- Acute gastroenteritis (AGE) is a common condition in children that causes diarrhea and vomiting. It is usually caused by viruses like rotavirus. While causative agents do not change management, evaluation focuses on differentiating AGE from other potential causes and assessing dehydration severity. Management involves oral rehydration for mild cases and intravenous fluids for moderate to severe dehydration to correct fluid and electrolyte losses. Antibiotics are not routinely used while oral medications like racecadotril and ondansetron may assist rehydration in some cases. Close monitoring is important to watch for complications or need for further treatment.

1. 6TH PUTRAJAYA UPDATES IN
EMERGENCY MEDICINE
ACUTE GASTROENTERITIS IN CHILDREN:
TARGETED EVALUATION, ACTION AND
MONITORING
AISHA FADHILAH BINTI ABANG ABDULLAH

2. • Introduction
• Definition
• Epidemiology
• Evaluation
• Management of AGE in the emergency setting
• Risk Management Pitfalls

3. INTRODUCTION
● Gastroenteritis is a common paediatric condition.
● Volume of fluid loss: 5ml - ≥ 200 ml/kg/day.
● Dehydration and electrolyte losses are the main causes of morbidity and
mortality.
● Aim is to reduce duration and severity plus to avoid dehydration, but when
this occurs appropriate fluid management is essential.

4. INTRODUCTION
● Causative agent: viral or bacterial will not change the management.
● Routine and stool investigation not necessary in uncomplicated cases.
● Remember, a variety of serious conditions such as appendicitis, bacterial
enteritis, diabetic ketoacidosis, pyelonephritis, pneumonia, intussusception,
and toxic ingestions can present with symptoms identical to gastroenteritis.

5. DEFINITION
• A decrease in the consistency of stools (loose or liquid)
and/or an increase in the frequency of evacuations (typically
≥ 3 in 24 hours), with or without fever or vomiting.
• Diarrhoea typically lasts less than 7 days and not longer than
14 days.
• However in neonates, a change in stool consistency is more
indicative of diarrhoea than stool number.

6. EPIDEMIOLOGY
• One cause of childhood mortality, was reported as around half a million in 2019.
• Numbers reduced since 2000, due to vaccinations and improved management.
• Hospital- and population-based studies showed that 45% to 75% of children with AGE
had a pathogenic enteric organism isolated from their stools.
• Most frequent agent: Rotavirus, norovirus, Campylobacter or Salmonella.
• At present, there is no detailed epidemiological study on the burden of disease in
children from Malaysia.
• However, it was estimated that 1.3% of all medically certified and uncertified deaths (or
69 deaths per year) among children younger than 5 years of age were due to acute
gastroenteritis.

7. EVALUATION
The history and physical examination serve 2 vital functions:
1. Differentiating gastroenteritis from other causes of vomiting and diarrhoea in
children
2. Estimating the degree of dehydration.

8. Does the child really have acute gastroenteritis? Are
we missing another diagnosis?
1.Age: <6mo with rotavirus more severe dehydration
2.Vomiting: frequency, content
3.Diarrhoea: frequency, stool consistency, blood
4.Abdominal pain: character, intensity/ severity, frequency, localized pain
5.Short history: drugs and travel
6.Recurrent episodes: think inflammatory bowel
7.Fever and other systemic signs: infective, metabolic, malignancy
8.Urination: frequency, amount, colour

9. Clinical Dehydration Scale (CDS)
•CDS for children (score 0 to 8).
•The final 3 categories were: no dehydration (CDS score: 0), some dehydration (CDS score: 1–4),
and moderate/severe dehydration (CDS score: 5–8)
•Useful in predicting the need for intravenous (IV) rehydration, weight gain, need for blood test,
need for hospitalization, and the length of stay in hospital and in the ED

10. MANAGEMENT IN
EMERGENCY SETTING
Recognise signs of shock
• Mental status: alert, fatigue, irritable, lethargic, comatose
• Thirst: normal, thirsty, eager or unable to drink
• Tears, skin turgor, mucous membrane, sunken eyes, cold peripheries/ slow cap. refill time
• Blood pressure: normal, hypotension
• Heart rate: normal, tachycardia, bradycardia
• Respiratory rate: normal, fast, deep
• Urine output: normal, reduced, minimal or nil

11. FOCUS ON CORRECTION OF
DEHYDRATION!
• Oral rehydration should be the first-line therapy (AAP, ESPGAN, WHO,
Paediatric Protocol)
• Minimal or no dehydration: No immediate treatment
• Small, more frequent feeds with REGULAR ASSESSMENT
• Aim ~ 500mls/day for <2years old, 1L/day for older children
• On going losses: ORS 10ml/kg
• Home care: No excessive loss, able to drink fluids, no unfavourable social
circumstances

12. FOCUS ON CORRECTION OF
DEHYDRATION!
• Moderate dehydration:
• 50-100mls/kg fluids to replace the estimated fluid deficit
• Usually achieved by intravenous infusion of fluids
• Whilst maintaining ORS/ oral fluids for ongoing losses
• REGULAR ASSESSMENT of general condition and vital signs
• •Consider further evaluation in cases where history suggest excessive
hypotonic solutions (diluted formula, water only, sports drinks etc.).

