Manshiet Al-Bakry Hospital

Pediatric Departement
Gastroenteritis

Gastroenteritis
The term gastroenteritis denotes infection of the gastrointestinal tract caused by bacterial,
viral, or parasitic pathogens. Many of these infections are foodborne illnesses.
The most common manifestations are diarrhea and vomiting, which can also be associated
with systemic features such as abdominal pain and fever.

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Manshiet Al-Bakry Hospital
Pediatric Departement
Gastroenteritis

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Manshiet Al-Bakry Hospital
Pediatric Departement
Gastroenteritis

TREATMENT
The broad principles of management of acute gastroenteritis in children include:
1. Oral rehydration therapy
2. Enteral feeding and diet selection
3. Antimicrobials
4. Antiemetics
5. Zinc supplementation
6. Probiotics.

Antimotility agents are contraindicated in children with dysentery and probably have no
role in the management of acute watery diarrhea in otherwise healthy children.

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Manshiet Al-Bakry Hospital
Pediatric Departement
Gastroenteritis

1- Oral rehydration therapy

For each diarrheal stool or vomiting episode:
<10 kg body weight: 60-120 mL ORS
>10 kg body weight: 120-240 mL ORS

Oral rehydration should be given to infants and children slowly, especially if they have
emesis. It can be given initially by a dropper, teaspoon, or syringe, beginning with as little as
5 mL at a time. Limitations to oral rehydration therapy include shock, an ileus,
intussusception, carbohydrate intolerance (rare), severe emesis, and high stool output (>10
mL/kg/hr).

2- Enteral feeding and diet selection

Continue breast-feeding, or resume age-appropriate normal diet after initial hydration,

including adequate caloric intake for maintenance
Infants too weak to eat can be given milk or formula through a nasogastric tube. Lactose-
containing formulas are usually well tolerated. Complex carbohydrates, fresh fruits, lean
meats, yogurt, and vegetables are all recommended. Carbonated drinks or commercial juices
with a high concentration of simple carbohydrates should be avoided.

3- Antimicrobials

Timely antibiotic therapy in select cases of diarrhea can reduce the duration and severity of
diarrhea and prevent complications (Table). Although these agents are important to use in
specific cases, their widespread and indiscriminate use leads to the development of
antimicrobial resistance. Nitazoxanide, an anti-infective agent, has been effective in the
treatment of a wide variety of pathogens including C. parvum, G. lamblia, E. histolytica,
Blastocystis hominis, C. difficile, and rotavirus.thus can be used emperically until culture
results or serological tests are obtained.

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Manshiet Al-Bakry Hospital
Pediatric Departement
Gastroenteritis

4- Antiemetics:
Because persistent vomiting can limit oral rehydration therapy using antiemetics would help
more effective oral rehydration. agents such as the phenothiazines are of little value and are
associated with potentially serious side effects (lethargy, dystonia, malignant hyperpyrexia).
Nonetheless,Ondansetron is an effective and less-toxic antiemetic agent
{0.1-0.3 mg/kg once /day}.

Fluid and electrolyte replacement in gastroenteritis

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Manshiet Al-Bakry Hospital
Pediatric Departement
Gastroenteritis

Grades of dehydration
Mild Moderate severe
Clinical picture  Thirsty  Sunken eyes Shocked
 Irritable  Depressed fontanelles (capillary
 Decreased skin turgor refill > 3
 Dry tongue and eye seconds)

Mild dehydration:

No need for hospitalization unless there is persistent vomiting or electrolyte

imbalance otherwise fluid and electrolyte correction achieved by ORS

Fluid and electrolyte replacement in gastroenteritis include 2 phases:

Phase 1: shock therapy during 1st hr

20 ml/Kg ringer lactate or preferably normal saline over 20 minutes, this can be
repeated 2 more times.

