Policy

Clinical Guideline
South Australian Paediatric Practice Guidelines
Gastroenteritis in Children
Policy developed by: SA Child Health Clinical Network
Approved SA Health Safety & Quality Strategic Governance Committee on:
8 October 2013
Next review due: 28 September 2016

Summary

Clinical Practice Guideline for the management of Gastroenteritis

in children

Keywords

Gastroenteritis, diarrhoea, fever, vomiting, abdominal pain,

hypokalaemia, hypernatraemia, ataxia, hyperreflexia, seizures,
irritability, lethargy, tachycardia, urine, dysentery, drowsiness,
paediatric practice guideline, clinical guideline, gastroenteritis in
children

Policy history

Is this a new policy? Y

Does this policy amend or update an existing policy? N
Does this policy replace an existing policy? N
If so, which policies?

Applies to

All SA Health Portfolio

All Department for Health and Ageing Divisions
All Health Networks
CALHN, SALHN, NALHN, CHSALHN, WCHN, SAAS
Other

Staff impact

All Clinical, Medical, Nursing, Allied Health, Emergency, Dental,

Mental Health, Pathology

PDS reference CG102

Version control and change history

Version
1.0
2.0

Date from
08/10/2013
06/05/2014

Date to
5/5/2014
Current

Amendment
Original version
Revised Version

Department for Health and Ageing, Government of South Australia. All rights reserved.

South Australian Paediatric Practice Guidelines

Gastroenteritis in children
Department of Health, Government of South Australia. All rights reserved.

Note
This guideline provides advice of a general nature. This statewide guideline has been prepared to
promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach.
The guideline is based on a review of published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked
from this site and does not sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details
of each patient and professionally assess the applicability of the relevant guideline to that clinical
situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician
must document in the patients medical record, the decision made, by whom, and detailed reasons for
the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the
individual clinicians are responsible for discussing care with consumers in an environment that is
culturally appropriate and which enables respectful confidential discussion. This includes:

The use of interpreter services where necessary,

Advising consumers of their choice and ensuring informed consent is obtained,

Providing care within scope of practice, meeting all legislative requirements and
maintaining standards of professional conduct, and

Documenting all care in accordance with mandatory and local requirements

ISBN number:
Endorsed by:
Last Revised:
Contact:

ISBN : 978-1-74243-614-2
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 1 of 16

South Australian Paediatric Practice Guidelines

Gastroenteritis in children
X

Table of Contents
Management flowchart for gastroenteritis ...........................3
Important points ...................................................................4
Introduction ..........................................................................4
Definitions and abbreviations ..............................................4
Management summary ........................................................4
Assessment .........................................................................6
Management ........................................................................8
Medication ......................................................................... 10
APPENDICES ................................................................... 11
References ........................................................................ 15

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 2 of 16

South Australian Paediatric Practice Guidelines

Gastroenteritis in children
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Management flowchart for gastroenteritis

ACUTE GASTROENTERITIS

DEGREE OF
DEHYDRATION

MODERATE
5-9%

MILD
<5%

LOW RISK

HIGH RISK

age < three months

co-existing medical
problems

psycho-social issues

Meets Rapid Rehydration

Criteria

illness present < 48 hrs

child age > 6 mths

no pre-existing chronic
medical condition

YES

RAPID REHYDRATION

50mL/kg total (12.5mL/kg/hr)

ORS over 4 hrs (oral or NGT)
OR

10mL/kg/hr 0.9% sodium

chloride + 5% glucose for 4 hrs

Give trial of oral

fluids (6mL/kg/hr)

DISCHARGE
Maintenance oral fluids
+ extra 10mL/kg per watery
bowel action
+ reintroduce normal diet
Advice sheet

SEVERE
>9%
RESUSCITATE URGENTLY

0.9% sodium chloride 20mL/kg

IV/IO

Repeat until circulation stable

Check EUC, BGL, VBG

Discuss with ED/Paediatric

Consultant

NO

SLOW REHYDRATION

ORS or IVT (0.9%

sodium chloride + 5%
glucose)

over 8 or 24 hours (see

text)

Admit to EECU if at
WCH or paediatric
ward(d/w ED or
paediatric consultant)

ADMIT TO HOSPITAL

Na+ <150

Na+ >150

REASSESS

HYDRATED AND
TOLERATING
ORAL FLUIDS
(6mL/kg /hour)

