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Acute gastroenteritis in children

Article  in  Australian family physician · May 2005


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Acute gastroenteritis
in children
-,
BACKGROUND Gastroenteritis (GEl i, I, Gastroenteritis (GE) is inflammation of the mucous
inflammation of the mucous membranes of the membranes of the gastrointestinal tract, and is
gastrointestinal tract, and is characterised by characterised by vomiting and/or diarrhoea. Acute
vomiting and/or diarrhoea. The most common diarrhoea is defined as the abrupt onset of increased
causes arc viruses, but bacterial, protozoal and fluid content of stool above the normal value of 10
helminthic GE occur,particularly in developing mLikg/day.' In practical terms it is associated with Annette Webb,
countries. Vomiting and diarrhoea can be increased frequency and fluid consistency of stools. MBBS, FRACP, is a
nonspecific symptoms in children, and the consultant paediatrician
General practitioners commonly manage GE in
diagnosis of viral GE should be made after careful and Gastroenterology
children. Parents or carers will consult a GP in up to Fellow, Department of
exclusion of other causes.
75% of cases of childhood GE.'-' A United Kingdom Gastroenterology and
OBJECTIVE This article outline" theassessment study estimated that an average of 10 100 new Clinical Nutrition, Royal
Children's Hospital,
and man:agernent of children with acute CE. episodes of infectious intestinal disease in children Victoria.
DISCUSSION The most important complication aged less than 5 years of age are seen in general
of GE is dehydration. The amount of weight loss practice each week.'
as a percema~c of normal body weight provides In Australia, there are approximately 4000 episodes
the best estimateof degree (If dehydration. of diarrhoea per 1000 children less than 15 years
Clinical signs are not presentuntilthe child of age per year' In the United States there are 1-2
has Iost ut least 4% of their body weight. The episodes of acute diarrhoea per child below 5 years
best signs for identifYing dehydration include of age annually, with 220 000 hospital admissions
decreased peripheral perfusion, abnormal skin
(approximately 10% of all admissions for children in
t\lrg-or, and an abnormal respiratory pattern. Fluid
this age range) and 325-425 deaths per year'"
replacement iR the mainstay of man:tg~ment and
Over the past 2 decades, worldwide mortality
most Infantss nnd children can be rehydrated safety
from viral GE has fallen, mostly as a consequence of
with oral rehydration solution. Antiemetics and Mike Starr,
amidiarrhoeals are not indicated in children with widespread use of oral rehydration solutions (DRS)'
MBBS, FRACP, is a
acute GE. general paediatrician.
Aetiology infectious diseases
Viruses account for approximately 70% of episodes of physician, and
Consultant in
acute infectious diarrhoea in children, with rotavirus Emergency Medicine,
(Figure 11 being the most common cause. Rotavirus Royal Children's
infection is associated with approximately half Hospital. Victoria.
mike.starr@rch.org.au
of acute GE hospitalisations in children,' peaking
in the 6-24 months age group. Rotavirus also
causes the majority of cases of severe viral GE in
developing countries."

Australian Family Physician Vol.34, No.. 4, April 2005 ~ 227

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Theme: Acute gastroenteritis inchildren

GE, but tends to be associated with more persistent


diarrhoea. Other protozoa include cryptosporidium spp.
and Entamoeba histo/ytica.

Clinical features
Children with viral GE typically present with watery
diarrhoea without the presence of blood, with or
without vomiting, low grade fever and anorexia. Most
are less than 5 years of age.The typical peak period is
in the autumn or winter months. A history of contact
with GE may be present.
Bacterial GE may be associated with food or water
borne infections. It is usually characterised by the

Figure 1. Negatively stained rotavirua particles seen by electron


presence of bloody diarrhoea, mucous in the stools
microscopy in faecal extract. Reproduced withpermission: and a high fever. A travel history should be sought.
Professor Ruth Bishop Haemolytic uraemic syndrome should be considered
in any child with bloody diarrhoea, pallor, and poor
Bacteria account for approximately 15% of episodes; urine output. It is characterised by acute renal
bacterial GE is generally more common in the first few impairment, thrombocytopenia and microangiopathic
months of life, and then in the school aged child.' The haemolytic anaemia."
most common bacterial causes are salmonella spp., It must be noted that GE is a diagnosis of exclusion
Campy/obacter jejuni, Escherichia coli, and shigella spp. as vomiting and diarrhoea can benonspecific symptoms
Giardia lamblia is the most common protozoal cause of in young children, and it is important to exclude other

