Forehead temporal. This works for children age 3 months and older. If a child under 3 months old has signs of illness, this can be used for a first pass. The provider may want to confirm with a rectal temperature. Ear tympanic. Ear temperatures are accurate after 6 months of age, but not before. Armpit axillary. This is the least reliable but may be used for a first pass to check a child of any age with signs of illness.
Mouth oral. Use the rectal thermometer with care. It may accidentally injure the rectum. It may pass on germs from the stool. Below are guidelines to know if your young child has a fever. Was this helpful? Yes No Tell us more. Check all that apply. Wrong topic—not what I was looking for. It was hard to understand. It didn't answer any of my questions. I still don't know what to do next.
All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions. Patient Education. Viral Gastroenteritis in Children Viral gastroenteritis is often called stomach flu. Symptoms of viral gastroenteritis Symptoms of gastroenteritis include loose, watery stools diarrhea , sometimes with nausea and vomiting.
How is viral gastroenteritis spread? Treatment Most cases of viral gastroenteritis get better without treatment. Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq cdc. Type Accommodation and the title of the report in the subject line of e-mail.
Oral Rehydration, Maintenance, and Nutritional Therapy. Prepared by Caleb K. King, M. Bresee, M. Hughes, M. Acute gastroenteritis remains a common illness among infants and children throughout the world. Oral rehydration therapy ORT includes rehydration and maintenance fluids with oral rehydration solutions ORS , combined with continued age-appropriate nutrition. Although ORT has been instrumental in improving health outcomes among children in developing countries, its use has lagged behind in the United States.
This report provides a review of the historical background and physiologic basis for using ORT and provides recommendations for assessing and managing children with acute diarrhea, including those who have become dehydrated.
Recent developments in the science of gastroenteritis management have substantially altered case management. Physicians now recognize that zinc supplementation can reduce the incidence and severity of diarrheal disease, and an ORS of reduced osmolarity i.
The combination of oral rehydration and early nutritional support has proven effective throughout the world in treating acute diarrhea. The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. MMWR ;41[No. RR] , and this report updates those recommendations. This report reviews the historical background and scientific basis of ORT and provides a framework for assessing and treating infants and children who have acute diarrhea.
The discussion focuses on common clinical scenarios and traditional practices, especially regarding continued feeding. Limitations of ORT, ongoing research in the areas of micronutrient supplements, and functional foods are reviewed as well. These updated recommendations were developed by specialists in managing gastroenteritis, in consultation with CDC and external consultants.
Articles were then reviewed for their relevance to pediatric practice, with emphasis on U. Unpublished references were sought from the external consultants and other researchers. In the United States, adoption of these updated recommendations could substantially reduce medical costs and childhood hospitalizations and deaths caused by diarrhea.
Direct medical costs for rotavirus diarrhea, which represents approximately one third of all hospitalizations for diarrhea among U. Worldwide, diarrheal diseases are a leading cause of pediatric morbidity and mortality, with 1. Although the total number of deaths from diarrhea is still unacceptably high, these numbers have been reduced substantially in the s and s. A substantial portion of the decrease in mortality is attributable to worldwide campaigns to treat acute diarrhea with oral rehydration therapy ORT.
The development of ORT represents a successful collaboration between basic and applied biomedical research 7. The application of ORT also represents a case of reverse technology transfer 8 , because protocols originally implemented to benefit patients in developing countries have changed the standard of care in industrialized countries as well.
ORT encompasses two phases of treatment: 1 a rehydration phase, in which water and electrolytes are administered as oral rehydration solution ORS to replace existing losses, and 2 a maintenance phase, which includes both replacement of ongoing fluid and electrolyte losses and adequate dietary intake.
Although ORT implies rehydration alone, the definition used in this report has been broadened to include maintenance fluid therapy and appropriate nutrition.
The full benefits of ORT for acute gastroenteritis have not been realized, especially in countries with developed market economies that have lagged behind less-developed countries in their use of ORT.
One reason for this low usage of ORT might be the ingrained use of intravenous IV therapy or the reduced appeal of a technologically simple solution 9, This is especially true in the United States, where children with all forms of dehydration are treated with IV fluids rather than ORT In addition, the practice of continued feeding during diarrheal episodes has been difficult to establish as accepted standard of care.
