Most diarrhea and vomiting in children is due to infective gastroenteritis ) but not all. It may be the presentation of a urinary tract infection (UTI), meningitis, appendicitis, intussusception or systemic illness. In the unwell child, especially if anuric, consider hemolytic uremic syndrome (hemolytic anemia, acute renal failure and thrombocytopenia).
Assessment
There are essentially two aspects to the assessment of a child with gastroenteritis:
• Diagnosis: Does the child have a cause other than infective gastroenteritis?
• Degree of dehydration: Does the child need admission to hospital? Is there any reason why oral rehydration is not appropriate?
An initial weight measurement should form part of the initial assessment of any child who presents with diarrhea and vomiting. Any child who is toxic, vomiting blood or bile or has severe abdominal pain or abdominal signs needs immediate consultant referral. Be especially careful of those children with chronic illnesses and poor growth, and of the very young.
You must assess degree of dehydration on clinical signs and change in body weight (if recent weight available).
• With mild dehydration (<4%) there are no clinical signs.
• Moderate dehydration (4–6%) tends to be accompanied by dry mucous membranes and sunken eyes.
• With increasing severity to 7–9%, the signs of dehydration are more pronounced with cool peripheries, decreased skin turgor, impaired peripheral circulation and acidotic breathing.
• A shocked child needs immediate intravenous resuscitation.
Fecal samples should be collected for microbiological culture if the child has significant associated abdominal pain or blood in the motions, as a bacterial cause of gastroenteritis is more likely.
Management
The child with diarrhea should continue to be fed unless severely dehydrated. Most children can be rehydrated with oral or nasogastric feeds unless shocked. Do not give medications to reduce the vomiting or diarrhea. They do not work and may be harmful.
Oral rehydration
There is no evidence that milk, or other foods, should be diluted or excluded during the diarrheal illness, unless there is documented lactose intolerance, although a short period without food will not harm children. Breastfeeding should continue.
For mildly dehydrated children, increased frequency of normal drinks, giving small amounts often, will be adequate. Do not give fizzy drinks or fruit juice as their osmolarity is too high. For moderately dehydrated children, who are still drinking, small frequent amounts of fluids should be given according to the volumes given on the charts below. The fluids should be oral rehydrating fluids.
Commercially available preparations usually have 35–50 mmol sodium/Liter. Examples include Diorylate or Rehydrat. Clear instructions and a written information sheet should be given to the parents together with an indication of when to seek review. Indications for admission are:
• refusal to take fluid
• severe pain
• bilious vomiting
• abdominal distension
• blood in the motions
• altered level of consciousness
• increasing dehydration
• parents coping poorly
Nasogastric rehydration
Nasogastric rehydration is a safe and effective way of rehydrating most children with moderate to severe dehydration, even if the child is vomiting. There are a number of possible regimens. Current practice is to replace deficit over 6 hours and then give daily maintenance over the next 18 hours using oral rehydration solution. To calculate hourly rates see Table 7.4.
However, recent recommendations from the American Academy of Pediatrics say that rapid nasogastric rehydration over a 4-hour period is safe and effective. Using 100 ml/kg weight over 4 hours for a moderately dehydrated child or for more severe even 150 ml/kg weight over 4 hours is an appropriate replacement rate. In most cases it is not necessary to check electrolytes.
Intravenous rehydration
Any child with severe dehydration requires immediate boluses of 20 ml/kg weight normal saline until circulation restored (i.v. or i.o.). Urgent U&Es, glucose, FBC, blood gas and urinalysis. Consider whether a septic work-up and parenteral antibiotics are needed or a surgical consultation.
Always remember the ABC approach to a sick child. If serum Na+ is between 130 mmol/liter and 150 mmol/Liter, aim to replace deficit and maintenance over 24 hours after the circulation has been restored by fluid boluses. Reassess clinically and reweigh on the ward at 6 and 12 hours.
Contact a gastroenterology consultant if the child is hemodynamically unstable, has a past history of gut surgery or other significant disease. If serum Na+ is less than 130 mmol/Liter or more than 150 mmol/Liter, aim to replace deficit carefully over 48–72 hours, and consult with senior staff.
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