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Policy Directive

Department of Health, NSW73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

spacespace

Children and Infants with Gastroenteritis - Acute Management

space

Document Number PD2010_009

Publication date 03-Feb-2010

Functional Sub group Clinical/ Patient Services - Baby and child

Summary Clinical Practice Guidelines for the treatment of infants and children withgastroenteritis.

Replaces Doc. No. Children and Infants with Gastroenteritis - Acute Management[PD2009_064]

Author Branch Statewide Services Development

Branch contact Trish Boss 9424 5706

Applies to Area Health Services/Chief Executive Governed Statutory HealthCorporation, Board Governed Statutory Health Corporations, AffiliatedHealth Organisations - Non Declared, Affiliated Health Organisations -Declared, Public Health System Support Division, Community Health

Centres, NSW Ambulance Service, Public HospitalsAudience Emergency Departments, Paediatric Units

Distributed to Public Health System, Divisions of General Practice, NSW AmbulanceService, Private Hospitals and Day Procedure Centres, TertiaryEducation Institutes

Review date 03-Feb-2013

Policy Manual Patient Matters

File No. 06/3557

Status Active

Director-GeneralspaceThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory

for NSW Health and is a condition of subsidy for public health organisations.


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POLICY STATEMENT

PD2010_009 Issue date: February 2010 Page 1 of 1

INFANTS AND CHILDREN:ACUTE MANAGEMENT OF GASTROENTERITIS

PURPOSE

The infants and children: acute management of gastroenteritis clinical practice guideline(attached) has been developed to provide direction to clinicians and is aimed at achievingthe best possible paediatric care in all parts of the state.

The clinical practice guideline was prepared for the NSW Department of Health by anexpert clinical reference group under the auspice of the state wide Paediatric ClinicalPractice Guideline Steering Group.

MANDATORY REQUIREMENTS

This policy applies to all facilities where paediatric patients are managed. It requires all

Health Services to have local guidelines/protocols based on the attached clinical practiceguideline in place in all hospitals and facilities likely to be required to assess or managechildren with gastroenteritis.

The clinical practice guideline reflects what is currently regarded as a safe andappropriate approach to the acute management of gastroenteritis in infants and children.However, as in any clinical situation there may be factors which cannot be covered by asingle set of guidelines. This document should be used as a guide, rather than as acomplete authoritative statement of procedures to be followed in respect of eachindividual presentation. It does not replace the need for the application of cl inical judgement to each indiv idual presentat ion.

IMPLEMENTATION

Chief Executives must ensure:

Local protocols are developed based on the infants and children: acutemanagement of gastroenteritis clinical practice guideline.

Local protocols are in place in all hospitals and facilities likely to be required toassess or manage paediatric patients with gastroenteritis.

Ensure that all staff treating paediatric patients are educated in the use of thelocally developed paediatric protocols.

Directors of Clinical Governance are required to inform relevant clinical staff treatingpaediatric patients of the revised protocols.

REVISION HISTORY

Version Approved by Amendment notes

December 2004(PD2005_238)

Director-General New policy

October 2009(PD2009_064)

Deputy Director-GeneralPopulation Health

Second edition

February 2010(PD2010_009)

Deputy Director-GeneralPopulation Health

Third edition. Corrects table on page 8.

ATTACHMENT1. Infants and Children: Acute Management of Gastroenteritis – Clinical Practice

Guideline.


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Infants and children:

A cute M anagem ent of G astroenteritis

third edition

CLINICAL PRACTICE GUIDELINES


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N SW D EPA RTM EN T O F H EA LTH

73 M iller Street

N orth Sydney N SW 2060

Tel. (02) 9391 9000

Fax. (02) 9391 9101

w w w .health.nsw .gov.au

This w ork is copyright. It m ay be reproduced in w hole or part for study or training

purposes subject to the inclusion of an acknow ledgem ent of the source. It m ay not be

reproduced for com m ercial usage or sale. Reproduction for purposes other than those

indicated above requires w ritten perm ission from the N SW D epartm ent of H ealth.

N SW D epartm ent of H ealth 2009

SH PN: (SSD) 090178

ISBN : 978-1-74187-453-2

For further copies of this docum ent please contact:

Better H ealth C entre –Publications W arehouse

PO Box 672

N orth Ryde BC , N SW 2113

Tel. (02) 9887 5450

Fax. (02) 9887 5452

Inform ation Production and D istribution

Tel. (02) 9391 9186

Fax. (02) 9391 9580

E-m ail: bhc@ nsccahs.nsw .gov.au

Further copies of this docum ent can be dow nloaded from the

N SW H ealth w ebsite: w w w .health.nsw .gov.au

A revision of this docum ent is due in 2011.

N ovem ber 2009 - third edition


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NSW HEALTH Infa nts and Children — Acute Mana geme nt of Ga stroenteritis PAGE 1

C ontents

Introduction ...............................................................................................3

Summary .....................................................................................................4

Significant C hanges from 2002 C PG Version .........................................................4

Gastroenteritis in Infancy and Childhood ..................................................5

Principles of Fluid M anagem ent .............................................................................6

M edications ...........................................................................................................6

D ifferential D iagnoses ............................................................................................7

Table 1: Clinical A ssessm ent of D ehydration and Initial Treatm ent ..........................8

M anagem ent A lgorithm ........................................................................................9

Enteral Rehydration Therapy ...................................................................10

O ral Rehydration Solutions (O RS) .........................................................................10M ethod of G iving O ral Fluids ...............................................................................12

D ischarge C riteria ..............................................................................................12

Nasogastric Rehydration Therapy ...........................................................13

Intravenous Fluid Therapy .......................................................................15

Introductory N otes ..............................................................................................15

Resuscitation ..............................................................................................15

Rapid IV Rehydration ...........................................................................................16

Standard IV Rehydration ......................................................................................17

H ypernatraem ia ..............................................................................................19

H yponatraem ia ..............................................................................................19

Investigations and Observations .............................................................20

Reintroduction of D iet .........................................................................................21


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PAGE 2 NSW HEALTH Infa nts and Children — Acute Mana gemen t of Ga stroente ritis

References ................................................................................................22

Bibliography .............................................................................................24

Appendices .............................................................................................29

A ppendix O ne –Glossary .....................................................................................29

Appendix Tw o –IVT Com position ....................................................................................30

A ppendix Three –Parent O ral Rehydration D ocum entation Form .........................31

A ppendix Four –Parent Inform ation ....................................................................33

A ppendix Five –Resources ...................................................................................34

A ppendix Six –Significant C hanges From 2002 C PG Version ...............................35

A ppendix Seven –A lternative C alculation for M aintenance Fluids ........................35A ppendix Eight –W orking Party M em bers ...........................................................36


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Introduction

These G uidelines are aim ed at achieving the

best possible paediatric care in all parts of the

State. The docum ent should not be seen as a

stringent set of rules to be applied w ithout

the clinical input and discretion of the

m anaging professionals. Each patient should

be individually evaluated and a decision m ade

as to appropriate m anagem ent in order to

achieve the best clinical outcom e.