Although substantial in vitro and in vivo data support the role of continued nutrition in improving gastrointestinal function and anthropometric, biochemical, and clinical outcomes 18,19 , early appropriate feeding is often withheld. In , CDC prepared the first national guidelines for managing childhood diarrhea Since the last recommendations were published in MMWR , data have emerged regarding diarrhea treatment, including the importance of zinc supplementation and the value of more effective oral solutions of lower osmolarity i.
These recommendations update the previous report, review the historical background and scientific basis of ORT, and provide a framework for assessing and treating infants and children who have acute diarrhea. The discussion focuses on common clinical scenarios and traditional practices, especially with regard to continued feeding.
Limitations of ORT, ongoing research in the areas of micronutrient supplements, and functional foods are reviewed. Early attempts at treating dehydration resulting from diarrhea were described in the s during epidemics of Vibrio cholerae infections 21, In the s, oral solutions were developed 23 , and the effect of potassium replacement in reducing mortality was recognized, which led to substantial decreases in case fatality rates.
By the s, patients with cholera were being successfully treated with IV fluids Studies documenting the effectiveness of IV rehydration fluids among economically disadvantaged populations provided an impetus to develop less expensive but equally effective oral solutions.
Studies published in from Dhaka and Calcutta demonstrated the effectiveness of ORS for cholera patients, including those with high stool output 25, In , oral electrolyte solutions were tested through the large-scale treatment of refugees from Bangladesh 12, The resulting success of oral solutions hastened development of the first World Health Organization WHO guidelines for ORT and the production of standard packets of oral rehydration salts. Now, ORT is accepted as the standard of care for the clinically efficacious and cost-effective management of acute gastroenteritis 9, Human survival depends on the secretion and reabsorption of fluid and electrolytes in the intestinal tract.
During diarrheal disease, the volume of intestinal fluid output is substantially increased, overwhelming the reabsorptive capacity of the gastrointestinal tract. Applied clinical research, first implemented among patients with cholera 25,29 , demonstrated that although the secretory nature of diarrhea in cholera results in substantial stool losses of water and electrolytes, intact Na-coupled solute co-transport mechanism allows efficient reabsorption of salt and water In addition to V.
Even those infectious agents typically classified as causing osmotic diarrhea i. Studies of intestinal solute transport mechanisms were also crucial in outlining the processes by which solute absorption is maintained.
Water passively follows the osmotic gradient generated by the transcellular transport of electrolytes and nutrients. Although three principle mechanisms of sodium absorption have been described 28 , the mechanism essential to the efficacy of ORS is the coupled transport of sodium and glucose molecules at the intestinal brush border 34 Figure.
Co-transport across the luminal membrane is facilitated by the protein sodium glucose co-transporter 1 SGLT1. Once in the enterocyte, the transport of glucose into the blood is facilitated by GLUT2 glucose transporter type 2 in the basolateral membrane.
This mechanism remains intact, even in patients with severe diarrhea ORS in which additional co-transporters of Na e. Solutions with a high concentration of co-transporters increase the risk from hypertonic solutions that decrease rather than improve sodium and water transport into the bloodstream.
However, solutions of lower osmolarity, but that maintain the glucose to sodium ratio, perform optimally as oral solutions for diarrhea management see Choice of ORS. Home Management of Acute Diarrhea. Treatment with ORS is simple and enables management of uncomplicated cases of diarrhea at home, regardless of etiologic agent. As long as caregivers are instructed properly regarding signs of dehydration or are able to determine when children appear markedly ill or appear not to be responding to treatment, therapy should begin at home.
Early intervention can reduce such complications as dehydration and malnutrition. Early administration of ORS leads to fewer office, clinic, and emergency department ED visits 37 and to potentially fewer hospitalizations and deaths. Initiation of Therapy. In all cultures, treatment of diarrhea usually begins at home All families should be encouraged to have a supply of ORS in the home at all times and to start therapy with a commercially available ORS product as soon as diarrhea begins.
