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

TREATMENT

Medical Care
Prehospital care
Children with acute gastroenteritis rarely require intravenous (IV) access. In those presenting with
circulatory collapse due to severe dehydration or sepsis, IV access should be obtained and followed
by an immediate 20-mL/kg bolus of normal saline.

Emergency department care

The American Academy of Pediatrics (AAP), the European Society of Pediatric Gastroenterology and
Nutrition (ESPGAN), and the World Health Organization (WHO) all recommend oral rehydration
solution (ORS) as the treatment of choice for children with mild-to-moderate gastroenteritis in both
developed and developing countries, based on the results of dozens of randomized, controlled trials
and several large meta-analyses.
[2, 16, 22, 23]

One large meta-analysis of 16 trials including 1545 children with mild-to-moderate dehydration found
that compared with IV rehydration, children treated with ORS had a significant reduction in length of
hospital stay and fewer adverse events, including seizures and death.
[24] The overall rate of ORS
failure (percentage of children eventually requiring IV hydration) in studies comparing ORS with IV
hydration was about 4%.
[25]

Initial care in the emergency department should focus on correction of dehydration. The type and
amount of fluid given should reflect the degree of dehydration in the child.

Minimal orno dehydration

No immediate treatment is required. If the child is breastfed, the mother should be encouraged to
breastfeed more frequently than usual and for longer at each feed. If the child is not exclusively
breastfed, then oral maintenance fluids (including clean water, soup, rice water, yogurt drink, or other
culturally appropriate fluid) should be given at a rate of approximately 500 mL/day for children younger
than 2 years, 1000 mL/day for children aged 2-10 years, and 2000 mL/day for children older than 10
years.
In addition, ongoing fluid losses should be replaced with 10 mL/kg body weight of additional ORS for
each loose stool and 2 mL/kg body weight of additional ORS for each episode of emesis (both for
breastfed and nonbreastfed children).

A study of 647 children in Canada by Freedman et al found that patients with mild gastroenteritis and
minimal dehydration experienced fewer treatment failures when offered half-strength apple juice
followed by their preferred drinks compared with children given a standard electrolyte maintenance
solution.
[26, 27]

Mild-to-moderate dehydration

Children should be given 50-100 mL/kg of ORS over a 2- to 4-hour period to replace their estimated
fluid deficit, with additional ORS given to replace ongoing losses (10 mL/kg body weight for each stool
and 2 mL/kg body weight for each episode of emesis). After the initial rehydration phase, patients may
be transitioned to maintenance fluids as described above.

ORS should be given slowly by the parent using a teaspoon, syringe, or medicine dropper at the rate
of 5 mL every 1-2 minutes. If tolerated by the patient, the rate of ORS delivery can be increased slowly
over time.

For patients who do not tolerate ORS by mouth, nasogastric (NG) feeding is a safe and effective
alternative. Multiple clinical trials have found NG rehydration to be as efficacious as IV rehydration, but
more cost effective and with fewer adverse events.
[24, 28]

Patients should be reassessed frequently by the clinician to ensure adequacy of oral intake and
resolution of the various signs and symptoms of dehydration.

Severe d ehydration

Severe dehydration constitutes a medical emergency requiring immediate resuscitation with IV fluids.
IV access should be obtained and patients should be administered a bolus of 20-30 mL/kg lactated
Ringer (LR) or normal saline (NS) solution over 60 minutes. If pulse, perfusion, and/or mental status
do not improve, a second bolus should be administered. After this, the patient should be given an
infusion of 70 mL/kg LR or NS over 5 hours (children < 12 months) or 2.5 hours (older children). If no
peripheral veins are available, an intraosseous line should be placed. Serum electrolytes, bicarbonate,
urea/creatinine, and glucose levels should be tested.

Once resuscitation is complete and mental status returns to normal, rehydration should continue with
ORS as described above, as it has been shown to decrease the rate of hyponatremia and
hypernatremia when compared with IV rehydration.

Type of ORS

A large Cochrane meta-analysis confirmed several earlier studies showing that reduced-osmolarity
ORS (osmolarity< 250 mmol/L) is associated with fewer treatment failures, lower stool output, and
less frequent vomiting compared with standard-osmolarity ORS for patients with noncholera
gastroenteritis.
[29] Patients with cholera, however, appear to have higher rates of hyponatremia with
reduced-osmolarity ORS compared with standard-osmolarity ORS, without any of the added benefits
seen in patients with noncholera gastroenteritis.
[30]

Multiple preparations of reduced-osmolarity ORS are available in the United States, including
Pedialyte, Infalyte, and Naturalyte. Available formulations in Europe include Dioralyte and Diocalm
Junior. In developing countries, clinicians can use WHO ORS sachets or a homemade solution of 3 g
(1 tsp) salt and 18 g (6 tsp) sugar added to 1 liter of clean water.
New research suggests that polymer-based ORS, made from complex carbohydrates such as rice,
wheat, or maize, may reduce stool output and length of diarrhea compared with glucose-based ORS.
[31, 32] With these solutions, carbohydrates are slowly digested in the small intestine, releasing glucose
to facilitate sodium uptake without adding a significant osmotic load to bowel contents. Although not
widely available in the United States currently, polymer-based ORS may become the preferred
solution for oral rehydration of children with diarrhea in the future.

Feeding andnutrition

In general, children with gastroenteritis should be returned to a normal diet as rapidly as possible.
Early feeding reduces illness duration and improves nutritional outcome.

Breastfed infants should continue to breast feeding throughout the rehydration and maintenance
phases of acute gastroenteritis. Formula-fed infants should restart feeding at full strength as soon as
the rehydration phase is complete (ideally in 2-4 hours). Weaned children should restart their normal
fluids and solids as soon as the rehydration phase is complete. Fatty foods and foods high in simple
sugars should be avoided.

For the majority of infants, clinical trials have found no benefit of lactose-free formulas over lactose-
containing formulas. Similarly, highly specific diets, such as the BRAT (bananas, rice, applesauce, and
toast) diet, have not been shown to improve outcomes and may provide suboptimal nutrition for the
patient.

Prevention
Prophylaxis with Probiotics
Some meta-analyses have suggested that probiotics improve outcomes in children with acute
gastroenteritis. A large placebo-controlled study in India showed that prophylaxis with a probiotic
formula of L. plantarum in healthy newborns in the first 5 days of life led to a significant reduction in
the rate of sepsis and lower respiratory tract infections in the first 2 months of life.
[33] However, among
preschool children with acute gastroenteritis who completed another study, those who received a 5-
day course of L. rhamnosus did not have better outcomes than those in the placebo group.
[34] In
another multicenter study of children who presented to the emergency department with gastroenteritis,
a 5-day course of a probiotic with L. rhamnosus + L. helveticus did not prevent the development of
moderate-to-severe gastroenteritis.
[35]

Medication
 
 

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