Clinical Practice Guidelines

Gastroenteritis


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network


  • RCH: Consider 

    Criteria Led Discharge

    See also:

    Background to condition:

    • Infectious gastroenteritis causes diarrhoea with or without vomiting (non-bilious) or cramping abdominal pain.
    • Many cases can be managed effectively with oral rehydration.
    • Enteral rehydration is preferable to intravenous hydration.
    • Shocked children require urgent resuscitation with 20 mls/kg boluses of IV Normal Saline.
    • Children on fortified formulas need to have their fortification ceased during acute illness.

    Assessment:

    Is the diagnosis of gastroenteritis correct?:
    Consider important differential diagnoses:
    • UTI
    • Appendicitis
    • Other infections
    • Surgical causes of acute abdomen

    Consider the diagnosis carefully if there is

    • Abdominal pain
    • Isolated Vomiting

    Are there significant comorbidities /risk factors?

    Red flags

    The following features may occur in gastroenteritis, but should prompt careful consideration of differential diagnoses and review by a senior doctor:
    • severe abdominal pain or abdominal signs
    • persistent diarrhoea (> 10 days)
    • blood in stool
    • very unwell appearance
    • bilious (green) vomit
    • vomiting without diarrhoea

    Children with the following features should be discussed with a senior doctor:  

    • short gut syndrome
    • ileostomy
    • complex/cyanotic congenital heart disease
    • renal transplant or renal insufficiency
    • very young ( <6 months)
    • poor growth
    • use of fortified feeds (concentrated feeds or caloric additives)
    • recent use of potentially hypertonic fluids (eg Lucozade)
    • other chronic disease
    • repeated presentations for same/similar symptoms

    4. Degree of dehydration, see dehydration guideline:

    Investigations:

    In most children with gastroenteritis no investigations are required.
    Faecal samples may be collected for bacterial culture if the child has significant associated abdominal pain or blood in the faeces, as a bacterial cause of gastroenteritis is more likely. However, these results usually don't alter treatment. Extensive testing for viral and bacterial causes is expensive and usually does not influence treatment.


    Some viruses (e.g. enteroviruses) and other organisms (e.g. Dientamoeba fragilis and Blastocystis hominis) can be found in the stools of healthy individuals and their detection does not change the management. Testing is usually not indicated.

    Consider stool microbiological investigations if: 
     
    •        the diarrhoea has not improved by day 7, particularly if the child has recently been abroad 
    •        you suspect septicaemia 
    •        there is blood and/or mucus in the stool, particularly if protracted or the child is systemically unwell  
    •        the child is immunocompromised.

     Blood tests (electrolytes, glucose) are not necessary in simple gastroenteritis but are required for children with:

    • severe dehydration
    • renal disease or diuretic use
    • altered conscious state
    • 'doughy' skin (suggesting hypernatraemia)
    • home therapy with excessively hypertonic fluids (eg homemade solutions with added salt) or excessively hypotonic solutions (eg prolonged plain water or diluted formula)
    • profuse or prolonged losses
    • ileostomy

    Acute management:

     Ondansetron
    • Not recommended for children < 6 months old or < 8kg
    • Should only be administered once in this setting.

    Anti-diarrhoeals are not recommended.

    Table 1: Ondansetron wafer dose (drug dose)
     Weight   Ondansetron wafer dose

     8 -15 kg

     2mg

    15-30 kg 

     4mg

    > 30 kg 

     8 mg


    Oral rehydration

    • Lemonade, homemade oral rehydration solutions (ORS) and sports drinks are not appropriate fluids for rehydration
    • Stop any feed fortifications (such as extra scoops of formula or Polyjoule)
    • Encourage parents to find methods to help children drink.  Eg: cup, icypole or syringe, aiming for small amounts of fluid often.
    • Continue breastfeeding.
    • Suggest ORS eg. GastrolyteTM, HYDRAlyteTM, PedialyteTM 
    • Early feeding (as soon as rehydrated) reduces stool output, and aids gastrointestinal tract recovery.
    • Recommend usual diet once rehydrated.
    • If diarrhoea worsens in setting of formula feeding, consider the temporary (2 weeks) use of lactose free formula.

