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Acute Gastroenteritis: Evidence-Based Management of Pediatric Patients

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Acute Gastroenteritis: Evidence-Based Management of Pediatric Patients

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  About This Issue

For a pediatric patient who presents with acute gastroenteritis, the degree of dehydration can help guide the management and necessary interventions. In this issue, you will learn:

•   What signs and symptoms indicate a case of acute gastroenteritis and which suggest a more serious illness
•   How to use various dehydration scales to approximate a patient’s degree of dehydration
•   When laboratory testing is indicated, and which tests are essential in cases of severe dehydration
•   How to use antiemetics to increase the chance that oral rehydration will be successful
•   Which solutions are best for oral rehydration of mild-to-moderately dehydrated patients and which are recommended for severely dehydrated patients
•   Alternate methods for rehydration when intravenous access may be difficult
•   Which strains of probiotics should be recommended for reduction of the duration of diarrhea
•   Evidence-based recommendations for diet and fluid intake for patients who are discharged home

  Issue Information

Author: KeriAnne Brady, MD, FAAP

Peer Reviewers: Landon A. Jones, MD; Alexander Toledo, DO, PharmD, FAAEM, FAAP

Publication Date: February 1, 2018

CME Expiration Date: February 1, 2021

CME Credits: 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2A or 2B Credits. Specialty CME credits also include 4 Infectious Disease credits.

PubMed ID: 29369591

  Issue Features
  Table of Contents
  1. Abstract
  2. Case Presentations
  3. Selected Abbreviations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Etiology and Pathophysiology
    1. Etiology
      1. Viral Pathogens
      2. Bacterial Pathogens
      3. Antibiotics
    2. Pathophysiology
  7. Differential Diagnosis
    1. Inflammatory Bowel Disease
    2. Allergic Colitis
    3. Other Diagnoses
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
    3. Determining the Degree of Dehydration
  10. Diagnostic Studies
    1. Laboratory Studies
    2. Stool Studies
    3. Imaging Studies
  11. Treatment
    1. Antiemetics
      1. Dosages and Administration Routes for Ondansetron
      2. Side Effects of Ondansetron
    2. Oral Rehydration
    3. Nasogastric and Intravenous Hydration
      1. Intravenous Fluid Resuscitation
      • Dextrose-Containing Fluids
      • Rapid Versus Standard Rehydration
    4. Antidiarrheal Agents
      1. Loperamide
      2. Bismuth Subsalicylate
      3. Probiotics
      4. Zinc
  12. Special Populations
  13. Controversies and Cutting Edge
    1. Racecadotril
    2. Gelatin Tannate
    3. Prebiotics
    4. N-acetylcysteine
  14. Disposition
  15. Summary
  16. Risk Management Pitfalls in Management of Pediatric Patients With Gastroenteritis
  17. Time- and Cost-Effective Strategies
  18. Case Conclusions
  19. Clinical Pathway for Management of Pediatric Patients With Suspected Acute Gastroenteritis
  20. Tables
    1. Table 1. Differential Diagnosis of Conditions That Cause Vomiting and-or Diarrhea
    2. Table 2. The 4- and 10-Point Gorelick Scale for
      Dehydration for Children Aged 1 Month to 5 Years
    3. Table 3. Antibiotic Therapy for Bacterial Gastroenteritis
  21. References
 
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Abstract

Although most cases of acute gastroenteritis require minimal medical intervention, severe dehydration and hypoglycemia may develop in cases of prolonged vomiting and diarrhea. The mainstay of treatment for mild-to-moderately dehydrated patients with acute gastroenteritis should be oral rehydration solution. Antiemetics allow for improved tolerance of oral rehydration solution, and, when used appropriately, can decrease the need for intravenous fluids and hospitalization. This issue reviews the common etiologies of acute gastroenteritis, discusses more-severe conditions that should be considered in the differential diagnosis, and provides evidence-based recommendations for management of acute gastroenteritis in patients with mild-to-moderate dehydration, severe dehydration, and hypoglycemia.

 

Case Presentations

An 18-month-old girl who is up-to-date on her immunizations and has no prior medical history presents with vomiting and diarrhea for the last 3 days. She initially had multiple episodes of nonbloody, nonbilious emesis that stopped yesterday. On the second day, watery, voluminous diarrhea started. Her parents estimate she has had approximately 20 episodes of diarrhea since yesterday; they cannot quantify urine output because she has had so many episodes of diarrhea. The girl does not have a fever or other symptoms. On examination, she is lying on the stretcher with her eyes closed. The girl weighs 12 kg, and her vital signs are: rectal temperature, 37.6°C (99.7°F); heart rate, 165 beats/min; blood pressure, 90/65 mm Hg; respiratory rate, 22 breaths/min; oxygen saturation, 100% on room air. Although she is crying during the examination, the girl produces no tears. Her lips are dry and her eyes appear sunken. Her abdomen is soft, with no tenderness elicited on palpation. Her capillary refill is 2 seconds. She has watery, yellow-colored stool in her diaper. Should you give this child a dose of ondansetron and attempt oral hydration or does she need intravenous hydration? Do you need to send the stool for culture? Do any laboratory studies need to be performed?

