Comprehensive Care Plan
Vomiting and Diarrhea in Children:
Guidelines for Emergency Department
Approach and Management
Project Team
Itai (Tal) Shavit, MD, Project leader
Cheri Nijssen-Jordan, MD, Director, ACH-ED
Michelle Ovenden, MD
Shannon L Wilson, RN
Lori Vollmerhaus, RN
Laurie Leckie, RN
Irene Milligan, RN
Debbie Guyader, RN
2
1. INTRODUCTION
2. EMERGENCY DEPARTMENT TRIAGE OF CHILDREN
WITH VOMITING AND DIARRHEA
3. ACUTE GASTROENTERITIS IN CHILDREN
A. ASSESSMENT OF DEHYDRATION
Risk of dehydration
Clinical assessment
Laboratory evaluation
B. TREATMENT OF THE SEVERELY DEHYDRATED CHILD
C. TREATMENT OF MILD TO MODERATE DEHYDRATION
D. SPECIAL CONSIDERATIONS
4. SELECTED REFERENCES
APPENDIX A
Intravenous Rehydration Record in Severe Dehydration
APPENDIX B
Rapid Intravenous Rehydration Record in Children Who Can Not
Retain Oral Fluids
3
1. INTRODUCTION
Vomiting and Diarrhea represent two of the most common reasons for children to
present to emergency departments. Gastroenteritis and associated hypovolemia
account for more than 4500 children visits to the Alberta Children’s Hospital
Emergency Department, every year. The children arrive in varying states of hydration
requiring a multifaceted approach to assessment and treatment. Family members and
care providers often arrive with high expectations of advanced treatment (especially
intravenous therapy) without that oral rehydration with close follow-up is the best
care for the child. Nurses and physicians can have different perspectives on
appropriate therapy leading to huge variation in methods of care even within the same
emergency team.
The following document provides evidence-based recommendations. The guidelines
described are based on the most updated studies but intend to provide a general
clinical approach only. All medical care personnel should apply medical knowledge
and clinical judgment in using these guidelines. The guidelines do not deal with cases
in which the history is unreliable (e.g. due to language barrier) or when caregivers are
uncooperative.
4
2. EMERGENCY DEPARTMENT TRIAGE OF CHILDREN
WITH VOMITING AND DIARRHEA
LEVEL I - Resuscitation
Conditions that are threats to life (or associated with imminent risk of
deterioration) requiring immediate aggressive interventions. Time to physician
assessment immediate
1. Cadiopulmonary arrest
Patients with cardiac or pulmonary arrest (or imminent arrest)
2. Signs of Shock (at least two)
Poor skin perfusion and Tachycardia
Altered level of consciousness
Vital signs are unobtainable or systolic blood pressure lower that expected for age
3. Unconscious or unresponsive patient
4. Signs of severe dehydration (at least 4 signs)
Ill appearance,
Dry mucous membrane
Sunken fontanelle
Sunken eyes
Absence of tears
Prolonged capillary refill
Reduced skin turgor
5. Active seizure
5
LEVEL II - Emergent
Emergent, conditions that are potential treat to life, the child requiring rapid
medical intervention or delegated acts. Time to physician assessment ≤ 15
minutes
1. Vomiting + Significant Medical history (at least one)
Vomiting can be a sign of other problems. These possibilities must be considered:
Head injury - These patients may have high-risk mechanism of injury
Abdominal injury - These patients may need acute surgical intervention
Suspected intoxication
History of Diabetes or present complains of polyuria and polydipsia
History of gastrointestinal disease
History of sickle cell anemia with abdominal pain
History of physical abuse
History of chronic disease (e.g. Metabolic disease or Immunodeficiency)
2. Risk for acute abdomen (at least one)
More than two bile (green) emesis
Severe abdominal pain
Distended abdomen accompanied by abnormal or reduced bowel sounds
Positive peritoneal signs
Hematemesis,
Bloody diarrhea
3. Risk for Meningitis or sepsis (at least one)
Bulging fontanelle
Nuchal rigidity
Photophobia
Purpura or petechiae on skin
Hypothermia
Age less than 3 month
Infants less than 3 months old with a temperature of <36°C or >38°C and a history of
abnormal behaviour or abnormal examination are at higher risk of sepsis than older
infants. Infants more than 3 months old with fever and a toxic appearance should be
rapidly assessed and treatment initiated.
