This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with gastroenteritis in Queensland.
This guideline has been developed by senior ED clinicians and Paediatricians across Queensland and endorsed for statewide use by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.
Acute gastroenteritis accounts for approximately 6.3% of emergency presentations in Australia and New Zealand.1 It is usually characterised by a sudden onset of diarrhoea (loose or liquid stools that occur more frequently than usual), with or without vomiting, fever or abdominal pain.2 There is often a history of contact with another person with similar symptoms.
Viral pathogens including norovirus are responsible for approximately 70% of episodes of acute infectious diarrhoea in children.3,4,5 Bacterial infections (most commonly Campylobacter and Salmonella) account for approximately 15% of episodes.3,4
Dehydration can occur secondary to gastroenteritis. While untreated or poorly treated dehydration may be fatal, there are also risks associated with over-hydration and/or inappropriate electrolyte replacement, which can result in death from cerebral oedema.6
Hypernatraemia is a complication of gastroenteritis most commonly seen in infants less than one year of age, particularly those who have been given inappropriately concentrated formula or hyperosmolar home-made rehydration solutions, or in children who are unable to express the feeling of thirst and self-regulate fluid intake.7
The purpose of the assessment (history-taking and physical examination) is to:
History should include specific information on:
The aim of the physical examination is to assess hydration level, identify comorbidities and exclude other non-infectious causes of vomiting/diarrhoea. A careful assessment of conscious state and abdominal examination is required.
In the absence of the ability to accurately measure weight loss, a combination of clinical signs and symptoms are used to estimate the degree of dehydration.
Recognising the severity of dehydration (especially mild to moderate) can be challenging as parental report of vomiting, diarrhoea, and oral intake is unreliable6 and clinical signs can be imprecise and incorrect.3,8,9
Consider seeking senior emergency/paediatric advice as per local practice if uncertain of hydration status.
Seek senior emergency/paediatric advice as per local practice for a child in shock.
| Assessment | None | Clinical dehydration (5-10% fluid loss) | Clinical shock (over 10% fluid loss) |
|---|---|---|---|
| Level of consciousness | Alert and responsive | Altered responsiveness | Decreased level of consciousness |
| Skin colour | Skin colour unchanged | Skin colour unchanged | Pale or mottled skin |
| Extremities | Warm extremities | Warm extremities | Cold extremities |
| Eyes | Eyes not sunken | Sunken eyes | Sunken eyes |
| Mucous membranes | Moist mucous membranes | Dry mucous membranes | Dry mucous membranes |
| Heart rate | HR normal | HR normal | Increased HR |
| Breathing | RR normal | Increased RR | Increased RR |
| Peripheral pulses | Peripheral pulses normal | Normal peripheral pulses | Weak peripheral pulses |
| Capillary refill | Capillary refill normal | Capillary refill normal | Prolong capillary refill (greater than 2 seconds) |
| Skin turgor | Skin turgor normal | Decreased skin turgor | Decreased skin turgor |
| Blood pressure | BP normal | BP normal | Decreased BP (decompensated shock) |
| |||
| Surgical conditions | Appendicitis, intussusception, bowel obstruction, malrotation with volvulus, strangulated hernia, testicular torsion |
| Non-enteric infections | Sepsis, UTI, meningitis, pneumonia, otitis media, toxic shock syndrome, endemic infection in returned traveller, other focal infections |
| Metabolic disease | DKA and inborn errors of metabolism |
| Other | Haemolytic uremic syndrome, inflammatory bowel disease, raised ICP, foreign body ingestion |
The very young infant and the malnourished child are more likely to have another diagnosis.
Consider seeking senior emergency/paediatric advice as per local practice if red flags are identified on assessment.
Most patients with gastroenteritis do not require any investigations and tests to differentiate between bacterial and viral aetiology are not recommended as they will not influence management.
If there is clinical suspicion for Salmonella (for example bloody stools or a close contact), a stool sample should be collected. Dependent on the age of the patient, further investigations may also be required and clinicians should refer to the Salmonella guideline [PDF 378.12 KB].
