Summary of Key Articles Supporting
Alberta Health Services Calgary Zone
Childhood Vomiting & Diarrhea Pathway
Reference
Number
Subject
Comments
References
1
‘Gorelick Score’
 Gorelick M, et.al.‘Validity and
reliability of clinical signs in
the diagnosis of dehydration
in children.’ Pediatrics
1997;99;e6
2
Regular Diet
This study did not formally
derive a score, but its results
for four clinical signs can be
readily converted into a score.
[hyperlink to slide 12, ACH
teaching slides]
Continuing regular diet during
acute gastroenteritis
significantly enhances recovery
from illness. Full strength nondiluted cow’s milk can be
continued in all but a few
children with more severe
disease
[hyperlink to slides 45-49, Texas
teaching slides]
3
Ondansetron
Solid evidence for ondansetron
decreasing IV use, vomiting,
and hospital admissions; little
evidence for dimenhydranate
[Hyperlink to slide 13-16, ACH
teaching slides]
4
Oral Rehydration
Solid evidence for oral
rehydration [Hyperlink to slide
20-21, ACH Teaching Slides]
 Brown KH, et al.‘ Use of
nonhuman milks in the
dietary management of young
children with acute diarrhea:
a meta-analysis of clinical
trials’ Pediatrics 1994;93:1727.
 Brown KH. ‘Dietary
management of acute
diarrheal disease:
contemporary scientific
issues. J Nutr
1994:124:1455S.
 Duggan C, et al. ‘Feeding the
gut: the scientific basis for
continued enteral nutrition
during acute diarrhea. J
Pediatr 1997;131:801-8
 DeCamp L. ‘Use of antiemetic
agents in acute
gastroenteritis: a systematic
review and meta-analysis.’
Arch Pediatr Adolesc Med.
2008;162:858-865.
 Freedman S. ‘Oral
ondansetron for
gastroenteritis in a pediatric
emergency department.’
NEJM 2006;354:1698-705.
 Hartling, L, et al. ‘Oral versus
intravenous rehydration for
treating dehydration due to
gastroenteritis in children.’
5
Choice of oral
rehydration fluid
6
Assessment of
Dehydration
7
Rapid Rehydration
8
Nasogastric
Rehydration
Solid Evidence for low-sodium
(75 meq/l) WHO formulation
(superior to 90 mg/l Na), but no
evidence for Pedialyte (45
meq/l). However Pathway
Committee elected to use
Pedialyte for several practical
reasons:
1) Low sodium WHO
formulation not available in
Canada,
2) Pedialyte used in virtually all
Canadian Children’s Hospitals,
3) Pedialyte widely available in
community pharmacies,
4) No published evidence of
adverse effects,
5) Based on blinded test by
Committee members, Pedialyte
judged to be best tasting, and
6) Pedialyte provided to AHS
free of charge by Ross.
No single sign is very accurate.
However signs on physical
exam are best (capillary refill,
poor overall appearance, dry
mucuous membrance) in
contrast with reported
symptoms by parents.
No RCTs have been published
(one RCT likely to be published
soon) [Hyperlink to slide 24,
ACH teaching slides]
If IV access cannot be obtained
in children with either severe
dehydration who are clinically
stable or moderate
dehydration who have failed
oral rehydration, consider NG
Cochrane Database of
Systematic Reviews 2006,
Issue 1.
 Spandorfer P. ‘Oral versus
intravenous rehydration of
moderately dehydrated
children: a randomized,
controlled trial.’ Pediatrics
2005;115:295–301.
 Hahn S, et al. ‘Reduced
osmolarity oral rehydration
solution for treating
dehydration caused by acute
diarrhoea in children.’
Cochrane Database of
Systematic Reviews 2002,
Issue 1.
 Steiner M, et. al. ‘Is This Child
Dehydrated?’ JAMA.
2004;291:2746-2754
 Gorelick M. ‘Rapid
intravenous rehydration in
the ED: a systematic review.’
PemDatabase.Org
 Nager et al. ‘Comparison of
nasogastric and intravenous
methods of rehydration in
pediatric patients with acute
dehydration.’ Pediatrics
9
Hypo/Hypernatremia
10
Addition of glucose to
IV fluid
11
Probiotics
12
Dioctahedral smectite
13
Loperamide
hydration as an option to IV
rehydration. [Hyperlink to slide
23, ACH teaching slides]
Administration of hypotonic IV
fluids to children with
dehydration occasionally
results in profound
hyponatremia which can be
fatal. Administer only isotonic
IV fluids to children with
dehydration. [Hyperlink to slide
25, ACH teaching slides]
While there is some evidence
(one retrospective case-control
study) to suggest treating
patients with dehydration with
glucose containing IV fluids
reduces rate of return to care,
the pathway committee
thought the evidence was not
sufficiently strong to
recommend its routine use.
Routinely adding D5 to IV
hydration fluids is not
recommended.
While some strains have been
shown to be effective at
reducing duration of diarrhea,
products available in Canada
have either known significant
adverse effects (risk of sepsis),
inadequate quality control, or
not proven to be effective. Not
recommended. [Hyperlink to
slide 19 and 20, ACH teaching
slides]
Widely used in Europe for
children with diarrhea.
Evidence supports its benefit
but no commercial products
are available in Canada.
[Hyperlink to slide 20, ACH
Teaching Slides]
Effective at reducing duration
2002;109:566–72
 Choong K. ‘Hypotonic versus
isotonic saline in hosptialised
c 24ildren: a systematic
review.’ Arch Dis Child
2008;91:828-835.
 Reynolds R, et al. ‘Disorders
of sodium balance.’ BMJ
2006;332:702–5.
 Moritz M, et al. ‘Disorders of
water metabolism in children:
hyponatremia and
hypernatremia.’ 2002;23:371.
 Levy J, et al. ‘Intravenous
dextrose during outpatient
rehydration in pediatric
gastroenteritis.’ Acad Emerg
Med. 2007;14:324-331.
 Allen S, et al. ‘Probiotics for
treating infectious diarrhoea.’
Cochrane Database of
Systematic Reviews. 2004
 Szajewska H, et al. ‘Metaanalysis: Smectite in the
treatment of acute infectious
diarrhoea in children.’
Aliment Pharmacol Ther
2006;23:217
 Li S, et al. ‘Loperamide
of diarrhea, but associated with
significant side effects. Not
recommended.
[Hyperlink to slide 17, ACH
Teaching Slides]
therapy for acute diarrhea in
children: systematic review
and Meta-Analysis.’ PloS Med
2007;4: e98.