Gastroenteritis in Children

Billy looked at the following guidelines to summarize the approach to a child with gastroenteritis: 

UK NICE Guideline: Diarrhoea and vomiting in children under 5 (Issued: April 2009) http://guidance.nice.org.uk/cg84

CPS Guideline: Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis (Posted: Nov 1, 2006) http://www.cps.ca/documents/position/oral-rehydration-therapy

History:

onset of diarrhea and/or vomiting (gastro is sudden in onset)

duration of vomiting and diarrhea (diarrhea 5-7 days, max 2 weeks; vomiting 1-2 days, max 3 days)

sick contact

pathogen exposure

travel history

History suggestive of increased risk of dehydration:

young age (esp <6mo)

low birth weight infants

>5 diarrhea in 24h

>2 vomiting in 24h

no oral intake

signs of malnutrition

Think about differential diagnosis if:

fever >38 in children younger than 3 months

fever >39 in children older than 3 months (fever workup required)

shortness of breath or tachypnoea

altered conscious state

neck stiffness

bulging fontanelle in infants

non-blanching rash

blood and/or mucus in stool

bilious (green) vomit

severe or localised abdominal pain

abdominal distension or rebound tenderness.

SSx of dehydration and shock

Table 1 in NICE

Increasing severity of dehydration

No clinically detectable dehydration

Clinical dehydration

Clinical shock

Symptoms (remote and face-to-face assessments)

Appears well

Red flag Appears to be unwell or deteriorating

–

Alert and responsive

Red flag Altered responsiveness (for example, irritable, lethargic)

Decreased level of consciousness

Normal urine output

Decreased urine output

–

Skin colour unchanged

Skin colour unchanged

Pale or mottled skin

Warm extremities

Warm extremities

Cold extremities

Signs (face-to-face assessments)

Eyes not sunken

Red flag Sunken eyes

–

Moist mucous membranes (except after a drink)

Dry mucous membranes (except for 'mouth breather')

–

Normal heart rate

Red flag Tachycardia

Tachycardia

Normal breathing pattern

Red flag Tachypnoea

Tachypnoea

Normal peripheral pulses

Normal peripheral pulses

Weak peripheral pulses

Normal capillary refill time

Normal capillary refill time

Prolonged capillary refill time

Normal skin turgor

Red flag Reduced skin turgor

–

Normal blood pressure

Normal blood pressure

Hypotension (decompensated shock)

Table 2 in CPS

TABLE 2

Clinical assessment of degree of dehydration *

Mild (under 5%)

Moderate (5-10%)

Severe (over 10%)

Slightly decreased urine output

Slightly increased thirst

Slightly dry mucous membrane

Slightly elevated heart rate

Decreased urine output

Moderately increased thirst

Dry mucous membrane

Elevated heart rate

Decreased skin turgor

Sunken eyes

Sunken anterior fontanelle

Markedly decreased or absent urine output

Greatly increased thirst

Very dry mucous membrane

Greatly elevated heart rate

Decreased skin turgor

Very sunken eyes

Very sunken anterior fontanelles

Lethargy

Cold extremities

Hypotension

Coma

*Some of these signs may not be present

SSx of hypernatremic dehydration:

jittery

increased muscle tone

hyperreflexia

convulsions

drowsiness or coma

Labs:

No routine blood work

Serum sodium, potassium, urea, creatinine, glucose if IV fluids or signs of hypernatremia

Blood gas if shock suspected

Stool culture if:

blood and/or mucus in stool

immunocompromized

septicemia suspected

travel history

diarrhea not improved by day 7

uncertainty about diagnosis of gastroenteritis