DEPARTMENT
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. Inaccu-
rate 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 clin-
ical dehydration scales to assess the level of dehydration and
Rebecca A. Carson, Pediatric Nurse Practitioner, Emergency
Medicine and Trauma Services, Children’s 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, Children’s
National Medical Center, Washington, DC.
Conflicts of interest: None to report.
Correspondence: Rebecca A. Carson, DNP, CPNP-PC/AC,
Children’s 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.
http://dx.doi.org/10.1016/j.pedhc.2016.04.012
www.jpedhc.org
Practice Guideline
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 prac-
tices 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) -, ---.
KEY WORDS
Pediatric, acute gastroenteritis, clinical practice guideline,
outpatient treatment
Acute gastroenteritis (AGE) is one of the most com-
mon childhood illnesses in the United States, account-
ing 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 gastrointes-
tinal inflammation (Fox, Richards, Jenkins, & Powell,
2012). The primary treatment goals for children with
viral AGE are rehydration and prevention of complica-
tions 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 treat-
ment while avoiding unnecessary laboratory tests, diag-
nostic imaging, and medications (Centers for Disease
Control and Prevention [CDC], 2003; Cincinnati
-/- 2016 1
Children’s Hospital Medical Center, 2011). Most  Parasitic (noninflammatory): Isospora belli, Cryp-
children have only mild or moderate dehydration tosporidium, Giardia lamblia
associated with AGE, and the success rate of ORT as a  Bacterial (inflammatory): Campylobacter jejuni,
treatment method is approximately 96% (Nir, Nadir, Clostridium difficile, Escherichia coli (including
Schechter, & Kline-Kremer, 2013). Despite recommen- O157:H7), Salmonella, Shigella, Yersinia enteroco-
dations that pediatric patients with mild to moderate litica
dehydration receive ORT as the mainstay of treatment,
many providers unnecessarily order laboratory tests,
Population
diagnostic imaging, and intravenous fluids that do not
This clinical guideline is intended for children older
provide prognostic value or shorten the self-limited
than 6 months with symptoms of AGE for fewer than
illness (Kharbanda et al., 2013). The purpose of this
7 days. In infants with AGE who are younger than
clinical practice guideline is to describe current evalua-
6 months, fluid and electrolyte balance should evalu-
tion and management of pediatric patients with AGE in
ated and other possible causes of the symptoms should
the outpatient setting.
be considered. In children with vomiting alone, alterna-
tive diagnoses should be considered, particularly in the
SEARCH METHODS
presence of bloody or bilious emesis, severe abdominal
Searches were conducted on PubMed, CINAHL, Em-
pain, or a toxic appearance. Routine AGE care may not
base, and the Cochrane Library.
be appropriate for patients with significant comorbid-
ities, immunodeficiency, or chronic illness. If an elec-
Search Terms
trolyte or metabolic
 (pediatric OR child*) AND (acute gastroenteritis In children with
imbalance is discov-
OR diarrhea) AND (dehydration OR rehydr* OR
oral rehydr*)
ered or suspected as a vomiting alone,
result of abnormal
physical examination
alternative
Filters findings, then routine diagnoses should
 Humans care should not be fol- be considered,
 English lowed. Patients with a
 NOT (appendicitis OR appendec*[Title]) toxic appearance,
particularly in the
 Date range 2006- present concern for severe sys- presence of bloody
temic illness (sepsis), or bilious emesis,
and severe dehydra-
ETIOLOGY AND PATHOPHYSIOLOGY
tion should be stabi-
severe abdominal
Children younger than 5 years are disproportionately pain, or a toxic
lized and transferred
affected by AGE, experiencing one to five episodes
of gastroenteritis per year (Farthing et al., 2013). Enter-
to the inpatient setting appearance.
for additional care.
itis pathogens enter the body through the fecal-oral
route and infect enterocytes, leading to damage of
Risk Factors
the intestinal epithelium, which causes transudation
According to the Cincinnati Children’s Hospital Medical
of fluid into the intestinal lumen. Clinical manifesta-
Center (2011), risk factors include the following:
tions of AGE depend on both the organism and host.
Viruses account for 75% to 90% of AGE cases, but bac-  Age < 24 months
teria or parasitic infections may be the cause, especially  Day care attendance or exposure to sick contacts
in vulnerable populations (Churgay & Aftab, 2012).  Recent travel to a foreign country
Rotavirus represented the most common viral path-  Immunocompromised status
ogen; however, with widespread use of the rotavirus  Low socioeconomic status
vaccine beginning in 2006, a substantial decrease in
disease prevalence, morbidity, and health care utiliza- EVALUATION
tion and costs has been appreciated (Leshem et al., History
2014). In general, viral AGE infections are usually  Diarrhea: Onset, frequency, volume of stool
self-limited, but severe cases may lead to dehydration output, appearance of stool, presence of blood,
that requires further intervention to avoid fluid and tenesmus
electrolyte derangement.  Vomit: Onset, frequency, bilious or nonbilious,
presence of blood
Pathogens  Abdominal pain: Onset, location, duration, migra-
 Viral (noninflammatory): Most commonly Nor- tion, cramping, continuous or intermittent, appetite
walk and Rotavirus; also Caliciviruses (Norovirus  Accompanying symptoms: nausea, fever, head-
and Sapovirus), Astrovirus, Enteric adenovirus ache, myalgias

