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Document Scope: Departmental

Document Type: Clinical Practice Guideline

Approved on 2013-12-02

Next Review Date: 2016-12-02

Acute Gastroenteritis: In Children Aged 2 Months Through 5 Years

Version: 1

© 2012 The Hospital for Sick Children ('SickKids'). All Rights Reserved. This document may be reproduced or used strictly for non-commercial clinical

purposes. However, by permitting such use, SickKids does not grant any broader license or waive any of its exclusive rights under copyright or

otherwise at law; in particular, this document may not be used for publication without appropriate acknowledgement to SickKids. This Clinical Practice

Guideline has been developed to guide the practice of clinicians at the Hospital for Sick Children. Use of this guideline in any setting must be subject to

the clinical judgment of those responsible for providing care. SickKids does not accept responsibility for the application of this guideline outside

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This CPG is department specific and applies to activities only within the Division of Paediatric Emergency Medicine.

1.0 Introduction This Clinical Practice Guideline (CPG) has been adapted from the Cincinnati Children’s Hospital Medical Center CPG, Prevention and Management of Acute Gastroenteritis (AGE): In children aged 2 months to 18 years (2011).

Acute gastroenteritis (AGE) is a diarrheal disease of rapid onset, with or without accompanying symptoms and signs, such as nausea, vomiting, fever, or abdominal pain (King 2003, Guerrant 2001). It is a common cause of presentation to the emergency department (ED) in children under 5 years old. Because most patients included in this guideline will have self-limited viral or bacterial diarrhea, dehydration caused by the disease is the focus of treatment in this guideline. The purpose of this clinical practice guideline is to provide a framework for assessment and management of children with AGE, based on the most current and best scientific information, which will assist the interdisciplinary team in the Division of Paediatric Emergency Medicine. 1.1 Target Population Inclusions: These guidelines are intended primarily for use in children aged 2 months through 5 years of age with signs and symptoms of acute gastroenteritis (diarrhea of recent onset not caused by chronic disease with or without accompanying nausea, vomiting, fever, or abdominal pain) presenting to the emergency department. Exclusions: These guidelines do NOT address all considerations needed to manage those with the following:

toxic appearance or requiring intensive care

acute abdomen, bowel obstruction or ileus

previously diagnosed disorders including immunodeficiency or those affecting major organ systems

diarrhea and/or vomiting accompanied by chronic metabolic disorders (e.g. diabetes, PKU)

AGE accompanying failure to thrive

episodes of diarrhea lasting longer than 7 days

diagnosis of hyponatremic or hypernatremic dehydration 1.2 Target Users Include but are not limited to:

Emergency Medicine physicians and nurses

Emergency Medicine trainees

Patients and families 1.3 Challenges & Objectives Challenges in the management of AGE include:

prevention of dehydration

diagnosing degree of dehydration

http://www.cincinnatichildrens.org/templates/cchmc2010/templatei.aspx?pageid=99194








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determining the practical role of probiotics and other medications

prevention of AGE spread to contacts In the target population, the objectives of this guideline are to:

improve the use of appropriate clinical and laboratory assessment

increase the use of oral rehydration and early progression to usual diet

reduce the number of hospitalizations

reduce the length of stay

improve parental involvement in decision making around the management of AGE

decrease use of ED services for management of mild cases

improve prevention of transmission of AGE

2.0 Etiology Infectious agents are the most common causes of AGE. Viruses, primarily rotavirus species, are responsible for 70 to 80% of infectious diarrhea cases in the developed world. Various bacterial pathogens account for another 10 to 20% of cases; as many as 10% may be attributable to diarrheagenic Escherichia coli (Cohen 2005). Parasitic organisms such as Giardia species cause fewer than 10% of cases. See Table 1 for etiologic agents. Incidence is affected by climate and season. Other factors that increase the risk of AGE in children include attendance at day care centers and impoverished living conditions with poor sanitation (Burkhart 1999). Table 1: Etiologic Agents for Pediatric Infectious Gastroenteritis

Viruses (about 70%)

• Rotaviruses • Noroviruses (Norwalk-like viruses) • Enteric adenoviruses • Caliciviruses • Astroviruses • Enteroviruses

Bacteria (10-20%)

• Campylobacter jejuni • Non-typhoid Salmonella spp • Enteropathogenic Escherichia coli • Shigella spp • Yersinia enterocolitica • Shiga toxin producing E coli • Salmonella typhi and S paratyphi • Vibrio cholerae

Protozoa (<10%)

• Cryptosporidium • Giardia lamblia • Entamoeba histolytica

Helminths • Strongyloides stercoralis








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(Elliott 2007)

3.0 Guideline Recommendations 3.1 Assessment and Diagnosis Clinical Assessment 1. The history and physical examination should be the primary basis for the diagnosis of AGE. (Elliott 2007; Grade C). Specific information should be sought about the following topics (SickKids Consensus).