Although producing a homemade solution with appropriate concentrations of glucose and sodium is possible, serious errors can occur 39 ; thus, standard commercial oral rehydration preparations should be recommended where they are readily available and attainable. The most crucial aspect underlying home management of diarrhea is the need to replace fluid losses and to maintain adequate nutrient intake. Regardless of the fluid used, an age-appropriate diet should also be given 18, Infants should be offered more frequent breast or bottle feedings, and older children should be given more fluids.
Severity Assessment. Caregivers should be trained to recognize signs of illness or treatment failure that necessitate medical intervention. Infants with acute diarrhea are more prone to becoming dehydrated than are older children, because they have a higher body surface-to-volume ratio, a higher metabolic rate, relatively smaller fluid reserves, and they are dependent on others for fluid. For this reason, parents of infants with diarrhea should promptly seek medical evaluation as soon as the child appears to be in distress Box 1.
No guidelines have established a specific age under which evaluation is mandated, but usually, the smaller the child, the lower the threshold for health-care provider assessment. When fever is present, infants and children should be evaluated to rule out other serious illnesses e. Underlying conditions, including premature birth, metabolic and renal disorders, immune compromise, or recent recovery from surgery, might prompt early evaluation, as might concurrent illness, including a concurrent respiratory tract infection.
Reports from parents or other caregivers of dehydration can indicate the need for immediate health-care provider evaluation. Reports of changing mental status are of particular concern. When the child's condition is in doubt, immediate evaluation by a health-care professional should be recommended.
Clinical examination of the child provides an opportunity for physical assessment, including vital signs, degree of dehydration, and a more detailed history, and for providing better instructions to the caregivers. Referral for Evaluation. In developed countries, the decision whether to bring a child to an office or ED setting for evaluation is usually made after consultation with a physician or other health-care provider by telephone.
Questions should focus on those factors putting a child at risk for dehydration. Whenever possible, quantification is helpful. The clinician should determine how many hours or days the child has been ill, the number of episodes of diarrhea or vomiting, and the apparent volume of fluid output.
The child's mental status should be determined. Parents and other caregivers might not mention underlying conditions without prompting; therefore, questions from the health-care provider regarding past medical history are essential. Clinical Assessment. Dehydration and electrolyte losses associated with untreated diarrhea cause the primary morbidity of acute gastroenteritis.
Diarrhea can be among the initial signs of nongastrointestinal tract illnesses, including meningitis, bacterial sepsis, pneumonia, otitis media, and urinary tract infection. Vomiting alone can be the first symptom of metabolic disorders, congestive heart failure, toxic agent ingestion, or trauma. To rule out other serious illnesses, a detailed history and physical examination should be performed as part of the evaluation of all children with acute gastroenteritis.
The clinical history should assess the onset, frequency, quantity, and character i. Recent oral intake, including breast milk and other fluids and food; urine output; weight before illness; and associated symptoms, including fever or changes in mental status, should be noted. The past medical history should identify underlying medical problems, history of other recent infections, medications, and human immunodeficiency virus HIV status. A relevant social history can include the number and nature of caregivers, which can affect instructions regarding follow-up care.
Physical Examination. As part of the physical examination, an accurate body weight must be obtained, along with temperature, heart rate, respiratory rate, and blood pressure. When recent premorbid weight is unknown but a previous growth curve is available, an estimate of fluid loss can be obtained by subtracting current weight from expected weight as determined on the basis of the previous weight-for-age percentile.
The quality of this estimate will vary, depending on the number and variability of prior data points, differences among scales, and other factors. The general condition of the patient should be assessed, with special concern given to infants and children who appear listless, apathetic, or less reactive.
The appearance of the eyes should be noted, including the degree to which they are sunken and the presence or absence of tears. The condition of the lips, mouth, and tongue will yield critical clues regarding the degree of dehydration, even if the patient has taken fluid recently.
Deep respirations can be indicative of metabolic acidosis. Faint or absent bowel sounds can indicate hypokalemia. Examination of the extremities should be included because general perfusion and capillary refill can help in assessment of dehydration. An especially valid sign is the presence of prolonged skin tenting Visual examination of stool can confirm abnormal consistency and determine the presence of blood or mucus. Dehydration Assessment. Certain clinical signs and symptoms can quantify the extent of a patient's dehydration Table 1.
