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Pediatric
Gastroenteritis Medication
Updated: Nov 26, 2018
Author: Randy P Prescilla, MD; Chief Editor: Russell W Steele, MD  more...

MEDICATION

Medication Summary
The goals of pharmacotherapy are to reduce morbidity, prevent complications, and provide
prophylaxis. Antidiarrheal (ie, kaolin-pectin) and antimotility agents (ie, loperamide) are
contraindicated in the treatment of acute gastroenteritis in children because of their lack of benefit and
increased risk of adverse effects, including ileus, drowsiness, and nausea.

Probiotics are live microbial feeding supplements commonly used in the treatment and prevention of
acute diarrhea. Possible mechanisms of action include synthesis of antimicrobial substances,
competition with pathogens for nutrients, modification of toxins, and stimulation of nonspecific immune
responses to pathogens. Two large systematic reviews have found probiotics (especially Lactobacillus
GG) to be effective in reducing the duration of diarrhea in children presenting with acute
gastroenteritis.
[36, 37] A recent meta-analysis found probiotics may be especially effective for the
prevention of C difficile –associated diarrhea in patients receiving antibiotics.
[38] As probiotic
preparations vary widely, it is difficult to estimate the effectiveness of any single preparation.

A recent review of 24 published studies found zinc supplementation may be effective in reducing the
duration of diarrhea in children older than 6 months in areas where zinc deficiency and moderate
malnutrition is prevalent.
[39] The World Health Organization (WHO) recommends zinc
supplementation (10-20 mg/day for 10-14 days) for all children younger than 5 years with acute
gastroenteritis, although little data exist to support this recommendation for children in developed
countries.

The mainstay of therapy includes prevention with the rotavirus vaccine and treatment with
antimicrobials and antiemetics.

Vaccines

Class Summary
In February 2006, the US Food and Drug Administration (FDA) approved the RotaTeq vaccine for the
prevention of rotavirus gastroenteritis. The vaccine has been endorsed by the American Academy of
Pediatrics (AAP).In April 2008, the FDA approved Rotarix, another oral vaccine, for the prevention of
rotavirus gastroenteritis. The current recommendation is to administer 2 separate doses of Rotarix to
patients aged 6-24 weeks. Rotarix was efficacious in a large study, which reported that Rotarix
protected patients with severe rotavirus gastroenteritis and decreased the rate of severe diarrhea or
gastroenteritis of any cause.
[40] Recent large trials in both Latin America and Africa have also found
Rotarix to be effective in decreasing diarrhea morbidity and mortality in children.
[41, 42, 43]

Rotavirus vaccine (RotaTeq, Rotarix)

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Currently, 2 orally administered live-virus vaccines are marketed in the United States. Each is
indicated to prevent rotavirus gastroenteritis, a major cause of severe diarrhea in infants.

RotaTeq is a pentavalent vaccine that contains 5 live reassortant rotaviruses and is administered as a
3-dose regimen against G1, G2, G3, and G4 serotypes, the 4 most common rotavirus group A
serotypes. It also contains attachment protein P1A (genotype P[8]).

Rotarix protects against rotavirus gastroenteritis caused by G1, G3, G4, and G9 strains and is
administered as a 2-dose series in infants aged 6-24 weeks.

Clinical trials reported that the vaccines prevented 74-78% of all rotavirus gastroenteritis cases, nearly
all severe rotavirus gastroenteritis cases, and nearly all hospitalizations due to rotavirus.

Antibiotics

Class Summary
Since the majority of cases of acute gastroenteritis in developed and developing countries are due to
viruses, antibiotics are generally not indicated. Even in cases (eg, dysentery) in which a bacterial
pathogen is suspected, antibiotics may prolong the carrier state (Salmonella infection) or may
increase the risk of developing hemolytic-uremic syndrome (enterohemorrhagic Escherichia coli
infection).
[44]

In patients with positive stool assays or high clinical suspicion for C difficile infection, the offending
antibiotic should be stopped immediately. Metronidazole (30 mg/kg/day divided qid for 7 days) can be
used as a first-line agent, with oral vancomycin reserved for resistant infections.
[44]