2 Volume -  Number - Journal of Pediatric Health Care

 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)
Note. ORT = oral rehydration therapy.
From Deforest & Thompson, 2012.
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

 Epidemiologic clues: travel history, day care atten- Clinical Dehydration Scales
dance, sick contacts, diet history Data support the use of validated clinical dehydration
 Attempted treatment: medications, nonpharmaco- scales (World Health Organization [WHO] Scale for
logic remedies, tolerance of oral fluids, types of Dehydration, the Gorelick scale, or the Clinical Dehy-
oral fluids offered dration Scale) for the rapid and objective assessment
of dehydration status to facilitate stratification of
patients into treatment categories, especially in pa-
Physical Examination tients for whom a pre-illness weight is unavailable
The priority of physical examination is to determine the (Tables 1 and 2; Jauregui et al., 2014; Pringle
level of dehydration or the presence of any other diag- et al., 2011). Careful physical examination and vital
nosis. Any child with severe abdominal pain and fever sign review should accompany the dehydration
that demonstrates concern for an acute surgical assessment. The WHO scale notes that lethargy and
abdomen should have a thorough physical examina- fatigue or sleepiness are not equivalent assessments,
tion and consultation from a surgeon. with lethargy referring to a child who cannot be
 Vital signs: Weight, temperature, heart rate, respi- awakened because of an altered mental state (WHO,
ratory rate, blood pressure, pulse oximetry 2011).
 General: Appearance, activity level, mental status
 Head/eyes/ears/nose/throat: Fontanelle sunken MANAGEMENT PRINCIPLES
or flat; sunken eyes; presence or absence of tears; The outpatient treatment of pediatric patients with AGE
moisture of mucous membranes should be guided by a dehydration assessment or pre-
 Respiratory: Tachypnea or Kussmaul breathing illness weight that indi-
could be a sign of acidosis cates total volume loss The mainstay of
 Cardiovascular: Examine for signs of inadequate (Tables 3-5). The therapy for children
cardiac output/hypovolemia; tachycardia, hypo- mainstay of therapy for
children with mild or
with mild or
tension, weak or thready pulses, delayed capillary
refill time, and cool extremities may indicate severe moderate dehydration moderate
dehydration and impending hypovolemic shock should focus on ORT dehydration should
 Gastrointestinal: Inspect the abdomen for disten- with an emphasis on
focus on ORT with
sion; auscultate for bowel sounds, which may be replacing deficits and
hyperactive in the presence of acute infection; preventing ongoing an emphasis on
palpate for organomegaly, masses, or tenderness; fluid losses. Providers replacing deficits
periumbilical tenderness is a common finding, should minimize unnec-
essary medications and
and preventing
but focal tenderness extending from the umbilicus
or peritoneal signs are indicative of a possible sur- tests that increase costs ongoing fluid
gical abdomen and may potentially losses.
 Genitourinary: Examine all males for testicular tor- cause harm.
sion or hernia; a more thorough genital examina- Drugs that alter in-
tion may be warranted based on history if testinal motility or secretion, anticholinergic agents,
ovarian pathology or sexually transmitted infec- opiates, and antibiotics are not recommended
tion is suspected (Cincinnati Children’s Hospital Medical Center, 2011).

www.jpedhc.org -/- 2016 3

 TABLE 2. Suggested discharge and admission criteria
Suggested discharge criteria
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 medica-
tion 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 recom-
mendations, recent research has shown that ondanse-
tron 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 mod-
erate 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
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 Well, alert
Eyes Normal
Thirst Drinks normally, not thirsty
Feel: skin pinch Goes back quickly
Decide The patient has NO SIGNS OF
DEHYDRATION (< 5%)
Treat Home therapy to prevent dehydration
and malnutrition
From World Health Organization, 2011.
4 Volume -  Number -
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
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 vom-
iting
Oral rehydration solution
Only clear liquids should be offered for oral rehydra-
tion. Fluids with a high sugar content may increase
the osmotic pull of water into the intestinal lumen,
which causes hypernatremia and exacerbates the diar-
rhea. 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 pa-
tients (e.g., Pedialyte and Infalyte)
 Sports drinks (e.g., Gatorade and Powerade) or
low-calorie sports drinks (e.g., Gatorade G2)
with ½ tsp salt per 32-oz bottle (University of
Virginia Health System, 2014)
B. Moderate dehydration C. Severe dehydration
Restless, irritable Lethargic or unconscious
Sunken Sunken
Thirsty, drinks eagerly Drinks poorly or not able to drink
Goes back slowly Goes back very slowly
If the patient has 2 or more signs in If the patient has 2 or more signs in
column B, then the patient has column C, then the patient has
SOME DEHYDRATION (5%-10%) SEVERE DEHYDRATION (> 10%)
Weigh the patient if possible and Begin intravenous hydration urgently
begin oral rehydration therapy
Journal of Pediatric Health Care
 TABLE 4. The 10- and 4-Point Gorelick Dehydration Scale for children ages 1 month to 5 years
Characteristic No or minimal dehydration Moderate dehydration Severe dehydration
General appearance
Infants Thirsty, alert, restless Lethargic or drowsy Limp, cold, cyanosis
Older children Thirsty, alert, restless Alert, dizzy Apprehensive, cold, cyanosis
Capillary refill Normal Prolonged or minimal Very prolonged
Tears Present Absent Absent
Mucous membranes* Moist Dry Very dry
Eyes* Normal Sunken Deeply sunken
Breathing* Present Deep Deep and rapid
Quality of pulses* Normal Weak, thready Feeble or impalpable
Skin elasticity Instant recoil Recoil slowly Recoil > 2 seconds
Heart rate Normal Tachycardia Tachycardia
Urine output Normal Reduced 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.