Assessment of the anterior fontanel might be helpful in selected instances, but it can be unreliable or misleading 41, Increases in heart rate and reduced peripheral perfusion can be more sensitive indicators of moderate dehydration, although both can be difficult to interpret because they can vary with the degree of fever. Decreased urine output is a sensitive but nonspecific sign.
Urine output might be difficult to measure for infants with diarrhea; however, if urinalysis is indicated, a finding of increased urine specific gravity can indicate dehydration. Because of this threshold effect, distinguishing between mild and moderate dehydration on the basis of clinical signs alone might be difficult.
Therefore, these updated recommendations group together patients with mild to moderate dehydration and specify that the signs of dehydration might be apparent over a relatively wide range of fluid loss i. The goal of assessment is to provide a starting point for treatment and to conservatively determine which patients can safely be sent home for therapy, which ones should remain for observation during therapy, and which ones should immediately receive more intensive therapy.
Utility of Laboratory Evaluation. Supplementary laboratory studies, including serum electrolytes, to assess patients with acute diarrhea usually are unnecessary 44, Stool cultures are indicated in cases of dysentery but are not usually indicated in acute, watery diarrhea for the immunocompetent patient. However, certain laboratory studies might be important when the underlying diagnosis is unclear or diagnoses other than acute gastroenteritis are possible.
For example, complete blood counts and urine and blood cultures might be indicated when sepsis or urinary tract infection is a concern. Seven basic principles guide optimal treatment of acute gastroenteritis Box 2 43 ; more specific recommendations for treating different degrees of dehydration have been recommended by CDC, WHO, and AAP Table 2 9, 20 , Treatment should include two phases: rehydration and maintenance.
In the rehydration phase, the fluid deficit is replaced quickly i. In the maintenance phase, maintenance calories and fluids are administered. Rapid realimentation should follow rapid rehydration, with a goal of quickly returning the patient to an age-appropriate unrestricted diet, including solids.
Gut rest is not indicated. Breastfeeding should be continued at all times, even during the initial rehydration phases. The diet should be increased as soon as tolerated to compensate for lost caloric intake during the acute illness. Lactose restriction is usually not necessary although it might be helpful in cases of diarrhea among malnourished children or among children with a severe enteropathy , and changes in formula usually are unnecessary. Full-strength formula usually is tolerated and allows for a more rapid return to full energy intake.
During both phases, fluid losses from vomiting and diarrhea are replaced in an ongoing manner. Antidiarrheal medications are not recommended for infants and children, and laboratory studies should be limited to those needed to guide clinical management.
Minimal Dehydration. For patients with minimal or no dehydration, treatment is aimed at providing adequate fluids and continuing an age-appropriate diet. Patients with diarrhea must have increased fluid intake to compensate for losses and cover maintenance needs; use of ORS should be encouraged.
In principle, 1 mL of fluid should be administered for each gram of output. In hospital settings, soiled diapers can be weighed without urine , and the estimated dry weight of the diaper can be subtracted. Nutrition should not be restricted see Dietary Therapy. Mild to Moderate Dehydration. Children with mild to moderate dehydration should have their estimated fluid deficit rapidly replaced.
Using a teaspoon, syringe, or medicine dropper, limited volumes of fluid e. If a child appears to want more than the estimated amount of ORS, more can be offered. Although administering ORS rapidly is safe, vomiting might be increased with larger amounts. Nasogastric NG feeding allows continuous administration of ORS at a slow, steady rate for patients with persistent vomiting or oral ulcers.
Clinical trials support using NG feedings, even for vomiting patients Rehydration through an NG tube can be particularly useful in ED settings, where rapid correction of hydration might prevent hospitalization.
Although rapid IV hydration can also prevent hospital admission, rapid NG rehydration can be well-tolerated, more cost-effective, and associated with fewer complications In addition, a randomized trial of ORS versus IV rehydration for dehydrated children demonstrated shorter stays in EDs and improved parental satisfaction with oral rehydration Certain children with mild to moderate dehydration will not improve with ORT; therefore, they should be observed until signs of dehydration subside.
Similarly, children who do not demonstrate clinical signs of dehydration but who demonstrate unusually high output should be held for observation.