The form al definition of clinical practice

guidelines com es from the N ational H ealth

and M edical Research C ouncil:

‘System atically developed statem ents toassist practitioner and patient decisions

about appropriate health care for specific

clinical circum stances.’

(Nat ional Health and Medical Research

Council ‘A Guide to the Development,

implementation and evaluation of

Clinical Practice Guidelines’, Endorsed

16 November 1998, available from

www.nhmrc.gov.au/publications/

synopses/cp30syn.htm)

It should be noted that this docum ent

reflects w hat is currently regarded as a

safe and appropriate approach to care.

H ow ever, as in any clinical situation there

m ay be factors w hich cannot be covered bya single set of guidelines. This docum ent

should be used as a guide, rather than as

a com plete authoritative statem ent of

procedures to be follow ed in respect of each

individual presentation. It does not replace

the need for the application of clinical

judgm ent to each individual presentation.

This docum ent represents basic clinical

practice guidelines for the acute

m anagem ent of gastroenteritis in children

and infants. Further inform ation m ay be

required in practice; suitable w idely available

resources are included as Appendix Five.

Each A rea H ealth Service is responsible forensuring that local protocols based on these

guidelines are developed. A rea H ealth

Services are also responsible for ensuring

that all staff treating paediatric patients are

educated in the use of the locally developed

paediatric guidelines and protocols.

In the interests of patient care it is critical

that contem poraneous, accurate and

com plete docum entation is m aintained

during the course of patient m anagem ent

from arrival to discharge.

Parental anxiety should not be

discounted: it is often of significance

even if the child does not appear

especially unwell.


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Sum m ary

G astroenteritis is a com m on paediatric

condition. A ppropriate m anagem ent

attem pts to avoid dehydration, but w hen

this occurs appropriate fluid m anagem ent

is essential.For rehydration the enteral

route is preferred, but if intravenous

fluids are used then low sodiumcontaining fluids m ust be avoided. For

intravenous rehydration 0.9% N orm al

Saline (N aC l) + 2.5% G lucose is preferred.

0.9% N orm al Saline (N aC l) + 5% G lucose

m ay also be used. If rehydrating over 24

hours then 0.45% N aC l + 2.5% G lucose is

an acceptable alternative. O ral rehydration

solutions m ay be offered orally oradm inistered nasogastrically.

In cases of severe dehydration or clinical

deterioration after adm ission or despite

treatm ent, the A dm itting M edical O fficer

in charge or consulting paediatrician

should be notified and should personally

review the patient as soon as possible. W hereother m edical staff act as a delegate for

the A dm itting M edical O fficer, the hospital

m ust have clear w ritten protocols defining

this arrangem ent.

For hospitals em ploying junior m edical staff:

The Admitting Medical Officer MUST be

notified within an hour of the decision

to admit the child. Details of the physical

findings and proposed fluid therapy should

be discussed. Hospitals should have an

internal policy that defines roles if senior

registrars act as a delegate for the A M O .

These C linical Practice G uidelines should

be read in conjunction w ith other relevant

C linical Practice G uidelines (e.g. the

Recognit ion of a Sick Child in Emergency

Departments , and Acute Management of

Infants and Children with Acute Abdom inal

Pain ). W hen dealing w ith children

suspected of having gastroenteritis,it is

essential that infection control

measures be implemented to prevent

cross-contam ination and spread.


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G astroenteritis in Infancy

and C hildhood

This com m on acute intestinal

com m unicable infection causes

vom iting, diarrhoea and fever. It is

usually viral, but som etim es bacterial

or parasitic. C om m unity outbreaks are

sporadic and seasonal.

A sm all proportion of those affected

w ill suffer severe dehydration and

electrolyte disturbance. U ntreated or

poorly treated dehydration m ay

progress to shock and death. There are

also risks from over-hydration and/or

inappropriate electrolyte replacem ent,

including death from cerebral oedem a.

Som e other serious illnesses are

som etim es incorrectly diagnosed as

gastroenteritis.Warning signs of

other diagnoses must be recognised

and investigated(see page 7).

Suggested hospital requirements

for management of children withgastroenteritis

24-hour availability of nurses and

m edical practitioners experienced in

the m anagem ent of sick children.

A ccess to 24-hour standard

biochem istry for inpatient

m anagem ent. This m ay include point

of care testing.

A vailability of standard resuscitation

intravenous fluids, including 0.9%

N aC l (w ithout added glucose) or

H artm ann’s solution (w ithout added

glucose).

A vailability of rehydration intravenous

fluids, including 0.9% N aC l + 2.5%

G lucose, 0.45% N aCl + 2.5% G lucose.

Intravenous paediatric giving sets w ith

burettes, appropriate infusion pum ps.

A ppropriate O ral Rehydration Solutions

such as G astrolyte® , G astrolyte-R® ,

Repalyte® , H ydralyte®

A ppropriate giving sets and enteralinfusion pum ps (e.g. Kangaroo® pum p).

Availability of assistance when

treating severely ill children

The treatm ent of children w ith severe

dehydration should be discussed w ith

a paediatrician and consideration be

given to transfer to a facility w ith a

paediatric intensive care unit.

For advice regarding the m anagem ent

of seriously ill children or to arrange

their transfer to any of the children’s

hospitals contact N SW N ew born and

Paediatric Em ergency Transport Service

(NETS) Hotline number:1300 36 2500.


