com
Clinical Review
Box 1 | Causes of acute gastroenteritis in children gens. Ingestion of food containing toxins produced
by bacterial contaminants (for example, Staphylococcus
Viruses (about 70%) aureus in ice cream or Bacillus cerus in reheated rice)
• Rotaviruses causes rapid onset of vomiting or diarrhoea (or both).
• Noroviruses (Norwalk-like viruses) Water may be contaminated with bacteria, viruses, or
• Enteric adenoviruses protozoa including Giardia lamblia, cryptosporidium,
• Caliciviruses V cholerae, and Entamoeba histolytica, which causes amoe
• Astroviruses bic dysentery. With increasing rates of overseas travel
• Enteroviruses and immigration, clinicians in developed countries
increasingly see children with “traveller’s diarrhoea”
Protozoa (<10%)
caused by a range of organisms not normally seen in
• Cryptosporidium
that environment.
• Giardia lamblia
• Entamoeba histolytica How is it diagnosed?
Bacteria (10-20%) Diagnosis can be made clinically. Information should
• Campylobacter jejuni be sought about recent contact with people with gastro
• Non-typhoid Salmonella spp enteritis, nature and frequency of stool and vomitus,
• Enteropathogenic Escherichia coli fluid intake and urine output, travel, and use of anti
• Shigella spp
biotics and other drugs that may cause diarrhoea.
Chronic constipation is common in children, and
• Yersinia enterocolitica
faecal overflow incontinence may present as spurious
• Shiga toxin producing E coli
diarrhoea. Diarrhoea and vomiting are non-specific
• Salmonella typhi and S paratyphi
symptoms in young children, and the diagnosis of
• Vibrio cholerae gastroenteritis should be questioned in children with
Helminths high fever, prolonged symptoms, or signs suggesting a
• Strongyloides stercoralis
surgical cause (such as severe abdominal pain, bilious Clinicians often overestimate the extent of dehydra
vomiting, abdominal mass). Children with diabetes tion. Clinical signs are usually not present until a child
mellitus and inborn errors of metabolism may present has lost at least 5% of his or her body weight. Docu
with vomiting. Children with underlying diseases may mented recent weight lost is a good indicator of the
be at increased risk of complications and referral to a degree of dehydration, but this information is rarely
paediatric service should be considered. available. The best clinical indicators of more than 5%
It is not necessary or practical to take stool specimens dehydration are prolonged capillary refill, abnormal
from all children with gastroenteritis. Samples should be skin turgor, and absent tears.9 The recommendations for
taken during outbreaks—especially in childcare, school, assessing and managing dehydration shown in table 1
hospital, or residential settings—where there is a public are adapted from the World Health Organization clas
health imperative to identify the pathogen and estab sification and are supported by the literature.9-11 Serum
lish its source. Samples should be cultured for bacteria electrolytes are not routinely required but should be
and tested for viral pathogens. Testing for rotavirus, measured before and after starting intravenous fluids.
norovirus, and sometimes other viruses is available in
most children’s hospitals using methods for rapid anti How is gastroenteritis treated?
gen detection (such as enzyme linked immunosorbent Table 1 summarises the management of dehydra
assay). Rapid diagnosis allows for isolation of the child tion2 4 10-23 and table 2 lists the type of evidence sup
to prevent nosocomial infection, which is common porting management decisions in gastroenteritis (a
and is often used as a marker of the effectiveness of longer version of table 2 (table A) is available on bmj.
precautions to control contact infection. Stool samples com). Management aims to prevent and treat dehy
should also be taken from children with bloody diar dration, maintain nutrition, and minimise harm.
rhoea, a history of recent foreign travel, and from young
or immunocompromised children with high fever. In Which fluid therapy?
many countries legislation requires clinicians to notify Children with no dehydration or mild dehydration
public health authorities about a range of viral and bac can usually be managed at home, although children
terial infections. with high risk for complications or who cannot be
adequately cared for at home should be considered
How is dehydration assessed? for admission.2 11 13 Children with mild-moderate
It is important to assess hydration in gastroenteritis as dehydration who do not tolerate oral fluids should be
hydration status determines the immediate manage admitted for observation. Oral rehydration solutions
ment of this condition. The infant or child with profuse are preferable to other clear fluids for preventing and
watery diarrhoea and frequent vomiting is most at risk. treating dehydration.2 4 11 Fluids high in sugar (such as
cola, apple juice, and sports drinks, which contain ≤20
mmol/l sodium and have a high osmolality of 350-750
Unanswered research questions
mOsm/l) may exacerbate diarrhoea and should be
• How safe and effective is home based care for children avoided.11 Breast feeding should be continued during
with mild-moderate dehydration?
acute gastroenteritis and supplemented with an oral
• What role do food based oral rehydration solutions have rehydration solution if needed.11 12
in developed communities?