Hydration status should be reassessed on a regular basis, and might be performed in an ED, office, or other outpatient setting. After dehydration is corrected, further management can be implemented at home, provided that the child's caregivers demonstrate comprehension of home rehydration techniques including continued feeding , understand indications for returning for further evaluation, and have the means to do so. Even among children whose illness appears uncomplicated on initial assessment, a limited percentage might not respond adequately to ORT; therefore, a plan for reassessment should be agreed upon.
Caregivers should be encouraged to return for medical attention if they have any concerns, if they are not sure that rehydration is proceeding well, or if new or worsening symptoms develop. Severe Dehydration. Severe dehydration constitutes a medical emergency requiring immediate IV rehydration.
This might require two IV lines or even alternative access sites e. The patient should be observed closely during this period, and vital signs should be monitored on a regular basis.
Serum electrolytes, bicarbonate, blood urea nitrogen, creatinine, and serum glucose levels should be obtained, although commencing rehydration therapy without these results is safe. Normal saline or LR infusion is the appropriate first step in the treatment of hyponatremic and hypernatremic dehydration.
Hypotonic solutions should not be used for acute parenteral rehydration Severely dehydrated patients might require multiple administrations of fluid in short succession. Overly rapid rehydration is unlikely to occur as long as weight-based amounts are administered with close observation. Errors occur most commonly in settings where adult dosing is administered to infants e. Edema of the eyelids and extremities can indicate overhydration.
Diuretics should not be administered. After the edema has subsided, the patient should be reassessed for continued therapy. Smaller amounts also will facilitate closer evaluation.
Hydration status should be reassessed frequently to determine the adequacy of replacement therapy. A lack of response to fluid administration should raise the suspicion of alternative or concurrent diagnoses, including septic shock and metabolic, cardiac, or neurologic disorders. As soon as the severely dehydrated patient's level of consciousness returns to normal, therapy usually can be changed to the oral route, with the patient taking by mouth the remaining estimated deficit.
An NG tube can be helpful for patients with normal mental status but who are too weak to drink adequately. Although no studies have specifically documented increased aspiration risk with NG tube use in obtunded patients, IV therapy is typically favored for such patients. Although leaving IV access in place for these patients is reasonable in case it is needed again, early reintroduction of ORS is safer. Using IV catheters is associated with frequent minor complications, including extravasation of IV fluid, and with rare substantial complications, including the inadvertent administration of inappropriate fluid e.
In addition, early ORS will probably encourage earlier resumption of feeding, and data indicate that resolution of acidosis might be more rapid with ORS than with IV fluid Clinical Management in the Hospital. Children may feel stomach pain for a range of reasons and may need treatment. Adoption can give a secure family life to children who can? Allergy occurs when the body overreacts to a 'trigger' that is harmless to most people.
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The State of Victoria and the Department of Health shall not bear any liability for reliance by any user on the materials contained on this website. Skip to main content. Conditions and Treatments. Home Conditions and Treatments. Gastroenteritis in children. Actions for this page Listen Print. Summary Read the full fact sheet. On this page. Causes of gastroenteritis in children Symptoms of gastroenteritis Children with gastroenteritis must keep drinking Go to the doctor if your child is very sick Watch for signs of dehydration How to prevent dehydration in children with gastroenteritis Children with gastroenteritis can eat their usual foods How to prevent the spread of gastroenteritis Where to get help.
Causes of gastroenteritis in children Gastroenteritis is caused by different things — including viruses, bacteria, bacterial toxins, parasites, particular chemicals and some drugs.
If your child gets gastro more than once the cause may be different each time. Infectious gastroenteritis in children Gastroenteritis can spread quickly. Some of the common types of infectious gastroenteritis include: Escherichia coli infection Campylobacter infection Cryptosporidium infection Giardiasis Salmonellosis Shigellosis Viral gastroenteritis. Symptoms of gastroenteritis Children may not have all symptoms, but in general, gastroenteritis symptoms can include: loss of appetite bloating nausea vomiting abdominal cramps abdominal pain diarrhoea bloody stools poo — in some cases pus in stools — in some cases generally feeling unwell — including lethargy and body aches.
Children with gastroenteritis must keep drinking If your child has gastroenteritis, make sure they drink clear fluids or breastmilk if your baby is breastfeeding. It will help if you: Offer babies a drink every time they vomit.
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