Viral gastroenteritis in children
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
no dehydration
fluid compensation/maintenance with oral rehydration therapy
Amount of oral rehydration solution (ORS) per episode of vomiting or diarrhoeal stool: weight <10 kg = 60 to 120 mL, weight >10 kg = 120 to 240 mL.[42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com This should be continued until the vomiting and diarrhoea have subsided.
Daily fluid maintenance requirement is 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent 1 kg over 20 kg.
Small amounts of ORS should be given at frequent intervals and the volume gradually increased until the child can drink as desired.[43]Leung AK, Robson WL. Acute diarrhea in children: what to do and what not to do. Postgrad Med. 1989 Dec;86(8):161-4, 167-74. http://www.ncbi.nlm.nih.gov/pubmed/2685791?tool=bestpractice.com Using a spoon or dropper for very small infants can significantly increase retention of ORS.
In a child who refuses to drink, squirting the ORS into the mouth with a syringe may help. Flavoured ORS or ORS popsicles, which may be more acceptable to some children, may also be tried.[62]te Loo DM, van der Graaf F, Ten WT. The effect of flavoring oral rehydration solution on its composition and palatability. J Pediatr Gastroenterol Nutr. 2004 Nov;39(5):545-8. http://www.ncbi.nlm.nih.gov/pubmed/15572897?tool=bestpractice.com
age-appropriate diet
Treatment recommended for ALL patients in selected patient group
Children should continue to be fed an age-appropriate diet as soon as tolerated.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
For infants who are breastfed, breastfeeding should be continued throughout.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
It is not necessary to dilute formula or to give lactose-free formula in feeding non-breastfed infants.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Infants should be offered more frequent bottle or breastfeedings.
ondansetron
Additional treatment recommended for SOME patients in selected patient group
Use of ondansetron should be considered when vomiting interferes with oral rehydration therapy.
Oral and single-dose ondansetron, rather than intravenous ondansetron, should be used if possible. In one randomised controlled trial (n = 194), one dose of oral ondansetron decreased the proportion of children who continued vomiting within 4 hours from 42.9% to 19.5% (95% CI 0.20 to 0.72), and also showed a decrease in the number of vomiting episodes within 4 hours (incidence rate ratio 0.51 [95% CI 0.29 to 0.88]).[56]Bonvanie IJ, Weghorst AA, Holtman GA, et al. Oral ondansetron for paediatric gastroenteritis in primary care: a randomised controlled trial. Br J Gen Pract. 2021 Oct;71(711):e728-35.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407859
http://www.ncbi.nlm.nih.gov/pubmed/34426397?tool=bestpractice.com
Usually 1 single dose (either oral or intravenous) is sufficient. Occasionally, patients may require a repeated dose. The medication can be used for both inpatients and outpatients, but only after the patient has been clinically assessed. The medication should be used with caution in children whose diarrhoea is a major concern, as the use of medication might aggravate the diarrhoea. Clinicians must balance the confirmed benefits of antiemetic therapy against the cost and risk of adverse events in patients with gastroenteritis-related vomiting.[57]Leung AK, Robson WL. In children with vomiting related to acute gastroenteritis, are antiemetic medications an effective adjunct to fluid and electrolyte therapy? Part B: clinical commentary. Paediatr Child Health. 2008 May;13(5):393-4.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532885
http://www.ncbi.nlm.nih.gov/pubmed/19412370?tool=bestpractice.com
[58]Leung AK, Robson WL. Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting. Paediatr Drugs. 2007;9(3):175-84.
http://www.ncbi.nlm.nih.gov/pubmed/17523698?tool=bestpractice.com
[59]Leung AK, Robson WL. In children with vomiting related to acute gastroenteritis, are anti-emetic medications an effective adjunct to fluid and electrolyte therapy? Part A: evidence-based answer and summary. Paediatr Child Health. 2008 May;13(5):391-4.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532883
http://www.ncbi.nlm.nih.gov/pubmed/19412369?tool=bestpractice.com
[60]Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open. 2012 Jul 19;2(4):e000622.