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C alls to N ETS are voice recorded and

form part of the N ETS m edical record

for the patient.

Principles of FluidManagement

Infants and children w ith gastro-

enteritis require additional fluids to

prevent dehydration, or for

rehydration.

The enteral route is preferred for

rehydration of children w ith m ild or

m oderate dehydration. This is w ith anO ral Rehydration Solution (O RS) either by

m outh or via nasogastric tube.

Suitable fluids should be offered, for

oral rehydration

– Babies w ho are breastfed should

receive sm all frequent breastfeeds

to ensure norm al urine output. This

m ay be supplem ented w ith an O RS.

– For all other children, offer an

O RS. Those requiring m ixing m ust

follow the m anufacturer’s

instructions.Do not add flavouring

or sweet drinks to an ORS.

– If an O RS is unavailable, or refused,

dilute juice/lem onade (m ixed as 1part juice/lem onade w ith 4 parts

w ater) can be used only if a child

is not dehydrated.These are less

desirable fluid opt ions .

– Do not use ‘sports drinks’as they

are not an appropriate rehydration

fluid for children w ith gastroenteritis.

– Do not use low -calorie or diet drinks.

Suitable volum es should be offered: try

to give about 0.5m L/kg every 5 m inutes.

A chieving successful oral rehydration

dem ands constant attention and

persistence, usually by parents.

The principles and practice of oral

replacem ent therapy are described on

page 10.

Intravenous rehydration is often a

reasonable alternative for m oderate

dehydration (see Table 1 on page 8)

and is essential w here severe

dehydration and/or shock are present. C hildren receiving fluid rehydration

require regular tim ely reassessm ent.

The principles and practice of

intravenous replacem ent therapy are

described on page 15.

NB: Careful calculations of fluid

volume and rate are requiredregardless of route of administration.

Medications

There are no indications for using

anti-m otility or anti-diarrhoeal agents in

the m anagem ent of acute gastroenteritis

in infants or children.

M any antiem etic m edications have a risk

of significant side effects, like dystonic

reactions and sedation, and should be

avoided [e.g. prom ethazine,

prochlorperazine]. M edications such as

5H T-3 receptor antagonists, such as

ondansetron, m ay have som e clinical

benefit, how ever the evidence is notconclusive. Experienced clinicians choosing


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to use that m edication generally should

lim it the use to a single dose.

Pro-biotics and Zinc m ay have som e

clinical benefits in the m anagem ent of

gastroenteritis, and m ay be available in

som e com m ercially available products such

as yoghurts. These can be given to children

w hen a norm al diet is reintroduced.

A ntibiotics are rarely required in

gastroenteritis, even w hen bacterial in

aetiology. If unsure, consult a paediatrician

or paediatric infectious disease specialist.

Rotavirus vaccines are available and have a

significant benefit in the prevention of

gastroenteritis in young infants. A dditional

inform ation is available at the N ational

C entre for Im m unisation Research and

Surveillance of Vaccine Preventable

D iseases w ebsite

ht t p://w w w .ncirs.usyd.e d u.a u/fa cts/rotavirus_vaccine_for_children_

june_2007.pdf

Differential Diagnoses

A lw ays keep in m ind the possibility that

the diagnosis of gastroenteritis could be

incorrect.Gastroenterit is consists of the

tr iad of vomit ing, diarrhoea and fever. Be

cautious of evaluating the child w ith

vom iting alone. The follow ing list is not

exclusive. C onsider also:

A cute appendicitis

Strangulated hernia

Intussusception or other causes of

bow el obstruction

U rinary tract infection

M eningitis and other types of sepsis

A ny cause of raised intracranial

pressure

D iabetic ketoacidosisInborn errors of m etabolism

Inflam m atory bow el disease

H aem olytic uraem ic syndrom e

A lw ays consider another diagnosis if

there is:

A bdom inal distension Bile-stained vom iting

Fever >39ºC

Blood in vom itus or stool

Severe abdom inal pain

Vom iting in the absence of diarrhoea

H eadache

Beware! The very young infant and

the malnourished child are more likely

to suffer severe disease, or to have

another diagnosis.

Table 1 on page 8 gives an overview of

dehydration definition, signs and sym ptom s,

along w ith initial enteral or parenteral fluid

therapy. W herever 0.9% N aCl + 2.5%

G lucose is advised, 0.9% N aC l + 5%

G lucose w ould be an acceptable alternative.

The flow chart on page 9 outlines a

treatm ent overview and highlights decision

points in regard to the initial m anagem ent

of an infant or child w ith gastroenteritis.


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T a b l e 1

: C l i n i c a l A s s e s s m e n t o f D e h y d r a t i o n a n d I n i t i a l T r e

a t m e n t

N o s i n g

l e s y m p

t o m o r c l

i n i c a

l s i g n r e

l i a b l y p r e

d i c t s t h e

d e g r e e

o f d e

h y d r a

t i o n

D e s c r

i p t i o n o f

d e h y d

r a t i o n

D e h y d r a t i o n

( % o

f B o d y

W e i g h t )

S

i g n s a n d S y m p t o m s

R e p l a c e m e n t

F l u i d R o u t e

R e p

l a c e m e n t F l u i d T y p e

N o

C l i n i c a

l

S i g n s o

f

D e

h y d

r a t i o n

R

e d u c e

d u r i n e o u

t p u

t

T

h i r s t

N

o p

h y s

i c a

l s i g n s

O r a

l

I n o

r d e r o

f p r e

f e r e n c e

1 . F r e q u e n

t b r e a s t

f e e

d s w

h e r e a p

p r o p r i a

t e / p o s s

i b l e

2 . O r a

l R e

h y d r a

t i o n

S o

l u t i o n

( s e e p a g e

1 0 )

3 . 1 / 5 s t r e n g

t h c l e a r

f l u

i d s

i . e . : 4

p a r t s w a

t e r a n

d 1

p a r t

j u i c e

/ l e m o n a

d e ( i f a n

O R

S r e f u s e d )

M i l d

3 %

R

e d u c e

d u r i n e o u

t p u

t

T

h i r s t

D

r y m u c o u s m e m

b r a n e s

M

i l d T a c h y c a r d

i a

O r a

l

I n o

r d e r o

f p r e

f e r e n c e

1 . F r e q u e n

t b r e a s t

f e e

d s w

h e r e p o

s s i b l e / a p p r o p r i a

t e

m a y

b e s u p p

l e m e n

t e d w

i t h a n

O R S

2 . O r a

l R e

h y d r a

t i o n

S o

l u t i o n

( s e e p a g e

1 0 )

N a s o g a s t r i c

O r a l R e

h y d r a

t i o n

S o

l u t i o n e . g .

