Gastroenteritis An Evidence Based Approach To Typical Vomiting, Diarrhea, and Dehydration

December 2004
Volume 1, Number 5
Author
Mark A Hostetler, MD, MPH, FACEP, FAAP
Assistant Professor, Department of Pediatrics, and
Chief, Section of Emergency Medicine, University Of
Chicago, Pritzker School of MedicineChicago, IL.
Peer Reviewers
Albert K Nakanishi, MD, MPH, FAAP
Associate Professor of Pediatrics, Saint Louis University
School of Medicine, Cardinal Glennon Childrens
HospitalSaint Louis, MO.
Paula J Whiteman, MD, FACEP
Medical Director, Pediatric Emergency Medicine,
Encino-Tarzana Regional Medical Center; Attending
Physician, Cedars-Sinai Medical CenterLos Angeles,
CA.
CME Objectives
Upon completing this article, you should be able to:
1. list perceived barriers to the initiation of oral
rehydration therapy in the ED;
2. identify physical examination ndings that help
the emergency physician determine the degree to
which a young child is dehydrated; and
3. discuss the indications for oral and intravenous
rehydration for dehydrated young children in the
ED.
Date of original release: December 31, 2004.
Date of most recent review: December 29, 2004.
See Physician CME Information on back page.
Editor-in-Chief
Lance Brown, MD, MPH, FACEP, Chief,
Division of Pediatric Emergency
Medicine; Associate Professor
of Emergency Medicine and
Pediatrics; Loma Linda University
Medical Center and Childrens
Hospital, Loma Linda, CA.
Editorial Board
Jerey R. Avner, MD, FAAP, Professor
of Clinical Pediatrics, Albert Einstein
College of Medicine; Director,
Pediatric Emergency Service,
Childrens Hospital at Monteore,
Bronx, NY.
Beverly Bauman, MD, FAAP,
FACEP, Assistant Chief, Pediatric
Emergency Services, Oregon Health
& Sciences University, Portland, OR.
T. Kent Denmark, MD, FAAP,
FACEP, Residency Director,
Pediatric Emergency Medicine;
Assistant Professor, Departments
of Emergency Medicine and
Pediatrics; Loma Linda University
Medical Center and Childrens
Hospital, Loma Linda, CA.
Michael J. Gerardi, MD, FAAP,
FACEP, Clinical Assistant Professor,
Medicine, University of Medicine
and Dentistry of New Jersey;
Director, Pediatric Emergency
Medicine, Childrens Medical
Center, Atlantic Health System;
Department of Emergency
Medicine, Morristown
Memorial Hospital.
Ran D. Goldman, MD, Associate
Professor, Department of Pediatrics,
University of Toronto; Division of
Pediatric Emergency Medicine
and Clinical Pharmacology and
Toxicology, The Hospital for Sick
Children, Toronto.
Martin I. Herman, MD, FAAP,
FACEP, Associate Professor,
Pediatrics, Division Critical Care
and Emergency Services, UT Health
Sciences, School of Medicine;
Assistant Director Emergency
Services, Lebonheur Childrens
Medical Center, Memphis TN.
Marilyn P. Hicks, MD, FACEP,
Medicine Education, Department
of Emergency Medicine, WakeMed,
Raleigh, NC; Adjunct Assistant
Professor, Department of
Emergency Medicine, University of
North Carolina, Chapel Hill, Chapel
Hill, NC.
Mark A. Hostetler, MD, MPH,
Assistant Professor, Department
of Pediatrics; Chief, Section of
Emergency Medicine; Medical
Department, The University
of Chicago, Pritzker School of
Medicine, Chicago, IL.
Alson S. Inaba, MD, FAAP, PALS-NF,
Pediatric Emergency Medicine
Attending Physician, Kapiolani
Medical Center for Women &
Children; Associate Professor of
Pediatrics, University of Hawaii
John A. Burns School of Medicine,
Honolulu, HI; Pediatric Advanced
Life Support National Faculty
Representative, American Heart
Association, Hawaii & Pacic
Island Region.