A 2-year-old boy with no past medical history is brought to the ED by his parents. His mother states that his illness started with vomiting, approximately 4 episodes, that has now resolved. He has had 10 episodes of watery, nonbloody stools in the last 2 days. He is drinking well and has appropriate urine output. The boy attends daycare, and several other children at the daycare center have the same symptoms. On examination, he is playing with his toy cars while sitting on the stretcher. His vital signs are within normal limits. He has moist oral mucosa and normal cardiac and lung examinations. His abdomen is soft, with no tenderness elicited. You diagnose him with acute gastroenteritis and inform his parents that they should continue with aggressive oral hydration. The parents ask you whether there is any medication you could prescribe that might stop his diarrhea. They also want to know if there are specific foods he should avoid. As you consider the parents' questions, you think about whether you should prescribe an antidiarrheal agent for this child? Should you recommend that the parents prescribe the traditional BRAT (bananas, rice, applesauce, toast) diet for the next few days? Are probiotics appropriate in this clinical scenario?

 

Selected Abbreviations

 AGE  Acute gastroenteritis
 D2.5NS  Dextrose 2.5% in normal saline
 D5NS  Dextrose 5% in normal saline
 ESPGHAN  European Society for Pediatric Gastroenterology, Hepatology and Nutrition
 NG  Nasogastric
 NS  Normal saline (0.9% sodium chloride)
 ORS  Oral rehydration solution

 

Introduction

Nausea, vomiting, and diarrhea are some of the most common presenting complaints of pediatric patients presenting to the emergency department (ED); and these symptoms may be associated with abdominal pain. The most common discharge diagnosis for children who present with these symptoms is acute gastroenteritis (AGE). AGE is defined as inflammation of the stomach and intestines, typically resulting from viral infection or bacterial toxins. Both vomiting AND diarrhea must be present for the diagnosis of AGE. Most cases of AGE are due to viral pathogens and are usually mild and self-limited, with no need for major medical intervention. Bacterial and parasitic infections are less common, but should be considered in the appropriate clinical context. Antibiotic-associated diarrhea and Clostridium difficile colitis are also possible etiologies of AGE symptoms.

This issue of Pediatric Emergency Medicine Practice discusses various etiologies of AGE, details how to determine the level of a patient's dehydration, and reviews practice guidelines and high-quality studies that can inform the emergency clinician of the most recent and proven treatments for AGE.

 

Critical Appraisal of the Literature

A literature search was performed in PubMed using the search terms gastroenteritis, colitis, cows' milk protein allergy, and allergic colitis. Filters included the English language and ages birth to 18 years. No date limits were imposed. Several thousand articles were found, which were screened by title and then abstract. The Cochrane Database of Systematic Reviews and policy statements by the American Academy of Pediatrics (AAP) were also searched. One hundred-seventy articles were reviewed in full, and 119 were ultimately selected for inclusion.

There are many randomized controlled trials related to pediatric AGE. The most common topics include the use of antiemetics, the ideal intravenous (IV) fluid for resuscitation, and the utility of probiotics. While many of these studies come to similar conclusions about the utility of various treatments, several involve relatively few subjects. The most recent practice guidelines published by the AAP are over 20 years old,1 but more recent studies exist. The studies by Roslund et al and Ramsook et al are robust randomized trials of oral ondansetron use in AGE.2,3 Articles evaluating probiotic use were also reviewed, such as Dinleyici et al4 and Van Niel et al,5 that evaluate Saccharomyces and Lactobacillus therapy for diarrhea, respectively. There is also a recent guideline for the treatment of AGE in children that was developed and published in 2014 by the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Pediatric Infectious Diseases.6 These recommendations were also endorsed by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

 

Risk Management Pitfalls in Management of Pediatric Patients With Gastroenteritis

3. “I didn’t find out that the patient had hypoglycemia until the electrolyte panel came back.”

If you are starting IV hydration in a child that you suspect has severe dehydration, point-of-care glucose testing should be performed rather than waiting for the formal metabolic panel. Young children have low glucose reserves and can easily develop hypoglycemia when they are dehydrated. Hypoglycemia should be treated promptly.

5. “The child was slightly tachycardic but had no other signs of dehydration on examination and had only been sick for a few hours. It was late at night and the child was sleeping, so we gave IV fluids immediately.”

Almost all children with mild-to-moderate dehydration due to AGE can rehydrate via the enteral route. IV placement is painful, IV fluids are more expensive, and the complication rate is higher than from enteral rehydration.

9. “She had been vomiting for the last 3 days. I just assumed that she had the AGE that everyone else was coming in with lately. It turns out she had acute pancreatitis.”

Most cases of vomiting alone will be early AGE; however, there are many other serious entities that will also cause vomiting. Prolonged vomiting without diarrhea is concerning. Look carefully for signs and symptoms that might suggest other diagnoses, such as severe abdominal pain, jaundice, polyuria/polydipsia, bilious emesis, abdominal distension, etc.

 

 

Tables

gastroenteritis - Acute Gastroenteritis - dehydration - inflammatory bowel disease - pediatric - Table 1. Differential Diagnosis of Conditions That Cause Vomiting and-or Diarrhea

 

 

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.

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  CME Information

Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Specialty CME: Included as part of the 4 hours, this CME activity is eligible for 4 hours of Infectious Disease credits, subject to your state and institutional requirements.

Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Brady, Dr. Jones, Dr. Toledo, Dr. Claudius, Dr. Horeczko, Dr. Mishler, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.

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