Pediatric Gastroenteritis in Emergency Medicine

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Though often considered a benign disease, acute gastroenteritis remains a leading cause of pediatric morbidity and mortality around the world, accounting for 520,000 deaths annually in children younger than 5 years. ^[1] See the video below.

Viruses remain by far the most common cause of acute gastroenteritis in children, both in high-resource and low-resource settings, though several bacterial species also play an important role in acute gastroenteritis, especially in low-resource settings. The two primary mechanisms responsible for acute gastroenteritis are as follows:

Damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to osmotic diarrhea

Toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhea

These include the following:

Diarrhea

Vomiting

Increase or decrease in urinary frequency

Abdominal pain

Signs and symptoms of infection – Presence of fever, chills, myalgias, rash, rhinorrhea, sore throat, cough; these may be evidence of systemic infection or sepsis

Changes in appearance and behavior – Including weight loss and increased malaise, lethargy, or irritability, as well as changes in the amount and frequency of feeding and in the child’s level of thirst

History of recent antibiotic use – Increases the likelihood of Clostridium difficile

History of travel to endemic areas

Assessment of dehydration

According to the World Health Organization (WHO), a patient exhibiting 2 of the following signs can be considered to have some amount of dehydration:

Restless, irritable

Sunken eyes

Thirsty, drinks eagerly

Skin pinch goes back slowly

According to the WHO, a patient exhibiting 2 of the following signs can be considered to have severe dehydration:

Lethargic or unconscious

Sunken eyes

Not able to drink or drinking poorly

Skin pinch goes back very slowly

See Clinical Presentation for more detail.

Workup in pediatric gastroenteritis can include the following:

Baseline electrolytes, bicarbonate, and urea/creatinine – In any child being treated with intravenous fluids for severe dehydration

Fecal leukocytes and stool culture – May be helpful in children presenting with dysentery

Stool analysis for C difficile toxins – In children older than 12 months with a recent history of antibiotic use

Stool analysis for ova and parasites – In patients with a history of prolonged watery diarrhea (>14 days) or travel to an endemic area

Complete blood count (CBC) and blood cultures – Any child with evidence of systemic infection

If indicated, urine cultures, chest radiography, and/or lumbar puncture should be performed. Several studies have found that combinations of clinical signs and symptoms may have better sensitivity and specificity for detecting dehydration in children than do individual signs or symptoms. ^{[2, 3, 4, 5, 6]}

See Workup for more detail.

Oral rehydration solution

The American Academy of Pediatrics, the European Society of Pediatric Gastroenterology and Nutrition (ESPGAN), and the World Health Organization (WHO) all recommend oral rehydration solution (ORS) as the treatment of choice for children with mild to moderate gastroenteritis, including those in both high-resource and low-resource settings, based on the results of dozens of randomized, controlled trials and several large meta-analyses. ^{[7, 8, 9]}

Pharmacologic therapy

Agents used in the treatment or prevention of acute pediatric gastroenteritis include the following:

Probiotics – Live microbial feeding supplements commonly used in the treatment and prevention of acute diarrhea

Zinc – To treat diarrhea; ^[10] the WHO recommends zinc supplementation for all children younger than 5 years with acute gastroenteritis in low-resource settings, though little data exist to support this recommendation for children in high-resource settings

Metronidazole – In patients infected with C difficile and Giardia

Tetracycline and doxycycline – For cholera (azithromycin should be used for children younger than 8 years)

Vaccine – In February 2006, the US Food and Drug Administration (FDA) approved the RotaTeq vaccine for prevention of rotavirus gastroenteritis

See Treatment and Medication for more detail.

Though often considered a benign disease, acute gastroenteritis remains a leading cause of morbidity and mortality in children around the world, accounting for 520,000 deaths annually in children younger than 5 years, or roughly 10% of all child deaths worldwide. ^[1] Because the disease severity depends on the degree of fluid loss, accurately assessing dehydration status remains a crucial step in preventing mortality. Luckily, most cases of dehydration in children can be accurately diagnosed by a careful clinical examination and treated with simple, cost-effective measures.

See the video below depicting a child with acute gastroenteritis.

