Acute Gastroenteritis with Dehydration in the Emergency Department

Acute Gastroenteritis: Evidence-Based Management of Pediatric Patients

Below is a free preview. Log in or subscribe for full access. Or, get a free sample article ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion:
Please provide a valid email address.

*NEW* Quick Search this issue!

Table of Contents
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

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


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



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.



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



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.

  1. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice parameter: the management of acute gastroenteritis in young children. Pediatrics. 1996;97(3):424-435. (Practice guidelines)
  2. Roslund G, Hepps TS, McQuillen KK. The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial. Ann Emerg Med. 2008;52(1):22-29. (Prospective study; 106 subjects)
  3. Ramsook C, Sahagun-Carreon I, Kozinetz CA, et al. A randomized clinical trial comparing oral ondansetron with placebo in children with vomiting from acute gastroenteritis. Ann Emerg Med. 2002;39(4):397-403. (Prospective study; 145 subjects)
  4. Dinleyici EC, Kara A, Dalgic N, et al. Saccharomyces boulardii CNCM I-745 reduces the duration of diarrhoea, length of emergency care and hospital stay in children with acute diarrhoea. Benef Microbes. 2015;6(4):415-421. (Prospective study; 363 subjects)
  5. Van Niel CW, Feudtner C, Garrison MM, et al. Lactobacillus therapy for acute infectious diarrhea in children: a meta-analysis. Pediatrics. 2002;109(4):678-684. (Meta-analysis; 9 studies)
  6. Guarino A, Ashkenazi S, Gendrel D, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr. 2014;59(1):132-152. (Guideline)
  7. O’Ryan M, Lucero Y, O’Ryan-Soriano MA, et al. An update on management of severe acute infectious gastroenteritis in children. Expert Rev Anti Infect Ther. 2010;8(6):671-682. (Review)
  8. Liu L, Johnson HL, Cousens S, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379(9832):2151-2161. (Epidemiological study)
  9. Schnadower D, Finkelstein Y, Freedman SB. Ondansetron and probiotics in the management of pediatric acute gastroenteritis in developed countries. Curr Opin Gastroenterol. 2015;31(1):1-6. (Review)
  10. Bonadio WA. Acute infectious enteritis in children. Emergency department diagnosis and management. Emerg Med Clin North Am. 1995;13(2):457-472. (Review)
  11. Elliott EJ. Acute gastroenteritis in children. BMJ. 2007;334(7583):35-40. (Review)
  12. Szajewska H, Dziechciarz P. Gastrointestinal infections in the pediatric population. Curr Opin Gastroenterol. 2010;26(1):36-44. (Review)
  13. Dalby-Payne JR, Elliott EJ. Gastroenteritis in children. BMJ Clin Evid. 2011;2011. (Systematic review)
  14. Davey HM, Muscatello DJ, Wood JG, et al. Impact of high coverage of monovalent human rotavirus vaccine on emergency department presentations for rotavirus gastroenteritis. Vaccine. 2015;33(14):1726-1730. (Time-series analysis)
  15. Atchison CJ, Stowe J, Andrews N, et al. Rapid declines in age group-specific rotavirus infection and acute gastroenteritis among vaccinated and unvaccinated individuals within 1 year of rotavirus vaccine introduction in England and Wales. J Infect Dis. 2016;213(2):243-249. (Review)
  16. Wikswo ME, Kambhampati A, Shioda K, et al. Outbreaks of acute gastroenteritis transmitted by person-to-person contact, environmental contamination, and unknown modes of transmission--United States, 2009-2013. MMWR Surveill Summ. 2015;64(12):1-16. (Surveillance summary)
  17. Payne DC, Vinjé J, Szilagyi PG, et al. Norovirus and medically attended gastroenteritis in U.S. children. N Engl J Med. 2013;368(12):1121-1130. (Surveillance study)