Stool Output: frequency, consistency, presence of blood/mucous

Emesis: frequency, bilious vs. non-bilious, hematemesis, last episode

Fluid Intake: volume, type

Urine output: frequency, last episode

Fever, appetite, weight loss

Use of antibiotics or other drugs that may cause diarrhea

Sick contacts, travel

Underlying illness: cardiac disease, diabetes, renal disease, cystic fibrosis 2. Clinical assessment is initially performed for the presence and degree of dehydration (Steiner 2004; Grade A). See Appendix 1 for physical parameters associated with degree of dehydration. Different scales are used to diagnose the degree of dehydration. See Table 2 for a clinical dehydration scale developed in Canada. (Goldman 2008; Grade B). Note 1: Prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern are the best individual examination measures for predicting 5% dehydration in children (Steiner 2004; Grade A). Note 2: Clinical diagnosis of dehydration has been shown to be imprecise and thus a general classification of a child’s dehydration status such as none, some (mild/moderate), or severe is suggested by the literature as a useful starting point in the management of the child at risk for dehydration (Steiner 2004; Grade A, King 2003). Note 3: Acute body weight change is considered the gold standard measure of dehydration in a child but is often impractical for the initial assessment due to lack of an accurate pre-illness weight measurement (Gorelick 1997, Duggan 1996; Grade B).








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Table 2: Clinical Dehydration Scale

0 1 2

General Appearance Normal Thirsty, restless, or lethargic but irritable when touched

Drowsy, limp, cold, sweaty

Eyes Normal Slightly sunken Very sunken

Mucous Membranes Moist Sticky Dry

Tears Present Decreased Absent

No / minimal dehydration = score of 0-1 Some dehydration (mild to moderate) = score ≥ 2 Severe dehydration / shock (Bailey, 2010, Goldman 2008; Grade B) Laboratory Studies 1. Laboratory tests are not routinely required in the ED and may be misinterpreted, leading to inappropriate treatment (WHO report 2003; Grade C). Note 1: Urinalysis is not valid in the assessment of dehydration. Specific gravity, urinary ketones and urine output do not correlate with the degree of dehydration (Steiner 2007; Grade B). Note 2: Serum electrolytes (including glucose, sodium, potassium, BUN, creatinine and serum bicarbonate) should be measured before starting intravenous fluids. A normal bicarbonate concentration may be useful in ruling out dehydration (Steiner 2004; Grade A). Note 3: Most children present with isonatremic dehydration. Suspect hypernatremic dehydration in case of hypertonic oral intake (e.g., salt solutions), hypotonic fluid loss (e.g., profuse watery diarrhea), and decreased level of consciousness or lethargy beyond expected from apparent mild signs of dehydration or associated seizure. Younger infants are at a higher risk (Local Expert Opinion 2009; Grade C). Note 4: Tests for specific pathogens, such as those for rotavirus, ova and parasites, bacteria, fecal antigen tests for parasites and C difficile toxin are not indicated in the ED (Northrup 1994; Grade C). These tests should be considered if unusual causes of gastroenteritis are suspected (e.g., recent travel, bloody diarrhea) or with prolonged symptoms. Note 5: Children with evidence of lethargy should have a bedside glucose test performed as soon as possible to determine if hypoglycemia is a contributing factor (Reid 2003; Grade B).








