DEPARTMENT

Practice Guidelines

Clinical Practice Guideline

for the Treatment of
Pediatric Acute
Gastroenteritis in the
Outpatient Setting
Rebecca A. Carson, DNP, CPNP-PC/AC,
Shawna S. Mudd, DNP, CPNP-AC, & P. Jamil Madati, MD

ABSTRACT
Acute gastroenteritis (AGE) is a common illness in childhood
that usually can be treated in the outpatient setting. Inaccurate assessment or delayed treatment of AGE can lead to an
increased risk for invasive interventions. A literature search
was conducted using PubMed, CINAHL Plus, the Cochrane
Library, and Embase. Results of the query were refined to
narrow the focus of relevant studies for the provider caring
for dehydrated children in the outpatient setting. Use of clinical dehydration scales to assess the level of dehydration and

Rebecca A. Carson, Pediatric Nurse Practitioner, Emergency

Medicine and Trauma Services, Childrens National Medical
Center, Washington, DC.
Shawna S. Mudd, Assistant Professor, Department of Acute and
Chronic Care, Johns Hopkins University School of Nursing,
Baltimore, MD.
P. Jamil Madati, Pediatric Emergency Medicine Physician,
Assistant Professor of Pediatrics and Emergency Medicine,
George Washington University School of Medicine, Childrens
National Medical Center, Washington, DC.
Conflicts of interest: None to report.
Correspondence: Rebecca A. Carson, DNP, CPNP-PC/AC,
Childrens National Medical Center, 111 Michigan Ave,
Washington, DC 20010; e-mail: beckyanncarson@gmail.com.
0891-5245/$36.00
Copyright Q 2016 by the National Association of Pediatric
Nurse Practitioners. Published by Elsevier Inc. All rights
reserved.
Published online June 3, 2016.
http://dx.doi.org/10.1016/j.pedhc.2016.04.012

610

Volume 30 ! Number 6

early initiation of oral rehydration therapy promote optimal

patient outcomes. Oral rehydration therapy remains the
best means of rehydrating, and ondansetron is a safe and
effective adjunct to help children with persistent vomiting.
The purpose of this practice guideline is to identify best practices for AGE in children older than 6 months with symptoms
for less than 7 days who are being cared for in the outpatient
setting. J Pediatr Health Care. (2016) 30, 610-616.

KEY WORDS
Pediatric, acute gastroenteritis, clinical practice guideline,
outpatient treatment

Acute gastroenteritis (AGE) is one of the most common childhood illnesses in the United States, accounting for more than 1.7 million outpatient visits each
year (Freedman, Thull-Freedman, Rumantir, Atenafu,
& Stephens, 2013). Up to 16% of emergency department
(ED) visits are attributed to AGE, defined as three or
more episodes of diarrhea and/or vomiting and possibly
accompanied by other symptoms including fever,
nausea, or abdominal pain that results from gastrointestinal inflammation (Fox, Richards, Jenkins, & Powell,
2012). The primary treatment goals for children with
viral AGE are rehydration and prevention of complications due to dehydration from fluid loss from ongoing
diarrhea and/or vomiting (Farthing et al., 2013).
Nationally recognized recommendations for AGE are
oral rehydration therapy (ORT) as the primary treatment while avoiding unnecessary laboratory tests, diagnostic imaging, and medications (Centers for Disease
Control and Prevention [CDC], 2003; Cincinnati
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Childrens Hospital Medical Center, 2011). Most