  18. Deshpande ND, Shivakumar S, Bawa KS, et al. Pseudomembranous colitis. Indian Pediatr. 1993;30(3):372-374. (Case report)
  19. Schutze GE, Willoughby RE, Committee on Infectious Diseases, et al. Clostridium difficile infection in infants and children. Pediatrics. 2013;131(1):196-200. (Policy statement)
  20. Kaya A, Toyran M, Civelek E, et al. Characteristics and prognosis of allergic proctocolitis in infants. J Pediatr Gastroenterol Nutr. 2015;61(1):69-73. (Observational study; 60 subjects)
  21. Nowak-Wegrzyn A. Food protein-induced enterocolitis syndrome and allergic proctocolitis. Allergy Asthma Proc. 2015;36(3):172-184. (Review)
  22. Boyle JT. Gastrointestinal bleeding in infants and children. Pediatr Rev. 2008;29(2):39-52. (Review)
  23. Heine RG. Gastrointestinal food allergies. Chem Immunol Allergy. 2015;101:171-180. (Review)
  24. Colletti JE, Brown KM, Sharieff GQ, et al. The management of children with gastroenteritis and dehydration in the emergency department. J Emerg Med. 2010;38(5):686-698. (Review)
  25. World Health Organization. The treatment of diarrhoea. A manual for physicians and other senior health workers. Available at: Accessed January 15, 2018. (Government report)
  26. Friedman JN, Goldman RD, Srivastava R, et al. Development of a clinical dehydration scale for use in children between 1 and 36 months of age. J Pediatr. 2004;145(2):201-207. (Prospective cohort study; 137 subjects)
  27. Goldman RD, Friedman JN, Parkin PC. Validation of the clinical dehydration scale for children with acute gastroenteritis. Pediatrics. 2008;122(3):545-549. (Prospective observational study; 205 subjects)
  28. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99(5):E6. (Prospective cohort study; 186 subjects)
  29. Pringle K, Shah SP, Umulisa I, et al. Comparing the accuracy of the three popular clinical dehydration scales in children with diarrhea. Int J Emerg Med. 2011;4:58. (Prospective study; 49 subjects)
  30. Freedman SB, Vandermeer B, Milne A, et al. Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis. J Pediatr. 2015;166(4):908-916. (Meta-analysis; 9 studies, 1039 subjects)
  31. Falszewska A, Dziechciarz P, Szajewska H. Diagnostic accuracy of clinical dehydration scales in children. Eur J Pediatr. 2017. (Prospective observational study; 128 subjects)
  32. Falszewska A, Dziechciarz P, Szajewska H. The diagnostic accuracy of Clinical Dehydration Scale in identifying dehydration in children with acute gastroenteritis: a systematic review. Clin Pediatr (Phila). 2014;53(12):1181-1188. (Review)
  33. Steiner MJ, Nager AL, Wang VJ. Urine specific gravity and other urinary indices: inaccurate tests for dehydration. Pediatr Emerg Care. 2007;23(5):298-303. (Prospective cohort study; 79 subjects)
  34. Shaoul R, Okev N, Tamir A, et al. Value of laboratory studies in assessment of dehydration in children. Ann Clin Biochem. 2004;41(Pt 3):192-196. (Retrospective review; 300 subjects)
  35. Bonadio WA, Hennes HH, Machi J, et al. Efficacy of measuring BUN in assessing children with dehydration due to gastroenteritis. Ann Emerg Med. 1989;18(7):755-757. (Prospective study; 50 subjects)
  36. Narchi H. Serum bicarbonate and dehydration severity in gastroenteritis. Arch Dis Child. 1998;78(1):70-71. (Prospective study; 106 subjects)
  37. Vega RM, Avner JR. A prospective study of the usefulness of clinical and laboratory parameters for predicting percentage of dehydration in children. Pediatr Emerg Care. 1997;13(3):179-182. (Prospective study; 97 subjects)
  38. Churgay CA, Aftab Z. Gastroenteritis in children: part 1. Diagnosis. Am Fam Physician. 2012;85(11):1059-1062. (Review)
  39. Meloni GF, Tomasi PA, Spanu P, et al. C-reactive protein levels for diagnosis of Salmonella gastroenteritis. Pediatr Infect Dis J. 1999;18(5):471-473. (Confirmatory study; 248 subjects)
