Acute Gastroenteritis in Infants and Young Children

- Recommendations

Table 3. Recommendations
A. What are the risk factors that can influence the clinical outcome of children with severe AGE?
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
A1		ESPGHAN/ESPID 2014	Rotavirus is the most severe enteric pathogen of childhood diarrhea.	Low	conditional
		ESPGHAN/ESPID 2014	The high incidence of dehydration in infants<6 months is related to a higher exposure to rotavirus.	Low	conditional
		ESPGHAN/ESPID 2014	In developing countries, a young age (<6 months) is related to the severity and persistence of diarrhea.	Intermediate	Strong
		ESPGHAN/ESPID 2014	Children attending day care centers have a greater risk of mild and severe diarrheal illness than children at home.	Low	Conditional
		ESPGHAN/ESPID 2014	Predominant breast-feeding may reduce the risk of AGE in young European infants.	Low	Conditional
		ESPGHAN/ESPID 2014	In developing areas early weaning may be associated with earlier onset of severe or prolonged diarrhea.	Low	Conditional
		ESPGHAN/ESPID 2014	Fever, severe dehydration, and lethargy, which are more common in rotavirus infection, indicate systematic involvement and are associated with severe diarrhea.	low	conditional
		ESPGHAN/ESPID 2014	In European countries, there is evidence, although weak, of a link between low socioeconomic status and the severity or persistence of diarrhea.	low	Conditional

Table 4. Recommendations
A. Diagnosis
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
B1	Indications for medical visit:	ESPGHAN/ESPID 2014	Infants and toddlers with AGE should be referred for medical evaluation if any of the following are present: · Age <2 months · Severe underlying disease (eg. diabetes and renal failure) · Persistent vomiting · High output diarrhea with elevated stool volumes (>8 episodes/day) · Family-reported signs of severe dehydration.	Low Very low Low Low low	Conditiona1 Conditional Conditional Conditional conditional

Table 5: Diagnosis
Diagnosis: Assessment of Dehydration
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
		ESPGHAN/ESPID 2014	The best measure of dehydration is the percentage loss of body weight.	Very low	Conditional
		ESPGHAN/ESPID 2014	Historical points are moderately sensitive as a measure of dehydration.	Low	Conditional
		ESPGHAN/ESPID 2014	Classification into subgroups with no or minimal dehydration, mild-moderate dehydration, and severe dehydration is an essential basis for appropriate treatment.	High	Strong
		ESPGHAN/ESPID 2014	Parental reports of dehydration symptoms are so low in specificity that they may not be clinically useful; however, parental report of normal urine output decreases the likelihood of dehydration.	Very Low	Conditional
		ESPGHAN/ESPID 2014	Little is known about the severity of diarrhea and/or vomiting and dehydration in industrialized countries; therefore, recommendations are largely based on data from developing countries. In the latter, infants and young children with frequent high-output diarrhea and vomiting are most at risk.	Low	Conditional
		ESPGHAN/ESPID 2014	Clinical tests for dehydration are imprecise, generally showing only fair-moderate agreement among examiners.	Low	Conditional
		ESPGHAN/ESPID 2014	It would be helpful to have a common tool to evaluate dehydration. The use of the clinical dehydration scale (CDS) is supported by consistent evidence, and it is easy to use in the assessment of dehydration.	Low	Conditional
		ESPGHAN/ESPID 2014	This scale should be used in combination with other criteria to guide the need of medical interventions in individual cases.	Low	Conditional

Table 6:
Diagnosis Clinical features suggestive of bacterial versus viral etiology of diarrhea:
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
		ESPGHAN/ESPID 2014	High fever (>40^oC), overt fecal blood, abdominal pain, and central nervous system involvement each suggests a bacterial pathogen. Vomiting and respiratory symptoms are associated with viral etiology.	Low	Conditional

