Chapter 71: Acute Gastroenteritis

Introduction
The following is based on Integrated Management of Childhood Illness (IMCI)
and the College of Paediatrics, Academy of Medicine of Malaysia guidelines
on the management of Acute Diarrhoea in Children 2011 and modifications
have been made to Treatment Plan C in keeping with Advanced Paediatric
Life Support (APLS) principles.

Acute gastroenteritis is a leading cause of childhood morbidity and mortality

and an important cause of malnutrition.

Many diarrhoeal deaths are caused by dehydration and electrolytes loss.

Mild and moderate dehydration is safely and effectively treated with ORS
solution but severe dehydration requires intravenous fluid therapy. If you
have gone through the PALS or APLS course, First assess the state of
perfusion of the child.Is the child in shock? Signs of shock include
tachycardia, weak peripheral pulses, delayed capillary refill time > 2 seconds,
cold peripheries, depressed mental state with or without hypotension. Any
child with shock go straight to treatment Plan C. OR you can also use
the WHO chart below to assess the degree of dehydra- tion and then choose
the treatment plan A, B or C, as needed.
Assess:
Look at childs general condition Well, alert

Restless or irritable

Look for sunken eyes

No sunken eyes

Sunken eyes

Offer the child fluid

Drinks normally

Drinks eagerly, thirsty

Pinch skin of abdomen

Skin goes back immediately

Skin goes back slowly

Classify:
Mild Dehydration
<5% Dehydrated*
IMCI: No signs of Dehydration

2 above signs:

Moderate Dehydration 5Dehydrated IMCI: Some sign

of Dehydration

Treat:
Plan A

Plan B

Give fluid and food to treat

diarrhoea at home

Give fluid and food for some

dehydration

*% of body weight (in g) loss in fluid (Fluid Deficit) e.g. a 10 kg child with 5% dehydration has lo
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PLAN A: TREAT DIARRHOEA AT HOME
Counsel the mother on the 3 rules of home treatment:
Give Extra Fluid, Connue Feeding, When to return
1. Give Extra Fluids (as much as the child will take) tell the mother:
- breaseed frequently and for longer at each feed
- if the child is exclusively breas ed, give ORS or cooled boiled water in addion to
breastmilk
- if the child is not exclusively breased, give one or more of the following: ORS,
food-based fluids (soup and rice water) or cooled boiled water It is especially important to give ORS at
home when:
- the child has been treated with Plan B or Plan C during this visit - the child cannot return to a clinic if the
diarrhoea gets worse
teach the mother how to mix and give ORS. Give the mother 8 packets of ORS to use at home.
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lethargic or unconscious
not able to drink or drinks poorly

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show mother how much ORS to give in addion to the usual fluid intake: Up to 2 years : 50 to 100ml aer
each loose stool
2 years or more : 100 to 200ml aer each loose stool
(If weight is available, give 10ml/kg of ORS aer each loose stool)
tell mother to
- give frequent small sips from a cup or spoon
- if child vomits, wait 10 minutes, then con nue but more slowly - connue giving extra fluid unl diarrhoea
stops
2. Connue Feeding
breased infants should connue nursing on demand
formula fed infants should con nue their usual formula immediately on rehydraon lactose-free or
lactose-reduced formula usually are unnecessary
children receiving semi-solid or solid foods should connue to receive their usual
food during the illness
foods high in simple sugar should be avoided as osmoc load may worsen the
diarrhoea

3. When to Return (to clinic/hospital) When child is

not able to drink or breaseed or drinking poorly becomes sicker
develops a fever
has blood in stool
PLAN B: TREAT SOME DEHYDRATION WITH ORS
Give recommended amount of ORS over 4-hour period:
Table 2. Determining the amount of ORS to give in the first 4 hours
Age1 Weight In ml
Up to 4 months <6kg 200-400
4 - 12months 6- <10kg 400-700
12 months -2 years 10- <12kg 700-900
2 - 5 years 12- 19kg 900-1400

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footnote: 1. Use the childs age only when you do not know the weight. The approximate amount of ORS required (in ml)
can be calculated by mulplying the childs weight (in kg) x 75
2. If the paent wants more ORS than shown, give more

Show the mother how to give ORS soluon

give frequent small sips from cup or spoon
if the child vomits, wait 10 minutes, then connue but more slowly
(i.e. 1 spoonful every 2 - 3 minutes).
connue breaseeding whenever the child wants
Aer 4 hours
reassess the child and classify the child for dehydraon
select the appropriate plan to connue treatment (Plan A, B or C) begin feeding the child
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If the mother must leave before compleng treatment
show her how to prepare ORS solu on at home.
show her how much ORS to give to finish the 4-hour treatment at home.
give her enough ORS packets to complete rehydra on. Also give her 8 packets as
recommended in Plan A.
explain the 3 Rules of Home Treatment (Plan A):
1. GIVE EXTRA FLUID 2. CONTINUE FEEDING 3. WHEN TO RETURN

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PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

Start intravenous (IV) or intraosseous (IO) fluid immediately.If patient can
drink, give ORS by mouth while the drip is being set up. Initial fluids for
resuscitation of shock: 20 ml/kg of NaCl 0.9% or
Hartmann solution as a rapid IV bolus. Repeated if necessary until patient is
out of shock or if fluid overload
is suspected. Review patient after each bolus. Calculate the fluid needed
over the next 24 hours:
Fluid for Rehydration (also called fluid deficit)
+ Maintenance (minus the fluids given for resuscitation). Fluid for
Rehydration: percentage dehydration X body weight in grams Maintenance
fluid (NaCl 0.45 / D5%)
(See Ch 3 Fluid And Electrolyte Guidelines)1st 10 kg = 100 ml/kg;10-20
kg = 1000 ml/day + 50 ml/kg for each kg above 10 kg
>20 kg = 1500 ml/day + 20 ml/kg for each kg above 20 kg.
Example:
A 6-kg child is clinically shocked and 10% dehydrated as a result of
gastroenteritis. Initial therapy:
20 ml/kg for shock = 6 20 = 120 ml of 0.9% saline given as a rapid
intravenous bolus.

