This year’s winter is definitely more unique than ever. Temperatures in high 50’s and no snow on Christmas has altered winter break plans as well as the cycle for the most common pediatric condition such as acute gastroenteritis (AGE), commonly known as “stomach flu”.
AGE usually presents with vomiting, diarrhea, fever and abdominal cramping pain. In medical literature, diarrhea is defined as a passage of three or more loose or watery stools per day (or more frequent passages of stool than is normal for the individual). Frequent passage of formed stools is not diarrhea, nor is passing of pasty stool by a breastfed infant.
Vomiting is usually the first of presenting symptoms, and more commonly than not, it occurs in the middle of the night. After emesis subsides, diarrhea begins. Ongoing fluid and electrolyte losses lead to dehydration in children which is the major cause of morbidity in children with acute gastroenteritis.
Viruses are the cause of most of the cases of acute gastroenteritis in children worldwide. Children with viral infections usually present with low-grade fever, vomiting and watery diarrhea without blood. Bacterial infections usually infiltrate the lining of the gastrointestinal track. Children with bacterial infections present with high fevers, vomiting and bloody diarrhea.
Most cases of acute gastroenteritis are self-limiting, requiring only early fluid replacement. Parents should start with a commercially oral re-hydration solutions, i.e. Pedialyte, as soon as possible. I usually do not recommend making homemade oral re-hydration solutions, due to serious electrolyte imbalances that can occur if made improperly. Most of the commercial oral re-hydration solutions, although flavored, are not palate friendly. I find it that most toddlers and small kids would drink it if it cooled in the refrigerator, and they are allowed to sip it up from the straw just like juice. Older kids, seem to prefer when oral re-hydration solutions are made into an ice pops.
I strongly discourage parents from giving kids oral re-hydration solution with added red coloring. If child is still vomiting, the vomit mixed with oral re-hydration solution may look like blood to a concern parent. The same applies to watery stools. Red color can be seen in stools and urine and be confused with blood, thus creating unnecessary concern on the part of the parent and physician.
Juices, sports drinks, tea, and soft drinks should be avoided in the management of the gastroenteritis. Many of these beverages have a high osmolality due to their high sugar content and not enough sodium and potassium; consequently, the use of these fluids may worsen diarrhea by increasing number of loose stools and increasing the risk of low sodium level, which can lead to seizure.
Treatment of acute gastroenteritis can be divided into two distinct phases: re-hydration and maintenance. During re-hydration, oral re-hydration fluids are replaced rapidly (as much as a child can consume) in a period of 3 to 4 hours. During the maintenance phase, calories, in addition to fluids, are administered. Parents are instructed gradually introducing solids into patient’s diet with a goal of returning the patient quickly to an age-appropriate, unrestricted diet.
In infants, breastfeeding or formula feedings should be continued during both the re-hydration and maintenance phases. The diet should be advanced as tolerated to compensate for lost caloric intake during the acute illness. Lactose restriction ordinarily is not indicated, although such restriction might be helpful in cases of children who have a severe vomiting or diarrhea.
In cases of uncomplicated or viral acute gastroenteritis antibiotics are not indicated and may actually cause harm by prolonging carrier stage. Anti-diarrheal drugs are not recommended in children because they can cause sever adverse effects. The World Health Organization recommends adding zinc to oral re-hydration fluids.
Zinc is an essential micro-nutrient that protects cells from oxidative injury. In cases of acute or chronic diarrhea, there is a significant loss of zinc due to increased intestinal output. It has been postulated that zinc may improve the absorption of water and electrolytes, thus reducing the stool frequency and shortening duration of diarrhea.
Probiotic is another great supplement to the oral re-hydration therapy. It replenishes GI track with good bacteria and promoting a balance in the intestinal flora. I always recommend to obtain probiotics that are require refrigeration since they seem to work better. They can be found in stores like Whole Foods and specialized pharmacies.