Gastroenteritis in Children: Principles of Diagnosis and

Treatment
B. CLAIR ELIASON, M.D., Medical College of Wisconsin, Milwaukee, Wisconsin
RICHARD B. LEWAN, M.D., Waukesha Family Practice Residency Program, Waukesha, Wisconsin
Am Fam Physician. 1998 Nov 15;58(8):1769-1776.

Gastroenteritis in children is a common reason for visits to family physicians. Most cases of
gastroenteritis have a viral etiology and are self-limited. However, more severe or prolonged
cases of gastroenteritis can result in dehydration with significant morbidity and mortality. This
is often the scenario in third-world countries, where gastroenteritis results in 3 million deaths
annually. A proper clinical evaluation will allow the physician to estimate the percentage of
dehydration and determine appropriate therapy. In some situations, laboratory studies such as
determination of blood urea nitrogen and serum electrolytes may be helpful. Stool studies are
indicated if a child is having bloody diarrhea or if an unusual etiology is suspected, such as
Escherichia coli O157:H7 or Cryptosporidium. Most children with gastroenteritis can be
treated with physiologically balanced oral rehydration solutions. In children who are
hypovolemic, lethargic and estimated to be more than 5 percent dehydrated, initial treatment
with intravenous boluses of isotonic saline or Ringer's lactate may be required. Children with
severe diarrhea need nutrition to restore digestive function and, generally, food should not be
withheld.

GastroenteritisamongchildrenintheUnitedStatesisacommonandusuallynonfatalillness,
althoughitresultsin3milliondeathsannuallyworldwide. Acleanwatersupply,goodnutrition,
reasonablephysicalcleanlinessandappropriatedisposalofhumanwastehasallowedtheUnited
Statesandotherdevelopedcountriestocontrolthetransmissionandvirulenceofinfectious
agentsthatcausediarrhea.Mostcasesofgastroenteritisinthiscountryareselflimitedand
requireminimalintervention.Occasionalepisodesofsevere,lifethreateninggastroenteritismay
occur,however,necessitatingaggressivetherapeuticintervention.
1

Mostfamilyphysicianswilloccasionallyencounteraseverelyillchildwithgastroenteritiswho
needsaggressivefluidmanagement.Inappropriateuseoforalliquids,suchasbrothswithavery
highsodiumcontent(upto250mEqperL)orsoftdrinkswithaverylowsodiumcontent(1to2
mEqperL)maytransformamildisotonicdehydrationintoamorecomplexhypertonicor
hypotonicdehydration. Anunderstandingofthecommonetiologiesofgastroenteritis,alongwith
theprinciplesoffluidandelectrolytemanagement,isimportantforallphysicianswhocarefor
children.
2

Thisarticlereviewscommonetiologiesofgastroenteritisinchildren,appropriateassessmentof
hydrationstatusandapproachestofluidreplacement.Specificeducationalpointsandprinciples
oftreatmentareemphasized.Thehistoryandphysicalexaminationarethecornerstoneof
diagnosisandassessmentand,alongwithoccasionallaboratorytests,shouldguidetherapy.

Illustrative Cases
CASE 1

Afouryearoldboypresentedwithathreedayhistoryofbloodydiarrheawithnovomitinganda
temperatureupto40C(104F).Overtheprevious24hoursthechildhadhadwatery,bloody
bowelmovementsevery20minutes.Hisfluidintakeconsistedofsoftdrinks,andurinationwas
infrequent.Oneotherfamilymemberhadnonbloodydiarrhea.

Onphysicalexamination,thepatient'stemperaturewas39.7C(103.6F),hisrespiratoryratewas
30andhispulseratewas130whensupineand160whenupright.Thepatientweighed15kg(33
lb)andhadabloodpressuremeasurementof80/60mmHg.Hewasalertbutirritable,withadry
mouthandnotearing.Hisskinturgorandcapillaryrefillingwerenormal.Bowelsoundswere
increased,andtheabdominalexaminationwasotherwisenormal.
Laboratoryresultsshowedthefollowingelectrolytelevels:sodium,118mEqperL(118mmol
perL);potassium,3.2mEqperL(3.2mmolperL);chloride,90mEqperL(90mmolperL);
bicarbonate,14mEqperL(14mmolperL);creatinine,0.8mgperdL(70molperL),and
bloodureanitrogen,20mgperdL(7.1mmolperL).Thechildwaseventuallydiagnosedwitha
bacterialinfectioncausedbyaShigellaspecies.
CASE 2

