Lippincott Williams & Wilkins



Summary of ESPGHAN/ESPID recommendations on the management of acute gastroenteritis

|QUESTION |RECOMMENDATION |GRADE system |Muir-Gray |

| | | |system |

|RISK FACTORS FOR SEVERE AND/OR PERSISTENT DISEASE |

|Is there a relationship between |In children with persistent diarrhea the main pathogens | | |

|severe or persistent diarrhea |detected are: | | |

|and etiology? | | | |

| |Rotavirus, norovirus, astrovirus, enteroaggregative |Weak recommendation, low |III, C |

| |Escherichia coli and atypical E. coli |quality evidence | |

| |Giardia |Weak recommendation, moderate |I,A |

| | |quality evidence | |

| |Cryptosporidium and Entamoeba histolytica |Weak recommendation, low |III, C |

| | |quality evidence | |

|Risk factor: younger age |The high incidence of dehydration in infants younger than 6|Weak recommendation, low |III,C |

| |months is related to a higher exposure to rotavirus |quality evidence | |

| |In developing countries, a young age (8 |Strong recommendation, low |III,C |

| |episodes/day) |quality evidence | |

| |Family-reported signs of severe dehydration |Strong recommendation, very |Vb,D |

| | |low quality evidence | |

|How is dehydration assessed? |The best measure of dehydration is the percentage loss of |Weak recommendation; low |Vb,D |

| |body weight |quality evidence | |

| |Historical points are moderately sensitive as a measure of |Weak recommendation, moderate |III,C |

| |dehydration |quality evidence | |

| |Classification into subgroups with no or minimal |Strong recommendation, |I,A |

| |dehydration, mild to moderate dehydration, and severe |moderate quality evidence | |

| |dehydration is an essential basis for appropriate treatment| | |

| |Parental reports of dehydration symptoms are so low in |Strong recommendation, low |Vb,C |

| |specificity that they may not be clinically useful. |quality evidence | |

| |However, parental report of normal urine output decreases | | |

| |the likelihood of dehydration | | |

| |Little is known about the severity of diarrhea and/or |Weak recommendation, low |III,C |

| |vomiting and dehydration in industrialized countries, |quality evidence | |

| |therefore recommendations are largely based on data from | | |

| |developing countries. In the latter, infants and young | | |

| |children with frequent high output diarrhea and vomiting | | |

| |are most at risk | | |

| |Clinical tests for dehydration are imprecise, generally |Weak recommendation; moderate |III,C |

| |showing only fair to moderate agreement among examiners |quality evidence | |

| |The best three individual examination signs for assessment |Weak recommendation; moderate |III,C |

| |of dehydration are prolonged capillary refill time, |quality evidence | |

| |abnormal skin turgor, and abnormal respiratory pattern. | | |

|Scoring systems to assess |It would be helpful to have a common tool to evaluate |Weak recommendation; low |III,C |

|dehydration and severity of |dehydration. The use of the Clinical Dehydration Scale |quality evidence | |

|illness |(CDS) is supported by consistent evidence and it is easy to| | |

| |use in the assessment of dehydration | | |

| |However this scale should not be the only tool upon which |Weak recommendation, low |III,C |

| |to decide the need of medical interventions in individual |quality evidence. | |

| |cases | | |

|Is there any clinical feature |High fever (>40°C), overt fecal blood, abdominal pain, and |Weak recommendation, low |III,C |

|that may suggest a bacterial |central nervous system involvement each suggests a |quality evidence | |

|versus viral etiology of |bacterial pathogen. Vomiting and respiratory symptoms are | | |

|diarrhea? |associated with a viral etiology | | |

|DIAGNOSTIC WORKUP |

|Diagnostic workup |Acute gastroenteritis does not generally require specific |Strong recommendation, low |Vb, D |

| |diagnostic work up. |quality evidence. | |

|Are microbiological |Children presenting with AGE do not require routine |Strong recommendation, low |Vb,D |

|investigations useful in |etiological investigation. However, there may be particular|quality evidence | |

