Acute Gastroenteritis Management in Children · Fluid management is the mainstay of therapy in children with acute gastroenteritis and there is very limited place for medication.2,5

CHS Document ID 00703 Acute Gastroenteritis Management in Children Children’s Health Services

Custodian/Review Officer: Chair, GBMA Clinical Procedures Editorial Group Version no: 1.0 Applicable To: Medical and Nursing staff working in Children�’s Health Services Approval Date: 14/08/2011 Effective Date: 15/08/2011 Next Review Date: August, 2013 Authority:GBMA Clinical Procedures Editorial Group Approving Officer: CEO Children�’s Health Services Name: Dr Peter Steer �…�…�…�…�…�…�…�…�…�…�…�…�… Signature Supersedes: N/A Key Words: Children; acute gastroenteritis; emergency management; and admission, discharge criteria, 00703. Accreditation References: EQuIP 5 criteria 1.3.1, 1.4.1, 1.5.1

1. Purpose This procedure provides clinical practice guidelines for the treatment of children (0-14 years of age) with acute gastroenteritis.

2. Scope This procedure relates to all Children�’s Health Services (CHS) and Metro Children�’s Health Services staff involved with the care and management of children with acute gastroenteritis.

3. Introduction Acute gastroenteritis is one of the most common illnesses causing children to present to an emergency service. It accounts for approximately 6.3% of emergency presentations in Australia and New Zealand.1 Infectious gastroenteritis is usually characterised by diarrhoea of rapid onset, with or without vomiting, fever or abdominal pain.2 There is often a history of contact with another person with similar symptoms.

Viral pathogens are responsible for approximately 70% of episodes of acute infectious diarrhoea in children, with rotavirus being the most common cause.3,4 Bacterial infections account for approximately 15% of episodes.3,4 The most commonly reported bacterial causes of gastroenteritis in Australia are the Campylobacter and Salmonella species.3

A small proportion of children affected with acute gastroenteritis will suffer severe dehydration and electrolyte disturbance. Untreated or poorly treated dehydration may progress to shock and death.5 There are also risks from over-hydration and/or inappropriate electrolyte replacement, which may result in death from cerebral oedema.5

Current practice focuses on the prevention and management of dehydration in children. Most cases of acute gastroenteritis may be managed effectively with oral rehydration therapy (ORT). Effective use of ORT in the emergency service has been proven to reduce inpatient admissions.6

4. Assessment The history, physical examination and investigations should be directed at answering the following questions:

4.1 Is this gastroenteritis? Several conditions can masquerade as gastroenteritis and it is important to actively exclude these when making the diagnosis of gastroenteritis.7

Version No.: 1.0; Effective From: 15/08/2011 Page 1 of 13

CHS Proc 00703: Acute Gastroenteritis Management in Children

Printed copies are uncontrolled


Differential diagnoses to consider include:2

surgical conditions�—appendicitis, intussusception, bowel obstruction, malrotation with volvulus, and strangulated hernia

non-enteric infections�—UTI, meningitis, pneumonia, otitis media, other focal infections metabolic disease�—DKA, and inborn errors of metabolism other�—haemolytic uremic syndrome, inflammatory bowel disease, and raised intracranial pressure.

The following features may occur in gastroenteritis, but should raise the suspicion of a diagnosis other than gastroenteritis.7 A senior doctor should be notified if any of the following is present:

severe or localised abdominal pain abdominal distension isolated vomiting bilious (green) vomit blood in stool or vomit patients looks very unwell high grade fever > 38.5 degrees Celsius if < 3 months of age, or > 39 degrees Celsius if > 3 months

of age headache.

ALERT: The very young infant and the malnourished child are more likely to suffer severe disease, or to have another diagnoses.

4.2 Is this child dehydrated or at risk of dehydration? Dehydration is the primary serious complication of acute gastroenteritis. A clinical assessment of dehydration severity is important, keeping the risk factors for dehydration in mind, as this will help determine the initial fluid management of the child.5

There are a number of risk factors are associated with an increased risk of dehydration. 7,8 Children with these risk factors are more likely to require a period of observation in the emergency service before discharge:

age < 1 year, particularly pre-term infants and those < 6 months infants with low birth weight and failure to thrive > 5 diarrhoeal stools in last 24 hours > 2 vomits in last 24 hours not offered or have not been able to tolerate supplementary fluids before presentation stopped breast feeding during illness signs of malnutrition immunocompromised children.

