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Clinical Practice Guideline for the Treatment of Pediatric Acute

Gastroenteritis in the Outpatient Setting
Rebecca A. Carson, DNP, CPNP-PC/AC; Shawna S. Mudd, DNP, CPNP-AC; P. Jamil Madati, MD

J Pediatr Health Care. 2016;30(6):610-616.

Abstract and Introduction

Abstract

Acute gastroenteritis (AGE) is a common illness in childhood that usually can be treated in the outpatient setting. Inaccurate
assessment or delayed treatment of AGE can lead to an increased risk for invasive interventions. A literature search was
conducted using PubMed, CINAHL Plus, the Cochrane Library, and Embase. Results of the query were refined to narrow the
focus of relevant studies for the provider caring for dehydrated children in the outpatient setting. Use of clinical dehydration
scales to assess the level of dehydration and early initiation of oral rehydration therapy promote optimal patient outcomes. Oral
rehydration therapy remains the best means of rehydrating, and ondansetron is a safe and effective adjunct to help children with
persistent vomiting. The purpose of this practice guideline is to identify best practices for AGE in children older than 6 months
with symptoms for less than 7 days who are being cared for in the outpatient setting.

Introduction

Acute gastroenteritis (AGE) is one of the most common childhood illnesses in the United States, accounting for more than 1.7
million outpatient visits each year (Freedman, Thull-Freedman, Rumantir, Atenafu, & Stephens, 2013). Up to 16% of emergency
department (ED) visits are attributed to AGE, defined as three or more episodes of diarrhea and/or vomiting and possibly
accompanied by other symptoms including fever, nausea, or abdominal pain that results from gastrointestinal inflammation (Fox,
Richards, Jenkins, & Powell, 2012). The primary treatment goals for children with viral AGE are rehydration and prevention of
complications due to dehydration from fluid loss from ongoing diarrhea and/or vomiting (Farthing et al., 2013).

Nationally recognized recommendations for AGE are oral rehydration therapy (ORT) as the primary treatment while avoiding
unnecessary laboratory tests, diagnostic imaging, and medications (Centers for Disease Control and Prevention [CDC], 2003;
Cincinnati Children's Hospital Medical Center, 2011). Most children have only mild or moderate dehydration associated with
AGE, and the success rate of ORT as a treatment method is approximately 96% (Nir, Nadir, Schechter, & Kline-Kremer, 2013).
Despite recommendations that pediatric patients with mild to moderate dehydration receive ORT as the mainstay of treatment,
many providers unnecessarily order laboratory tests, diagnostic imaging, and intravenous fluids that do not provide prognostic
value or shorten the self-limited illness (Kharbanda et al., 2013). The purpose of this clinical practice guideline is to describe
current evaluation and management of pediatric patients with AGE in the outpatient setting.

Search Methods

Searches were conducted on PubMed, CINAHL, Embase, and the Cochrane Library.

Search Terms

(pediatric OR child*) AND (acute gastroenteritis OR diarrhea) AND (dehydration OR rehydr* OR oral rehydr*)

Filters

Humans

English

NOT (appendicitis OR appendec*[Title])

Date range 2006- present

Etiology and Pathophysiology

Children younger than 5 years are disproportionately affected by AGE, experiencing one to five episodes of gastroenteritis per
year (Farthing et al., 2013). Enteritis pathogens enter the body through the fecal-oral route and infect enterocytes, leading to

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damage of the intestinal epithelium, which causes transudation of fluid into the intestinal lumen. Clinical manifestations of AGE
depend on both the organism and host. Viruses account for 75% to 90% of AGE cases, but bacteria or parasitic infections may
be the cause, especially in vulnerable populations (Churgay & Aftab, 2012). Rotavirus represented the most common viral
pathogen; however, with widespread use of the rotavirus vaccine beginning in 2006, a substantial decrease in disease
prevalence, morbidity, and health care utilization and costs has been appreciated (Leshem et al., 2014). In general, viral AGE
infections are usually self-limited, but severe cases may lead to dehydration that requires further intervention to avoid fluid and
electrolyte derangement.

