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Posted: 23 Jul 2010 08:32 AM PDT

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 (38). 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 (18,19). 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.g., sepsis and meningitis). 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. Children with dysentery (blood or mucus in stool) or prolonged diarrhea (lasting >14 days) should be evaluated because stool cultures and antimicrobial therapy might be indicated.

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

Diarrhea is characterized by the passage of loose or watery stools; a common case definition of acute diarrhea is >3 loose or watery stools/day. The volume of fluid lost through stools can vary from 5 mL/kg body weight/day (approximately normal) to >200 mL/kg body weight/day (%%68

69%%). 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.

History

The clinical history should assess the onset, frequency, quantity, and character (i.e., the presence of bile, blood, or mucus) of vomiting and diarrhea. 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 (%%8283%%). 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 (41,42). Among infants and children, a decrease in blood pressure is a late sign of dehydration that heralds shock and can correspond to fluid deficits >10%. 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.

Prior guidelines, including CDC’s 1992 recommendations (

95 ) and the American Academy of Pediatrics (AAP) 1996 guidelines (%%9798%%), divide patients into subgroups for mild (3%–5% fluid deficit), moderate (6%–9% fluid deficit), or severe (>10% fluid deficit, shock, or near shock) dehydration. Other classification schemes, including the 1995 WHO (%%101102%%) and 2001 European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines (%%103104%%), divide patients into those indicating no signs of dehydration (<3%–5%), some signs of dehydration (5%–10%), and severe dehydration (>10%). Studies that have evaluated the correlation of clinical signs of dehydration with posttreatment weight gain indicate that the first signs of dehydration might not be evident until 3%–4% dehydration, with more numerous clinical signs evident at 5% dehydration and signs indicating severe dehydration not evident until fluid loss reaches 9%–10% (40,41). 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.e., from 3%–9%) (Table 1). 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 (44,45). 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.

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