Table 7. Recommendations
Laboratory Diagnosis
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
		ESPGHAN/ESPID 2014	Acute gastroenteritis does not generally require a specific diagnostic workup.	Very low	Conditional
		ESPGHAN/ESPID 2014	Children presenting with AGE do not require routine etiological investigation; however, there may be particular circumstances in which microbiological investigations may be necessary for diagnosis and treatment.	Very low	Conditional
		ESPGHAN/ESPID 2014	Microbiological investigations may be considered in children with underlying chronic conditions (eg, oncologic diseases, IBDs, etc), in those in extremely severe conditions, or in those with prolonged symptoms in whom specific treatment is considered.	Very low	Conditional
		ESPGHAN/ESPID 2014	The differentiation of a bacterial from nonbacterial etiology is not likely to change treatment. C-reactive protein (CRP) and procalcitonin measurements are not routinely recommended to identify a bacterial etiology.	Very low	conditional
		ESPGHAN/ESPID 2014	Based on available data we do not recommend the routine use of fecal markers to distinguish between viral and bacterial AGE in the clinical setting.	Very low	conditional
		ESPGHAN/ESPID 2014	Tests of dehydration are imprecise, and, generally, there is only fair-to-moderate agreement with the examiner’s estimate.	low	Conditional
		ESPGHAN/ESPID 2014	The only laboratory measurement that appears to be useful in decreasing the likelihood of >5% dehydration is serum bicarbonate (normal serum bicarbonate).	low	Conditional
		ESPGHAN/ESPID 2014	Electrolytes should be measured in hospital settings: · In moderately dehydrated children whose history and physical examination findings are inconsistent with a severe diarrheal disease, and in all severely dehydrated children. In all children starting IV therapy, and during therapy, because hyper- or hyponatremia will alter the rate at which IV rehydration fluids will be given.	Very low	Conditional
		ESPGHAN/ESPID 2014	There is no indication for endoscopy except in selected circumstances or cases such as differential diagnosis with IBD at its onset.	Very low	conditional

Table 8:Home Management
A- ORS
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
	Home management ORS	ESPGHAN/ESPID 2014	Reduced osmolarity ORS (50/60 mmol/L Na⁺) should be used as first-line therapy for the management of children with AGE.	High	Strong
		ESPGHAN/ESPID 2014	Reduced osmolarity ORS is more effective than full strength ORS as measured by such important clinical outcomes as reduced stool output, reduced vomiting, and reduced need for supplemental IV therapy.	High	Strong
		WHO 2005	If ORS therapy fails, such children should be given ORS solution by nasogastric (NG) tube or Ringer's Lactate Solution intravenously (IV) (75 ml/kg in four hours), usually in hospital. After confirming that the signs of dehydration have improved, it is usually possible to resume ORS successfully.	Good Practice Statement
		WHO 2005	ORS therapy should not be given in the following conditions: · Abdominal distension with paralytic ileus, which may be caused by opiate drugs (e.g. codeine, loperamide) and hypokalaemia. Glucose malabsorption, indicated by a marked increase in stool output.	Good Practice Statement