The gold standard in assessing the degree of dehydration is to measure weight loss (bare weight).2 Unfortunately, a recent weight is rarely available and one has to rely on a combination of clinical signs and symptoms to estimate the degree of dehydration.

Parental report of vomiting, diarrhoea, or decreased oral intake is unreliable in identifying dehydration in children.5 Clinical signs of dehydration can be imprecise and incorrect, making accurate prediction of the degree of dehydration difficult.3,9,10 While it may be easy to recognise the child at the extremes of the spectrum, that is, minimal or no dehydration (<5%) or severe dehydration/shock (>10%), it is not easy to identify the child with clinical (mild to moderate) dehydration (5-10%).3

Assessment of hydration status helps determine the initial volume, rate and type of fluid therapy to be administered. It also:7

determines conservatively which children may safely be sent home for therapy and which ones should remain for observation during therapy (no dehydration)

provides a starting point for treatment (clinical dehydration) with adjustments made to the fluid regimen over time, based on regular assessment during the rehydration process

determines which children should immediately receive more intensive therapy (severe dehydration/shock).





Table 1: Clinical detection of dehydration and assessment of severity

Increasing severity of dehydration

None Clinical Dehydration Clinical Shock

(suspected or confirmed)

Appearance Well Unwell or deteriorating -

Level of consciousness

Alert & responsive Altered responsiveness level of consciousness

Skin colour Unchanged Unchanged Pale or mottled skin

Extremities Warm Warm Cold

Eyes Not sunken Sunken -

Mucous membranes

Moist Dry -

Heart rate Normal Normal

Breathing Normal

Peripheral pulses Normal Normal Weak

Capillary refill Normal Normal Prolonged >2 sec

Skin turgor Normal -

Blood pressure Normal Normal (decompensated shock)

More numerous and more pronounced symptoms and signs of clinical dehydration indicate greater severity.

For clinical shock, one or more of the symptoms and/or signs will be present.

If in doubt, manage as if dehydration falls into the more severe category.

Source: National Collaborating Centre for Women's and Children's Health7




4.3 Should investigations be performed? In children presenting with acute gastroenteritis, routine investigations are not usually indicated.2,11 Children who are severely dehydrated or who are not tolerating ORT and require IV hydration should have U&E�’s measured.

There are potential biochemical complications associated with gastroenteritis that can only be identified through blood testing. Hypernatraemia is almost entirely a complication of gastroenteritis in infants under the age of 12 months, particularly those who have been given inappropriately concentrated formula or home-made rehydration solutions.12

The following investigations may be performed when indicated as below:7

Biochemistry (Na+, K+, urea, creatinine, and glucose) when: IV therapy is required symptoms and signs suggest hypernatraemia (jittery movements, increased muscle tone,

hyperflexia, convulsions, drowsiness or coma) an altered level of consciousness is present there is a co-morbidity of renal disease or the child is prescribed diuretics home therapy with hyper- or hypotonic fluids.

FBC, CRP, LP and blood cultures: perform if septicaemia or invasive disease such as osteomyelitis or meningitis is suspected do not perform FBC or CRP to differentiate between viral and bacterial gastroenteritis. This

is neither sensitive, nor specific and does not change management. Acid-base levels and chloride:

investigations for acid-base status and chloride should be measured with a venous blood gas if shock is suspected or confirmed.





Stool MCS: suspected septicaemia. blood and/or mucous in stool. immunocompromised state. consider stool MCS if the child has been recently abroad, had persistent diarrhoea for > 7

days, and if there is an uncertainty about the diagnosis of gastroenteritis.

5. Management Fluid management is the mainstay of therapy in children with acute gastroenteritis and there is very limited place for medication.2,5 Management of gastroenteritis is therefore guided by the degree of dehydration. 5.1 No dehydration In children with gastroenteritis but without clinical signs of dehydration, the focus is on prevention of dehydration.

All children presenting with gastroenteritis should receive a fluid challenge with an oral rehydration solution (ORS) at triage, whilst awaiting assessment. This will help ascertain whether they are able to maintain their hydration. Commercially available low osmolarity ORS (Glucolyte, GastrolyteTM, HYDRAlyteTM, or PedialyteTM) is the most appropriate fluid to use.7 They are specifically designed for enteral rehydration, contain appropriate amounts of sodium, glucose and other electrolytes, and have appropriate osmolality to maximise water absorption from the gut. Small amounts of ORS (0.5 mL/kg) should be offered frequently (every 5 minutes), as this has been demonstrated to be better tolerated.13,14,15 Mothers should be encouraged to continue breastfeeding.

