Urgent Care Management of Acute Gastroenteritis in Pediatric Patients (Pharmacology CME and Infectious Disease CME)

Table of Contents

 

About This Course

The course covers:

The signs and symptoms that indicate a case of acute gastroenteritis (AGE) in a pediatric patient versus a more serious illness that may require transfer to the emergency department

Indications for laboratory testing in pediatric patients with AGE

The appropriate use of antiemetics to increase the chance that oral rehydration will be successful

Oral rehydration strategies for mild-to-moderately dehydrated patients

Evidence-based recommendations for diet and fluid intake for patients who are discharged home, including the latest evidence on the use of probiotics and prebiotics in the treatment of AGE

1. About This Course
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
   1. Etiology
      1. Viral Pathogens
      2. Bacterial Pathogens
      3. Antibiotics
      4. Parasites
   2. Pathophysiology
6. Differential Diagnosis
   1. Inflammatory Bowel Disease
   2. Toxic Megacolon
   3. Hemolytic Uremic Syndrome
   4. Allergic Colitis
   5. Other Diagnoses
7. Urgent Care Evaluation
   1. History
   2. Physical Examination
   3. Determining the Degree of Dehydration
8. Diagnostic Studies
   1. Laboratory Studies
   2. Stool Studies
   3. Imaging Studies
9. Treatment
   1. Oral Rehydration
   2. Antiemetics
      1. Dosages and Administration Routes for Ondansetron
      2. Side Effects of Ondansetron
      3. Prescription Ondansetron
   3. Nasogastric and Intravenous Hydration
      1. Intravenous Fluid Resuscitation
         • Treatment of Hypoglycemia
         • Rapid Versus Standard Rehydration
   4. Antidiarrheal Agents
      1. Loperamide
      2. Bismuth Subsalicylate
      3. Probiotics, Prebiotics, and Synbiotics
      4. Zinc
10. Special Populations
11. Controversies and Cutting Edge
    1. Racecadotril
    2. Gelatin Tannate
    3. Bimodal Release Ondansetron
12. Disposition
13. Summary
14. Time- and Cost-Effective Strategies
15. Critical Appraisal of the Literature
16. Risk Management Pitfalls in Management of Pediatric Patients With Gastroenteritis
17. Case Conclusions
18. Clinical Pathway for Urgent Care Management of Pediatric Patients With Suspected Acute Gastroenteritis
19. References

Abstract

Although most cases of acute gastroenteritis require minimal medical intervention, dehydration and hypoglycemia may develop in cases of prolonged vomiting and diarrhea. The mainstay of treatment for patients with mild-to-moderate dehydration with acute gastroenteritis is 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 course 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 pediatric patients presenting to urgent care.

Case Presentations

CASE 1: 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, she had several large-volume, watery, nonbloody stools. Her parents estimate she has had approximately 10 episodes of diarrhea since yesterday. They are unsure of how many wet diapers because she has had so many episodes of diarrhea.
• She has no fever, cough, rhinorrhea, or rash. Her parents report no recent travel, no new animal exposure, and no antibiotic use within the last 6 weeks.
• On examination, she is sitting in her mother’s lap, awake and alert, with her eyes open. The girl weighs 12 kg, and her vital signs are: 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 mouth is dry and her eyes appear sunken. Her abdomen is soft, non-distended with no tenderness, no masses, and no hepatosplenomegaly. Her capillary refill is 3 seconds. She has watery, yellow-colored stool in her diaper.
• You wonder whether you should give this child a dose of ondansetron and attempt oral hydration, or start IV hydration. You consider sending her stool for culture and/or ordering laboratory studies...

CASE 2: A 2-year-old boy is brought to the urgent care by his mother, who 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…

• The boy has no past medical history. He attends daycare, and several other children at the daycare center have the same symptoms.
• He is drinking well and has normal urine output.
• On examination, he is playing with his toy cars while sitting on the exam table. 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 the boy with acute gastroenteritis and inform his mother that she should continue with aggressive oral hydration. She asks you whether there is any medication you could prescribe that might stop his diarrhea. She also wants to know if there are specific foods he should avoid.
• You wonder if you should prescribe an antidiarrheal agent for this child...

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Urgent Care Management of Pediatric Patients With Suspected Acute Gastroenteritis

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * 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) DOI: 10.1097/MPG.0000000000000375

6. United States Centers for Disease Control and Prevention. Norovirus Worldwide. Accessed April 1, 2022. (CDC webpage)

23. * 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) DOI: 10.1016/j.jemermed.2008.06.015

25. World Health Organization Department of Child and Adolescent Health and Development. The treatment of diarrhoea: a manual for physicians and other senior health workers, 4th rev. Accessed April 1, 2022. (Clinical manual)

37. * Prisco A, Capalbo D, Guarino S, et al. How to interpret symptoms, signs and investigations of dehydration in children with gastroenteritis. Arch Dis Child Educ Pract Ed. 2021;106(2):114-119. (Review) DOI: 10.1136/archdischild-2019-317831

52. * Freedman SB. Acute infectious pediatric gastroenteritis: beyond oral rehydration therapy. Expert Opin Pharmacother. 2007;8(11):1651-1665. (Review) DOI: 10.1517/14656566.8.11.1651

61. * 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.e26. (Prospective study; 106 patients) DOI: 10.1016/j.annemergmed.2007.09.010

65. * Fugetto F, Filice E, Biagi C, et al. Single-dose of ondansetron for vomiting in children and adolescents with acute gastroenteritis-an updated systematic review and meta-analysis. Eur J Pediatr. 2020;179(7):1007-1016. (Meta-analysis; 2146 patients) DOI: 10.1007/s00431-020-03653-0

75. United States Food and Drug Administration. New information regarding QT prolongation with ondansetron (Zofran). 2012. Accessed April 1, 2022. (FDA drug safety communication)

78. * 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 patients) DOI: 10.1067/mem.2002.122706

84. Multi-DOSE Oral Ondansetron for Pediatric Acute GastroEnteritis (DOSE-AGE). ClinicalTrials.gov Identifier: NCT03851835. Accessed April 1, 2022. (Clinical trial description)

85. * King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16. (Practice guidelines) PMID: 14627948

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Keywords: urgent care, gastroenteritis, acute gastroenteritis, AGE, dehydration, hypoglycemia, methemoglobinemia, dehydration, diarrhea, vomiting, hypoglycemia, oral rehydration solution, nasogastric hydration, antiemetic, ondansetron, nasogastric tube, nasogastric hydration, probiotics, prebiotics, synbiotics, zinc, norovirus, colitis, allergic colitis, Clostridioides difficile colitis, C diff colitis, inflammatory bowel disease, BRAT diet