children have only mild or moderate dehydration
associated with AGE, and the success rate of ORT as a
treatment method is approximately 96% (Nir, Nadir,
Schechter, & Kline-Kremer, 2013). Despite recommendations that pediatric patients with mild to moderate
dehydration receive ORT as the mainstay of treatment,
many providers unnecessarily order laboratory tests,
diagnostic imaging, and intravenous fluids that do not
provide prognostic value or shorten the self-limited
illness (Kharbanda et al., 2013). The purpose of this
clinical practice guideline is to describe current evaluation and management of pediatric patients with AGE in
the outpatient setting.
SEARCH METHODS
Searches were conducted on PubMed, CINAHL, Embase, and the Cochrane Library.
Search Terms
! (pediatric OR child*) AND (acute gastroenteritis
OR diarrhea) AND (dehydration OR rehydr* OR
oral rehydr*)
Filters
! Humans
! English
! NOT (appendicitis OR appendec*[Title])
! Date range 2006- present
ETIOLOGY AND PATHOPHYSIOLOGY
Children younger than 5 years are disproportionately
affected by AGE, experiencing one to five episodes
of gastroenteritis per year (Farthing et al., 2013). Enteritis pathogens enter the body through the fecal-oral
route and infect enterocytes, leading to damage of
the intestinal epithelium, which causes transudation
of fluid into the intestinal lumen. Clinical manifestations of AGE depend on both the organism and host.
Viruses account for 75% to 90% of AGE cases, but bacteria or parasitic infections may be the cause, especially
in vulnerable populations (Churgay & Aftab, 2012).
Rotavirus represented the most common viral pathogen; however, with widespread use of the rotavirus
vaccine beginning in 2006, a substantial decrease in
disease prevalence, morbidity, and health care utilization and costs has been appreciated (Leshem et al.,
2014). In general, viral AGE infections are usually
self-limited, but severe cases may lead to dehydration
that requires further intervention to avoid fluid and
electrolyte derangement.
Pathogens
! Viral (noninflammatory): Most commonly Norwalk and Rotavirus; also Caliciviruses (Norovirus
and Sapovirus), Astrovirus, Enteric adenovirus
www.jpedhc.org

! Parasitic (noninflammatory): Isospora belli, Cryptosporidium, Giardia lamblia

! Bacterial (inflammatory): Campylobacter jejuni,
Clostridium difficile, Escherichia coli (including
O157:H7), Salmonella, Shigella, Yersinia enterocolitica
Population
This clinical guideline is intended for children older
than 6 months with symptoms of AGE for fewer than
7 days. In infants with AGE who are younger than
6 months, fluid and electrolyte balance should evaluated and other possible causes of the symptoms should
be considered. In children with vomiting alone, alternative diagnoses should be considered, particularly in the
presence of bloody or bilious emesis, severe abdominal
pain, or a toxic appearance. Routine AGE care may not
be appropriate for patients with significant comorbidities, immunodeficiency, or chronic illness. If an electrolyte or metabolic
In children with
imbalance is discovered or suspected as a
vomiting alone,
result of abnormal
alternative
physical examination
diagnoses should
findings, then routine
care should not be folbe considered,
lowed. Patients with a
particularly in the
toxic
appearance,
presence of bloody
concern for severe systemic illness (sepsis),
or bilious emesis,
and severe dehydrasevere abdominal
tion should be stabipain, or a toxic
lized and transferred
to the inpatient setting
appearance.
for additional care.
Risk Factors
According to the Cincinnati Childrens Hospital Medical
Center (2011), risk factors include the following:
!
!
!
!
!

Age < 24 months

Day care attendance or exposure to sick contacts
Recent travel to a foreign country
Immunocompromised status
Low socioeconomic status

EVALUATION
History
! Diarrhea: Onset, frequency, volume of stool
output, appearance of stool, presence of blood,
tenesmus
! Vomit: Onset, frequency, bilious or nonbilious,
presence of blood
! Abdominal pain: Onset, location, duration, migration, cramping, continuous or intermittent, appetite
! Accompanying symptoms: nausea, fever, headache, myalgias
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611

TABLE 1. Treatment principles for management of dehydration

Mild Dehydration (< 5%)
Continue hydration
ORT with teaching on frequent small
volumes of liquid
Encourage regular diet (unrestricted
breastfeeding)
Replace ongoing losses (assume
1 diarrheal stool/emesis equals 2 oz
liquid or 10 ml/kg)

Moderate Dehydration (5-10%)

Needs ORT
Defer solids until rehydrated
May continue unrestricted
breastfeeding with oral rehydration
solution adjunct
Replace ongoing losses
(assume 1 diarrheal stool/
emesis equals 2 oz liquid
or 10 ml/kg)

Severe Dehydration (> 10%)

Needs IV rehydration
Place saline lock IV catheter and give
0.9% sodium chloride 20 ml/kg
bolus IV push; repeat if warranted and
patient is responding to fluid bolus
Recommend point of care glucose and
electrolytes if patient is listless and lethargic
Measure intake and output
Initiate ORT with teaching on frequent
small volumes of liquid once IV access obtained
May need maintenance IV fluids; hold
potassium-containing fluids until patient has voided

Note. ORT = oral rehydration therapy.

From Deforest & Thompson, 2012.