Children at increased risk of dehydration should be observed in the emergency service for 1 to 4 hours. Ondansetron for children > 6 months of age and > 8 kg may be considered if persistent vomiting prevents oral rehydration.16,17,18 Occasional vomiting alone during the trial of fluids should not be considered as failure of ORT. The number and volume of vomits per hour should be documented in the clinical record.

Advice should be given to carers to prevent primary dehydration. Breastfeeding and other milk feeds should be continued and no special formulas are required. It is important to encourage parents to give small amounts of fluid frequently, as this is generally tolerated better. The fluid may be measured in a syringe and given to the child either by syringe, teaspoon, cup or icy pole. Fruit juices and carbonated drinks should be discouraged as this may worsen diarrhoea. Consider giving an extra 5 mL/kg of ORS after each large watery stool to those at increased risk of dehydration.14 5.2 Clinical dehydration (5-10%) In children with clinical signs of dehydration, the focus is on rehydration. Breastfeeding should always be continued throughout the rehydration phase.

The fluid deficit in this subset of children is usually at least 5% (of body weight lost as fluid) and can be calculated as 50 mL/kg.7. In most children this volume may be replaced over 4 hours (rapid rehydration).2,7,14 A slower rate (replacing deficit over 8�–12 hours) is recommended for children with significant co-morbidities (e.g. renal disease, cardiac disease, diabetes, on diuretics etc.) and for infants < 6 months of age to avoid fluid overload.19

The aim of rapid rehydration is to correct dehydration in the emergency service, avoid hospital admission, and to facilitate the return to an age-appropriate, unrestricted diet. Rapid rehydration is possible via the oral, NG or IV route. Ongoing losses (vomit, diarrhoeal stools) during therapy only need to be replaced if the volume is large.14 In such cases, calculate and add the volume to the replacement volume and administer over the next hour.

Rehydration via the enteral route (oral or NG) is preferred for children with clinically significant dehydration. Enteral rehydration is as effective as the IV route, has fewer complications, decreases admission rates, has a shorter hospital stay and quicker return to normal diet and fluids, and is more cost-effective.20-24 Furthermore, there is evidence that ORS is associated with less vomiting and diarrhoea and improved weight gain at discharge compared to IV therapy.20





Unfortunately, NG rehydration is often underutilised in the emergency service despite significant advantages over IV therapy. For older children (> 2 years of age), it may be difficult to insert and maintain a NG and in this instance IV rehydration may need to be considered. NG rehydration is most suitable for infants and young children (< 2 years of age).

Contraindications to enteral rehydration include: suspected or confirmed shock ileus reduced level of consciousness (risk of aspiration).

Oral fluid replacement is the initial route of choice. During ORT small amounts (0.5 mL/kg) of ORS are given frequently (every 5 minutes) via syringe/cup. If there is significant vomiting, ondansetron may be administered to facilitate oral intake. If a child is dehydrated due to persistent vomiting or unwilling (refuses) to accept oral fluids over approximately 1 hour, or there is a concern about the carer's ability to participate in delivering ORT, NG (preferred) or IV rehydration may be offered. Most children will stop vomiting after NG fluids are commenced and this method is often successful even if the child is vomiting.3,25

If the IV route is used, blood (for VBG, U&E�’s, BSL) should be collected at the same time. A senior doctor should be notified if there are any electrolyte abnormalities, as the rate and composition of fluid may need to be adjusted.

Oral 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 ration of 1:1.4, and a sodium concentration of 60mmol/L are used.20 This composition is recommended by the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition for use in developed countries.20 Table 2: Composition of oral rehydration solutions

Na+

(mmol/L) Carbohydrate (mmol/L)

Osmolality (mOsm/L)

WHO 90 111 331

Gastrolyte(R) 60 90 240

Repalyte(R) 60 90 240

Hydralyte(R) Icy Pole 55 80 240

Hydralyte(R) liquid 45 90 240

Pedialyte(R) 45 126 250

Source: Canavan, Arant5 Fruit juices, soft drinks and cordials are commonly used in rehydration therapy, especially if the child refuses to drink ORS. These fluids should preferably not be used as rehydration fluid, due to the minimal sodium content and the excessive glucose content which may worsen diarrhoea. Although diluting soft drinks and fruit juices reduces glucose concentration, the fluid has insufficient sodium to act as an appropriate rehydration fluid. Table 3: Composition of other oral fluids

Na+

(mmol/L)

Carbohydrate

(mmol/L)

Osmolality

(mOsm/L)

Apple juice 3 690 730

Soft drinks ~2 ~700 ~750

Sports drinks ~20 ~255 ~330

Source: Canavan, Arant5





For IV rehydration, 0.9% Sodium Chloride (NaCl) + 5% Glucose is an appropriate fluid choice.