|children with AGE? |circumstances in which microbiological investigations may | | |

| |be necessary for diagnosis and treatment | | |

| |Microbiological investigations may be considered in |Strong recommendation, very |Vb,D |

| |children with underlying chronic conditions (e.g. oncologic|low quality evidence | |

| |diseases, inflammatory bowel diseases etc.), in those in | | |

| |very severe conditions, or in those with prolonged symptoms| | |

| |in whom specific treatment is considered. | | |

|Is there any reliable |The differentiation of a bacterial from non bacterial |Weak recommendation, low |Vb, D |

|hematological marker of |etiology is not likely to change treatment. C-reactive |quality evidence | |

|bacterial diarrhea? |protein and procalcitonin are not routinely recommended to | | |

| |identify a bacterial etiology | | |

|Can any stool marker |Based on available data we do not recommend the routine use|Weak recommendation, low |Vb,D |

|differentiate a bacterial from a|of fecal markers to distinguish between viral and bacterial|quality evidence | |

|nonbacterial agent? |AGE in the clinical setting | | |

|Does any biochemical test change|Tests of dehydration are imprecise, and generally there is |Weak recommendation, low |III,C |

|the approach to the child with |only fair to moderate agreement with examiner’s estimate. |quality evidence | |

|AGE? | | | |

| |The only laboratory measurement that appears to be useful |Weak recommendation, low |III,C |

| |in decreasing the likelihood of >5% dehydration is serum |quality evidence | |

| |bicarbonate (normal serum bicarbonate). | | |

|Electrolytes should be measured |In moderately dehydrated children whose history and |Strong recommendation, low |Va,D |

|in hospital settings |physical examination findings are inconsistent with a |quality evidence | |

| |severe diarrheal disease, and in all severely dehydrated | | |

| |children | | |

| |In all children starting intravenous (IV) therapy, and |Strong recommendation, low |Va,D |

| |during therapy, because hyper- or hyponatremia will alter |quality evidence | |

| |the rate at which IV rehydration fluids will be given | | |

|Is endoscopy and/or histology |There is no indication for endoscopy except in selected |Strong recommendation, low |Vb,D |

|useful for the management of |circumstances or cases such as differential diagnosis with |quality evidence | |

|children with AGE? |inflammatory bowel disease at its onset. | | |

|HOSPITAL MANAGEMENT |

|What are the indications for |The recommendations for hospital admission are based on |Strong recommendation, low |Vb,D |

|hospitalization? |consensus and include any of the following conditions |quality evidence | |

| |Shock | | |

| |Severe dehydration (> 9% of body weight) | | |

| |Neurological abnormalities (lethargy, seizures, etc.) | | |

| |Intractable or bilious vomiting | | |

| |Failure of oral rehydration | | |

| |Suspected surgical condition | | |

| |Conditions for a safe follow-up and home management are | | |

| |not met. | | |

|What hygiene and isolation |For AGE, contact precautions are advised in addition to |Strong recommendation, very low|Vb, D |

|precautions are indicated for a |standard precautions (hand hygiene, personal protective |quality evidence | |

|child with AGE? |equipment, soiled patient-care equipment, environmental | | |

| |control including textiles, laundry and adequate patient | | |

| |placement) | | |

|What are the indications for |When oral rehydration is not feasible, enteral rehydration|Strong recommendation, moderate|I,A |

|nasogastric rehydration? |by the nasogastric route is the preferred method of |quality evidence | |

| |rehydration and should be proposed before IV rehydration | | |

| |Enteral rehydration is associated with significantly fewer|Strong recommendation, moderate|I,A |

| |major adverse events and a shorter hospital stay than IV |quality evidence | |

| |rehydration and is successful in most children | | |

| |The rapid (40-50 ml/kg within 3-6 hours ) and standard (24|Weak recommendation, moderate |II,B |

| |hours) nasogastric rehydration regimens are equally |quality evidence | |

| |effective and may be recommended. | | |

|What are the indications for |Intravenous fluids are required in the following cases: |Strong recommendation, low |Vb,D |

