Acute Gastroenteritis v. 2.

0: Oral Rehydration Therapy (ORT)

PHASE I (ED/Urgent Care): ORT

Executive Summary

Explanation of Evidence Ratings

Test your knowledge

Summary of Version Changes

Inclusion Criteria
Vomiting and/or diarrhea of recent onset not due
to chronic disease, with or without fever, nausea,
or abdominal pain

Citation Information

Exclusion Criteria
Patient < 3 months of age
Toxic appearance (consider sepsis)
Diarrhea >7 days (consider chronic disease, bacterial
enteritis)
Bloody diarrhea (consider HUS)
Comorbid conditions (Medically Complex Children
(MCC), renal failure, cardiac disease)
Bilious emesis (consider bowel obstruction)
On diuretic therapy
Hyponatremia (<130 mEq/L) or Hypernatremia
(>155 mEq/L)
Acute surgical abdomen

!
Routine testing
for stool pathogens
not recommended

Moderate Dehydration (5-10%)

Overt Shock
(Dehydration >10%)

Prolonged capillary refill (>2 seconds)

Abnormal skin turgor ('tenting' or
inelastic skin)
Tachypnea

Minimal (<5%) to No
Dehydration
Educate on prevention
of dehydration

Give Ondansetron if
Moderately Dehydrated

Off
Pathway

!
Anti-diarrheal
agents are not
recommended

Failed oral
challenge
(if attempted)

Consider holding if diarrhea is chief

complaint

Consider oral
challenge

Begin ORT

Initial ORT Challenge

5 mL q 5 mins if <10 kg
10 mL q 5 mins if 10 kg

Antimicrobials
not recommended

Reassess after
20 min

Hold ORT for 20

minutes
Then restart ORT
at initial rate

Increase ORT
Yes

Emesis after
initial ORT?

No

Passed oral
challenge
(if attempted);
Educate and
prepare for
discharge

10 mL q 5 mins if <10kg
20 mL q 5 mins if 10kg
Assess in 30-60 mins

Discharge Instructions
Continue
to
Phase
Change
Phase
II

Yes

Continued
emesis?

No

Discharge Criteria

Clinical status improved

Tolerating ORT or regular diet
Adequate family teaching
Follow-up established

For questions concerning this pathway,

contact: AcuteGastroenteritis@seattlechildrens.org
2015, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Continue ORT at home for 46 additional hours; then

resume regular diet, or
lactose free formula if
predominantly formula fed
ED Acute Gastroenteritis
discharge instructions and
ORT worksheet
Lactobacillus for 5 days

Last Updated: June 2015

Next Expected Review: June 2020

Acute Gastroenteritis v. 2.0: IV or NG Rehydration

PHASE II (ED/Urgent Care):
IV or NG Rehydration

Executive Summary

Explanation of Evidence Ratings

Test your knowledge

Summary of Version Changes

Citation Information
Check vital signs
Check BP, HR, RR
Evaluate heart and lung sounds

!
Consider
checking
blood glucose

Involve caregiver and patient in

decision to hydrate with IV or NG
IV

NG

1st IV Fluid Bolus

Consider
myocarditis if
patient deteriorates
after fluid boluses

1st NG Fluid Bolus

NS 20 mL/kg over 30-60 mins (Max dose: 1,000 mL)

Upon initiation
initiation of
of IV,
IV, check
check electrolytes
electrolytes
Upon
Consider
Consider ondansetron
ondansetron if
if not
not already
already given
given or
or tolerated
tolerated

Pedialyte 20 mL/kg over 60 mins (Max dose: 600 mL)

Consider ondansetron if not already given or tolerated

Recheck Vital Signs; Re-examine

Recheck Vital Signs; Re-examine

If improved, consider returning to ORT

If improved, consider returning to ORT

2nd IV Fluid Bolus

2nd NG Fluid Bolus

NS 20 mL/kg over 30-60 mins

Pedialyte 20 mL/kg over 60 mins

Urgent Care Transfer

Criteria:

Not
tolerating ORT following
nd

Recheck Vital
Signs; Re-examine

2 IV/NG bolus (send by

BLS)
Need for a 3rd IV/NG bolus
(send by BLS)
Overt shock (IV access,
bolus started, ALS transport)
Worsening clinical status
**Continue treatment as
outlined by pathway while
awaiting transport**

Evaluate for Discharge

No, does not

meet discharge
criteria

Clinical status improved

IV or NG fluids not required
Tolerating ORT or regular diet
Adequate family teaching
Follow-up established

