Infection leads to gut biome alteration and host’s own immune system leads to inflammation of the lining of the stomach and intestines causing abdominal pain, nausea, vomiting, diarrhea, and hematochezia.
Key Questions in history:
- Color of both the emesis and stool (bilious or bloody emesis and bloody stools)
- History of recent travel and sick contacts
- Quantity of urine output
- Regular medications or recent Antibiotic intake
- Vital Signs including CRT
- Hypotension is a late finding in children
- Segregate as mild dehydration (< 3% loss of body weight - Normal exam), moderate dehydration (3%-9% loss of body weight - may have slightly sunken eyes, decreased tears, dry mouth, and slightly increased heart rate) or severe dehydration (> 9% loss of body weight - lethargic and tachycardic, with no tears, very dry mouth, and prolonged capillary refill)
- Abdo exam - localised tenderness to palpation. AGE might cause mild diffuse abdominal pain but not focal tenderness.
- Bloods are not required in mild to moderate illness. Inflammatory markers such as CRP has not been shown to differentiate viral versus bacterial causes of AGE and is not recommended in obvious cases of AGE.
- Stool cultures and other stool studies are not required in most cases of uncomplicated AGE. However, in children with prolonged (> 3 days) or bloody diarrhea, toxic-appearance, and those with h/o recently travel abroad, stool cultures may be appropriate.
- Stool ova and parasite examinations (Giardiasis, Toxocariasis and Cysticercosis) are low-yield tests and should only be sent with appropriate travel history or prolonged disease with negative prior stool cultures or if there is evidence of weight loss or failure to thrive.
- Fecal calprotectin is an inflammatory marker in the stool which may aid in differentiating viral from bacterial AGE. Children with bacterial infections had signicantly higher levels of fecal calprotectin in the stool than children with viral infections. In general, fecal calprotectin does not affect the acute management of vomiting and diarrhea in the ED but it may be helpful in the outpatient workup of other illnesses, and can be sent in consultation with pediatric gastroenterology.
Loperamide is an opioid receptor agonist that acts as both an antisecretory and antimotility agents but has the potential of causing drowsiness and ileum. Thus it is strongly discouraged in children of all ages. Bismuth Salicylate is another option but it may cause salicylate toxicity if it is used incorrectly and therefore, it is also not recommended for use in children.
- Probiotics are nonpathogenic organisms that work by regulating the gut biome and help to lessen in ammatory pathways. These agents help to decrease stool volume and frequency in AGE. Numerous studies have shown that Lactobacillus rhamnosus GG and Saccharomyces boulardii can reduce the length of diarrheal symptoms in children, with very few side effects but probiotics are probably most effective if started early. Also probiotics seem to have the greatest impact on diarrhea due to viral causes.
- Prebiotics are food products that promote the growth and activity of bacteria that reside in the gut and Synbiotics are a combination of probiotics and probiotics.
Safety Netting and discharge advise: Advise parents and carers of children:
- To continue usual feeds, including breast or other milk feeds and include ORS solution as supplemental fluid
- To discourage the drinking of fruit juices and carbonated drinks
- A rough calculation of the amount of ORS needed to replace emesis and diarrhea is 10 mL/kg for each episode of emesis or diarrhoea
- To seek advice if the child refuses to drink the ORS solution or vomits persistently
- Usual duration of diarrhoea is 5–7 days and in most children it stops within 2 weeks
- Usual duration of vomiting is 1 or 2 days and in most children it stops within 3 days
- Advise regarding hand Hygiene and inform that children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting.
- Start ondansetron early to children presenting with AGE.
- Mainstay of treatment is oral rehydration with ORS and IV fluids are indicated only in severe dehydration or in children who are unable to take ORS orally.
- Laboratory studies are not indicated in mild-to-moderate dehydration due to AGE. In children with severe dehydration, start IV fluids and do renal function, blood glucose and electrolytes.
- Probiotics can help decrease the duration of their diarrhea by approximately 24 hours but should be prescribed for children with AGE early in the course of their illness.Viral infections are the most common cause of AGE, so stool cultures are not needed.
References and Further Reading:
- Roslund G, Hepps TS, McQuillen KK. The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial. Ann Emerg Med. 2008;52(1):22-29.
- O’Ryan M, Lucero Y, O’Ryan-Soriano MA, et al. An update on management of severe acute infectious gastroenteritis in children. Expert Rev Anti Infect Ther. 2010;8(6):671-682.
- Bonadio WA. Acute infectious enteritis in children. Emer- gency department diagnosis and management. Emerg Med Clin North Am. 1995;13(2):457-472.
- Bruzzese E, Lo Vecchio A, Guarino A. Hospital management of children with acute gastroenteritis. Curr Opin Gastroen- terol. 2013;29(1):23-30.
- Sýkora J, Siala K, Huml M, et al. Evaluation of faecal calpro- tectin as a valuable non-invasive marker in distinguishing gut pathogens in young children with acute gastroenteritis. Acta Paediatr. 2010;99(9):1389-1395.
- Duman M, Gencpinar P, Biçmen M, et al. Fecal calprotectin: can be used to distinguish between bacterial and viral gas- troenteritis in children? Am J Emerg Med. 2015;33(10):1436- 1439.
- Leung AK, Robson WL. Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting. Paediatr Drugs. 2007;9(3):175-184.
- Freedman SB. Acute infectious pediatric gastroenteritis: beyond oral rehydration therapy. Expert Opin Pharmacother. 2007;8(11):1651-1665.
- Levine DA. Antiemetics for acute gastroenteritis in children. Curr Opin Pediatr. 2009;21(3):294-298.
- Marchetti F, Bonati M, Maestro A, et al. Oral ondansetron versus domperidone for acute gastroenteritis in pediatric emergency departments: multicenter double blind ran- domized controlled trial. PLoS One. 2016;11(11):e0165441.
- Freedman SB, Tung C, Cho D, et al. Time-series analysis of ondansetron use in pediatric gastroenteritis. J Pediatr Gastroenterol Nutr. 2012;54(3):381-386.
- Magrone T, Jirillo E. The interplay between the gut immune system and microbiota in health and disease: nutraceutical intervention for restoring intestinal homeostasis. Curr Pharm Des. 2013;19(7):1329-1342.
- Vandenplas Y, De Greef E, Hauser B, et al. Probiotics and prebiotics in pediatric diarrheal disorders. Expert Opin Phar- macother. 2013;14(4):397-409.
- Caffarelli C, Cardinale F, Povesi-Dascola C, et al. Use of pro- biotics in pediatric infectious diseases. Expert Rev Anti Infect Ther. 2015;13(12):1517-1535.
- Thomas DW, Greer FR, Committee on Nutrition; Section on Gastroenterology, Hepatology, and Nutrition. Probiotics and prebiotics in pediatrics. Pediatrics. 2010;126(6):1217-1231.
- Colletti JE, Brown KM, Sharieff GQ, et al. The management of children with gastroenteritis and dehydration in the emer- gency department. J Emerg Med. 2010;38(5):686-698.
- Freedman SB, Willan AR, Boutis K, et al. Effect of dilute apple juice and preferred uids vs electrolyte mainte- nance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974.
- Granado-Villar D, Cunill-De Sautu B, Granados A. Acute gastroenteritis. Pediatr Rev. 2012;33(11):487-494.
- Gordon M, Akobeng A. Racecadotril for acute diarrhoea in children: systematic review and meta-analyses. Arch Dis Child. 2016;101(3):234-240.