Andy Jagoda, MD, FACEP, Vice-Chair
of Academic Affairs, Department
of Emergency Medicine; Residency
Program Director; Director,
International Studies Program,
Mount Sinai School of Medicine,
New York, NY.
Brent R. King, MD, FACEP, FAAP,
FAAEM, Professor of Emergency
Medicine and Pediatrics; Chairman,
Department of Emergency
Medicine, The University of Texas
Houston Medical School,
Houston, TX.
Robert Luten, MD, Professor,
Pediatrics and Emergency
Medicine, University of Florida,
Jacksonville, Jacksonville, FL.
Ghazala Q. Sharie, MD, FAAP,
FACEP, FAAEM, Associate
Clinical Professor, Childrens
Hospital and Health Center/
University of California, San
Diego; Director of Pediatric
Emergency Medicine, California
Emergency Physicians.
Gary R. Strange, MD, MA, FACEP,
Professor and Head, Department of
Emergency Medicine, University of
Illinois, Chicago, IL.
EMERGENCY MEDICINE PRACTICE
PE DI ATRI C
AN EVIDENCE-BASED APPROACH TO PEDIATRIC EMERGENCY MEDICINE EMPRACTICE.NET
Gastroenteritis: An
Evidence-Based Approach
To Typical Vomiting,
Diarrhea, And Dehydration
Gastroenteritis season is upon us! Your ED and waiting room are overowing with
anxious parents who have brought their children to you with varying degrees of
vomiting, diarrhea, and dehydration. The charge nurse is concerned that things are
getting backed up. Every parent insists that their child is severely dehydrated and
needs intravenous uids and admission. Many of your strongest nurses, on the other
hand, seem to think that almost none of these children needed to be brought to the ED
in the rst place, and they have started PO challenges on just about every child.
As you prepare to evaluate the next patient in the to-be-seen rack, you real-
ize that the ED really is getting terribly backed up. Whereas putting in an IV and
checking some lytes seemed reasonable when there were just a few children present-
ing with vomiting and diarrhea, you realize it is time to get very serious about the
situation. You need to gure out which children truly need intravenous hydration
and laboratories checked, which children are appropriate candidates for oral rehydra-
tion, and which parents need some quick reassurance and the discharge papers.
During inevitable winter nights like this, several questions enter your mind.
Are any of those published practice guidelines worth the paper on which theyre
printed? If so, do they apply to my patients in my ED? Whats the deal with oral
rehydration? Are there any uids I am not supposed to be using, and if so, why not?
How can I reliably identify the dehydrated kids? Are any labs helpful, and if so, in
what circumstances? Did I wash my hands after that last patient?
T
REATING children for vomiting, diarrhea, and possible dehydration is
extremely common in any ED that sees children. Before delving into a
discussion of vomiting and diarrhea, an important denition needs to be pre-
sented up front. The word: gastroenteritis. The ofcial dictionary denition
TM
PDF Editor
Pediatric Emergency Medicine Practice 2 EBMedPractice.net December 2004
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Table 1. Differential Diagnosis For Children With Vomiting.