During the rehydration phase, children should be regularly reviewed and reassessed after 4 hours to ensure the clinical signs of dehydration have resolved.

Rehydration therapy is regarded as successful if the clinical signs of dehydration have resolved. Persistence of signs may be due to initial underestimation of the fluid deficit and persistent vomiting and/or diarrhoea. In such cases, further rehydration via NG or IV therapy should occur. Strong consideration should be given at this point to measure U&E's and BSL to ensure an electrolyte abnormality is not contributing to failure of rehydration.

After successful rehydration, breastfeeding, other milk feeds or fluid intake should be encouraged. In children at increased risk of dehydration, consider administering an additional 5 mL/kg of ORS after each large watery stool.14

5.3 Severe dehydration/shock (>10% fluid loss) If a child presents in shock, the emergency service consultant should be informed immediately. Urgent IV or IO access should be established and a bolus of 20 mL/kg 0.9% NaCl administered rapidly. Blood should be collected for testing�—U&E�’s, VBG and BSL. Fluid boluses of 20 mL/kg should be repeated if signs of shock persist and consideration should be given to other causes of shock, e.g. sepsis. Early consideration should be given for transfer to a Level 5 or 6 emergency or PICU service.

After adequate circulating blood volume has been re-established, the child will require ongoing management of rehydration and maintenance fluid. The deficit can be estimated as at least 10 % (of body weight) and the volume should be replaced with 100 mL/kg of 0.9% NaCl + 5% Glucose over the next 8 hours.5 Reassessment of the child should occur frequently. Ongoing losses (vomiting and diarrhoea) should be replaced if significant. A VBG and U&E's should be repeated early and expert advice sought from the Consultant (emergency or paediatric) if any electrolyte abnormalities are present.

5.4 Feeding after rehydration Historically, a period of gut rest has been advocated in children with acute gastroenteritis. This practice has now been abandoned, as growing evidence has demonstrated advantages of early refeeding.6 Early feeding promotes mucosal recovery, reduces the duration and volume of diarrhoea, improves weight gain and improves nutritional outcome.20 Feeding should be reintroduced after the acute phase of rehydration (2 to 4 hours) or earlier if the child indicates a strong desire for milk or food during rehydration.

Formula-fed infants should receive their usual full strength formula milk. Weaned infants and children should receive their usual fluids and diets. There is no evidence to support graded re-feeding and this practice should be discouraged.20

Lactose containing feeds (e.g. milk and standard cow milk based formula) are safe and effective for most infants and children and special formulae (lactose-free and soy-based) are usually not required.20 Some children may develop transient lactose intolerance, but this is rarely clinically significant. On the rare occasion that a child experiences an acute exacerbation of diarrhoea after lactose is introduced, advise to change to lactose free formula for 2 weeks, and then revert to original formula. Breast feeding should never be stopped.

Highly processed, high fat foods containing high amounts of simple sugars should be avoided. Commencing children on high complex carbohydrate foods such as potato, rice and pasta may be better tolerated. Avoid fruit juices and carbonated drinks as this may make diarrhoea worse.

5.5 Ondansetron A single dose of oral ondansetron is safe and effective in reducing the vomiting associated with gastroenteritis.16,17,18 It should be considered if ORT has failed due to persistent vomiting. Ondansetron may cause an increase in diarrhoea but further studies are required to determine if it is clinically significant. Administration is not recommended in children younger than 6 months of age or if the weight is less than 8 kg. It is important to consider other causes of vomiting and exclude ileus before administering ondansetron.