https://bmjopen.bmj.com/content/2/4/e000622.long
http://www.ncbi.nlm.nih.gov/pubmed/22815462?tool=bestpractice.com
[ ]
Is there randomized controlled trial evidence to support the use of antiemetics for reducing vomiting in children and adolescents with acute gastroenteritis?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.403/fullShow me the answer
Primary options
ondansetron: children 8-15 kg: 2 mg orally as a single dose; children 16-30 kg: 4 mg orally as a single dose; children >30 kg: 8 mg orally as a single dose; children: 0.1 to 0.15 mg/kg intravenously as a single dose, maximum 4 mg
mild dehydration (<5%)
rehydration with 50 mL/kg oral rehydration therapy over 4 hours
Signs of mild dehydration include: alert state; slightly decreased urine output; slightly increased thirst; slightly dry mucous membrane; slightly elevated heart rate; normal capillary refill; normal skin turgor; normal eyes; and normal anterior fontanelle.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 Children with mild dehydration should be rehydrated with an oral rehydration solution (ORS) at 50 mL/kg over 4 hours.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Small amounts of ORS should be given at frequent intervals and the volume gradually increased until the child can drink as desired.[43]Leung AK, Robson WL. Acute diarrhea in children: what to do and what not to do. Postgrad Med. 1989 Dec;86(8):161-4, 167-74. http://www.ncbi.nlm.nih.gov/pubmed/2685791?tool=bestpractice.com Using a spoon or dropper for very small infants can significantly increase retention of ORS.
In a child who refuses to drink, squirting the ORS into the mouth with a syringe may help. Flavoured ORS or ORS popsicles, which may be more acceptable to some children, may also be tried.[62]te Loo DM, van der Graaf F, Ten WT. The effect of flavoring oral rehydration solution on its composition and palatability. J Pediatr Gastroenterol Nutr. 2004 Nov;39(5):545-8. http://www.ncbi.nlm.nih.gov/pubmed/15572897?tool=bestpractice.com
fluid compensation/maintenance with oral rehydration therapy
Treatment recommended for ALL patients in selected patient group
Amount of oral rehydration solution (ORS) per episode of vomiting or diarrhoeal stool: weight <10 kg = 60 to 120 mL, weight >10 kg = 120 to 240 mL.[42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com This should be continued until the vomiting and diarrhoea have subsided.
Daily fluid maintenance requirement is 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent 1 kg over 20 kg.
Small amounts of ORS should be given at frequent intervals and the volume gradually increased until the child can drink as desired.[43]Leung AK, Robson WL. Acute diarrhea in children: what to do and what not to do. Postgrad Med. 1989 Dec;86(8):161-4, 167-74. http://www.ncbi.nlm.nih.gov/pubmed/2685791?tool=bestpractice.com Using a spoon or dropper for very small infants can significantly increase retention of ORS.
In a child who refuses to drink, squirting the ORS into the mouth with a syringe may help. Flavoured ORS or ORS popsicles, which may be more acceptable to some children, may also be tried.[62]te Loo DM, van der Graaf F, Ten WT. The effect of flavoring oral rehydration solution on its composition and palatability. J Pediatr Gastroenterol Nutr. 2004 Nov;39(5):545-8. http://www.ncbi.nlm.nih.gov/pubmed/15572897?tool=bestpractice.com
age-appropriate diet
Treatment recommended for ALL patients in selected patient group
Children should continue to be fed an age-appropriate diet as soon as tolerated.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
For infants who are breastfed, breastfeeding should be continued throughout.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
It is not necessary to dilute formula or to give lactose-free formula in re-feeding non-breastfed infants.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Infants should be offered more frequent bottle or breastfeedings.
ondansetron
Additional treatment recommended for SOME patients in selected patient group
Use of ondansetron should be considered when vomiting interferes with oral rehydration therapy.