Infancy Childhood Adolescence
Mechanical Gastroesophageal reux
Malrotation with midgut volvulus
Pyloric stenosis
Intussusception
Incarcerated hernia
Tracheoesophageal stula
Constipation
Incarcerated hernia
Meckels diverticulum
Bowel obstruction
Constipation
Incarcerated hernia
Meckels diverticulum
Bowel obstruction
Inammatory/
Infectious
Necrotizing enterocolitis
Gastroenteritis
Sepsis
Meningitis
Pneumonia
Otitis media
Gastritis/Gastroenteritis
Otitis media
Appendicitis
Pancreatitis
Henoch-Schnlein purpura
Biliary tract disease
Gastroenteritis
Appendicitis
Henoch-Schnlein purpura
Pancreatitis
Gastritis
Biliary tract disease
Genitourinary Urinary tract infection Urinary tract infection Urinary tract infection
Pregnancy
Testicular/Ovarian torsion
CNS Hydrocephalus
Intracranial hemorrhage
Intracranial tumor
Migraine headache
Hydrocephalus
Intracranial tumor
Reyes syndrome
Migraine headache
Hydrocephalus
Intracranial tumor
Glaucoma
Metabolic Diabetic ketoacidosis
Congenital adrenal hyperplasia
Urea cycle defects
Organic acidurias
Amino acidopathies
Fatty acid oxidation disorders
Diabetic ketoacidosis
Urea cycle defects
Fatty acid oxidation disorders
Diabetic ketoacidosis
Other/Atypical Occult trauma (abuse)
Toxic ingestions
Munchausen by proxy
Sickle cell
Toxic ingestions
Occult trauma (abuse)
Munchausen by proxy
Sickle cell
Toxic ingestions
Occult trauma (abuse)
Munchausen/Munchausen by proxy
*Source: Adapted from Hostetler MA, Bracikowski A. Gastrointestinal Disorders. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosens Emergency Medi-
cine: Concepts and Clinical Practice, 5th ed. St. Louis, MO: Mosby; 2002:2300.
of gastroenteritis is an acute inammation of the lining
of the stomach and intestines, characterized by anorexia,
nausea, diarrhea, abdominal pain, and weakness.
1
The
hallmark of gastroenteritis is diarrhea. Because of nausea,
most children also have some vomiting as a part of a viral
gastroenteritis. Too often clinicians can be overheard using
the term gastroenteritis as slang for vomiting they think
is clinically benign. For practical purposes, gastroenteri-
tis should only apply to children with nausea or vomiting
AND diarrhea. Although there is a very broad differen-
tial diagnosis for children exhibiting vomiting without
diarrhea (See Table 1), the differential diagnosis narrows
substantially when both vomiting and diarrhea are promi-
nent symptoms. In most cases in the United States and the
developed world, gastroenteritis is caused by self-limited
viral infections, and the main concern is dehydration.
The language used to describe dehydration in chil-
dren is familiar to most pediatricians. Some physicians,
however, may not be accustomed to talking about dehy-
dration in terms of percentages. In essence, the theoretical
ideal is to have a very recent, known preillness weight,
and then to measure a weight on the same scale during the
illness to determine the water weight lost due to vomit-
ing and diarrhea. This change is usually expressed as a
percentage. For example, if a physician knew that a child
had a recent weight of 10 kg, has had vomiting and diar-
rhea, and now weighs 9 kg, it would be said that the child
was 10% dehydrated (1 kg lost divided by the preillness
weight of 10 kg). In practice, however, a recent weight is
seldom, if ever, known. More commonly, physicians use a
combination of signs and symptoms to estimate the broad
category of dehydration (ie, none, mild, moderate, severe)
and then assign a percentage number that matches this
category. For example, the signs and symptoms that are
typically seen in children with moderate dehydration are
thought to occur in children who are between 5% and 10%
dehydrated. This leads physicians to see a child, deter-
mine that they are moderately dehydrated, and then say
a very precise thing like, This child is 8% dehydrated. It
has to be recognized that this numeric value is in no way
calculated or based on any other numbers, values, or tests.
This process can be bewildering and seem almost mystical
TM
PDF Editor
3 Pediatric Emergency Medicine Practice
September 2003 www.empractice.net
December 2004 EBMedPractice.net
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Table 2. Clinical Criteria Commonly Used For Classifying Dehydration Severity.
Mild (3-5%) Moderate (6-9%) Severe (> 10%)
Mental Status Well-appearing Ill-appearing, non-toxic Lethargic, toxic
Heart rate Normal to increased Tachycardia Marked tachycardia
Breathing Normal Increased Increased, deep
Pulse Normal quality Normal to decr quality Poor quality
Capillary rell Normal (< 2 sec) Normal to sl prolonged (2-4 sec) Markedly prolonged
Perfusion Warm Cool Cold, mottled
Blood pressure Normal Normal Hypotensive
Eyes Normal Slightly sunken Very sunken
Tears Normal Decreased Absent
Mucous Membranes Moist Tacky Very dry
Skin turgor (recoil) Instant recoil Delayed (2 sec) Very prolonged
Urine output Normal to slightly decreased Decreased Minimal
*Source: Adapted as a composite from: WHO, 1995; Gorelick MH, Shaw KN, Murphy KO, 1997; Friedman JN, Goldman RD, Srivastava R, et al, 2004. See
references 6, 10, and 11.
