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Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management

Key priorities for implementation

Diagnosis

  • Perform stool microbiological investigations if:
    • you suspect septicaemia or
    • there is blood and/or mucus in the stool or
    • the child is immunocompromised

Assessing dehydration and shock

  • Use table below to detect clinical dehydration and shock

Fluid management

  • 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 below)
    • offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration (see below)
  • In children with clinical dehydration, including hypernatraemic dehydration:
    • use low-osmolarity ORS solution (240–250mOsm/l)* 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 below)
    • 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 below) shows clinical evidence of deterioration despite oral rehydration therapy
    • a child persistently vomits the ORS solution, given orally or via a nasogastric tube
  • 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 both 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

Nutritional management

  • 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

Information and advice for parents and carers

  • Advise parents, carers and children that:
    • 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

Assessing dehydration

  • These children 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 six or more diarrhoeal stools in the past 24 hours
    • children who have vomited three times or more in the past 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

Symptoms and signs of clinical dehydration and shock

Red flag symptoms and signs may help to identify children at increased risk of progression to shock. If in doubt, manage as if there are red flag symptoms or signs. Dashes (–) indicate that these clinical features do not specifically indicate shock

Increasing severity of dehydration
—————————————————————›
No clinically detectable dehydrationClinical dehydrationClinical shock
Symptoms (remote and face-to-face assessments)
Appears well
  • Appears to be unwell or deteriorating
-
Alert and responsive
  • 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
  • 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
  • Sunken eyes
-
Moist mucous membranes (except after a drink) Dry mucous membranes (except for ‘mouth breather’) -
Normal heart rate
  • Tachycardia
Tachycardia
Normal breathing pattern
  • 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
  • Reduced skin turgor
-
Normal blood pressure Normal blood pressure Hypotension (indicates decompensated shock)

 

* The ‘BNF for children’ (BNFC) 2008 edition lists the following products with this composition: Dioralyte, Dioralyte Relief, Electrolade and Rapolyte.

† This recommendation is adapted from the following guidelines commissioned by the Department of Health:

  • Health Protection Agency (2006) Guidance on Infection Control In Schools and other Child Care Settings. London. Available from www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947358374
  • 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 2009. Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy): 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. 

First included: June 2009.