G a s t r o

l y t e ® ( s e e p .

1 0 )

I n t r a v e n o u s

– R a p

i d

– S t a n

d a r d

0 . 9 %

N a

C l + 2 . 5

% G

l u c o s e

0 . 9 %

N a

C l + 2 . 5

% G

l u c o s e o r 0

. 4 5 %

N a

C l +

2 . 5 %

G l u c o s e

M o

d e r a

t e

5 %

D

r y m u c o u s m e m

b r a n e s

T

a c h y c a r d

i a

A

b n o r m a

l r e s p

i r a

t o r y p a

t t e r n

L

e t h a r g y

R

e d u c e

d s k

i n t u r g o r

S

u n

k e n e y e s

N a s o g a s t r i c

1 . O r a

l R e

h y d r a

t i o n

S o

l u t i o n e . g

. G a s t r o

l y t e ®

( s e e p a g e

1 0 )

I n t r a v e n o u s

– R a p

i d

– S t a n

d a r d

0 . 9 %

N a

C l + 2 . 5

% G

l u c o s e

0 . 9 %

N a

C l + 2 . 5

% G

l u c o s e o r 0

. 4 5 %

N a

C l +

2 . 5 %

G l u c o s e

S e v e r e

1 0 %

A

b o v e s i g n s

P

o o r

P e r f u s i o n

: M o

t t l e d , c o o l

l i m b s /

S l o w c a p

i l l a r y r e

f i l l / A l t e r e

d

c

o n s c

i o u s n e s s

S

h o c k

: t h r e a

d y p e r i p

h e r a

l p u l s e s

w

i t h m a r k e

d t a c h y c a r d

i a a n d

o t h e r

s

i g n s

o f p o o r p e r f u s i o n s t a t e d a

b o v e

I n t r a v e n o u s o r

i n t r a o s s e o u s

2 0 m

L / k g s t a

t

a n

d r e a s s e s s

f l u

i d n e e

d s

U s e

e i t h e r :

0 . 9 %

N a

C l o r

H a r t m a n n

’ s s o

l u t i o

n f o r

r e s u

s c i t a

t i o n a n

d t h e n r e a s s e s s t

h e c h

i l d .

O n g

o i n g

f l u

i d r e p

l a c e m e n

t s h o u

l d b e w

i t h

e i t h

e r :

0 . 9

% N

a C l + 2 . 5

% G

l u c o

s e o r

0 . 4 5 %

N a

C l + 2 . 5

% G

l u c o s e


13/41


Management Algorithm

H istory and exam ination results in provisional diagnosis of gastroenteritis. C linical assessm ent of

degree of dehydration (see table on page 8). If no sign of dehydration, continue frequent sm all

volum es of oral fluids increasing volum e and reducing frequency as fluids are tolerated.

Mild dehydration

O ffer frequent, sm all volum es

O RS (achieving about

0.5m L/kg every 5 m inutes).

Moderate dehydrationC hild not shocked

Severe dehydration

C hild shocked

Reassess frequent ly

Tolerating oral fluids and

clinical/fam ily status

satisfactory:

•Educate fam ily & provide

Fact Sheet.

•Discharge hom e.

•A dvise about planned

m edical follow -up and need

for earlier review .

Not tolerating oral fluids:

•Continue to encourage oral

fluids.

•Adm it to hospital if

dehydration progressing and oral intake is inadequate.

•C onsider nasogastric

rehydration or intravenous

rehydration.

•Consider the need for EU C .

4 options

1. “Aggressive” and diligentoral rehydration.

2. Rapid NG rehydration:Ensure the nasogastric tubeis inserted in the stom ach, e.g. aspirating fluid and testingacid by pH tape. C om m enceG astrolyte® via an enteralinfusion pum p e.g. Kangaroo® at 10m L/kg/hr for 4 hours.

3. Rapid IV rehydration: TakeEUC , check BG L. C om m ence10m L/kg/hr for 4 hours using 0.9% N aCl + 2.5% G lucose.

4. Standard IV rehydration:Take EU C , check BG L.C om m ence 0.9% N aC l +2.5% G lucose or 0.45%N aCl + 2.5% G lucose.

If contemplating IV rehydra-tion and there is difficultygaining vascular accesscommence oral/nasogastricrehydration.

O r if:

•D eteriorating clinical status

•W orrying signs/sym ptom s (see page 8)

Seek urgent medical advice/review.

Further consultation may be necessary.

Local hospital policy should define theappropriate consultation m echanism .

C om m ence/continue oral intake.

It is expected that the clinical status of an infant or child who is receiving rehydration therapy

for gastroenteritis should gradually improve.

Reassess clinically and consider EU C w ithin 6–8 hours.

•G ive oxygen until signs ofshock are reversed.

•G ain vascular accessurgently.

•If IV difficult, use theintraosseous route.

•Take EU C , BG L (if possible)but do not delay in givingbolus of 20m L/kg 0.9%N aC l or H artm anns stat.

•Reassess for signs of shock.

•Repeat bolus if necessaryuntil signs of shock arereversed.

•Reassess hydration status.Based on this assessm entadm inister IV fluidreplacem ent over 24 hours.Reassess fluid balancefrequently.

•M onitor continuously andclinically reassessfrequently.

Requires admission to hospital

for prompt management

and constant supervision

N O T IM PRO VIN G IM PRO VIN G


14/41

PAGE 10 NSW HEALTH Infa nts and Children — Acute Mana gemen t of Ga stroent eritis

M ost children w ith gastroenteritis and

m ild- m oderate dehydration can be

successfully rehydrated w ith oral

rehydration solutions either by m outh or

nasogastric tube.