4. Neonates
Neonates may present with hyperbilirubinemia, undiagnosed congenital heart
abnormalities, bowel obstruction, and sepsis. The signs of serious problems may be
very subtle, such as minimal temperature abnormalities, feeding disturbance, or
increased lethargy. Parental anxiety is often very high, and these patients should be
brought into the ED treatment area and have prompt physician assessment or verbal
review.
6
LEVEL III -Urgent
Conditions that could potentially progress to a serious problem and requiring
emergency intervention. May be associated with significant discomfort or
affecting daily function or activities. Time to physician assessment ≤ 30 minutes.
1. 10 or more episodes of vomiting over the last 24 hours
2. Recurrent vomiting over the last 3 days
3. Seizure prior to ED arrival
LEVEL IV – Less Urgent
Less urgent. Conditions that related to patient age or potential for deterioration
or complications would benefit from intervention or reassurance within 1 –2
hours. Time to physician assessment ≤ 60 minutes.
1. Mild or Moderate Dehydration - Risk of dehydration increases when vomiting and
diarrhea are both present. Simple viral gastroenteritis does not usually cause serious
problems in most children. Signs of dehydration vary by age. Young children may
have behaviour or mental status changes that can range from simple fussiness, to
being very lethargic or even unconscious. Clues found in vital signs: dry mucous
membranes, decreased tears, decreased urine output and skin turgor. Questions should
include: how many times the patient has vomited, whether it occurred only when
eating or drinking, and time of the last episode (exact times are best). The same is true
for diarrhea. If there have been <5 loose bowel movements per day, then dehydration
or electrolyte imbalances are unlikely. In children with >10 bms/d (with or without
blood) more serious causes should be considered. Patients with 10 or more episodes
of vomiting in the previous 24 hours should be upgraded to a level III.
2. Mucousy Diarrhea
3. Diarrhea lasting for more than 5 days
4. 5 or more episodes of vomiting over the last 12 hours
5. Recent close contact with person who had meningitis
7
LEVEL V – Non Urgent
Level V conditions may be acute but non-urgent, or may be part of a chronic
problem (with or without evidence of deterioration). Investigation or
interventions for some of these illnesses or injuries can be delayed or referred to
other areas of the hospital or health care system. Level V conditions include the
following. Time to physician assessment ≤ 120 minutes.
Vomiting alone or diarrhea alone in a child older than 3 months, with no history of
high risk, no signs of dehydration, and with normal mental status and vital signs.
Always true for Pediatric Triage: If patients look sick they
should be triaged as Level I or II
8
3. ACUTE GASTROENTERITIS IN CHILDREN
A. ASSESSMENT OF DEHYDRATION
Risk of dehydration
The evaluation of the child with symptoms of acute gastroenteritis begins with the
assessment of dehydration. Risk of dehydration is related to age; young infants are
more prone to dehydration. Retrospective case-control studies from developing
countries have confirmed that severe symptoms, including frequent vomiting and
watery diarrhea, predict an increased risk of dehydration. The severity of
dehydration is usefully expressed in terms of weight loss as a percentage of total
body weight. If a recent weight record is available (for example, from the parent
held medical record) dehydration can be estimated with some accuracy.
*Young infants are more prone to dehydration. Try to get recent weight record.
Clinical assessment
Clinical criteria for the assessment of dehydration were examined in various studies.
