Acute Gastroenteritis in Infants and Young Children

Acute Gastroenteritis (AGE) is a common pediatric illness. In the Middle East region, AGE persists as the second major cause of pediatric mortality and morbidity following acute lower respiratory tract infections^3,4

Acute gastroenteritis (AGE) in children is considered one of the most common causes of visits to health centers, one of the most frequent reasons of hospitalization and the third leading cause of death related to infectious diseases worldwide^5,6.

The incidence of diarrhea ranges from 0.5 to 2 episodes per child per year in children <3 years in Europe⁸. On average, children below 3 years of age in developing countries experience 3 episodes of diarrhea each year⁷.

Rotavirus (RV)is the leading cause of AGE in infants and young children and the major contributor to hospitalization for diarrhea in countries that have no RV vaccines in their national immunization schedules^9,10,11. With the continuing decline in cases of RV-associated AGE, since the implementation of routine childhood vaccination against RV, norovirus (NoV) infection has become the most common cause of medically treated AGE ^12,13.

In 2012, a study conducted in two locations in Egypt over 2112 children to determine the causes of acute diarrhea in children younger than 5-years seeking treatment. Bacteria were identified as a sole pathogen in 20%, RV in 14% and Cryptosporidium in 5% of the cases. Adenovirus (AdV), astrovirus (AsV), NoV and G. lamblia were detected as the sole pathogen in 2%, 3%, 9% and 7% of the cases, respectively. E. histolytica was never detected as the sole pathogen¹⁴. 

The most common enteric infections in the 0-12 months age group were NoV, RV, enterotoxigenic E. coli (ETEC), AsV, Campylobacter spp. and AdV. When identified, Shigella was more commonly identified during the second year after birth (13-24 months). The rates of infection for Cryptosporidium spp. and G. lamblia were similar among children of both age groups¹⁴. 

High fever (>40 ̊C), overt fecal blood, abdominal pain, and central nervous system involvement each suggests a bacterial pathogen. Vomiting and respiratory symptoms are associated with a viral etiology⁷.

Many diarrheal deaths are caused by dehydration⁸. It would be helpful to have a common tool to evaluate dehydration. The Clinical Dehydration Scale (CDS) is easy to use in the assessment of dehydration⁷.

Dehydration from AGE of any etiology and at any age, except when it is severe, can be safely and effectively treated in over 90% of cases by Oral Rehydration Salts (ORS) solution⁸.

For prevention of recurrent AGE, exclusive breastfeeding until age six months, and continued breastfeeding with complementary foods until two years of age is considered an important aspect in prevention⁷. 

Contact and standard precautions including (hand hygiene, personal protective equipment, soiled patient-care equipment, environmental control including textiles, laundry and adequate patient placement)⁸.

This guideline focuses on prevention and management of acute gastroenteritis in infants and young children. The objectives of these Clinical Practice Guidelines are to provide evidence-based guidance on the diagnosis, management and prevention of Acute Gastroenteritis (AGE) specifically adjusted to the customs of the Egyptian community and to integrate it with the already existing health care system through the following:

1- Standardization of clinical practice of acute gastroenteritis in Egypt.

2- Reduction of morbidity and mortality from acute gastroenteritis.

These Clinical Practice Guidelines intended to be used in infants and young children less than 5 years of age presenting with acute gastroenteritis without co-morbidities in all healthcare facilities

Patient Population (P):

·  Both genders

·  Age: 2months - 5 years

·  Disease: Acute gastroenteritis

·  Co-morbidities: No

Intervention (I):

·  Diagnosis

·  Management

·   Prevention

Professionals (P):

·  Pediatricians, Family Physicians, Emergency Physicians, Primary Health Care Practitioners.

·  Nurses.

·  Parents and Care-givers.

Outcomes (O):

·  Primary outcome: standardization of clinical practice of acute gastroenteritis in Egypt.

·  Secondary outcome: reduction of morbidity and mortality from acute gastroenteritis.

Healthcare Settings (H):

·  Primary, secondary and tertiary healthcare facilities.

·  Governmental: University, MOH, Ministry of Defense, Ministry of Interior.

·  Non-governmental: Private, NGO. 

Guideline development process and methods

After reviewing all the inclusion and exclusion criteria and quality appraisal results, the GDG/ GAG recommended using the following source original clinical practice guidelines (CPGs):

1- ESPGHAN/ESPID guidelines 2014

2- IDSA guidelines 2017

3-WHO guidelines 2005:

         -   Adoption for most of the guideline recommendations.

         -   Development of Good Practice Statements

Recommendations and Good Practice Statements (GPS)

This version of the CPG includes recommendations and good practice statements on the following four sub-sections:

A. Diagnosis of acute gastroenteritis

The guideline covers (Age group) 2months - 5 years

B. Management of acute gastroenteritis.

This section includes recommendations and good practice statements on management of acute gastroenteritis in infants and young children

C. Prevention of acute gastroenteritis.

We can summarize the guidelines’ recommendations for acute gastroenteritis in the following:

·  Risk Factors:

Rotavirus is the most severe enteric pathogen of childhood diarrhea.     (low, conditional)

The high incidence of dehydration in infants<6 months is related to a higher exposure to rotavirus.       (low, conditional)

In developing countries, a young age (<6 months) is related to the severity and persistence of diarrhea.    (Intermediate, Strong)

Children attending day care centers have a greater risk of mild and severe diarrheal illness than children at home.       (low, Conditional)

Predominant breast-feeding may reduce the risk of AGE in young European infants.      (Low, Conditional)

In developing areas early weaning may be associated with earlier onset of severe or prolonged diarrhea.          (Low, Conditional)

Fever, severe dehydration, and lethargy, which are more common in rotavirus infection, indicate systematic involvement and are associated with severe diarrhea (low           conditional)

In European countries, there is evidence, although weak, of a link between low socioeconomic status and the severity or persistence of diarrhea(          low      Conditional)

·  Diagnosis: Indications for medical Visit

Indications for medical visit: Infants and toddlers with AGE should be referred for medical evaluation if any of the following are present (low, conditional)

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.