Table I. Guidelines to tbe assessment and management of dehydration l4

Assessment of dehydration Signs Treatment

No/mild dehydration No signs or decreased peripheral ORS/water/usual fluids if no dehydration.


s4% body weight loss perfusion: thirsty, alert and restless ORS only is preferred in high risk patients,
particularly those <6 months of age.
Child should be assessed regularly,
especially if <6 months and should
be seen again within 8 hours

Moderate 4-6% body weight loss Decreased peripheral perfusion, thirsty, Infants in this group may require
alert and restless, rapid pulse, sunken rehydration via the nasagastric route
eyes and fontanelle, dry mucous
membranes, deep acidotic breathing,·
pinched skin retracts slowly" (1-2 seconds)

Severe >7% body weight loss All of the above plus Intravenous rehydration is required until
In infants; drowsy, limp, cold, sweaty, organ perfusion is restored. ORS can
cyanotic limbs and altered conscious then be given
level Check electrolytes
In older children: apprehensive, cold,
sweaty, cyanotic limbs, rapid weak pulse,
low blood pressure

"these are the only signs proven to discriminate between hydration and dehydration (~4%)

228 4 Australian Famill' Physician Vol.34, No. 4, April 20()5


Theme: Acute gastroenteritis in children

Figure za-c. Assessment of capillary refill. Reproduced withpermission: Advanced Paediatric LifeSupport 4th ed: instructor materials.
Advanced LifeSupport Group, 200S

Figure2a. Press for5 seconds Figure 2b. Release. Colour should return Figure 2c. A delayof more than 2 seconds
within 2 seconds in the wellperfused, in associationwith othersigns of shock
warm child and in a warm child suggests poor
peripheral perfusion

causes for these symptoms. Other causes of these o abnormal respiratory pattern Ideep acidotic
symptoms include: breathing)"
o surgical conditions (acute appendicitis/pelvic These are the only signs proven to discriminate
abscess, malrotation with volvulus of the midgut, between hydration and dehydration (4% or greater)."
intussusception)
o inflammatory bowel disease
Which children require hospital admission?
• systemic infections (eg. urinary tract infections, Children without dehydration can be managed at
pneumonia, meningitis), and home and should be offered their normal fluids Isee
o metabolic conditions leg. diabetes meliitusJ. Resources). These can be given as small volumes
but more frequently. Children with mild to moderate
Assessment of dehydration dehydration should be observed for 4-6 hours to ensure
successful rehydration (2-4 hours) and maintenance
The most important complication of GE is dehydration. of hydration (1-2 hours). Children at high risk of
The risk of dehydration is increased with younger age, dehydration on the basis of age 1<6 months), high
and is most common in: frequency of stools 1>8 per 24 hoursl or vomits 1>4 per
o infants less than 6 monthsof age 24 hours) should be observed for at least 4-6 hours to
o those with anatomical abnormalities of their gut (eg. ensure adequate maintenance of hydration, and hospital
short gut syndrome). and admission should be considered.
o those on hyperosmolar feeds (eg. polyjouleJ. Hospital admission is required for children:
The amount of weight loss as a percentage of normal o with severe dehydration (> 7% body weight loss)
body weight provides the best estimate of degree o whose carers or parents are thought to be unable to
of dehydration, however, it is not always practical to manage the child's condition at home.
calculate this. If a child is seen early in the episode, Hospital admission should be considered for:
it is important to measure weight accurately for later o children with significant comorbidity (eg. shortbowel

comparison if required. Clinical signs are not present until syndrome, diabetes, congenital heart diseaseJ."
the child has lost at least 4% of their bodyweight ITable
What fluids to use?
11. The bestsigns for identifying dehydration include:
o decreased peripheral perfusion as evidenced by Several studies have shown that ORS correct
prolongation of capillary refill time (Figure 2a-cl dehydration more quickly and with fewer adverse
• abnormal skin turgor (pinched skin retracts slowly in effects than intravenous therapy.IS.17 Most infants and
1-2 seconds). and children can be rehydrated safely with ORS. This may