Re-examine Exclusion Criteria

Patient < 3 months age
Toxic appearance (consider sepsis)
Diarrhea > 7 days (consider chronic
disease, bacterial enteritis)
Bloody diarrhea (consider HUS)
Comorbid conditions (MCC, renal failure,
cardiac disease)
Bilious emesis (consider bowel obstruction)
On diuretic therapy
Hyponatremia (<130 mEq/L) or
Hypernatremia (>155 mEq/L) (if
electrolytes checked)
Acute surgical abdomen

Yes, meets
discharge
criteria

Off
Pathway

Admit on
AGE
pathway

Continue
Phase to
Phase
III
Change

For questions concerning this pathway,

contact: AcuteGastroenteritis@seattlechildrens.org
2015, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Discharge Instructions

Continue
ContinueORT
ORTatathome
homefor
for4-6
4-6
additional
additionalhours;
hours;then
thenresume
resume
regular
regulardiet,
diet,or
orlactose
lactosefree
free
formula
formulaififpredominantly
predominantly
formula
formulafed
fed
ED Acute Gastroenteritis
discharge instructions and
ORT worksheet
Lactobacillus for 5 days

Last Updated: June 2015

Next Expected Review: June 2020

Acute Gastroenteritis v. 2.0: Inpatient Management

Executive Summary

Explanation of Evidence Ratings

PHASE III: INPATIENT MANAGEMENT

Test your knowledge
Citation Information

!
Consider secretory
diarrhea if there is
copious output in the
absence of oral intake

Summary of Version Changes

Admit on AGE powerplan
Start IV D5 NS + 20 mEQ KCL/liter OR
NG Pedialyte at maintenance rate
Assess need for additional NS or
Pedialyte bolus

Assess at 0800 (or after 4 hours of IV/NG

fluids if admitted between 0800-1600)
Vomiting: 1 episodes in the past 4 hours?
Intake > Output?

Anti-emetics are
not recommended
outside of the ED /
Urgent Care

Yes, ready for

oral challenge

No, not ready for

oral challenge

Continue maintenance IV/NG fluids

Not ready
for ORT

IV: Replace ongoing stool and emesis

losses with NS 1:1 every 4 hours
NG: Replace ongoing stool and emesis
losses with Pedialyte 1:1 every 4 hours

Reassess for switch to ORT every 4

hours

ORT or Regular Diet Challenge

Ready
for ORT

Discontinue IV or NG fluids
ORT: 5 mL q 5 mins if <10kg; 10 mL q 5 mins if
10kg, or resume regular diet (lactose-free formula if
predominently formula fed)
Reassess after 20 minutes
Send prescription for Lactobacillus GG

Emesis after
initial ORT?

No

Increase ORT/ Diet

10 mL q 5 mins if <10kg
20 mL q 5 mins if 10kg
Assess in 30-60 mins

Antimicrobials
not recommended

Emesis
No emesis

Hold ORT for 20

minutes
Then restart ORT
at initial rate
Continued
emesis
> 48 hrs

No emesis,
evaluate for
discharge

Discharge Criteria
Sufficient rehydration as
indicated by weight gain OR
normal respiratory rate,
capillary refill, and skin turgor
IV or NG fluids not required
Tolerating ORT or regular diet
Adequate family teaching
Follow-up established

Yes

Consider other
diagnoses
Discharge Instructions
Yes, RN notifies
MD when
discharge
criteria are met

Continue ORT, or
Resume regular diet, or
lactose free formula if
predominantly formula fed
Acute Gastroenteritis And
Oral Rehydration Therapy
handout (PE636)
Lactobacillus for 5 days

For questions concerning this pathway,

contact: AcuteGastroenteritis@seattlechildrens.org
2015, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: June 2015

Next Expected Review: June 2020

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Acute Gastroenteritis (AGE) Citation

Title: Acute Gastroenteritis (AGE) Pathway
Authors:
Seattle Childrens Hospital
James OCallaghan
Sabreen Akhter
Elizabeth Austin
Bryan Dryer
Sara Fenstermacher
Jeffrey Foti
Kristi Klee
Michael Leu
Date: June 2015
Retrieval Website: http://www.seattlechildrens.org/pdf/acute-gastroenteritis-algorithm.pdf
Example:
Seattle Childrens Hospital, OCallaghan J, Akhter S, Austin E, Dryer B, Fenstermacher S, Foti J,
Klee K, Leu MG. 2015 June. Acute Gastroenteritis (AGE) Pathway. Available from: http://
www.seattlechildrens.org/pdf/acute-gastroenteritis-algorithm.pdf

