Management
Refer to flowchart [PDF 669.61 KB] for a summary of the emergency management for children presenting with symptoms of gastroenteritis:
Fluid management is the mainstay of therapy directed by the degree of hydration. Medication is not routinely recommended.2,6
Most children presenting to an ED with symptoms of gastroenteritis can be managed conservatively with an oral fluid trial as outlined below. For any child who requires nasogastric (NG) or IV rehydration, strict fluid balance must be recorded, with weighing of all nappies if relevant and at least daily weights.
Fluids
Child in shock
Seek senior emergency/paediatric advice as per local practice for a child in shock. Consider contacting paediatric critical care (onsite or via Retrieval Services Queensland (RSQ)) if signs of shock persist after two fluid boluses.
Consider sepsis in child with persisting signs of shock following fluid bolus.
Fluid resuscitation for the management of shocked childrenBolus dose (IV or IO) |
Sodium Chloride 0.9% administered rapidly in 20 mL/kg bolus. Repeat in 20 mL/kg boluses as clinically indicated.
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Ongoing fluid therapy |
Sodium chloride 0.9% and 5% glucose running at maintenance plus correction of estimated deficit (usually 10% in the shocked patient) over 24hrs. Use potassium containing fluids in children who are hypokalaemic and consider in children with significant ongoing losses (see potassium prescribing guideline [PDF])
Reassess frequently and replace significant ongoing losses. Rate may be revised on senior emergency/paediatric advice following identification of an electrolyte disturbance. |
Calculating fluid ratesMaintenance fluids: - First 10kg – 4ml/kg/hr
- Second 10kg – 2ml/kg/hr
- Every kg after 20kg – 1ml/kg/hr
PLUS Replacement of deficit: % dehydration x weight (in kg) x 10 replacement time (usually 24-48hrs) | Example- 25kg child
- 10% dehydration
Maintenance fluids: PLUS Replacement of 10% deficit: 10 x 25 x 10 ÷ 24 = 104ml/hr TOTAL: 169ml/hr |
Child with clinical signs of dehydration
In children with clinical signs of dehydration, the focus is on rehydration.
Acute gastroenteritis can often be managed effectively with oral rehydration therapy (ORT). This has been shown to reduce inpatient admissions when used in ED.10Oral rehydration solutions use the principle of glucose-facilitated sodium transport whereby glucose enhances sodium and secondarily water transport across the mucosa of the upper intestine. Water absorption across the lumen of the gut is maximised when solutions with a sodium to glucose ratio of 1:1.4, and a sodium concentration of 60mmol/L are used.11 Appropriate rehydration solutions include Glucolyte, GastrolyteTM, HYDRAlyteTM and PedialyteTM.
The most appropriate route of fluid administration (oral, NG or IV) is influenced by the age of the child and the severity of dehydration. Where possible enteral (NG and oral) rehydration is preferred (see Trial of fluids form [PDF]). In comparison with IV administration, enteral rehydration has been associated with better health outcomes (quicker return to normal diet, less vomiting and diarrhoea and improved weight gain at discharge), fewer complications, shorter hospital stay, and is more cost effective. NG rehydration is usually successful regardless of vomiting (though vomiting usually ceases following commencement of NG fluids). 3,12
Breastfeeding should always be continued throughout the rehydration phase.
Recommended routes of fluid administration for children with clinical signs of dehydrationOral | NG | IV |
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- Routinely recommended as initial route of choice for children with mild to moderate clinical dehydration.
- Contraindicated in children with reduced level of consciousness (due to risk of aspiration) or ileus.
| - Consider for children aged less than three years:
- with more severe dehydration
- unable to tolerate oral rehydration (due to persistent vomiting/fluid refusal)
- May be considered for older children but generally not well tolerated.
- Contraindicated in children with reduced level of consciousness (due to risk of aspiration) or ileus.
| - Consider for children aged more than three years:
- with more severe dehydration
- unable to tolerate oral rehydration (due to persistent vomiting/fluid refusal)
- Consider for children aged less than tree years if NG fluids have failed.
