Evidence Based Strategies: Guidance for Acute Gastroenteritis

Column Author: Brittany Moore, MD | Pediatric Resident  

Column Editor: Angela D. Etzenhouser, MD, FAAP | Associate Director, Pediatric Residency Program Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

You are seeing a 4-year-old patient who presents to clinic for vomiting and diarrhea for two days. You may have asked yourself the following questions: Does this patient need labs? Do they need antibiotics? What is the utility of probiotics?

Diarrhea with or without vomiting is a common cause for outpatient pediatric visits. Acute gastroenteritis is a common cause of diarrhea.^1-3 The leading etiology is viral followed by bacterial and parasitic with each of these etiologies requiring different evaluation, management and treatment.

Acute viral gastroenteritis is caused by a multitude of different viruses with rotavirus having the highest prevalence prior to routine administration of the rotavirus vaccine.⁴ The implementation of routine vaccination against rotavirus in 2007 led to a substantial decrease in the incidence of rotavirus by almost 12-fold when comparing fully vaccinated patients to patients of similar age in the pre-vaccine era.⁵ Norovirus is a common, highly contagious virus known to cause major outbreaks in communities.² Acute viral gastroenteritis is primarily spread through fecal-oral transmission with prevention strategies geared toward proper handwashing hygiene.^3,6 Patients typically present with acute onset diarrhea with or without vomiting, fever, and/or abdominal pain. This condition is most often self-limited and usually lasts five to seven days. The mainstay of treatment is supportive with a focus on oral rehydration.

The Department of Evidence Based Practice at Children’s Mercy Hospital recently updated the clinical pathway for the management of acute gastroenteritis.⁷ The updated clinical pathway is to be used for immunocompetent patients who are 3 months of age and older with less than seven days of diarrhea with or without vomiting, fever, and/or abdominal pain.⁷ Patients with mild-to-moderate dehydration should be encouraged to take in oral fluids such as an electrolyte solution in small, yet frequent, aliquots.^1,7 For patients who are unable to tolerate oral fluids, parenteral rehydration and obtaining a point-of-care glucose may be necessary.⁷ If the patient does not show clinical improvement after parenteral rehydration and correction of hypoglycemia, admission may be indicated. 

There have been studies investigating the utility of probiotic and prebiotic use in the treatment of acute viral gastroenteritis. However, the results are widely variable and inconsistent.^8-10 Of note, meta-analyses of studies that solely investigated Lactobacillus rhamnosus noted no benefit.^8,9 The decision to recommend prebiotics and probiotics should be made after discussion of the risks and benefits with the primary caregiver.

Viral etiology is the most common cause of acute gastroenteritis.⁴ However, assessment for risk factors of bacterial and parasitic enteritis is necessary for appropriate management of these patients. A stool culture should be obtained if the patient is known to have bloody diarrhea; exposure to a person with known bacterial gastroenteritis (in the household or at child care); history of consuming potentially contaminated water, undercooked meat, unpasteurized dairy products, or raw shellfish; recent community outbreaks; or recent international travel.^6,9 The symptoms for acute bacterial gastroenteritis can be consistent with parasitic enteritis, so a stool ova and parasite panel should also be obtained if ^,7,9

The use of antibiotics in patients with acute bacterial gastroenteritis depends upon the pathogen as well as the risk of the patient developing invasive disease.^6,7 Antibiotics for the treatment of Salmonella, Campylobacter and Shigella should be considered in patients with severe symptoms (diarrhea lasting more than one week, worsening symptoms, and prolonged fever) or who are immunocompromised.⁷ Of note, patients with E. coli 0157:H7/other Shiga toxin-producing E. coli should not be treated with antibiotics.⁷ Close follow-up of these patients is paramount to ensure good urine output and to evaluate the need for laboratory evaluation such as a complete blood count in patients who have tested positive for E. coli 0157:H7 or Shiga toxin-producing E. coli.⁶ A more detailed discussion on treatment of acute bacterial gastroenteritis is beyond the scope of this article.

In summary, acute gastroenteritis is most likely secondary to a viral pathogen, and the mainstay of treatment consists of supportive measures. When there is clinical concern for severe dehydration, parenteral rehydration may be necessary along with assessing the patient’s glycemic status. Gastroenteritis is typically managed in the outpatient setting. However, there are times when a patient requires inpatient admission. Treatment of bacterial gastroenteritis is multifactorial and further information can be found in the Children’s Mercy clinical pathway for acute gastroenteritis.

References:

1. Guarino A, Aguilar J, Berkley J, et al. Acute gastroenteritis in children of the world: what needs to be done? J Pediatr Gastroenterol Nutr. 2020;70(5):694-701. PMID: 32079974. PMCID: PMC7613312. doi:10.1097/MPG.0000000000002669
2. Dennehy PH. Viral gastroenteritis in children. Pediatr Infect Dis J. 2011;30:63-64.
3. Schmidt MA, Groom HC, Rawlings AM, et al. Incidence, etiology, and healthcare utilization for acute gastroenteritis in the community, United States. Emerg Infect Dis. 28(11):2234-2242. doi:10.3201/eid2811.220247
4. Burnett E, Parashar UD, Winn A, et al. Major changes in spatiotemporal trends of US rotavirus laboratory detections after rotavirus vaccine introduction-2009-2021. Pediatr Infect Dis J. 2022;41:759-763.
5. Krishnarajah G, Duh MS, Korves C, Demissie K. Public health impact of complete and incomplete rotavirus vaccination among commercially and Medicaid insured children in the United States. PLoS One. 2016;11(1):e0145977. PMID: 26751375. PMCID: PMC4709043. doi:10.1371/journal.pone.0145977
6. Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021–2024, Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.doi:10.1542/9781610025782 
7. Children’s Mercy Hospital Evidence Based Practice Committee. Acute gastroenteritis clinical pathway. Children’s Mercy Kansas City. February 1, 2024. Accessed March 31, 2024. https://www.childrensmercy.org/health-care-providers/evidence-based-practice/cpgs-cpms-and-eras-pathways/acute-gastroenteritis-care-process-model/
8. Szajewska H, Kołodziej M, Gieruszczak-Białek D, et al. Systematic review with meta-analysis: Lactobacillus rhamnosus GG for treating acute gastroenteritis in children - a 2019 update. Aliment Pharmacol Ther. 2019;49:1376-1384.
9. Schnadower D, Tarr PI, Freedman SB. Letter: Lactobacillus rhamnosus GG offers no benefit over placebo in children with acute gastroenteritis. Aliment Pharmacol Ther. 2019;50:620-622.
10. Szajewska H, Guarino A, Hojsak I, et al. Use of probiotics for the management of acute gastroenteritis in children: an update. J Pediatr Gastroenterol Nutr. 2020;71:261-269.