Pathogens

Viral (noninflammatory): Most commonly Norwalk and Rotavirus; also Caliciviruses (Norovirus and Sapovirus),
Astrovirus, Enteric adenovirus

Parasitic (noninflammatory): Isospora belli, Cryptosporidium, Giardia lamblia

Bacterial (inflammatory): Campylobacter jejuni, Clostridium difficile, Escherichia coli (including O157:H7), Salmonella,
Shigella, Yersinia enterocolitica

Population

This clinical guideline is intended for children older than 6 months with symptoms of AGE for fewer than 7 days. In infants with
AGE who are younger than 6 months, fluid and electrolyte balance should evaluated and other possible causes of the
symptoms should be considered. In children with vomiting alone, alternative diagnoses should be considered, particularly in the
presence of bloody or bilious emesis, severe abdominal pain, or a toxic appearance. Routine AGE care may not be appropriate
for patients with significant comorbidities, immunodeficiency, or chronic illness. If an electrolyte or metabolic imbalance is
discovered or suspected as a result of abnormal physical examination findings, then routine care should not be followed.
Patients with a toxic appearance, concern for severe systemic illness (sepsis), and severe dehydration should be stabilized and
transferred to the inpatient setting for additional care.

Risk Factors

According to the Cincinnati Children's Hospital Medical Center (2011), risk factors include the following:

Age < 24 months

Day care attendance or exposure to sick contacts

Recent travel to a foreign country

Immunocompromised status

Low socioeconomic status

Evaluation
History

Diarrhea: Onset, frequency, volume of stool output, appearance of stool, presence of blood, tenesmus

Vomit: Onset, frequency, bilious or nonbilious, presence of blood

Abdominal pain: Onset, location, duration, migration, cramping, continuous or intermittent, appetite

Accompanying symptoms: nausea, fever, headache, myalgias

Epidemiologic clues: travel history, day care attendance, sick contacts, diet history

Attempted treatment: medications, nonpharmacologic remedies, tolerance of oral fluids, types of oral fluids offered

Physical Examination

The priority of physical examination is to determine the level of dehydration or the presence of any other diagnosis. Any child
with severe abdominal pain and fever that demonstrates concern for an acute surgical abdomen should have a thorough
physical examination and consultation from a surgeon.

Vital signs: Weight, temperature, heart rate, respiratory rate, blood pressure, pulse oximetry

General: Appearance, activity level, mental status

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Head/eyes/ears/nose/throat: Fontanelle sunken or flat; sunken eyes; presence or absence of tears; moisture of mucous
membranes

Respiratory: Tachypnea or Kussmaul breathing could be a sign of acidosis

Cardiovascular: Examine for signs of inadequate cardiac output/hypovolemia; tachycardia, hypotension, weak or thready
pulses, delayed capillary refill time, and cool extremities may indicate severe dehydration and impending hypovolemic
shock

Gastrointestinal: Inspect the abdomen for distension; auscultate for bowel sounds, which may be hyperactive in the
presence of acute infection; palpate for organomegaly, masses, or tenderness; periumbilical tenderness is a common
finding, but focal tenderness extending from the umbilicus or peritoneal signs are indicative of a possible surgical
abdomen

Genitourinary: Examine all males for testicular torsion or hernia; a more thorough genital examination may be warranted
based on history if ovarian pathology or sexually transmitted infection is suspected

Clinical Dehydration Scales

Data support the use of validated clinical dehydration scales (World Health Organization [WHO] Scale for Dehydration, the
Gorelick scale, or the Clinical Dehydration Scale) for the rapid and objective assessment of dehydration status to facilitate
stratification of patients into treatment categories, especially in patients for whom a pre-illness weight is unavailable ( and ;
Jauregui et al., 2014; Pringle et al., 2011). Careful physical examination and vital sign review should accompany the dehydration
assessment. The WHO scale notes that lethargy and fatigue or sleepiness are not equivalent assessments, with lethargy
referring to a child who cannot be awakened because of an altered mental state (WHO, 2011).