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3.2 Management Recommendations Prevention of Dehydration 1. Continued use of the child’s preferred, usual, and age appropriate diet should be encouraged to prevent or limit dehydration (Brown 1994, Fayad 1993, Alarcon 1992). Regular diets are generally more effective than restricted and progressive diets, and in numerous trials have consistently produced a reduction in the duration of diarrhea (Alarcon 1991, Margolis 1990, Placzek 1984, Khin 1985). (Grade A) Note 1: There is no evidence to support the use of the historical BRAT diet (consisting of bananas, rice, applesauce and toast); however it may be offered as part of the child’s usual diet. Encourage complex carbohydrates (e.g., rice, wheat, bread and cereals), meats, yogurt, fruits and vegetables in the diet. (King 2003; Grade C). Note 2: Clear liquids are not recommended as a substitute for oral rehydration solutions (ORS) or regular diets in the prevention or therapy of dehydration (King 2003; Grade C) (See Appendix 2). Encourage continuation of breast feeds during rehydration with ORS (Khin 1985; Grade A). Note 3: The vast majority of patients with AGE do not develop clinically important lactose intolerance. In selected patients with persistent symptoms (suspect if >7 days of diarrhea or buttock excoriation in an infant <6mo), lactose-free formulas are recommended (Brown 1994; Grade A). 2. It is recommended that the vomiting child be offered frequent small feedings of any tolerated foods or oral rehydration solutions (ORS) (Wan 1999, Santosham 1985; Grade A). Rehydration 1. No dehydration Instructions should be provided regarding adequate fluid intake and continued age-appropriate diet. In case of vomiting, small frequent feedings should be offered (Local Expert Opinion 2009; Grade C). Note: ORS may be used to compensate for ongoing losses: 10ml/kg for each episode of diarrhea, 2ml/kg for each episode of vomiting (Local Expert Opinion 2009; Grade C). 2. Some dehydration (Mild to Moderate dehydration) Oral rehydration should be the first line of treatment, with intravenous therapy (IVT) being used if the oral route fails (Gavin 1996, Gore 1992, Cohen 1995, Molina 1995, Fayad 1993, Santosham 1982, Santosham 1985, Atherly-John 2002, Nager 2002, Listernick 1986, Tamer 1985, King 2003, Holliday 1996, Cochrane 2009, Freedman 2009). (Grade A) Note 1: Administer small volume of ORS frequently (i.e.; 5 ml every 2-3 minutes and increase as tolerated up to 30 ml every 5 minutes. Aim for 25-50 ml/kg ORS over 1-2 hours (Local Expert Opinion 2009; Grade C). Note 2: There is no need to demonstrate the successful completion of an oral rehydration period before discharge. Factors such as frequency of vomiting and heart rate are stronger predictors of ED revisits (Freedman 2009, Grade B).








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Note 3: For every 25 children (95% CI 14 to 100) treated with ORS one would fail and require IVT. The ORS group has a higher risk of paralytic ileus, while the IVT group is exposed to risks of intravenous therapy (Cochrane 2009; Grade A). Note 4: Once ORS has failed intravenous therapy (20 ml/kg of normal saline IV bolus in 60 minutes) or ORS via nasogastric (NG) tube is indicated. Reassess frequently. Treatment should be repeated as indicated by clinical signs or symptoms (Neville 2006; Grade A & Local Expert Opinion 2009). 3. Severe dehydration Prompt IVT is indicated for shock/near-shock (20 ml/kg normal saline or ringer’s lactate as fast as possible). Therapy must be repeated until adequate degree of rehydration is achieved. Reassessment after each therapeutic manoeuvre is vital (Fleisher 2006; Grade C). Maintenance Rehydration 1. On-going IV fluids or NG ORS following the initial period of fluid resuscitation is indicated:

when unable to replace the estimated fluid deficit and keep up with the on-going losses using oral feedings alone after discussion with family regarding choice of IV or NG

in severely dehydrated children with obtunded mental status (Cohen 1995, Mackenzie 1991, Santosham 1982, Nager 2002, Vesikari 1987, Listernick 1986, Tamer 1985; Grade A).

Note 1: Use Normal saline with 5% glucose as the maintenance infusion fluid. The isotonic solution protects from dilutional hyponatremia (Neville 2006; Grade A). Administration of larger amounts of IV dextrose is associated with reduced return visits requiring admission in children with gastroenteritis and dehydration (Levy 2007; Grade B).

Note 2: Calculation of maintenance IV fluid rate: 4 ml/kg/hr for first 10 kg of body weight + 2 ml/kg/hr for next 10 kg of body weight + 1 ml/kg/hr for the remainder (Behrman 2004; Grade C) Oral Feeding Following Rehydration 1. Refeeding of the usual diet should be started at the earliest opportunity after an adequate degree of rehydration is achieved (Cohen 1995, Fayad 1993, Santosham 1982, Fox 1990, Hjelt 1989, Gazala 1988, Walker-Smith 1997; Grade A). Note 1: A meta-analysis of 16 studies found no significant clinical advantage to diluting milk or formula in the management of AGE (Brown 1994; Grade A). Note 2: Following rehydration therapy in the child with mild to moderate dehydration, regular diets may be supplemented with ORS containing at least 45mEq Na+/L, and targeted to deliver 10ml/kg for each stool or emesis (Cohen 1995; Grade