Oral Rehydration SolutionsO ral rehydration solutions (O RS) are

specifically designed fluids that contain an

appropriate am ount of sodium , glucose

and other electrolytes and are of the

appropriate osm olality, to m axim ise w ater

absorption from the gut. They use the

principle of glucose-facilitated sodium

transport w hereby glucose enhancessodium and secondarily w ater transport

across the m ucosa of the upper intestine.

The sodium and glucose concentrations

and the osm olality are of vital im portance.

The W orld H ealth O rganisation (W H O )

recom m ends an O RS that has a sodium

concentration of 90m m ol/L. In developedcountries w ith non-cholera diarrhoea, it is

generally thought that 90m m ol/L is a little

high, as non-cholera gastroenteritis does

not result in the sam e sodium losses that

are seen in cholera.

M any different O RS w ith varying sodium

concentrations have been developed. It

has been show n that w ater absorption

across the lum en of the hum an intestine is

m axim al using solutions w ith a sodium

concentration of 60m m ol/L1 (such as

G astrolyte® ) and this is the concentration

recom m ended by the European Society of

Paediatric G astro-enterology and

N utrition.2 H ow ever som e children w ho

are not particularly dehydrated w ill refuseto drink such an O RS because of its salty

taste. O RS w ith slightly less sodium such

as Hydralyte® m ay be m ore palatable,

particularly as this com es in an iceblock

form .

O RS w ith sim ilar com positions to

H ydralyte® are safe and effective. These

hypo-osm olar solutions (such as

G astrolyte® and H ydralyte® ) are m ore

effective at prom oting w ater absorption

than isotonic or hypertonic solutions.3,4,5

The com position of various O RS and other

fluids is show n in Tables 2 and 3. Fruit

juices and soft drinks are inappropriate

because of the m inim al sodium contentand the excessive glucose content and

hence excessive osm olality, w hich w ill

w orsen diarrhoea. A lthough diluting juices

and soft drinks reduces glucose

concentration, the fluid has insufficient

sodium to act as a rehydration fluid.

Sports drinks have varying sodium andcarbohydrate levels, and are considered

inappropriate as rehydration solutions.

Enteral Rehydration Therapy


15/41

NSW HEALTH Infa nts and Children — Acute Mana gemen t of Ga stroent eritis PAGE 11

Table 3: Composition of Oral Fluids

Comparisons of Oral Fluids

N a+ C arbohydrate O sm olality(m m ol/L) (m m ol/L) (m O sm /L)

A pple Juice 3 690 730

Soft drinks ~2 ~700 ~750

Sports drinks ~20 ~255 ~330

Table 2: Composit ion of Oral Rehydration Solutions

Comparisons of ORS

N a C arbohydrate O sm olality(m m ol/L) (m m ol/L) (% ) (m O sm /L)

W H O 90 G 111 (2% ) 331

G astrolyte® 60 G 90 (2% ) 240

G astrolyte-R® 60 RSS 6g/L (2.5% ) 226

Repalyte® 60 G 90 (2% ) 240

Terry W hite/C hem -m art® 60 G 90 (2% ) 240

H ydralyte® 45 G 90 (2.5% ) 240

G = glucose, RSS = rice syrup solids


16/41


Discharge Criteria

C hildren w ith gastroenteritis can be dis-

charged, even if they still have som e

vom iting, if the follow ing discharge criteria

are m et:

1. D iagnosis of gastroenteritis

2. C hild is rehydrated or only m ildly

dehydrated

3. G astrointestinal losses not profuse

4. C hild has passed urine in ED or w ithin

the last 4 hours

5. Parent has dem onstrated the ability togive an O RS appropriately

6. C linical staff confident parent w ill take

child to G P for review w ithin 48hrs

and represent for m edical review if

child’s condition deteriorates.

7. If a child w ith gastroenteritis and

dehydration does not fulfil the

discharge criteria, they w ill need to be

adm itted for ongoing m anagem ent.

Method of Giving Oral Fluids

It is im portant to give sm all am ounts of

fluid frequently, for exam ple 0.5m L/kg

every five m inutes. The fluid can be

m easured in a syringe and given to the

child either by syringe, teaspoon or cup.The child is far m ore likely to tolerate

these sm all am ounts of fluid than if he/she

drinks a large am ount at once.

O bviously if the child tolerates this fluid

the parent can gradually increase the

volum e and decrease the frequency of the

fluid offered. Success can be optim ised in

the Em ergency D epartm ent setting by

giving the parents a docum entation chart

(see A ppendix 3) to record the fluid given

and any vom its, diarrhoea or urine passed.

It is im portant to educate the parents that

seeing a doctor w ill not cure their child of

his/her vom iting and diarrhoea. Sm all,

frequent am ounts of fluid w ill hopefully

m inim ise the vom iting, but w ill not reduce

the diarrhoea. The aim is for the input to

exceed the output by enough to rehydrate

and then m aintain hydration.

Occasional vomiting alone should not

be considered as failure of oral

rehydration therapy.


17/41


Increasing num bers of hospitals in

developed countries are using an O RS via

continuous nasogastric (N G ) infusion.8,9

This has been show n to be as effective as

intravenous rehydration,8-15 less

expensive8,15 and reduces lengths of

hospital stay8 w hen com pared w ithstandard intravenous rehydration. It is

usually unnecessary to perform EU C for

children being rehydrated w ith nasogastric

O RS.

N asogastric rehydration is w here an O RS is

infused continuously via a nasogastric tube

w ith a pum p such as a Kangaroo® pum p.

Choose an ORS with a sod ium

concentration of 60mmol/L such as

Gastrolyte®, as this is the optimal

concentration and taste is not an issue

when using an NG tube. H ydralyte® has

only 45 m m ol/L of sodium , and is not the

preferred nasogastric solution (but w hen

given orally often has better com pliance

due to taste). N asogastric rehydration is

often successful even in children w ith

frequent vom iting. Staff need to be

com petent in placing nasogastric tubes in

children and babies and follow local

protocols and training/accreditation

procedures. Facilities need to be equipped

to deliver N G rehydration in regards to

equipm ent and education before this form

of rehydration should be introduced.