Table 4: Ondansetron wafer dosage guidelines

Weight Dose

8-15 kg 2 mg (1/2 wafer)

15-30 kg 4 mg (1 wafer)

>30 kg 8 mg ( 2 wafers)

Source: Royal Children�’s Hospital, Melbourne19 5.6 Anti-diarrhoeal agents Anti-diarrhoeal agents (such as Loperamide) should not be used in the treatment of acute gastroenteritis in children as the potential risks outweigh the benefit. Their use can cause adverse consequences, including lethargy, paralytic ileus, toxic mega-colon, central nervous system depression, coma, and even death.26,27 5.7 Antibiotic therapy Viral agents cause most gastroenteritis and thus antibiotics are of no use. Even in confirmed uncomplicated bacterial gastroenteritis, antibiotic therapy is of little benefit and may, in fact, cause harm.28

Antibiotics may be indicated in the following circumstances:7

suspected or confirmed septicaemia extra-intestinal spread of bacterial infection infants younger than 6 months of age with salmonella gastroenteritis malnourished or immunocompromised children with salmonella gastroenteritis clostridium difficile-associated pseudomembranous enterocolitis, giardiasis, dysenteric shigellosis,

dysenteric amoebiasis or cholera. 5.8 Probiotics Certain probiotics (Lactobacillus caseii GG) have been shown to reduce the duration of diarrhea.32 However, these formulations are not currently available in Australia. Other probiotics may be effective but there is currently no evidence to support their use.29 5.9 Rotavirus vaccine A major recent advance in the prevention of gastroenteritis has been the development and registering of two oral rotavirus vaccines, whose safety and efficacy have been confirmed in recent large scale trials.27 Importantly, neither is associated with appreciable adverse effects or the increased risk of intussusception, which was seen with the first registered vaccine.30 They provide cross protection against common serotypes and decreased rates of severe gastroenteritis, decreased need for intravenous fluids, and decreased hospital admission.27 The rotavirus vaccine is administered at the 2, 4 and 6 month immunisation schedule.30

See the flowchart on emergency management of acute gastroenteritis in children �– Appendix 1.

6. Disposition There is little evidence upon which to base recommendations regarding requirements for the level of care for children with acute gastroenteritis. Many factors, both medical and non-medical, may influence a decision to discharge a child, or to admit a child who has presented to the emergency service.

When a decision is made to transfer a child to a Level 6 facility, referral must be made through RSQ.31

Activation of the QLD emergency medical system coordination centre (QCC)

Further information on the preparation of a infant prior to transport can be obtained through RSQ Clinical Guidelines paediatric section (page 31-35).31

Statewide RSQ clinical guidelines�—Paediatrics

http://qheps.health.qld.gov.au/rts/docs/rsq_activation.pdf

http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf





7. Abbreviations Term Definition

BSL Blood sugar level

Children 0-14 years of age

CHS Children�’s Health Services

CRP C-reactive protein

DKA Diabetic ketoacidosis

ED Emergency department

FBC Full blood count

IO Intraosseous

IV Intravenous

K+ Potassium

LOC Level of consciousness

LP Lumbar puncture

Na+ Sodium

MCS Microscopy, culture and sensitivity pathology test

NaCl Sodium chloride

NG Nasogastric

ORS Oral rehydration solution

ORT Oral rehydration therapy

PICU Paediatric Intensive Care Unit

PO Orally

RSQ Retrieval Services Queensland

Senior doctor Senior registrar or consultant

U&E's Urea and electrolytes (serum electrolyte analysis)

UTI Urinary tract infection

8. References and Suggested Reading 1. Acworth J., Babl F., Borland M., et al. Patterns of presentations to the Australian and New Zealand

paediatric emergency research network. Emergency Medicine Australasia. 2009; 21 (1): 59-66.

2. Heinz P. Management of acute gastroenteritis in children. Paediatrics and Child Health. 2008; 18 (10): 453-457.

3. Elliott EJ., Dalby-Payne JR. Acute infectious diarrhoea and dehydration in children. Medical Journal of Australia. 2004; 181 (10): 565-570.

4. Webb A., Starr M. Acute gastroenteritis in children. Australian Family Physician. 2005; 35 (4): 227-231.

5. Canavan A., Arant BS. Diagnosis and management of dehydration in children. American Family Physician. 2009; 80 (7): 692-696.

6. Boyd R., Busuttil M., Stuart P. Pilot study of a paediatric emergency department oral rehydration protocol. Emergency Medicine Journal. 2005; 22 (2): 116-117.