13. FOCUS ON CORRECTION OF
DEHYDRATION!
• Severe dehydration: Medical emergency!
• If unable to get peripheral vein, then intraosseous line should be placed.
• Resuscitate with intravenous fluids 10-20mls/kg boluses
• Followed by intravenous maintenance and deficit correction
• Blood gas, glucose level and electrolytes
• Resume oral rehydration and normal diet as soon as possible

14. MANAGEMENT IN
EMERGENCY SETTING
• Breastfeeding should not be interrupted. Formula feeds should not be
diluted. No milk changes is necessary accept for certain cases (refer).
• NO routine antibiotics
• NO recommendations on anti-emetics (some have profound sedative effects
that interferes with oral rehydration therapy)
• NO recommendations on anti motility drugs, adsorbents, bulk-forming agents

15. ORAL REHYDRATION SALT

16. NOT…

17. SILICATES – DIOSMECTITE
(SMECTA®)
• binds selected bacterial pathogens and rotavirus
• restore integrity of damaged intestinal epithelium
• reduce stool output and duration of diarrhoea, especially those who were
rotavirus- positive
• 6 randomised-controlled trials showed that as compared to placebo,
diosmectite significantly reduced the duration of diarrhoea by
approximately 22.7 hours.
• chance of a cure on intervention day 3 was significantly increased in
diosmectite vs. the control group (RR 1.64, 95% CI: 1.36-1.98).
• No side effects

18. HIDRASEC
•Racecadotril (active metabolite: Thiorphan)
•Decreases intestinal hypersecretion of water and electrolytes.
•Adjunct to oral rehydration therapy
•In two clinical studies in children, racecadotril reduced by 40% and 46%,
respectively, the stool weights in the first 48 hours.
•No CNS toxicity, no potential for abuse or physical dependence.

19. ONDANSETRON
•5-hydroxytryptamine-3 receptor antagonist.
•One oral dose in the emergency setting may be used to assist with oral
rehydration.
•Oral ondansetron reduces vomiting, the need for intravenous rehydration, and
hospitalizations; however, benefits are limited to children with evidence of
dehydration (Nino-Serna et al., 2020).

20. RISK MANAGEMENT
PITFALLS
1.Failure to place an IV in a paediatric patient can be due to inexperience but can
also be due to severe dehydration in children.
2.Steps will reduce the risk of missing an alternative diagnosis leading to an
unexpected return visit
✔Document serial examinations and response to hydration strategy.
✔Talk to the nurse to make sure you have not missed any important information or
events that took place while the patient was in ED.
3.Inform the family and document location-, time-, and action-specific return
precautions.

21. RISK MANAGEMENT
PITFALLS
4. Specific discharge advise: for example,
“Return immediately if your child continues to vomit and is unable to keep any fluids
down” is preferred as opposed to “Return if worsening.”
5. Early appendicitis and gastroenteritis can be difficult to distinguish on clinical
grounds alone. 10% to 33% of young children with appendicitis will present with a
symptom complex that includes diarrhoea. Bilious vomiting is ALWAYS abnormal.
6. Consider extended observation or hospital admission for any infant < 1year of age
with gastroenteritis, especially if the family has limited access to healthcare.

22. REFERENCES:
1.Lee WS et al. (2011). Guidelines on the management of Acute Diarrhoea in children. College of Paediatrics, Academy
of Medicine of Malaysia (AMMCOP).
2.World Health Organization. (2005). The treatment of diarrhoea: a manual for physicians and other senior health
workers -- 4th revision.
3.Sandhu BK. (2001). Practical guidelines for the management of gastroenteritis in children. J Pediatr Gastroenterol Nutr.
Oct. 33 Suppl 2:S36-9.
4.King CK, Glass R, Bresee JS, Duggan C. (2003)Managing acute gastroenteritis among children: oral rehydration,
maintenance, and nutritional therapy. MMWR Recomm Rep. Nov 21. 52:1-16.
5.Nino-Serna, L. F., Acosta-Reyes, J., Veroniki, A. A., & Florez, I. D. (2020). Antiemetics in Children With Acute
Gastroenteritis: A Meta-analysis. Pediatrics, 145(4), e20193260. https://doi.org/10.1542/peds.2019-3260.
6.Burstein B, Rogers S, Klassen TP, Freedman SB. Trends in Management of Children With Acute Gastroenteritis in US
Emergency Departments. JAMA Netw Open. 2022;5(5):e2211201. doi:10.1001/jamanetworkopen.2022.11201

23. THANK YOU