Rapid versus Standard Rehydration
There are clinical instances when the rapid administration
of uid, particularly intravenously administered uid, can
be difcult for the patient to tolerate. Certainly, in cases
of myocarditis, some congenital heart conditions, brain
masses, and cases of diabetic ketoacidosis, physicians will
need to individualize uid administration and be rela-
tively cautious with regard to the rapidity and volume of
uid administration. This is not the case for children with
gastroenteritis. In the absence of other complicating fac-
tors, rapid rehydration, either orally or intravenously, has
been found to be safe and effective. This concept is well
supported in the available literature.
19-23

Laboratory Investigations
Although it is clear that the vast majority of children
do not require laboratory studies, current data lack the
sensitivity and specicity to guide exactly which patients
should be tested.
8,24
Rather than being used to diagnose or
conrm dehydration, testing is better used to verify that
no other abnormalities are present. Disorders of glucose
and sodium are particularly important to identify, as these
alter management the most. Unfortunately, the literature
on when to order laboratory tests is relatively weak.
Epidemiology, Etiology, Pathophysiology
Epidemiology
Worldwide, diarrheal disease and dehydration account
for as much as one-third of all deaths among infants and
children under the age of 5 years.
5,12,25
There are more than
1.5 million annual visits among children for vomiting
and diarrhea to US EDs resulting in 200,000 hospitaliza-
tions and approximately 300 deaths.
25-27
In developing
countries mortality rates are much higher, and in children
under the age of 5 years, there are an estimated 2 million
deaths annually.
26
Although these numbers remain high,
to physicians not familiar with it. But understanding this
practice can be very helpful in allowing physicians with
different levels of training and experience to understand
each other.
In this issue of Pediatric Emergency Medicine PRACTICE,
well review an evidence-based approach to the evaluation
and management of children with good old gastroen-
teritis.
Critical Appraisal Of The Literature
Gastroenteritis is one of the most common chief com-
plaints encountered in the ED. A wide range of topics
related to gastroenteritis and dehydration can be found
in the literature, including epidemiology, evaluation, and
management.
2
The literature consists of a heterogeneous
mix of prospective cohorts, retrospective reviews, and ran-
domized controlled trials. Although the quality is gener-
ally fairly good, both the quality and quantity of pediatric-
specic research in this area continue to increase. There is,
in addition, an important set of public policy guidelines.
3-7
Assessment Of Dehydration
Of all the topics in this area, the assessment of dehydration
is perhaps the most protean. Selected physical examina-
tion ndings (general appearance, capillary rell, skin tur-
gor/recoil, respiratory pattern) have the highest predictive
value, whereas historical features have little or no value.
8-11

(See Table 2.)
Enteral versus Intravenous Rehydration
Associated with fewer side effects, lower cost, shorter
treatment times, and fewer admissions, enteral rehydra-
tion is safe and effective and the preferred treatment for
children with mild or moderate dehydration.
12-18
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even death.
15,21,34,35
In order to maintain adequate intravas-
cular volume, both glucose and sodium need to be trans-
ported across the intestinal membrane in an equimolar
fashion.
36,37
The degree to which underlying inammatory
changes occur to the bowel mucosa depends on the etio-
logic agent. These inammatory changes result in damage
to the intestinal villi, the overall structure of the mucosa,
and the overall absorptive capacity of the gastrointestinal
tract. Limited absorption results in a greater output of
diarrheal uid and worsening dehydration. Interestingly,
fasting, which can occur with the nausea and vomiting of
gastroenteritis, actually worsens the capacity of the bowel
to absorb uid. Continued feedings not only slow the
progression of dehydration by adding to the overall uids
available to the childs intravascular space, the presence of
the feedings in the bowel lumen promotes mucosal recov-
ery and improves uid absorption.
