Chapter 78: Acute Gastroenteritis

Introduction
• Acute gastroenteritis (AGE) is a leading cause of childhood morbidity and
mortality and an important cause of malnutrition.
• Many diarrhoeal deaths are caused by dehydration and electrolytes loss.
• Dehydration can be safely and effectively treated with Oral Rehydration
Solution (ORS) but severe dehydration may require intravenous fluid
therapy.
First assess the state of perfusion of the child.
Is the child in shock?
• Signs of shock (haemodynamic instability) include tachycardia, weak
peripheral pulses, delayed capillary refill time > 2 seconds, cold peripheries,
depressed mental state with or without hypotension.
Any child with shock go straight to treatment Plan C.
You can also use the WHO chart below to assess the degree of dehydration
and then choose the treatment plan A, B or C, as needed.

Assess:
Look at child’s Well, alert Restless or Lethargic or
general condition irritable unconscious
Look for sunken No sunken eyes Sunken eyes Sunken eyes
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eyes
Offer the child Drinks normally Drinks eagerly, Not able to drink or
fluid thirsty drinks poorly
Pinch skin of Skin goes back Skin goes back Skin goes back very
abdomen immediately slowly slowly (> 2 secs)
Classify ≥ 2 above signs: ≥ 2 above signs:
Mild Dehydration Moderate Severe
Dehydration Dehydration
<5% Dehydrated* 5-10% Dehydrated > 10% Dehydrated
IMCI: No signs IMCI: Some signs
of Dehydration of Dehydration
Treat Plan A Plan B Plan C
Give fluid and food Give fluid and food Give fluid for severe
to treat diarrhoea for some dehydration.
at home dehydration Provide food as
soon as child
tolerates.
*% of body weight (in g) loss in fluid (Fluid Deficit) e.g. a 10 kg child with 5%
dehydration has loss 5/100 x 10000g = 500 mls of fluid deficit.

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PLAN A: TREAT DIARRHOEA AT HOME
Counsel the mother on the 3 rules of home treatment:
Give Extra Fluid, Continue Feeding, When to return
1. Give Extra Fluids (as much as the child will take)
• Tell the mother:
• Breastfeed frequently and for longer at each feed.
• If exclusively breastfed, give Oral Rehydration Solution (ORS) or cooled
boiled water in addition to breastmilk.
• If the child is not exclusively breastfed, give one or more of the
following: ORS, food-based fluids (soup and rice water) or cooled boiled
water.
• It is especially important to give ORS at home when:
• The child has been treated with Plan B or Plan C during this visit.
• Teach the mother how to mix and give ORS. Give her 8 sachets to use
at home.
• Show mother how much ORS to give in addition to the usual fluid intake:
Up to 2 years : 50 to 100ml after each loose stool
2 years or more : 100 to 200ml after each loose stool
(If weight is available, give 10ml/kg of ORS after each loose stool)
• Tell mother to
• Give frequent small sips from a cup or spoon.

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• If child vomits, wait 10 minutes, then continue but more slowly.
• Continue giving extra fluid until diarrhoea stops.
2. Continue Feeding
• Breastfed infants should continue nursing on demand.
• Formula fed infants should continue their usual formula immediately on
rehydration.
• Lactose-free or lactose-reduced formula usually are unnecessary.
• Children receiving semi-solid or solid foods should continue to receive
their usual food during the illness.
• Foods high in simple sugar should be avoided as osmotic load may
worsen the diarrhoea.
3. When to Return (to clinic/hospital)
• When the child:
• Is not able to drink or breastfeed or drinking poorly.
• Becomes sicker.
• Develops a fever.
• Has blood in stool.

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 PLAN B: TREAT SOME DEHYDRATION WITH ORS
Give the recommended amount of ORS over 4-hour period:
Determine the amount of ORS to be given in the first 4 hours.
Age Up to 4 months 4 - 12 mths 12 mths - 2 yrs 2 - 5 yrs
Weight Less than 6 kgs 6 to 10 kgs 10-12 kgs 12 to 19 kgs
Volume 200-400 mls 400-700 mls 700-900 mls 900-1400 mls
1. Use the child’s age only when you do not know the weight.
The approximate amount of ORS required (in ml) can be calculated by
multiplying the child’s weight (in kg) x 75.
2. If the patient wants more ORS than shown, give more.