    Trial of oral fluids in the emergency department: 

    • Most children with mild/no dehydration can be discharged without a trial of fluids after appropriate advice and follow-up arranged.
    • Aim for 10-20 mls/kg fluid over 1 hour of ORS; give frequent small amounts.
    • Significant ongoing GI losses (frequent vomiting or profuse diarrhoea) minimises the chance of success at home.
      Consider early NGT rehydration in these children.
    Nasogastric Rehydration (NGTR)
    • Nasogastric rehydration is a safe and effective way of rehydrating most children with moderate dehydration, even if the child is vomiting. It is preferred over the IV route.
    • Most children stop vomiting after NGT fluids are started. If vomiting continues, consider ondansetron and slow NG fluids temporarily.
    • Use ORS eg. GastrolyteTM, HYDRAlyteTM, PedialyteTM .
    • This is not applicable to children with dehydration from respiratory illnesses eg bronchiolitis or with hypernatremia who require a tailored rehydration plan [insert link to bronchiolitis, hypernatremia guideline]
    Rapid nasogastric rehydration:
    • 25ml/kg/hr for 4 hours
    • Suitable for the majority of patients with gastroenteritis and moderate dehydration (see indications for 'slower' NGR and indications for IV rehydration below)
    • To calculate hourly rate  see table 2:
    Table 2: Recommended hourly rate for Rapid nasogastric rehydration (Not intravenous rehydration)
    Weight on Admission mls/hr Total infusion time 

     7 kg

    175

     4 hrs

     8 kg

    200

     4 hrs

     9 kg

    225

     4 hrs

     10 kg

    250

     4 hrs

     12 kg

    300

     4 hrs

     14 kg

    300

     4.5 hrs

     16 kg

    300

     5 hrs

     18 kg

    300

     6 hrs

     20 kg

    300

     6.5 hrs


    Slower nasogastric rehydration:

    Slower rehydration is preferred for the following patients:

    • Infants < 6 months
    • Comorbidities present.
    • Children with significant abdominal pain.

    Replace deficit over first 6 hours and then give daily maintenance over the next 18 hours. To calculate hourly rate,  see table 3:

    Table 3 : recommended hourly rate for Slower nasogastric rehyration
    The calculated amounts do not need to be modified for exact degree of dehydration and should be used for patients with moderate or severe dehydration based on clinical signs.

    Weight on Admission                                                       Degree of dehydration
                                               Moderate                                                        Severe

    Weight

    mls/hr
    0 - 6 hrs

    mls/hr 
    7 - 24 hrs

    mls/hr
    0 - 6 hrs

    mls/hr
    7 - 24 hrs
     

    3 kg

    30

    20

    50

    20

    4 kg

    40

    30

    65

    30

    5 kg

    50

    35

    80

    35

    6 kg

    60

    40

    100

    40

    7 kg

    70

    45

    115

    45

    8 kg

    80

    50

    130

    50

    9 kg

    90

    55

    150

    55

    10 kg

    100

    60

    165

    60

    12 kg

    120

    65

    200

    65

    15 kg

    150

    70

    250

    70

    20 kg

    200

    85

    285 
    for 7 hrs*

    85
    for 17 hrs**

    30 kg

    300

    90

    300
    for 10 hrs*

    115
    for 14 hrs**


    * RCH enteral pumps deliver a maximum of 300 ml/hr;
    ** ie residual maintenance delivered over shorter time course

    Ongoing profuse losses during NGT rehydration:

    • If vomiting continues consider ondansetron and slow NG fluids temporarily.
    • For patients who continue to have significant vomiting (2 large vomits in 1 hour) or significant abdominal pain during NGTR, re-examine the patient to exclude differential diagnoses including development of ileus. If satisfied with examination, then halve rate of NGT fluids.
    • If vomiting continues despite halved rate or profuse ongoing diarrhoea, consider
      • Slower NGTR
      • IV fluids

    Intravenous rehydration

    Indications:

    • Current evidence suggests NGTR is safer and more effective but IV rehydration is indicated for severe dehydration and if NGTR fails (eg. ongoing profuse losses or abdominal pain).
    • Also suitable for children who already have an IV insitu.
    • Certain comorbidities, particularly GIT conditions (eg. short gut or previous gut surgery) - discuss these patients with senior staff.

