Acute Gastroenteritis in children

Causes:

Viruses- Rotavirus, Norovirus, Adenovirus, etc

Bacteria- Salmonella, Shigella, E coli 0157, Campylobacter, etc

Protozoa- Giardiasis, Amoebiasis, etc

Other reasons for vomiting or diarrhoea:

Sepsis

Surgical  causes:

  – Intussusception

  – Bowel obstruction

  – Acute appendicitis

Systemic illness:

  – Diabetes / DKA

  – CAH 

  – Addison’s disease

Raised ICP

Malabsorption (CF, Coeliac)

IBD (UC, Crohn’s)

Consider other differential if any of:

– Fever >39 (or >38 in under 3m age)

– Non-blanching rash

– Altered Consciousness level

– Neck stiffness/ Bulging fontanelle

– History of head injury

– Tachypnoea or shortness of breath

– Severe or localized abdo pain

– Abdominal distension/ rebound tenderness

– Bilious vomiting

– Blood / mucus in stools

– History / suspicion of poisoning

History key questions:

– Onset, sequence and duration of symptoms

– How many vomits in last 24 hours, any bile in vomit?

– How many diarrhoea episodes in last 24 hours

– Stool colour, soft/ watery? Any blood or mucous?

– Feeding history, in last 24h

– Passing urine? When last PU?

– Is recent weight known? Any weight loss noted? 

– Any recent foreign travel, visit to animal farm?

– Any known illness or immunodeficiency? 

– Are contact with ill people? 

– Any recent medication use (particularly antibiotics)? 

 

Examination:

– ABCDE, Glucose

– Weight, Height

– Looking unwell? In shock?

– HR, BP, RR, Temp, SaO2

– Assess hydration status

  (Moist mm, tears, skin turgor, CRT)

– If dehydrated, estimate percentage*

– Full systemic examination to exclude differentials

At high risk of dehydration if:

– Infants (especially <6m age)

– Infants born with low birth weight

– > 6 diarrhoeal stools within 24 hours

– > 3 vomits within 24 hours

– Stopped breastfeeding during illness

– Not offered / unable to tolerate 

  supplementary fluids before presentation

– Children with signs of malnutrition

– Co-morbidities/ previous bowel surgery

 

Investigations:

– Generally none for mild/ mod dehydration

– Check U&E in severe dehydration

  ?hypernatremic dehydration

– Check for possible hypoglycaemia 

– If shocked, bld gas for metab acidosis

– If sepsis likely, FBC, CRP, bld culture

– Consider LP in young child

– Urinanalysis if <3m to exclude UTI

– Stool culture if dysentry/ immunocompromised

Management:

A.G.E. with no/  mild dehydration:

– Discharge with suitable advice

– Small frequent feeds/ meals

– Ensure adequate urine output

– Safety netting

 

A.G.E. with mod dehydration:

– Observe 4 – 6 hours for

  oral fluid challenge 

– Give ORS 50ml/kg over 4 hours

– Review every 2 – 4 hours

– If not accepting, give via NGT

– IV fluids if still vomiting/ worsening

– Discharge with advice once hydrated

– Safety netting

 

 

A.G.E. with severe dehydration/ shock:

– Fluid resuscitation with 20ml/lg bolus of normal saline

– Review response, give further 20ml/kg if required

– If improving, continue IV fluids with 

  maintenance + correction for dehydration

– Correct hypoglycaemia (if found)

– Correct electrolyte imbalance*

 

Maintenance fluids in children:

First 10kg = 100ml/kg/d, then add

For next 10kg = 50ml/kg/d, then add

Beyond 20kg weight= 20ml/kg/d

Correction volume in 24 hours= 

Percentage dehydration x 10 x Weight (kg)