|intravenous rehydration? |Shock |quality evidence | |

| |Dehydration with altered level of consciousness or severe | | |

| |acidosis | | |

| |Worsening of dehydration or lack of improvement despite | | |

| |oral or enteral rehydration therapy | | |

| |Persistent vomiting despite appropriate fluid | | |

| |administration orally or via a nasogastric tube | | |

| |Severe abdominal distension and ileus | | |

|How to administer intravenous |Children presenting with shock secondary to AGE should |Strong recommendation, very low|Vb,D |

|fluids for children presenting |receive rapid IV infusion of isotonic crystalloid solution|quality evidence | |

|with shock? |(0.9% saline or lactated Ringer’s solution) with a 20 | | |

| |ml/kg bolus. | | |

| |If the blood pressure has not improved after the first |Strong recommendation, very low|Vb,D |

| |bolus, a second (or even a third) bolus of 20 ml/kg should|quality evidence | |

| |be administered over 10-15 min and other possible causes | | |

| |of shock should be considered. | | |

|For children with severe |Children with severe dehydration requiring IV fluids may |Strong recommendation, moderate|II,B |

|dehydration without shock |receive rapid rehydration with 20 ml/kg/h of 0.9% saline |quality evidence | |

| |solution for 2-4 hours | | |

| |In IV-rehydrated children, a dextrose-containing solution |Weak recommendation, low |III,C |

| |may be used for maintenance |quality evidence | |

| |A solution containing not less than 0.45% saline (at least|Weak recommendation, low |III,C |

| |77 mEq/L [Na+]) is recommended during the first 24 hours |quality evidence | |

| |of IV rehydration therapy to prevent hyponatremia | | |

| |After the child starts to urinate and if serum electrolyte|Weak recommendation, low |Vb,D |

| |values are known, add 20 mEq/L of K+ chloride |quality evidence | |

|Intravenous rehydration rates |Rapid rehydration with 20 ml/kg/h for 2-6 hours followed |Weak recommendation, low |II,B |

| |by oral rehydration or continuous infusion of dextrose |quality evidence | |

| |solution is adequate for initial rehydration of most | | |

| |patients requiring hospital assistance | | |

| |More rapid IV rehydration may be associated with |Strong recommendation, low |II,B |

| |electrolyte abnormalities and is associated with long time|quality evidence. | |

| |to hospital discharge and therefore is not recommended. | | |

|Composition of fluids for |Isotonic (0.9%) saline solution effectively reduces the |Strong recommendation, low |III,C |

|rehydration |risk of hyponatremia and is recommended for initial |quality evidence | |

| |rehydration in most cases. In the rare but extremely | | |

| |severe cases of shock, Ringer’s lactate solution is | | |

| |recommended | | |

| |Glucose may be added to saline solution once fluid volume |Weak recommendation, low |III,C |

| |has been restored in the subsequent phase of IV |quality evidence. | |

| |rehydration (“maintenance”) | | |

|Treatment of hypernatremia |Oral or nasogastric rehydration with hypo-osmolar ORS is |Weak recommendation, very low |III, C |

| |an effective and safe treatment and has fewer side effects|quality evidence | |

| |than IV rehydration | | |

|If the child is hypernatremic |Use an isotonic solution (0.9% saline) for fluid deficit |Strong recommendation, very low|III,C |

|and needs IV rehydration |replacement and maintenance |quality evidence | |

| |Replace the fluid deficit slowly, typically over 48 hours,|Weak recommendation, very low |III,C |

| |with the aim of reducing it to less than 0.5 mmol/L per |quality evidence | |

| |hour | | |

| |Monitor plasma sodium frequently |Weak recommendation, very low |Vb,D |

| | |quality evidence | |

|Can any therapeutic intervention|Administration of effective probiotic strains reduce the |Strong recommendation, low |II,B |

|reduce the length of hospital |duration of hospital stay and may be considered in |quality evidence | |

|stay? |children admitted with AGE | | |

| |Hospitalized children with severe rotavirus |Weak recommendation , very low |III,C |