Although generally not recommended for children younger than 8 years, tetracycline (50 mg/kg/day
PO divided qid for 3 days) and doxycycline (6 mg/kg PO as a single dose) remain the treatments of
choice for cholera. Alternative treatments with good efficacy include erythromycin and ciprofloxacin.
[44]

For patients with ova and parasite testing that confirms infection with Giardia, metronidazole (35-50
mg/kg/day PO divided q8h) remains the drug of choice. Nitazoxanide oral suspension (age 1-3 y: 100
mg PO q12h for 3 days; age 4-11 y: 200 mg PO q12h for 3 days) is as effective as metronidazole and
has the added benefit of treating other intestinal parasites, such as Cryptosporidium.
Metronidazole (Flagyl)
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Metronidazole is recommended as the treatment of choice for mild-to-moderate cases of C difficile

colitis. It provides effective therapy, with reported response rates from 95-100%. In vitro activity is
bactericidal and dose dependent. Standard dosing has been shown to promote fecal concentrations
capable of a 99.99% reduction of C difficile. IV metronidazole may be administered to those patients
who cannot tolerate oral medications because of its potential to accumulate in the inflamed colon. The
IV route is not as effective as the oral route.

Doxycycline (Bio-Tab, Doryx, Doxy)

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Doxycycline is a broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline

class. It is almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a
biologically active metabolite in high concentrations.

It inhibits protein synthesis and, thus, bacterial growth by binding to the 30S and possibly 50S
ribosomal subunits of susceptible bacteria. It may block dissociation of peptidyl tRNA from ribosomes,
causing RNA-dependent protein synthesis to arrest.

It is the treatment of choice for cholera. It is not recommended for children younger than 8 years.

Nitazoxanide (Alinia)
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Nitazoxanide inhibits growth of C parvum sporozoites and oocysts and G lamblia trophozoites. It elicits
antiprotozoal activity by interference with the pyruvate: ferredoxin oxidoreductase (PFOR) enzyme-
dependent electron transfer reaction, which is essential to anaerobic energy metabolism. It is available
as an oral suspension (20 mg/mL).

Tetracycline (Sumycin)
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Tetracycline treats gram-positive and gram-negative organisms, as well as mycoplasmal, chlamydial,

and rickettsial infections. It inhibits bacterial protein synthesis by binding with 30S and possibly 50S
ribosomal subunit(s). It is the treatment of choice for cholera. It is not recommended for children
younger than 8 years.

Antiemetics

Class Summary
A review of 7 randomized, controlled trials in children found that oral ondansetron reduced vomiting
and the need for intravenous (IV) rehydration and hospital admission, IV ondansetron and
metoclopramide reduced the number of episodes of vomiting and hospital admission, and
dimenhydrinate suppository reduced the d uration of vomiting.
[45, 46]

A previous large, prospective, randomized, double-blind trial compared a single dose of an orally
disintegrating ondansetron tablet with placebo in children presenting to an emergency department with
acute gastroenteritis.
[47] This study also found that children treated with ondansetron were less likely
to vomit and that they had greater oral intake, were less likely to require IV rehydration, and had a
reduced length of stay in the emergency department compared with children treated with placebo.

Several smaller studies have also demonstrated ondansetron to be effective in children.

[45, 48]

Ondansetron (Zofran)
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Ondansetron is a selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and
centrally. This is an off-label indication for pediatrics. Caution is advised with IV administration
because of reported QT prolongation with higher doses.

Metoclopramide (Reglan)
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Metoclopramide blocks dopamine receptors in chemoreceptor trigger zone of CNS and sensitizes
tissues to acetylcholine. This is an off-label indication for pediatrics. Use is limited because of its risk
for tardive dyskinesia.

Dimenhydrinate (Dramamine)
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Dimenhydrinate is an ethanolamine H1 antagonist containing diphenhydramine and 8-chloro-

theophylline. Its pharmacological effects principally result from diphenhydramine moiety, and it has
CNS depressant, anticholinergic, antiemetic, antihistamine, and local anesthetic effects.

Follow-up
 
 

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