Australian Family Physician Vol. 34, N(~ 4, April2()OS • 229


Theme: Acute gastroenteritis inchildren

be given orally or if this is unsuccessful. via nasogastric based on evidence that the risks of adverse effectsof
administration. The use of ORS is based on theprinciple loperamide outweigh its limited benefit in reducing
of glucose facilitated sodium transport in the small stool frequency.15,19 Antiemetics have no proven
intestine. The compositions of ORS currently available benefit and the risk of adverse effects such as acute
in Australia are listed in Table 2 and suitable fluids dystonic reactions preclude their use in children. 20
for nondehydrated children in Table 3. The preferred Patients with invasive bacterial infections with
ORS are those that are hypotonic with an osmolarity Salmonella typhi, shigella, cholera, and those with
between 200-250 mOsm/L.17 Children who refuse to amoebiasis and giardiasis should be treated with
drink can sometimes tolerate ORS icy-poles. antibiotics. Consider antibiotic use in infants less than
6 months of age with other salmonella infections,
Which children require investigation? those who are systemically unwell, and the
All children requiring intravenous rehydration should immunocomprornised,"
have blood taken for electrolytas, urea and creatinine.
Breast and formula feeding
Stool cultures should be obtained if there is a history
of bloody diarrhoea, recent travel, or if the history is Breastfed children should continue to breastfeed
suggestive of food poisoning. through the rehydration and maintenance phases
Damage to the intestinal villi can cause transient of their acute GE.21 Additional ORS can be given if
lactose malabsorption. In any child with prolonged required. In the dehydrated child who is normally
watery diarrhoea 1>7 days) associated with signs of fed with formula, formula feeds should stop during
carbohydrate malabsorption lexcoriation of buttocks], rehydration and restart as soon as the child is
faeces should be tested for reducing substances. If rehydrated. IS Dilution of formula is unnecessary when
confirmed lactase deficiency Ireducing substances in formula is reintroduced."
stool >0.5%) lactose free feeds may be indicated for
When should solids be restarted?
2-4 weeks. Lactose free feeds can be given in the
form of soy based preparations; low lactose feeds by Studies have shown that an early return to feeding
reduced lactose cow's milk based preparations." shortens the duration of diarrhoea and improves weight
gain without increasing vomiting or diarrhoea. 2o,22.23
When should medications be used? Often the child will refuse food initially. In general,
Antidiarrhoeal agents such as loperamide should not food should not be stopped for more than 24
be used to treat acute diarrhoea in children. This is hours, and children should be offered solid food if
hungry. The complete resumption of a child's 'normal'
Table 2. Oral rehydration preparations available in Australia' feeding (including lactose containing formula) after 4
hours of rehydration with ORS, has led to significantly
Na K CI Citrate Glucose higher weight gain and does not result in worsening of
Gastrolyle 60 20 60 10 90 diarrhoea or lactose intolerance after rehydration and
Hvdrolvte 60 20 60 10 90 during hospltelisation."
Repalyle 45 20 35 30 80
Conclusion
• Concentrations expressed asmmoVL of prepared solution
Vomiting and diarrhoea can be nonspecific symptoms
in children, and the diagnosis of viral GE needs to
be made after excluding other causes. Children need
to be assessed carefully for signs of dehydration.
Children without dehydration can be managed
Table 3. Suitable fluid for nondehydrated children 14
at home and should be offered their normal
fluids. Most infants and children can be rehydrated
Solution Dilution
safely with ORS. Children with severe rehydration
Sucrose (table sugar) 1 teaspoon in 200 mL boiled water
Fruit juice 1 part in 6 parts water 1>7%1 require hospital admission and those with
Cordials 1 part in 16parts water lesser degrees of dehydration require observation
Lemonade 1 part in 6 partswater and early review to ensure rehydration is
occurring appropriately.

230 ~ Austr:ili3n Family Physician Vol.34, No. 4, April 2005


Theme: Acute gastroenteritis in children

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Australian Family PhJ'~ician Vol. 34, No.4, April 2005 ~ 231

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