| |gastroenteritis may benefit from oral administration of |quality evidence, | |

| |serum immunoglobulins | | |

|When to discharge a child |Prompt discharge from hospital should be considered in |Weak recommendation, low |Vb,D |

|admitted because of acute |children admitted for AGE when the following conditions |quality evidence | |

|gastroenteritis |are fulfilled: | | |

| |• Sufficient rehydration is achieved as indicated by | | |

| |weight gain and/or clinical status | | |

| |• IV fluids are no longer required | | |

| |• Oral intake equals or exceeds losses | | |

| |• Medical follow-up is available via telephone or office | | |

| |visit | | |

|REHYDRATION |

|Reduced osmolarity ORS |Reduced osmolarity ORS (50/60 mmol/L Na) should be used as|Strong recommendation, moderate|I,A |

| |first-line therapy for the management of children with |quality evidence | |

| |AGE. | | |

| |Reduced osmolarity ORS is more effective than full |Strong recommendation, moderate|I,A |

| |strength ORS as measured by such important clinical |quality evidence | |

| |outcomes as reduced stool output, reduced vomiting and | | |

| |reduced need for supplemental intravenous therapy | | |

| |The ESPGHAN solution has been used successfully in several|Strong recommendation, moderate|II,A |

| |RCTs and in a number of non-RCTs in European children. It |quality evidence | |

| |may be used in children with AGE | | |

|Modified ORS |There is insufficient evidence to recommend in favor or |Weak recommendation, low |II,B |

| |against the universal addition of enriched ORS. |quality evidence | |

| |There is limited evidence for similar efficacy of ORS with|Weak recommendation, moderate |II,B |

| |standard taste and ORS with improved taste. |quality evidence | |

| |Frozen fruit-flavored ORS is better tolerated than |Weak recommendation; very low |III,C |

| |conventional ORS |quality evidence | |

|NUTRITIONAL MANAGEMENT |

|Early versus late feeding of a |Early resumption of feeding after rehydration therapy is |Strong recommendation, low |I,A |

|child with AGE. |recommended. However, further studies are needed to |quality evidence | |

| |determine whether the timing of refeeding affects the | | |

| |duration of diarrhea, total stool output, or weight gain | | |

| |in childhood acute diarrhea | | |

|Are modified formulas indicated |In non breast-fed infants and children younger than 5 |Weak recommendation, low |I,A |

|for AGE? |years of age, lactose-free feeds can be considered in the |quality evidence | |

| |management of AGE , mainly in the hospital setting | | |

| |There is insufficient evidence to recommend in favor or |Weak recommendation, low |I,A |

| |against the use of diluted lactose-containing milk |quality evidence | |

|Milk-free mixed diets, |The bread, rice, apple, toast (BRAT) diet has not been |Strong recommendation, low |Vb,D |

|cereal-based milk/formulas, home|studied and is not recommended |quality evidence | |

|available staple foods, and | | | |

|other types of food or drinks | | | |

| |Beverages with a high sugar content should not be used |Strong recommendation, low |III,C |

| | |quality evidence | |

|PHARMACOLOGIC THERAPY |

|Antiemetics: ondansetron |Ondansetron, at the dosages used in the available studies |Strong recommendation, low |II,B |

| |and administered orally or intravenously, may be effective|quality of evidence | |

| |in young children with vomiting related to AGE. However, | | |

| |before a final recommendation is made, a clearance on | | |

| |safety in children is needed. | | |

|Other antimetics |There is no evidence to support the use of other |Strong recommendation, low |II,B |

| |antiemetics |quality of evidence | |

|Antimotility or Antiperistaltic |Loperamide is not recommended in the management of AGE in |Strong recommendation, very low|II,B |

|drugs: Loperamide |children |quality evidence | |

|Adsorbents: Diosmectite |Diosmectite can be considered in the management of AGE |Weak recommendation, moderate |II,B |

| | |quality evidence | |

|Diosmectite plus Lactobacillis |Smectite plus Lactobacillus GG (LGG) and LGG alone are |Weak recommendation, low |II,B |