Signs and symptoms such as ill appearance, dry mucous membranes, sunken
fontanelle, sunken eyes, absence of tears, prolonged capillary refill, and reduced
skin turgor, can help the clinician to evaluate the degree of dehydration and
categorize them into mild, moderate and severe. These conventionally used clinical
criteria for evaluating dehydration have been codified by the American Academy of
Pediatrics and by the World Health Organization. However, there are major
inconsistencies between sources, the criteria have not been validated, and their
usefulness have been called into question. One research studied the validity and
reliability of various clinical findings and found that the following four findings
were independently associated with dehydration: general ill appearance, prolonged
capillary refill (>2 sec), dry mucous membranes and reduced tears. The combination
of all 4 signs is suggestive for dehydration of 10 percent or more.
*In the assessment of dehydration, the clinician must look for combination of
signs and symptoms.
9
Laboratory evaluation
The sensitivity and specificity of laboratory studies for the detection of dehydration
are poor. The majority of children with mild and moderate dehydration do not need
laboratory studies. These studies should be used as an adjunctive tool with a
comprehensive clinical evaluation in assessing moderate or severe dehydration. It is
reasonable to recommend that electrolytes, Urea, creatinine, and glucose be obtained
in any child with severe dehydration and in moderately dehydrated children whose
history and physical examination are inconsistent with each other or with the
presumptive diagnosis of acute gastroenteritis. Clinical reassessment and monitoring
of clinical signs during therapy are most important.
*In every child with severe dehydration, it is recommended that electrolytes,
Urea, creatinine, and glucose be obtained.
B. TREATMENT OF THE SEVERELY DEHYDRATED CHILD
Initial phase. The initial therapy applies to all forms of dehydration: hyponatremic,
hypernatremic or isonatremic. Severe dehydration should be considered as an
emergency and has to be treated with a rapid bolus of normal saline or ringer’s
lactate. There is no place for colloid infusion, most studies show adequate
crystalloid volume expansion to be superior to colloid infusion in severe
dehydration. The recommended crystalloid dose is 20 ml per kg of body weight over
approximately 15 to 30 minutes or as quickly as possible if there is uncompensated
shock. The patient has to be reassessed after each fluid bolus. The bolus may be
repeated a second or occasionally a third time until blood pressure is restored, heart
rate normalizes and peripheral perfusion improves. If the patient does not respond,
the clinician should consider the possibility of an underlying disorder such as septic
shock, toxic shock syndrome, or myocarditis. Urine output is the most important
indicator of restored intravascular volume and should be monitored using a bag. If
patient’s status is not improving and/or signs of shock are present - insertion of
Foley catheter is indicated.
10
*The patient has to be reassessed after each fluid bolus. Urine output is the
most important indicator of restored intravascular volume.
Subsequent Phase. At this time laboratory values are usually available, in particular
- serum sodium levels. This phase of treatment is devoted for continued
replacement of existing deficit, provision of maintenance fluid and electrolytes and
replacement of ongoing losses. Various strategies can be used to calculate these
parameters.
Hyponatremic/Isonatremic Dehydration: Treatment of hyponatremic dehydration
is similar to that for isonatremic dehydration, except that the extra losses of sodium
should be taken into account when calculating electrolyte administration. Half of the
replacement therapy in addition to maintenance needs to be given over the first 8
hours and the second half over the next 16 hours. Potassium is usually not provided
until the patient has voided and demonstrated acceptable renal function. Large
amounts of parentally provided potassium can lead to hyperkalemia and
cardiotoxicity and should be avoided. The fluids solution recommended after the
initial phase is D5¼NS or D5½NS with 20 mEq/L of KCl.
Hypernatremic Dehydration: Fluids should be given slowly. Correction of
dehydration and hypernatremia may take 48 hours and more. Therapy is adjusted to
return the serum sodium levels toward normal by not more than 10 mEq/L/24 hours.
If seizures occur, they should be treated with anticonvulsants and intravenous
administration of 3-5 ml per kg of a 3% sodium chloride solution.
C. TREATMENT OF MILD TO MODERATE DEHYDRATION
All children should be treated with Oral Rehydration Solution (ORS). ORS is the
preferred treatment of fluid and electrolytes losses caused by diarrhea in children
with mild to moderate dehydration. Children who have diarrhea and are not
11
dehydrated should continue to be fed age-appropriate diet. Children who require
rehydration should be fed age-appropriate diet as soon as they have been rehydrated.