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Fluid administration for children with clinical signs of dehydrationOral | NG/IV |
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- Offer small amounts of oral rehydration solution frequently via syringe/cup, aiming for 12.5ml/kg/hr (small volumes are better tolerated than larger volumes)13-16
- Appropriate rehydration solutions include Glucolyte, GastrolyteTM, HYDRAlyteTM and PedialyteTM
- Dilute apple juice, although not electrolyte replete, has been shown to have fewer treatment failures than oral rehydration solutions in mild gastroenteritis.17
- Soft drinks, cordials and sports drinks (Gatorade/Powerade) should preferably not be used as rehydration fluid due to the minimal sodium content.
- Water alone is NOT recommended.
| - Rapid rehydration (50 mL/kg over 4 hours) using oral rehydration solution (NG) or Sodium Chloride 0.9% + Glucose 5% (IV) is routinely recommended.
- Slower rate (over 8-12 hours) is recommended in children
- with significant co-morbidities (e.g. renal disease, cardiac disease, diabetes, on diuretics)
- infants less than 6 months of age to avoid fluid overload.
- who continue to vomit during rapid rehydration
- who are being admitted overnight
- Replace significant losses due to vomiting and diarrhoea (add volume loss to replacement and administer over next hour).
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Regular reassessment is recommended. Rehydration therapy is regarded as successful if the clinical signs of dehydration have resolved.
Persistence of signs after four hours may be due to:
- initial underestimation of the fluid deficit
- persistent vomiting and/or diarrhoea
- alternative/additional diagnosis
If signs of dehydration persist, further rehydration via NG or IV therapy is recommended. Consider testing for electrolyte abnormality.
Seek senior emergency/paediatric advice as per local practice if electrolyte abnormalities are identified on blood testing (as fluid adjustments may be required).
Feeding (using usual fluids) should be reintroduced after the acute phase of rehydration (two to four hours) or earlier if indicated by the child. Refer to Gastroenteritis Factsheet for further advice on feeding for parents/caregivers.
Child with no clinical signs of dehydration
In children with gastroenteritis without clinical signs of dehydration the focus is on prevention of dehydration.
Children should receive a fluid challenge with an oral rehydration solution at triage while awaiting medical assessment. Offer small amounts of oral rehydration solution frequently via syringe/cup, aiming for 10ml/kg/hour (small volumes are better tolerated than larger volumes)13-16 See Trial of fluids form [PDF].
Following medical assessment, children who have no risk factors for dehydration can be safely discharged home with reassurance, advice (including the Gastroenteritis fact sheet) and safety netting.
Children with risk factors for dehydration (see above), should have an extended period of observation and complete a trial of fluids over 1-4hrs.
Where relevant, breastfeeding should be encouraged.
Ondansetron
A single dose of oral ondansetron can be prescribed to reduce vomiting.
Ondansetron has been shown to reduce the need for IV rehydration, rate of representation and length of hospital stay in children with gastroenteritis16, 20.
Ondansetron for the management of vomiting in children with gastroenteritisDose |
Given orally or sublingually at a dose of 0.15 mg/kg (maximum 8 mg).
Tablets and wafers are available in 4 mg and 8 mg doses. Recommended doses are as follows: - 8-15 kg: 2 mg (half tablet or wafer)
- 15-30 kg: 4 mg
- greater than 30 kg: 8 mg (clinician may choose to dose at 6mg if this is more consistent with a calculated dose of 0.15mg/kg)
Not recommended for children aged less than 6 months, weight less than 8 kg or with ileus. |
Considerations |
Ondansetron prolongs the QT interval in a dose–dependent manner. Exercise caution in children who have or may develop prolongation of QTc (such as those with electrolyte disturbances, family history of long QT syndrome, heart failure or those on medications that may lead to a prolongation of the QTc).18,19 |
Antibiotics
Antibiotics are not routinely recommended as gastroenteritis is commonly viral in aetiology. In cases of uncomplicated bacterial gastroenteritis, there is no evidence of benefit but evidence of potential harm related to the use of antibiotic therapy.
Antibiotic therapy is recommended for:
Consider antibiotic therapy for malnourished or immunocompromised children.
Seek senior emergency/paediatric advice as per local practice regarding antibiotic prescription.
Other medications
The following medications are not routinely recommended:
- other anti-emetics including metoclopramide, prochlorperazine or dexamethasone – no evidence to support use and associated with significant side effects (e.g. dystonic reactions).
- anti-diarrhoeal agents including Loperamide – associated with adverse consequences including lethargy, paralytic ileus, toxic mega-colon, CNS depression, coma and even death.