|The World of Irish Nursing Continuing Education series begins a new module on Paediatrics this month.
Over the next 11 issues we will publish a series of articles on common paediatric illnesses and conditions, beginning this month with the management of acute gastroenteritis in children.
Subsequent articles will deal with: diagnosis and management of type 1 diabetes in children; the asthma emergency; treatment of UTIs; paediatric arthritis; palliative care of the dying child; epilepsy in children; severe constipation in infants and young children; febrile convulsions; eating disorders; and the management of burns in children.
Module co-ordinator: Moira Cassidy, RGN, staff writer with the World of Irish Nursing
A standardised definition of acute gastroenteritis does not exist, with a variety of definitions to be found in the literature. There are common features inherent in these definitions, such as diarrhoea, with or without vomiting, and sudden onset. There may be other associated clinical features such as fever, abdominal pain, poor appetite and nausea. The condition is usually self limiting but the problems of diarrhoea, vomiting and particularly dehydration can present significant risks to children. The major causes of acute gastroenteritis include bacteria and their toxins, viruses and parasites. Rotavirus and the adenoviruses have been identified particularly in children as a cause of acute gastroenteritis. Bacterial and parasitic infections are less common (see Table 1).1
Organisms that cause acute gastroenteritis
|Rotavirus||Campylobacter jejuni||Giardia lamblia|
|Enteric adenovirus||Escherichia coli||Cryptosporidium|
The assessment of an infant or child with acute gastroenteritis is of great importance in establishing the correct interventions needed and whether the child needs hospitalisation. Assessment should include a detailed history and clinical examination. A detailed nursing history will elicit information such as: dietary history; length of illness prior to admission; fluid intake, type, amount and frequency; urine amount and frequency; vomiting amount, frequency and characteristics; and stool amount, consistency, frequency and characteristics.
The characteristics of the stool are an important parameter as other conditions may be outruled such as intussusception, malabsorption and inflammatory conditions.2 The presenting feature of gastroenteritis is the passage of loose, watery stool. In addition, the infant may pass frequent stool and the colour of this stool may change from normal brown to watery yellow and later green. A stool specimen may be required in order to identify the causative organism and determine a diagnosis. A clinical examination will determine the childs colour, vital signs, capillary refill, behaviour and consciousness level.
|Assessment||Normal hydration||Mild dehydration < 5%||Moderate dehydration 5%-10%||Severe dehydration >10%|
|General appearance||Alert, good muscle tone||Alert, good muscle tone May be thirsty||Irritable or lethargic, sunken eyes, sunken anterior fontanelle||Confused, floppy, sunken eyes, reduced eyeball turgor, sunken anteriorfontanelle|
|Colour||Consistent: pink lips, palms of hands and nail beds||Pink lips and palms of hands||Pale||Mottled/pale/grey|
|Temperature of extremities||Warm||Normal or cool||Cool||Cold|
|Peripheral pulse||Strong||Strong||May be weak||Weak|
|Mucous membranes||Pink, moist||May be dry||Dry||Pale and dry|
|Capillary refill time||1-2 seconds||1-2 seconds||May be > 2 seconds||> 2 seconds|
|Respiration||Normal for age||Normal for age||Normal or elevated||Elevated|
|Skin turgor/oedema||Pinched skin immediately falls back to normal||Pinched skin immediately falls back to normal||Pinched skin slowly falls back to normal||Pinched skin remains tented|
|Heart rate||Normal for age||Normal for age||May be raised||Marked tachycardia|
|Urine output||Infant 2ml/kg/hr
|Reduced||Reduced||Reduced or anuric|
|Urine specific gravity||1.005-1.020||May be > 1.020||> 1.020||> 1.020|
|Blood pressure||Normal for age||Normal||Normal||May be normal or low|
|Oxygen saturation||97%-100%||97%-100% if recordable||May not be recordable|
|Body weight||Fairly stable (< 1% body gain or loss per day)||Weight loss < 50g/kg||Weight loss 50-100g/kg||Weight loss > 100g/kg|
Categories of dehydration
When a diagnosis of acute gastroenteritis is confirmed, the child is managed in accordance with their hydration status. It is therefore important to understand the categories of dehydration and the presenting signs when assessing hydration status.
Dehydration may be divided into three categories:
Normal body water content
Management of a child with gastroenteritis is predominantly supportive and depends on the severity of dehydration. If dehydration is present it must be treated. If the child has gastroenteritis measures must also be instigated to prevent dehydration. Children are more susceptible to any loss or change in their fluid balance because of a high percentage of extracellular fluid and total body water (see Table 3).
Management is based on whether dehydration is present, the category of dehydration, and if vomiting is present. The child with diarrhoea and no dehydration with or without vomiting can remain on an age appropriate diet. For infants, full strength milk or formula is recommended. This should not be gradually introduced as was recommended in the past.
If a child has mild to moderate dehydration oral rehydration therapy (OHT) using oral rehydration solution (OHS) should be initiated. Once rehydration has