Do not use nasogastric rehydration if

the child has:

an ileus (check for bow el sounds)

significantly reduced level of

consciousness

Do not use ‘rapid’ nasogastric

rehydration if child:

is younger than 6 m onths old

has a m edical condition w hich

increases the risk of fluid overload

D ifferent regim ens are used for

continuous nasogastric rehydration. O ne

sim ple m ethod is described below :

Perform observations –tem perature

(T), pulse (P), respiratory rate (R), blood

pressure (BP) and m ental state –before

com m encing, then repeat T, P, and R

at least hourly.

Establish N G access

G ive 10m L/kg/hour of G astrolyte®

over four hours for all m ild-m oderately

dehydrated children,after which the

infusion is ceased.

D o not take blood for EU C and BG L as

a routine.

A fter com pletion, the child is then

re-exam ined by the m edical officer and

a re-trial of oral fluids is com m enced.

N asogastric Rehydration Therapy


18/41


A fter 1–2 hours of com pleting rehydration

the child is reassessed and if he/she fulfils

the discharge criteria (page 12), m ay be

discharged w ith appropriate advice and

follow -up.

If the child does not tolerate N G

rehydration, (N B: 1 or 2 sm all vom its does

not necessarily m ean N G rehydration has

failed), IV rehydration w ill probably need

to be com m enced.This should be over

24 hours i.e. do not give rapid IV

rehydration after the child has already

received ‘rapid’ NG rehydration (see

page 16 for calculation).

Som e clinicians m ay choose to use a low er

N G infusion rate, either initially or over a

longer period of tim e; sim ilar to the

standard IV rehydration rate (see page 17).

If the child tolerated the N G rehydration

but fails the subsequent trial of oral fluids,the child w ill usually need to stay in

hospital. If further fluid in addition to that

taken orally is required after reassessm ent,

this can be given via the nasogastric tube.

A second administration of ‘rapid’ NG

rehydration should not be given (see

page 18 for calculation). A t this point,

EU C and BG L should be checked to ensure

that an electrolyte abnorm ality is not the

cause for failure of rehydration.

N G rehydration is m ost suitable for infants

and young children. From a practical

view point, older children w ould be m ore

suitable to be rehydrated orally or

intravenously.


19/41


Introductory notes

W hen IV fluid therapy is com m enced,

the first decision is w hether the child is

severely dehydrated and needs

resuscitation (see below ).

W hen resuscitation fluid (a bolus) hasbeen given for shock, and the signs of

shock corrected, then the next phase of

treatm ent is to provide standard IV

rehydration.

If a bolus has not been needed, the

next phase of treatm ent is to provide

either rapid IV rehydration or standard

IV rehydration.

In this G uideline, 0.9% N aC l + 2.5%

G lucose is considered to be an isotonic

solution, as the glucose is rapidly

m etabolised after infusion.

W henever an IV cannula is inserted for

the provision of IV fluids, blood should

be w ithdraw n and sent for EU C andBG L.

C hildren w ith gastroenteritis and

dehydration are at risk of

hypoglycaem ia; any fluid used for

rehydration should contain som e

glucose. For hypoglycaem ic children

(i.e. BG L


20/41


established. If neither is possible

com m ence nasogastric rehydration

w hile aw aiting assistance. These

adm inistration routes do not negate

the need for an IV line.

0.9% N aC l or H artm ann’s solution, 20m L/kg, should be given IV/IO initially

over 10–20 m inutes. These fluids

should N O T contain G lucose.

For hypoglycaem ic children (i.e. BG L


21/41


Sm all am ounts of oral fluids m ay be

com m enced earlier, during IV

rehydration, if appropriate. Intravenous

fluids should only be recom m enced if

on review the child still has signs of

dehydration, or if there are significant

ongoing losses.

If the rapid rehydration has been

com pleted late at night, and the child

has no signs of dehydration, the child

m ay safely be allow ed to sleep w ith

the IV capped, w ith a trial of oral fluids

to com m ence w hen the child w akes.

It is expected that the clinical status

(e.g. heart rate, perfusion and m ental

state) of the child receiving rapid IV

rehydration for gastroenteritis should

gradually im prove. Failure to im prove,

any deterioration, or the developm ent

of unexpected signs or sym ptom s

should lead to a reconsideration of the

diagnosis and m anagem ent, and

discussion w ith a Paediatrician.

Standard IV Rehydration

Standard rehydration refers to the

provision of m aintenance fluids, and

the correction of dehydration, usually

over 24 hours.

W hen the IV cannula is inserted, sendblood for EUC and BG L.

It is acceptable to com m ence fluid

therapy w ith either 0.9% N aC l + 2.5%

G lucose or 0.45% N aCl + 2.5%

G lucose for standard IV rehydration,

pending EUC results. 0.9% N aCl + 5%

G lucose and 0.45% N aC l + 5%

G lucose are acceptable alternatives.

Calculate the total volum e of IV fluids

likely to be needed for the next 24

hours, being m aintenance and deficit.

Do not include fluids already given for

resuscitation. If resuscitation has been

required, reassess dehydration state

now and calculate fluid requirem ent

from now . N ote that this calculation is

a ‘starting point’w hich w ill be review ed

according to progress, including

assessm ent of general appearance,

heart rate, urine output, ongoing losses

(vom iting, diarrhoea), or fever, at

intervals of not m ore than 6 hours.

Body Weight Fluid requirement mL/ day Fluid requirement mL/ hour

First 10 kg 100 m L/kg 4 m L/kg/hr

Second 10 kg + 50 m L/kg + 2 m L/kg/hr

Subsequent kg + 20 m L/kg + 1 m L/kg/hr


22/41


The m ajority of children w ill not

require rehydration for m ore than a

5% deficit in the first 24 hours.

The volum es for rehydration and

m aintenance are calculated separately,

as the basis for calculation of each isdifferent.

For rehydration: W eight (in kg) X %

dehydration X 10 = m L deficit needed

for rehydration. For exam ple, a 9 kg

child estim ated to be 5% dehydrated,

rehydration volum e is 9 X 5 X 10 =

450 m L. (see Table 1 on page 8 for a

guide to assessing dehydration)

For maintenance: C alculate volum e

according to the child’s w eight, as in

the table (page 17):

For exam ple: A child w eighing 25 kg

has a m aintenance fluid requirem ent

for 24 hours of:

(10 X 100) + (10 X 50) + (5 X 20) =

1600 m L per 24 hours.

