Acute Gastroenteritis

Important points in history

• Diarrhoea - frequency of stools, number of days, blood or mucous in stools.
• Vomiting - frequency, blood, contents, associated with feeding
• Local reports of cholera outbreak or other contacts unwell
• Recent antibiotic or other drug treatment
• Attacks of crying with pallor in an infant
• Feeding history
• Fever
• Local mankhwala (medicine)
• Urine Output
• Vaccination history (query Rotavirus)

Note - vomiting without diarrhoea is often NOT gastroenteritis, exclude other causes eg. UTI, appendicitis, sepsis, poisoning, DKA, raised ICP

Important points on examination

• Assess for emergency signs ABCD
• Shock (cold hands, capillary refill >3 secs, fast, weak pulse) shock protocol
• Severe Malnutrition (visible severe wasting or oedema of both feet) malnutrition
• Assess Hydration
• Abdominal examination looking particularly for surgical problems e.g. distension, tenderness, guarding or a mass
• Is there any evidence of sepsis?

Relevant Investigations

• Blood glucose if low BCS, or lethargic
• Stool culture rarely indicated or available (but important if suspected cholera see below)
• Creatinine, urea and electrolytes/blood gases if acidotic, poor urine output
• Blood culture if high fever, long history, suspicion of Typhoid

Indications for Admission

• Gastroenteritis with severe dehydration
• Vomiting all oral fluids/ ORS or unable to receive oral fluids in A&E (i.e. lethargy)
• Social concerns
• Uncertainty about diagnosis
• Repeated presentation with no improvement in symptoms

Drug Treatment

• Treatment with antiemetics and antimotility drugs is inappropriate in children
• Treatment with antibiotics is rarely indicated unless sepsis or dysentery suspected or patient is <3 months or immunocompromised.

Assessing Hydration

For all children with diarrhoea, hydration status should be classified as severe dehydration, some dehydration or no dehydration and appropriate treatment given.

Plan C - Fluid management of SEVERE dehydration (Adequately nourished child)

(for malnourished child malnutrition chapter)

Give Ringer's Lactate Solution (or if not available Normal Saline) divided as follows:

* Repeat if radial pulse is still very weak or not detectable.

• Child should remain in resuscitation room if in A&E for first part of PLAN C to allow regular review - if transferring to ward in special circumstances, ward team must be made aware of patient and be present to receive patient. Preferably use fluid burette/ infusion pump if available, to ensure accurate fluid measurement
• Reassess the child every 15-30 minutes. After first 30mls/kg document vital signs including hydration status. If no improvement, discuss with senior to consider repeat 30ml/kg.
• After completion of PLAN C, reassess if still needs IV fluids or can drink adequate amounts.
• Give ORS (about 5 ml/kg/hour) as soon as the child can drink.

When severe dehydration is corrected, prescribe Zinc

Plan B - Fluid management of SOME dehydration (Adequately nourished child)

(for malnourished child malnutrition chapter)

Give the child 75ml/kg of ORS over 4 hours to drink. If the weight is not known you can use the following approximations:

* Use the child's age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child's weight (in kg) by 75

• If the child wants more to drink, give more


• Show the mother how to give ORS solution
• Mark the level on a cup or bottle she should give every 1 hour and show her where to collect more
• a teaspoonful every 1-2 minutes if the child is under 2 years;
• frequent sips from a cup for an older child
• If the child vomits, wait 10 minutes. Then continue, but more slowly
• Continue breastfeeding whenever the child wants
• Tell the mother to report immediately if child is becoming too weak to drink or is vomiting repeatedly.
• Advise not to force feed.


• After 4 hours:
• Reassess the child and classify the child for dehydration.
• If the child has improved and the situation allows, most children can be discharged after this time to continue on Plan A with ORS at home.
• If child is still showing signs of dehydration consider admission. Oral rehydration is still preferable to IV if able to drink.

Give Zinc

Plan A - Fluid management of NO deydration

Children with diarrhoea but no dehydration should receive extra fluids to prevent dehydration. They should continue to receive an appropriate diet for their age, including continued breastfeeding. Most of these children can be discharged with advice as below:

1. Give extra Fluid (as much as the child will take)
• Tell the Mother:
• Breastfeed frequently and for longer at each feed.
• If the child is exclusively breastfed, give ORS or clean water in addition to breast milk.
• If the child is not exclusively breastfed, give one or more of the following: ORS solution, food-based fluids (such as soup, rice water, and yoghurt drinks), or clean water.

• It is especially important to give ORS at home when:
• the child has been treated with Plan B or Plan C during this visit.
• the child cannot return to a clinic if the diarrhoea gets worse.
• Teach the Mother how to mix and give ORS. Give the Mother ORS to use at Home. Show the Mother how much fluid to give in addition to the usual fluid intake:
• Up to 2 years 50 to 100 ml after each loose stool
• 2 years or more 100 to 200 ml after each loose stool
• Tell the mother:
• to give frequent small sips from a cup.
• If the child vomits, wait 10 minutes. Then continue, but more slowly
• Continue giving extra fluid until the diarrhoea stops
• If child is becoming lethargic not to force feed, but to report to a health centre immediately
2. Zinc Supplements
• The dose is:
• Up to 6 months 1/2 tablet (10 mg) per day for 10 days
• 6 months and more 1 tablet (20 mg) per day for 10 days
• Show the Mother how to give the Zinc:
• Infants, dissolve the tablet in a small amount of clean water, expressed milk or ORS in a small cup or spoon
• Older children, tablet can be chewed or dissolved in a small amount of clean water in a cup or spoon.

3. Continue Feeding
4. When to Return
Return if the child develops any of the following signs:
• drinking poorly or unable to drink or breastfeed
• diarrhoea or vomiting is increasing in frequency
• urine output is decreasing
• develops a fever
• has blood in the stool

Contents of Modified ORS and ReSoMal