Afourweekoldfemaletwinbornat37weeksofgestationhadlarge,waterydiarrhealstoolsfive
tosixtimesperdayforthreetofourdays,withsomevomiting.Shewastakingformulaandno
clearliquids.Hertwinsisterhadasimilarbutlesssevereillness.Theinfant'sneonatalcoursewas
normal.Attwoweeksofagesheweighed2.36kg(5lb,3oz).
Onphysicalexamination,theinfantweighed2.05kg(4lb,8oz),witharespiratoryrateof40and
aheartrateof120.Hertemperaturewas37.0C(98.7F),andherbloodpressuremeasurement
was30/0mmHg.Thepatientwaslethargicandweaklyresponsive,withcoolextremities.Her
skinturgorwasdecreased,andcapillaryrefillingtimewasabout3.0seconds.
Resultsoflaboratorytestsincludedthefollowing:sodiumlevel,145mEqperL(145mmolper
L);potassiumlevel,4.2mEqperL(4.2mmolperL);bicarbonatelevel,12mEqperL(12mmol
perL);bloodureanitrogenlevel,25mgperdL(8.9mmolperL);andcreatininelevel,0.8mg
perdL(70molperL).Theillnesswasprobablyviralinorigin.
CASE 3

Athreeyearoldboypresentedwithabdominalpain,feverandbloodydiarrhea.Nootherfamily
memberswereill.Thechildhadfourtofivebloodydiarrhealstoolsperday,withnovomiting
anddecreasedurination.
Onphysicalexamination,thechildhadatemperatureof39.6C(103.4F),arespiratoryrateof
20perminute,aheartrateof100andabloodpressureof70/30mmHg.Thepatientwasalert
andirritablewithnormalskinturgor,normalcapillaryrefillandanormalabdominal
examination.Rarepetechiaewerepresent.Theelectrolyte,bloodureanitrogenandcreatinine
levelswerenormal.
CASE 4

An18montholdgirlpresentedwithathreedayhistoryoffeverandfrequent,brightred,bloody
diarrhealstools.Shewastakingfluids,includingsomebroth.Therewasnovomiting,andno
otherfamilymemberswereill.ThechildhadrecentlytraveledtoMexico.
Onphysicalexamination,thechildhadatemperatureof39.6C(103.4F),aheartrateof140,a
respiratoryrateof25andbloodpressureof90/60mmHg.Thechildwasirritablebutnot
lethargicwithgoodcapillaryrefillbutdecreasedskinturgor.Bowelsoundswereincreasedwith
noguardingorreboundandsomegeneralizedtenderness.

Resultsoflaboratorytestsincludedthefollowing:sodium,155mEqperL(155mmolperL);
bloodureanitrogen,20mgperdL(7.1mmolperL);andcreatinine,0.9mgperdL(80molper
L).Thestoolculturewasnegativeafter24hours.

Diagnosis and Assessment of Hydration

Table1summarizespertinentitemsrelatingtocommonetiologiesofgastroenteritis.Mostlife
threateningviraldiarrhealillnessesoccurinchildrenunderthreemonthsofageorinthosewho
maybecompromisedbyprematurity,malnutritionorpoverty.Viralgastroenteritisinolder
childrenisgenerallyselflimitedandusuallyrequiresonlyoralrehydrationtherapy.
TABLE 1

Types of Gastroenteritis According to Etiology

Etiology

History

Viruses (rotavirus most

common), Norwalk virus,
other viruses

Vomiting
often present
before
diarrhea;
large-volume,
watery stools,
usually not
frequent or
bloody;
rotavirus
infection
usually
occurs in
winter

Physical
examinatio
n
Usually
varies, not
toxic; may be
mildly
dehydrated;
small
children may
be very ill

Age
Common
in infants
and
young
children

Laboratory
test
Management
Rotozyme
5%
(rapid test), dehydration:
electrolytes,
BUN,
creatinine
1. Usually can
and other
be treated
tests as
with oral
needed
liquids.
(i.e.,
urinalysis)
2. Breast
feeding may
be continued.