! Epidemiologic clues: travel history, day care attendance, sick contacts, diet history
! Attempted treatment: medications, nonpharmacologic remedies, tolerance of oral fluids, types of
oral fluids offered
Physical Examination
The priority of physical examination is to determine the
level of dehydration or the presence of any other diagnosis. Any child with severe abdominal pain and fever
that demonstrates concern for an acute surgical
abdomen should have a thorough physical examination and consultation from a surgeon.
! Vital signs: Weight, temperature, heart rate, respiratory rate, blood pressure, pulse oximetry
! General: Appearance, activity level, mental status
! Head/eyes/ears/nose/throat: Fontanelle sunken
or flat; sunken eyes; presence or absence of tears;
moisture of mucous membranes
! Respiratory: Tachypnea or Kussmaul breathing
could be a sign of acidosis
! Cardiovascular: Examine for signs of inadequate
cardiac output/hypovolemia; tachycardia, hypotension, weak or thready pulses, delayed capillary
refill time, and cool extremities may indicate severe
dehydration and impending hypovolemic shock
! Gastrointestinal: Inspect the abdomen for distension; auscultate for bowel sounds, which may be
hyperactive in the presence of acute infection;
palpate for organomegaly, masses, or tenderness;
periumbilical tenderness is a common finding,
but focal tenderness extending from the umbilicus
or peritoneal signs are indicative of a possible surgical abdomen
! Genitourinary: Examine all males for testicular torsion or hernia; a more thorough genital examination may be warranted based on history if
ovarian pathology or sexually transmitted infection is suspected
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Volume 30 ! Number 6

Clinical Dehydration Scales

Data support the use of validated clinical dehydration
scales (World Health Organization [WHO] Scale for
Dehydration, the Gorelick scale, or the Clinical Dehydration Scale) for the rapid and objective assessment
of dehydration status to facilitate stratification of
patients into treatment categories, especially in patients for whom a pre-illness weight is unavailable
(Tables 1 and 2; Jauregui et al., 2014; Pringle
et al., 2011). Careful physical examination and vital
sign review should accompany the dehydration
assessment. The WHO scale notes that lethargy and
fatigue or sleepiness are not equivalent assessments,
with lethargy referring to a child who cannot be
awakened because of an altered mental state (WHO,
2011).
MANAGEMENT PRINCIPLES
The outpatient treatment of pediatric patients with AGE
should be guided by a dehydration assessment or preillness weight that indiThe mainstay of
cates total volume loss
(Tables
3-5).
The
therapy for children
mainstay of therapy for
with mild or
children with mild or
moderate
moderate dehydration
should focus on ORT
dehydration should
with an emphasis on
focus on ORT with
replacing deficits and
an emphasis on
preventing
ongoing
fluid losses. Providers
replacing deficits
should minimize unnecand preventing
essary medications and
ongoing fluid
tests that increase costs
and may potentially
losses.
cause harm.
Drugs that alter intestinal motility or secretion, anticholinergic agents,
opiates, and antibiotics are not recommended
(Cincinnati Childrens Hospital Medical Center, 2011).
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TABLE 2. Suggested discharge and admission criteria

Suggested discharge criteria

Suggested admission criteria

Persistent fluid loss from significant vomiting and/or diarrhea
Abnormal electrolytes or acidosis
Diagnosis uncertainty
Inability to tolerate oral liquids, keep up with fluid losses, or
requires overnight fluid replacement for severe dehydration

Well appearing and active

Abdomen soft, nontender, and nondistended
Vital signs acceptable for age and fever/dehydration
Tolerated acceptable amounts of oral liquids in relation to
ongoing losses
# 3 episodes of vomiting and/or diarrhea
Achieves mild dehydration status on a clinical
dehydration scale

Ondansetron is a safe and effective antiemetic medication to facilitate oral rehydration in the acute care
setting (Freedman et al., 2014; Guarino et al., 2014).
Although reliance on pharmacologic intervention
shifts the therapeutic focus away from fluid and
electrolyte replacement and can result in adverse
effects, shared decision making should occur
between the provider and family to consider
ondansetron use in the outpatient setting when
persistent vomiting impedes ORT (Fedorowicz,
Jagannath, & Carter, 2011). Although the CDC may
remain in opposition to antiemetic agents in its recommendations, recent research has shown that ondansetron is a safe and effective method of encouraging
ORT in the acute care setting.
Diagnostic Studies
Laboratory tests
! Not recommended for children with mild or moderate dehydration
! Serum electrolytes and glucose for patients
requiring intravenous rehydration
! Consider a stool culture in patients with symptoms
for 7 or more days, bloody stools, age less than
3 months, exposure to an infectious pathogen,
foreign travel, immunocompromised status, or
who are toxic appearing