STILL VOMITING OR
DEHYDRATED

Admit to hospital (d/w

PED consultant/Paediatric
consultant)

Replace remaining deficit

over next 4 hours

plus maintenance
plus 2mL/kg/hr ongoing
losses

SLOW
REHYDRATION
over 48 hours

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 3 of 16

South Australian Paediatric Practice Guidelines

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Important points
>

>
>
>
>
>
>

Gastroenteritis is a common infection of the gastrointestinal tract

characterised by any combination of diarrhoea, fever, vomiting and abdominal
pain
Similar symptoms may occur in other illnesses which should be considered
before the diagnosis of gastroenteritis is made
Dehydration and electrolyte abnormalities are the commonest complications
requiring treatment
Electrolyte abnormalities such as hypernatraemia (Na > 150mmol/L) and
hypokalaemia are potentially dangerous and close monitoring is critical.
Most cases of gastroenteritis can be managed using oral hydration. Enteral
rehydration is preferable to intravenous (IV) hydration
Severe dehydration can cause life-threatening shock and should be managed
with 20ml/kg boluses of IV 0.9% sodium chloride
Give careful consideration to where a child lives, and ease of access to
medical attention if condition deteriorates, is required prior to discharge

Introduction
>

>
>

>
>
>

Gastroenteritis in children is a common infectious disease characterised by

any combination of diarrhoea, vomiting, fever, and abdominal pain. It is
usually caused by a viral infection but may be bacterial or parasitic in origin.
Outbreaks in the community are seasonal and sporadic
Most children with gastroenteritis can be managed in the outpatient setting
using oral fluids and parental education
A small number of children become significantly dehydrated, requiring more
aggressive rehydration under clinical supervision. Untreated or poorly-treated
dehydration can lead to shock and death
The risks of treatment include iatrogenic over-hydration and cerebral oedema
from the use of solutions with inadequate sodium concentrations.
Children with pre-existing conditions that make them more susceptible to
dehydration or electrolyte derangement require close monitoring
A number of potentially serious conditions which have symptoms in common
with gastroenteritis and must be considered before the diagnosis of
gastroenteritis is made. Warning signs of other diagnoses must be recognised
and investigated (See APPENDIX 1)

Definitions and abbreviations

>

ORS - Oral rehydration solution

Management summary
>

Establish diagnosis
>
>

>

Suspect gastroenteritis if there is a sudden increase in stool

frequency and a change in stool consistency to loose or watery
Early in the illness the only symptoms may be vomiting and fever.
It is important to exclude other serious conditions which may
present in this way (See appendix 1)
Ask about contacts who have a similar illness, recent travel and
exposure to a potential source of enteric infection (contaminated
food or water)

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 4 of 16

South Australian Paediatric Practice Guidelines

Gastroenteritis in children
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>

>

Assess level of dehydration

>

>

Dehydration is expressed as a percentage of pre-illness body

weight, using the assumption that 1kg of body weight
approximates 1000ml water
Clinical estimation of dehydration is imprecise, even with
experienced clinicians. The following signs have been found to be
the most useful: (see Table 1)
> Comparison of body weights may be available
particularly in repeat presentations
> Reduced skin turgor (prolonged time for pinched skin fold
to return to normal)
> Increased capillary refill time
> Abnormal respiratory pattern
> Sunken eyes
> Thirst
> Tachycardia
> Reduced urine output

>

Note that in Hypernatraemic dehydration clinical estimation of

dehydration may be more difficult, Consider hypernatremia in
the presence of:
> Lethargy
> Irritability
> A doughy skin consistency
> Ataxia, tremor
> Hyperreflexia, seizures, reduced conscious level

>

Clinical assessment of dehydration allows an estimate of fluid

deficit to be made which guides the amount of fluid replacement to
give. Regular reassessment is important, to assess adequacy of
treatment and allow for ongoing losses
Severe dehydration may be associated with hypovolaemic shock
and requires immediate fluid resuscitation using 20ml/kg 0.9%
sodium chloride solution intravenously. Where the dehydration has
occurred very rapidly there may be evidence of shock with a lesser
degree of dehydration

>

>

In children with gastroenteritis caused by Norovirus or Rotavirus,

vomiting usually lasts for 1-2 days, and diarrhoea for 5-7 days, but
stools may take some weeks to return to normal