A. Nutrition
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
		ESPGHAN/ESPID 2014	Early resumption of feeding after rehydration therapy is recommended. Further studies are, however, needed to determine whether the timing of refeeding affects the duration of diarrhea, total stool output, or weight gain in childhood acute diarrhea.	High	Strong
		ESPGHAN/ESPID 2014	The routine use of lactose-free feeds is presently not recommended in outpatient setting.	High	Strong
		ESPGHAN/ESPID 2014	There is insufficient evidence to recommend in favor or against the use of diluted lactose-containing milk.	High	Strong
		ESPGHAN/ESPID 2014	The bread, rice, apple, toast (BRAT) diet has not been studied and is not recommended.	Very low	conditional
		ESPGHAN/ESPID 2014	Beverages with a high sugar content should not be used.	low	conditional
Pharmacology Therapy:
N	Health questions	Source Guideline	Recommendations	Quality of evidence	Strength of Recommendation
A1		ESPGHAN/ESPID 2014	Children age> 6 months in developing countries may benefit from the use of zinc in the treatment of AGE; however, in regions where zinc deficiency is rare, no benefit from the use of zinc is expected.	High	Strong
		ESPGHAN/ESPID 2014	Folic acid is not recommended for the management of children with AGE.	Intermediate	Strong
		ESPGHAN/ESPID 2014	Active treatment with probiotics, in adjunct to ORS, is effective in reducing the duration and intensity of symptoms of gastroenteritis. Selected probiotics can be used in children with AGE.	High	Strong
		ESPGHAN/ESPID 2014	The use of the following probiotics should be considered in the management of children with AGE as an adjunct to rehydration therapy: L rhamnosus GG and S boulardii.	High	Strong
		ESPGHAN/ESPID 2014	Ondansetron, at the dosages used in the available studies and administered orally or intravenously, may be effective in young children with vomiting related to AGE. Before a final recommendation is made, a clearance on safety in children is, however, needed.	Intermediate	Strong
		ESPGHAN/ESPID 2014	There is no evidence to support the use of other antiemetics.	Intermediate	Strong
		ESPGHAN/ESPID 2014	Loperamide is not recommended in the management of AGE in children.	Intermediate	Strong
		ESPGHAN/ESPID 2014	Smectite can be considered in the management of AGE.	Intermediate	Strong
		ESPGHAN/ESPID 2014	Smectite plus LGG and LGG alone are equally effective in the treatment of young children with AGE. Combined use of the 2 interventions is not justified.	Intermediate	Strong
		ESPGHAN/ESPID 2014	Other absorbents (namely, kaolin–pectin and attapulgite-activated charcoal) are not recommended.	Low	Conditional
		ESPGHAN/ESPID 2014	Racecadotril can be considered in the management of AGE.	Intermediate	Strong
		ESPGHAN/ESPID 2014	Bismuth subsalicylate is not recommended in the management of children with AGE.	Low	Conditional
		ESPGHAN/ESPID 2014	New evidence has confirmed that probiotics are effective in reducing the duration of symptoms in children with AGE.	High	Strong
		ESPGHAN/ESPID 2014	The use of prebiotics in the management of children with AGE is not recommended.	Intermediate	Strong

