Clinical Practice Guideline for the Treatment of Pediatric Acute Gastroenteritis in the Outpatient Setting

Rebecca A. Carson, DNP, CPNP-PC/AC; Shawna S. Mudd, DNP, CPNP-AC; P. Jamil Madati, MD

J Pediatr Health Care. 2016;30(6):610-616.

Abstract and Introduction

Abstract

Acute gastroenteritis (AGE) is a common illness in childhood that usually can be treated in the outpatient setting. Inaccurate assessment or delayed treatment of AGE can lead to an increased risk for invasive interventions. A literature search was conducted using PubMed, CINAHL Plus, the Cochrane Library, and Embase. Results of the query were refined to narrow the focus of relevant studies for the provider caring for dehydrated children in the outpatient setting. Use of clinical dehydration scales to assess the level of dehydration and early initiation of oral rehydration therapy promote optimal patient outcomes. Oral rehydration therapy remains the best means of rehydrating, and ondansetron is a safe and effective adjunct to help children with persistent vomiting. The purpose of this practice guideline is to identify best practices for AGE in children older than 6 months with symptoms for less than 7 days who are being cared for in the outpatient setting.

Introduction

Acute gastroenteritis (AGE) is one of the most common childhood illnesses in the United States, accounting for more than 1.7 million outpatient visits each year (Freedman, Thull-Freedman, Rumantir, Atenafu, & Stephens, 2013). Up to 16% of emergency department (ED) visits are attributed to AGE, defined as three or more episodes of diarrhea and/or vomiting and possibly accompanied by other symptoms including fever, nausea, or abdominal pain that results from gastrointestinal inflammation (Fox, Richards, Jenkins, & Powell, 2012). The primary treatment goals for children with viral AGE are rehydration and prevention of complications due to dehydration from fluid loss from ongoing diarrhea and/or vomiting (Farthing et al., 2013).

Nationally recognized recommendations for AGE are oral rehydration therapy (ORT) as the primary treatment while avoiding unnecessary laboratory tests, diagnostic imaging, and medications (Centers for Disease Control and Prevention [CDC], 2003; Cincinnati Children's Hospital Medical Center, 2011). Most children have only mild or moderate dehydration associated with AGE, and the success rate of ORT as a treatment method is approximately 96% (Nir, Nadir, Schechter, & Kline-Kremer, 2013). Despite recommendations that pediatric patients with mild to moderate dehydration receive ORT as the mainstay of treatment, many providers unnecessarily order laboratory tests, diagnostic imaging, and intravenous fluids that do not provide prognostic value or shorten the self-limited illness (Kharbanda et al., 2013). The purpose of this clinical practice guideline is to describe current evaluation and management of pediatric patients with AGE in the outpatient setting.

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Table 1. Treatment principles for management of dehydration
Mild Dehydration (< 5%)	Moderate Dehydration (5–10%)	Severe Dehydration (> 10%)
Continue hydration ORT with teaching on frequent small volumes of liquid Encourage regular diet (unrestricted breastfeeding) Replace ongoing losses (assume 1 diarrheal stool/emesis equals 2 oz liquid or 10 ml/kg)	Needs ORT Defer solids until rehydrated May continue unrestricted breastfeeding with oral rehydration solution adjunct Replace ongoing losses (assume 1 diarrheal stool/emesis equals 2 oz liquid or 10 ml/kg)	Needs IV rehydration Place saline lock IV catheter and give 0.9% sodium chloride 20 ml/kg bolus IV push; repeat if warranted and patient is responding to fluid bolus Recommend point of care glucose and electrolytes if patient is listless and lethargic Measure intake and output Initiate ORT with teaching on frequent small volumes of liquid once IV access obtained May need maintenance IV fluids; hold potassium-containing fluids until patient has voided

Note. ORT = oral rehydration therapy.
From Deforest & Thompson, 2012.

