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Clinical Practice Guidelines : Gastroenteritis

Gastroenteritis
This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network RCH: Consider Criteria Led Discharge See Also: Dehydration IV fluids Hypernatraemia Hyponatraemia Sections: Management Oral rehydration NG tube rehydration IV rehydration Monitoring Notes Early Feeding

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?: The following features may occur in gastroenteritis, but should prompt careful consideration of differential diagnoses & review by a senior doctor: severe abdominal pain or abdominal signs persistent diarrhoea (> 10 days) blood in stool looks very unwell bilious (green) vomit vomiting without diarrhoea Consider important differential diagnoses:
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Clinical Practice Guidelines : Gastroenteritis

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: Children with the following require Senior Medical Assessment Short gut syndrome Ileostomy Complex/cyanotic congenital heart disease Renal transplants or renal insufficiency Very young (<6 months) Poor growth Fortified feeds (concentrated feeds or caloric additives) recent use of potentially hypertonic fluids (eg Lucozade) other chronic diseases 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 microbiological culture if the child has significant associated abdominal pain or blood in the motions, as a bacterial cause of gastroenteritis is more likely. However these results usually don't alter treatment. Blood tests (electrolytes, glucose) are not necessary in simple gastroenteritis but are required for: severe dehydration comorbidity of renal disease or on diuretics altered conscious state 'doughy' skin (suggests 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:
Rehydration

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Clinical Practice Guidelines : Gastroenteritis

Ondansetron drug dose Not recommended for children < 6 months old or < 8kg Should only be administered once in this setting. Table 1: Ondansetron wafer dose Weight 8 -15 kg 15-30 kg > 30 kg Oral rehydration
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Ondansetron wafer Dose 2mg 4mg 8mg

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Lemonade, homemade ORS and sports drinks are not appropriate fluids for rehydration Encourage parents to find methods to help children drink. Eg: cup, icypole or syringe, aiming for small amounts of fluid often. Continue breastfeeding. Suggest oral rehydration solutions (ORS) eg. GastrolyteTM, HYDRAlyteTM, PedialyteTM 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) minimise 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. 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 . 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 7 kg 8 kg 9 kg 10 kg 12 kg 14 kg 16 kg 18 kg 20 kg SLOWER NASOGASTRIC REHYDRATION:
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mls/hr TOTAL INFUSION TIME 175 200 225 250 300 300 300 300 300 4 hrs 4 hrs 4 hrs 4 hrs 4 hrs 4.5 hrs 5 hrs 6 hrs 6.5 hrs

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Clinical Practice Guidelines : Gastroenteritis

Slower rehydration is preferred for the following patients: Infants < 6 months Co-morbidities present. Children with significant abdominal pain. Replacing deficit over first 6 hours and then 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 mls/hr 0 - 6 hrs 3.0 kg 4.0 kg 5.0 kg 6.0 kg 7.0 kg 8.0 kg 9.0 kg 10 kg 12 kg 15 kg 20 kg 30 40 50 60 70 80 90 100 120 150 200 mls/hr 7 - 24 hrs 20 30 35 40 45 50 55 60 65 70 85 mls/hr 0 - 6 hrs 50 65 80 100 115 130 150 165 200 250 285 for 7 hrs* 300 for 10 hrs* Severe mls/hr 7 - 24 hrs 20 30 35 40 45 50 55 60 65 70 85 for 17 hrs** 115 for 14 hrs**

30 kg

300

90

* RCH enteral pumps deliver a maximum of 300 ml/hr;

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** 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, IV fluids are likely to be required. Profuse ongoing diarrhoea may require change to IV fluids (discuss with senior).

Intravenous Rehydration
Indications: 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 co-morbidities, particularly GIT conditions ( eg. short gut or previous gut surgery) -discuss these patients with senior staff. IV Fluids see guideline: Initial boluses: 20ml/kg Normal saline boluses, repeated until shock is corrected. If > 40 ml/kg boluses required, involve senior staff and ICU. Measure blood glucose and treat hypoglycaemia with 5ml/kg of 10% dextrose. Measure Na, K and glucose at the outset & at least 24 hourly from then on (more frequent testing is indicated for patients with co-morbidities 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. Ongoing fluids: 5% Dextrose + 0.9% Normal saline (Rates see table). Use a fluid containing KCl (20mmol/L) if serum K < 3mmol/l or give oral supplements. Table 4: Recommended starting rate for IV REHYDRATION AFTER INIITIAL BOLUSES (0-24 hours) WEIGHT on ADMISSION [kg] 3.0 kg 4.0 kg 5.0 kg 6.0 kg 7.0 kg 8.0 kg DEGREE OF DEHYDRATION Moderate or Severe [mls/hr] 20 25 30 40 45 50
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Clinical Practice Guidelines : Gastroenteritis

9.0 kg 10 kg 12 kg 15 kg 20 kg 30 kg 40 kg 50 kg 60 kg

60 65 75 90 100 135 165 195 225

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, nasogastric or iv fluids. Careful reassessment after 4-6 hours needs to occur, 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. Consider early feeding.

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
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For advice or ICU level transfer ring the Sick Child Hotline: (03) 9345 7007

Discharge requirements:
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 handout on gastroenteritis should be given to parents before discharge & encourage review the next day with the GP.

Parent information sheet:

Gastroenteritis Fact Sheet

Additional Notes
Early Feeding Stop any feed fortifications (such as extra scoops of formula or Polyjoule) Early feeding (as soon as rehydrated) reduces stool output, and aids gut recovery. In infants, if diarrhoea increases once feed reintroduced consider the temporary (2 weeks) use of hydrolysed formula (Peptijunior, Neocate) until gut recovery. Parents may need to purchase this off PBS (authority script). Recommend usual diet once rehydrated including continuing breastfeeding. Anti-diarrhoeals and maxalon are not recommended. Information Specific to RCH When admitted, children with gastroenteritis are usually admitted under the General Paediatric Team, and often to the Short Stay Unit. Ondansetron wafers must have consultant approval prior to administration.

Last Updated 20-Mar-2011. Content authorised by: Webmaster. Enquiries: Webmaster. WebHelp.

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