N ote:

– M aintenance fluids for infants less

than 6–9 m onths is 120m L/kg

– There are alternative m ethods for

calculating m aintenance fluid

requirem ents (see A ppendix 7 for

an exam ple).

A dd the tw o volum es (rehydration +

m aintenance) together. C alculate the

rate to give the total volum e over 24

hours. Start by giving 0.9% N aC l +

2.5% G lucose or 0.45% N aCl + 2.5%

G lucose over the first 6-8 hours, then

review the child’s progress.

DO NOT USE LOW SODIUM-

CONTAINING FLUIDS (any fluid w ith

less sodium than 0.45% N aC l)FOR

ONGOING TREATMENT.

Form al review by a M edical O fficer

after 6–8 hours is generally required.C heck hydration. C heck patient

physically, including m ental state.

Take note of parental observations or

concerns.

There is som e em erging evidence that

0.9% N aC l + 2.5% G lucose solution

m ay be a m ore appropriate IV solutionfor rehydration in gastroenteritis16.

Rapid im provem ent over 2–4 hours is

the ‘norm ’. O nset of any new sym ptom s

(e.g. drow siness, headache, abdom inal

pain) dem and urgent review . A typical

behaviour of the patient should raise

the question of an alternate diagnosis.

Repeat EU C if the child still appears

unw ell, if the electrolytes w ere

m arkedly abnorm al initially, or if the

child w as seriously unw ell initially.

Repeat EU C should also be planned for

the child w ho continues on IV fluids.

A dd potassium ~3 m m ol/kg/24hrs

w hen urine is passed, if initial serumpotassium w as norm al (up to 5 m m ol/

kg/24hrs if m arked hypokalaem ia is

present). G enerally this is achieved by

adding 10 m m ol of potassium as KC l

to each 500 m L bag of IV fluid.


23/41


Hypernatraemia (serum sod ium>149 mmol/L)

Do not follow the Acute Gastroenteritis

Guideline for fluid administration.

Early consultation with a Paediatrician

is essential.

H ypernatraem ic dehydration is uncom m on,

but potentially m ore dangerous than w hen

serum sodium is initially norm al or slightly

low . There is a greater likelihood of cerebral

oedem a, seizures and brain dam age.

C linically, the degree of dehydration m ay

be underestim ated.

If shock is present, resuscitate w ith a fluid

bolus of 20 m L/kg, using 0.9% N aC l or

H artm ann’s solution.

C ontinuing rehydration should proceed

slow ly (usually over at least 48 hours),

initially using 0.9% N aC l + 2.5% G lucose.

Hyponatraemia (serum sodium


24/41


G enerally, children being enterally

rehydrated do not require blood tests.

If nasogastric rehydration is required

beyond 4 hours of rapid nasogastric

rehydration, check EU C and BG L.

M edical reassessm ent of the patient,

including hydration status, is required.

A ll children w ith severe dehydration or

w ith intravenous therapy, need EU C ,

BG L.

C onsider blood culture and FBC if the

child has a tem perature >39ºC .

G enerally urine culture is not required

but urinalysis is helpful.

It is generally unnecessary to send

stool for M C & S or viral studies. In

som e circum stances (e.g. bloody

diarrhoea, history of travel, and

com m unity outbreak of gastroenteritis)

it m ay be appropriate to undertake

these tests.

Infants and children w ho are severely

dehydrated require constant

observation and m onitoring, including,

w here possible, cardiac m onitoring,

pulse oxim etry, frequent blood

pressure m easurem ent and urine

output m easurem ent.

Every child being treated in hospital for

gastroenteritis, w hether or not having

intravenous therapy, requires

observation of, and recording of,

standard observations (e.g. pulse,

respiration, tem perature etc.) on a

regular basis (not less than 4-hourly).

C hildren needing IV fluid therapy

require EU C and BG L check at initial

assessm ent. If initial EU C w as m arkedly

abnorm al, or if the child’s condition

has not started to im prove, or if the

child w as severely dehydrated recheck

EU C at 6–8 hours. Results should be

checked w ithin tw o hours.

If there is failure to im prove,

deterioration or developm ent of new

signs, there should be discussion w ith

the A dm itting M edical O fficer.

A daily lightly clothed w eight can be a

useful clinical param eter in the

assessm ent of progress afteradm ission, as w ell as a retrospective

guide to the accuracy of the initial

assessm ent of dehydration.

Investigations and O bservations


25/41


Reintroduction of Diet

C hildren w ho are not dehydrated should

continue to be fed an age-appropriate

diet. C hildren w ho require rehydration

should recom m ence age appropriate diets

as soon as vom iting settles. This should bew ithin the first 12–24 hours. Form ula-fed

infants should recom m ence full strength

form ula.

Refer to G astroenteritis fact sheet jointly

developed by the C hildren’s Hospital

W estm ead, the Sydney C hildren’s H ospital

and the John H unter C hildren’s H ospital.The fact sheet is available at:

w w w .chw .edu.a u/pa rents/fa ctsheets

w w w .sch.edu .a u/he a lth /fa ctshe et s

w w w .ka leidoscope .org.a u/pa rents/

factsheets .htm


26/41


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A ppendices

Appendix One – Glossary

Word/

Abbreviation

Definition

A dm itting M edicalO fficer

M ost senior m edical officer under w hom the child is adm itted tohospital

BG L Blood G lucose (Sugar) Level

FBC Full Blood C ount

H artm ann’s solution Isotonic intravenous solution (see ‘Com position’table A ppendix Tw o)

O RS O ral Rehydration Solution

EUC Electrolytes, Urea and Creatinine. Ideally this should include m easurem ent

of serum sodium , potassium , chloride, bicarbonate, urea and creatinine. It

is recognised that not all local laboratories offer all of these param eters 24

hours. It is essential that the serum sodium be m easured on any child

w ho is receiving intravenous rehydration therapy.


