A Synopsis of the American Academy of Pediatrics' Practice Parameter on the

Management of Acute Gastroenteritis in Young Children

Lawrence F. Nazarian
Pediatrics in Review 1997;18;221
DOI: 10.1542/pir.18-7-221

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ARTICLE

A Synopsis of the American Academy of Pediatrics

Practice Parameter on the Management of Acute
Gastroenteritis in Young Children
This article provides a summary of the practice parameter on gastroenteritis. The reader is urged to refer to the
original document for a more thorough presentation.1

Focus of the Parameter

Gastroenteritis was chosen as a topic
for study because it is a common
condition that can cause serious
illness and death, especially in
younger children. In addition, there
is documented variation in how
clinicians manage this disorder.
Acute gastroenteritis is defined as
diarrheal disease of rapid onset, with
or without accompanying symptoms
and signs such as nausea, vomiting,
fever, or abdominal pain. The recommendations apply to children
of 1 month to 5 years of age who
otherwise are healthy and who live
in developed countries. Most patients
covered by the guideline will have
viral or self-limited bacterial illness;
however, the same principles can be
applied to patients who have bacterial dysentery or protozoal disease.
The clinician managing a patient
who has diarrhea must make many
decisions, from whether to obtain a
stool culture to when the child may
return to child care. Three aspects of
management were chosen for study,
based on their clinical importance
as well as the availability of data:
rehydration, particularly the role
of oral rehydration therapy (ORT);
refeeding; and the use of antidiarrheal agents.

Creation of the Parameter

The parameter was written by a
committee consisting of three pediatric gastroenterologists, two pediatric infectious disease specialists,
two pediatric epidemiologists, and
a practitioner of general pediatrics,
who served as chair. The work of
1

Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice parameter: the management of
acute gastroenteritis in young children.
Pediatrics. 1996;97:424 436

the group was guided by the AAPs

Provisional Committee on Quality
Improvement
A literature search identified
more than 4,000 potentially relevant
documents, from which 230 were
chosen for thorough evaluation. The
findings in these articles were subjected to statistical analysis, which
served as the basis for the subcommittees recommendations. Statistical
conclusions were augmented by
consensus of the committee members. The document was subjected to
rigorous review at several points in
its production. A panel of pediatric
practitioners as well as representatives of the American Academy of
Family Practice provided input.
Critiques of the parameter were
provided by pediatric gastroenterologists, pediatric infectious disease
specialists, and the Board of
Directors of the AAP.
The recommendations contained
in the parameter follow, together
with background material that
provides the rationale for each.

Rehydration
Recommendation: ORT is the
preferred treatment for fluid
and electrolyte losses caused by
diarrhea in children who have
mild-to-moderate dehydration
(based on evaluation of controlled
clinical trials documenting the
effectiveness of ORT).
Considerable experience with the
use of ORT in developing countries
has demonstrated its efficacy and
safety. Studies in developed countries are fewer, but their findings
reinforce the positive conclusions in
children who are mildly to moderately dehydrated.
ORT involves encouraging the
child to drink a glucose-electrolyte
solution to replace lost fluid and to
keep up with continuing losses. In

treating the dehydrated child, use of

solutions such as cola, fruit juice,
and sports beverages is not recommended; their electrolyte content is
inappropriate, and they contain too
much carbohydrate.
Studies on ORT have involved
rehydration with solutions containing 50 to 90 mmol/L of sodium.
The commercially available solutions in the United States contain
45 to 50 mmol/L of sodium and are
best suited for use as maintenance
solutions; however, they can be used
to rehydrate children who are mildly
to moderately dehydrated and otherwise healthy. Because these products
are easy to obtain and taste better
than saltier solutions, clinicians
generally prefer to use them.
The clinician must be able to
evaluate the degree of dehydration
in each patient. Severely dehydrated
children who are approaching or
are in a state of shock must receive
immediate and aggressive intravenous (IV) therapy. Very ill children must be evaluated for a serious
underlying condition, such as sepsis
or a cardiac disorder. Frequent clinical re-evaluation must be part of
managing children who are this ill.
When the patient is stable, hydration
may be continued orally.
Children who have diarrhea but
clearly are not dehydrated may be
given glucose-electrolyte solution
in addition to their regular diets to
replace stool losses; however,
every child who has loose stools
does not require ORT. Special
solutions are not necessary as
long as the well-hydrated child
can consume an age-appropriate
diet and is encouraged to drink
more than the usual amounts of
those fluids customarily found in
his or her diet.
Patients who are mildly or
moderately dehydrated should
receive glucose-electrolyte ORT