    IV Fluids see guideline:

    • If shocked: 20ml/kg 0.9% sodium chlodride (normal saline) boluses, repeated until shock is corrected. If > 40 ml/kg boluses required, see shock guideline {link}
    • Measure blood glucose and treat hypoglycaemia with 5ml/kg of 10% glucose.
    • Rapid IV Rehydration: In older children > 4 years with moderate dehydration with no comorbidities, no electrolyte disturbance and no significant abdominal pain, consider 10 ml/kg/hr (up to 1000ml/hr) for 4 hours of Plasma-Lyte 148 and 5% Glucose OR 0.9% sodium chloride (normal saline) and 5% Glucose, then reassess.
    • Standard IV Rehydration: Otherwise, rehydrate at the rates in Table 4 below for the first 24 hours.
    • Use Plasma-Lyte 148 and 5% Glucose OR 0.9% sodium chloride (normal saline) and 5% Glucose for rehydration after any required boluses. If serum K < 3mmol/L, add KCl 20mmol/L, or give oral supplements.
    • Measure Na, K and glucose at the outset and at least 24 hourly from then on (more frequent testing is indicated for patients with comorbidities or if more unwell). Venous blood gases provide rapid results. It is not necessary to send an electrolyte tube to the lab unless measurement of urea or creatinine is clinically indicated.
    • Consider septic work-up or surgical consult in severely unwell patients with gastroenteritis.

     

    Table 4: Recommended starting rate for IV Rehydration after initial boluses (0-24 hours) – Standard Rehydration

    Weight on [kg]     Degree of dehydration Moderate or Severe  [mls/hr] 

    3.0 kg

    20

    4.0 kg

    25

    5.0 kg

    30

    6.0 kg

    40

    7.0 kg

    45

    8.0 kg

    50

    9.0 kg

    60

    10 kg

    65

    12 kg

    75

    15 kg

    90

    20 kg

    100

    30 kg

    135

    40 kg

    165

    50 kg

    195

    60 kg

    225


    After 1st 24 hours, if needed, use  Standard Intravenous Fluids unless abnormal ongoing losses or electrolyte disturbance.
    Sodium abnormalities

    • If serum sodium is taken and is   <135mmol/l or >145mmol/l see  Hypernatremia guideline or  Hyponatremia guideline.

    Monitoring of rehydration

    • Bare weigh patient 6 hourly in moderate and severe dehydration, who are receiving NGTR or iv fluids.
    • Carefully reassess after 4-6 hours, then 8 hourly to guide ongoing fluid therapy. Look particularly for:
      • weight change
      • clinical signs of dehydration
      • urine output
      • ongoing losses
      • signs of fluid overload, such as puffy face and extremities.

    Discharge after RAPID nasogastric rehydration: 
    Medical review before discharge required if:

    • < 4% wt gain
    • Signs of dehydration or otherwise unwell
    • ≥ 3 large stools during rehydration
    • Abdominal pain worsening
    • Advice and  Gastroenteritis Fact Sheet should be given to parents before discharge.  Encourage review the next day with the GP. 

    Consider consultation with local paediatric team when:

    • Risk factors identified
    • Electrolyte abnormalities
    • Diagnosis in doubt
    • Assessed as severe dehydration

    Consider transfer when:

    • severe electrolyte abnormalities
    • severe dehydration or shock

      For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Information specific to RCH

    When admitted, children with gastroenteritis are usually admitted under a General Medical team, and often to the Short Stay Unit.


    Last updated August 2015