Managing children with gastroenteritis in LTHT Paediatric Emergency Department (PED)

A Fluid Challenge and why it is Important for your Child 

• When to suspect gastroenteritis?
• Which children are at risk of dehydration? (based on NICE 2009)
• IV and NG fluid therapy calculations
• Additional Information
• Discharge information
• Ondansetron Use in Paediatric ED for Gastroenteritis

When to suspect gastroenteritis?

Sudden change in stool consistency to loose or watery stools (try to establish the normal consistency as part of the clinical history) and/or a sudden onset of vomiting
Ensure to ask about recent travel abroad, exposure to known enteric source of infection, contact with someone else with acute diarrhoea/ vomiting
Consider informing Public Health England if you suspect an outbreak of gastroenteritis.
Whilst gastroenteritis is common, children may develop diarrhoea and vomiting for other reasons. It should not be assumed that the cause is a primary gastrointestinal problem, particularly if just vomiting and no diarrhoea. Consider:

• Other infections e.g. Urinary Tract Infection (UTI), otitis media, pneumonia, meningitis, tropical, Sepsis
• Surgical intestinal disease e.g. intussusception, appendicitis, small intestinal obstruction
• Poisoning (accidental / deliberate / Non-accidental injury (NAI))
• Metabolic abnormality Especially Diabetic Ketoacidosis (DKA)
• Neurological (Raised Intracranial Pressure (ICP), Space occupying lesions)
• Pregnancy related

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Which children are at risk of dehydration? (based on NICE 2009)

Children <1 year old, particularly if <6 months old Infants with low birth weight
Children with >5 diarrhoea stools in 24 hours Children with >2 vomiting episodes in 24 hours
Children who either have not been offered, or could not tolerate supplementary fluids prior to presentation
Infants who have stopped breastfeeding prior to presentation Children with signs of malnutrition

Children with bloody diarrhoea must have a senior review as the consideration of HUS (haemolytic Uraemic syndrome) must be made. The management of which is outside of the scope of this guideline

Note: If proceeding down the amber pathway, bloods other than bedside glucose/capillary gases not routinely indicated.

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IV and NG fluid therapy calculations

IV fluid therapy or NG fluids

http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=5026

Example calculation for 12Kg Child.

Maintenance:

100ml/kg for first 10kg= 1000ml 50ml/kg for next 2kg= 100ml
= 1100ml maintenance over 24 hours
= 46mls/hr

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Additional information

If giving via Naso-gastric Tube, ensure is given as continuous feed and complete fluid chart as appropriate

Continue breastfeeding during Oral Rehydration therapy if possible

Monitor PAWS closely

Intravenous fluid therapy calculations

Use 0.9% Sodium Chloride for fluid boluses in the treatment of shock Use 0.9% Sodium Chloride + 5% glucose for maintenance therapy

Management of hypoglycaemia (Lab plasma Glucose <2.6mmol/L, <3.0mmol/L on POCT bedside blood glucose)

Gain IV access and take bloods as per hypoglycaemia guidance (hypo box in the treatment room)

http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1231

Give bolus of 2ml/kg of 10% glucose intravenously

Recheck blood glucose after 5 minutes

• if remains <2.6mmol/L (lab glucose) or <3.0 mmol/L (POCT bedside glucose) consider repeat bolus and call for senior help

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Discharge Information

Most diarrhoea lasts for 5-7 days, and in most it stops within 2 weeks

Most vomiting lasts for 1-2 days, and in most it stops within 3 days

Seek review from a specified healthcare professional (usually GP) if the symptoms do not resolve within this period, but they do not meet the criteria to need to return to the emergency department

Discharge all children with the Gastroenteritis leaflet or direct them to the online leaflet from healthier together
https://what0-18.nhs.uk/professionals/gp-primary-care-staff/safety-netting-docu ments-parents/diarrhoea-andor-vomiting-advice-sheet

• washing hands with soap (liquid if possible) in warm running water and careful drying are the most important factors in preventing the spread of gastroenteritis
• hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food
• towels used by infected children should not be shared
• children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis
• children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting
• children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea.

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Ondansetron Use in Paediatric ED for Gastroenteritis

It is common practice to provide anti-emetics to children not tolerating a fluid challenge whom are suspected to have gastroenteritis in Paediatric ED. This is an unlicenced indication and there is no dose for this indication in the BNFc. It has been agreed jointly between PED and Leeds Children’s Hospital Pharmacy teams that the safe dose is:

8 - 29kg - 0.1mg/kg dose
>30kg - 4mg dose

Children weighing 30kg or over can have a dose of 4mg.  It is advisable they receive this dose via the sublingual route.

Please note - children with Long QT syndrome should not be given ondansetron.