36-38
The primary patho-
physiology on which oral rehydration strategies are based
revolves around the cotransport of glucose and sodium,
and the localized improvement to the bowel mucosa, due
to the presence of feedings in the lumen.
Differential Diagnosis
Gastroenteritis, particularly when caused by a virus that
sweeps through a community, is a clinical diagnosis. The
hallmarks are nausea, vomiting, and diarrhea, with or
without signs of dehydration. Fever may be present. The
diarrhea is typically watery, and it is unusual to have the
stool be positive for blood either grossly or on occult test-
ing. Only 10% of gastroenteritis is associated with bloody
diarrhea.
32
The most common infectious causes of grossly
bloody diarrhea include Shigella and enterotoxigenic E.
coli 0157:H7, the variant associated with hemolytic uremic
syndrome.
39
(Table 4.) Severe abdominal pain and altered
mental status, in particular, are not seen in typical gas-
troenteritis and should prompt the clinician to explore
alternative diagnoses. A discussion of alternative diagno-
ses is beyond the scope of this review. However, just as the
truism not all that wheezes is asthma rings true for most
clinicians, an analogous not all that vomits and has diar-
rhea is gastroenteritis should ring similarly true.
40-42
In
particular, the differential diagnosis for vomiting is large
and must take into consideration a wide variety of factors,
especially the patients age.
43
(See Table 1.)

Prehospital Care
Prehospital personnel should follow local EMS protocols
for pediatric patients. Initial evaluation and management
in the eld and during transport should focus on the rapid
cardiopulmonary assessment and management of im-
paired perfusion with intravenous uids. Hemodynami-
cally stable children with vomiting and diarrhea, normal
mental status, and normal perfusion do not require any
prehospital interventions, other than transport.

ED Evaluation
When presented with a child with vomiting and diar-
Table 3. Infectious Etiologies Identied In
Children Admitted For Dehydration.
Description (%)
Viral enteritis NOS* 21.9
Rotavirus 1.9
Salmonella spp. 1.0
Shigella spp. 1.0
Bacterial enteritis NOS* 0.7
Clostridium spp. 0.6
E. coli (pathologic/invasive) 0.5
*Source: Adapted from McConnochie KM, Conners GP, Lu E, Wilson C.
See reference 30.
NOS = not otherwise specied
spp = species
they have been reduced almost by half over the past 2
decades, in large part due to the widespread use of oral
rehydration therapy.
26,28
Societal costs are signicant, with
an estimated $1 billion per year in total costs estimated to
society for rotaviral disease alone.
29
In one study of those
patients admitted to the hospital, simple, uncomplicated
gastroenteritis accounted for 75% of all cases of admitted
dehydration, and of these cases, 51% were estimated to be
mildly dehydrated (at least 5% dehydrated), 16% moder-
ately dehydrated (approximately 10% dehydrated), and
26% were severely dehydrated (> 10% dehydration).
30
The
etiologic agents that commonly cause gastroenteritis are
highly transmissible (via the fecal-oral route). This ease of
transmission most likely explains why cases of gastroen-
teritis occur in groups, such as day cares, schools, families,
and wider communities.
Etiology
Viruses are responsible for up to 80% of all cases of gastro-
enteritis, with the remainder being caused by bacteria and
parasites.
31,32
Common viral etiologies include rotavirus,
enteric adenovirus, and Norwalk virus.
4,31
Less common
entities include calicivirus and astrovirus. Rotavirus ac-
counts for approximately one third of all hospitalizations
of acute gastroenteritis in children.
29
Although much less
common than viruses, the most common etiologic agents
for bacterial gastroenteritis in the developed world include
Campylobacter jejuni, Salmonella spp, Shigella spp, Yersinia
enterocolitica, and Escherichia coli species.
33
In one popu-
lation-based study of children admitted to the hospital
with dehydration, an infectious agent was identied in a
minority of cases. However, when an etiologic agent was
identied, the most common were nonspecic viruses and
rotavirus. (See Table 3.)