Home management
Anti- Infective Therapy
N	Health questions	Source Guideline		Recommendations	Quality of evidence	Strength of Recommendation
		ESPGHAN/ESPID 2014		Anti-infective therapy should not be given to the vast majority of otherwise healthy children with acute gastroenteritis.	Very Low	Conditional
		ESPGHAN/ESPID 2014		Antibiotic therapy for acute bacterial gastroenteritis is not needed routinely but only for specific pathogens or in defined clinical settings.	Very Low	Conditional
		ESPGHAN/ESPID 2014		The choice of the antimicrobial agent depends on the local prevalence of the 3 pathogens (Shigella spp, Campylobacter spp, and Salmonella enterica) and the resistance patterns.	Very Low	Conditional
		ESPGHAN/ESPID 2014		In children with watery diarrhea, antibiotic therapy is not recommended unless the patient has recently traveled or may have been exposed to cholera.	Very Low	Conditional
		ESPGHAN/ESPID 2014		Bloody diarrhea with low or no fever is typical of STEC (enterohemorrhagic E coli), but can be mild shigellosis or salmonellosis. Antibiotics are not recommended unless epidemiology suggests shigellosis.	Very Low	Conditional
		ESPGHAN/ESPID 2014		Parenteral rather than oral antibiotic therapy is recommended for: · Patients unable to take oral medications (vomiting, stupor, etc) · Patients with underlying immune deficiency who have AGE with fever · Severe toxemia, suspected or confirmed bacteremia Neonates and young infants (< 3 months) with fever. Sepsis workup and antibiotics should be considered according to local protocols.	Very Low	Conditional
		ESPGHAN/ESPID 2014		Antiparasitic treatment is generally not needed in otherwise healthy children; however, it may be considered if symptoms are severe.	Low	conditional
		ESPGHAN/ESPID 2014		Severe cases of giardiasis can be treated with metronidazole, nitazoxanide, albendazole, or tinidazole.	Low	conditional
		ESPGHAN/ESPID 2014		Cryptosporidiasis should be treated mainly in immunocompromised children with nitazoxanide.	Low	conditional
		ESPGHAN/ESPID 2014		Amebic colitis should be treated with metronidazole.	Low	conditional
		ESPGHAN/ESPID 2014		Specific antiviral treatment is usually not indicated in AGE.	Very Low	Conditional
		ESPGHAN/ESPID 2014		Severe cytomegalovirus colitis, especially in an immunocompromised child, should be treated with ganciclovir.	Low	conditional
Hospital Management
Hospitalization
N	Health questions	Source Guideline	Recommendations		Quality of evidence	Strength of Recommendation
		ESPGHAN/ESPID 2014	The recommendations for hospital admission are based on consensus and include any of the following conditions: · Shock · Severe dehydration (>9% of body weight) · Neurological abnormalities (lethargy, seizures, etc) · Intractable or bilious vomiting · Failure of oral rehydration · Suspected surgical condition Conditions for a safe follow-up and home management are not met.		Very low	Conditional
		ESPGHAN/ESPID 2014	Contact precautions are advised in addition to standard precautions (hand hygiene, personal protective equipment, soiled patient-care equipment, environmental control including textiles, laundry and adequate patient placement).		Very low	Conditional
		ESPGHAN/ESPID 2014	Prompt discharge from hospital should be considered in children admitted for AGE when the following conditions are fulfilled: · Sufficient rehydration is achieved as indicated by weight gain and/or clinical status · IV fluids are no longer required · Oral intake equals or exceeds losses Medical follow-up is available via telephone or office visit.		Very low	Conditional
2- Rehydration therapy (enteral and parenteral):
		ESPGHAN/ESPID 2014	When oral rehydration is not feasible, enteral rehydration by the nasogastric (NG) route is the preferred method of rehydration, and should be proposed before IV rehydration.		High	Strong
		ESPGHAN/ESPID 2014	Enteral rehydration is associated with significantly fewer major adverse events and a shorter hospital stay than IV rehydration and is successful in most children.		High	Strong
		ESPGHAN/ESPID 2014	The rapid (40–50 mL/kg within 3–6 hours) and standard (24 hours) NG rehydration regimens are equally effective and may be recommended.		Intermediate	Strong
		ESPGHAN/ESPID 2014	IV fluids are required in the following cases: · Shock · Dehydration with altered level of consciousness or severe acidosis · Worsening of dehydration or lack of improvement despite oral or enteral rehydration therapy · Persistent vomiting despite appropriate fluid administration orally or via an NG tube Severe abdominal distension and ileus.		Very low	Conditional
		ESPGHAN/ESPID 2014	Children presenting with shock secondary to AGE should receive rapid IV infusion of isotonic crystalloid solution (0.9% saline or lactated Ringer’s solution) with a 20-mL/kg bolus.		Very Low	Conditional
		ESPGHAN/ESPID 2014	If the blood pressure has not improved after the first bolus, a second (or even a third) bolus of 20 mL/kg should be administered >10 to 15 minutes and other possible causes of shock should be considered.		Very Low	Conditional