Show the mother how to give ORS solution

• Give frequent small sips from cup or spoon.
• If the child vomits, wait 10 minutes, then continue but more slowly
(i.e. 1 spoonful every 2 - 3 minutes).
• Continue breastfeeding whenever the child wants.
After 4 hours
Reassess the child and classify the child for dehydration.
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Select the appropriate plan to continue treatment (Plan A, B or C).

Begin feeding the child.
If the mother must leave before completing treatment
• Show her how to prepare ORS solution at home.
• Show her how much ORS to give to finish the 4-hour treatment at home.
• Give her enough ORS packets to complete rehydration. Also give her
8 packets as recommended in Plan A.
• Explain the 3 Rules of Home Treatment (Plan A):
1. GIVE EXTRA FLUID
2. CONTINUE FEEDING
3. WHEN TO RETURN

Important!
• If possible, observe the child at least 6 hours after re-hydration to be
sure the mother can maintain hydration giving the child ORS solution by
mouth.
• If there is an outbreak of cholera in your area, give an appropriate oral
antibiotic after the patient is alert.

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PLAN C: TREAT SEVERE DEHYDRATION QUICKLY
• Airway, Breathing and Circulation (ABCs) should be assessed and
established quickly.
• Start intravenous (IV) or intraosseous (IO) fluid immediately.
If patient can drink, give ORS by mouth while the drip is being set up.
• Initial fluids for resuscitation of shock: 20 ml/kg of 0.9% Normal Saline (NS)
or Hartmann’s solution as a rapid IV bolus.
• Repeated if necessary until patient is out of shock or if fluid overload is
suspected. Review patient after each bolus and consider other causes of
shock if child is not responsive to fluid bolus, e.g. septicaemia.
• Once circulation restores, commence rehydration, provide maintenance
and replace ongoing losses.
• For rehydration use isotonic solution: 0.9% NS or Hartmann’s solution
(0.45% NS in neonates).
Fluid deficit: Percentage dehydration X body weight in grams (to be
given over 4-6 hours).
Maintenance fluid (See Chapter 3 Fluid And Electrolyte Guidelines)
Example:
A 12-kg child is clinically shocked and 10% dehydrated as a result of gastroenteritis.
Initial therapy: To establish ABCs
• 20 ml/kg for shock = 12× 20 = 120 ml of 0.9% NS given as a rapid

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intravenous bolus. Repeat if necessary.
• Fluid for Rehydration/Fluid deficit: 10/100 x 12000 = 1200 ml
• Daily maintenance fluid = 1st 10 kg 100 × 10 = 1000 ml
Subsequent 2 kg 2 x 50 = 100 ml
Total = 1100 ml/day
• To rehydrate (1200 ml over 6 hours) 0.9%NS or Hartmann’s solution
+ maintenance (1100 ml over 24 hours) with 0.9%NS D5%.
• Replace on going diarrhoea/vomiting lossess orally whenever possible:
5- 10ml/kg for each episode.

The cornerstone of management is to reassess the hydration status

frequently (e.g. at 1-2 hourly), and adjust the infusion as necessary.
• Caution - more judicious fluid administration rate will be required in
certain situations:
• Children less than 6 months age.
• Children with co-morbidities.
• Children that need careful fluid balance, i.e.: heart or kidney problems,
severe malnutrition (See Chapter Approach To Severly Malnourished
Chidren).
• Children with severe hyponatraemia/ hypernatraemia (See Chapter 3
Paediatric Fluids and Electrolyte Guidelines).
• Start giving more of the maintenance fluid as oral feeds e.g. ORS (about
5ml/kg/hour) as soon as the child can drink, usually after 3 to 4 hours for
infants, and 1 to 2 hours for older children. This fluid should be administered
frequently in small volumes (cup and spoon works very well for this process).

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 • Generally normal feeds should be administered in addition to the
rehydration fluid, particularly if the infant is breastfed.
• Once a child is able to feed and not vomiting, oral rehydration according
to Plan A or B can be used and the IV drip reduced gradually and taken off.
• If you cannot or fail to set up IV or 10 line, arrange for the child to be sent
to the nearest centre that can do so immediately.
• Meanwhile as arrangements are made to send the child (or as you make
further attempts to establish IV or 10 access),
• Try to rehydrate the child with ORS orally (if the child can drink) or by
nasogastric or orogastric tube. Give ORS 20 ml/kg/hour over 6 hours.
Continue to give the ORS along the journey.
• Reassess the child every 1-2 hours.
• If there is repeated vomiting or increasing abdominal distension, give
the fluid more slowly.
• Reassess the child after six hours, classify dehydration
• Then choose the most appropriate plan (A, B or C) to continue treatment.
• If there is an outbreak of cholera in your area, give an appropriate oral
antibiotic after the patient is alert.
Other indications for intravenous therapy
• Unconscious child.
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• Failed ORS treatment due to continuing rapid stool loss ( >15-20ml/kg/hr).