  40. Bruzzese E, Lo Vecchio A, Guarino A. Hospital management of children with acute gastroenteritis. Curr Opin Gastroenterol. 2013;29(1):23-30. (Review)
  41. Pothoulakis H, Triadafilopoulos G, LaMont JT. Antibiotic-associated colitis. Compr Ther. 1985;11(12):68-73. (Review)
  42. Brook I. Pseudomembranous colitis in children. J Gastroenterol Hepatol. 2005;20(2):182-186. (Review)
  43. Kucik CJ, Martin GL, Sortor BV. Common intestinal parasites. Am Fam Physician. 2004;69(5):1161-1168. (Review)
  44. Weatherhead JE, Hotez PJ. Worm infections in children. Pediatr Rev. 2015;36(8):341-352. (Review)
  45. Sýkora J, Siala K, Huml M, et al. Evaluation of faecal calprotectin as a valuable non-invasive marker in distinguishing gut pathogens in young children with acute gastroenteritis. Acta Paediatr. 2010;99(9):1389-1395. (Prospective analysis; 107 subjects)
  46. Duman M, Gencpinar P, Biçmen M, et al. Fecal calprotectin: can be used to distinguish between bacterial and viral gastroenteritis in children? Am J Emerg Med. 2015;33(10):1436-1439. (Prospective study; 84 subjects)
  47. Razzaq R, Sukumar SA. Ultrasound diagnosis of clinically undetected Clostridium difficile toxin colitis. Clin Radiol. 2006;61(5):446-452. (Case reports)
  48. Leung AK, Robson WL. Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting. Paediatr Drugs. 2007;9(3):175-184. (Review)
  49. Freedman SB. Acute infectious pediatric gastroenteritis: beyond oral rehydration therapy. Expert Opin Pharmacother. 2007;8(11):1651-1665. (Review)
  50. Levine DA. Antiemetics for acute gastroenteritis in children. Curr Opin Pediatr. 2009;21(3):294-298. (Review)
  51. Starke PR, Weaver J, Chowdhury BA. Boxed warning added to promethazine labeling for pediatric use. N Engl J Med. 2005;352(25):2653. (Correspondence)
  52. Das JK, Kumar R, Salam RA, et al. The effect of antiemetics in childhood gastroenteritis. BMC Public Health. 2013;13 Suppl 3:S9. (Meta-analysis; 7 studies)
  53. Marchetti F, Bonati M, Maestro A, et al. Oral ondansetron versus domperidone for acute gastroenteritis in pediatric emergency departments: multicenter double blind randomized controlled trial. PLoS One. 2016;11(11):e0165441. (Prospective study; 356 subjects)
  54. Freedman SB, Tung C, Cho D, et al. Time-series analysis of ondansetron use in pediatric gastroenteritis. J Pediatr Gastroenterol Nutr. 2012;54(3):381-386. (Retrospective cohort study; 3508 patient visits)
  55. Reeves JJ, Shannon MW, Fleisher GR. Ondansetron decreases vomiting associated with acute gastroenteritis: a randomized, controlled trial. Pediatrics. 2002;109(4):e62. (Prospective study; 107 subjects)
  56. Stork CM, Brown KM, Reilly TH, et al. Emergency department treatment of viral gastritis using intravenous ondansetron or dexamethasone in children. Acad Emerg Med. 2006;13(10):1027-1033. (Prospective study; 166 subjects)
  57. Freedman SB, Powell EC, Nava-Ocampo AA, et al. Ondansetron dosing in pediatric gastroenteritis: a prospective cohort, dose-response study. Paediatr Drugs. 2010;12(6):405-410. (Prospective observation study; 105 subjects)
  58. Mullarkey C, Crowley E, Martin C. The addition of ondansetron to a oral rehydration protocol for children with acute gastroenteritis. Ir Med J. 2013;106(9):266-268. (Retrospective study; 449 subjects)
  59. Ibrahim K, Al Ansari K. Flavored intravenous ondansetron administered orally for the treatment of persistent vomiting in children. J Trop Pediatr. 2016;62(4):288-292. (Prospective study)
  60. Freedman SB, Uleryk E, Rumantir M, et al. Ondansetron and the risk of cardiac arrhythmias: a systematic review and postmarketing analysis. Ann Emerg Med. 2014;64(1):19-25. (Review)
  61. United States Food & Drug Administration. FDA drug safety communication: new information regarding QT prolongation with ondansetron (Zofran). Available at: Accessed January 15, 2018. (Government report)