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A) (see Appendix 2). Avoid giving fruit juice until diarrhoea has stopped, due to evidence that suggests that this prolongs diarrhoea (Valois 2005; Grade A). Pharmacological Therapies 1. Anti-diarrheals The routine management of children with AGE should not include anti-diarrheal agents (King 2003; Grade C). Note 1: Racecadotril, an enkephalinase inhibitor (antisecretory agent) significantly reduced stool output in two controlled clinical trials among children (Salazar-Lindo 2000, Cezard 2001; Grade A), therefore more studies are needed. Caution is advocated in disorders of carbohydrate intolerance due to the presence of saccharose as an excipient and in children younger than 2 years due to potential for CNS depression. Note 2: Loperamide (antimotility agent) reduces mean amount and duration of diarrheal episodes in clinical trial among children (Li 2007; Grade A). However its use is not recommended due to the reported serious adverse events (ileus, lethargy or death). 2. Anti-emetics In children with frequent and persistent vomiting, the administration of an anti-emetic may increase the success rate of oral rehydration therapy (ORT). The safety profile of the medication and cost-effective outcomes should be considered (King 2003; Grade C). Note 1: There is a lack of high quality evidence for the effectiveness of intravenous metoclopramide and intravenous dexamethasone in the treatment of children with gastroenteritis, therefore they are not recommended (Cubeddu 1997, Stork 2006; Grade A). There is a high incidence of side effects with Metoclopramide (somnolence, nervousness, irritability, dystonic reactions). Note 2: Ondansetron reduces vomiting during ORT, need for IV fluids and hospital admission rates in children with vomiting (Brussese 2013, Churgay 2012, Carter 2012, Reeves 2002, Ramsook 2002, Freedman 2006, Roslund 2008; Grade A). There is evidence suggesting that following administration of Ondansetron there is increase in diarrheal episodes, however this adverse event seems clinically insignificant. Ondansetron is administered as a single oral dissolving tablet, by weight:

8-15kg 2mg PO >15-30kg 4mg PO >30kg 8mg PO

ORS should be resumed 15 minutes after administration of Ondansetron. Note 3: Dimenhydrinate, a histamine receptor blocker, has been proven safe and effective in controlling post-operative nausea and vomiting in children. No clinical trials have been conducted to study its efficacy in children with acute gastroenteritis and therefore should not be utilized. 3. Antimicrobial Agents








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Antimicrobial therapies should be used only for selected children with AGE who present with special risks or evidence of a serious bacterial infection (Barbara 2000; Grade B). Note 1: Antibiotics increase likelihood of hemolytic uremic syndrome if the pathogen is enterohemorrhagic E. coli (O157:H7) and are therefore contraindicated, if identified (Wong 2000; Grade B). Note 2: Giardia lamblia and Cryptosporidium are common causes of persistent diarrhea and, if found, treatment is available with metronidazole (AAP 2003, Grade C). Adjunct Therapies 1. There is some evidence of possible clinical benefit of probiotics in children with gastroenteritis (shortening the duration of diarrhea and reducing the stool frequency). The available studies varied in quality, in the specific probiotics studied, in the treatment regimens used and in the outcomes examined and therefore more research is needed before recommending its routine use (Allen 2004, Salvatore 2007; Grade A). Probiotics have also been associated with decrease in infection transmission. Family preference may be central to the decision to use probiotics. Note 1: The following organisms have consistently showed benefit in one or more study:

Lactobacillus rhamnosus GG

Saccharomyces boulardii More recent clinical trials did not show a positive effect of Lactobacillus rhamnosus GG on the clinical course of children with gastroenteritis (Salazar-Lindo 2004, Basu 2007; Grade A). Ongoing studies are trying to determine what dose is needed to achieve a significant effect. Note 2: Probiotics may be more effective for rotavirus diarrhea, compared to all-cause diarrhea (Allen 2004; Grade A). Note 3: The microorganisms used to culture yogurt, Streptococcus thermophilus and Lactobacillus bulgaricus, are not considered probiotics because they do not survive the acidity of the stomach to colonize the intestines. One study of malnourished infants found that yogurt, compared to milk was not effective in reducing the duration of diarrhea (Allen 2004, Bhatnagar 1998; Grade A). 2. Zinc supplementation could be effective in the treatment of diarrhea and vomiting in children with gastroenteritis in developing countries, by reducing stool frequency (Lazzerini 2008; Grade A). There is insufficient evidence to justify recommending zinc supplementation for well-nourished children with gastroenteritis. Disposition Considerations 1. Prompt discharge should be considered when the following levels of recovery are reached:

sufficient rehydration achieved as indicated by clinical status;

IV or NG fluids not required;

adequate family teaching has occurred; and

medical follow up is available via telephone or office visit (Local Expert Opinion 2009; Grade C)








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Note 1: There is no need to demonstrate the successful completion of an oral rehydration period before discharge. Factors such as frequency of vomiting and heart rate are stronger predictors of ED revisits (Freedman 2009; Grade B). 2. Inpatient care is indicated for children in case of:

severe dehydration (>9% of body weight) exists;

significant electrolyte abnormality such as hyponatremia or hypernatremia;

substantial difficulties exist in administrating ORT, including intractable vomiting, ORS refusal, or inadequate ORS intake;

ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes;

factors such as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation;

caregivers cannot provide adequate care at home; or

social or logistical concerns exist that might prevent return evaluation, if necessary (King 2003, Local Expert Opinion 2009; Grade C) 3.3 Education The following information should be offered to all parents and careers on the management of gastroenteritis. These recommendations are based on evidence that is presented elsewhere in the guideline or local expert opinion (Grade C). 1. Recommendations and advice for parents In children without clinical dehydration and who are not at increased risk of dehydration:

continue usual feeds including breast or other milk

encourage the child to drink plenty of fluids In children without clinical dehydration but who are at increased risk of dehydration:

continue usual feeds including breast or other milk

encourage the child to drink plenty of fluids

offer ORS as additional supplemental fluid In children with clinical dehydration:

rehydration is usually possible with ORS

give the specified amount of ORS (50 ml/kg for rehydration plus maintenance volume) over a 4 hour period

give this amount of ORS in small but frequent feeds

continue breast feeding in addition to giving the ORS

be concerned if : 1. the child refuses to take the ORS or persistently vomits 2. the child does not appear to be recovering or is worsening

seek advice from a specified healthcare professional if concerned








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Following rehydration in the ED:

the child should be encouraged to drink plenty of their usual fluids including milk feeds if these were stopped

reintroduce the child’s usual diet. Restrictive diets, such as BRAT are unnecessary

give a specified volume of ORS (5-10 ml/kg) following the passage of large watery stools in children at increased risk of dehydration

Other instructions:

the usual duration of diarrhea is 5-7 days and in most children it resolves within 2 weeks.

the usual duration of vomiting is 1-2 days and in most children it resolves within 3 days.

seek advice from a specified healthcare professional if children’s symptoms are not resolving as expected or if there’s blood in the diarrhea or vomit

2. Recommendations to prevent spread of gastroenteritis

hand washing with soap (liquid where possible) in warm running water, for minimum 15 seconds and careful drying is the most important factor in the prevention of spread of diarrhea and vomiting

hand washing should occur after going to the toilet (children) or changing diapers (parents) and before handling of food

towels, toys and utensils used by infected children should not be shared

children should not attend any childcare facility or school when fever, diarrhea or vomiting is present and may return to school or other childcare facility once the stool is formed

4.0 Development Process 4.1 Implementation of CPG: Facilitators to implementation

Tools/Appendices

Nursing Medical Directive for Ondansetron Organizational barriers to implementation

Physician behaviour Potential health benefits for patients

Uniform assessment

Quicker evidence based care

Involvement / education of family Key review criteria / indicators for monitoring and audit purposes

Audit percentage of patients managed according to the CPG

Evaluate change in admission rate and re-visit rate following treatment with Ondansetron 4.2 Development Process & Statement of Evidence








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A search was performed to determine existing published guidelines on acute gastroenteritis. Identified guidelines were screened to ensure that the clinical questions developed by the working group were covered within the retrieved guidelines. Cincinnati Children’s Acute Gastroenteritis CPG (2006) was assessed using the AGREE tool. Group consensus was to adapt this CPG. A literature search was completed (January 2006 - March 2009) using OVID, Embase, Cochrane, CCTR, ACPJournal Club and DARE, using key words: gastroenteritis, dysentery, enteritis, enterocolitis, esophagitis, gastritis, antiemetic, odansetron and oral rehydration therapy. 2006-2009 literature was reviewed by an interdisciplinary CPG development team. Modifications to the Cincinnati CPG were discussed & agreed upon by consensus. The above described literature search was repeated in 2013. No evidence was obtained to change the focus of the recommendations made in the original guideline. Once the guideline has been in place for three years, the development team will reconvene to explore the continued validity of the guideline. This phase can be initiated at any point that evidence indicates a change is needed.

Table 1. Grades of Recommendation

A

Recommendation supported by at least one randomized controlled trial, systematic review or meta-analysis.

B

Recommendation supported by at least one cohort comparison, case study or other experimental study.