Although most children with dehydration drink read
• What is the role and safety of new generation antiemetics
ily, some refuse rehydration solutions because they dis
and antidiarrhoeal agents?
like the taste, feel nauseated, or have profuse vomiting.
• What is the role of zinc supplementation in well nourished
Older children may be afraid of vomiting and parents
children?
may perceive fluids are the cause of vomiting. If small
• Do probiotics have a role as adjuvant therapy, and what
type, dose, and regimen is optimal? sips cannot be tolerated, use of a syringe can help in
infants. If oral intake is inadequate, a fine bore naso
Table 1 | Assessment and management of dehydration10 The most common adverse effect of intravenous can
Dehydration Clinical signs Pinch test* Management nulation is infiltration at the cannula site, but infection,
(% weight loss) pain, bleeding, and physical and emotional trauma may
No dehydration None Normal (skin fold Most can be managed at home; encourage also occur. Intravenous therapy is more expensive than
retracts immediately) normal diet and fluids (continue breast milk); oral rehydration therapy and requires hospital admis
consider admission if high risk of dehydration
(very young, diagnosis in doubt, large losses) sion. Iatrogenic complications—especially electrolyte
Some dehydration: Two or more of Slow (skin fold visible Some can be managed at home with oral disturbance due to inappropriate composition, rate of
includes previous restlessness <2 sec) rehydration therapy; some need to be observed administration, or volume of intravenous fluids—may
categories of mild or irritability, and, if therapy is not tolerated or large ongoing lead to complications, including hyponatraemia with
(5%) and moderate sunken eyes, thirst losses occur, may need nasogastric or
(6-9%) dehydration (eagerness to intravenous fluids over 4-6 h; normal diet when brain injury or death (box 3). If rapid intravenous rehy
drink) tolerated dration is used, careful supervision is needed to avoid
Severe dehydration Two or more of Very slow (skin fold Check acid base status, urea, electrolytes fluid overload (dehydration is often overestimated) and
(<10%) with or abnormally sleepy visible >2 sec) before intravenous fluids; if shock present, first electrolyte imbalance.
without shock or lethargic, resuscitate with intravenous bolus; rehydrate
sunken eyes, intravenously (enteral fluids have been used)
drinking poorly or over 4-6 h with regular clinical and biochemical Which oral rehydration solution?
not at all† review Solutions with low osmolality (200-250 mOsm/l) and
*A measure of skin turgor. Assessed by pinching the skin of the abdomen or thigh between the thumb and the bent sodium (60-70 mmol/l) that contain glucose, potas
forefinger in a longitudinal manner. Results are unreliable in obese or severely malnourished children.
†Other signs of severe dehydration include circulatory collapse (weak rapid pulse, cool or blue extremities, sium, and a base (such as citrate) are recommended for
prolonged capillary refill time, or hypotension), rapid breathing, and sunken anterior fontanelle. developed and developing communities (table 2; table
B on bmj.com).16-18 Although cereal based oral dehydra
gastric tube is usually well tolerated.14 15 Alternatively, tion solutions are beneficial in cholera-like diarrhoea,19
fluids may be given intravenously.11 Enteral (oral or evidence of benefit in non-cholera diarrhoea is scant
nasogastric) and intravenous fluids are equally safe and and further trials are needed to evaluate efficacy and
effective for mild-moderate dehydration,14 15 and rehy cost effectiveness.
dration can usually be achieved in four to six hours.
In developed communities children with severe What about diet?
dehydration are routinely admitted for intravenous In a systematic review, probiotics—used as an adjunct
therapy, although enteral rehydration has been to oral rehydration therapy—decreased the duration
used safely in severe dehydration with fewer adverse of diarrhoea, especially in rotavirus gastroenteritis
effects than intravenous therapy (table 2).14 15 Children (table 2).20 Further research is needed to determine the
with shock require intravenous resuscitation before optimal type, dosage, and regimen of probiotics before
rehydration.2 10 11 they are recommended for routine use.
Box 3 | Complications of acute gastroenteritis mended for routine use because of the risk of adverse
effects (table 2; table A on bmj.com).3 10 11 Although new
• Dehydration
generation antiemetics (such as the serotonin antagonist
• Metabolic acidosis
ondansetron) do not have extrapyramidal effects and
• Electrolyte disturbance (hypernatraemia, hyponatraemia,
reduce the duration and frequency of vomiting, they
hypokalaemia)
also increase diarrhoea. Antimotility agents (such as
• Carbohydrate (lactose, glucose) intolerance
loperamide) decrease the duration of diarrhoea, but
• Susceptibility to reinfection
they have potential severe adverse effects and evidence
• Development of food (cow’s milk, soy protein) intolerance that benefits outweigh potential harms is lacking.6
• Haemolytic uraemic syndrome In developing countries, oral zinc given at the onset
• Iatrogenic complications (due to inappropriate of symptoms decreases the duration and severity of
composition or amount of intravenous fluids) acute diarrhoea and is recommended by the WHO.10
• Death Vitamin A does not influence the course of acute
gastroenteritis.