  62. Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2011(9):CD005506. (Systematic review; 7 studies, 1020 subjects)
  63. Sturm JJ, Hirsh DA, Schweickert A, et al. Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: are we masking alternative diagnoses? Ann Emerg Med. 2010;55(5):415-422. (Retrospective review; 34,117 subjects)
  64. Freedman SB, Hall M, Shah SS, et al. Impact of increasing ondansetron use on clinical outcomes in children with gastroenteritis. JAMA Pediatr. 2014;168(4):321-329. (Retrospective observational analysis; 804,000 patient visits)
  65. Lifschitz CH. Treatment of acute diarrhea in children. Curr Opin Pediatr. 1997;9(5):498-501. (Review)
  66. Hoekstra JH, European Society of Paediatric Gastroenterology, Hepatology and Nutrition Working Group on Acute Diarrhoea. Acute gastroenteritis in industrialized countries: compliance with guidelines for treatment. J Pediatr Gastroenterol Nutr. 2001;33 Suppl 2:S31-S35. (Review)
  67. Freedman SB, Ali S, Oleszczuk M, et al. Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. Evid Based Child Health. 2013;8(4):1123-1137. (Review)
  68. Bellemare S, Hartling L, Wiebe N, et al. Oral rehydration versus intravenous therapy for treating dehydration due to gastroenteritis in children: a meta-analysis of randomised controlled trials. BMC Med. 2004;2:11. (Meta-analysis; 14 studies)
  69. Yiu WL, Smith AL, Catto-Smith AG. Nasogastric rehydration in acute gastroenteritis. J Paediatr Child Health. 2003;39(2):159-161. (Retrospective review; 166 subjects)
  70. Freedman SB, Sivabalasundaram V, Bohn V, et al. The treatment of pediatric gastroenteritis: a comparative analysis of pediatric emergency physicians’ practice patterns. Acad Emerg Med. 2011;18(1):38-45. (Survey; 235 responders)
  71. Dale J. Oral rehydration solutions in the management of acute gastroenteritis among children. J Pediatr Health Care. 2004;18(4):211-212. (Review)
  72. Freedman SB, Willan AR, Boutis K, et al. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. (Prospective noninferiority study; 647 subjects)
  73. Granado-Villar D, Cunill-De Sautu B, Granados A. Acute gastroenteritis. Pediatr Rev. 2012;33(11):487-494. (Review)
  74. Guarino A, Albano F, Guandalini S, et al. Oral rehydration: toward a real solution. J Pediatr Gastroenterol Nutr. 2001;33 Suppl 2:S2-S12. (Review)
  75. Churgay CA, Aftab Z. Gastroenteritis in children: part II. Prevention and management. Am Fam Physician. 2012;85(11):1066-1070. (Review)
  76. Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics. 2002;109(4):566-572. (Prospective study; 96 subjects)
  77. Fox J, Richards S, Jenkins HR, et al. Management of gastroenteritis over 10 years: changing culture and maintaining the change. Arch Dis Child. 2012;97(5):415-417. (Retrospective audit)
  78. Nir V, Nadir E, Schechter Y, et al. Parents’ attitudes toward oral rehydration therapy in children with mild-to-moderate dehydration. ScientificWorldJournal. 2013;2013:828157. (Survey; 100 responders)
  79. Reid SR, Losek JD. Hypoglycemia complicating dehydration in children with acute gastroenteritis. J Emerg Med. 2005;29(2):141-145. (Retrospective prevalence study; 196 subjects)
  80. Janet S, Molina JC, Marañón R, et al. Effects of rapid intravenous rehydration in children with mild-to-moderate dehydration. Pediatr Emerg Care. 2015;31(8):564-567. (Prospective observation study; 83 subjects)
  81. Levy JA, Bachur RG, Monuteaux MC, et al. Intravenous dextrose for children with gastroenteritis and dehydration: a double-blind randomized controlled trial. Ann Emerg Med. 2013;61(3):281-288. (Prospective double-blind study; 188 subjects)