Those who have returned from overseas should have investigations to exclude diseases endemic in the region of travel. Consider discussion with Infectious Diseases in such cases.
Other investigations may be considered based on possible alternative diagnoses.
| Investigation type | Indication |
|---|---|
| Blood glucose level | Consider as part of initial assessment for children who are very lethargic or have had very little oral intake. |
| Point of care ketone testing | Urinary or blood ketones can be used as a surrogate biochemical marker of a starvation state. If available, may help guide decisions around the need/length of fluid trial/rehydration but should be used in conjunction with clinical picture. |
| Biochemistry (Na+, K+, urea, creatinine, and glucose) and venous blood gas |
Consider for the following children:
|
Urine dipstick MCS only required if: |
Recommended for the following children:
|
| Stool MCS |
Recommended for the following children:
Consider in the following children:
|
Refer to flowchart [PDF 669.61 KB] for a summary of the emergency management for children presenting with symptoms of gastroenteritis:
Fluid management is the mainstay of therapy directed by the degree of hydration. Medication is not routinely recommended.2,6
Most children presenting to an ED with symptoms of gastroenteritis can be managed conservatively with an oral fluid trial as outlined below. For any child who requires nasogastric (NG) or IV rehydration, strict fluid balance must be recorded, with weighing of all nappies if relevant and at least daily weights.
Seek senior emergency/paediatric advice as per local practice for a child in shock. Consider contacting paediatric critical care (onsite or via Retrieval Services Queensland (RSQ)) if signs of shock persist after two fluid boluses.
Consider sepsis in child with persisting signs of shock following fluid bolus.
| Bolus dose (IV or IO) |
Sodium Chloride 0.9% administered rapidly in 20 mL/kg bolus. Repeat in 20 mL/kg boluses as clinically indicated. |
| Ongoing fluid therapy |
Sodium chloride 0.9% and 5% glucose running at maintenance plus correction of estimated deficit (usually 10% in the shocked patient) over 24hrs. Use potassium containing fluids in children who are hypokalaemic and consider in children with significant ongoing losses (see potassium prescribing guideline [PDF])
Reassess frequently and replace significant ongoing losses. Rate may be revised on senior emergency/paediatric advice following identification of an electrolyte disturbance. |
Calculating fluid ratesMaintenance fluids:
PLUS Replacement of deficit: | Example
Maintenance fluids:
PLUS Replacement of 10% deficit: TOTAL: 169ml/hr |
In children with clinical signs of dehydration, the focus is on rehydration.
Acute gastroenteritis can often be managed effectively with oral rehydration therapy (ORT). This has been shown to reduce inpatient admissions when used in ED.10Oral rehydration solutions use the principle of glucose-facilitated sodium transport whereby glucose enhances sodium and secondarily water transport across the mucosa of the upper intestine. Water absorption across the lumen of the gut is maximised when solutions with a sodium to glucose ratio of 1:1.4, and a sodium concentration of 60mmol/L are used.11 Appropriate rehydration solutions include Glucolyte, GastrolyteTM, HYDRAlyteTM and PedialyteTM.
The most appropriate route of fluid administration (oral, NG or IV) is influenced by the age of the child and the severity of dehydration. Where possible enteral (NG and oral) rehydration is preferred (see Trial of fluids form [PDF]). In comparison with IV administration, enteral rehydration has been associated with better health outcomes (quicker return to normal diet, less vomiting and diarrhoea and improved weight gain at discharge), fewer complications, shorter hospital stay, and is more cost effective. NG rehydration is usually successful regardless of vomiting (though vomiting usually ceases following commencement of NG fluids). 3,12
Breastfeeding should always be continued throughout the rehydration phase.
| Oral | NG | IV |
|---|---|---|
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| Oral | NG/IV |
|---|---|
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Regular reassessment is recommended. Rehydration therapy is regarded as successful if the clinical signs of dehydration have resolved.
