Gastroenteritis in Children: Principles of Diagnosis and Treatment
Gastroenteritis in children is a common reason for visits to family physicians. Most cases of gastroenteritis have a viral etiology and are self-limited. However, more severe or prolonged cases of gastroenteritis can result in dehydration with significant morbidity and mortality. This is often the scenario in third-world countries, where gastroenteritis results in 3 million deaths annually. A proper clinical evaluation will allow the physician to estimate the percentage of dehydration and determine appropriate therapy. In some situations, laboratory studies such as determination of blood urea nitrogen and serum electrolytes may be helpful. Stool studies are indicated if a child is having bloody diarrhea or if an unusual etiology is suspected, such as Escherichia coli O157:H7 or Cryptosporidium. Most children with gastroenteritis can be treated with physiologically balanced oral rehydration solutions. In children who are hypovolemic, lethargic and estimated to be more than 5 percent dehydrated, initial treatment with intravenous boluses of isotonic saline or Ringer's lactate may be required. Children with severe diarrhea need nutrition to restore digestive function and, generally, food should not be withheld.
Gastroenteritis among children in the United States is a common and usually nonfatal illness, although it results in 3 million deaths annually worldwide.1 A clean water supply, good nutrition, reasonable physical cleanliness and appropriate disposal of human waste has allowed the United States and other developed countries to control the transmission and virulence of infectious agents that cause diarrhea. Most cases of gastroenteritis in this country are self-limited and require minimal intervention. Occasional episodes of severe, life-threatening gastroenteritis may occur, however, necessitating aggressive therapeutic intervention.
Most family physicians will occasionally encounter a severely ill child with gastroenteritis who needs aggressive fluid management. Inappropriate use of oral liquids, such as broths with a very high sodium content (up to 250 mEq per L) or soft drinks with a very low sodium content (1 to 2 mEq per L) may transform a mild isotonic dehydration into a more complex hypertonic or hypotonic dehydration.2 An understanding of the common etiologies of gastroenteritis, along with the principles of fluid and electrolyte management, is important for all physicians who care for children.
This article reviews common etiologies of gastroenteritis in children, appropriate assessment of hydration status and approaches to fluid replacement. Specific educational points and principles of treatment are emphasized. The history and physical examination are the cornerstone of diagnosis and assessment and, along with occasional laboratory tests, should guide therapy.
On physical examination, the patient's temperature was 39.7°C (103.6°F), his respiratory rate was 30 and his pulse rate was 130 when supine and 160 when upright. The patient weighed 15 kg (33 lb) and had a blood pressure measurement of 80/60 mm Hg. He was alert but irritable, with a dry mouth and no tearing. His skin turgor and capillary refilling were normal. Bowel sounds were increased, and the abdominal examination was otherwise normal.
Laboratory results showed the following electrolyte levels: sodium, 118 mEq per L (118 mmol per L); potassium, 3.2 mEq per L (3.2 mmol per L); chloride, 90 mEq per L (90 mmol per L); bicarbonate, 14 mEq per L (14 mmol per L); creatinine, 0.8 mg per dL (70 µmol per L), and blood urea nitrogen, 20 mg per dL (7.1 mmol per L). The child was eventually diagnosed with a bacterial infection caused by a Shigella species.
On physical examination, the infant weighed 2.05 kg (4 lb, 8 oz), with a respiratory rate of 40 and a heart rate of 120. Her temperature was 37.0°C (98.7°F), and her blood pressure measurement was 30/0 mm Hg. The patient was lethargic and weakly responsive, with cool extremities. Her skin turgor was decreased, and capillary refilling time was about 3.0 seconds.
Results of laboratory tests included the following: sodium level, 145 mEq per L (145 mmol per L); potassium level, 4.2 mEq per L (4.2 mmol per L); bicarbonate level, 12 mEq per L (12 mmol per L); blood urea nitrogen level, 25 mg per dL (8.9 mmol per L); and creatinine level, 0.8 mg per dL (70 µmol per L). The illness was probably viral in origin.
On physical examination, the child had a temperature of 39.6°C (103.4°F), a respiratory rate of 20 per minute, a heart rate of 100 and a blood pressure of 70/30 mm Hg. The patient was alert and irritable with normal skin turgor, normal capillary refill and a normal abdominal examination. Rare petechiae were present. The electrolyte, blood urea nitrogen and creatinine levels were normal.