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Self-Assessment
Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a
part of required departmental training at Seattle Childrens Hospital, you MUST logon to Learning Center.
(1)

Which one of the following is NOT an exclusion criteria?

a)
toxic appearance
b)
bloody diarrhea
c)
rotavirus infection
d)
diarrhea for more than 7 days
e)
bilious emesis

(2)

Which of the following statements concerning probiotics is/are TRUE?

a)
probiotics are considered adjunctive therapy.
b)
probiotics may be more effective for rotavirus diarrhea, compared to all-cause diarrhea
c)
yogurt is considered a good source of probiotics
d)
a and b
e)
a and c
f)
b and c
g)
all of the above

(3)

The historical BRAT diet (consisting of bananas, rice, applesauce, and toast) is unnecessarily restrictive.
a)
true
b)
false

(4)

Which of the following statements is/are TRUE concerning the clinical assessment of dehydration in AGE?
a)
Prolonged capillary refill time, abnormal skin turgor, and respiratory rate are the best individual examination
measures
b)
A normal bicarbonate concentration may be useful in ruling out dehydration
c)
Acute body weight change is considered the gold standard measure of dehydration
d)
It is recommended that the history and physical examination be the primary basis for the diagnosis of AGE
e)
all of the above

(5)

Which of the following discharge criteria are TRUE?

a)
tolerating ORT and/or regular diet
b)
tolerating BRAT diet
c)
medical follow up is available via telephone or office visit
d)
a and b
e)
a and c
f)
b and c
g)
all of the above

(6)

Ondansetron has been shown to be a safe and effective therapy in hospitalized children.
a)
true
b)
false

(7)

Which of the following is(are) the recommended diet(s) to prevent or limit dehydration?
a)
BRAT diet
b)
clear liquid diet
c)
Paleo diet
d)
regular diet
e)
a and b
f)
a and d
g)
b and d
h)
a, b, and d

(8)

Which of the following liquids are appropriate for use in oral rehydration therapy?
a)
Pedialyte
b)
Gatorade
c)
Gatorade with added salt, in the ratio of 1L Gatorade + 1 tbsp salt
d)
a and b
e)
a and c
f)
all of the above

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Answer Key

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Evidence Ratings
This pathway was developed through local consensus based on published evidence and expert
opinion as part of Clinical Standard Work at Seattle Childrens. Pathway teams include
representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical
Effectiveness, and other services as appropriate.
When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed
as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the
following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):
Quality ratings are downgraded if studies:
Have serious limitations
Have inconsistent results
If evidence does not directly address clinical questions
If estimates are imprecise OR
If it is felt that there is substantial publication bias
Quality ratings are upgraded if it is felt that:
The effect size is large
If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
If a dose-response gradient is evident
Guideline Recommendation is from a published guideline that used methodology deemed
acceptable by the team.
Expert Opinion Our expert opinion is based on available evidence that does not meet GRADE
criteria (for example, case-control studies).

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Summary of Version Changes

Version 1.1 (11/08/2011): Go Live
Version 1.2 (07/28/2014): Administrative update
Version 2.0 (06/17/2015): Periodic review; updated literature search,
recommendations, and pathway tools

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Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards accepted at the time of
publication.
However, in view of the possibility of human error or changes in medical sciences, neither the
authors nor Seattle Childrens Healthcare System nor any other party who has been involved in
the preparation or publication of this work warrants that the information contained herein is in
every respect accurate or complete, and they are not responsible for any errors or omissions or
for the results obtained from the use of such information.
Readers should confirm the information contained herein with other sources and are
encouraged to consult with their health care provider before making any health care decision.

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Bibliography
Literature Search Strategy
Search Methods, Acute Gastroenteritis, Clinical Standard Work
Studies were identified by searching electronic databases using search strategies developed and executed
by a medical librarian, Susan Klawansky. Searches were performed in November 2014 in the following
databases on the Ovid platform: Medline and Cochrane Database of Systematic Reviews; elsewhere:
Embase, Clinical Evidence, National Guideline Clearinghouse, TRIP and Cincinnati Childrens EvidenceBased Care Recommendations. Retrieval was limited to 2007 to current, ages 0-18, and English language.
In Medline and Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were used
respectively, along with text words, and the search strategy was adapted for other databases as appropriate.
Concepts searched were gastroenteritis, dysentery, enteritis, adenoviridae infections, rotavirus infections or
rotavirus. All retrieval was further limited to certain evidence categories, such as relevant publication types,
index terms for study types and other similar limits. Additional articles were identified by team members and
added to results.