30

Pathophysiology
No matter what the infectious agent is, acute gastroenteri-
tis is associated with varying degrees of uid shifts, with
the potential to cause signicant dehydration, shock, and
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Table 4. Common Infectious Agents Causing Vomiting And Diarrhea In Children.
Agent Source/Symptoms Antimicrobial Treatment
Campylobacter jejuni Source: contaminated, poorly cooked chicken; un-
pasteurized milk; fecal-oral contact.
Symptoms: fever, abdominal pain, diarrhea (occa-
sionally bloody). Abdominal pain can mimic that of
appendicitis. Mild infection lasts 1-2 days.
Treatment recommended
Shortens illness and prevents relapse
E. coli 0157:H7 Source: contaminated, poorly cooked meat, often
beef; fecal-oral contact.
Symptoms: diarrhea, which may be bloody and pro-
fuse; abdominal pain, which may be severe; nausea
and vomiting. Complications including hemolytic-
uremic syndrome and renal failure.
Treatment not recommended
May increase risk of hemolytic-uremic
syndrome
Giardia lamblia Source: contaminated water; fecal-oral contact.
Symptoms: explosive, foul-smelling stools associated
with excessive atulence, abdominal distention, and
anorexia. Fever is usually absent
Treatment recommended for
symptomatic infections
Salmonella spp. Source: Contaminated, poorly cooked food (poultry,
eggs, dairy products); fecal-oral contact; reptiles.
Symptoms: abdominal cramps, vomiting and diar-
rhea often in association with fever.
Treatment recommended for specic,
high-risk patients (very young, very sick,
immunocompromised)
Shigella spp. Source: Contaminated food or water; fecal-oral
contact.
Symptoms: Symptoms vary from mild diarrhea and
no constitutional symptoms to patients with severe
crampy abdominal pain, profuse diarrhea that may
be bloody, fever, and prostration.
Treatment recommended for all patients
Staphylococcal food poisoning Source: Contaminated food.
Symptoms: abrupt onset nausea, vomiting, abdomi-
nal cramping, and diarrhea usually 2-4 hours after
eating contaminated food.
Norwalk virus Source: Contaminated food or water; fecal-oral.
Symptoms: Nausea, vomiting, abdominal pain lasting
24-48 hours.
Rotavirus Source: Fecal-oral route.
Symptoms: Foul-smelling profuse, non-bloody,
watery diarrhea, most common during the winter
months, usually lasting 3-8 days.
Vibrio spp Source: Contaminated water or food.
Symptoms: Profuse rice water diarrhea with varying
degrees of abdominal cramps and fever (but is most
often described as being painless and without fever).
Treatment recommended
Results in prompt eradication
*spp = species
rhea, the main challenge for most emergency physicians
is determining the degree of dehydration and the overall
severity of illness. The gold standard for the diagnosis
of dehydration is the comparison of a recent preillness
weight with current weight. It is difcult to conceive of
an instance when an emergency physician would have
this information. In lieu of serial weights, emergency
physicians must estimate uid decits based on surrogate
information available in the history, physical examination,
and, occasionally, laboratory values.
TM
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History
The history may yield important information regarding
alternative diagnoses. Important information to explore
with the family includes factors such as fever, pain, pres-
ence of blood or mucus in the stool, blood or bile in the
emesis, headache, trauma, infectious contacts, ingestions,
and travel. If the history suggests typical gastroenteritis,
the history may help in assessing the trajectory of the
illness. This is particularly helpful when evaluating a
child who is not currently dehydrated, but may rapidly
become so. When assessing for risk of present and future
dehydration, physicians may ask about the number and
quantity of vomiting or diarrheal episodes as an estimate
of ongoing volume loss, the number of wet diapers as a
surrogate for urinary output, and the amount and type
of oral intake. The number of diapers wet with urine is
exceedingly difcult to assess in the context of multiple
diapers wet with diarrhea.
Physical Examination
The physical examination may also yield important
information regarding alternative diagnoses. Abdominal
distention or peritoneal signs suggest intra-abdominal di-
agnoses other than simple, uncomplicated gastroenteritis.