3. Prolonged
withholding of
food not
appropriate
unless severe,
protracted
vomiting is
present.

Shigella, Salmonella,
Campylobacter, other
bacteria,Entamoeba
histolytica

Bloody stools Variable;

common
may have a
(50% of
high fever
patients);
may have
bacterial
infection
without blood;
more

All age
groups

Stool
5 to 10%
culture;
dehydration:
stool
examination
for
1. Depending
leukocytes
on age,
(>5 white
reliability of
blood cells
family, oral
per highhydration may

Etiology

History

Physical
examinatio
n

Age

frequent,
small-volume
bowel
Escherichia coliO157:H7

Associated
with bloody
diarrhea and
hemolytic
uremic
syndrome in
children;
occurs in
clusters of
patients who
have
ingested
contaminated
foods

Laboratory
test
Management

power field in
a stool
smear); CBC
May be quite
toxic; always
evaluate
mental
status

More
common
in
children
<4
years of
age

be most
appropriate;
for some
patients,
hospitalization
is important.

Capability of 10%
serotyping
dehydration:
is important;
electrolytes,
BUN,
1. Treat
creatinine,
vigorously
CBC,
with isotonic
platelets;
intravenous
clotting
fluids and
studies;
supportive
peripheral
therapy.
smear; LDH

Others:
Cryptosporidium;Clostridiu
m difficile; Giardia lamblia;
Vibrio cholera;Cyclospora

BUN = blood urea nitrogen; CBC = complete blood cell count; LDH = lactate dehydrogenase.

Astoolspecimenshouldbeexaminedforwhitebloodcellsinanychildwhoappearstoxicwith
highfeveranddiarrhea.Thefindingofwhitebloodcellsshouldpromptfurtherinvestigationto
ruleoutinvasivebacterialdisease.Thepresenceofgrossbloodinthediarrhealstoolalso
suggestsamoreseriousinfection,sochildrenwithbloodydiarrheashouldundergoarectalswab
orstoolculture. Otherlaboratorytestsareoptionalandaredictatedbytheseverityofillness.
IfEscherichiacoliisidentifiedinapatientwithbloodydiarrhea,serotypingshouldbedoneto
specificallyidentifytheO157:H7strain,whichcancausehemolyticuremicsyndrome,a
potentiallyfatalillness. Thepetechiaeinthepatientinillustrativecase4areanindicationofa
consumptivecoagulopathy,whichmayoccurwithE.coliO157:H7infections.
2

Inmostchildrenwithdehydrationgreaterthan5percent,serumelectrolytes,bloodureanitrogen
andcreatininelevelsshouldbemeasured.OtherteststhatmaybeindicatedarelistedinTable1.
Ifunusualcausesofgastroenteritisaresuspected(i.e.,traveltoareasatrisk,affectedcontactor
immunosuppression),threefreshstoolspecimensshouldbeevaluatedforroutineculture,ova,
parasitesandCryptosporidiumspecies.Thechildinillustrativecase4wasinfected
withEntamoebahistolytica,whichwasidentifiedinonlyoneofthreestoolspecimens.Other

unusualcausesofgastroenteritisincludeClostridiumdifficile,Cryptosporidiumspecies, Giardia
lamblia, Vibriocholera andCyclospora.
4

Table2 offersaguideforassessingthestateofhydrationinchildren.Recentweightchange
documentedwiththesamescaleisveryhelpfulinassessingfluidloss. Accurateweightsmay
behardertoobtaininyoungerchildren,thereforethetechniqueisimportant.Thecomparisonof
weightsinillustrativecase2wasveryhelpful,sinceitindicatedmorethan10percent
dehydration,anindicationthatwasconsistentwiththeclinicalassessmentofdehydrationinthis
patient.Theassessmentofmentalstatusisalsoimportantintheevaluationofanillchild.Achild
whoishappyandplayfulusuallyhasnosignificanthydrationproblem.Increasingdisturbancesin
mentalstatus,fromrestlessnesstoirritabilityandthentolethargy,indicateageneraloverall
worseninginthepatient'sconditionandshouldhelpguidetheaggressivenessoffluid
resuscitation.
1,79

1,8,9

TABLE 2

Methods for Assessing Degree of Dehydration

Degree of dehydration
Normal < 5%

Factor
Capillary refilling time

5 to 10%

> 10%

0.8
seconds

1.5 seconds or 1.5 to 3.0

less
seconds

> 3.0 seconds

Elevated BUN (normal

BUN: 8 to 25 mg per
dL )