Persistence of signs after four hours may be due to:
If signs of dehydration persist, further rehydration via NG or IV therapy is recommended. Consider testing for electrolyte abnormality.
Seek senior emergency/paediatric advice as per local practice if electrolyte abnormalities are identified on blood testing (as fluid adjustments may be required).
Feeding (using usual fluids) should be reintroduced after the acute phase of rehydration (two to four hours) or earlier if indicated by the child. Refer to Gastroenteritis Factsheet for further advice on feeding for parents/caregivers.
In children with gastroenteritis without clinical signs of dehydration the focus is on prevention of dehydration.
Children should receive a fluid challenge with an oral rehydration solution at triage while awaiting medical assessment. Offer small amounts of oral rehydration solution frequently via syringe/cup, aiming for 10ml/kg/hour (small volumes are better tolerated than larger volumes)13-16 See Trial of fluids form [PDF].
Following medical assessment, children who have no risk factors for dehydration can be safely discharged home with reassurance, advice (including the Gastroenteritis fact sheet) and safety netting.
Children with risk factors for dehydration (see above), should have an extended period of observation and complete a trial of fluids over 1-4hrs.
Where relevant, breastfeeding should be encouraged.
A single dose of oral ondansetron can be prescribed to reduce vomiting.
Ondansetron has been shown to reduce the need for IV rehydration, rate of representation and length of hospital stay in children with gastroenteritis16, 20.
| Dose |
Given orally or sublingually at a dose of 0.15 mg/kg (maximum 8 mg).
Tablets and wafers are available in 4 mg and 8 mg doses. Recommended doses are as follows:
Not recommended for children aged less than 6 months, weight less than 8 kg or with ileus. |
| Considerations | Ondansetron prolongs the QT interval in a dose–dependent manner. Exercise caution in children who have or may develop prolongation of QTc (such as those with electrolyte disturbances, family history of long QT syndrome, heart failure or those on medications that may lead to a prolongation of the QTc).18,19 |
Antibiotics are not routinely recommended as gastroenteritis is commonly viral in aetiology. In cases of uncomplicated bacterial gastroenteritis, there is no evidence of benefit but evidence of potential harm related to the use of antibiotic therapy.
Antibiotic therapy is recommended for:
Consider antibiotic therapy for malnourished or immunocompromised children.
Seek senior emergency/paediatric advice as per local practice regarding antibiotic prescription.
The following medications are not routinely recommended:
Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.
| Includes children with the following (as a guide): | |||
|---|---|---|---|
| |||
| Less than 1 year | 1-4 years | 5-11 years | Over 12 years |
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| Reason for contact | Who to contact |
|---|---|
| For immediate onsite assistance including airway management | The most senior resources available onsite at the time as per local practices. Options may include:
|
| Paediatric critical care advice and assistance | Onsite or via Retrieval Services Queensland (RSQ). If no onsite paediatric critical care service contact RSQ on 1300 799 127:
RSQ (access via QH intranet) Notify early of child potentially requiring transfer. Consider early involvement of local paediatric/critical care service. In the event of retrieval, inform your local paediatric service. |
| Reason for contact | Who to contact |
|---|---|
| Advice (including management, disposition or follow-up) |
Follow local practices. Options:
|
| Referral | First point of call is the onsite/local paediatric service |
| Do I need a critical transfer? |
|
| Request a non-critical inter-hospital transfer |
|
| Non-critical transfer forms |
|
The majority of children with gastroenteritis who present with no or mild signs of clinical dehydration can be safely discharged home.
Consider discharge for the following children:
A longer period of observation in SSU or inpatient service may be considered for children with risk factors for dehydration including children aged less than one year especially if pre-term or failure to thrive, signs of malnutrition, immunocompromised or other underlying chronic medical conditions.
On discharge, parents/caregivers should be provided with a Gastroenteritis fact sheet.
With GP if symptoms worsen or persist after two to three days.
Admission to an inpatient service or SSU (where relevant) is recommended for the following children: