Acute gastroenteritis (AGE) is a common condition in children, characterized by inflammation of the gastrointestinal tract, resulting in symptoms such as diarrhea, vomiting, abdominal pain, and fever.

  • Acute watery diarrhea is defined as a change in the consistency of stool leading to loose or liquid stools and/or an increase in the frequency of evacuations to three or more in 24 hours, with or without fever or vomiting lasting 7 days or less.
  • Most frequent causes of AGE in children are viral infections(> 60% of cases) , particularly rotavirus (in less than 5 years) and norovirus, although bacterial and parasitic infections can also occur.

Degree of Dehydration

Severe dehydration (at least two of the following signs)Some dehydration (two or more of the following signs)No dehydration
Lethargy/unconsciousness
Sunken eyes
Unable to drink or drink poorly
Skin pinch goes back very slowly (≥2 seconds)		Restlessness and irritability
Sunken eyes
Drinks eagerly and thirsty		Not enough signs to classify as some or severe dehydration.

History and Examination

SymptomsSigns
Diarrhea (frequency, consistency, blood or mucus), vomiting, abdominal pain, fever, poor appetite, lethargy, decreased urine outputDehydration (e.g., sunken eyes, dry mucous membranes, prolonged capillary refill time, decreased skin turgor), abdominal tenderness, fever

Differential diagnosis (D/D) & Complication

D/D

  • Food poisoning (sudden onset, multiple affected individuals, associated with specific food)
  • Appendicitis (right lower quadrant pain, rebound tenderness, fever)
  • Inflammatory bowel disease (chronic diarrhea, weight loss, family history)

Complications: Dehydration, electrolyte imbalances, malnutrition, sepsis, metabolic acidosis (in severe cases)

Investigation

  • Stool RME and culture (if bacterial or parasitic infection is suspected)
  • Renal Function Test and RBS

Admission criteria

  • Admission may be necessary for severe dehydration, inability to tolerate oral fluids, significant electrolyte imbalances, or signs of sepsis

Management

  • Supportive care:
    1. Oral rehydration therapy (ORT) using oral rehydration salts (ORS) for mild to moderate dehydration
    2. Intravenous fluid therapy for severe dehydration or inability to tolerate oral fluids
    3. Age-appropriate diet continuation or reintroduction as soon as possible

Fluid Therapy in Acute Watery Diarrhea

Plan A (No Dehydration)

Goal: Replacement of ongoing losses of fluid and electrolytes
Treatment facility: Home
Rehydration fluid: ORS
Monitoring: Watch for vomiting, early
signs of dehydration, blood
in stools, etc.		For every loose stool: 10 mL/kg
Age up to 2 months—5 teaspoons/purge
2 months to < 2 years → 50–100 mL
Age 2–10 years → 100–200 mL
Older child: As much as desired Plus Free access to drinking water

Plan B (Some Dehydration)

Goal:Correction of existing
deficits of fluid and
electrolytes
Treatment facility: Health Facility
Rehydration fluid: ORS +Ringer Lactate
Monitoring: Monitor every hour and reassess after 4 hours ; If still in plan B,
repeat as above ; If rehydrated, shift
to plan A		IVF Ringer Lactate 75 mL/kg Over 4 hours
Plus
Non-breastfed infants <6 months—100–200 mL of clean drinking water

Older children and adults: Free access to plain water in addition to ORS

Plan C (Severe Dehydration)

Goal: Urgent replacement of
existing deficits of fluid and
electrolytes
Treatment facility: Health facility

Rehydration fluid: Ringer Lactate
Monitoring:
Monitor ½ hourly and
reassess after 6 hours (infants) 3 hours (older children)
; If still in plan C, repeat as
above ; If rehydrated, shift to
plan B/A		IVF fluid
Infants
30 mL/kg Over 1 hour
70 mL/kg Over 5 hours

Age > 1 year
30 mL/kg Over ½ hour
70 mL/kg Over 2½ hours

Plus
ORS (5 mL/kg/h) start orally as soon as child is able to drink

Note:

  • Monitar Vitals (BP, Pulse, Temperature), frequency of stool, urine output and dehydration status
  • Normal saline (0.9% NaCl) or half strength Darrow’s solution may be used if Ringer Lactate (RL) is not available.
  • For Severely malnaurished child, rehydrate slowly over 6-12 hours.
  • In children who fail on oral rehydration, administration of rehydration fluids either by nasogastric (NG) tube or intravenously (IV) is effective and recommended.

Rx:

  1. Antibiotic

Indication:

  • Infants < 3 months
  • Children with underlying chronic conditions or immunodeficiency
  • Children with SAM
  • Infections with Shigella, enterotoxigenic Escherichia coli (ETEC) (not Shiga-like toxin producing), Vibrio cholerae, and Yersinia enterocolitica
  • Invasive bacterial infection
  • Antiparasitic agents for confirmed parasitic infections (e.g., metronidazole for giardiasis)
PathogenDrug of ChoiceAlternative
ShigellaParenteral, IV, IM: Ceftriaxone
(50 mg/kg for 2–5 days)		Cefixime PO (8 mg/kg/day);
ciprofloxacin PO (20–30 mg/kg/day)
Enterotoxigenic
Escherichia coli		Azithromycin PO
(10 mg/kg/day) for 3 days		Cefixime (8 mg/kg/day) for 5 days
Vibrio choleraeSingle dose of doxycycline
(>2 years) 2–4 mg/kg		Single dose of azithromycin/
ciprofloxacin 20 mg/kg
Salmonella (non-typhi)
Only in high-risk children		Parenteral ceftriaxone
(50–100 mg/kg/day)		Azithromycin PO (10 mg/kg/day);
ciprofloxacin PO (20–30 mg/kg/day)

2. Zinc

  • Helps in reducing the duration, severity of diarrhea, and in preventing further episodes of diarrhea for next 3 months
  • Dose: 6 months to 5 years of age: 20 mg/day × 14 days; 2–6 months: 10 mg/day × 14 days

3. Probiotics

  • Effective in reducing the duration and intensity of symptoms
  • Selected probiotic strains (including Lactobacillus rhamnosus GG, Saccharomyces boulardii, and also L. reuteri DSM 17938) can be considered as an adjunct to ORS.

Nutritional Management

  • < 6 months: continue breastfeeding; do not use diluted or modified formula
  • Start regular oral feeding no later than 4-6 hours after onset of rehydration
  • Give home availaible fluids such as pulses-based drink (rice water and dal water); vegetable soup; yogurt drink with salt (salted Lassi); lemon drink, , and coconut water. Plain water can be given in between.
  • Extra meal a day with energy rich foods for at least a week or two, after the diarrhea stops or until the child is back on its original weight.

Advices

  • Encourage hand hygiene and proper food handling to prevent the spread of infection

Referral

  • Refer to a pediatric gastroenterologist for further evaluation and management if the child is not responding to treatment or has persistent or recurrent symptoms

Follow up

  • Follow up within 1-2 weeks after the acute episode to ensure resolution and monitor for complications