Children should resume their normal diet once their Is a lactose-free diet necessary?
appetite returns.2 10 11 Published guidelines recommend Carbohydrate (particularly lactose) intolerance is a
early reintroduction of milk and solids including com common complication of viral gastroenteritis as a result
plex carbohydrates, lean meats, yogurt, and vegetables, of damage to and loss of mature enterocytes contain
but foods high in fat and sugars should be avoided. ing lactase. Lactose intolerance is usually mild and self
Early refeeding reduces the duration of diarrhoea. In limiting and does not require treatment.3 21 If lactose
formula fed infants feeds do not need to be diluted intolerance persists, a lactose-free formula is recom
when reintroduced. mended for four to six weeks.3 21 The damaged gut is
more permeable to foreign antigens and intolerance to
What is the role of drugs? food proteins (β lactoglobulin in cow’s milk and other
Drugs are rarely needed.3 10 11 They deal with the symp proteins) is occasionally seen after gastroenteritis; it can
toms rather than causes of disease and may distract be managed by a period of dietary exclusion.3 10 11
from the use of appropriate fluid therapy. Antibiotics
are not indicated in viral or uncomplicated bacterial Can gastroenteritis be prevented?
gastroenteritis and may cause harm. For example, in Although rotavirus may be spread in aerosols, gastro
non-typhoid Salmonella infections antibiotics increase enteritis is usually spread by the faecal-oral route.
the risk of prolonged carriage and disease relapse. Treat Bacterial gastroenteritis can occur in young children
ing gastroenteritis due to Shiga toxin producing E coli served uncooked fermented meats, undercooked
with antibiotics may increase the risk of haemolytic hamburgers, unwashed fruits and salads, and water
uraemic syndrome. Antibiotics are required, however, contaminated by animal faeces. Gastroenteritis may
for bacterial gastroenteritis complicated by septicaemia also be acquired from environmental sources, such
and in cholera, shigellosis, amoebiasis, giardiasis, and as children’s animal farms, swimming pools, and
enteric fever. beaches. Good hygiene is important to prevent spread
Antidiarrhoeal and antiemetic agents are not recom of infection. This includes careful hand washing,
nappy disposal, and preparation and storage of food
and drinking water, as outlined in the WHO’s five step
Additional educational resources guide to safe food (table C on bmj.com). Hygiene is
Clinical resources particularly important in institutions, including hospi
Clinical evidence (www.clinicalevidence.com/ceweb/ tals where nosocomial infection is common.
conditions/chd/chd.jsp) A major recent advance in prevention has been the
Cochrane Library (www.cochrane.org) development and licensing of two oral rotavirus vac
Evidence-based Paediatrics and Child Health (www. cines, whose safety and efficacy have been confirmed
evidencebasedpediatrics.com) in recent large scale trials, each involving more than
Managing acute gastroenteritis among children (www.cdc. 60 000 children.24 25 Rotateq (Merck) is a three dose live
gov/mmwr/preview/mmwrhtml/rr5216al.htm) human-bovine pentavalent reassortant vaccine. Rota
Glass RI, Parashar UD. The promise of new rotavirus rix (GSK) is two dose attenuated human (strain G1P)
vaccines. N Engl J Med 2006;354:75-7 monovalent vaccine. Both vaccines are highly immuno
Information resources for patients genic. They provide cross protection against common
BUPA. Gastroenteritis in children (http://hcd2.bupa. serotypes and decrease rates of severe gastroenteritis,
co.uk/fact_sheets/html/gastroenteritis_children.html) the need for intravenous fluids, and hospital admis
Cincinnati Children’s Hospital Medical Centre, USA. sion. Importantly, neither is associated with appreci
Gastroenteritis (www.cincinnatichildrens.org/health/info/ able adverse effects or increased risk of intussusception,
abdomen/diagnose/gastroenteritis.htm)
which was seen with the first licensed vaccine, Rota
Health Institute. An Australian government initiative.
Shield. Free access to rotavirus vaccine in all communi
Gastroenteritis in children (www.healthinsite.gov.au/
topics/Gastroenteritis_in_Children)
ties is imperative and will have an enormous impact on
childhood morbidity and mortality.
I am grateful to Michael Fasher and Alison Kesson for useful feedback on this Accepted: 9 November 2006
article before submission.