< 10 mg
per dL

10 to 20 mg
per dL

21 to 25 mg per
dL

> 25 mg per dL

Skin turgor

Normal

Slightly
decreased

Decreased

Decreased (pinch retracts

slowly >2 seconds)

Deep and rapid,

Normal
acidotic breathing (pH <
7.35; decreased
bicarbonate)

Slightly
increased
respiratory
rate

Increased
respiratory rate

Breathing is deep and

rapid

Infants and young

children

Thirsty, alert,
restless

Restless or
lethargic:
irritable to touch

Limp, drowsy; may be

comatose; cyanotic
extremities (cold sweats)

Older children

Thirsty, alert,
restless

Thirsty, alert,
postural
hypotension

Usually conscious;
wrinkled skin at fingers and
toes; cyanotic extremities

General state

Degree of dehydration
Normal < 5%

Factor

5 to 10%

> 10%
(cold sweats)

Pulse

Slight
increase;
normal
strength

Rapid and weak

Rapid, feeble, sometimes

impalpable

Systolic blood pressure

Normal

Decreased

May be unrecordable

BUN = blood urea nitrogen.

NOTE:

Clinical findings are most reliable when the examination is performed by two or more different
physicians.7 Other helpful but not specific signs include sunken fontanel, absent tears, decreased urine output,
sunken eyes, thirst and dry mucous membranes.
Information from references 1 and 7 through 9.

Vitalsigns,includingrespiratoryrate,addsignificantlytotheassessmentofhydration.Children
withdiarrheaandexcessivefluidlossusuallydevelopanonaniongapmetabolicacidosiswitha
decliningbicarbonatelevel.Tocompensate,therateanddepthofbreathingincrease
(compensatoryrespiratoryalkalosis).Aposturalchangeinheartrateisausefulclueinassessing
thefluidstateofchildrenoverfouryearsofage.Anincreasegreaterthan20beatsperminute
whenmovingfromalyingtoastandingpositionisanindicatorofhypovolemia.Ifthepostural
changesaregreater,thefluiddepletionislikelytobegreater.However,changesinposturalblood
pressurehavenotbeenfoundtobeveryusefulinchildrenundernineyearsofage.
10

Treatment
Thehistoryandphysicalexamination,withanassessmentofthechild'shydrationstatus,guide
thefluidtreatmentofchildren.WorldwideandintheUnitedStates,oralrehydrationsolutions
suchastheWorldHealthOrganizationsolutionsandotherclearliquidsarethecornerstoneof
treatment.
In1985,theAmericanAcademyofPediatrics(AAP)publishedapolicystatementonthe
treatmentofinfantswithacutediarrheacomplicatedbymildtomoderatedehydration. TheAAP
recommendedrapidrehydrationinfourtosixhourswithanoralglucoseelectrolyterehydration
solutionfollowedbydilutedformulaormilk.Contrarytowidespreadbeliefandpractice,lactose
basedmilkdoesnothavetobeeliminated.Inolderinfantsorchildren,ricecereal,bananas,
potatoesorothernonlactose,carbohydraterichfoodsshouldbeofferedshortlyaftersuccessful
rehydration.Inafollowupstudyofpracticingfamilyphysiciansandpediatricians,itwasnoted
thattheseclinicianstendedtotakemuchlongerthanrecommendedtorehydratetheirpatients,
oftenusedalactosefreeformulaanddidnotreinstitutefeedingoffullstrengthformulasoon
enough.
11

12

Arecentmetaanalysisof13studiesonthesafetyoforalrehydrationsolutionsnotedthatthe
failurerateofrehydrationwasonly3.6percent.Significantevidence hasnowaccumulated
13

supportingtheusefulnessoforalrehydrationsolutionsastheinitialtreatmentofchoiceinlow
riskinfantsandchildren,asdefinedinTable3.Patientswithdepressedbicarbonatelevels(13to
18mEqperL[13to18mmolperL])orthosewhovomitatleastfivetimesina24hourperiod
maybenefitfromaninitialintravenousinfusionofisotonicsolution,20mLperkgover20
minutes,followedbyoraladministrationoffluids. Continuedvomiting,largevolumediarrhea,
orboth,wouldconstituteareasonforhospitaladmission.Factorsthatsignificantlycontributeto
theprogressionofdehydrationincludewithdrawalofbreastfeeding,notgivingoralrehydration
solutionsduringdiarrheaandvomitingmorethantwotimesaday.
14