7. National Collaborating Centre for Women's and Children's Health. Diarrhoea and vomiting caused by gastroenteritis: Diagnosis, assessment and management in children younger than 5 years [internet]. London (UK): National Collaborating Centre for Women's and Children's Health; 2009 [cited 2011 May 9]. Available from: http://www.nice.org.uk/nicemedia/pdf/CG84FullGuideline.pdf

8. Southern Health (Victoria). Evidence-based practice guideline for the management of diarrhoea with or without vomiting in children [internet]. Victoria (AU): Southern Health; 2005 [cited 2011 May 9]. Available from: http://www.mihsr.monash.org/hfk/pdf/diarrhoea-sh-infect-cont-20051122.pdf

9. Gorelick MH., Shaw KN., Murph KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997; 99 (5): 724.

10. Steiner MJ., DeWalt DA., Byerley JS. Is this child dehydrated?. The Journal of the American Medical Association. 2004; 291 (22): 2746-2754.

11. American Academy of Pediatrics. Practice parameter: The management of acute gastroenteritis in young children. Pediatrics.1996; 97 (3): 424-435.

12. Moritz ML., Ayus JC. The changing pattern of hypernatraemia in hospitalised children. Pediatrics. 1999; 104 (3): 435-439.

13. World Health Organisation. The treatment of diarrhoea: A manual for physicians and other senior health workers [internet]. Geneva: World Health Organisation; 1995 [cited 2011 May 9]. Available from: http://whqlibdoc.who.int/publications/2005/9241593180.pdf

14. Centre for Disease Control and Prevention. Managing acute gastroenteritis among children: Oral rehydration, maintenance, and nutritional therapy [internet]. Atlanta (GA): Centre for Disease Control and Prevention; 2003 [cited 2011 May 9]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm

15. Colletti JE., Brown KM., Sharieff GQ, et al. The management of children with gastroenteritis and dehydration in the emergency department. The Journal of Emergency Medicine. 2010; 38 (5): 686-698.

16. Freedman SB., Adler M., Seshadri R., et al. Oral ondansetron for gastroenteritis in a pediatric emergency department. The New England Journal of Medicine. 2006; 354 (16): 1698-705.

17. Howard S. Does oral ondansetron reduce vomiting and the need for intravenous fluids and hospital admission in children presenting with vomiting secondary to gastroenteritis?. Archives of Disease in Childhood. 2010; 95 (11): 945-947.

18. Reeves JJ., Shannon MW., Fleisher GR. Ondansetron decreases vomiting associated with acute gastroenteritis: a randomized, controlled trial. Paediatrics. 2002; 62, 109.

19. Royal Children�’s Hospital, Melbourne. Gastroenteritis [internet]. Melbourne (AU): Royal Children�’s Hospital, Melbourne; 2009 [cited 2011 May 11]. Available from: http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=12364

20. Guarino A., Albano F., Ashkenazi S., et al. European society for paediatric gastroenterology, hepatology, and nutrition/European society for pediatric infections diseases: Evidence-based guidelines for the management of acute gastroenteritis in children in Europe. Journal of Pediatric Gastroenterology and Nutrition. 2008; 46: S81-S184.

21. Spandorfer PR., Alessandrini EA., Joffe MD., et al. Oral versus intravenous rehydration of moderately dehydrated children. Pediatrics. 2005; 115 (2): 295-301.

22. Nager AL., Wang VJ. Comparison of nasogastric and intravenou methods of rehydration in pediatric patients with acute dehydration. Pediatrics. 2002; 109 (4): 566-572.

23. Fonseca BK., Holdgate A., Craig JC. Enteral versus intravenous rehydration therapy for children with gastroenteritis. Archives of Pediatrics & Adolescent Medicine. 2004; 158 (5): 483-490.

24. Atherly-John YC., Cunningham SJ., Crain EF. A randomized trial of oral versus intravenous rehydration in a pediatric emergency department. Archives of Pediatrics & Adolescent Medicine. 2002; 156 (12): 1240-1243.

25. Nazarian LF., Berman JH., Brown G., et al. Practice parameter: The management of acute gastroenteritis in young children. Pediatrics. 1996; 97 (3):424-435.

http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=12364





26. Harris C., Wilkinson F., Mazza D., et al. Evidence based guideline for the management of diarrhoea with or without vomiting in children. Australian Family Physician. 2008; 37 (6): 22-28.