|GG |equally effective in the treatment of young children with |quality evidence. | |

| |AGE. Combined use of the two interventions is not | | |

| |justified. | | |

|Other absorbents |Other adsorbents (namely, kaolin-pectin and attapulgite, |Weak recommendation, very low |III,C |

| |activated charcoal) are not recommended. |quality evidence | |

|Racecadotril |Racecadotril can be considered in the management of AGE |Weak recommendation, moderate |II,B |

| | |quality evidence | |

|Bismuth subsalicylate |Bismuth subsalicylate is not recommended in the management|Strong recommendation, low |III,C |

| |of children with AGE. |quality evidence | |

|Zinc |Children older than 6 months in developing countries may |Strong recommendation, moderate|I,A |

| |benefit from the use of zinc in the treatment of AGE. |quality of evidence | |

| |However, in regions where zinc deficiency is rare, no | | |

| |benefit from the use of zinc is expected | | |

|Probiotics |Active treatment with probiotics, in adjunct to ORS, is |Strong recommendation, moderate|I,A |

| |effective in reducing the duration and intensity of |quality evidence | |

| |symptoms of gastroenteritis. Selected probiotics can be | | |

| |used in children with AGE | | |

| |New evidence has confirmed that probiotics are effective |Strong recommendation, moderate|I,A |

| |in reducing the duration of symptoms in children with AGE |quality evidence | |

| |The use of the following probiotics should be considered | | |

| |in the management of children with AGE as an adjunct to | | |

| |rehydration therapy: | | |

| |L. rhamnosus GG |Strong recommendation, low |I,A |

| | |quality evidence | |

| |S boulardii |Strong recommendation, low |I,A |

| | |quality evidence | |

| |L reuteri DSM 17938 |Weak recommendation, very low |II, B |

| | |quality evidence | |

| |Heat-killed L acidophilus LB |Weak recommendation, very low |I, A |

| | |quality evidence | |

|Synbiotics |None of the synbiotics studied thus far can be recommended|Weak recommendation, low |II,B |

| |until confirmatory data are available |quality evidence. | |

|Prebiotics |The use of prebiotics in the management of children with |Weak recommendation, low |II,B |

| |AGE is not recommended |quality evidence | |

|Micronutrients |Folic acid is not recommended for the management of |Weak recommendation, very low |II,B |

| |children with AGE |quality evidence | |

|Gelatine tannate |Gelatine tannate is not recommended for the management of |Weak recommendation, very low |III,C |

| |children with AGE |quality of evidence | |

|ANTI-INFECTIVE THERAPY |

|Anti-infective therapy |Anti-infective therapy should not be given to the vast |Strong recommendation, low |Va,D |

| |majority of otherwise healthy children with acute |quality evidence | |

| |gastroenteritis | | |

|Antimicrobial therapy of |Antibiotic therapy for acute bacterial gastroenteritis is |Strong recommendation, low |Va,D |

|bacterial gastroenteritis |not needed routinely but only for specific pathogens or in|quality evidence | |

| |defined clinical settings | | |

|Shigella gastroenteritis |Antibiotic therapy is recommended for culture proven or |Strong recommendation, moderate|II,B |

| |suspected Shigella gastroenteritis. |quality evidence | |

| |The first-line treatment for shigellosis is azithromycin |Strong recommendation, moderate|II,B |

| |for five days |quality evidence | |

|Salmonella gastroenteritis |Antibiotic therapy is not effective on symptoms and does |Strong recommendation, moderate|I,A |

| |not prevent complications. It is associated with a |quality of evidence | |

| |prolonged fecal excretion of Salmonella. Therefore | | |

| |antibiotics should not be used in an otherwise healthy | | |

| |child with Salmonella gastroenteritis | | |

| |Antibiotics are suggested in high-risk children to reduce |Strong recommendation, low |Vb,D |

| |the risk of bacteremia and extra-intestinal infections |quality evidence | |

| |These include neonates and young infants ( ................
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