		ESPGHAN/ESPID 2014	Children with severe dehydration requiring IV fluids may receive rapid rehydration with 20mL/kg/h of 0.9% saline solution for 2 to 4 hours.		Intermediate	Strong
		ESPGHAN/ESPID 2014	In IV-rehydrated children, a dextrose-containing solution may be used for maintenance.		Low	Conditional
		ESPGHAN/ESPID 2014	A solution containing not <0.45% saline (at least 77 mmol/L [Na⁺]) is recommended during the first 24 hours of IV rehydration therapy to prevent hyponatremia.		Low	Conditional
		ESPGHAN/ESPID 2014	After the child starts to urinate and if serum electrolyte values are known, add 20 mmol/L of K⁺ chloride.		Very Low	Conditional
		ESPGHAN/ESPID 2014	Rapid rehydration with 20mL/kg/h for 2 to 4 hours followed by oral rehydration or continuous infusion of dextrose solution is adequate for initial rehydration of most patients requiring hospital assistance.		Intermediate	Strong
		ESPGHAN/ESPID 2014	More rapid IV rehydration may be associated with electrolyte abnormalities and is associated with long time to hospital discharge, and therefore is not recommended.		Intermediate	Strong
		ESPGHAN/ESPID 2014	Isotonic (0.9%) saline solution effectively reduces the risk of hyponatremia and is recommended for initial rehydration in most cases. In the rare but extremely severe cases of shock, Ringer’s lactate solution is recommended.		Low	Conditional
		ESPGHAN/ESPID 2014	Glucose may be added to saline solution once fluid volume has been restored in the subsequent phase of IV rehydration (‘‘maintenance’’).		Low	Conditional
Management of electrolyte imbalance:
	Management Of Hypernatremia:	ESPGHAN/ESPID 2014	Oral or NG rehydration with hypo osmolar ORS is an effective and safe treatment and has fewer adverse effects than IV rehydration.		Low	Conditional
		ESPGHAN/ESPID 2014	If the child is hypernatremia and needs IV rehydration: · Use an isotonic solution (0.9% saline) for fluid deficit replacement and maintenance. · Replace the fluid deficit slowly, typically for 48 hours, with the aim of reducing it to <0.5mmol/L/h. Monitor plasma sodium frequently.		Low	Conditional
	Management of Hyponatremia	WHO 2005	ORS solution is safe and effective therapy for nearly all children with hyponatremia. An exception is children with oedema, for whom ORS solution provides too much sodium.		Good Practice Statement
	Management of Hypokalemia	WHO 2005	Hypokalemia is worsened when base (bicarbonate or lactate) is given to treat acidosis without simultaneously providing potassium.		Good Practice Statement
		WHO 2005	Hypokalaemia can be prevented, and the potassium deficit corrected, by using ORS solution for rehydration therapy and by giving foods rich in potassium during diarrhea and after it has stopped.
Prevention:
1- Strategies:
		IDSA 2017	Hand hygiene should be performed after using the toilet, changing diapers, before and after preparing food, before eating, after handling garbage or soiled laundry items, and after touching animals or their feces or environments, especially in public settings such as petting zoos.		Intermediate (moderate)	Strong
		IDSA 2017	Infection control measures including use of gloves and gowns, hand hygiene with soap and water, or alcohol-based sanitizers should be followed in the care of people with diarrhea.		High	Strong
		IDSA 2017	The selection of a hand hygiene product should be based upon a known or suspected pathogen and the environment in which the organism may be transmitted.		low	Strong
		IDSA 2017	Appropriate food safety practices are recommended to avoid cross-contamination of other foods or cooking surfaces and utensils during grocery shopping, food preparation, and storage; ensure that foods containing meats and eggs are cooked and maintained at proper temperatures.		moderate	Strong
		IDSA 2017	Healthcare providers should direct educational efforts toward all people with diarrhea, but particularly to people with primary and secondary immune deficiencies, pregnant women, parents of young children, and the elderly as they have increased risk of complications from diarrheal disease.		low	Strong
		IDSA 2017	Ill people with diarrhea should avoid swimming, water-related activities, and sexual contact with other people when symptomatic while adhering to meticulous hand hygiene.		low	Strong
2- Vaccination
		IDSA 2017	Rotavirus vaccine should be administered to all infants without a known contraindication.		high	Strong
		IDSA 2017	Two typhoid vaccines (oral and injectable) are licensed in the United States but are not recommended routinely. Typhoid vaccination is recommended as an adjunct to hand hygiene and the avoidance of high-risk foods and beverages, for travelers to areas where there is moderate to high risk for exposure to Salmonella enterica subspecies enterica serovar Typhi, people with intimate exposure (eg, household contact) to a documented Salmonella enterica subspecies enterica serovar Typhi chronic carrier, and microbiologists and other laboratory personnel routinely exposed to cultures of Salmonella enterica subspecies enterica serovar Typhi. Booster doses are recommended for people who remain at rik.		high	Strong