27. Singh A., Fleurat M. Acute gastroenteritis - an update. Pediatric Emergency Medicine Practice. 2010; 7 (7): 1-21.

28. Elliott EJ. Acute gastroenteritis in children. British Medical Journal. 2007; 334 (7583): 35-40.

29. Allen SL, Okoko B., Martinez E., et al. Probiotics for treating infectious diarrhoea. Cochrane Database for Systematic Review. 2003. Issue 11, Art. No.: CD003048.

30. Australian Government�—Department of Health and Ageing. Rotavirus vaccine and intussusception [internet]. Canberra (AU): Australian Government�—Department of Health and Ageing; 2011 [cited August 8]. Available from: http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/77C90639C62B415BCA25782D001DC80D/$File/intussusception-provider.pdf

31. Statewide Clinical Coordination and Retrieval Services. Clinical guidelines: Section two [intranet]. Brisbane (AU): Queensland Government (Queensland Health); 2008 [cited July 25]. Available from: http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf

9. Supporting Documents Emergency management of children with acute gastroenteritis flow chart Gastroenteritis in children fact sheet

10. Consultation Key stakeholders who reviewed this version are:

Staff Specialist �– Emergency Department, Logan Hospital Staff Specialist �– Emergency Department, Royal Children�’s Hospital Paediatric Registrar �– Emergency, Royal Children�’s Hospital Clinical Nurse Consultant Emergency Department, Mater Children�’s Hospital Staff Specialist �– Emergency Department, Mater Children�’s Hospital Director of Paediatrics, Ipswich Hospital Clinical Nurse Consultant Emergency Department, Logan Hospital Nurse Practitioner �– Paediatrics, Logan Hospital Manager �– Clinical Standards, Queensland Ambulance Service Director of Paediatric Emergency Medicine, Children�’s Health Services Clinicians (medical, nursing, allied health) working within Level 4, Level 5 and Level 6 Children�’s

Health and Metro Children's Health Services in emergency, inpatient and ambulatory services Children�’s Health Services District clinical leaders �— medical, nursing and allied health District Chief Executive Officers �— Children�’s Health Services, Metro South, Metro North and West-

Moreton Health Service Districts Queensland Ambulance Services �— Manager Clinical Standards.

Acknowledgements: Children�’s Health Services would like to acknowledge the contribution made by:

Dr Jason Acworth�—Director of Paediatric Emergency Medicine, Children's Health Services Donna Franklin�—Project Manager SEQ PP, Children's Health Services Dr John Gavranich�—Director of Paediatrics, Ipswich Hospital Dr Sharon Anne McAuley �—Staff Specialist (ED), Mater Children's Hospital Dr Michelle Davison�—Staff Specialist (ED), The Prince Charles Hospital Dr Yolande Weiner�—Staff Specialist (ED), Logan Hospital Shahn Horrocks�—Nurse Practitioner (ED), Gold Coast and Logan Hospitals Andrea Hetherington�—Clinical Nurse Consultant (Paediatrics) (ED), Logan Hospital Elizabeth Ruddy�—Clinical Nurse Consultant (ED), Mater Children's Hospital.

http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/77C90639C62B415BCA25782D001DC80D/$File/intussusception-provider.pdf

http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/77C90639C62B415BCA25782D001DC80D/$File/intussusception-provider.pdf

http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf

http://qheps.health.qld.gov.au/ed/docs/child_gastro.pdf





11. Procedure Revision and Approval History Version No Modified by Amendments authorised by Approved by

1.0 GBMA Clinical Procedures Editorial Group

Children�’s Health Services Dr Peter Steer �– CEO CHS

9. Audit / Evaluation Strategy Level of risk High

Audit strategy 32. Staff survey to evaluate awareness of procedure and emergency management practices

33. Observe practice 34. Review documentation, i.e. chart audit, to evaluate compliance with

procedure Audit tool attached Nil

Audit date Annual snapshot review (August)

Audit responsibility Individual Greater Brisbane Metropolitan hospitals, i.e. Ipswich, Logan, Redland, MCH, RCH, TPCH, Redcliffe, Caboolture

Key Elements / Indicators / Outcomes

KPI 1 �— greater than 80% staff awareness of procedure

KPI 2 �— greater than 80% compliance with procedure


10. Appendix 1 – Emergency Management of Children with Acute Gastroenteritis





11. Appendix 2 – Admission/Discharge Criteria for Children with Acute

Gastroenteritis


