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Overview

Dehydration caused by diarrhoea and vomiting may be life-threatening in some young children; however, most children will recover well at home and interaction with healthcare services poses infection risk. Determining which unwell children should be referred for inpatient management is an important role for primary care.

This Guidelines summary provides recommendations on:

  • diagnosing gastroenteritis
  • assessing dehydration and shock
  • fluid and nutrition management for gastroenteritis in children
  • antibiotic therapy
  • escalation of care
  • giving information and advice to parents and carers.

It includes a table addressing signs and symptoms of dehydration and shock, including red-flag signs and symptoms that may help to identify children at increased risk of progression to shock.

This guideline should be read in conjunction with NG143.

Diagnosis

Clinical diagnosis

  • Suspect gastroenteritis if there is a sudden change in stool consistency to loose or watery stools, and/or a sudden onset of vomiting. 
  • If you suspect gastroenteritis, ask about: 
    • recent contact with someone with acute diarrhoea and/or vomiting and 
    • exposure to a known source of enteric infection (possibly contaminated water or food) and  
    • recent travel abroad.
  •  Be aware that in children with gastroenteritis: 
    • diarrhoea usually lasts for 5–7 days, and in most it stops within 2 weeks 
    • vomiting usually lasts for 1–2 days, and in most it stops within 3 days. 
  • Consider any of the following as possible indicators of diagnoses other than gastroenteritis: 
    • fever: 
      • temperature of 38°C or higher in children younger than 3 months 
      • temperature of 39°C or higher in children aged 3 months or older 
    • shortness of breath or tachypnoea 
    • altered conscious state 
    • neck stiffness 
    • bulging fontanelle in infants 
    • non-blanching rash 
    • blood and/or mucus in stool 
    • bilious (green) vomit 
    • severe or localised abdominal pain 
    • abdominal distension or rebound tenderness. 

Laboratory investigations

  • Consider performing stool microbiological investigations if:
    • the child has recently been abroad or  
    • the diarrhoea has not improved by day 7 or 
    • there is uncertainty about the diagnosis of gastroenteritis. 
  • Perform stool microbiological investigations if: 
    • you suspect septicaemia or 
    • there is blood and/or mucus in the stool or
    • the child is immunocompromised.
  • Notify and act on the advice of the public health authorities if you suspect an outbreak of gastroenteritis.
  • If stool microbiology is performed: 
    • collect, store and transport stool specimens as advised by the investigating laboratory
    • provide the laboratory with relevant clinical information. 
  • Perform a blood culture if giving antibiotic therapy.
  • In children with Shiga toxin-producing Escherichia coli (STEC) infection, seek specialist advice on monitoring for haemolytic uraemic syndrome. 

Assessing dehydration and shock

Clinical assessment

  • During remote or face-to-face assessment ask whether the child:
    • appears unwell
    • has altered responsiveness, for example is irritable or lethargic
    • has decreased urine output
    • has pale or mottled skin
    • has cold extremities.
  • Recognise that the following are at increased risk of dehydration:
    • children younger than 1 year, especially 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
    • children who have not been offered or have not been able to tolerate supplementary fluids before presentation
    • infants who have stopped breastfeeding during the illness
    • children with signs of malnutrition.
  • Use table 1 to detect clinical dehydration and shock.

Table 1: Symptoms and signs of clinical dehydration and shock

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.

Increasing severity of dehydration
—————————————————————›
No clinically detectable dehydrationClinical dehydrationClinical shock
Symptoms (remote and face-to-face assessments)
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
Signs (remote and face-to-face assessments)
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.

Fluid management

Primary prevention of dehydration 

  • 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 the section on Assessing dehydration and shock)   
    • offer ORS solution as supplemental fluid to those at increased risk of dehydration (see the section on Assessing dehydration and shock).

Treating dehydration

  • Use ORS solution to rehydrate children, including those with hypernatraemia, unless intravenous fluid therapy is indicated (see recommendations 1.3.3.1 and 1.3.3.5 in the full guideline).
  • In children with clinical dehydration, including hypernatraemic dehydration:
    • use low-osmolarity ORS solution (240–250 mOsm/l)[A] for oral rehydration therapy 
    • 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 (see table 1)
    • 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.

Fluid management after rehydration

  • 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.

For recommendations on the use of intravenous fluid therapy, refer to the full guideline.

Nutritional management

  • 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.

Antibiotic therapy

  • 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. 

Other therapies

  • Do not use antidiarrhoeal medications.

