Gastroenteritis is a common presentation in paediatrics with around 20% of the UK population developing symptoms each year. Most cases of gastroenteritis can be managed in the community. Some children will need referral to the paediatric team for further investigation and/or support with their fluid intake – the features of cases we would like to see for review are outlined below. Local Health Protection Unit (HPU) should be contacted if you are aware of a community/local outbreak as further investigation and samples may be required.

Features of gastroenteritis

• Key symptom = diarrhoea (3+ loose stools/24 hours)

• Other features – sudden onset nausea/vomiting, blood or mucus in stool, fever/malaise

Diagnosis is usually clinical. Important things to discuss with children and parents include:

– Symptom severity – frequency and consistency of stools/vomits

– Presence or absence of blood in stools

– Is there a possible source of infection? Think about unwell relatives/childcare contacts/travel history/ takeaway food/BBQs

Assess for dehydration/shock https://cks.nice.org.uk/gastroenteritis#!scenario:1

Signs/symptoms No clinically detectable dehydration

Clinical

dehydration

Clinical shock
Symptoms (remote & Face to face)

– Appears well Alert and responsive

– Normal urine output

– Skin colour unchanged

– Warm extremities

– Appears to be unwell or deteriorating*

– Altered responsiveness (for example irritable, lethargic)*

– Decreased urine output

– Skin colour unchanged

– Warm extremities

– Decreased level of consciousness

– Pale or mottled skin Cold extremities
Signs (face-to-face assessments) – Eyes not sunken– Moist mucous membranes (except after drink)– Normal HR, RR, BP, CRT– Normal breathing pattern– Normal peripheral pulses– Normal skin turgor– Normal blood pressure – Sunken eyes* – Dry mucous membranes (except for mouth breathing)– Tachycardia*– Tachypnoea*– Normal peripheral pulses and CRT – Reduced skin turgor*– Normal blood pressure – Tachycardia– Tachypnoea*– Weak peripheral pulses and prolonged CRT– Hypotension (decompensated shock)

* Red flag symptoms and signs indicating children at risk of progression to shock

Children at increased risk of dehydration include:

• Children younger than 1 year of age, particularly younger than 6 months.

• Infants who were of low birthweight.

• Children who have passed >5 diarrhoeal stools in the previous 24 hours.

• Children who have vomited more than twice in the previous 24 hours.

• Children who have not been offered, or have not been able to tolerate, supplementary fluids before presentation.

• Infants who have stopped breastfeeding during their illness.

• Children with signs of malnutrition.

Are there any features suggesting an alternative/serious diagnosis?

• High grade fevers (T >38oC in children less than 3 months of age, T >39oC in children aged 3 months +)

• Dyspnoea/Tachypnoea • Neck stiffness • Bulging fontanelle

• Non blanching rash

• Bilious vomiting

• Blood/mucus in stool

The following are ‘Red Flags’ for dehydration and should be urgently referred to Paediatrics:

• Altered responsiveness (eg: lethargy or irritability)

• Appears to be unwell or deteriorating

• Sunken eyes

• Reduced skin turgor

• Tachycardia

• Tachypnoea

• Pale or mottled skin

Not all children require stool to be sent for sampling. NICE recommend sending stool for culture if:

– Blood or mucus is seen in the stool

– There is a history of a recent hospital stay/course of antibiotics

– The child is immunocompromised

Consider sending stool for culture if:

– Diarrhoea is not improved past Day 7

– There is recent travel outside Western Europe, N. America, Australia/New Zealand

– If there is diagnostic uncertainty

Seek advice on samples from the local health protection unit (HPU) regarding contacts of people infected with certain organisms, for example Escherichia coli O157, where there may be serious clinical sequelae to an infection.

Management in the community

Rehydration advice is key for the parents of those children who don’t require assessment in hospital.

