Gastroenteritis in Children
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Background
Gastroenteritis is a very common presentation in children.
It is defined as (according to the paediatric society of gastroenterology (1)):
“Acute gastroenteritis is defined as a decrease in the consistency of stools (loose or liquid) and/or an increase in the frequency of evacuations (typically 3 or more in 24 hours), with or without fever or vomiting, lasting < 14 days .”
Rotavirus, closely followed by norovirus, are the overall most common causative agents of gastroenteritis in children (1).
The most common bacterial causative agents are campylobacter and salmonella (1).
Presentation
- Diarrhoea and Vomiting.
- With/without fever.
- In severe cases there may be signs of dehydration and/or shock (patients < 6months old are at more risk of this complication (1,2)).
Ask about…
- Recent contact with someone with D&V
- Exposure to potential source of contaminant (e.g. undercooked food, dirty water, etc.)
- Recent travel abroad
Diarrhoea usually lasts for 5–7 days, and in most it stops within 2 weeks (2).
Vomiting usually lasts for 1–2 days, and in most it stops within 3 days (2).
If any of the following are present, a diagnosis other than gastroenteritis should be considered (2) (see Vomiting in Children under 5) …
- 38°C or higher in children < 3 months.
- 39°C or higher in children > 3 months.
- Blood and/or mucus in stool
- Bilious (green) vomit
- Abdo distention
- Severe abdo pain
- Increased work of breathing (WOB).
- Altered consciousness.
- Bulging fontanelle
- Non-blanching rash
Management
Diagnosis and Investigation
Gastroenteritis is normally a clinical diagnosis.
The following should be monitored to assess for signs of dehydration (adapted from (2))…
| No clinically detectable dehydration | Clinical dehydration | Clinical shock |
|---|---|---|
| Alert and responsive | Red flag Altered responsiveness (for example, 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 | Red flag Sunken eyes | – |
| Moist mucous membranes (except after a drink) | Dry mucous membranes (except for 'mouth breather') | – |
| Normal heart rate | Red flag Tachycardia | Tachycardia |
| Normal breathing pattern | Red flag Tachypnoea | Tachypnoea |
| Normal peripheral pulses | Normal peripheral pulses | Weak peripheral pulses |
| Normal capillary refill time | Normal capillary refill time | Prolonged capillary refill time |
| Normal skin turgor | Red flag Reduced skin turgor | – |
| Normal blood pressure | Normal blood pressure | Hypotension (decompensated shock) |
However, stool MC&S should be performed if (2)…
- you suspect septicaemia or
- there is blood and/or mucus in the stool or
- the child is immunocompromised.
Consider stool MC&S if (2)…
- the child has recently been abroad or
- the diarrhoea has not improved by day 7 or
- there is uncertainty about the diagnosis of gastroenteritis.
If the patient is infected with E. coli, specialist advice should be sought on monitoring for haemolytic uraemic syndrome (HUS).
Haemolytic Uraemic Syndrome (HUS).
HUS is a rare but very serious complication of E. coli infection.
It is a triad of:
- AKI
- Thrombocytopaenia
- Microangiopathic haemolytic anaemia
Management involves electrolyte replacement and red cell / platelet infusion.
Treatment
Gastroenteritis is typically a self-limiting condition.
The main treatment goal is the prevention of dehydration (2):
- Encourage oral fluid intake.
- Continue breastfeeding and other milk feeds.
- Avoid fruit juices and carbonated drinks, especially in those at increased risk of dehydration.
- Include ORS solution as supplemental fluid to those at increased risk of dehydration.
- Consider NG tube if there is severe vomiting / inadequate oral intake.
IV fluids may be used to treat dehydration if (2) …
- Shock is suspected.
- There are red flag symptoms (see table).
- There is deterioration despite oral rehydration therapy.
- The patient persistently vomits the ORS solution, given orally or NG tube.
Antibiotics should not be routinely given to children with gastroenteritis (2).
Antibiotics should be given if (2)…
- Suspected septicaemia / extra-intestinal spread of the infection
- < 6 months old with salmonella infection
- Malnourished or immunocompromised with salmonella infection
- With Clostridium difficile-associated pseudomembranous enterocolitis, giardiasis, dysenteric shigellosis, dysenteric amoebiasis or cholera.
Advice to give to parents (3)…
- Wash hands regularly with soap.
- Children should not return to school until 48 hours after the last episode of diarrhoea or vomiting.
- Children should not swim in pools until 2 weeks after the last episode of diarrhoea or vomiting.
Guidelines
European Society for Paediatric Gastroenterology, Hepatology, and Nutrition
https://www.espghan.org/knowledge-center?kcc=32fb9cf3-97bd-4e82-87ef-b5411944ec48
Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management
Clinical guideline [CG84]Published: 22 April 2009
https://www.nice.org.uk/guidance/cg84/chapter/Recommendations
Health protection in children and young people settings, including education
https://www.gov.uk/government/publications/health-protection-in-schools-and-other-childcare-facilities
References
- Guarino A, Ashkenazi S, Gendrel D, Lo Vecchio A, Shamir R, Szajewska H. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases Evidence-Based Guidelines for the Management of Acute Gastroenteritis in Children in Europe. Journal of Pediatric Gastroenterology and Nutrition. 2014;59(1):132–52.
- Recommendations | Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management | Guidance | NICE [Internet]. NICE; 2009 [cited 2024 May 26]. Available from: https://www.nice.org.uk/guidance/cg84/chapter/Recommendations
- GOV.UK [Internet]. 2024 [cited 2024 May 26]. Health protection in children and young people settings, including education. Available from: https://www.gov.uk/government/publications/health-protection-in-schools-and-other-childcare-facilities