Adequate fluid balance in humans depends on the secretion and reabsorption of fluid and electrolytes in the intestinal tract; diarrhea occurs when intestinal fluid output overwhelms the absorptive capacity of the gastrointestinal tract. The 2 primary mechanisms responsible for acute gastroenteritis are (1) damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to an osmotic diarrhea, and (2) the release of toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhea. ^[11]

However, even in severe diarrhea, various sodium-coupled solute co-transport mechanisms remain intact, allowing for the efficient reabsorption of salt and water. By providing a 1:1 proportion of sodium to glucose, classic oral rehydration solution (ORS) takes advantage of a specific sodium-glucose transporter (SGLT-1) to increase the reabsorption of sodium, which leads to the passive reabsorption of water. Rice- and cereal-based ORS may also take advantage of sodium-amino acid transporters to increase reabsorption of fluid and electrolytes. ^[11]

Children in the United States experience, on average, 1.3-2.3 episodes of diarrhea each year. Overall, acute gastroenteritis accounts for than 1.5 million outpatient visits, 220,000 hospitalizations, and direct costs of more than $2 billion each year in the United States alone. ^[12]

Annually, children under five experience an estimated 1.7 billion diarrheal episodes worldwide, leading to 124 million outpatient visits, 9 million hospitalizations, and 520,000 deaths. ^{[13, 14, 15, 1]}

Though the prevalence of acute gastroenteritis in children has changed little over the past 4 decades, the mortality has declined sharply, from 4.6 million in the 1970s to 3 million in the 1980s and 2.5 million in the 1990s. ^[16] One of the most important reasons for this decline has been the increasing international support for the use of ORS as the treatment of choice for acute diarrhea, with the proportion of diarrheal episodes treated with ORS rising from 15% in 1984 to 40% in 1993. ^[16]

Research has shown that early daycare attendence may be a risk factor for AGE in infants, but also protective against AGE later in childhood. One study found that first-year daycare attendance advances the timing of acute gastroenteritis infections, resulting in increased acute gastroenteritis disease burden in the first year of life and relative protection thereafter. The study also added that protection against acute gastroenteritis infection persists at least up to age 6 years. ^[17]

Most cases of AGE follow a relatively benign course, with less than 2% of diarrheal episodes progressing to severe disease. Even among children who develop severe diarrhea, mortality is only about 2%. ^[13] Younger children under two years of age tend to be at higher risk of death. ^[13] In all cases, early and appropriate rehydration can reduce mortality in both high and low-resource settings.

Parents should be reassured that AGE is generally a benign disease, and in most cases will improve on its own within one week without specific treatment. For children without signs of dehydration who are being discharged home, parents should be told to continue breastfeeding/general feeding of the child, and can encourage extra fluid intake as long as the child tolerates. Parents should be told to return if their child develops intractable vomiting, signs of more severe dehydration such as irritablity or lethargy, sunken eyes, reduced skin pinch, decreased tears, or refusal to drink fluids. Parents should also be told to return if the child develops high fevers, seizures, worsening abdominal pain, or bloody diarrhea, or if the diarrhea continues to persist beyond 1-2 weeks. 

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Symptom or Sign

No or Minimal Dehydration

Mild to Moderate Dehydration

Severe Dehydration

Mental status

Alert

Restless, irritable

Lethargic, unconscious

Thirst

Drinks normally

Drinks eagerly

Drinks poorly

Heart rate

Normal

Normal to increased

Tachycardia

Quality of pulses

Normal

Normal to decreased

Weak or impalpable

Breathing

Normal

Normal or fast

Deep

Eyes

Normal

Slightly sunken

Deeply sunken

Tears

Present

Decreased

Absent

Mouth and tongue

Moist

Dry

Parched

Skin fold

Instant recoil

Recoil < 2 seconds

Recoil >2 seconds

Capillary refill

Normal

Prolonged

Prolonged or minimal

Extremities

Warm

Cool

Cold, mottled, cyanotic

Urine output

Normal

Decreased

Minimal

*Adapted from King et al. MMWR Recomm Rep. 2003;52(RR-16):1-16. ^[11]

Severe Dehydration

Two of the following signs:

-Lethargic or unconscious

-Sunken eyes

-Not able to drink or drinking poorly

-Skin pinch goes back very slowly

Some Dehydration

Two of the following signs:

-Restless, irritable

-Sunken eyes

-Thirsty, drinks eagerly

-Skin pinch goes back slowly

No Dehydration

Not enough of the above signs to classify as some or severe dehydration

*Adapted from World Health Organization. ^[7]

Adam C Levine, MD, MPH Associate Professor of Emergency Medicine, The Warren Alpert Medical School of Brown University

Adam C Levine, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Karen A Santucci, MD, MD 

Karen A Santucci, MD, MD is a member of the following medical societies: Alpha Omega Alpha, Academic Pediatric Association, American Academy of Pediatrics, Sigma Xi, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children’s Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

James Li, MD Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, David W Marby, MD †, to the development and writing of this article.

Pediatric Gastroenteritis in Emergency Medicine

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