If the child is not clinically dehydrated:

– Continue with usual feeds including breast/other milk feeds – Encourage oral fluid intake

– If child is at increased risk of dehydration offer oral rehydration salts solution (ORS) to supplement their fluid intake

– Parents should discourage drinking of fruit juice/fizzy drinks (the high osmolarity of these drinks can worsen diarrhoea).

If the child is clinically dehydrated but can be managed safely at home:

– Offer rehydration with Oral Rehydration Solution (ORS) e.g. dioralyte<6 years old: 50ml/kg ORS over 4 hours to replace deficit, alongside ORS at maintenance volume (see below). Continue breastfeeds but don’t routinely offer other oral fluids.6+ years old: give 200ml ORS post each episode of diarrhoea, alongside the child’s typical oral fluids.

Calculating maintenance fluid requirements is based on body weight:

0-10kg = 100ml/kg

10-20kg = 1000ml plus 50ml/kg for each additional kg over 10kg

20+kg = 1500ml plus 20ml/kg for each additional kg over 20kg

Eg. For a child who weighs 22kg 1500ml + (2×20) = 1540ml/day

Avoid reintroducing solid food until the child is rehydrated. Consider whether response to fluid challenge can be monitored safely in the community and refer to secondary care if this is not felt possible.

After rehydration

– Encourage children to drink plenty of their normal fluids.

– Avoid fizzy drinks and fruit juices until diarrhoea has completely resolved

– Gradually reintroduce their typical diet

– Avoid withholding food for more than 4 hours

– If the child is at increased risk of dehydration (see above) give 5ml ORS/kg after each loose stool to avoid recurrence of dehydration.

We would not recommend anti-diarrhoeal medications or anti-emetics for children with suspected gastroenteritis

Children with gastroenteritis do not routinely require antibiotics – please seek advice if there is recent history of travel abroad or a causative organism is isolated.

Give advice on infection control including not to return to childcare setting/school for 48 hours after last vomit/diarrheal stool and not swimming for 2 weeks if cryptosporidiosus is suspected/confirmed.

The following is some advice for parents to help with fluid rehydration at home:

It can be difficult to persuade an unwell child to comply with a fluid challenge!

Tricks we find helpful include:

– Little and often

– We do not recommend neat fruit juice

– Oral rehydration solution with some squash can go down well (particularly lemon!)

– Using syringes and straws can be helpful in getting fluids in

– Giving an ice lolly can help with fluid intake

When to refer?

Not all cases of gastroenteritis can be managed safely in the community. We would like to see children for urgent (same day) review if:

– Signs and symptoms suggesting shock

– Any ‘Red Flags’ as detailed above

– You identify features suggestive of an alternative diagnosis as above

– Child is unable to drink, vomits persistently and/or is not felt able to safely be rehydrated at home

– Bloody diarrhoea

*Consider referral to the paediatric team for assessment if:

– Features suggesting dehydration

– Child is at risk of dehydration (see above)

– Underlying prematurity/chronic illness (e.g. cardiac or renal disease)/concurrent illness

– High output diarrhoea including frequent, high volume stools (unusual in UK setting)

– No improvement seen in community in 48 hours– If a child is anuric for more than 12 hours prior to assessment by primary care

It is not unusual for children to have persistent, diarrhoea for 1-2 weeks after an acute episode of gastroenteritis. If they are otherwise well, without significant weight loss, significant pain, or signs of dehydration, further advice can be sought via Advice & Guidance on ERS. Temporary lactose intolerance is not uncommon and lactose exclusion could also be considered. Further information on lactose intolerance can be found on the allergyuk website including advice on how to perform this (link under ‘Supporting Information’.

We are happy to discuss urgent referrals via the Paediatric Assessment Unit (PAU) telephone, which is carried by a Consultant, Registrar or Nurse Practitioner between 08:00am and 20:30 pm. Please call Kingston Hospital switchboard (0208 546 7711) and ask to be put through to the PAU Telephone. If the child seems very unwell, we may ask them to come via A&E where we can see them quickly and resuscitate if needed.