Table 1. Treatment principles for management of dehydration

Mild Dehydration (< 5%)
Continue hydration
ORT with teaching on frequent
small volumes of liquid
Encourage regular diet
(unrestricted breastfeeding)
Replace ongoing losses
(assume 1 diarrheal
stool/emesis equals 2 oz liquid
or 10 ml/kg)
Moderate Dehydration (5–10%)
Needs ORT
Defer solids until rehydrated
May continue unrestricted
breastfeeding with oral
rehydration solution adjunct
Replace ongoing losses
(assume 1 diarrheal
stool/emesis equals 2 oz liquid
or 10 ml/kg)
Severe Dehydration (> 10%)
Needs IV rehydration
Place saline lock IV catheter and give 0.9% sodium
chloride 20 ml/kg bolus IV push; repeat if warranted
and patient is responding to fluid bolus
Recommend point of care glucose and electrolytes if
patient is listless and lethargic
Measure intake and output
Initiate ORT with teaching on frequent small
volumes of liquid once IV access obtained
May need maintenance IV fluids; hold potassium-
containing fluids until patient has voided

Note. ORT = oral rehydration therapy.

From Deforest & Thompson, 2012.

Table 2. Suggested discharge and admission criteria

Suggested discharge criteria Suggested admission criteria

Well appearing and active
Abdomen soft, nontender, and nondistended
Vital signs acceptable for age and Persistent fluid loss from significant vomiting and/or diarrhea
fever/dehydration Abnormal electrolytes or acidosis
Tolerated acceptable amounts of oral liquids Diagnosis uncertainty
in relation to ongoing losses Inability to tolerate oral liquids, keep up with fluid losses, or requires
≤ 3 episodes of vomiting and/or diarrhea overnight fluid replacement for severe dehydration
Achieves mild dehydration status on a
clinical dehydration scale

Management Principles

The outpatient treatment of pediatric patients with AGE should be guided by a dehydration assessment or pre-illness weight that
indicates total volume loss (, and ). The mainstay of therapy for children with mild or moderate dehydration should focus on ORT
with an emphasis on replacing deficits and preventing ongoing fluid losses. Providers should minimize unnecessary medications
and tests that increase costs and may potentially cause harm.

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Table 3. World Health Organization Scale for dehydration for children ages 1 month to 5 years in low- and middle-income
countries

  A. Mild dehydration B. Moderate dehydration C. Severe dehydration

Look at
Well, alert Restless, irritable Lethargic or unconscious
condition
Eyes Normal Sunken Sunken
Drinks normally, not
Thirst Thirsty, drinks eagerly Drinks poorly or not able to drink
thirsty
Feel:
skin Goes back quickly Goes back slowly Goes back very slowly
pinch
The patient has NO
If the patient has 2 or more signs in If the patient has 2 or more signs in
SIGNS OF
Decide column B, then the patient has SOME column C, then the patient has SEVERE
DEHYDRATION (<
DEHYDRATION (5%-10%) DEHYDRATION (> 10%)
5%)
Home therapy to
Weigh the patient if possible and begin
Treat prevent dehydration Begin intravenous hydration urgently
oral rehydration therapy
and malnutrition

From World Health Organization, 2011.

Table 4. The 10- and 4-Point Gorelick Dehydration Scale for children ages 1 month to 5 years

Characteristic No or minimal dehydration Moderate dehydration Severe dehydration

General appearance      
Infants Thirsty, alert, restless Lethargic or drowsy Limp, cold, cyanosis
Older children Thirsty, alert, restless Alert, dizzy Apprehensive, cold, cyanosis
Capillary refill Normal Prolonged or minimal Very prolonged
Tears Present Absent Absent
Mucous membranes* Moist Dry Very dry
Eyes* Normal Sunken Deeply sunken
Breathing* Present Deep Deep and rapid
Quality of pulses* Normal Weak, thready Feeble or impalpable
Skin elasticity Instant recoil Recoil slowly Recoil > 2 seconds
Heart rate Normal Tachycardia Tachycardia
Urine output Normal Reduced Not passed in many hours

*Four-point scale examination signs.

