Quick Guide to Pediatric Acute Gastroenteritis

Key Concepts and Management

Definition:

  • Diarrhea (equal or more than 3 soft/liquid stools in 24 hours), with/without vomiting, fever. Duration: less than 7 days, maximum 14 days.
  • Main complication: Dehydration.

Common Etiology:

  • Viral (70-90%): Rotavirus (vaccination reduces), Norovirus (currently most common), Adenovirus, Astrovirus. Fecal-oral transmission.
  • Bacterial: Salmonella, Shigella, Campylobacter, E. coli (HUS risk), C. difficile. Often with fever, bloody diarrhea.
  • Parasitic: Giardia, Cryptosporidium. Prolonged diarrhea.

Essential History:

  • Characteristics of diarrhea/vomiting (frequency, volume, blood/mucus).
  • Fluid intake and diuresis (urinations).
  • Pre-illness weight (key to dehydration).
  • Exposure (daycare, travel, antibiotics).

Physical Examination (Signs of Dehydration):

  • General condition: Irritable, lethargic.
  • Mucous membranes: Dry.
  • Skin turgor: Decreased (fold).
  • Capillary refill: Prolonged (more than 2 seconds).
  • Sunken eyes, absent tears.
  • Rapid/weak pulse, abnormal breathing.
  • Extreme thirst, oliguria/anuria.

Dehydration Classification (Weight Loss):

  • Mild: less than 5% infants, less than 3% older children.
  • Moderate: 5-9% infants, 3-5% older children.
  • Serious: equal or more than 10% infants, equal or more than 6% older children.

Complementary Diagnostic Tests (Only if):

  • Severe or refractory dehydration.
  • Bloody/persistent diarrhea (more than 7 days).
  • Persistent high fever, systemic involvement.
  • Immunocompromised, infants less than 3 months with involvement.
  • Ex: Stool culture, electrolytes, kidney function.
Key Signs Mild Dehydration Moderate Dehydration Severe dehydration
General Appearance Thirsty, restless Thirsty, sleepy Hypotonic, lethargic, shock
Mucous membranes Pasty dry Very dry
Skin Turgor Normal Decreased (slow fold) Very reduced (very slow fold)
Capillary Filling Normal (less than 2s) Slow (2-3s) Very slow (more than 3s)
Weight Loss (%) <5% (Infants) / <3% (Children) 5-9% (Infants) / 3-5% (Children) >= 10% (Infants) / >= 6% (Children)

Oral Rehydration (OR):

  • Pillar of treatment. Low osmolarity ORS (NOT juices, sodas, sports drinks).
  • Administer in small quantities and frequently (5-10 ml every 5-10 min).
  • Volume: 50-100 ml/kg in 3-4 hours + 5-10 ml/kg for each stool/vomit.
  • If vomiting is persistent or uncooperative: Consider NGS (gastroclysis).
  • Contraindications (RO): Shock, severe dehydration, uncontrollable vomiting (ORT failure), ileus.

Intravenous Rehydration (IVR):

  • Indications: Shock, severe dehydration (equal to or more than 10%), neurological impairment, RO/NGT failure.
  • Initial bolus: 0.9% saline (10-20 ml/kg in 10-20 min), repeat if necessary.

Nutritional Management:

  • Early feedback: Start as soon as possible after initial rehydration (4-6h).
  • Breastfeeding: Continue on demand.
  • Formulas: Use as usual (do not dilute).
  • Avoid: Restrictive diets (BRAT), prolonged fasting.
  • Foods to introduce: Boiled rice, potato, chicken, white fish, apple/banana (cooked), yogurt.
  • Foods to temporarily avoid: Concentrated sugars, juices/soft drinks.

Adjuvant Pharmacological Treatments:

  • Antiemetics: Ondansetron (selected cases of uncontrollable vomiting to facilitate RO). Cautious use. Not routine.
  • Antidiarrheals: Not routine. Loperamide (contraindicated under 12 years, bloody diarrhea). Racecadotril, smectite (may reduce duration/symptoms).
  • Probiotics: Certain strains (L. GG, S. boulardii) may slightly shorten duration.
  • Antibiotics: NOT routine (mostly viral). Indications: Severe/bloody Shigella, cholera, affected infants less than 3 months old, immunocompromised, malnutrition. Contraindicated in E.coli O157:H7 (HUS risk).
  • Zinc: WHO recommends (developing countries: 20 mg/day children over 6 m, 10 mg/day less than 6 m for 10-14 days). Non-routine ESPGHAN in developed countries (malnutrition only).

Main Complications:

  • Dehydration (more severe).
  • Hemolytic uremic syndrome (HUS) (with E.coli/Shigella).
  • Malnutrition, hypoglycemia, secondary lactose intolerance.

Medical Care Criteria (Parents should ask if):

  • More than 8 bowel movements/24 hours, more than 2 vomiting.
  • Age less than 2 months, underlying disease.
  • Signs of dehydration: weakness, sunken eyes, dry mouth, crying without tears, scant urine.
  • Blood in stool, uncontrollable high fever.
  • Altered mental status, intense abdominal pain.

Hospitalization Criteria:

  • Shock, severe dehydration (equal or more than 9% weight loss).
  • Neurological alterations (lethargy, seizures).
  • Uncontrollable vomiting or failure of RO/NGS.
  • Inability of caregivers for home management.
  • Suspected abdominal surgery, anuria (more than 12 hours).
  • Infants less than 3 months with significant AGE.

Hygiene and Sanitation:

  • Handwashing: Meticulous (after diaper change, before handling food). Most effective measure.
  • Food hygiene: Safe water, complete cooking of food, proper storage.
  • Disinfection of surfaces in the home/daycare.
  • Exclusion from daycare/schools: Up to 48 hours without symptoms.

Vaccination:

  • Rotavirus vaccine: Oral, safe, highly effective. Reduces incidence/severity.
  • Measles Vaccine: Also reduces diarrhea.

Breastfeeding:

  • Exclusive for the first 6 months: Significant protective factor against gastrointestinal infections.

Complementary Video:

Here you can access my class on Pediatric Acute Gastroenteritis on YouTube:

Watch video on YouTube (Duration: 24:10)

This video is an external resource.