15

TABLE 3

Candidates for Oral Rehydration Therapy

Mild to moderate dehydration (< 10%)

Age > 4 months

No persistent vomiting

Unlikely to have an underlying cause other than viral gastroenteritis

Isonatremia is present

Serum bicarbonate level >18 mEq per L (18 mmol per L)

Childrenwithgastroenteritislose40to70mEqperL(40to70mmolperL)ofsodiumand10to
20mEqperL(10to20mmolperL)ofpotassiumindiarrhealstools.Appropriateoral
rehydrationsolutionsshouldcomeclosetomatchingthesodiumandpotassiumcontentofthe
diarrhealstools,especiallyinchildrenwithgastroenteritiswhoareunderoneyearofageorwho
areotherwisecompromised.OralrehydrationsolutionssuchasPedialyte,Infalyteorthe
equivalent(Table4)effectivelytreatchildrenlessthantwoyearsofagewithmildtomoderate(3
to9percent)dehydrationsecondarytogastroenteritis. Brothsshouldbeavoidedinthetreatment
ofdiarrheabecauseoftheirhighsodiumcontent.Ricebasedoralrehydrationsolutionseemsto
offersomebenefitinthetreatmentofhighoutputdiarrhea,especiallythatassociatedwith
cholera. Table5

listssomeguidelinesfortreatmentofmildtoseverediarrhealstates(including
cholera)whereoralrehydrationtherapymaybetheonlytherapyavailable.
16

17

18

TABLE 4

Comparison of Oral Rehydration Solutions

Composition
Glucose (g
per dL)

Sodium (mEq
per L)

Potassium (mEq
per L)

Chloride (mEq
per L)

WHO solution

2.0

90

20

80

Hydra-Lyte

1.2

84

10

59

Rehydralyte

2.5

75

20

65

Pedialyte

2.5

45

20

35

Generic pediatric solution*

2.5

45

20

35

Lytren

2.0

50

25

45

Resol

2.0

50

20

50

Infalyte

2.0

50

20

40

Ricelyte

Starch
polymers

50

25

45

Jell-O (one-half strength)

8.0

6 to 17

0.2

Gatorade

5.0

24

17

Soft drinks

7.0 to 12.0

1 to 7

0.1 to 0.4

Apple juice

12.0

0.1 to 3.5

24 to 43

Solutions
Commercial solutions

Home remedies (not

recommended)

Solutions

Composition
Glucose (g
per dL)

Sodium (mEq
per L)

Potassium (mEq
per L)

Chloride (mEq
per L)

Broth

250

WHO = World Health Organization.

*Similar to Pedialyte.
Information from references 1 and 2.

TABLE 5

Oral Rehydration Therapy for Severe Diarrheal States, Including Cholera

1. For mild dehydration, give oral rehydration, 100 mL per kg for the first 4 hours, then re-evaluate.
May give more if the patient desires.

2. Give additional fluids after each liquid bowel movement (children up to 2 years: 50 to 100 mL; 2 to
10 years: 100 to 200 mL; over 10 years, as much as desired).

3. Patient may drink water ad libitum but should continue intake of oral rehydration solution.

4. If there is no dehydration, give oral rehydration solution to replace stool losses.

5. If the patient is stable, give a two-day supply of oral rehydration solution.

6. Patients who are unable to drink or severely dehydrated (10% or more), or both, need rapid fluid
replacement (intravenous) when possible. Large amounts of fluids are necessary.

Information from A manual for the treatment of diarrhoea. Geneva, Switzerland: World Health Organization,
1990. Publication WHO/CDD/SER/80.2 Rev. 2. 1990.