Imaging
! Diagnostic imaging is typically not required unless
the diagnosis of AGE is in question
Fluid Replacement
Oral rehydration therapy
! Goal fluid intake: 15 ml/kg/1 hour or 60 ml/kg/
4 hours (Table 6)
! Add 10 ml/kg for every episode of diarrhea or vomiting
Oral rehydration solution
Only clear liquids should be offered for oral rehydration. Fluids with a high sugar content may increase
the osmotic pull of water into the intestinal lumen,
which causes hypernatremia and exacerbates the diarrhea. Water causes hyponatremia from the hypotonic
osmotic gradient, which may result in seizure. Suitable
oral rehydration solutions include:
! WHO oral rehydration solution packets
! Commercial electrolyte solutions for pediatric patients (e.g., Pedialyte and Infalyte)
! Sports drinks (e.g., Gatorade and Powerade) or
low-calorie sports drinks (e.g., Gatorade G2)
with tsp salt per 32-oz bottle (University of
Virginia Health System, 2014)

TABLE 3. World Health Organization Scale for dehydration for children ages 1 month to 5 years in
low- and middle-income countries
A. Mild dehydration
Look at condition
Eyes
Thirst
Feel: skin pinch
Decide

Well, alert
Normal
Drinks normally, not thirsty
Goes back quickly
The patient has NO SIGNS OF
DEHYDRATION (< 5%)

Treat

Home therapy to prevent dehydration

and malnutrition

B. Moderate dehydration

C. Severe dehydration

Restless, irritable
Sunken
Thirsty, drinks eagerly
Goes back slowly
If the patient has 2 or more signs in
column B, then the patient has
SOME DEHYDRATION (5%-10%)
Weigh the patient if possible and
begin oral rehydration therapy

Lethargic or unconscious
Sunken
Drinks poorly or not able to drink
Goes back very slowly
If the patient has 2 or more signs in
column C, then the patient has
SEVERE DEHYDRATION (> 10%)
Begin intravenous hydration urgently

From World Health Organization, 2011.

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613

TABLE 4. The 10- and 4-Point Gorelick Dehydration Scale for children ages 1 month to 5 years
Characteristic
General appearance
Infants
Older children
Capillary refill
Tears
Mucous membranes*
Eyes*
Breathing*
Quality of pulses*
Skin elasticity
Heart rate
Urine output

No or minimal dehydration

Moderate dehydration

Thirsty, alert, restless

Thirsty, alert, restless
Normal
Present
Moist
Normal
Present
Normal
Instant recoil
Normal
Normal

Lethargic or drowsy
Alert, dizzy
Prolonged or minimal
Absent
Dry
Sunken
Deep
Weak, thready
Recoil slowly
Tachycardia
Reduced

Severe dehydration
Limp, cold, cyanosis
Apprehensive, cold, cyanosis
Very prolonged
Absent
Very dry
Deeply sunken
Deep and rapid
Feeble or impalpable
Recoil > 2 seconds
Tachycardia
Not passed in many hours

*Four-point scale examination signs.

Scoring of 4-point scale: $ 2 clinical signs (4 pt) $ 5% body weight change; $ 3 clinical signs (4 pt) $ 10% body weight change.
Scoring of 10-point scale (all signs/symptoms): $ 3 clinical signs $ 5% body weight change; $ 7 clinical signs $ 10% body weight change.
From Pringle et al., 2011.

! Known pregnancy (category B)

! Salted rice water, salted yogurt drink, soup with

salt (WHO, 2011)

Diet
Breastfed infants should continue unrestricted feeding.
National guidelines recommend the reintroduction of
nutrition within the first 24 hours of illness once initial
rehydration is achieved (CDC, 2008). Early realimentation of an age-appropriate diet containing simple
starches, fruits and vegetables, lean meats, and yogurt
aids co-transport molecules, thereby increasing fluid
and electrolyte uptake while reducing stool losses
(CDC, 2003). Although the BRAT diet of bananas, rice,
applesauce, and toast is no longer promoted because
of the low energy density and lack of protein or fat,
these foods can still be added to the reintroduction
diet to add bulk to diarrheal stool.