Oral and single-dose ondansetron, rather than intravenous ondansetron, should be used if possible. In one randomised controlled trial (n = 194), one dose of oral ondansetron decreased the proportion of children who continued vomiting within 4 hours from 42.9% to 19.5% (95% CI 0.20 to 0.72), and also showed a decrease in the number of vomiting episodes within 4 hours (incidence rate ratio 0.51 [95% CI 0.29 to 0.88]).[56]Bonvanie IJ, Weghorst AA, Holtman GA, et al. Oral ondansetron for paediatric gastroenteritis in primary care: a randomised controlled trial. Br J Gen Pract. 2021 Oct;71(711):e728-35.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407859
http://www.ncbi.nlm.nih.gov/pubmed/34426397?tool=bestpractice.com
Usually 1 single dose (either oral or intravenous) is sufficient. Occasionally, patients may require a repeated dose. The medication can be used for both inpatients and outpatients, but only after the patient has been clinically assessed. The medication should be used with caution in children whose diarrhoea is a major concern, as the use of medication might aggravate the diarrhoea. Clinicians must balance the confirmed benefits of antiemetic therapy against the cost and risk of adverse events in patients with gastroenteritis-related vomiting.[57]Leung AK, Robson WL. In children with vomiting related to acute gastroenteritis, are antiemetic medications an effective adjunct to fluid and electrolyte therapy? Part B: clinical commentary. Paediatr Child Health. 2008 May;13(5):393-4.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532885
http://www.ncbi.nlm.nih.gov/pubmed/19412370?tool=bestpractice.com
[58]Leung AK, Robson WL. Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting. Paediatr Drugs. 2007;9(3):175-84.
http://www.ncbi.nlm.nih.gov/pubmed/17523698?tool=bestpractice.com
[59]Leung AK, Robson WL. In children with vomiting related to acute gastroenteritis, are anti-emetic medications an effective adjunct to fluid and electrolyte therapy? Part A: evidence-based answer and summary. Paediatr Child Health. 2008 May;13(5):391-4.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532883
http://www.ncbi.nlm.nih.gov/pubmed/19412369?tool=bestpractice.com
[60]Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open. 2012 Jul 19;2(4):e000622.
https://bmjopen.bmj.com/content/2/4/e000622.long
http://www.ncbi.nlm.nih.gov/pubmed/22815462?tool=bestpractice.com
[ ]
Is there randomized controlled trial evidence to support the use of antiemetics for reducing vomiting in children and adolescents with acute gastroenteritis?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.403/fullShow me the answer
Primary options
ondansetron: children 8-15 kg: 2 mg orally as a single dose; children 16-30 kg: 4 mg orally as a single dose; children >30 kg: 8 mg orally as a single dose; children: 0.1 to 0.15 mg/kg intravenously as a single dose, maximum 4 mg
moderate dehydration (5% to 10%)
rehydration with 100 mL/kg oral rehydration therapy over 4 hours
Signs of moderate dehydration include: alert state, fatigued, or irritable; decreased urine output; moderately increased thirst; dry mucous membranes; elevated heart rate; prolonged capillary refill; decreased skin turgor; sunken eyes; and sunken anterior fontanelle.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 Children with moderate dehydration should be rehydrated with an oral rehydration solution (ORS) at 100 mL/kg over 4 hours.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Small amounts of ORS should be given at frequent intervals and the volume gradually increased until the child can drink as desired.[43]Leung AK, Robson WL. Acute diarrhea in children: what to do and what not to do. Postgrad Med. 1989 Dec;86(8):161-4, 167-74. http://www.ncbi.nlm.nih.gov/pubmed/2685791?tool=bestpractice.com Using a spoon or dropper for very small infants can significantly increase retention of ORS.