C

Recommendation supported by expert opinion or experience of a consensus panel.

Note: Table 1 serves as a guideline to the hierarchy of evidence available; with meta-analysis considered to be the highest level of evidence and expert opinion considered to be the lowest level of evidence that can be used to support each recommendation in this CPG. 4.3 Guideline Group and Reviewers Original Guideline Group Membership: Ayelet Rimon Babad; Clinical Fellow, Emergency Medicine Richard Raptopoulos; Research Registered Nurse, Emergency Medicine Shagan Kaur; Research Registered Nurse, Emergency Medicine Bill Mounstephen; Director, Emergency Medicine Cindy Capstick; Manager, Emergency Medicine Jennifer Pepper; Quality Analyst & CPG Coordinator, Quality & Risk Management Additional members, Guideline Group Review 2013: Stephen Porter, MD; Medical Director, Emergency Medicine








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Internal Reviewers: Jill Adolphe, parent & Family Advisory Council Co-chair Margot Follett Rowe, Quality Analyst, Emergency Medicine Stephen Freedman, Staff Physician, Emergency Medicine Katherine Nash, Registered Nurse, Emergency Medicine Bruce Minnes, Staff Physician, Associate Director (Clinical), Emergency Medicine Jonathon Pirie, Staff Physician, Emergency Medicine Lisa Robinson, Advanced Nursing Practice Educator, Emergency Medicine Suzan Schneeweiss, Staff Physician, Emergency Medicine 4.5 External Reviewers: Dr. Ran Goldman - BC Childrens' Dr. Ken Farion - CHEO NOTE: These recommendations result from review of literature and practices current at the time of their formulations. This protocol does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the guidelines to meet the specific and unique requirements of individual patients. Adherence to this pathway is voluntary. The physician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

5.0 References

1. AAP: American Academy of Pediatrics Red Book. 26th Edition, 2003

2. Acute Gastroenteritis Guideline Team, Cincinnati Children's Hospital Medical Center: Evidence-based clinical care guideline for medical management of acute gastroenteritis in children aged 2 months through 5 years, Guideline 5, pages 1-20, December 21, 2011.

3. Alarcon P, Montoya R, Perez F, Dongo JW, Peerson JM, Brown KH. Clinical trial of home available, mixed diets versus a lactose-free, soy-protein formula for the dietary management of acute childhood diarrhea. J Pediatr Gastroenterol Nutr. 1991 Feb;12(2):224-32.

4. Alarcon P, Montoya R, Rivera J, Perez F, Peerson JM, Brown KH. Effect of inclusion of beans in a mixed diet for the treatment of Peruvian children with acute watery diarrhea. Pediatrics. 1992 Jul;90(1 Pt 1):58-65.

5. Allen SJ, Okoko B, Martinez E, Gregorio G, Dans LF. Probiotics for treating infectious diarrhoea. Cochrane Database Syst Rev. 2004;(2):CD003048.










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6. Atherly-John YC, Cunningham SJ, Crain EF. A randomized trial of oral vs intravenous rehydration in a pediatric emergency department. Arch Pediatr Adolesc Med. 2002 Dec;156(12):1240-3.

7. Avery ME, First LR. Pediatric Medicine. Baltimore, 1993.

8. Basu S, Chatterjee M, Ganguly S, Chandra PK. Efficacy of Lactobacillus rhamnosus GG in acute watery diarrhoea of Indian children: a randomised controlled trial. J Paediatr Child Health. 2007 Dec;43(12):837-42.

9. Barbara G, Stanghellini V, Berti-Ceroni C, De Giorgio R, Salvioli B, Corradi F, Cremon C, Corinaldesi R. Role of antibiotic therapy on long-term germ excretion in faeces and digestive symptoms after Salmonella infection. Aliment Pharmacol Ther. 2000 Sep;14(9):1127-31.

10.Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics: Pathophysiology of Body Fluids and Fluid Therapy, 17th ed. Philadelphia: Saunders; 2004.

11.Bhatnagar S, Singh KD, Sazawal S, Saxena SK, Bhan MK. Efficacy of milk versus yogurt offered as part of a mixed diet in acute noncholera diarrhea among malnourished children. J Pediatr. 1998 Jun;132(6):999-1003.

12.Brown KH, Peerson JM, Fontaine O. Use of nonhuman milks in the dietary management of young children with acute diarrhea: a meta-analysis of clinical trials. Pediatrics. 1994 Jan;93(1):17-27.

13.Bruzzese E, Lo Vecchio A and Guarino, A. Hospital management of children with acute gastroenteritis. Curr Opin Gastroenterol. 2013 Jan 29(1) 60 (6), p.