Escalation of care

  • During remote assessment:   
    • arrange emergency transfer to secondary care for children with symptoms suggesting shock (see table 1)   
    • refer for face-to-face assessment children: 
      • with symptoms suggesting an alternative serious diagnosis (see the fourth recommendation in the section, Diagnosis) or 
      • at high risk of dehydration, taking into account the risk factors listed in the second recommendation in the section, Assessing dehydration and shock or
      • with symptoms suggesting clinical dehydration (see table 1) or 
      • whose social circumstances make remote assessment unreliable      
    • provide a 'safety net' for children who do not require referral. The safety net should include information for parents and carers on how to: 
      • recognise developing red flag symptoms (see table 1) and 
      • get immediate help from an appropriate healthcare professional if red flag symptoms develop.
  • During face-to-face assessment:   
    • arrange emergency transfer to secondary care for children with symptoms or signs suggesting shock (see table 1)   
    • consider repeat face-to-face assessment or referral to secondary care for children: 
      • with symptoms and/or signs suggesting an alternative serious diagnosis (see Clinical diagnosis) or   
      • with red flag symptoms and/or signs (see table 1) or  
      • whose social circumstances require continued involvement of healthcare professionals       
      • provide a safety net for children who will be managed at home. The safety net should include: 
        • information for parents and carers on how to recognise developing red flag symptoms (see table 1) and 
        • information on how to get immediate help from an appropriate healthcare professional if red flag symptoms develop and 
        • arrangements for follow-up at a specified time and place, if necessary.

Information and advice for parents and carers

Caring for a child with diarrhoea and vomiting at home

  • Inform parents and carers that:   
    • most children with gastroenteritis can be safely managed at home, with advice and support from a healthcare professional if necessary     
    • the following symptoms may indicate dehydration: 
      • appearing to get more unwell
      • changing responsiveness (for example, irritability, lethargy)   
      • decreased urine output   
      • pale or mottled skin   
      • cold extremities   
    • they should contact a healthcare professional if symptoms of dehydration develop.
  • Advise parents and carers of children:   
    • who are not clinically dehydrated and are not at increased risk of dehydration (see the second recommendation in the section, Assessing dehydration and shock): 
      • to continue usual feeds, including breast or other milk feeds   
      • to encourage the child to drink plenty of fluids   
      • to discourage the drinking of fruit juices and carbonated drinks     
    • who are not clinically dehydrated but who are at increased risk of dehydration (see the second recommendation in the section, Assessing dehydration and shock): 
      • to continue usual feeds, including breast or other milk feeds   
      • to encourage the child to drink plenty of fluids   
      • to discourage the drinking of fruit juices and carbonated drinks   
      • to offer ORS solution as supplemental fluid      
    • with clinical dehydration: 
      • that rehydration is usually possible with ORS solution   
      • to make up the ORS solution according to the instructions on the packaging   
      • to give 50 ml/kg of ORS solution for rehydration plus maintenance volume over a 4-hour period   
      • to give this amount of ORS solution in small amounts, frequently   
      • to seek advice if the child refuses to drink the ORS solution or vomits persistently   
      • to continue breastfeeding as well as giving the ORS solution   
      • not to give other oral fluids unless advised   
      • not to give solid foods.     
  • Advise parents and carers that after rehydration:   
    • the child should be encouraged to drink plenty of their usual fluids, including milk feeds if these were stopped      
    • they should avoid giving the child fruit juices and carbonated drinks until the diarrhoea has stopped   
    • they should reintroduce the child's usual diet   
    • they should give 5 ml/kg ORS solution after each large watery stool if you consider that the child is at increased risk of dehydration (see the second recommendation in the section, Assessing dehydration and shock).
  • Advise parents and carers that:   
    • the usual duration of diarrhoea is 5–7 days and in most children it stops within 2 weeks   
    • the usual duration of vomiting is 1 or 2 days and in most children it stops within 3 days   
    • they should seek advice from a specified healthcare professional if the child's symptoms do not resolve within these timeframes.  

Preventing primary spread of diarrhoea and vomiting

  • Advise parents, carers and children that[B]:
    • washing hands with soap (liquid if possible) in warm running water and careful drying are the most important factors in preventing the spread of gastroenteritis
    • hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food
    • towels used by infected children should not be shared
    • children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis
    • children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting
    • children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea.

Footnotes

[A] The ‘BNF for children’ (BNFC) 2008 edition lists the following products with this composition: Dioralyte, Dioralyte Relief, Electrolade and Rapolyte.
[B] This recommendation is adapted from the following guidelines commissioned by the Department of Health:

  • Public Health England (2017) Health protection in schools and other childcare facilities
  • Working Group of the former PHLS Advisory Committee on Gastrointestinal Infections (2004) Preventing person-to-person spread following gastrointestinal infections: guidelines for public health physicians and environmental health officers. Communicable Disease and Public Health 7 (4): 362–384.

 

© NICE 2018. Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management. Available from: www.nice.org.uk/guidance/CG84. All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

Published date: June 2009.

Last updated: November 2018.

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Lead image: Boris Ryaposov/stock.adobe.com