On physical examination, the child had a temperature of 39.6°C (103.4°F), a heart rate of 140, a respiratory rate of 25 and blood pressure of 90/60 mm Hg. The child was irritable but not lethargic with good capillary refill but decreased skin turgor. Bowel sounds were increased with no guarding or rebound and some generalized tenderness.
Results of laboratory tests included the following: sodium, 155 mEq per L (155 mmol per L); blood urea nitrogen, 20 mg per dL (7.1 mmol per L); and creatinine, 0.9 mg per dL (80 µmol per L). The stool culture was negative after 24 hours.
|Diagnosis and Assessment
Table 1 summarizes pertinent items relating to common etiologies of gastroenteritis. Most life-threatening viral diarrheal illnesses occur in children under three months of age or in those who may be compromised by prematurity, malnutrition or poverty. Viral gastroenteritis in older children is generally self-limited and usually requires only oral rehydration therapy.
A stool specimen should be examined for white blood cells in any child who appears toxic with high fever and diarrhea. The finding of white blood cells should prompt further investigation to rule out invasive bacterial disease. The presence of gross blood in the diarrheal stool also suggests a more serious infection, so children with bloody diarrhea should undergo a rectal swab or stool culture.2 Other laboratory tests are optional and are dictated by the severity of illness. If Escherichia coli is identified in a patient with bloody diarrhea, serotyping should be done to specifically identify the O157:H7 strain, which can cause hemolytic uremic syndrome, a potentially fatal illness.3 The petechiae in the patient in illustrative case 4 are an indication of a consumptive coagulopathy, which may occur with E. coli O157:H7 infections.
|In most children with dehydration greater than 5 percent,
serum electrolytes, blood urea nitrogen and creatinine levels should be
measured. Other tests that may be indicated are listed in Table 1.
If unusual causes of gastroenteritis are suspected (i.e., travel to areas
at risk, affected contact or immunosuppression), three fresh stool
specimens should be evaluated for routine culture, ova, parasites and
Cryptosporidium species. The child in illustrative case 4 was infected
with Entamoeba histolytica, which was identified in only one of
three stool specimens. Other unusual causes of gastroenteritis include
Clostridium difficile, Cryptosporidium species,4
Vibrio cholera6 and Cyclospora.4
Table 21,7-9 offers a guide for assessing the state of hydration in children. Recent weight change documented with the same scale is very helpful in assessing fluid loss.1,8,9 Accurate weights may be harder to obtain in younger children, therefore the technique is important. The comparison of weights in illustrative case 2 was very helpful, since it indicated more than 10 percent dehydration, an indication that was consistent with the clinical assessment of dehydration in this patient. The assessment of mental status is also important in the evaluation of an ill child. A child who is happy and playful usually has no significant hydration problem. Increasing disturbances in mental status, from restlessness to irritability and then to lethargy, indicate a general overall worsening in the patient's condition and should help guide the aggressiveness of fluid resuscitation.
Vital signs, including respiratory rate, add significantly to the assessment of hydration. Children with diarrhea and excessive fluid loss usually develop a nonanion-gap metabolic acidosis with a declining bicarbonate level. To compensate, the rate and depth of breathing increase (compensatory respiratory alkalosis). A postural change in heart rate is a useful clue in assessing the fluid state of children over four years of age. An increase greater than 20 beats per minute when moving from a lying to a standing position is an indicator of hypovolemia. If the postural changes are greater, the fluid depletion is likely to be greater. However, changes in postural blood pressure have not been found to be very useful in children under nine years of age.10
The history and physical examination, with an assessment of the child's hydration status, guide the fluid treatment of children. Worldwide and in the United States, oral rehydration solutions such as the World Health Organization solutions and other clear liquids are the cornerstone of treatment.