• Failed ORS treatment due to frequent, severe vomiting, drinking poorly.
• Abdominal distension with paralytic ileus, usually caused by some
antidiarrhoeal drugs (e.g. codeine, loperamide ) and hypokalaemia
• Glucose malabsorption, indicated by marked increase in stool output and
large amount of glucose in the stool when ORS solution is given
(uncommon).
Indications for admission to Hospital
• Shock or severe dehydration.
• Failed ORS treatment and need for intravenous therapy.
• Concern for other possible illness or uncertainty of diagnosis.
• Patient factors, e.g. young age, unusual irritability/drowsiness, worsening
symptoms.
• Caregivers not able to provide adequate care at home.
• Social or logistical concerns that may prevent return evaluation if necessary.

* Lower threshold for children with obesity/undernutrition due to possibility

of underestimating degree of dehydration.

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Other problems associated with diarrhoea
• Fever
• May be due to another infection or dehydration.
• Always search for the source of infection if there is fever, especially if it
persists after the child is rehydrated.
• Seizures
• Consider:
- Febrile convulsion (assess for possible meningitis)
- Hypoglycaemia
- Hyper/hyponatraemia
• Lactose intolerance
• Usually in formula-fed babies less than 6 months old with infectious
diarrhoea.
• Clinical features:
- Persistent loose/watery stool
- Abdominal distension
- Increased flatus
- Perianal excoriation
• Making the diagnosis: compatible history; check stool for reducing
sugar (sensitivity of the test can be greatly increased by sending the
liquid portion of the stool for analysis simply by inverting the diaper).

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• Treatment: If diarrhoea is persistent and watery (over 7-10 days) and
there is evidence of lactose intolerance, a lactose free formula
(preferably cow’s milk based) may be given.
• Normal formula can usually be reintroduced after 3-4 weeks.
• Cow’s Milk Protein Allergy
• A known potentially serious complication following acute gastroenteritis.
• To be suspected when trial of lactose free formula fails in patients with
protracted course of diarrhoea.
• Children suspected with this condition should be referred to a paediatric
gastroenterologist for further assessment.

Nutritional Strategies
• Usually no necessity to withold feeding.
• Undiluted vs diluted formula
• No dilution of formula is needed for children taking milk formula.
• Lactose free formula (cow’s milk-based or soy based)
• Not recommended routinely. Indicated only in children with lactose
intolerance.
• Cow’s milk based lactose free formula is preferred.

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 PHARMACOLOGICAL AGENTS
Antimicrobials
• Antibiotics should not be used routinely.
• They are reliably helpful only in children with bloody diarrhoea, probable
shigellosis, and suspected cholera with severe dehydration.
Antidiarrhoeal medications
• Diosmectite (Smecta®) has been shown to be safe and effective in
reducing stool output and duration of diarrhoea. It can be used as an ad-
junct in the management of AGE. It acts by restoring integrity of damaged
intestinal epithelium, also capable to bind to selected bacterial pathogens
and rotavirus.
• Other anti diarrhoeal agents like kaolin (silicates), loperamide
(anti-motility) and diphenoxylate (anti motility) are not recommended.
Antiemetic medication
• Not recommended, potentially harmful.
Probiotics
• Probiotics has been shown to reduce duration of diarrhoea in several
randomized controlled trials. However, the effectiveness is very strain and
dose specific. Therefore, only probiotic strain or strains with proven
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efficacy in appropriate doses can be used as an adjunct to standard

therapy.
Zinc supplements
• It was found that zinc supplements during an acute episode of diarrhoea
may be of benefit in children aged 6 months or more in areas where the
prevalence of zinc deficiency or the prevalence of malnutrition is high.
• WHO recommends zinc supplements as soon as possible after diarrhoea
has started.
• Dosage for age 6 months and above 20mg/day, for 10-14 days.
Prebiotics
• Not recommended.

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