·  Dehydration Assessment:

The best measure of dehydration is the percentage loss of body weight. (Very low, Conditional)

Historical points are moderately sensitive as a measure of dehydration. (Low, Conditional)

Classification into subgroups with no or minimal dehydration, mild-moderate dehydration, and severe dehydration is an essential basis for appropriate treatment.      (High, Strong)

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)

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)

Clinical tests for dehydration are imprecise, generally showing only fair-moderate agreement among examiners.       (Low, Conditional)

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)

This scale should be used in combination with other criteria to guide the need of medical interventions in individual cases.           (Low   Conditional)

High fever (>40oC), 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)

Laboratory Diagnosis:

Acute gastroenteritis does not generally require a specific diagnostic workup.       (Very low        Conditional)

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)

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)

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)

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)

Tests of dehydration are imprecise, and, generally, there is only fair-to-moderate agreement with the examiner’s estimate. (low     Conditional)

The only laboratory measurement that appears to be useful in decreasing the likelihood of >5% dehydration is serum bicarbonate (normal serum bicarbonate).      (Low, Conditional)

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)

There is no indication for endoscopy except in selected circumstances or cases such as differential diagnosis with IBD at its onset.    (Very low, conditional)

Home management:

1-  ORS:

Reduced osmolarity ORS (50/60 mmol/L Na+) should be used as first-line therapy for the management of children with AGE.         (High   Strong)

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)

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.                     

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.

2-  Nutrition:

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)

The routine use of lactose-free feeds is presently not recommended in outpatient setting. (High   Strong)

There is insufficient evidence to recommend in favor or against the use of diluted lactose-containing milk. (High           Strong)

The bread, rice, apple, toast (BRAT) diet has not been studied and is not recommended. (Very low        conditional)

Beverages with a high sugar content should not be used.      (low            conditional)

3-  Pharmacotherapy

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)

Folic acid is not recommended for the management of children with AGE.    (Intermediate  Strong)

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)

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)

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)

There is no evidence to support the use of other antiemetics.            (Intermediate  Strong)

Loperamide is not recommended in the management of AGE in children.    (Intermediate  Strong)

Smectite can be considered in the management of AGE.      (Intermediate            Strong)

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)

Other absorbents (namely, kaolin–pectin and attapulgite-activated charcoal) are not recommended.      (Low   Conditional)

Racecadotril can be considered in the management of AGE.            (Intermediate  Strong)

Bismuth subsalicylate is not recommended in the management of children with AGE.   (Low   Conditional)

New evidence has confirmed that probiotics are effective in reducing the duration of symptoms in children with AGE. (High   Strong)

The use of prebiotics in the management of children with AGE is not recommended. (Intermediate  Strong)

4-  Anti- infective therapy

Anti-infective therapy should not be given to the vast majority of otherwise healthy children with acute gastroenteritis.   (Very Low      Conditional)

Antibiotic therapy for acute bacterial gastroenteritis is not needed routinely but only for specific pathogens or in defined clinical settings.    (Very Low     Conditional)

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)

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)

   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)

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)

Antiparasitic treatment is generally not needed in otherwise healthy children; however, it may be considered if symptoms are severe.        (Low            conditional)

Severe cases of giardiasis can be treated with metronidazole, nitazoxanide, albendazole, or tinidazole.     (Low   conditional)

Cryptosporidiasis should be treated mainly in immunocompromised children with nitazoxanide.      (Low   conditional)

Amebic colitis should be treated with metronidazole.   (Low  conditional)

Specific antiviral treatment is usually not indicated in AGE.  (Very Low            Conditional)

Severe cytomegalovirus colitis, especially in an immunocompromised child, should be treated with ganciclovir.    (Low   conditional)

Hospital management:

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)

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)

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):

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)

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)

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)

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)

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)

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)

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)

In IV-rehydrated children, a dextrose-containing solution may be used for maintenance.  (  Low   Conditional)

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)

After the child starts to urinate and if serum electrolyte values are known, add 20 mmol/L of K+ chloride.    (Very Low      Conditional)

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)

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)

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)

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:

Oral or NG rehydration with hypo osmolar ORS is an effective and safe treatment and has fewer adverse effects than IV rehydration.           (Low  Conditional)

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)

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.               

Hypokalemia is worsened when base (bicarbonate or lactate) is given to treat acidosis without simultaneously providing potassium.                    

Hypokalemia 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:

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)

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)

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)

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)

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)

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

Rotavirus vaccine should be administered to all infants without a known contraindication.        (high   Strong)

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 risk. (High       Strong).

➡️Guideline Registration

PREPARE (Practice guideline REgistration for transPAREncy), WHO Collaborating Center for Guideline Implementation and Knowledge Translation, EBM Center, University of Lanzhou, Lanzhou, China. Registration Number: ((submitted and in process)). Link: http://www.guidelines-registry.org/