Paediatrics - Gastroenteritis: Timely assessment and intervention
    
Foley, Judith, Gastroenteritis: Timely assessment and intervention. World of Irish Nursing, Vol. 10, No. 1. January 2002, pp 27-28.

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

Assessment nbsp;

Table 1

Organisms that cause acute gastroenteritis

Virus  Bacteria Parasite
Rotavirus Campylobacter jejuni Giardia lamblia
Enteric adenovirus Escherichia coli Cryptosporidium
Norwalk virus Salmonella
Shigella

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.  
 
Table 2
 
Hydration assessment
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
Child 1ml/kg/hr
Adolescent 0.5ml/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:

Assessment is a continuous process and with correct assessment, early recognition and intervention, a child will not progress from mild to moderate to severe dehydration.  Davenport and the Advanced Life Support Group have developed criteria to allow the assessment of hydration status (see Table 2).4

Management
Table 3

Normal body water content

  • Premature infant 90% 
  • 12-24 months 64%
  • Newborn infant 70% 
  • Adult 60%

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


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