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Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management
Clinical guideline [CG84]Published: 22 April 2009
This guideline covers diagnosing, managing and referring infants and young children younger than 5 years who present with acute diarrhoea (lasting up to 14 days) with or without vomiting. It aims to improve the diagnosis and management of infective gastroenteritis and appropriate escalation of care.
Infective gastroenteritis in young children is characterised by the sudden onset of diarrhoea, with or without vomiting. Most cases are due to an enteric virus, but some are caused by bacterial or protozoal infections. The illness usually resolves without treatment within days; however, symptoms are unpleasant and affect both the child and family or carers. Severe diarrhoea can quickly cause dehydration, which may be life threatening.
Perform stool microbiological investigations if:
you suspect septicaemia or
there is blood and/or mucus in the stool or
the child is immunocompromised.
Interpret symptoms and signs taking risk factors for dehydration into account.
Within the category of ‘clinical dehydration’ there is a spectrum of severity indicated by increasingly numerous and more pronounced symptoms and signs.
For clinical shock, one or more of the symptoms and/or signs listed would be expected to be present. Dashes (–) indicate that these clinical features do not specifically indicate shock. Symptoms and signs with red flags may help to identify children at increased risk of progression to shock. If in doubt, manage as if there are symptoms and/or signs with red flags.
Clinical dehydration | Clinical shock | |
|---|---|---|
Appears well | Red flag Appears to be unwell or deteriorating | – |
Alert and responsive | Red flag Altered responsiveness (for example, irritable, lethargic) | Decreased level of consciousness |
Normal urine output | Decreased urine output | – |
Skin colour unchanged | Skin colour unchanged | Pale or mottled skin |
Warm extremities | Warm extremities | Cold extremities |
No clinically detectable dehydration | Clinical dehydration | Clinical shock |
|---|---|---|
Alert and responsive | Red flag Altered responsiveness (for example, irritable, lethargic) | Decreased level of consciousness |
Skin colour unchanged | Skin colour unchanged | Pale or mottled skin |
Warm extremities | Warm extremities | Cold extremities |
Eyes not sunken | Red flag Sunken eyes | – |
Moist mucous membranes (except after a drink) | Dry mucous membranes (except for ‘mouth breather’) | – |
Normal heart rate | Red flag Tachycardia | Tachycardia |
Normal breathing pattern | Red flag Tachypnoea | Tachypnoea |
Normal peripheral pulses | Normal peripheral pulses | Weak peripheral pulses |
Normal capillary refill time | Normal capillary refill time | Prolonged capillary refill time |
Normal skin turgor | Red flag Reduced skin turgor | – |
Normal blood pressure | Normal blood pressure | Hypotension (decompensated shock) |
Suspect hypernatraemic dehydration if there are any of the following:
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma.
Do not routinely perform blood biochemical testing.
Measure plasma sodium, potassium, urea, creatinine and glucose concentrations if:
intravenous fluid therapy is required or
there are symptoms and/or signs that suggest hypernatraemia.
Measure venous blood acid–base status and chloride concentration if shock is suspected or confirmed.
In children with gastroenteritis but without clinical dehydration:
continue breastfeeding and other milk feeds
encourage fluid intake
discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration (see recommendation 1.2.1.2)
offer ORS solution as supplemental fluid to those at increased risk of dehydration (see recommendation
Use ORS solution to rehydrate children, including those with hypernatraemia, unless intravenous fluid therapy is indicated
In children with clinical dehydration, including hypernatraemic dehydration:
use low-osmolarity ORS solution (240–250 mOsm/l) for oral rehydration therapy (the BNF for children (BNFC) 2008 edition lists the following products with this composition: Dioralyte, Dioralyte Relief, Electrolade and Rapolyte)
give 50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid
give the ORS solution frequently and in small amounts
consider supplementation with their usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs
consider giving the ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently
monitor the response to oral rehydration therapy by regular clinical assessment.
Use intravenous fluid therapy for clinical dehydration if:
shock is suspected or confirmed
a child with red flag symptoms or signs (see table 1) shows clinical evidence of deterioration despite oral rehydration therapy
a child persistently vomits the ORS solution, given orally or via a nasogastric tube.
Treat suspected or confirmed shock with a rapid intravenous infusion of 20 ml/kg of 0.9% sodium chloride solution.
If a child remains shocked after the first rapid intravenous infusion:
immediately give another rapid intravenous infusion of 20 ml/kg of 0.9% sodium chloride solution and
consider possible causes of shock other than dehydration.
Consider consulting a paediatric intensive care specialist if a child remains shocked after the second rapid intravenous infusion.
When symptoms and/or signs of shock resolve after rapid intravenous infusions, start rehydration with intravenous fluid therapy (see recommendation 1.3.3.6).
If intravenous fluid therapy is required for rehydration (and the child is not hypernatraemic at presentation):
use an isotonic solution such as 0.9% sodium chloride, or 0.9% sodium chloride with 5% glucose, for fluid deficit replacement and maintenance
for those who required initial rapid intravenous fluid boluses for suspected or confirmed shock, add 100 ml/kg for fluid deficit replacement to maintenance fluid requirements, and monitor the clinical response
for those who were not shocked at presentation, add 50 ml/kg for fluid deficit replacement to maintenance fluid requirements, and monitor the clinical response
measure plasma sodium, potassium, urea, creatinine and glucose at the outset, monitor regularly, and alter the fluid composition or rate of administration if necessary
consider providing intravenous potassium supplementation once the plasma potassium level is known.
If intravenous fluid therapy is required in a child presenting with hypernatraemic dehydration:
obtain urgent expert advice on fluid management
use an isotonic solution such as 0.9% sodium chloride, or 0.9% sodium chloride with 5% glucose for fluid deficit replacement and maintenance
replace the fluid deficit slowly – typically over 48 hours
monitor the plasma sodium frequently, aiming to reduce it at a rate of less than 0.5 mmol/l per hour.
Attempt early and gradual introduction of oral rehydration therapy during intravenous fluid therapy. If tolerated, stop intravenous fluids and complete rehydration with oral rehydration therapy.
After rehydration:
encourage breastfeeding and other milk feeds
encourage fluid intake
in children at increased risk of dehydration recurring, consider giving 5 ml/kg of ORS solution after each large watery stool. These include:
children younger than 1 year, particularly those younger than 6 months
infants who were of low birth weight
children who have passed more than five diarrhoeal stools in the previous 24 hours
children who have vomited more than twice in the previous 24 hours.
Restart oral rehydration therapy if dehydration recurs after rehydration.
During rehydration therapy:
continue breastfeeding
do not give solid foods
in children with red flag symptoms or signs (see table 1), do not give oral fluids other than ORS solution
in children without red flag symptoms or signs (see table 1), do not routinely give oral fluids other than ORS solution; however, consider supplementation with the child’s usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they consistently refuse ORS solution.
After rehydration:
give full-strength milk straight away
reintroduce the child’s usual solid food
avoid giving fruit juices and carbonated drinks until the diarrhoea has stopped.
Do not routinely give antibiotics to children with gastroenteritis.
Give antibiotic treatment to all children:
with suspected or confirmed septicaemia
with extra-intestinal spread of bacterial infection
younger than 6 months with salmonella gastroenteritis
who are malnourished or immunocompromised with salmonella gastroenteritis
with Clostridium difficile-associated pseudomembranous enterocolitis, giardiasis, dysenteric shigellosis, dysenteric amoebiasis or cholera.
For children who have recently been abroad, seek specialist advice about antibiotic therapy.
Do not use antidiarrhoeal medications.