Estimated fluid therapy over next 24 hours:

Fluid for Rehydration: 10/100 x 6000 = 600 ml

100ml/kg for daily maintenance fluid = 100 6 = 600 ml

Rehydration + maintenance = 600 + 600 =1200 ml

Start with infusion of 1200/24 = 50 ml/h

The cornerstone of management is to reassess the hydration status

frequently (e.g. at 1-2 hourly), and adjust the infusion as necessary.

Start giving more of the maintenance fluid as oral feedse.g. ORS (about 5
ml/kg/hour) as soon as the child can drink, usually after 3 to 4 hours for
infants, and 1 to 2 hours for older children. This fluid should be administered
frequently in small volumes (cup and spoon works very well for this process).

Generally normal feeds should be administered in addition to the rehydration

fluid, particularly if the infant is breastfed.

Once a child is able to feed and not vomiting, oral rehydration according to
Plan A or B can be used and the IV drip reduced gradually and taken off.

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If you cannot or fail to set up IV or IO line, arrange for the child to be sent to
the nearest centre that can do so immediately. Meanwhile as arrangements
are made to send the child (or as you make further attempts to establish IV or
IO access),
Try to rehydrate the child with ORS orally (if the child can drink) or by
nasogastric or orogastric tube. Give ORS 20 ml/kg/hour over 6 hours.
Continue to give the ORS along the journey.
Reassess the child every 1-2 hours If there is repeated vomiting or
increasing abdominal distension, give
the fluid more slowly. Reassess the child after six hours, classify dehydration
Then choose the most appropriate plan (A, B or C) to continue treatment.
If there is an outbreak of cholera in your area, give an appropriate
oral antibiotic after the patient is alert.
Other indications for intravenous therapy
Unconscious child. Continuing rapid stool loss ( > 15-20ml/kg/hour).
Frequent, severe vomiting, drinking poorly. Abdominal distension with
paralytic ileus, usually caused by some
antidiarrhoeal drugs ( e.g. codeine, loperamide ) and hypokalaemia.
Glucose malabsorption, indicated by marked increase in stool output and
large amount of glucose in the stool when ORS solution is given
(uncommon).
IV regime as for Plan C but the replacement fluid volume is calculated
according to the degree of dehydration. (5% for mild, 5-10% for moderate
dehydration).
Indications for admission to Hospital
Moderate to severe dehydration. Need for intravenous therapy (as above).
Concern for other possible illness or uncertainty of diagnosis. Patient

factors, e.g. young age, unusual irritability/drowsiness,

worsening symptoms. Caregivers not able to provide adequate care at
home. Social or logistical concerns that may prevent return evaluation if
necessary.
* Lower threshold for children with obesity due to possibility of
underestimating degree of dehydration.
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Other problems associated with diarrhoea

Fever May be due to another infection or dehydration. Always search for

the source of infection if there is fever, especially if it persists after the child
is rehydrated.

Seizures Consider:- Febrile convulsion (assess for possible meningitis) Hypoglycaemia- Hyper/hyponatraemia

Lactose intolerance Usually in formula-fed babies less than 6 months old

with infectious diarrhoea. Clinical features: - Persistent loose/watery stool Abdominal distension- Increased flatus- Perianal excoriation Making the
diagnosis: compatible history; check stool for reducing sugar (sensitivity of
the test can be greatly increased by sending the liquid portion of the stool for
analysis simply by inverting the diaper). Treatment: If diarrhoea is
persistent and watery (over 7-10 days) and there is evidence of lactose
intolerance, a lactose free formula may be given. Normal formula can
usually be reintroduced after 23 weeks.

Cows Milk Protein Allergy A known potentially serious complication

following acute gastroenteritis. To be suspected when trial of lactose free
formula fails in patients with protracted course of diarrhoea. Children
suspected with this condition should be referred to a paediatric
gastroenterologist for further assessment.

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Non pharmacological / Nutritional strategies
Undiluted vs diluted formula No dilution of formula is needed for children

taking milk formula.

Soy based or cow milk-based lactose free formula Not recommended
routinely. Indicated only in children with suspected
lactose intolerance.
Pharmacological agents

Antimicrobials Antibiotics should not be used routinely. They are reliably

helpful only in children with bloody diarrhoea, probable shigellosis, and
suspected cholera with severe dehydration.

Antidiarrhoeal medications The locally available diosmectite (Smecta) has

been shown to be safe and effective in reducing stool output and duration of
diarrhoea. It acts by restoring integrity of damaged intestinal epithelium, also
capable to bind to selected bacterial pathogens and rotavirus. Other anti
diarrhoeal agents like kaolin (silicates), loperamide (anti- motility) and
diphenoxylate (anti motility) are not recommended.

Antiemetic medication Not recommended, potentially harmful.

Probiotics Probiotics has been shown to reduce duration of diarrhoea in

several randomized controlled trials. However, the effectiveness is very strain
and dose specific. Therefore, only probiotic strain or strains with proven
efficacy in appropriate doses can be used as an adjunct to standard therapy.

Zinc supplements It has been shown that zinc supplements during an

episode of diarrhoea reduce the duration and severity of the episode and
lower the incidence of diarrhoea in the following 2-3 months.WHO
recommends zinc supplements as soon as possible after diarrhoea has
started. Dose up to 6 months of age is 10 mg/day, and age 6 months and
above 20mg/day, for 10-14 days.