywords: Anti-diarrhoeals, anti-infective agents, diarrhoea, fluid therapy, oral administration

Correspondence to:Shek Kam Chuen, MBBS, FRCSEd, FHKAM(Emergency Medicine)Tuen Mun Hospital, Accident and Emergency Department, TsingChung Koon Road, Tuen Mun, N.T., Hong KongEmail: [email protected]

Paulin Ng,MBChB, FRCSEd, FHKAM(Emergency Medicine)Hung Chung Yung, MBBS, FRCSEd, FH KAM(Emergency Medicine)Lam Ka Keung, MBBS, MRCSEdLau Chu Leung, MBBS, MRCSEdChing Wai Ming, MBChB, MRCSEdKam Chak Wah, MRCP, FRCSEd, FHKAM(Emergency Medicine & Surgery)

Background

Acute gastroenteritis is characterised by rapid onset

of diarrhoea with or without vomiting, nausea, fever,and abdominal pain.1 It is a common paediatric illness

often treated in emergency departments and

outpatient clinics. In the United States, most children

younger than five years old have gastroenteritis two

to three times a year; while children attending daycare have approximately five illnesses per year.2 In

Hong Kong, acute gastroenteritis contributed one-

sixth of the paediatric admission in a teaching hospital

and caused 10 out of 2,737 post-neonatal deaths

between 1980-1992.3

Acute gastroenteritis is a clinical syndrome produced

by a variety of viral, bacterial, and parasitic

enteropathogens. In developed countries, viral

enteropathogens cause 30-40% of all infectious

diarrhoeal diseases. Rotaviruses are the most commonviral enteropathogens in children and they are


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Shek et al./Acute gastroenteritis in children 153

responsible for 40% of dehydrating diarrhoeal cases.2,4

Enteric adenoviruses are the second most common

cause of viral diarrhoea, isolated from a median of3% (range 0 to 6%) of the cases.4 Limited data are

available in Hong Kong. In an Acute Diarrhoeal

Diseases Surveillance (pilot program) conducted by

the Department of Health in 2001, stool specimens

were collected from selected patients (both adults and

children) attending 64 general outpatient clinics with

acute diarrhoeal diseases. Vi bri o parahaemolyticus,

Salmonella and Campylobacter were found 28, 27 and

17 out of 565 specimens respectively. Norwalk-like

viruses and Rotavirus were found in 52 and 7 out of

600 specimens respectively.

There are great variations in management of acute

gastroenteritis in Hong Kong. In one study looking

at the management practice by primary care physicians

and parents' perception of appropriate treatment of

acute diarrhoea in Hong Kong, mi smanagement

predominated both among the professionals and

laypeople. Oral rehydration solut ion (ORS) was only

recommended by 14% of their primary care doctors.

Other advices included giving more water (37%), lessmilk (7%) and soya-based mi lk (21%). Caregivers' top

priorities for the treatment of diarrhoeal illness in

children were fever control (41%) followed by

replacing fluid loss (30%), stopping diarrhoea (26%)

and stopping vomiting (4%). Only half of the

caregivers considered it important to continue giving

solid foods, and soft cereal foods (congee and bread)

were favoured. There was also a strong belief that drugs

should be given.3

Objectives

This article is intended to provide an evidence-based

recommendation for the management of children who

present to hospital with diarrhoea. Clinical assessment,

investigations (biochemistry and stool culture in

particular), admission, and treatment are addressed.

The review aims to aid doctors in recognising children

who need admission for observation and treatment

and those who may safely go home.

Method: search strategy and evaluation ofevidence

The search was performed using the MED LI NE,

EMBASE, ACP Journal club, DARE, CCTR, CDSR,

and Cinahl databases, and covered the years January

1966-February 2003. Relevant articles were also

identified from the references cited in publications

identified from these databases. The search was limited

to studies of human subjects published in English.

Subject headings employed were: "gastroenteritis",

"diarrhoea", "rehydration solutions" and

"dehydration". Text word searches were also done

using the terms "infectious diarrhoea" and "oral

rehydration solutions". For each topic the terms

"review", "meta-analysis", "clinical trials" and

"randomised controlled trial" were applied. The

Cochrane Library database of systematic reviews was

searched under the subject headings. Evidence from

the medical literature and the strength of the

recommendations given were then categorised

according to the scheme quoted in EVIDENCE,

which was published by the Hospital Authority of

Hong Kong (Table 1).5

Fluid replacement

Management of gastroenteri tis start s with a bri ef,

focused history that should include information on

the nature of symptoms (mainly diarrhoea and

vomiting), their frequency and duration, the amount

and type of fluids ingested during the last 24 hours,

and urine output. This should be followed by an

assessment of the hydration status of the patient, based

primarily on physical signs, as shown in Table 2. 4

However, the severity of dehydration is most

accurately assessed i n terms of weight loss as a

percentage of premorbid body weight.6 Physical

examination is useful in distinguishing gastroenteri tis

from other acute surgical abdominal conditions. The

introduction of oral replacement therapy (ORT) has

revolutionised the management of dehydration in

acute gastroenteritis. It is a simple and inexpensive

treatment. The basis of ORT is that an active co-


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Hong Kong j. emerg. med.Vol. 11(3)Jul 2004154

Table 1. Classifi cation scheme5

Category of evidence:

Ia Evidence from meta-analysis of randomised controlled trials

Ib Evidence from at least one randomised controlled trial

I Ia Evidence from at least one controlled study without randomisation

IIb Evidence from at least one other type of quasi-experimental study

III Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies

IV Evidence from expert commit tee reports or opinions or clinical experience of respected authorit ies, or both

Strength of recommendation:

A Directly based on category I evidence

B Directly based on category II evidence or extrapolated recommendation from category I evidence

C Directly based on category III evidence or extrapolated recommendation from category I or I I evidence

D Di rectly based on category IV evidence or extrapolated recommendation from category I , I I or I I I evidence

Table 2. Assessment of dehydration4,7

Variable Mild (3% -5% ) Moderate (6% -9% ) Severe (10% )

Blood pressure Normal Normal Normal to reduced

Quality of pulse Normal Normal or slightly decreased Moderately decreased

Heart rate Normal Increased Increased

Skin turgor Normal Decreased Decreased

Fontanelle Normal Sunken Sunken

Mucous membranes Slightly dry Dry DryEyes Normal Sunken orbits Deeply sunken orbits

Extremities Warm, normal capillary refill Delayed capillary refill Cool, mottled

Mental status Normal Normal to listless Normal to lethargic or comatose

Urine output Slightly decreased


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generally recommended rehydration regime is as

follows: -6,7

(a) "Mild" dehydration (3-5%):30-50 ml/kg as ORT over 3-4 hours

(b) "Moderate" dehydration (5-10%):

50-100 ml/kg as ORT over 3-4 hours

(c) "Severe" dehydration (>10%):

100-150 ml/kg as ORT over 3-4 hours

In case of severe dehydration with signs of shock,

20 ml/kg boluses of normal saline should be given

int ravenously [ IV, D].6,10 Sandhu et al noted that

the indications for intravenous therapy included

(1) shock, (2) >10% dehydration, or (3) failure of oral

replacement therapy [IV, D].10 We should reassess the

patient's hydration status and tolerance of fluid

regularly. Continue to supplement with ORS 10 ml/

kg for each watery stool or vomitus until the child

recovers.6,7,10 ORS with sodium concentrations as high

as 90 mmol/L or as low as 30 mmol/L appear to be

equally effective and safe [Ia, A].8 An ORS containing

sodium 60 mmol/L, glucose 90 mmol/L, potassium

20 mmol/L, and citrate 10 mmol/L with a low

osmolality of 240 mmol/L is safe and effective for theprevention and treatment of dehydration in European

children with acute gastroenteritis [Ib, A].6 A range

of ORS products are currently available in Hong

Kong, and these vary in their sodium and glucose

concentrations (Table 3).12

Although glucose-electrolyte ORS is extremely

effective in replacing fluid and electrolyte losses, it

has no effect on stool volume. Comparing with

standard ORS, one systematic review noted that rice-

based ORS for children with cholera had resulted in

significant reduction of 24-hour stool volume [Ib, A].13

Although rice-based ORS is well tolerated in infantsyounger than 6 months of age, more evidence is

required to justify its replacement of the glucose-based

hypotonic oral rehydration solutions.14

There is no systematic review or RCTs on "clear

fl uids" (water, carbonated dr inks, and t ranslucent

fruit juices) versus ORS for treatment of mild to

moderate dehydration caused by acute gastroenteritis.

Fruit juices and carbonated drinks are of low

electrolyte concentration but hypertonic owing to the

high sugar content. These solutions may exacerbate

diarrhoea [IV, D].7

Nutritional management

Conventional practice to treat acute gastroenteritis was

to delay feeding for 24 hours. Some might also

recommend the use of diluted milk formula or lactose-

free formula routinely. These practices have become

obsolete. Studies have shown that early refeeding ofage-appropriate food has the advantages of stimulating

mucosal growth and reducing the abnormal increase

in intestinal permeability in acute gastroenteritis [Ib,

A].12,15 Besides, early resumption of age-appropriate

food helps to meet the nutritional needs of the ill child.

In a recent multicentre European study, 230 weaned

children under three years of age with acute

gastroenteritis were randomly assigned to "early

refeeding" or "late refeeding". These children were not

Table 3. Composition of glucose-electrolyte solution12 (Adapted from: Yeung WKY. Acute gastroenteritis in infants and children.

Hong Kong Pract 1999;21:471-6.)

Solution Carbohydrate (mmol/L) Sodium (mmol/L) Potassium (mmol/L) Base (mmol/L) Osmolarity (mOsm/L)

Pedialyte 140 45 20 30 250

GES45 160 45 25 25 300

Infalyte 70 50 25 30 200

Rehydrate 140 75 20 30 310

WHO 111 90 20 30 310

Glucolyte 100 56 20 NA 240


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generally malnourished before the onset of their

illness. Oral rehydration was carried out over four

hours. The "early refeeding" group then received anormal diet without further delay. The "late refeeding"

group received maintenance ORS for a further 20

hours, and then restarted a normal diet. Both groups

were offered ORS 10 ml/kg after each watery stool.

There was no difference between the two groups in

the incidence of vomiting or watery stools on days

1 to 5, and weight gain was similar in both groups on

days 5 and 14.16 Breastfeeding should continue

through rehydration and maintenance phases of

treatment [IIb, B].6,10,17 Breastfeeding not only reduces

exposure to enteropathogens but also provides a variety

of humoral and cellular factors protective against

intestinal infection. Formula feeds should be restarted

after completion of rehydration [Ib, A].6

Transient lactase deficiency is common, particularly

after Rotavirus gastroenteri tis. However, persistent

lactose intolerance causing post-gastroenteritis

diarrhoea is a rather uncommon clinical problem.18 A

meta-analysis on the use of lactose-containing

formulas in children with diarrhoea noted that 80%or more could tolerate full-strength milk safely [Ia,

A]. However, children with severe diarrhoea might

have an increased rate of complications, though, and

for them lactose-reduced formulas should be

considered.18 If there is persistent diarrhoea after

reintroduction of feeds, evidence for lactose

intolerance should be sought. I f the stool pH is acidic

and contains more than 0.5% of reducing substances,

a lactose-free formula should be considered [III, C].6

Fatty foods or foods high in simple sugars (including

tea, juices, and soft drinks) should be avoided.4

Investigation modalities

Despite the large number of potential etiologic agents,

principles of management of acute gastroenteritis are

uniform and aim to prevent the two major

complications dehydration and malnutrition.

Microbiological investigation is not necessary in every

case,

4,6

but indicated in selected patients who require

admission to hospital, who have bloody or mucoid

diarrhoea suggesting colitis, who are immuno-

compromised, and in cases where there are diagnosticuncertainties [IV, D].6 When comprehensive

microbiologic methods are used, etiologic agents can

be identified in only about 50% of diarrhoea cases in

community-based studies and 70% in health-facility

cases.19 Besides, the finding of an enteropathogen in

the stool of a patient with gastroenteritis does not

establish a causal relationship. It has been estimated

that the culture-positive rate for Salmonella and

Shigella in unselected stool specimens from patients

with diarrhoea is 1.5-2.4%. Using the presence of

faecal leucocytes as a selection criterion for performing

stool cultures has been shown to increase the rate from

2% to 76%.20 Antigen testing for Rotavirus is a

valuable and sensitive test, which should be performed

in all young children under the age of three years who

are hospitalised with severe diarrhoea.21

Gross examination of the stool may help distinguish

the infectious causes of diarrhoea. Watery diarrhoea

without blood or mucus is indicative of a viral or an

enterotoxin-mediated bacterial infection. D iarrhoeacontaining blood, mucus, or both is indicative of a

cytotoxin-mediated or an enteroinvasive inflammatory

process.20 The presence of gross or occult blood in the

stool should raise suspicion of such pathogens as

Shigella species, Campylobacter species and

haemorrhagic E. coli strains.22

Medications

According to a few systematic reviews and RCTs, anti-

diarrhoeal and anti-moti li ty agents are not clinically

beneficial in the management of acute childhood

gastroenteritis, and their side effect profile is

unacceptable. Infants and children with acute

gastroenteritis should not be treated with anti-

diarrhoeal agents [Ib, A] .6,7 Bacterial gastroenteritis is

usually self-limited in the otherwise healthy child.

Clinical recovery is frequently achieved within a few

days and excretion of the causative organisms

continues for a relatively short duration, usually not


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exceeding a few weeks. Most bacterial gastroenteritis

do not require or benefit from antibiotic treatment.6,14

Loperamide (Imodium)

There is no meta-analysis study on the use of

loperamide in acute gastroenteritis. Four RCTs have

demonstrated the beneficial effect of loperamide.23-26

Three RCTs comparing loperamide at doses of 0.4

mg/kg/day and 0.8 mg/kg/day (higher than the

recommended dose) with standard ORT versus

placebo with standard ORT had statistically significant

favourable outcomes (p


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significant, the clinical effects were modest. Other

beneficial effects included fewer stool,38 better weight

gain,38 and enhancement of intestinal absorption.42

However, there was no signif icant effect on duration

of fever,40,41 number of vomiting38,40,41 body weight

upon discharge39,41 and blood electrolyte.41 Furthermore,

there was no significant adverse effect reported in all

the studies. In view of the modest clinical effects,

dioctahedral smectite is not recommended [IIa, C].

There is no meta-analysis study or RCT on the use

of kaolin-pectin. There was no conclusive evidence

available to show that kaolin-pectin reduce the

duration, stool frequency, or stool fluid losses.7

Use of absorbents may have the disadvantage of

absorbing the nutrients, enzymes and antibiotics in

the intestine.12

Anti -microbial treatment

Most bacterial gastroenteritis do not require or benefit

from antibiotic treatment [Ib, A].6 Antibiotics are

indicated in gastroenteritis caused by Shigella,

Cholera, enteroinvasive E. coli and Clostridium

diff ici le [I I I , C].6,14

Antibiotic therapy is notrecommended for "uncomplicated" Salmonella

enteritis because it does not decrease the duration of

symptoms, diarrhoea, or organism excretion. Besides,

antibiotic therapy has been implicated in prolonging

the carrier state and promoting the emergence of

resistant bacterial strains.20 Therapy for Salmonella

gastroenteritis is reserved for infants younger than

3-6 months of age, in immuno-compromised patients,

and in those who are systemically ill [III, C]. 14

Antibiotics are also indicated in children with sickle

cell disease.2 For Campylobacter gastroenteritis,

erythromycin is indicated for patients with severe or

prolonged illness and to decrease the duration of

shedding.14 For Escherichia coli O157:H 7 infection,

antibiotic treatment may increase the risk of the

haemolytic-uraemic syndrome.43

Management plan and disposal

The indications for hospital admission include:(1) patient with 5% or more dehydration; (2) inability

to manage oral rehydration at home; (3) patient not

tolerating oral rehydration (refusing, vomiting,

insufficient intake); (4) failure of treatment, e.g.,worsening diarrhoea and/or dehydration despite ORT;

(5) other concerns, e.g., diagnosis uncertain, potential

for surgery, child "at risk", child irritable or drowsy,

or child younger than two months [IV, D]. 9 In

addition, parental education should be an essential

element of the management plan. A careful description

of the course of the disorder, firm understanding of

the signs that indicate deterioration, the use of ORT

and method of refeeding should be communicated to

the parents and preferably in a brochure for their

future reference.44

Conclusion

Acute gastroenteritis is a common paediatric illness

seen in emergency departments. Most episodes are self-

limiting. Most of the cases can be attributed to viruses.

Many patients can be managed with oral rehydration

and early reintroduction of feeding. Although most

children with gastroenteritis are successfully managedwith oral rehydration solutions as outpatients, those

high-risk children should be identified and evaluated

carefully. Very young children, children with chronic

diseases, and children with chronic malnutrition

should be managed promptly and in-hospital

treatment may be indicated. As most episodes are self-

limiting, laboratory studies are not usually needed.

Anti-microbial agents should be used judiciously and

only a minority of children will benefit from anti-

microbial therapy. Anti-moti li ty drugs and absorbents

should be discouraged because of limited evidence of

benefit.

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A Review on the Management of Acute Gastroenteritis in Children

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