Breast feeding should be continued throughout the rehydration. Which foods are
best for re-feeding? Controlled clinical trials showed that certain foods, including
complex carbohydrates (rice, potatoes, bread, and cereals), lean meat, yogurt, fruits
and vegetables are better tolerated. Fatty foods, or food high in simple sugars should
be avoided (including tea, juices, soft drinks). The classic BRAT diet (Bananas,
Rice, Applesauce, and Toast) can be tolerated but are low in energy density, protein
and fat.
*Children who require rehydration should be fed age-appropriate diet as soon
as they have been rehydrated.
D. SPECIAL CONSIDERATIONS
Vomiting. Vomiting occurs frequently in the course of acute gastroenteritis and
sometimes may be the only manifestation. Vomiting is not a contraindication to
attempt oral rehydration therapy. Most of the children who have vomiting can be
treated with ORS. Studies have demonstrated that small amounts of ORS can be
tolerated by most children. The therapy can be initiated with 5 ml (one teaspoon)
given every 1-2 minute. Although this technique is labor intensive, it can be done by
a parent and will deliver 150 to 300 ml/hour. Nasogastric continuous infusion of
ORS can also be used.
Children who can not retain oral rehydration. Some children refuse to drink it
because of it’s salty taste, in these cases frozen ice-pops may be a good alternative.
There may be several ways to improve palatability; one study showed that small
amounts of unsweetened Kool-Aid powder, Jell-O powder, and apple or orange
juice can be added to oral rehydration solutions without significantly altering
electrolyte composition and osmolality. This study is limited to laboratory data and
does not take into account the sucrose and fructose found in fruit juices and Jell-O
powder, which could significantly affect intestinal water absorption.
12
The IV route should be to treat any moderately dehydrated child who has persistent
vomiting or who does not tolerate oral rehydration. Also, ORS administration
requires caregiver’s compliance. If such personnel are not available, IV therapy is
indicated. In addition, children with extreme fatigue, illeus or gastrointestinal
distention may not be candidates for oral rehydration.
Rapid intravenous rehydration in children with mild to moderate dehydration
The data in the literature regarding this type of treatment is limited, but this type of
treatment seems safe and effective.
Isonatremic or hyponatremic patients with mild to moderate dehydration are treated
with IV fluids for 2 to 3 hours. Oral rehydration begins immediately after. Few
studies have been published on the outcome of children treated with this modality.
The investigators used different protocols for IV therapy, and all patients
demonstrated clinical improvement. Most of them tolerated oral therapy once the
rapid IV rehydration was completed. It seems that rapid IV rehydration may “break”
the vomiting cycle more quickly than oral rehydration. Additional studies are needed
to validate the safety and effectiveness of this treatment. In any child receiving IV
therapy, electrolyte levels should be measured initially and as needed when therapy
progresses.
Persistent diarrhea (7 days or more of diarrhea). Although persistent lactose
intolerance is uncommon, it is suggested that if persisted diarrhea occurred after the
reintroduction of milk, stool PH, and stool reducing substances should be measured,
and a lactose free formula should be considered if the stool was acid and contained
more than 0.5% reducing substances.
Microbiological investigation. Microbiological investigation is not necessary in
every case, but may be important in patients who require admission to hospital, in
those who have bloody or mucoid diarrhea, suggesting colitis, in high-risk patients
such as those with an immune deficiency, and in cases where there is diagnostic
uncertainty.
Antibiotic treatment. Most bacterial gastroenteritis does not require or benefit from
antibiotic treatment. Antibiotic treatment should be indicated in the very young
13
infant, in immunocompromised patients, and in those who are severely ill. Antibiotic
treatment is also recommended in patients with shigella dysentery infection, in
whom the treatment shortens the clinical illness and the duration of pathogen
excretion. Although Campilobacter Jejuni gastroenteritis is usually a mild and self
limited disease. Treatment is not generally indicated, Antimicrobial treatment
(erythromycin) is indicated in invasive cases or to eliminate the carrier state.