14.Burkhart DM. Management of acute gastroenteritis in children. Am Fam Physician. 1999 Dec;60(9):2555-63, 2565-6.

15.Carter B and Seupaul RA. UPdate: Antiemetics for vomiting associated with acute gastroenteritis in children. Ann Emerg Med 2012 March

16.Cézard JP, Duhamel JF, Meyer M, Pharaon I, Bellaiche M, Maurage C, Ginies JL, Vaillant JM, Girardet JP, Lamireau T, Poujol A, Morali A, Sarles J, Olives JP, Whately-Smith C, Audrain S, Lecomte JM. Efficacy and tolerability of racecadotril in acute diarrhea in children. Gastroenterology. 2001 Mar;120(4):799-805.

17.CHOICE Study Group. Multicenter, randomized, double-blind clinical trial to evaluate the efficacy and safety of a reduced osmolarity oral rehydration salts solution in children with acute watery diarrhea. Pediatrics. 2001 Apr;107(4):613-8.

18.Churgay CA and Aftab Z. Gastroenteritis in Children: Part I. Dignosis. Am Fam Physician 2012 Jun 1; 85 (11): 1059-1062.








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19.Cohen MB, Mezoff AG, Laney DW Jr, Bezerra JA, Beane BM, Drazner D, Baker R, Moran JR. Use of a single solution for oral rehydration and maintenance therapy of infants with diarrhea and mild to moderate dehydration. Pediatrics. 1995 May;95(5):639-45.

20.Cohen MB, Nataro JP, Bernstein DI, Hawkins J, Roberts N, Staat MA. Prevalence of diarrheagenic Escherichia coli in acute childhood enteritis: a prospective controlled study. J Pediatr. 2005 Jan;146(1):54-61.

21.Cubeddu LX, Trujillo LM, Talmaciu I, Gonzalez V, Guariguata J, Seijas J, Miller IA, Paska W. Antiemetic activity of ondansetron in acute gastroenteritis. Aliment Pharmacol Ther. 1997 Feb;11(1):185-91.

22.Duggan C, Refat M, Hashem M, Wolff M, Fayad I, Santosham M. How valid are clinical signs of dehydration in infants? J Pediatr Gastroenterol Nutr. 1996 Jan;22(1):56-61.

23.Fayad IM, Hashem M, Duggan C, Refat M, Bakir M, Fontaine O, Santosham M. Comparative efficacy of rice-based and glucose-based oral rehydration salts plus early reintroduction of food. Lancet. 1993 Sep 25;342(8874):772-5.

24.Fleisher GR, Ludwig S, Henretig FM. Textbook of Pediatric Emergency Medicine: Shock, 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2006.

25.Fox R, Leen CL, Dunbar EM, Ellis ME, Mandal BK. Acute gastroenteritis in infants under 6 months old. Arch Dis Child. 1990 Sep;65(9):936-8.

26.Freedman SB, Powell E, Seshadri R. Predictors of Outcomes in Pediatric Enteritis: A Prospective Cohort Study. Pediatrics. 2009;123:e9–e16.

27.Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med. 2006 Apr 20;354(16):1698-705.

28.Gavin N, Merrick N, Davidson B. Efficacy of glucose-based oral rehydration therapy. Pediatrics. 1996 Jul;98(1):45-51.

29.Gazala E, Weitzman S, Weizman Z, Gross J, Bearman JE, Gorodischer R. Early vs. late refeeding in acute infantile diarrhea. Isr J Med Sci. 1988 Mar;24(3):175-9.

30.Goldman RD, Friedman JN, Parkin PC. Validation of the clinical dehydration scale for children with acute gastroenteritis. Pediatrics. 2008 Sep;122(3):545-9.

31.Gore SM, Fontaine O, Pierce NF. Impact of rice based oral rehydration solution on stool output and duration of diarrhoea: meta-analysis of 13 clinical trials. BMJ. 1992 Feb 1;304(6822):287-91.








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32.Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997 May;99(5):E6.

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37.Khin MU, Nyunt-Nyunt-Wai, Myo-Khin, Mu-Mu-Khin, Tin U, Thane-Toe. Effect on clinical outcome of breast feeding during acute diarrhoea. Br Med J (Clin Res Ed). 1985 Feb 23;290(6468):587-9.

38.King CK, Glass R, Bresee JS, Duggan C. Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16.

39.Kleinman RE. American Academy of Pediatrics. Committee on Nutrition: Pediatric nutrition handbook. Washington, D.C., 2004.