Phase 2: Deficit and maintenance replacement

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 Manshiet Al-Bakry Hospital
Pediatric Departement
Gastroenteritis

 K replacement
If K level 3.5-5.520 meq i.e :1 cm kcl for each 100 cc fluids
If K level < 3.540 meq i.e : 2cm kcl for each 100 cc fluids
If K level >5.5 no kcl replacement

 Water and sodium correction

Isonatremic Hyponatremic(<125)* Hypernatremic**

Type of fluid Dextrose 10%:Normal saline
1:1
Amount of fluid Deficit: in infants:
 50 ml/Kg if mild dehydration
 100ml/Kg if moderate dehydration (Deficit + Maintenance)-
 150 ml/Kg if severe dehydration shock therapy
In children:
 30 ml/Kg if mild dehydration
 60 ml/Kg if moderate dehydration
 90 ml/Kg if severe dehydration
Maintenance:
 1st 10 Kg: 100 ml/Kg
 2nd 10 kg:50 ml/Kg
 Over 20 kg: 20 ml/Kg
Rate of fluid 1st 8 hrs 1/2 deficit + 1/3 maintenance Maintenance x (1.25-1.5)
nd
2 8 hrs1/4 deficit + 1/3 maintenance To be repeated every day
3rd 8 hrs ¼ deficit + 1/3 maintenance according to duration of
Or by using electric syringe correction which depends
(deficit+maintenance)- shock therapy over 23 hrs on Na level
145-157over 24 hrs
158-170over 48 hrs
171-183over 72 hrs
184-196 over 96 hrs
>196 needs dialysis

Any amounts of oral intake either ORS or feeding should be subtracted from
total fluid intake.

Special notes:

*Hyponatremic dehydration:

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Manshiet Al-Bakry Hospital
Pediatric Departement
Gastroenteritis

 Rate of correction of Na in hyponatremic dehydration shouldn’t exceed

10 meq/L/day to avoid pontine myelinolysis

Na deficit={desired(125)- actual} x wt x0.6

corrected using hypertonic saline each1 cc0.5 meq
or normal saline each 100cc15meq
this amount of fluid is to be subtracted from total fluid intake/day and given in
separate IV line as follows :1st 8hrs ½ amount ,2nd16 hrs1/2 amount

**Hypernatremic dehydration:

 Rate of correction of Na in hypernatremic dehydration shouldn’t exceed

12 meq/L/day to avoid brain edema
1. If rate of decline is slow,increase amount of fluid (Mx1.5),if still slow,
change type of fluid to Dextrose 10%:Dextrose5%:Normal saline1:2:1

2. If rate of decline is rapid,decrease amount of fluid(Mx1.25),if still

rapidchange type of fluid to

Dextrose 10%:Dextrose5%:hypertonic saline1:1:1

Or use hypertonic saline3% and dextrose 25% as follows:

1/3 total fluid amount is given in the form of hypertonic saline 3%

2/3 total fluid amount as follows:
1/5dextrose 25%
4/5dextrose 5%
Then calculate total desired amount of dextrose and modify fluid compositon.

Example:

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 Manshiet Al-Bakry Hospital
Pediatric Departement
Gastroenteritis

Total fluid intake for an infant 14 kg1200 CC in isonatremic dehydration ,1/2 this
amount given as glucose 10% i.e : glucose requirements =60 gm (every 100 cc glucose
10%->10 gm glucose) but in case of hypernatremic dehydration same glucose
requirements are given with different fluid preparation(usually calculated over 3 steps)

step 1:
Give 400 cc hypertonic saline 3% (1/3)
+160 cc dextrose 25%-->40 gm glucose (2/3)
+640 cc dextrose 5%-->32 gm glucose

Total glucose in composed fluid=40+32=72 while desired amount 60

So we subtract 25-30 cc from amount of dextrose 25% and add it to
amount of dextrose 5% as follows:

Step 2:
135 cc dextrose 25%-->33.75 gm glucose
+665 cc dextrose 5%-->33.25 gm glucose
Total glucose in composed fluid=33.75+33.25=67 while desired amount
60

Step 3:
105 cc dextrose 25%-->25.75 gm glucose
+695 cc dextrose 5%-->34.75 gm glucose
Total glucose in composed fluid=25.75+34.75=60.5 which is almost as
desired amount