  82. Sendarrubias M, Carrón M, Molina JC, et al. Clinical impact of rapid intravenous rehydration with dextrose serum in children with acute gastroenteritis. Pediatr Emerg Care. 2017. DOI: 10.1097/PEC.0000000000001064 (Prospective randomized study; 145 subjects)
  83. Levy JA, Bachur RG. Intravenous dextrose during outpatient rehydration in pediatric gastroenteritis. Acad Emerg Med. 2007;14(4):324-330. (Retrospective case control study; 168 subjects)
  84. Freedman SB, Parkin PC, Willan AR, et al. Rapid versus standard intravenous rehydration in paediatric gastroenteritis: pragmatic blinded randomised clinical trial. BMJ. 2011;343:d6976. (Prospective study; 126 subjects)
  85. Toaimah FH, Mohammad HM. Rapid intravenous rehydration therapy in children with acute gastroenteritis: a systematic review. Pediatr Emerg Care. 2016;32(2):131-135. (Systematic review; 3 studies, 464 subjects)
  86. Borron SW, Watts SH, Tull J, et al. Intentional misuse and abuse of loperamide: a new look at a drug with “low abuse potential.” J Emerg Med. 2017;53(1):73-84. (Review)
  87. MacDonald R, Heiner J, Villarreal J, et al. Loperamide dependence and abuse. BMJ Case Rep. 2015 May 2;2015. DOI: 10.1136/bcr-2015-209705 (Case report and review)
  88. Magrone T, Jirillo E. The interplay between the gut immune system and microbiota in health and disease: nutraceutical intervention for restoring intestinal homeostasis. Curr Pharm Des. 2013;19(7):1329-1342. (Review)
  89. Vandenplas Y, De Greef E, Hauser B, et al. Probiotics and prebiotics in pediatric diarrheal disorders. Expert Opin Pharmacother. 2013;14(4):397-409. (Review)
  90. Guarino A, Guandalini S, Lo Vecchio A. Probiotics for prevention and treatment of diarrhea. J Clin Gastroenterol. 2015;49 Suppl 1:S37-S45. (Review)
  91. Allen SJ, Martinez EG, Gregorio GV, et al. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev. 2010(11):CD003048. (Meta-analysis; 56 studies)
  92. Vandenplas Y. Probiotics and prebiotics in infectious gastroenteritis. Best Pract Res Clin Gastroenterol. 2016;30(1):49-53. (Review)
  93. Feizizadeh S, Salehi-Abargouei A, Akbari V. Efficacy and safety of Saccharomyces boulardii for acute diarrhea. Pediatrics. 2014;134(1):e176-e191. (Meta-analysis; 22 studies)
  94. Szajewska H, Skórka A, RuszczyÅ„ski M, et al. Meta-analysis: Lactobacillus GG for treating acute gastroenteritis in children--updated analysis of randomised controlled trials. Aliment Pharmacol Ther. 2013;38(5):467-476. (Meta-analysis; 2963 subjects)
  95. Cruchet S, Furnes R, Maruy A, et al. The use of probiotics in pediatric gastroenterology: a review of the literature and recommendations by Latin-American experts. Paediatr Drugs. 2015;17(3):199-216. (Review)
  96. Barnes D, Yeh AM. Bugs and guts: practical applications of probiotics for gastrointestinal disorders in children. Nutr Clin Pract. 2015;30(6):747-759. (Review)
  97. Caffarelli C, Cardinale F, Povesi-Dascola C, et al. Use of probiotics in pediatric infectious diseases. Expert Rev Anti Infect Ther. 2015;13(12):1517-1535. (Review)
  98. Thomas DW, Greer FR, Committee on Nutrition; Section on Gastroenterology, Hepatology, and Nutrition. Probiotics and prebiotics in pediatrics. Pediatrics. 2010;126(6):1217-1231. (Review)
  99. Canani RB, Cirillo P, Terrin G, et al. Probiotics for treatment of acute diarrhoea in children: randomised clinical trial of five different preparations. BMJ. 2007;335(7615):340. (Prospective study; 571 subjects )
  100. Freedman SB, Williamson-Urquhart S, Schuh S, et al. Impact of emergency department probiotic treatment of pediatric gastroenteritis: study protocol for the PROGUT (Probiotic Regimen for Outpatient Gastroenteritis Utility of Treatment) randomized controlled trial. Trials. 2014;15:170. (Study currently ongoing, prospective; 886 subjects planned)
