Critical Alerts

• Assess dehydration status: Drives management
• Oral rehydration is first-line: ORS superior to IV for mild-moderate
• Ondansetron enables oral rehydration: Reduces vomiting, reduces IV need
• No routine antibiotics: Most is viral
• Avoid antidiarrheals in children: Loperamide not recommended
• Red flags for surgical cause: Bilious vomiting, severe abdominal pain, bloody stool

Key Diagnostics

Emergency Treatments

Overview

Acute gastroenteritis (AGE) is inflammation of the gastrointestinal tract, usually caused by viral infection, resulting in diarrhea with or without vomiting, fever, and abdominal pain. It is one of the most common childhood illnesses worldwide and a leading cause of pediatric ED visits. Management focuses on assessment and treatment of dehydration.

Classification

By Severity (Based on Dehydration):

By Duration:

Epidemiology

• Incidence: 1-2 episodes/year in children <5 years
• ED visits: 1.5 million/year in US for AGE
• Hospitalizations: 200,000/year in US
• Mortality: Rare in developed countries; major cause of death globally
• Peak age: 6-24 months

Etiology

Viral (Most Common):

Bacterial (10-20%):

Parasitic:

Concerning for Non-Gastroenteritis Cause

Signs of Severe Dehydration/Shock

• Lethargic or unresponsive
• Absent tears, very dry mucous membranes
• Sunken eyes and fontanelle
• Mottled, cool extremities
• Capillary refill >3 seconds
• Tachycardia with weak pulses

Other Causes of Vomiting and Diarrhea in Children

Clinical Diagnosis

• AGE is primarily a clinical diagnosis
• Focus on assessing dehydration severity
• Identify red flags for alternative diagnoses

Laboratory Studies

Not Routinely Indicated for uncomplicated AGE

Consider Testing:

Imaging

• Not indicated for uncomplicated AGE
• Consider abdominal X-ray or ultrasound if surgical cause suspected

Discharge Criteria

• Tolerating oral fluids
• Adequate urine output
• No signs of significant dehydration
• No red flags for alternative diagnosis
• Reliable caregivers
• Follow-up arranged

Admission Criteria

• Severe dehydration
• Failure of oral rehydration
• Persistent vomiting despite ondansetron
• Concern for surgical cause
• High-risk patient (young infant, immunocompromised)
• Electrolyte abnormalities
• Social concerns

Follow-Up

Condition Explanation (For Parents)

• "Your child has a stomach bug (gastroenteritis) causing diarrhea and vomiting."
• "It is usually caused by a virus and will get better on its own in a few days."
• "The most important thing is to keep your child hydrated."
• "Give small, frequent sips of oral rehydration solution."

Home Care

• Offer ORS (Pedialyte) frequently
• Continue breastfeeding or formula
• Resume regular diet when ready
• Avoid sugary drinks and fruit juices
• Handwashing to prevent spread

Warning Signs (Return Immediately)

• Unable to keep down any fluids
• No wet diapers for 6+ hours (infants) or no urination for 8+ hours (older children)
• Bloody or bilious vomiting
• Severe abdominal pain
• Very sleepy or difficult to wake
• Sunken eyes, no tears
• Fever not improving after 3 days

Infection Control

• Frequent handwashing (especially after diapers)
• Keep child home from daycare until symptom-free for 24 hours
• Clean contaminated surfaces with bleach solution

Infants <6 Months

• Higher risk of dehydration
• Lower threshold for IV fluids
• Continue breastfeeding frequently
• May need admission for observation

Immunocompromised Children

• Prolonged, severe illness
• Higher risk of bacterial and parasitic causes
• Lower threshold for stool cultures
• May need antibiotics

Children with Chronic Diseases

• Diabetes: Monitor for dehydration, DKA
• Short gut syndrome: Higher fluid losses
• Cardiac disease: Caution with IV fluids

Recent Travelers

• Consider parasites (Giardia, Cryptosporidium)
• Consider ETEC, Shigella
• Stool O&P if prolonged symptoms

Performance Indicators

Documentation Requirements

• Dehydration assessment
• Intake and output
• Treatment given and response
• Red flags evaluated
• Discharge instructions

Diagnostic Pearls

• Clinical diagnosis: Labs rarely change management
• Assess dehydration clinically: Weight loss is gold standard but often unavailable
• Bilious vomiting is an emergency: Not gastroenteritis until proven otherwise
• Bloody stool in infant: Consider intussusception
• Prolonged diarrhea: Think parasites, post-infectious lactose intolerance
• Fever without GI symptoms initially: Consider UTI

Treatment Pearls

• Oral rehydration is underused: More effective, less invasive than IV
• Ondansetron enables ORT: Use it
• Small, frequent sips: Better tolerated than large volumes
• Resume diet early: No need for prolonged clear liquids
• No loperamide in children: Unsafe
• Antibiotics rarely needed: Most is viral

Disposition Pearls

• Most can go home: With ORS and education
• Low threshold to admit young infants: Higher risk
• Follow-up is important: Ensure improvement
• Caregiver education: Key to preventing re-visits