HNY Policy and Pathway Repository - York

The passage of three or more loose/watery stools per day

Paediatric Normal Values (adapted from APLS)
Age	Resp Rate	Heart Rate	Systolic BP
Neonate <4w	40-6	120-160	>60
Infant <1 y	30-40	110-160	70-90
Toddler 1-2 yrs	25-35	100-150	75-95
2-5 yrs	25-30	95-140	85-100

Exclude Red Flag Symptoms (risk of progression to shock)

• Appears to be unwell or deteriorating
• Altered responsiveness (e.g. irritable, lethargic)
• Sunken eyes
• Tachycardia
• Tachypnoea
• Reduced skin turgor

 

High risk of dehydration

• Children <1 year of age, especially <6 months
• Low birth weight infants
• Vomited ≥ 3 times a day in last 24 hours
• Passing ≥ 6 stools in last 24 hours
• Urinated less than twice in last 24 hours
• Not offered or not tolerated oral supplementary fluids
• Infants who have stopped breastfeeding during illness
• Children with signs of malnutrition

General Points

• The most common cause of diarrhoea in children is acute gastroenteritis
• In children under 5 years around 80% are attributable to viruses
• Rotavirus is the most common cause of medically treated gastroenteritis in resource rich countries, however, since routine Rotavirus immunisation was introduced, the incidence has reduced dramatically
• Dehydration in obese children is frequently under-estimated
• Young infants (<6 months) may progress to shock more rapidly
• Continue or restart the child’s preferred, usual diet as soon as possible, this is particularly important in breastfed children.
   

Important features in the history

• Onset, sequence and duration of symptoms
• Other family members unwell
• Recent foreign travel
• Consumption of possible unsafe food, e.g. takeaway, BBQ.
• Recent visit to petting farms (E.Coli 0157)
• Recent medication use, particularly antibiotics
• Weight loss
• Known immunodeficiency
   

Documentation

• Number of episodes of diarrhoea and vomiting in past two to three days.
• Presence of blood in stool.
• Number of times child has urinated in past 24 hours and how many hours since last urine passed
   

Differential Diagnoses

• Systemic infection, e.g. UTI, pneumonia, sepsis.
• Surgical conditions, e.g. appendicitis, intussusception, sub-acute bowel obstruction.
• Metabolic conditions, e.g. diabetes mellitus.
• Antibiotic associated diarrhoea.
• Haemolytic Uraemic Syndrome. Features that may indicate diagnoses other than gastroenteritis
• Temperature >38C if under 3 months old or >39C if over 3 months old.
• Shortness of breath or tachypnoea.
• Altered level of consciousness.
• Neck stiffness.
• Non-blanching rash.
• Blood and/or mucus in diarrhoea.
• Bilious (green) vomiting.
• Severe or localized abdominal pain.
• Abdominal distension or rebound tenderness.
• Bulging fontanelle (in infants).
   

Assessment

An overall assessment is more accurate than looking at individual symptoms and signs. Prolonged capillary refill time, abnormal skin turgor and absent tears have been shown to be the best individual examination measures to assess for dehydration. (Freedman et al, 2015) See table below

 

Management in Primary Care

No features of dehydration

• Continue usual feeds.
• Encourage regular fluid intake.
• Offer low-osmolarity oral rehydration salt (ORS) solution if child is at increased risk of dehydration (see maintenance fluid requirements in appendix 1).
• Discourage fruit juices and carbonated drinks.

With features of dehydration but safe to manage at home

• Give ORS solution frequently and in small amounts to rehydrate the child.
• 50ml/kg of ORS plus continuing losses should be given over 4 hours (see fluid deficit in appendix 1).
• If breastfed, supplement normal feeds with ORT.
• If not breastfed, consider supplementing with usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if child refuses sufficient quantities of ORS solution.
• Avoid giving solid food until the child is rehydrated.

Seek review if

• Not taking requirements.
• Not keeping fluids down.
• Becoming more unwell.
• Has a reduced urine output.

Medication

• Advise that drug treatment with anti-diarrhoeal drugs, anti-emetics, zinc supplements and probiotics is not recommended for use in children in primary care.
• Do not routinely prescribe antibiotics to children with gastroenteritis
  • Arrange treatment of confirmed microbial pathogens, if appropriate, following stool culture and sensitivity testing.

After rehydration

• Restart the child’s preferred, usual diet as soon as possible, this is particularly important in breastfed children.

Stool culture

• Recent foreign travel.
• No improvement in diarrhoea by day 7.
• Recent hospitalisation and/or antibiotic treatment. Reducing cross-infection
• Hand washing.
• Prompt disinfection of contaminated surfaces.
• Prompt washing of soiled clothes.
• Avoid public swimming pools for 2 weeks after diarrhoea has resolved.

When to Arrange Emergency Hospital Admission

• Child appears unwell, there are features suggesting severe dehydration and/or progression to shock.
• There is intractable or bilious vomiting.
• There is acute-onset painful, bloody diarrhoea or confirmed E.coli 0157 infection.
• There is a suspected serious complication, e.g. haemolytic uraemic syndrome or sepsis.
   

When to Consider Hospital Admission

• There are clinical features suggesting a serious alternative diagnosis.
• There is an inadequate response to oral rehydration solution.
• There are red flag features indicting risk of progression to shock.
• There are risk factors for developing dehydration.

 

Patient information leaflets/ PDAs

Patient info/childrens-health/acute-diarrhoea-in-children/gastroenteritis-in-children

Oxfordhealth.nhs.uk - Parent Minor Illness Leaflet

Gastroenteritis pathway 

Gastroenteritis leaftet 
 

References

1. National Institute for Clinical Excellent [NICE] (2009) Diarrhoea and vomiting caused by gastroenteritis in under 5’s: diagnosis and management CG84 [online]
2. National Institute for Clinical Excellent [NICE] (2017) Gastroenteritis – Clinical Knowledge Summaries. [Viewed 12 Aug 2021]
3. Freedman et al. (2015) Diagnosing clinically significant dehydration in children with acute gastroenteritis using non-invasive methods: a meta-analysis). The Journal of Paediatrics 166(4), 908-916
    

Appendix 1

Calculation of maintenance fluid requirements The daily fluid requirement can be estimated from the child’s weight using the following formula:

1st 10kg of weight	100ml/kg	Per 24h
2nd 10kg of weight	50ml/kg
All additional kg of weight above 20kg (up to 50kg)	20ml/kg

 

For example, a 30kg child

First 10kg = 10kg x 100ml/kg = 1000ml

Second 10kg = 10kg x 50ml/kg = 500ml

Additional kg = 10kg x 20ml/kg = 200ml

Total = 1700ml/24h

 

Calculation of fluid deficit

If dry –give 50ml/kg (5%) for fluid deficit replacement, over 4 hours in addition to maintenance fluid requirements

For example, a 30kg child will require

Deficit = 30kg x 50ml/kg = 1500ml/4h (in addition to maintenance fluid

 

Trial ORS ml/h according to weight, given in 5-10 min intervals
Weight (kg)	Maintenance volume in 24h	Maintenance fluid every 10 min (ml) assuming 12h non-drinking time in 24h	Hourly volume (ml) based on 12h non-drinking time
5	500	7	42
6	600	8.5	50
7	700	10	59
8	800	11	67
9	900	13	75
10	1000	14	84
11	1050	15	88
12	1100	16	92
13	1150	16	96
14	1200	17	100
15	1250	18	105
16	1300	18	109
18	1400	20	117
20	1500	21	125
25	1600	23	134
30	1700	24	142
35	1800	25	150
40	1900	26	195
≥45	2000	28	167