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221

PRACTICE PARAMETER
Gastroenteritis
at 50 mL/kg (mild dehydration) or
100 mL/kg (moderate dehydration)
of solution over a 4-hour period.
Replacement of stool losses (at
10 mL/kg for each stool) and of
emesis (estimated volume) will
require adding appropriate amounts
of solution to the total.
If all but sips of fluid are vomited,
oral hydration can be achieved by
administering small amounts very
frequently. For example, a teaspoonful of solution given every 2 minutes
will result in an hourly intake of
150 mL. This method is obviously
labor-intensive and time-consuming.
As the child becomes better hydrated,
however, he or she may be able to
keep down larger amounts at a time
and be rehydrated more efficiently.
Similarly, a child who is reluctant
to drink ORT solution may respond
to frequent administration of small
amounts. Some of the commercial
solutions are flavored and will be
palatable to children who refuse
the unflavored version. Solution
frozen into an ice-pop form may
be accepted better. The more dehydrated a child, the more likely he
or she will be to drink the solution
without objection.
Although oral rehydration is
encouraged and should be used
more than it is, the clinician must
be prepared to administer IV fluids
to children who are seriously dehydrated and to those who do not
respond to the oral regimen.

Refeeding
Recommendation: Children who
have diarrhea and are not dehydrated should continue to be fed
age-appropriate diets. Children
who require rehydration should be
fed age-appropriate diets as soon
as they have been rehydrated
(based on evaluation of controlled
clinical studies documenting the
benefits of early feeding of liquid
and solid foods).
Conventional practice has been to
delay giving food to children who
have diarrhea. When feeding has
been resumed, only a restricted
spectrum of foods has been recommended, and dairy products have
been avoided. It is clear from analysis of the literature that when used
with glucose-electrolyte ORT, early
222

feeding of a regular diet does not

worsen the course or symptoms of
mild diarrhea and may reduce the
duration of diarrhea modestly.
Which foods are best still is
being studied. A good rule is to
avoid fatty foods and foods high
in simple sugars, such as sweetened
tea, juices, and soft drinks. Clinical
experience shows good tolerance of
complex carbo-hydrates (rice, wheat,
potatoes, bread, and cereals), lean
meats, yogurt, fruits, and vegetables.
The BRAT diet (bananas, rice,
applesauce, and toast) contains
well-tolerated foods but is too
limited and does not supply
optimal nutrition.
Most children who have diarrhea
will tolerate full-strength milk or
formula well. Although diarrhea
often is associated with a reduction
in intestinal lactase, this change
is not clinically significant in
80% or more of pediatric patients.
Introducing the childs regular
form of milk early in the course
of therapy is recommended and
usually will prove beneficial. If
the clinician suspects that a child
is demonstrating lactose intolerance,
a lactose-free preparation may be
substituted.

Therapy with Antidiarrheal

Compounds
Recommendation: Generally,
pharmacologic agents should not
be used to treat acute diarrhea
(based on limited studies and
strong committee consensus).
This recommendation addresses
those drugs that are used to alter the
course of diarrhea by decreasing
stool water and electrolyte losses,
shortening the course of illness,
or relieving discomfort. Clinicians
should be aware that a change
toward more formed stools does
not necessarily indicate successful
therapy. Even formed stools can
have a high water content, and the
cosmetic change may give a false
sense of security, delaying more
effective therapy.
The literature on the use of these
agents in children is limited. Their
efficacy is not supported by available data. In addition, some of the
agents carry the potential for serious
adverse effects, especially in younger