Rehydrate or prevent dehydration

>

>

>

In mild or no dehydration oral administration of ORS (see

Appendix 2) is recommended using frequent, small volumes. This
can be successful even in the presence of ongoing vomiting.
Short, frequent breast feeds can be used for breast fed infants
Moderate dehydration can be managed with oral or intravenous
rehydration, either rapidly or over 24 hours. Choice of method will
depend on a number of factors discussed below
Infants and children with severe dehydration should be
resuscitated with IV crystalloid, oxygen and close monitoring.
Replacement of the fluid deficit should occur over 24 hours once
the child has an adequate circulation

See APPENDIX 4 for a summary of management decisions

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 5 of 16

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Assessment
>

Primary care / outpatient history and examination

History
In taking the history it is important to determine:
> Frequency and nature of vomiting and diarrhoea
> Fluid intake
> Urine output
> Symptoms indicating diseases other than gastroenteritis (SEE APPENDIX
1).
> Recent antibiotics
> The presence of a similar illness in family members or close contacts
> The presence of bile-stained vomiting (volvulus or obstruction) or
blood/mucous in the stool (intussusception or dysentery) should be
specifically sought
Examination
This should focus on detecting and quantifying the degree of dehydration (Table 1),
as well as excluding other diseases
Young infants usually present with non-specific symptoms and signs of illness and
are more prone to developing significant dehydration rapidly. A higher level of
surveillance should therefore be given to them
Table 1: Clinical Estimation of Dehydration in Children with Diarrhoea and
Vomiting
Mild
Body
Weight
Clinical
signs

Moderate
dehydration
5-9% loss

<5% loss
None or minimal
signs
Normal level
of alertness
Warm
peripheries
Normal
drinking
Normal pulse
and
respiratory
rate

Pinch
test for
skin
turgor

Normal. Skin fold

retracts immediately

Thirst
Sunken eyes
with minimal/
no tears
Dry mucous
membranes
(not accurate
in mouthbreather)
Irritability or
restlessness
Mild
tachycardia
Increased
capillary refill
time

Slow. Skin fold

visible <2s

Severe dehydration
>9% loss
Signs from mild-mod.
Group (more marked)
plus:
Abnormal
drowsiness or
lethargy
Capillary refill >2s
Poor peripheral
perfusion
Tachycardia and
tachypnoea
Acidotic
breathing (deep,
rapid breaths)

Very slow. Skin fold

visible>2s

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 6 of 16

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Note:
> The degree of dehydration is an estimate and should be reassessed frequently
while treatment is being given
> Clusters of signs are more accurate than one or two signs alone

Investigations
Electrolyte and acid-base measurements are not routinely required and do not
add to the clinical estimate of degree of dehydration
Indications include:
> any child requiring intravenous therapy (IVT)
> any child with severe dehydration
> altered conscious state or convulsions
> hypernatraemia is suspected clinically - doughy skin, lethargy and
irritability more than expected for degree of clinical dehydration
> if there is suspicion of Haemolytic Uraemic Syndrome (bloody diarrhoea
with pallor, haematuria and poor urine output)
> children with pre-existing medical conditions that predispose to electrolyte
abnormalities e.g. cystic fibrosis, renal impairment
Blood Sugar Level (point of care) Young children with gastroenteritis are
susceptible to hypoglycaemia. Measure BSL in young infants, patients with large
ketones in the urine and patients who are more lethargic than would be expected
for their degree of dehydration. If BSL<3.0 mmol/L give 5ml/kg 10% glucose after
taking blood for hypoglycaemia screen (see hypoglycaemia guideline)
Complete Blood Examination may sometimes be helpful in the investigation of
vomiting and fever without diarrhoea
Urinalysis should be performed in every patient, if possible, to measure the level of
ketones present and look for glycosuria
Most cases of gastroenteritis are viral (predominantly rotavirus or norovirus) and
few bacterial causes benefit from antibiotic treatment. Routine stool examination is
therefore not warranted when the presentation is typical
Microbiological examination of the stool may be useful in the following situations:
> bloody diarrhoea
> suspected food poisoning or epidemic
> prolonged (>7-10 days) diarrhoea
> recent overseas travel
> child in residential institution/childcare
> any diagnostic uncertainty