In a child who refuses to drink, squirting the ORS into the mouth with a syringe may help. Flavoured ORS or ORS popsicles, which may be more acceptable to some children, may also be tried.[62]te Loo DM, van der Graaf F, Ten WT. The effect of flavoring oral rehydration solution on its composition and palatability. J Pediatr Gastroenterol Nutr. 2004 Nov;39(5):545-8. http://www.ncbi.nlm.nih.gov/pubmed/15572897?tool=bestpractice.com
fluid compensation/maintenance with oral rehydration therapy
Treatment recommended for ALL patients in selected patient group
Amount of oral rehydration solution per episode of vomiting or diarrhoeal stool: weight <10 kg = 60 to 120 mL, weight >10 kg = 120 to 240 mL.[42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com This should be continued until the vomiting and diarrhoea have subsided.
Daily fluid maintenance requirement is 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent 1 kg over 20 kg.
age-appropriate diet
Treatment recommended for ALL patients in selected patient group
Children should continue to be fed an age-appropriate diet as soon as tolerated.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
For infants who are breastfed, breastfeeding should be continued throughout.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
It is not necessary to dilute formula or to give lactose-free formula in re-feeding non-breastfed infants.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Infants should be offered more frequent bottle or breastfeedings.
ondansetron
Additional treatment recommended for SOME patients in selected patient group
Use of ondansetron should be considered when vomiting interferes with oral rehydration therapy.
Oral and single-dose ondansetron, rather than intravenous ondansetron, should be used if possible. In one randomised controlled trial (n = 194), one dose of oral ondansetron decreased the proportion of children who continued vomiting within 4 hours from 42.9% to 19.5% (95% CI 0.20 to 0.72), and also showed a decrease in the number of vomiting episodes within 4 hours (incidence rate ratio 0.51 [95% CI 0.29 to 0.88]).[56]Bonvanie IJ, Weghorst AA, Holtman GA, et al. Oral ondansetron for paediatric gastroenteritis in primary care: a randomised controlled trial. Br J Gen Pract. 2021 Oct;71(711):e728-35.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407859
http://www.ncbi.nlm.nih.gov/pubmed/34426397?tool=bestpractice.com
Usually 1 single dose (either oral or intravenous) is sufficient. Occasionally, patients may require a repeated dose. The medication can be used for both inpatients and outpatients, but only after the patient has been clinically assessed. The medication should be used with caution in children whose diarrhoea is a major concern, as the use of medication might aggravate the diarrhoea. Clinicians must balance the confirmed benefits of antiemetic therapy against the cost and risk of adverse events in patients with gastroenteritis-related vomiting.[57]Leung AK, Robson WL. In children with vomiting related to acute gastroenteritis, are antiemetic medications an effective adjunct to fluid and electrolyte therapy? Part B: clinical commentary. Paediatr Child Health. 2008 May;13(5):393-4.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532885
http://www.ncbi.nlm.nih.gov/pubmed/19412370?tool=bestpractice.com
[58]Leung AK, Robson WL. Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting. Paediatr Drugs. 2007;9(3):175-84.
http://www.ncbi.nlm.nih.gov/pubmed/17523698?tool=bestpractice.com
[59]Leung AK, Robson WL. In children with vomiting related to acute gastroenteritis, are anti-emetic medications an effective adjunct to fluid and electrolyte therapy? Part A: evidence-based answer and summary. Paediatr Child Health. 2008 May;13(5):391-4.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532883
http://www.ncbi.nlm.nih.gov/pubmed/19412369?tool=bestpractice.com
[60]Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open. 2012 Jul 19;2(4):e000622.