children. The drugs are grouped by

their mechanisms of action.
DRUGS THAT ALTER
INTESTINAL MOTILITY

Loperamide decreases transit velocity and may increase the ability of

the gut to retain fluid. Because it is
more specific for mu-opiate receptors in the gut than other opiates,
it has fewer effects on the central
nervous system. When used in conjunction with ORT, loperamide has
been shown to reduce stool losses
and shorten the course of diarrhea
in children; however, these benefits
were modest. Adverse effects
include lethargy, ileus, respiratory
depression, and coma, especially in
infants. Death has been reported.
Because of the unacceptable risk
of side effects and because the
benefits are limited, loperamide
is not recommended to treat acute
diarrhea in children.
Other opiates and opiate-atropine
combinations can produce even
more toxic effects than loperamide,
including the worsening of diarrhea
in some patients, and are contraindicated in treating young children
who have diarrhea.
Anticholinergic agents act on
smooth muscle in the gastrointestinal tract and have been used to
decrease the cramping associated
with gastroenteritis. The efficacy of
these agents in treating children who
have diarrhea is not supported by
studies, and children are especially
susceptible to their toxic effects,
which include coma, respiratory
depression, and paradoxic hyperexcitability. Consequently, the use
of anticholinergic agents is not
recommended.
AGENTS THAT ALTER
SECRETION

Bismuth compounds, especially

bismuth subsalicylate, are believed
to act by inhibiting intestinal
secretion. Studies have demonstrated modest beneficial effects
in children who have diarrhea.
Treatment requires a dose of
medication every 4 hours for
5 days. In addition, there is at
least a theoretical concern about
the risk of Reye syndrome from
the salicylate absorption that has
been shown to occur with bismuth
subsalicylate. Although further

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July 1997

PRACTICE PARAMETER
Gastroenteritis
studies may demonstrate a therapeutic role for this agent, at
present routine use of bismuth
subsalicylate is not recommended
in the treatment of children who
have acute diarrhea.
AGENTS THAT ADSORB
FLUID AND TOXINS

Kaolin-pectin, fiber, activated charcoal, and attapulgite have been used

to treat patients who have diarrhea
in the belief that these agents adsorb
bacterial toxins and bind water to
reduce the number of bowel movements. The only agent currently
used widely is attapulgite. Although
major toxic effects are not a concern
with the use of adsorbents, evidence
of their efficacy is not conclusive,
and they are not recommended.

AGENTS THAT ALTER

INTESTINAL MICROFLORA

Patients who have diarrhea undergo

reduction of fecal flora, which leads
to increased water losses. Lactobacillus sp are believed to alter the
bacterial colonization of the gut
therapeutically. Although some studies have shown beneficial effects in
treating children who have rotavirus
infections, evidence that administration of Lactobacillus-containing
compounds alters the course of diarrhea is not consistent. Toxic effects
are not a concern, and additional
research may demonstrate a use for
these agents. However, at present,
the use of Lactobacillus-containing
compounds is not recommended
in the treatment of children who
have diarrhea.

Parental Education
Proper management of the child
who has gastroenteritis depends on
parental efforts, which are influenced
by how well parents understand the
dynamics of this condition. Education by the clinician should include
a careful description of the natural
course of the disorder, so that
expectations will be realistic. Most
important is a firm understanding
of the signs that indicate a childs
condition is worsening. A brochure
for parents based on the parameter
is available in English and Spanish
editions through the AAP.
Lawrence F. Nazarian, MD
Associate Editor
Chair, Subcommittee on Acute
Gastroenteritis

DEPARTMENT OF CORRECTIONS

Erratum
In the April 1997 issue of Pediatrics
in Review, the PIR Quiz on page 121
inadvertantly contains two questions
numbered 9. The question immediately following question 7 in this
quiz should be numbered 8; the final
question is correctly numbered 9.

Pediatrics in Review
Vol. 18 No. 7 July 1997
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223

A Synopsis of the American Academy of Pediatrics' Practice Parameter on the

Management of Acute Gastroenteritis in Young Children
Lawrence F. Nazarian
Pediatrics in Review 1997;18;221
DOI: 10.1542/pir.18-7-221

Updated Information &

Services

including high resolution figures, can be found at:

http://pedsinreview.aappublications.org/content/18/7/221

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testinal_disorders

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