Scoring of 4-point scale: ≥ 2 clinical signs (4 pt) ≥ 5% body weight change; ≥ 3 clinical signs (4 pt) ≥ 10% body weight change.
Scoring of 10-point scale (all signs/symptoms): ≥ 3 clinical signs ≥ 5% body weight change; ≥ 7 clinical signs ≥ 10% body weight
change.
From Pringle et al., 2011.

Table 5. Clinical Dehydration Scale for prediction of dehydration in ages children 1 to 36 months

Characteristic 0 1 2
General Thirsty, restless, or lethargic, but irritable when Drowsy, limp, cold and/or
Normal
appearance touched comatose
Eyes Normal Slightly sunken Very sunken
Mucous
Moist "Sticky" Dry
membranes
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Tears Tears Decreased tears Absent tears

Note. From Pringle et al., 2011.

Scoring: 0: no dehydration < 3%; 1–4: some dehydration ≥ 3% and < 6%; 5–8: moderate dehydration ≥ 6%.

Drugs that alter intestinal motility or secretion, anticholinergic agents, opiates, and antibiotics are not recommended (Cincinnati
Children's Hospital Medical Center, 2011). Ondansetron is a safe and effective antiemetic medication to facilitate oral
rehydration in the acute care setting (Freedman et al., 2014; Guarino et al., 2014). Although reliance on pharmacologic
intervention shifts the therapeutic focus away from fluid and electrolyte replacement and can result in adverse effects, shared
decision making should occur between the provider and family to consider ondansetron use in the outpatient setting when
persistent vomiting impedes ORT (Fedorowicz, Jagannath, & Carter, 2011). Although the CDC may remain in opposition to
antiemetic agents in its recommendations, recent research has shown that ondansetron is a safe and effective method of
encouraging ORT in the acute care setting.

Diagnostic Studies

Laboratory tests

Not recommended for children with mild or moderate dehydration

Serum electrolytes and glucose for patients requiring intravenous rehydration

Consider a stool culture in patients with symptoms for 7 or more days, bloody stools, age less than 3 months, exposure
to an infectious pathogen, foreign travel, immunocompromised status, or who are toxic appearing

Imaging

Diagnostic imaging is typically not required unless the diagnosis of AGE is in question

Fluid Replacement

Oral rehydration therapy

Goal fluid intake: 15 ml/kg/1 hour or 60 ml/kg/4 hours ()

Table 6. Recommended sip volume by weight based on goal fluid intake

Weight Sip volume per 5 minutes

< 10 kg 1 ml/kg
10 kg 10 ml
For every additional 5 kg Increase sip volume by 5 ml to maximum sip volume = 50 ml

Note. ORT = oral rehydration therapy.

Administer via syringe or medicine cup. Duration: 1 hour; once there has been no vomiting in 1 hour, increase volume per
sip or drink freely to goal fluid intake; continue ORT for 4 hours.

Add 10 ml/kg for every episode of diarrhea or vomiting

Oral Rehydration Solution. Only clear liquids should be offered for oral rehydration. Fluids with a high sugar content may
increase the osmotic pull of water into the intestinal lumen, which causes hypernatremia and exacerbates the diarrhea. Water
causes hyponatremia from the hypotonic osmotic gradient, which may result in seizure. Suitable oral rehydration solutions
include:

WHO oral rehydration solution packets

Commercial electrolyte solutions for pediatric patients (e.g., Pedialyte and Infalyte)

Sports drinks (e.g., Gatorade and Powerade) or low-calorie sports drinks (e.g., Gatorade G2) with ½ tsp salt per 32-oz
bottle (University of Virginia Health System, 2014)

Salted rice water, salted yogurt drink, soup with salt (WHO, 2011)

Ondansetron (Zofran)

Forms. Tab (4 mg, 8 mg); oral dissolving tablet (4 mg, 8 mg); oral solution 4 mg/5 ml; injection 2 mg/ml.