Table 2. Suggested discharge and admission criteria
Suggested discharge criteria	Suggested admission criteria
Well appearing and active Abdomen soft, nontender, and nondistended Vital signs acceptable for age and fever/dehydration Tolerated acceptable amounts of oral liquids in relation to ongoing losses ≤ 3 episodes of vomiting and/or diarrhea Achieves mild dehydration status on a clinical dehydration scale	Persistent fluid loss from significant vomiting and/or diarrhea Abnormal electrolytes or acidosis Diagnosis uncertainty Inability to tolerate oral liquids, keep up with fluid losses, or requires overnight fluid replacement for severe dehydration

Table 3. World Health Organization Scale for dehydration for children ages 1 month to 5 years in low- and middle-income countries
	A. Mild dehydration	B. Moderate dehydration	C. Severe dehydration
Look at condition	Well, alert	Restless, irritable	Lethargic or unconscious
Eyes	Normal	Sunken	Sunken
Thirst	Drinks normally, not thirsty	Thirsty, drinks eagerly	Drinks poorly or not able to drink
Feel: skin pinch	Goes back quickly	Goes back slowly	Goes back very slowly
Decide	The patient has NO SIGNS OF DEHYDRATION (< 5%)	If the patient has 2 or more signs in column B, then the patient has SOME DEHYDRATION (5%-10%)	If the patient has 2 or more signs in column C, then the patient has SEVERE DEHYDRATION (> 10%)
Treat	Home therapy to prevent dehydration and malnutrition	Weigh the patient if possible and begin oral rehydration therapy	Begin intravenous hydration urgently

From World Health Organization, 2011.

Table 4. The 10- and 4-Point Gorelick Dehydration Scale for children ages 1 month to 5 years
Characteristic	No or minimal dehydration	Moderate dehydration	Severe dehydration
General appearance
Infants	Thirsty, alert, restless	Lethargic or drowsy	Limp, cold, cyanosis
Older children	Thirsty, alert, restless	Alert, dizzy	Apprehensive, cold, cyanosis
Capillary refill	Normal	Prolonged or minimal	Very prolonged
Tears	Present	Absent	Absent
Mucous membranes*	Moist	Dry	Very dry
Eyes*	Normal	Sunken	Deeply sunken
Breathing*	Present	Deep	Deep and rapid
Quality of pulses*	Normal	Weak, thready	Feeble or impalpable
Skin elasticity	Instant recoil	Recoil slowly	Recoil > 2 seconds
Heart rate	Normal	Tachycardia	Tachycardia
Urine output	Normal	Reduced	Not passed in many hours

*Four-point scale examination signs.
Scoring of 4-point scale: ≥ 2 clinical signs (4 pt) ≥ 5% body weight change; ≥ 3 clinical signs (4 pt) ≥ 10% body weight change.
Scoring of 10-point scale (all signs/symptoms): ≥ 3 clinical signs ≥ 5% body weight change; ≥ 7 clinical signs ≥ 10% body weight change.
From Pringle et al., 2011.

Table 5. Clinical Dehydration Scale for prediction of dehydration in ages children 1 to 36 months
Characteristic	0	1	2
General appearance	Normal	Thirsty, restless, or lethargic, but irritable when touched	Drowsy, limp, cold and/or comatose
Eyes	Normal	Slightly sunken	Very sunken
Mucous membranes	Moist	"Sticky"	Dry
Tears	Tears	Decreased tears	Absent tears

Note. From Pringle et al., 2011.
Scoring: 0: no dehydration < 3%; 1–4: some dehydration ≥ 3% and < 6%; 5–8: moderate dehydration ≥ 6%.

Table 6. Recommended sip volume by weight based on goal fluid intake
Weight	Sip volume per 5 minutes
< 10 kg	1 ml/kg
10 kg	10 ml
For every additional 5 kg	Increase sip volume by 5 ml to maximum sip volume = 50 ml

Note. ORT = oral rehydration therapy.
Administer via syringe or medicine cup. Duration: 1 hour; once there has been no vomiting in 1 hour, increase volume per sip or drink freely to goal fluid intake; continue ORT for 4 hours.