Ondansetron (Zofran)
Forms
Tab (4 mg, 8 mg); oral dissolving tablet (4 mg, 8 mg);
oral solution 4 mg/5 ml; injection 2 mg/ml.
Dose
For age > 6 months: 0.15 mg/kg, maximum 8 mg as a
single dose to aid in tolerance of ORT for rehydration;
additional doses are associated with an increased risk
of diarrhea (Truven Health Analytics, 2016).
Alternative dosing by weight range (Deforest &
Thompson, 2012; Freedman, Adler, Seshadri, &
Powell, 2006):

Adjunct Therapy

< 8 kg: not recommended

8-15 kg: 2 mg
15-30 kg: 4 mg
> 30 kg: 8 mg

Probiotics
Probiotics are microorganisms that can be beneficial
when administered in adequate doses. Despite a
lack of consensus regarding treatment of pediatric
patients who have AGE with probiotics, findings
from clinical trials support the use of probiotics to
decrease the duration and intensity of AGE

Contraindications
! Long QT syndrome
! Concomitant drugs that prolong QT

TABLE 5. Clinical Dehydration Scale for prediction of dehydration in ages children 1 to 36 months
Characteristic

General appearance
Eyes
Mucous membranes
Tears

Normal
Normal
Moist
Tears

Thirsty, restless, or lethargic, but irritable when touched

Slightly sunken
Sticky
Decreased tears

Drowsy, limp, cold and/or comatose

Very sunken
Dry
Absent tears

Note. From Pringle et al., 2011.

Scoring: 0: no dehydration < 3%; 1-4: some dehydration $ 3% and < 6%; 5-8: moderate dehydration $ 6%.

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TABLE 6. Recommended sip volume by weight

based on goal fluid intake
Weight

Sip volume per 5 minutes

< 10 kg
10 kg
For every
additional 5 kg

1 ml/kg
10 ml
Increase sip volume by 5 ml to maximum
sip volume = 50 ml

Note. ORT = oral rehydration therapy.

Administer via syringe or medicine cup. Duration: 1 hour; once
there has been no vomiting in 1 hour, increase volume per sip
or drink freely to goal fluid intake; continue ORT for 4 hours.

(Guarino, Guandalini, & Lo Vecchio, 2015). The

quality of evidence on probiotics is low, and additional research should be conducted to strengthen
evidence. Lactobacillus rhamnosus GG (LGG) and
Saccharomyces boulardii have strong recommendations for use by international practice guidelines,
although the strength of evidence in these recommendations was low (Szajewska et al., 2014). Most
importantly, probiotics were not associated with
any adverse events (Freedman, Ali, Oleszczuk,
Gouin, & Hartling, 2013). Probiotics are considered
a supplement that is not regulated by federal quality
and safety standards, and therefore product
differences may result in varying efficacy, which
should be discussed with families before treatment
begins.
Dose.
! LGG, 10 billion colony-forming units/day for 5 to
7 days (Szajewska et al., 2014)
! S. boulardii, 250 to 750 mg/day for 5 to 7 days
(Szajewska et al., 2014)
Zinc
Once a child is able to eat, a zinc supplement may be
started to help reduce the severity and duration of
symptoms. Zinc has also been associated with reduced
incidence of diarrhea for 2 to 3 months (WHO, 2011).
Problems with this recommendation in the United
States relate to the increased risk for nausea and vomiting and the decreased incidence of zinc deficiency in
American children compared with developing countries (Bass, Pappano, & Humiston, 2007).
Dose.
! 10 to 20 mg/day for 10 to 14 days (WHO, 2011)
CONCLUSIONS
AGE is a common but self-limited illness in the United
States. Unfortunately, poor adherence to the recommended treatment with oral rehydration while minimizing ancillary diagnostic studies is often seen.

www.jpedhc.org

Using validated dehydration scales may help assess

the diverse presentations of dehydration more objectively and help stratify patients into dehydration categories for more accurate treatment. Furthermore,
ondansetron is a safe
Using validated
and effective medication in patients with
dehydration scales
persistent
vomiting
may help assess
that can facilitate use
the diverse
of ORT. Combining
objective dehydration
presentations of
assessment with ondehydration more
dansetron and oral
objectively and
rehydration in the
outpatient
setting
help stratify
helps promote familypatients into
centered, noninvasive
dehydration
rehydration,
which
they are then able to
categories for more
continue in the unreaccurate
stricted environment
treatment.
of their home.
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