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Dose. For age > 6 months: 0.15 mg/kg, maximum 8 mg as a single dose to aid in tolerance of ORT for rehydration; additional
doses are associated with an increased risk of diarrhea (Truven Health Analytics, 2016).

Alternative dosing by weight range (Deforest & Thompson, 2012; Freedman, Adler, Seshadri, & Powell, 2006):

< 8 kg: not recommended

8–15 kg: 2 mg

15–30 kg: 4 mg

> 30 kg: 8 mg

Contraindications

Long QT syndrome

Concomitant drugs that prolong QT

Known pregnancy (category B)

Diet

Breastfed infants should continue unrestricted feeding. National guidelines recommend the reintroduction of nutrition within the
first 24 hours of illness once initial rehydration is achieved (CDC, 2008). Early realimentation of an age-appropriate diet
containing simple starches, fruits and vegetables, lean meats, and yogurt aids co-transport molecules, thereby increasing fluid
and electrolyte uptake while reducing stool losses (CDC, 2003). Although the BRAT diet of bananas, rice, applesauce, and toast
is no longer promoted because of the low energy density and lack of protein or fat, these foods can still be added to the
reintroduction diet to add bulk to diarrheal stool.

Adjunct Therapy

Probiotics. Probiotics are microorganisms that can be beneficial when administered in adequate doses. Despite a lack of
consensus regarding treatment of pediatric patients who have AGE with probiotics, findings from clinical trials support the use of
probiotics to decrease the duration and intensity of AGE (Guarino, Guandalini, & Lo Vecchio, 2015). The quality of evidence on
probiotics is low, and additional research should be conducted to strengthen evidence. Lactobacillus rhamnosus GG (LGG) and
Saccharomyces boulardii have strong recommendations for use by international practice guidelines, although the strength of
evidence in these recommendations was low (Szajewska et al., 2014). Most importantly, probiotics were not associated with any
adverse events (Freedman, Ali, Oleszczuk, Gouin, & Hartling, 2013). Probiotics are considered a supplement that is not
regulated by federal quality and safety standards, and therefore product differences may result in varying efficacy, which should
be discussed with families before treatment begins.

Dose

LGG, 10 billion colony-forming units/day for 5 to 7 days (Szajewska et al., 2014)

S. boulardii, 250 to 750 mg/day for 5 to 7 days (Szajewska et al., 2014)

Zinc. Once a child is able to eat, a zinc supplement may be started to help reduce the severity and duration of symptoms. Zinc
has also been associated with reduced incidence of diarrhea for 2 to 3 months (WHO, 2011). Problems with this
recommendation in the United States relate to the increased risk for nausea and vomiting and the decreased incidence of zinc
deficiency in American children compared with developing countries (Bass, Pappano, & Humiston, 2007).

Dose

10 to 20 mg/day for 10 to 14 days (WHO, 2011)

Conclusions

AGE is a common but self-limited illness in the United States. Unfortunately, poor adherence to the recommended treatment
with oral rehydration while minimizing ancillary diagnostic studies is often seen. Using validated dehydration scales may help
assess the diverse presentations of dehydration more objectively and help stratify patients into dehydration categories for more
accurate treatment. Furthermore, ondansetron is a safe and effective medication in patients with persistent vomiting that can
facilitate use of ORT. Combining objective dehydration assessment with ondansetron and oral rehydration in the outpatient
setting helps promote family-centered, noninvasive rehydration, which they are then able to continue in the unrestricted
environment of their home.

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J Pediatr Health Care. 2016;30(6):610-616. © 2016 Mosby, Inc.

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