https://bmjopen.bmj.com/content/2/4/e000622.long
http://www.ncbi.nlm.nih.gov/pubmed/22815462?tool=bestpractice.com
[ ]
Is there randomized controlled trial evidence to support the use of antiemetics for reducing vomiting in children and adolescents with acute gastroenteritis?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.403/fullShow me the answer
Primary options
ondansetron: children 8-15 kg: 2 mg orally as a single dose; children 16-30 kg: 4 mg orally as a single dose; children >30 kg: 8 mg orally as a single dose; children: 0.1 to 0.15 mg/kg intravenously as a single dose, maximum 4 mg
rehydration with 100 mL/kg nasogastric (NG) oral rehydration therapy over 4 hours
Signs of moderate dehydration include: alert state, fatigued, or irritable; decreased urine output; moderately increased thirst; dry mucous membranes; elevated heart rate; prolonged capillary refill; decreased skin turgor; sunken eyes; and sunken anterior fontanelle.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375
Various measures may be attempted before proceeding to NG oral rehydration therapy:
Small amounts of oral rehydration solution (ORS) should be given at frequent intervals and the volume gradually increased until the child can drink as desired.[43]Leung AK, Robson WL. Acute diarrhea in children: what to do and what not to do. Postgrad Med. 1989 Dec;86(8):161-4, 167-74. http://www.ncbi.nlm.nih.gov/pubmed/2685791?tool=bestpractice.com
Using a spoon or dropper for very small infants can significantly increase retention of ORS. In a child who refuses to drink, squirting the ORS into the mouth with a syringe may help.
Flavoured ORS or ORS ice-lollies, which may be more acceptable to some children, may also be tried.[62]te Loo DM, van der Graaf F, Ten WT. The effect of flavoring oral rehydration solution on its composition and palatability. J Pediatr Gastroenterol Nutr. 2004 Nov;39(5):545-8. http://www.ncbi.nlm.nih.gov/pubmed/15572897?tool=bestpractice.com
Children with moderate dehydration refusing to drink should be rehydrated with an ORS at 100 mL/kg over 4 hours through NG gavage.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
NG gavage should be considered before intravenous hydration is attempted.
Complications associated with NG gavage include trauma to the nose, oesophagus, and stomach, as well as aspiration.
fluid compensation/maintenance with nasogastric (NG) oral rehydration therapy
Treatment recommended for ALL patients in selected patient group
Amount of NG oral rehydration solution per episode of vomiting or diarrhoeal stool: weight <10 kg = 60 to 120 mL, weight >10 kg = 120 to 240 mL.[42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com This should be continued until the vomiting and diarrhoea have subsided.
Daily fluid maintenance requirement is 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent 1 kg over 20 kg.
Both ongoing losses and maintenance fluids are calculated together and given evenly through NG gavage over 24 hours.
age-appropriate diet
Treatment recommended for ALL patients in selected patient group
Children should continue to be fed an age-appropriate diet as soon as tolerated.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
For infants who are breastfed, breastfeeding should be continued throughout.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
It is not necessary to dilute formula or to give lactose-free formula in re-feeding non-breastfed infants.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Infants should be offered more frequent bottle or breastfeedings.
ondansetron
Additional treatment recommended for SOME patients in selected patient group
Use of ondansetron should be considered when vomiting interferes with oral rehydration therapy.
Oral and single-dose ondansetron, rather than intravenous ondansetron, should be used if possible. In one randomised controlled trial (n = 194), one dose of oral ondansetron decreased the proportion of children who continued vomiting within 4 hours from 42.9% to 19.5% (95% CI 0.20 to 0.72), and also showed a decrease in the number of vomiting episodes within 4 hours (incidence rate ratio 0.51 [95% CI 0.29 to 0.88]).[56]Bonvanie IJ, Weghorst AA, Holtman GA, et al. Oral ondansetron for paediatric gastroenteritis in primary care: a randomised controlled trial. Br J Gen Pract. 2021 Oct;71(711):e728-35.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407859
http://www.ncbi.nlm.nih.gov/pubmed/34426397?tool=bestpractice.com
Usually 1 single dose (either oral or intravenous) is sufficient. Occasionally, patients may require a repeated dose. The medication can be used for both inpatients and outpatients, but only after the patient has been clinically assessed. The medication should be used with caution in children whose diarrhoea is a major concern, as the use of medication might aggravate the diarrhoea. Clinicians must balance the confirmed benefits of antiemetic therapy against the cost and risk of adverse events in patients with gastroenteritis-related vomiting.[57]Leung AK, Robson WL. In children with vomiting related to acute gastroenteritis, are antiemetic medications an effective adjunct to fluid and electrolyte therapy? Part B: clinical commentary. Paediatr Child Health. 2008 May;13(5):393-4.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532885
http://www.ncbi.nlm.nih.gov/pubmed/19412370?tool=bestpractice.com
[58]Leung AK, Robson WL. Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting. Paediatr Drugs. 2007;9(3):175-84.