In 1985, the American Academy of Pediatrics (AAP) published a policy statement on the treatment of infants with acute diarrhea complicated by mild to moderate dehydration.11 The AAP recommended rapid rehydration in four to six hours with an oral glucose-electrolyte rehydration solution followed by diluted formula or milk. Contrary to widespread belief and practice, lactose-based milk does not have to be eliminated. In older infants or children, rice cereal, bananas, potatoes or other nonlactose, carbohydrate-rich foods should be offered shortly after successful rehydration. In a follow-up study of practicing family physicians and pediatricians, it was noted that these clinicians tended to take much longer than recommended to rehydrate their patients, often used a lactose-free formula and did not reinstitute feeding of full-strength formula soon enough.12
A recent meta-analysis of 13 studies on the safety of oral rehydration solutions noted that the failure rate of rehydration was only 3.6 percent. Significant evidence13 has now accumulated supporting the usefulness of oral rehydration solutions as the initial treatment of choice in low-risk infants and children, as defined in Table 3. Patients with depressed bicarbonate levels (13 to 18 mEq per L [13 to 18 mmol per L]) or those who vomit at least five times in a 24-hour period may benefit from an initial intravenous infusion of isotonic solution, 20 mL per kg over 20 minutes, followed by oral administration of fluids.14 Continued vomiting, large-volume diarrhea, or both, would constitute a reason for hospital admission. Factors that significantly contribute to the progression of dehydration include withdrawal of breast feeding, not giving oral rehydration solutions during diarrhea and vomiting more than two times a day.15
Children with gastroenteritis lose 40 to 70 mEq per L (40 to 70 mmol per L) of sodium and 10 to 20 mEq per L (10 to 20 mmol per L) of potassium in diarrheal stools. Appropriate oral rehydration solutions should come close to matching the sodium and potassium content of the diarrheal stools, especially in children with gastroenteritis who are under one year of age or who are otherwise compromised. Oral rehydration solutions such as Pedialyte, Infalyte or the equivalent (Table 4) effectively treat children less than two years of age with mild to moderate (3 to 9 percent) dehydration secondary to gastroenteritis.16 Broths should be avoided in the treatment of diarrhea because of their high sodium content. Rice-based oral rehydration solution seems to offer some benefit in the treatment of high-output diarrhea, especially that associated with cholera.17 Table 518 lists some guidelines for treatment of mild to severe diarrheal states (including cholera) where oral rehydration therapy may be the only therapy available.8
Isotonic solutions such as normal saline and Ringer's lactate are usually the correct fluids for the initial treatment of dehydration that requires intravenous fluids (Tables 1 and 6). This would be the correct type of fluid for treatment of the children in the illustrative cases. The fluid is administered in boluses of 15 to 30 mL per kg every 20 minutes until hypovolemia is corrected and some urine flow is established. At that time, continued maintenance and further deficit replacement can be continued at a slower rate. Adjustments can then be made in tonicity of the fluid, and appropriate potassium may be added to the infusion as needed.
In children who are hypovolemic with signs of more than 5 percent dehydration with mental status changes, the initial fluid resuscitation should be aggressive, using boluses of isotonic fluid. Intravenous access should be initiated quickly while the child is being assessed. In children with normal cardiac and renal function, it is most important to give adequate amounts of fluid. Overhydrating is preferred to underhydrating. Any excess fluid will be eliminated eventually in the urine. If it is difficult to start an intravenous line, fluids can be given orally by a drip method or, if the situation is life-threatening, by an interosseous route until intravenous access is obtained.
The calculation of total fluid needs is based on the deficit, maintenance and ongoing losses. One of several accepted methods for the calculation of fluids is listed in Table 6. After the initial correction of hypovolemia, fluid correction proceeds at a slower pace. Generally, one half of the daily requirement is given over eight hours, with the remainder given over 16 hours. If the child has a hypertonic dehydration, isotonic fluid replacement is continued in order to not correct the hypernatremia too quickly, as that may cause cerebral edema and seizures. The correction of the hypernatraemia should take place slowly over one to two days, depending on its severity. After the deficit is corrected, maintenance fluid may be given as one-half normal saline.
Children with severe diarrhea need adequate nutrition in order to restore their digestive abilities, to recover from their illness and to prevent development of so-called "starvation diarrhea."2 Unless they have severe vomiting, children should not be deprived of nutrition for longer than one to two days. Breast feeding should be continued. Special elemental formulas may be needed at times to provide this nutrition until clinical recovery is adequate.1
B. CLAIR ELIASON, M.D.,
RICHARD B. LEWAN, M.D.,