Gastroenteritis in Children
Author: Brent Jenson, MD
The current season has presented several children to the office with vomiting and diarrheal illness needing intravenous fluid hydration.
Gastroenteritis is an infectious process of the gastrointestinal tract causing vomiting and diarrhea. Most people call this the "stomach flu" and it should not be confused with influenza virus that causes mainly respiratory infection. A virus, such as rotavirus or norovirus, causes pediatric gastroenteritis in most cases. Less commonly, the infective agent is bacterial, such as E. coli or C. Difficle. With the availability of rotavirus vaccine, norovirus is the most common cause of medically attended acute gastroenteritis in children less then 5 years of age.
Usually a benign disease, acute gastroenteritis remains a major cause of morbidity and mortality for children. The Centers of Disease Control estimates 1.87 million deaths in children annually worldwide. Ninety-eight percent of those deaths occur in non-developed countries. In the United States, acute gastroenteritis accounts for 1.5 million clinic visits, 220,000 hospitalizations and 1 billion dollars of health care costs annually.
The infectious agent, likely viral, causes inflammation and damage to the superficial lining of the intestines leading to a malabsorptive process resulting in high particle diarrhea. Toxins released by the infection can cause chloride ions to move into the intestinal space resulting in a secretory diarrhea. The clinical manifestations for a child may be as follows: diarrhea, vomiting, decreased urine output, abdominal pain, fever, rash or muscle pain. Signs of significant dehydration may be lethargy, sunken eyes, refusal to eat or drink, pinching of the skin that returns slowly, chapped lips and dry mouth.
The vast majority of children presenting to the office can be managed as an outpatient with minimal work up and oral rehydration. For children and infants showing signs of significant dehydration or pressing symptoms such as very high fever or blood in the stool or vomit, work up may be needed. This may include basic blood counts and electrolytes. Stool testing for rotavirus and norovirus antigens, C. Difficle toxin, culture, and ova/parasites may be ordered.
As most cases are viral, medicinal treatments are not usually needed. Antibiotics and anti-diarrheal medication are seldom used and can make the illness worse. Oral rehydration solutions are used for most infants (Pedialyte). Water is usually not recommended in children less than 1 year as this may drop blood sodium levels. In children of school age and teenagers, beverages such as PowerAde or Gatorade are a reasonable alternative. Pedialyte tastes very salty, but the presence of sodium in the solution may aid the hydration process. Small sips of fluids every 5 to 15 minutes tends to be more tolerated than larger less frequent volumes. Fluid goals per hour can be calculated based on weight and be given by a child's health care professional. For those who fail oral rehydration, hospitalization with intravenous fluids may be warranted.
Diet for children recovering from infectious gastroenteritis should be bland and basic. Care should be taken with foods high in simple sugars as the malabsorptive process can be present for some time after the acute illness is over. A probiotic may be useful in re-establishment of normal gut bacterial flora, which helps the body digest sugars. If chronic diarrhea persists, there could be a "toddler's diarrhea" or more involved process such as celiac sprue requiring a physician work up.
Prevention of pediatric gastroenteritis starts early with oral vaccination with rotavirus vaccine at 2, 4 and 6 months of age. A child vaccinated against rotavirus vaccine can still get rotavirus or other forms of gastroenteritis. Rotavirus vaccine tends to decrease the severity of rotavirus gastroenteritis and has been shown to decrease the rate of hospitalization. Good hygiene is a cornerstone of prevention with hand washing paramount. Children with infectious gastroenteritis should not go to childcare centers until symptoms have resolved. Infectious gastroenteritis can be passed from child to care taker. Parents should be cautious about sharing food and drink with their children when diarrhea is present. Strict hand washing should be standard for parents and siblings to prevent spread throughout the family.