IsotonicsolutionssuchasnormalsalineandRinger'slactateareusuallythecorrectfluidsforthe
initialtreatmentofdehydrationthatrequiresintravenousfluids(Tables1and6).Thiswouldbe
thecorrecttypeoffluidfortreatmentofthechildrenintheillustrativecases.Thefluidis
administeredinbolusesof15to30mLperkgevery20minutesuntilhypovolemiaiscorrected
andsomeurineflowisestablished.Atthattime,continuedmaintenanceandfurtherdeficit
replacementcanbecontinuedataslowerrate.Adjustmentscanthenbemadeintonicityofthe
fluid,andappropriatepotassiummaybeaddedtotheinfusionasneeded.
Inchildrenwhoarehypovolemicwithsignsofmorethan5percentdehydrationwithmental
statuschanges,theinitialfluidresuscitationshouldbeaggressive,usingbolusesofisotonicfluid.
Intravenousaccessshouldbeinitiatedquicklywhilethechildisbeingassessed.Inchildrenwith
normalcardiacandrenalfunction,itismostimportanttogiveadequateamountsoffluid.

Overhydratingispreferredtounderhydrating.Anyexcessfluidwillbeeliminatedeventuallyin
theurine.Ifitisdifficulttostartanintravenousline,fluidscanbegivenorallybyadripmethod
or,ifthesituationislifethreatening,byaninterosseousrouteuntilintravenousaccessis
obtained.
Thecalculationoftotalfluidneedsisbasedonthedeficit,maintenanceandongoinglosses.One
ofseveralacceptedmethodsforthecalculationoffluidsislistedinTable6.Aftertheinitial
correctionofhypovolemia,fluidcorrectionproceedsataslowerpace.Generally,onehalfofthe
dailyrequirementisgivenovereighthours,withtheremaindergivenover16hours.Ifthechild
hasahypertonicdehydration,isotonicfluidreplacementiscontinuedinordertonotcorrectthe
hypernatremiatooquickly,asthatmaycausecerebraledemaandseizures.Thecorrectionofthe
hypernatraemiashouldtakeplaceslowlyoveronetotwodays,dependingonitsseverity.After
thedeficitiscorrected,maintenancefluidmaybegivenasonehalfnormalsaline.
TABLE 6

Principles and Calculation of Fluid Replacement and Maintenance of

Intravenous Therapy in Dehydration

1. In hypovolemic children, boluses of isotonic fluid (15 to 30 mL per kg) should be given over 20
minutes.

2. Fluid boluses should be repeated every 20 minutes until hypovolemia is corrected and urine
output established.

3. Isotonic fluid (normal saline or Ringer's lactate) is usually the correct initial fluid.

4. After correction of hypovolemia, further intravenous therapy proceeds at a slower pace.

5. Replacement of fluid in 24 hours = deficit + maintenance + ongoing losses.

6. Deficit fluid = (percentage of dehydration) (body weight in g) = mL of fluid needed.

7. Twenty-four hour maintenance fluid equals 100 mL per kg for the first 10 kg, 50 mL per kg for the
next 10 kg, and 25 mL per kg for every kg over 20 kg. (Sodium = 3 to 5 mEq per kg per day;
potassium = 2 to 4 mEq per kg per day.)

Childrenwithseverediarrheaneedadequatenutritioninordertorestoretheirdigestiveabilities,
torecoverfromtheirillnessandtopreventdevelopmentofsocalledstarvation
diarrhea. Unlesstheyhaveseverevomiting,childrenshouldnotbedeprivedofnutritionfor
longerthanonetotwodays.Breastfeedingshouldbecontinued.Specialelementalformulasmay
beneededattimestoprovidethisnutritionuntilclinicalrecoveryisadequate.
2

The Authors
B. CLAIR ELIASON, M.D., is an associate professor and vice chair of graduate medical education in the
Department of Family and Community Medicine at the Medical College of Wisconsin, Milwaukee. He is a
graduate of Temple University School of Medicine, Philadelphia, and served a residency in family medicine and
pediatrics at Peter Bent Brigham Hospital in Boston.
RICHARD B. LEWAN, M.D., is an associate professor at the Medical College of Wisconsin and program director
of the Family Practice Residency Program at Waukesha Memorial Hospital, Waukesha, Wis. Dr. Lewan received
his medical degree from the University of Chicago School of Medicine and served a residency in family practice
at the University of IllinoisRockford.
Address correspondence to B. Clair Eliason, M.D., Department of Family and Community Medicine, Medical
College of Wisconsin, 1000 N. 92nd St., Milwaukee, WI 53226. Reprints are not available from the authors.

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