Antidiarrheal treatment. There is no evidence that these drugs have an effect (Bismuth
Subsalicylate may have some effect). There is no role for such drugs in the treatment
of gastroenteritis. It is possible that their use may have adverse consequences.
14
4. SELECTED REFERENCES
1. Warren D, Jarvis A, Leblanc L, and the National Triage Task Force
members. Canadian Paediatric Triage and Acuity Scale:
implementation guidelines for emergency departments. CJEM
2001;3(4 Suppl):S1-27.
2. Murphy MS. Guidelines for managing acute gastroenteritis based on a
systematic review of published research. Arch Dis Child 1998;79:279284.
3. Liebelt EL. Clinical and laboratory evaluation and management of
children with vomiting, diarrhea and dehydration. Curr op Ped.
1988;10:461-469.
4. American Academy of Pediatrics. Practice parameter: the management
of acute gastroenteritis in young children. Pediatrics 1996;97:424-435.
5. American Academy of Family Physicians. Burkhart DM. Management
of acute gastroenteritis in children. Am Fam Physician 1999;60:25551566.
6. Goepp JG, Hirschhorn B. Fluid therapy of diarrhoea. Industrialized
countries. In: Walker WA, Durie PR, Hamilton JR, Walker-Smith JA,
Watkins JB, eds. Pediatric gastrointestinal disease: pathophysiology,
diagnosis, management. Philadelphia: Decker BC, 1991:1567-1576.
7. Lulseged S. Predictors of moderate to severe dehydration in acute
diarrhoeal disease: a case control study. Ethiopian Medical Journal
1992;30:69-78.
8. Bhattacharya SK, Bhattacharya MK, Manna B, et al. Risk factors for
development of diarrhoea in young children: a case control study. Acta
Paediatrica 1995;84:160-164.
9. World Health Organization. The Treatment of Diarrhea: A Manual for
Physicians and Other Senior Health Workers. Geneva, Switzerland:
World Health Organization; 1995. WHO/CDD/SER/80.2 Rev. 3.
10. Mackenzie A, Barnes G, Shann F Clinical signs of dehydration in
children Lancet. 1989; ii:1529-1530.
11. Gorelick MH, Shaw KN, Baker MD. Performance of clinical signs in
the diagnosis of dehydration in children. Arch Pediatr Adolesc Med
1994;148:73. Abstract.
12. Nijssen-Jordan C. Can oral rehydration solution be safely flavored at
home? Pediatr Emerg Care 1997;13(6):374-5
13. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of
clinical signs in the diagnosis of degydration in children. Pediatrics.
1997;99:5,E6
14. Teach SJ, Yates EW, Feld LG. Laboratory predictors of fluid deficit in
acutely dehydrated children. Clin Pediatr 1997;36:395-400.
15. Show KN. Dehydration. In: Fleisher GR, Ludwig LS. Textbook of
Pediatric emergency Medicine, 4th edn. Lippincott Williams &
Wilkins, Philadelphia, PA: A Walter Kluer Co;2000:197-201.
16. Adelman RD, Solhaug MJ. Pathophysiology of body fluids and fluid
therapy. In: Behrman RE, Kliegman RM, Jenson HB, 16th eds. Nelson
15
Textbook of Pediatrics. Philadelphia, PA: WB Saunders Co;2000:215216.
17. Mahalanabis D, Snyder JD. Fluid and dietary therapy of diarrhoea. In:
Walker WA, Durie PR, Hamilton JR, Walker-Smith JA, Watkins JB,
eds. Pediatric gastrointestinal disease; pathophysiology, diagnosis,
management. Philadelphia: Decker BC, 1996:1843-1850.
18. Meyer A. Fluid and electrolyte therapy for children. Current Opinion
in Pediatrics 1994;6:303-309.
19. Duggan C, Santosham M, Glass RI. The management of acute diarrhea
in children: oral rehydration, maintenance, and nutritional therapy.