Identification
129 records identified
through database searching

1 additional records identified

through other sources

Screening
130 records after duplicates removed

130 records screened

84 records excluded

46 records assessed for eligibility

34 full-text articles excluded,

5 did not answer clinical question
6 did not meet quality threshold
1 outdated relative to other included study
19 duplicates
3 other

Eligibility

Included

12 studies included in pathway

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

To Bibliography, Pg 2

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Bibliography
1. Diarrhoea and vomiting in children. Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and
management in children younger than 5 years. National Collaborating Centre for Women's and Children's Health.
http://www.ncbi.nlm.nih.gov/books/NBK63844/. Updated 2009.
2. Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: An updated cochrane
systematic review with meta-analysis and mixed treatment comparison in a bayesian framework. BMJ Open.
2012;2(4).
3. Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in
children and adolescents. Cochrane Database of Systematic Reviews. 2011;9.
4. Freedman SB, Ali S, Oleszczuk M, Gouin S, Hartling L. Treatment of acute gastroenteritis in children: An
overview of systematic reviews of interventions commonly used in developed countries. Evid Based Child Health.
2013;8(4):1123-1137. Accessed 20130723; 11/27/2014 12:34:04 PM. http://dx.doi.org/10.1002/ebch.1932.
5. Guarino A. Albano F. Ashkenazi S. Gendrel D. Hoekstra JH. Shamir R. Szajewska H. European Society for
Paediatric Gastroenterology, Hepatology,and Nutrition.European Society for Paediatric Infectious Diseases.
European society for paediatric gastroenterology, hepatology, and Nutrition/European society for paediatric
infectious diseases evidence-based guidelines for the management of acute gastroenteritis in children in europe. J
Pediatr Gastroenterol Nutr. 2008;46(Suppl 2):S81-122. Accessed 20080507; 11/27/2014 12:34:04 PM. http://
dx.doi.org/10.1097/MPG.0b013e31816f7b16.
6. MacGillivray S, Fahey T, McGuire W. Lactose avoidance for young children with acute diarrhoea. Cochrane
Database of Systematic Reviews. 2013;10.
7. National GC. Best evidence statement (BESt). Use of Lactobacillus rhamnosus GG in children with acute
gastroenteritis. http://www.guideline.gov/
content.aspx?id=33576&search=%22acute+gastroenteritis%22+and+(child*+or+pediatr*+or+paediatr*);.
8. National GC. Evidence-based care guideline for prevention and management of acute gastroenteritis (AGE) in
children aged 2 months to 18 years. http://www.guideline.gov/
content.aspx?id=35123&search=%22acute+gastroenteritis%22+and+(child*+or+pediatr*+or+paediatr*);.
9. National GC. Oral rehydration therapy (ORT) in children. http://www.guideline.gov/
content.aspx?id=38900&search=%22acute+gastroenteritis%22+and+(child*+or+pediatr*+or+paediatr*);.
10. Seattle Childrens Hospital, OCallaghan J, Beardsley E, Black K, Drummond K, Foti J, Klee K, Leu MG, Ringer
C. 2011 September. Acute Gastroenteritis (AGE) Pathway.
11. Szajewska H, Guarino A, Hojsak I, et al. Use of probiotics for management of acute gastroenteritis: A position
paper by the ESPGHAN working group for probiotics and prebiotics. J Pediatr Gastroenterol Nutr . 2014;58(4):531539.
12. Szajewska H, Ruszczynski M, Kolacek S. Meta-analysis shows limited evidence for using lactobacillus
acidophilus LB to treat acute gastroenteritis in children. Acta Paediatr. 2014;103(3):249-255. Accessed 20140211;
11/27/2014 12:34:04 PM. http://dx.doi.org/10.1111/apa.12487.
13. Szajewska H, Skorka A, Ruszczynski M, Gieruszczak-Bialek D. Meta-analysis: Lactobacillus GG for treating
acute gastroenteritis in children--updated analysis of randomised controlled trials. Aliment Pharmacol Ther.
2013;38(5):467-476. Accessed 20130813; 11/27/2014 12:34:04 PM. http://dx.doi.org/10.1111/apt.12403

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