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 7 of 16

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Management
>

Minimal or no dehydration

Discharge home with advice about providing adequate amounts of appropriate

fluids and continuing a normal diet when tolerated. It is not necessary to pass a
trial of oral rehydration under supervision.
If ORS is refused dilute, unsweetened fruit juice (1:4) or cordial (1:10) can be used,
but this is sub-optimal for rehydration as it has insufficient sodium.
Written instructions including a guide to fluid requirements and factors which
should prompt a medical review should be provided upon discharge
Consider referral for a home nursing review with Royal District Nursing Service /
Country Home Link tel: 1300 110 600
Patients who should be admitted for 4-6 hours or transferred to an appropriate
centre for a supervised trial of oral rehydration include:
> those for whom the diagnosis is uncertain
> those in a high-risk group
> infants less than three months of age
> patients with co-existing medical problems
> patients living in geographic isolation or with limited access to medical
care
>
inability of caring adult to assess deterioration of child due to
tiredness/intellectual disability/mind altered state
> inability to return due to lack of transport or distance
> re-presentations during the same illness
>

Moderate dehydration

These children should be referred to a centre offering paediatric care for further
assessment and management or specialist advice should be sought
Decide on the method of rehydration
>

Rapid Rehydration
Preferred method provided:
>
the illness has been present for less than 48 hours,
>
the child is older than 6 months and
> the child does not have a chronic medical condition which affects fluid
balance (e.g. chronic renal failure, some cardiac conditions)

NOTE: The rapid rehydration fluid rate must not continue after 4 hours.
Reassessment must occur at this time
Rehydrate rapidly by giving a total volume of 50ml/kg ORS over 4 hours either
orally or via NGT using a kangaroo pump for constant infusion. Do not add
maintenance fluid to this volume
Nasogastric tubes are generally well tolerated in children less than 4 years of age.
Note that ongoing vomiting is not a contraindication to oral rehydration and that
fluid can be given orally via cup, spoon or syringe
IVT is more expensive and prone to more complications than NG therapy, however
if oral or nasogastric fluids are not tolerated, commence IV [0.9% sodium chloride
+ 5% glucose]* at 10ml/kg/hr for four hours (do not add maintenance fluid to this
volume). *See APPENDIX 3 for how to make up this solution
ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 8 of 16

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Reassess and weigh the child after this deficit volume has been given
> If the child is rehydrated and tolerates oral fluids (aim for 6mL/kg/hr)
then discharge home with advice sheet and LMO follow-up. Consider
referral for a home nursing review with Royal District Nursing Service /
Country Home Link tel: 1300 110 600.
> If living circumstances indicate limited access to medical attention
should childs condition deteriorate, caution is recommended. Consider
further observation and monitoring
> If the rapid rehydration finishes late at night and the child has improved
clinically it is reasonable to continue observations and allow the child
to sleep, with oral fluids commencing in the morning
> If dehydration persists the child will need overnight admission and
continued rehydration. Commence maintenance fluids as ORS [or
0.9% sodium chloride + 5% glucose] (for rates see APPENDIX 3), plus
fluid to correct the remaining deficit over the next 4 hours, plus
2mL/kg/hr to replace ongoing diarrhoeal losses. Reassess again once
the deficit volume has been given.
> Intravenous rehydration should be considered if oral/nasogastric
rehydration is not tolerated or if the child becomes dehydrated due to
excessive ongoing losses despite ORT
> Slow Rehydration
Patients who do not fit the criteria for rapid rehydration should be rehydrated over
24 hours. Calculate the sum of: Deficit + maintenance + ongoing losses.
The fluid deficit is calculated using the formula:

Fluid deficit in ml = % dehydration x weight in kg x 10

Give this over eight hours or more slowly in consultation with the relevant specialist
unit. Ongoing losses can be estimated to be 2ml/kg/hour in acute rotavirus.
ORT either orally or via NGT is preferable but I.V. [0.9% sodium chloride + 5%
glucose]* may be used if ORT is not tolerated. *See APPENDIX 3 for how to make
up this solution.
Review the patient at 4 hours and once the rehydration volume has been given.
Look particularly for:
Weight change
Clinical signs of dehydration
Urine output
Ongoing losses &
Signs of fluid overload, such as puffy face and extremities
Once the child is rehydrated continue fluids at maintenance + ongoing losses.
Potassium may be added to IV solutions once the child has passed urine and the
serum potassium is known.
Monitor electrolytes regularly if IV rehydration is being used
Feeding may commence once oral fluids are tolerated or once the child is hungry.
Full-strength milk/formula may be given to infants
>