MMWR. 1992:41(RR-16):1-20.
20. Moineau G, Newman J. Rapid intravenous rehydration in the pediatric
emergency department. Ped Emerg Care 1990;6;186-188.
21. Rahman O, Bennish ML, Alam, AN, et al. Rapid intravenous
rehydration by a means of a single polyelectrolyte solution with or
without dextrose. J Pediatr 1988;113:654-660.
22. Reid SR, Bonado WA. Outpatient rapid intravenous rehydration to
correct dehydration and resolve vomiting in children with acute
gastroenteritis. Ann Emerg Med 1996;28;318-323.
23. Scott DA, Edelman R. Treatment of gastrointestinal infections.
Ballieres Clinical Gastroenterology 1993;7;477-499.
24. Portnoy BL, DuPont HL, Pruitt D, Abdo JA, Rodriguez JT.
Antidiarrhoeal agents in the treatment of acute diarrhoea in children.
JAMA 1976;236:844-846.
Intravenous Rehydration Record in Severe Dehydration (Acute Gastroenteritis*)
ED Pre-treatment assessment
Weight
Pulse
Capillary Refill
Blood pressure
**Bag urine
≥2sec, < 2sec
kg
mmHg
Y/N
ED Treatment, phase I
Time
Ordered by
Time ended
Pulse
Capillary Refill
BP (mmHg)
≥2sec, < 2sec
≥2sec, < 2sec
≥2sec, < 2sec
IV 0.9NS 20cc per kg in 20 min
IV 0.9NS 20cc per kg in 20 min
IV 0.9NS 20cc per kg in 20 min
Bag urine
Y/N
Y/N
Y/N
ED Treatment, phase II
Sodium
mEq/L
Potassium
mEq/L
Glucose
mmol/L
Urea
mmol/L
Creatinine
mcmol/L
Maintenance treatment for Isonatremic or Hyponatremic Dehydration (D5W.45NS cc/h):
First 10kg - 4cc per kg, Second 10kg – 2cc per kg, Each additional kg – 1cc per kg
(Example: 8 year old, weighing 25 kg. For first 10kg – 4x10=40, for second 10kg – 2x10=20, for 5kg – 1x5=5. Total fluids to give: 65cc/h)
Time
Ordered by
Time ended
IV D5W.45NS
Pulse
Capillary Refill
BP (mmHg)
≥2sec, < 2sec
cc/h
Y/N
ED Post-treatment assessment
Weight
Pulse
kg
Capillary Refill
Blood pressure
≥2sec, < 2sec
mmHg
*This document is inappropriate for children with chronic diseases such as those with congenital heart disease or IDDM, or when diagnosis is uncertain
** Consider Foley Catheter if patient is not improving or signs of shock are present
Bag urine
17
Rapid Intravenous Rehydration Record in Children
Who Can Not Retain Oral Fluids (Acute Gastroenteritis*)
ED Pre-treatment assessment
Weight
Pulse
Capillary Refill
Blood pressure
Bag urine
≥2sec, < 2sec
kg
mmHg
Y/N
ED IV Treatment
Time
Ordered by
Pulse
mEq/L
Potassium
mEq/L
BP (mmHg)
Bag urine
≥2sec, < 2sec
IV 0.9NS 20cc per kg in 2-3 hours
Sodium
Capillary Refill
Glucose
mmol/L
Urea
Y/N
mmol/L
Creatinine
mcmol/L
ED Post- IV treatment assessment
Weight
Pulse
kg
Capillary Refill
Blood pressure
≥2sec, < 2sec
Bag urine
mmHg
ED Oral Rehydration Therapy
Oral Rehydration Solution (e.g. Pedyalite) given by parents (~100 to150cc an hour)
1. 10 minutes - 5cc (1 teaspoon) every 1-2 minutes
2. 20 minutes - 10cc every 5 minutes
3. 30 minutes - 20 cc every 10-15 minutes
*This document is inappropriate for children with chronic diseases such as those with congenital heart disease or IDDM, or when diagnosis is uncertain
Y/N