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OsmolalitymOsm/L Na

+

mmol/L Cl

-

mmol/L Glucoseg/L K

+

mmol/L

0.9% N aC l 300 150 150 – –

Hartm ann’s

Solution274 129 109 – 5

0.45% N aC l &

2.5% G lucose292 76 76 25 –

0.9% N aC l &

2.5% G lucose448 150 150 25 –

Appendix Two – IVT Composition


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Appendix Three – Parent Oral Rehydration

Documentation Form

Oral Fluids for your Child with Gastroenteritis

Please give your child:

1. Frequent breastfeeds if you are breastfeeding or

2. A n O ral Rehydration Solution

D ilute juice (e.g. 1 part apple juice to 4 parts w ater) is not as effective but som etim es m ay

be used if your child is not dehydrated.

Your child’s w eight is ______ kg.

Your child should drink about _________ m L every 5 m inutes (½ m L/kg) or 1 H ydralyte®

iceblock (62.5m L) every ______ M inutes.

U se the 10 m L syringe to m easure the fluid unless using H ydralyte® iceblock. G ive the fluid

to your child in a syringe, teaspoon, bottle or cup.

(O ne H ydralyte® iceblock = 62.5 m L)

Please record every tim e you give your child fluid and every tim e your child vom its, passes

urine or has diarrhoea:

TIME FLUID TYPE VOLUME VOMIT DIARRHOEA URINE1

2

3

4

5

6

7

8

9

10

11

12

13

14

1516


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NSW Child

Health Networks

ORAL FLUIDS for

YOUR CHILD with GASTROENTERITIS

The nurse w ho assessed your sick child has placed you into an appropriate category for

urgency to see the doctor. It is m ost likely that your child has gastroenteritis and needs fluid

treatm ent. H ere in hospital w e use oral fluids w hile you are w aiting to see a doctor.

If you have been giving your child fluids at hom e, you are probably here because you feelthis has been unsuccessful. The w ay w e give oral fluids here m ay be slightly different and is

often successful. The other side of this sheet explains exactly how m uch fluid and how

often w e w ant you to give it to your child.

W hen your child sees the doctor a decision w ill be m ade as to w hether you can go hom e,

or w hether your child needs a sm all tube through the nose into the stom ach or a drip to

provide extra fluid for a few hours. Som etim es this is all it takes to m ake your child feel a

lot better and you w ill then be able to go hom e. If this doesn’t im prove your child, he orshe m ay need to be adm itted to hospital for further treatm ent.


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Appendix Four – Parent Information

A G astroenteritis Fact Sheet jointly developed by John H unter C hildren’s Hospital,

Sydney C hildren’s Hospital and C hildren’s Hospital W estm ead is available at:

w w w .ka leido scope.o rg.a u/pa rent s/fa ctshe et s.ht m


w w w .chw .ed u.a u/pa rent s/fa ctshe et s

Disclaimer: The fact sheet is for educational purposes only. Please consult w ith your doctor

or other health professional to ensure th is information is right for your child.


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Appendix Five – Resources

Fuller details m ay be necessary in practice, especially for the m anagem ent of children

w ith m oderate or severe dehydration. Possible sources include:

N SW H ealth D epartm ent C IA P w ebsite, M anaging Y oung C hildren and Infants w ith

G astroenteritis in H ospitals at: w w w .ciap.health.nsw .gov.au also

The C hildren’s H ospital W estm ead H andbook, 2004 (Sections 7 — Fluid Therapy, and

Section 16 — G astroenterology), available as a book from the C hildren’s Hospital at

W estm ead, or at:w w w .chw .edu.a u/pa rents/fa ctsheet s

G astroenteritis Fact Sheet jointly developed by the John H unter C hildren’s Hospital,

Sydney C hildren’s Hospital and C hildren’s Hospital W estm ead at:

w w w .ka leido scope.o rg.a u/pa rent s/fa ctshe et s.ht m


w w w .chw .ed u.a u/pa rent s/fa ctshe et s


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Appendix Six – Significant Changes From

2002 CPG Version

Levels of dehydration m odified Rapid and standard rehydration techniques included and volum e calculations am ended

IV Fluid Therapy section m odified

Enteral Rehydration Therapy section included

M edications section revised and expanded

Indication for blood chem istry revised

Reintroduction of diet m odified H yponatrem ia section added

Parent fluid docum entation form included

Appendix Seven – Alternative Calculation

for Maintenance Fluids

Calculate the maintenance fluid requirement, for 24 hours, by age:

–Infants up to 9 m onths: 120–140m L/kg/24hrs

–Children 9–24 m onths: 90–100m L/kg/24hrs

–Children 2–4 years: 70–90m L/kg/24hrs

–Children 4–8 years: 60–70m L/kg/24hrs

–O lder children: 50–60m L/kg/24hrs


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Appendix Eight – Working Party Members

Dr Christopher Webber (Chair)

Paediatric Em ergency Physician and

C onsultant PaediatricianEm ergency D epartm ent

Sydney C hildren’s H ospital

Dr Matthew Chu

D irector of Em ergency M edicine

C anterbury H ospital

Dr Steven Doherty (to March 2007)Em ergency Physician

Em ergency D epartm ent

Tam w orth H ospital

Dr Patrick Moore

Staff Specialist Paediatrician

Fairfield H ospital

Dr Kristen Neville

Paediatric Endocrinologist

Sydney C hildren’s H ospital

Dr Susan Phin

Paediatric Em ergency Physician

Em ergency D epartm ent

C hildren’s Hospital W estm ead

Mr Phillip Way

C linical N urse C onsultant

Rural C ritical C areH unter N ew England A rea H ealth Service

Ms Rhonda Winskill

C linical N urse C onsultant, Paediatrics

H unter N ew England A rea H ealth Service

Ms Leanne Crittenden

C oordinatorN orthern C hild H ealth N etw ork

Ms Judy Lissing

C oordinator

G reater Eastern and Southern

C hild H ealth N etw ork

Ms Halina NagielloC oordinator

W estern C hild H ealth N etw ork

Ms Mary Crum

Senior A nalyst

C linical Policy Branch (Secretariat)

N SW H ealth

Mr Bart Cavalletto

M anager, Statew ide Paediatric Services

N SW H ealth


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