Severe dehydration

These children should be referred to a centre offering paediatric care for

assessment or seek specialist advice using the 13STAR (137827) number
> Dehydration with shock constitutes a medical emergency
ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 9 of 16

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> Once the airway and breathing have been assessed and supported as required,

with high-flow oxygen being given, IV access should be secured

> Take blood for EUC, venous gas, and Glucose
> Consider other causes for shock and manage accordingly
> Give a fluid bolus of 20ml/kg of 0.9% sodium chloride solution. Reassess. If

shock persists; repeat the fluid bolus. Once the circulation is restored commence
rehydration. If there is no improvement seek specialist advice
> NB: The rehydration volume calculation should take into account fluids already

given during resuscitation

> The patient should be weighed at least daily
>

Electrolyte Disturbances

1.Hypernatraemic dehydration (Na > 150mmol/L) is potentially dangerous and

close monitoring is critical.
> If Na > 150mmol/L speak to a specialist. Aim to replace deficit slowly (over 48

hours) to minimise risk of cerebral oedema. Admission to a unit where the patient
can be closely monitored is preferable and sodium levels need to be measured 4
hourly. Fluid choice (usually 0.9% sodium chloride) and rate should be in
discussion with a Paediatric specialist
> If Na <150mmol/L and intravenous rehydration is required, 0.9% sodium chloride

has been shown to have less risk of lowering serum sodium levels and is
recommended, particularly if serum sodium is <135mmol/L prior to rehydration
2,Hypokalaemia

Medication
Avoid the use of unnecessary medication in gastroenteritis
>

Antiemetics
>

>

>

>

Ondansetron in wafer or syrup form is available and has been shown

to be safe and effective for children with gastroenteritis down to 6
months of age
There is some evidence that it can reduce admission rates and
improve the success of oral rehydration. Usually only one dose is
required. Ondansetron can increase the volume and frequency of
diarrhoea and thus should not be used where diarrhoea is the only
symptom. Conditions in appendix 1 should be excluded prior to
administering Ondansetron. See APPENDIX 5 for dosage schedule
Metoclopramide (Maxolon) and Prochlorperazine (Stemetil) are not
recommended as there is a risk of extra-pyramidal side-effects and
they are often ineffective in children with gastroenteritis

Anti-diarrhoeal agents and anti-motility agents

These are not recommended as their efficacy is not proven and there is a risk of
adverse effects

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 10 of 16

South Australian Paediatric Practice Guidelines

Gastroenteritis in children
X

>

Antibiotics

These are rarely required, even in bacterial gastroenteritis. They may be

considered in young infants with high fevers in whom a bacterial cause is likely, in
patients with ongoing severe symptoms due to a bacterial pathogen or inpatients
who have travelled overseas recently. Consultation with a paediatrician or
infectious diseases specialist is recommended
>

Probiotics and Zinc

These should not be given routinely. Research is ongoing in this area

APPENDICES
Appendix 1- Differential Diagnoses and Warning Signs of
Serious Conditions Mimicking Gastroenteritis
Vomiting alone, although a common presenting feature in early gastroenteritis is a
symptom of many other illnesses.
Beware- very young children or malnourished children are likely to be more
severely ill or have another diagnosis.
Some of the differential diagnoses to consider are:
Surgical:
>
>
>

intestinal obstruction (e.g. Volvulus or intussusception)

acute appendicitis
raised intracranial pressure

>
>
>
>
>

urinary tract infection

pneumonia
meningitis
sepsis
metabolic (e.g. Diabetes mellitus, urea cycle defects)

Medical: -

WARNING SIGNS that should be recognised and prompt further investigation

include:
>
Abdominal distension
>

Localised abdominal tenderness or severe abdominal pain

>

Bile-stained vomiting

>

Fever>39C

>

Blood or mucus in stool

>

Headache

>

Neck stiffness

>

Bulging fontanelle

>

Non-blanching rash

>

Shortness of breath

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

Page 11 of 16

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Appendix 2 - Oral Rehydration Solutions