 Salted rice water, salted yogurt drink, soup with  Known pregnancy (category B)
salt (WHO, 2011)
Diet
Ondansetron (Zofran) Breastfed infants should continue unrestricted feeding.
National guidelines recommend the reintroduction of
Forms nutrition within the first 24 hours of illness once initial
Tab (4 mg, 8 mg); oral dissolving tablet (4 mg, 8 mg); rehydration is achieved (CDC, 2008). Early realimenta-
oral solution 4 mg/5 ml; injection 2 mg/ml. tion of an age-appropriate diet containing simple
starches, fruits and vegetables, lean meats, and yogurt
Dose aids co-transport molecules, thereby increasing fluid
For age > 6 months: 0.15 mg/kg, maximum 8 mg as a and electrolyte uptake while reducing stool losses
single dose to aid in tolerance of ORT for rehydration; (CDC, 2003). Although the BRAT diet of bananas, rice,
additional doses are associated with an increased risk applesauce, and toast is no longer promoted because
of diarrhea (Truven Health Analytics, 2016). of the low energy density and lack of protein or fat,
Alternative dosing by weight range (Deforest & these foods can still be added to the reintroduction
Thompson, 2012; Freedman, Adler, Seshadri, & diet to add bulk to diarrheal stool.
Powell, 2006):
Adjunct Therapy
< 8 kg: not recommended
8-15 kg: 2 mg
Probiotics
15-30 kg: 4 mg
Probiotics are microorganisms that can be beneficial
> 30 kg: 8 mg
when administered in adequate doses. Despite a
lack of consensus regarding treatment of pediatric
Contraindications patients who have AGE with probiotics, findings
 Long QT syndrome from clinical trials support the use of probiotics to
 Concomitant drugs that prolong QT decrease the duration and intensity of AGE

TABLE 5. Clinical Dehydration Scale for prediction of dehydration in ages children 1 to 36 months
Characteristic 0 1 2
General appearance Normal Thirsty, restless, or lethargic, but irritable when touched Drowsy, limp, cold and/or comatose
Eyes Normal Slightly sunken Very sunken
Mucous membranes Moist ‘‘Sticky’’ Dry
Tears Tears Decreased tears 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%.

www.jpedhc.org -/- 2016 5

 Using validated dehydration scales may help assess
TABLE 6. Recommended sip volume by weight the diverse presentations of dehydration more objec-
based on goal fluid intake tively and help stratify patients into dehydration cate-
Weight Sip volume per 5 minutes gories for more accurate treatment. Furthermore,
< 10 kg 1 ml/kg
ondansetron is a safe
10 kg 10 ml and effective medica- Using validated
For every Increase sip volume by 5 ml to maximum tion in patients with dehydration scales
additional 5 kg sip volume = 50 ml persistent vomiting
that can facilitate use may help assess
Note. ORT = oral rehydration therapy.
Administer via syringe or medicine cup. Duration: 1 hour; once of ORT. Combining the diverse
there has been no vomiting in 1 hour, increase volume per sip objective dehydration presentations of
or drink freely to goal fluid intake; continue ORT for 4 hours. assessment with on-
dansetron and oral dehydration more
rehydration in the objectively and
(Guarino, Guandalini, & Lo Vecchio, 2015). The
outpatient setting help stratify
quality of evidence on probiotics is low, and addi-
helps promote family-
tional research should be conducted to strengthen
centered, noninvasive patients into
evidence. Lactobacillus rhamnosus GG (LGG) and dehydration
rehydration, which
Saccharomyces boulardii have strong recommenda-
they are then able to categories for more
tions for use by international practice guidelines,
continue in the unre-
although the strength of evidence in these recom-
stricted environment accurate
mendations was low (Szajewska et al., 2014). Most treatment.
of their home.
importantly, probiotics were not associated with
any adverse events (Freedman, Ali, Oleszczuk,
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