InpatientCurriculum20052006

ACUTE GASTROENTERITIS
Introduction
In1992,theCentersforDiseaseControlpreparedthefirstnationalguidelinesformanagingpediatricdiarrheaand
publishedtheminMMWR.In1996,theSubcommitteeonAcuteGastroenteritis,oftheProvisionalCommitteeon
QualityImprovementoftheAAP,publishedapracticeparameterforthemanagementofacutegastroenteritisin
youngchildren(ages1moto5yo).Subsequently,in 2003theCDC publishedanupdatetotheiroriginal
recommendations,whichtheAAPendorsedin2004.
StatisticsintheUnitedStates:
accountsfor>1.5millionoutpatientvisits/year
accountsfor200,000hospitalizations/year
accountsfor300deaths/year
estimatedresponsiblefor9%of all hospitalizations ofchildren<5yo
incidenceofdiarrheainchildren<3yoestimatedat1.32.3episodes/child/year
**higherforchildrenindaycare
StatisticsWorldwide:
diarrhealdiseaseisleadingcauseofpediatricmorbidityandmortality
1.5(35) billionepisodesannuallyinchildren<5yo
1.52.5milliondeathsannuallyinchildren<5yo
**thesenumbersareasignificant improvement!
DefinitionsandTerms:
Acute Gastroenteritis (AGE):diarrhealdiseaseofrapidonset,withorwithout
accompanyingsymptoms,signs,suchasnausea,vomiting,fever,orabdominalpain
Diarrhea:thefrequentpassageofunformedliquidstools (3ormoreloose,waterystool
perday)
Dysentery:bloodormucusinstools
ExcludedfrommostdiscussionsofAGE:
o episodesofdiarrhealasting>10days
o diarrheaaccompanyingfailuretothrive
o vomitingwithnoaccompanyingdiarrhea
Etiologies:
7085%ofAGEindevelopedcountriesareduetoviruses
Rotavirusaccountsfor1/3ofallpediatricAGEhospitalizationsinU.S.
Mostcommonbacterialcauses:Campylobacter,Salmonella,Shigella,E.coli,Yersinia,
andC.difficile(iatrogenic)
Parasiticagents(e.g.Giardia)causelessthan10%ofcases
Early Intervention
Homeinterventionsareanimportantaspectofearlymanagementofacutegastroenteritis. Physicianscantriage
mostpatientsviaphoneorofficeexamination.

Reasonsforearlymedicalevaluationofchildrenwithacutediarrhea:

youngage(<6moor<8kg)
h/oprematurity,chronicmedicalcondition,concurrentillness
temperature>37.9if<3mo,or>38.9in336mo
visiblebloodinstool
highoutput
persistentemesis
caregiverreportofsignsofdehydration
changeinmentalstatus(includingirritability,apathyorlethargy)
suboptimalresponsetooralrehydrationattempts

Clinical Assessment
Athoroughandrelevanthistorymustbetaken,includingonset,frequency,characterandquantityofstools,aswell
asintake.Socialhistory(e.g.caregivers,daycare)andpastmedicalhistory(e.g.recentinfections,medications, and
medical problems)arealsonecessary.
Ideally,amountofacutechangeinweightisthebestwaytodeterminedegreeofdehydration.However,ifapre
illnessweightisnotavailable,clinicalsignsandsymptomscanbeutilizedtodeterminedegreeofdehydration.

Laboratory Management
RoutinecasesofAGEdonotrequireextensivelaboratoryworkup.
Stoolculturesareindicatedincasesofdysenteryorwherethe diagnosisofAGEisunclear.
Serumelectrolytesshouldbeconsideredincasesofmoderatetoseveredehydration, whenthe
caseisnotstraightforward, orwhenIVfluidsarerequired
Alsoconsiderelectrolytesifsymptomsofhyernatremia (irritability,doughyskin)

Fluid Management

Oralrehydrationtherapyhasrepeatedlybeenproventobeaseffectiveasintravenousfluidsintreatmentofmildto
moderatedehydrationbothoutpatientandinpatient. Methodsofdeliveryincludepoandng.
Somestudies havedemonstrateddecreasedERstaysandincreasedparentsatisfactionwithORStherapyoverIV
therapy.Thereisnodifference,however,indurationofillnessorhospitalizationrates.
Oralrehydrationsolutionscontainglucosepluselectrolytes.Many easilyavailablesolutions(e.g.Pedialyte)have45
50mmol/Lofsodium,whichisatlowerendofthatstudied.Thesearebestformaintenancefluids,butcanbeutilized
forrehydrationinotherwisehealthychildren.
Rehydration protocols:
Mild:
50cc/kgofORSplusreplacementover4hours**
beginwith5ccaliquotsq12minwithvolumesincreasingastolerated
Moderate:
100cc/kgofORSplusreplacementover4hours
Asformild,butshouldbeinsupervisedsetting(ER,office)
Severe:
20cc/kgofisotonicIVfluidsoveronehour
Repeatasnecessary
Continuereplacementforstools
**ongoinglossescanbematchedatapproximately10cc/kgforeachstool

Dietary, Medical and Other Adjuvant Therapy

 DietaryTherapy
Allchildrenshouldbereturnedtoageappropriatedietsuponinitialrehydration
Restingthegutisaninappropriateapproachearlyrefeedinghasbeenshowntoreduce
illnessduration,improvenutritionaloutcomesanddecreasechangestointestinal
permeability
Dilutingformulahasbeenshowntoprolongsymptomsanddelaynutritionalrecovery
Lactosefreeformulasarelargelyunnecessaryametaanalysisconcludedthatatleast
80%ofchildrencouldtoleratefullstrengthmilk.
BRATdietandotherrestrictivedietsareunnecessaryandprovidesuboptimalnutrition
Foodshighinsimplesugarsshouldbeavoidedduetoosmoticload(see:carbonatedsoft
drinks,juice,gelatindesserts, etc)
Medications
Antidiarrheals(e.g.loperamide,opiates,bismuthsubsalicylate)arenotrecommendedfor
useinAGE.Opiatesarecontraindicated,andtheothershavelimitedscientificevidence
tooutweighrisks)
Antiemeticscurrentlyantiemeticsare notrecommendedinthetreatmentofAGE.
Thoughsomeclinicalstudieshavedemonstratedthatondansetroncandecreasevomiting
andhospitalization.
Probiotics
Normally,gutflora(saccharolyticbacteria)fermentdietarycarbohydratesthathavenot
been absorbed.Diarrheareducesfecalflora.
Probiotics(e.g. LactobacillusGG) alterthecompositionofgutfloraandassistin restoring
normalgutfunction.
Morestudiesaresupportingtheuseofprobiotics,specifically LactobacillusGG,asan
adjuvanttherapyinAGE.

References
AmericanAcademyofPediatricsProvisionalCommitteeonQualityImprovementSubcommitteeonAcute
Gastroenteritis.Practiceparameter:themanagementofacutegastroenteritisinyoungchildren. Pediatrics. 1996
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BorowitzSM.Areantiemeticshelpfulinyoungchildrensufferingfromacuteviralgastroenteritis? ArchDisChild.
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GrunenbergN.Isgradualintroductionoffeedingbetterthanimmediatenormalfeedinginchildrenwith
gastroenteritis? ArchDis Child. 200388:4557.
Guandalini S,etal.LactobacillusGGadministeredinoralrehydrationsolutiontochildrenwithacutediarrhea:a
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KingCK,GlassR,BreseeJS,DugganC.Managingacutegastroenteritisamongchildren:oralrehydration,
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