Fig 1: Oral Rehydration Solution Composition
Name

Sodium
mmol/L

Potassium
mmol/L

Chloride
mmol/L

Citrate
mmol/L

Glucose
mmol/L

Osmolarity
mOsm/L

Glucose-electrolyte solutions

WHO

90

20

80

10

111

311

Gastrolyte
powder

60

20

60

10

90

240

Hydralyte

45

20

45

30

80

240

Repalyte/
ChemmartORS/
Restore ORS

60

20

60

10

90

240

Pedialyte

45

20

35

10

126

246

60

20

50

10

60

20

Not <30

10

Rice-based solutions
Gastrolyte R

6g pre226
cooked
rice/L
European Society of Paediatric Gastroenterology, Hepatology and Nutrition recommendation

Fig 2: Composition of other Oral Fluids

Sodium
mmol/L
Apple Juice
3
Soft Drinks
~2
Sports drinks
~20

Carbohydrate
mmol/L
690
~700
~255

74-111

200-250

Osmolarity mOsm/L
730
~750
~330

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

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Appendix 3 Fluid Requirements and Recommendations

Maintenance Fluids
0-6months 120-140 ml/kg/day
> 6months:
Body Weight
First 10kg
Second 10kg
Subsequent kg

Fluid requirement
ml/day
100ml/kg
+ 50ml/kg
+ 20ml/kg

Fluid requirement ml/hr

4ml/kg/hr
+2ml/kg/hr
+1ml/kg/hr

e.g. 25kg child: maintenance rate is 40+20+5 = 65 ml/hr

Rehydration Fluids
Oral Rehydration Solution
0.9% sodium chloride for resuscitation
0.9% sodium chloride for IV rehydration (with or without 5% glucose)*
0.45% sodium chloride + 5% glucose for maintenance
N.B. Do not give 4% glucose + 0.18% sodium chloride or 5% glucose for
rehydration
* Note: 0.9% sodium chloride with 5% glucose is a commercially available solution.
If unavailable: to make 0.9% sodium chloride with 5% glucose:
Remove 100ml of 0.9% sodium chloride from a 1000ml bag of 0.9% sodium
chloride and add 100ml of 50% glucose

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

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Appendix 4-Management Decisions in Gastroenteritis in

Children
When to treat at home:
> Family able to cope
> Absence of dehydration
> Vomiting not interfering with fluid intake
When to consult:
> Diagnosis in doubt
> Therapy in doubt
> Infant under three months of age
> Pre-existing disease
> Diabetes
> Cyanotic heart disease
> Chronic renal disease
> Previous bowel resection
> Malnutrition
> Failure to improve
When not to treat at home
> Moderate Dehydration
> Diagnosis in doubt
> Family unable to cope
> Deterioration
> Persistent vomiting
> Profuse diarrhoea

Appendix 5-Ondansetron Dosage Guidelines

Ondansetron is recommended for children over 2 years of age with frequent
vomiting likely to be due to gastroenteritis to assist in oral rehydration and relief of
nausea.
Some studies have used the medication safely for children from 6 months of age.
Dose is 0.15 mg/kg as mixture
If wafers are used:
> 2mg ( wafer) for children 8-15kg
> 4mg for children 15-30kg
> 8mg for children >30kg
Adverse effects are unusual but studies suggest that its use may prolong the
duration of diarrhoea. Ondansetron should not be used in children with prolonged
QT syndrome

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

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South Australian Paediatric Practice Guidelines