  101. Guandalini S, Pensabene L, Zikri MA, et al. Lactobacillus GG administered in oral rehydration solution to children with acute diarrhea: a multicenter European trial. J Pediatr Gastroenterol Nutr. 2000;30(1):54-60. (Prospective study; 287 subjects)
  102. Szajewska H, Ruszczycski M, KolaÄ´┐Żek S. Meta-analysis shows limited evidence for using Lactobacillus acidophilus LB to treat acute gastroenteritis in children. Acta Paediatr. 2014;103(3):249-255. (Meta-analysis; 304 subjects)
  103. PieÅ›cik-Lech M, UrbaÅ„ska M, Szajewska H. Lactobacillus GG (LGG) and smectite versus LGG alone for acute gastroenteritis: a double-blind, randomized controlled trial. Eur J Pediatr. 2013;172(2):247-253. (Prospective study; 88 subjects)
  104. Ä°ÅŸlek A, Sayar E, Yılmaz A, et al. The role of Bifidobacterium lactis B94 plus inulin in the treatment of acute infectious diarrhea in children. Turk J Gastroenterol. 2014;25(6):628-633. (Prospective study; 156 subjects)
  105. PieÅ›cik-Lech M, Shamir R, Guarino A, et al. Review article: the management of acute gastroenteritis in children. Aliment Pharmacol Ther. 2013;37(3):289-303. (Review)
  106. Vandenplas Y, De Hert S, group Ps. Cost/benefit of synbiotics in acute infectious gastroenteritis: spend to save. Benef Microbes. 2012;3(3):189-194. (Prospective study; 111 subjects)
  107. Parashette KR, Croffie J. Vomiting. Pediatr Rev. 2013;34(7):307-319. (Review)
  108. Gordon M, Akobeng A. Racecadotril for acute diarrhoea in children: systematic review and meta-analyses. Arch Dis Child. 2016;101(3):234-240. (Meta-analysis; 7 studies, 1591 subjects)
  109. Mennini M, Tolone C, Frassanito A, et al. Gelatin tannate for acute childhood gastroenteritis: a randomized, single-blind controlled trial. Paediatr Drugs. 2017;19(2):131-137. (Prospective study; 60 subjects)
  110. MichaÅ‚ek D, KoÅ‚odziej M, Konarska Z, et al. Efficacy and safety of gelatine tannate for the treatment of acute gastroenteritis in children: protocol of a randomised controlled trial. BMJ Open. 2016;6(2):e010530. (Proposed prospective study; 158 subjects)
  111. Noguera T, Wotring R, Melville CR, et al. Resolution of acute gastroenteritis symptoms in children and adults treated with a novel polyphenol-based prebiotic. World J Gastroenterol. 2014;20(34):12301-12307. (Prospective study; 300 subjects)
  112. Guerrero CA, Torres DP, García LL, et al. N-acetylcysteine treatment of rotavirus-associated diarrhea in children. Pharmacotherapy. 2014;34(11):e333-e340. (Case report)
  113. Sandhu BK, European Society of Paediatric Gastroenterology Hepatology Nutrition (ESPGHAN) Working Group on Acute Diarrhoea. Rationale for early feeding in childhood gastroenteritis. J Pediatr Gastroenterol Nutr. 2001;33 Suppl 2:S13-S16. (Review)
  114. Guarino A, Winter H, Sandhu B, et al. Acute gastroenteritis disease: report of the FISPGHAN Working Group. J Pediatr Gastroenterol Nutr. 2012;55(5):621-626. (Policy statement)
  115. Dugdale A, Lovell S, Gibbs V, et al. Refeeding after acute gastroenteritis: a controlled study. Arch Dis Child. 1982;57(1):76-78. (Prospective study; 59 subjects)
  116. Brandt KG, Castro Antunes MM, Silva GA. Acute diarrhea: evidence-based management. J Pediatr (Rio J). 2015;91(6 Suppl 1):S36-S43. (Review)
  117. McFarland LV, Ozen M, Dinleyici EC, et al. Comparison of pediatric and adult antibiotic-associated diarrhea and Clostridium difficile infections. World J Gastroenterol. 2016;22(11):3078-3104. (Review)
  118. Phavichitr N, Catto-Smith A. Acute gastroenteritis in children: what role for antibacterials? Paediatr Drugs. 2003;5(5):279-290. (Review)
  119. Pickering LK. Antibiotic therapy of colitis. Pediatr Infect Dis J. 2001;20(4):465-466. (Review)
Publication Information

KeriAnne Brady, MD, FAAP

Peer Reviewed By

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

Publication Date

February 2, 2018

Content you might be interested in
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.