40.Lalani A, Schneeweiss S. Handbook of Pediatric Emergency Medicine: Gastroenteritis and Oral Rehydration. Sudbury: Jones and Bartlett; 2008.

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44.Mackenzie A, Barnes G. Randomised controlled trial comparing oral and intravenous rehydration therapy in children with diarrhoea. BMJ. 1991 Aug 17;303(6799):393-6.








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Appendix 1: Symptoms and Signs of Dehydration

Symptom/Sign Minimal or no dehydration

(<3% loss body wt)

Mild to moderate dehydration

(3-9% loss body wt)

Severe dehydration

(>9% loss body wt)

Mental Status Well, alert Normal, fatigued or restless, irritable

Apathetic, lethargic, obtunded

Fontanel Normal Depressed Sunken

Thirst Drinks normally, may refuse Thirsty, eager to drink Drinks poorly, unable to drink

Mucous Membranes Moist Dry Parched

Tears Present Decreased Absent

Eyes Normal Slightly sunken Deeply Sunken

Heart Rate Normal Normal to increased Tachycardia Bradycardia in severe cases

Blood Pressure Normal Normal or orthostatic changes

Decreased

Breathing Normal Normal or tachypnea Tachypnea, hyperpnea

Quality of Pulses Normal Normal to decreased Weak, thready or impalpable

Capillary Refill Normal Prolonged >2 sec Prolonged >4 sec

Skin Turgor Instant recoil Recoil <2 sec Recoil >2 sec

Extremities Warm Cool Cold, mottled, cyanotic

Urine Output Normal to decreased Decreased Minimal

Adapted from King CK, Glass R, Bresee JS, Duggan C. MMWR 2003;52(RR16):1-16.








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Appendix 2: Oral Rehydration Solutions

Manufacturer / Brand Name

Product Description CHO gm

NA+ mEq/liter

K+ mEq/liter

Osmolarity mOsmol/liter

CHO:Na ratio mmol/liter: mol/liter

Solution appropriate for oral rehydration therapy

Generic

Shoppers Drug Mart

Pediatric Electrolyte®

Rexall

Liquid in litre or 8 oz sizes (single or 4-pk)

Freezer pops, 2.1 oz, 16 per box*

7 assorted flavours, varies by product

25 45 20 Flavoured 270

Unflavoured 250

3.1 : 1

Ross Pedialyte® Liquid in litre or 8 oz sizes (4-pk)

Freezer pops, 2.1 oz, 16 per box*

8 assorted flavours, varies by product

Mead Johnson Enfamil® Enfalyte®

Ready-to-use; no mixing or dilution required

Made with natural fruit flavour

6 oz per bottle, 24 bottles per case

Low osmolality (170 mOsm/kg water)

30 50 25 167 3.3 : 1

WHO-ORS** Standard ORS packet 20 90 20 330 1.2 : 1

WHO-ORS** Hypo-osmolar ORS packet 15 60 30 224 1.4 : 1

Solutions not appropriate for rehydration***

Cola 126 2 0.1 750 1944 : 1

Apple juice 125 3 32 730 1278 : 1

Chicken broth 0 250 8 500 0 : 1

Gatorade®, sports drink 59 20 3 330 62.5 : 1

* Labelled for children 1 year of age or older. ** WHO = World Health Organization *** Inappropriate and non-physiologic fluids are given for comparison only. 1. An effective rehydration solution:

is hypotonic (osmolarity <~310 mOsm/litre),

has enough sodium to replace loss,

adequately replaces potassium and HCO3 (as bicarbonate or citrate), and

takes advantage of equimolar NA:glucose co-transport which is 1:1 and linear until about a concentration of 100 mmol/litre.








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2. For non-cholera diarrhea, glucose:sodium ratios about 3 mmol/litre : 1 mmol/litre are effective in maintaining hydration.

3. In 2004, the World Health Organization (WHO) introduced a hypo-osmolar formulation ORS packet for non-cholera diarrhea. This formulation reduces stool volume, vomiting and need for IV therapy, and has also been shown to be safe and effective for children with cholera (CHOICE Study Group 2001 [A]). The WHO standard formula was originally developed to treat any acute gastroenteritis, including cholera in all age groups. WHO-ORS packets are not ready available in North America.








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Appendix 3: Algorithm - Evaluation & Management of Acute Gastroenteritis (2 mos to 5 yrs)

Algorithm: Evaluation & Management of Acute Gastroenteritis in Children Aged 2 months to 5 years ==> (See attachment section at end of document)








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Attachments:

Acute Gastro algorithm Feb 2010.doc

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