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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.
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?
|D2.5NS||Dextrose 2.5% in normal saline|
|D5NS||Dextrose 5% in normal saline|
|ESPGHAN||European Society for Pediatric Gastroenterology, Hepatology and Nutrition|
|NS||Normal saline (0.9% sodium chloride)|
|ORS||Oral rehydration solution|
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.
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.
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.
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.
Points & Pearls Excerpt
Most Important References
KeriAnne Brady, MD, FAAP
Landon A. Jones, MD; Alexander Toledo, DO, PharmD, FAAEM, FAAP
February 2, 2018
March 1, 2021
Physician CME Information
Date of Original Release: February 1, 2018. Date of most recent review: January 15, 2018. Termination date: February 1, 2021.
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.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
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.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
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