http://www.ncbi.nlm.nih.gov/pubmed/17523698?tool=bestpractice.com
[59]Leung AK, Robson WL. In children with vomiting related to acute gastroenteritis, are anti-emetic medications an effective adjunct to fluid and electrolyte therapy? Part A: evidence-based answer and summary. Paediatr Child Health. 2008 May;13(5):391-4.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532883
http://www.ncbi.nlm.nih.gov/pubmed/19412369?tool=bestpractice.com
[60]Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open. 2012 Jul 19;2(4):e000622.
https://bmjopen.bmj.com/content/2/4/e000622.long
http://www.ncbi.nlm.nih.gov/pubmed/22815462?tool=bestpractice.com
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Is there randomized controlled trial evidence to support the use of antiemetics for reducing vomiting in children and adolescents with acute gastroenteritis?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.403/fullShow me the answer
Primary options
ondansetron: children 8-15 kg: 2 mg orally as a single dose; children 16-30 kg: 4 mg orally as a single dose; children >30 kg: 8 mg orally as a single dose; children: 0.1 to 0.15 mg/kg intravenously as a single dose, maximum 4 mg
intravenous fluids
Additional treatment recommended for SOME patients in selected patient group
Intravenous fluids may be considered for those patients refusing nasogastric (NG) gavage or for whom NG gavage may be contraindicated (choanal atresia, oesophageal atresia).
Complications of intravenous therapy include interstitial infiltration of fluid at the cannula site, pain, bleeding, phlebitis, and seizures.
rehydration with intravenous fluids
Signs of moderate dehydration include: alert state, fatigued, or irritable; decreased urine output; moderately increased thirst; dry mucous membranes; elevated heart rate; prolonged capillary refill; decreased skin turgor; sunken eyes; and sunken anterior fontanelle.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375
Contraindications to the use of oral rehydration therapy in this group include protracted vomiting, impaired consciousness, paralytic ileus, and monosaccharide malabsorption.[42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Intravenous fluids should be given to replace the calculated deficit, ongoing losses, and the daily fluid maintenance requirement.
For children with mild and moderate dehydration, the deficit should be replenished in 4 hours and the rest given evenly throughout 24 hours. In these cases sodium chloride 0.45% with 5% glucose is the recommended intravenous fluid.
Early re-feeding should be started as soon as the physical condition of the patient allows.
Complications of intravenous therapy include interstitial infiltration of fluid at the cannula site, pain, bleeding, phlebitis, and seizures.
fluid compensation/maintenance with intravenous fluids
Treatment recommended for ALL patients in selected patient group
Amount of intravenous fluids per episode of vomiting or diarrhoeal stool: weight <10 kg = 60 to 120 mL, weight >10 kg = 120 to 240 mL.[42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com This should be continued until the vomiting and diarrhoea have subsided.
Daily fluid maintenance requirement is 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent 1 kg over 20 kg.