Gastroenteritis in children
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References
Several Guideline sites were consulted for existing guidelines regarding
diarrhoea, vomiting and gastroenteritis including:
> National Guideline Clearing House http://www.guideline.gov/
> National Institute for Health and Clinical Excellence (NICE)
http://guidance.nice.org.uk/CG/published
> UK NHS (http://libraries.nelh.nhs.uk/guidelinesFinder/)
> National Institute of Clinical Studies http://www.nhmrc.gov.au/nics/index.htm
> National Health and Medical Research Council
(http://www.nhmrc.gov.au/publications/index.htm)
The following guidelines were found to be suitable for adaptation using the AGREE
tool (http://www.agreecollaboration.org/pdf/agreeinstrumentfinal.pdf):
1. The Greater Eastern and Southern NSW Child Health Network Clinical
Practice Guidelines for Gastroenteritis
http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_009.pdf
2. The NICE guideline: Diarrhoea and vomiting caused by gastroenteritis:
diagnosis, assessment and management in children younger than 5 years
http://egap.evidence.nhs.uk/CG84/
The following articles were found to be relevant:
1. Harris C, Wilkinson F et al, Evidence based guideline for the management
of diarrhoea with or without vomiting in children, Australian Family
Physician 2008;37 (6 ) accessible at
http://www.racgp.org.au/Content/NavigationMenu/Publications/AustralianF
amilyPhys/2008issues/afp200806paediatricconditions/200806supplementd
iarrhoea.pdf
2. DeCamp LR, Byerley JS, Doshi N et al. Use of antiemetic agents in acute
gastroenteritis, a systematic review and meta-analysis. Arch Pediatr
Adolesc Med. 2008;162(9):858-865
3. Hartling L, Bellemare S, Wiebe N, et al. Oral versus intravenous
rehydration for treatment of dehydration due to gastroenteritis in children.
A Cochrane reiew. Cochrane Database of Systematic Reviews
2003(3):CD004390
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004390/frame
.html
4. Alhashimi D, Al-Hashimi H , Fedorowicz Z. Anitemetics for reducing
vomiting related to acute gastroenteritis in children and adolescents. A
Cochrane review.
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD005506/frame
.html
5. Diarrhoea in Children. The GUT Foundation publication, Revised in 2008
by Davidson G, Catto-Smith T and Elliott E.
http://www.gut.nsw.edu.au/assets/documents/Diarrhoea%20in%20Childre
n%20v8.pdf
6. Bellemare S, Hartling L, Wiebe N, Russell K, Craig WR, McConnell D, et
al. Oral rehydration versus intravenous therapy for treating dehydration
due to gastroenteritis in children: a meta-analysis of randomised controlled
trials. BMC Medicine 2004;2(1):11.
7. Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods
of rehydration in pediatric patients with acute dehydration. Pediatrics
2002;109(4):566-72
8. Dalby-Payne J, Elliott E. Gastroenteritis in Children. In: Tovey D, editor.
Clinical Evidence. 13 ed. London: BMJ; 2004. p. 343-353.
9. Elliott EJ, Dalby-Payne JR. 2. Acute infectious diarrhoea and dehydration
in children. Medical Journal of Australia 2004;181(10):565-70.

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

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Gastroenteritis in children
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10. Webb A, Starr M. Acute gastroenteritis in children. Australian Family

Physician 2005;34(4):227-31.
11. Conners GP, Barker WH, Mushlin AI, Goepp JG. Oral versus intravenous:
rehydration preferences of pediatric emergency medicine fellowship
directors. Pediatric Emergency Care 2000;16(5):335-8.
12. Armon K, Stephenson T, MacFaul R, Eccleston P, Werneke U. An
evidence and consensus based guideline for acute diarrhoea
management. Archives of Disease in Childhood 2001;85(2):132-42
13. Ramsook C, Sahagun-Carreon I, Kozinetz CA, Moro-Sutherland D. A
randomized clinical trial comparing oral ondansetron with placebo in
children with vomiting from acute gastroenteritis.[see comment]. Annals of
Emergency Medicine 2002;39(4):397-403.
14. Borowitz SM. Are antiemetics helpful in young children suffering from
acute viral gastroenteritis? Archives of Disease in Childhood
2005;90(6):646-8.
15. Cubeddu LX, Trujillo LM, Talmaciu I, Gonzalez V, Guariguata J, Seijas J,
Miller IA, Paska W. Antiemetic activity of ondansetron in acute
gastroenteritis. Alimentary Pharmacology and Therapeutics 1997;11;185191.
16. Freedman SB, Adler M, Seshadri R, Powell EC. Oral Ondansetron for
Gastroenteritis in a Pediatric Emergency Department. New England
Journal of Medicine 2006;354(16): 1698-1705.
17. Reeves JJ, Shannon MW, Fleisher GR. Ondansetron Decreases Vomiting
Associated With Acute Gastroenteritis: A Randomized, Controlled Trial.
Pediatrics 2002;109(4);e62.
18. Steiner MJ, DeWalt DA, Byerley JS. Is This Child Dehydrated? JAMA.
291(22):2746-54, 2004 Jun 9.

Information for parents

Parenting and Child Health. Womens and Childrens Health Network. Available at
URL:
http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=304&id=18
55

ISBN number:
ISBN : 978-1-74243-614-2
Endorsed by:
South Australian Paediatric Clinical Guidelines Reference Committee.
South Australian Child Health Clinical Network
Last Revised:
14/04/10
Contact:
South Australian Paediatric Clinical Guidelines Reference Committee:
[email protected]

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