For children with moderate dehydration sodium chloride 0.45% with 5% glucose is recommended to replace ongoing losses and maintain daily fluid requirements. This may be given evenly throughout 24 hours.
age-appropriate diet
Treatment recommended for ALL patients in selected patient group
Children should continue to be fed an age-appropriate diet as soon as tolerated.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
For infants who are breastfed, breastfeeding should be continued throughout.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
It is not necessary to dilute formula or to give lactose-free formula in re-feeding non-breastfed infants.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Infants should be offered more frequent bottle or breastfeedings.
severe dehydration (>10%)
rehydration with 20 mL/kg intravenous fluid over 1 hour
Signs of severe dehydration include: apathetic or lethargic state; markedly decreased or absent urine output; greatly increased thirst; very dry mucous membranes; greatly elevated heart rate; prolonged or minimal capillary refill; decreased skin turgor; very sunken eyes; very sunken anterior fontanelle; cold extremities; hypotension; and coma.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375
Intravenous sodium chloride 0.9% or Ringer's lactate, 20 mL/kg, should be given over 1 hour.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375
Vital signs should be monitored and the patient re-assessed on a regular basis.
Boluses of intravenous fluid may be required until pulse, perfusion, and mental status return to normal.[42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Hypotonic saline solutions are inappropriate for intravenous rehydration.
Oral rehydration therapy should be started as soon as the patient is well enough to take it.
Complications of intravenous therapy include interstitial infiltration of fluid at the cannula site, pain, bleeding, phlebitis, and seizures.
Rehydration and maintenance of hydration should be continued until the vomiting and diarrhoea have subsided.
post-stabilisation oral or nasogastric (NG) oral rehydration therapy maintenance
Treatment recommended for ALL patients in selected patient group
Oral rehydration therapy should be started as soon as the patient is well enough to take it.
Amount of oral rehydration solution per episode of vomiting or diarrhoeal stool: weight <10 kg = 60 to 120 mL, weight >10 kg = 120 to 240 mL.[42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com This should be continued until the vomiting and diarrhoea have subsided.
Daily fluid maintenance requirement is 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent 1 kg over 20 kg.
Both ongoing losses and maintenance fluids are calculated together and given evenly through NG gavage over 24 hours.
age-appropriate diet once stable
Treatment recommended for ALL patients in selected patient group
Children should continue to be fed an age-appropriate diet as soon as tolerated.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
For infants who are breastfed, breastfeeding should be continued throughout, even during the initial rehydration phases, if possible.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
It is not necessary to dilute formula or to give lactose-free formula in re-feeding non-breastfed infants.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Infants should be offered more frequent bottle or breastfeedings.
fluid compensation/maintenance with intravenous fluids
Treatment recommended for ALL patients in selected patient group
Contraindications to the use of oral rehydration therapy in this group include protracted vomiting, impaired consciousness, paralytic ileus, and monosaccharide malabsorption.[42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Once rehydrated, sodium chloride 0.45% with 5% glucose is recommended to replace ongoing losses and maintain daily fluid requirements.
Amount of intravenous fluids per episode of vomiting or diarrhoeal stool: weight <10 kg = 60 to 120 mL, weight >10 kg = 120 to 240 mL.[42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com This should be continued until the vomiting and diarrhoea have subsided.
Daily fluid maintenance requirement is 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent 1 kg over 20 kg.
Both ongoing losses and maintenance fluids are calculated together and given evenly over 24 hours.
Early re-feeding should be started as soon as the physical condition of the patient allows.
Complications of intravenous therapy include interstitial infiltration of fluid at the cannula site, pain, bleeding, phlebitis, and seizures.
age-appropriate diet once stable
Treatment recommended for ALL patients in selected patient group
Children should continue to be fed an age-appropriate diet as soon as the physical condition allows.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
For infants who are breastfed, breastfeeding should be continued throughout, even during the initial rehydration phases, if possible.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
It is not necessary to dilute formula or to give lactose-free formula in re-feeding non-breastfed infants.[40]Leung A, Prince T; Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis. Paediatr Child Health. 2006 Nov;11(8):527-31. https://academic.oup.com/pch/article/11/8/527/4560375 [42]King CK, Glass R, Bresee JS, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://www.ncbi.nlm.nih.gov/pubmed/14627948?tool=bestpractice.com
Infants should be offered more frequent bottle or breastfeedings.
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