(See Table 1.) Altered mental status carries a wide differ-
ential diagnosis as well, including central nervous system,
toxicologic, endocrine disorders such as diabetic
ketoacidosis and metabolic conditions (ie, inborn errors
of metabolism). (See The Critically Ill or Comatose Infant:
An Organized Approach, Emergency Medicine PRACTICE,
Volume 4, Number 10, October 2002.)
In cases of gastroenteritis, the physical examination
has the highest yield in estimating dehydration. Vital signs
should be measured and compared to age-based norms.
It is probably prudent to recheck abnormal values. Most
infants and young children with gastroenteritis have
some degree of tachycardia, tachypnea, and a low-grade
fever. Dehydration may be suggested by tachycardia out
of proportion to fever, and when an afebrile child is calm.
The anterior fontanel is normally at, but may become
sunken as the child becomes dehydrated. The eyes of a
dehydrated child may appear sunken in their orbits. Oral
mucous membranes can be assessed for dryness. In cases
of uncomplicated gastroenteritis, the abdomen is usually
soft and nondistended. Bowel sounds are variable and
generally unhelpful, as they may be hyperactive, normal,
or hypoactive. Rectal exams are rarely indicated.
Estimating Dehydration
The signs and symptoms of dehydration are generally
imprecise and inaccurate. Common recommendations are
based on opinion and dogma, making it very difcult for
clinicians to accurately predict the degree of dehydration.
Incorrect assessment of dehydration can have important
consequences. Failure to recognize or adequately treat
dehydration results in increased morbidity and mortality.
44

However, it seems that failure to identify seriously dehy-
drated children is rarely a problem for most emergency
physicians. Probably more common is the inappropriate
diagnosis of dehydration when it is not present. Inappro-
priate diagnoses of dehydration can lead to substantial
and inappropriate use of health care resources.
45

Multiple studies have shown that no single physical
nding is sufciently accurate to determine the degree to
which children are dehydrated.
8-10,46-48
This should come as
no surprise to experienced clinicians, who rarely base deci-
sions on a single sign or symptom. Instead, a combination
of signs and symptoms is often more helpful and accurate.
(See Table 5.) According to a systematic review of the
literature, the most useful signs for predicting dehydration
in children include abnormal capillary rell time (Likeli-
hood Ratio 4.1; 95% condence interval [CI], 1.7-9.8), skin
turgor (or recoil) (LR, 2.5; 95% CI, 1.5-4.2), and respiratory
pattern (LR, 2.0; 95% CI, 1.5-2.7).
8

Capillary rell is probably best assessed on the distal
pad of the ngertip (palmar surface), at the level of the
heart, in a warm ambient temperature. Gentle pressure
is applied until the capillary bed blanches and is then re-
leased. The time elapsed until restoration of normal color
represents the capillary rell time, with normal values
less than 1.5 to 2 seconds.
46
Delayed capillary rell sug-
gests peripheral vasoconstriction that can be seen in cold
ambient temperatures, as well as dehydration and shock.
Although skin turgor has been used to describe dehydra-
tion for many years, the actual technique is somewhat less
dened. One common method is to simply pinch a small
fold of skin from the lateral aspect of the abdominal wall
and watch for natural recoil back into normal position.
The normal amount of time for the skin to recoil back to
normal is unknown. One method of describing skin turgor
uses the following categories: normal (instant), delayed
(up to 2 seconds), or prolonged (2 seconds or greater).
47,48

The childs resting respiratory pattern should be observed
for a period of at least 1 full minute. In a potentially dehy-
drated child, hyperpnea (deep, rapid breathing without
other signs of respiratory distress) suggests acidemia
resulting from inadequate tissue perfusion.
In a prospective cohort analysis of 186 children with
gastroenteritis, the presence of an increasing number of
clinical signs (general condition, quality of radial pulse,
quality of respiration, skin elasticity, eyes, tears, mucous
membranes, urine output) was associated with increasing
levels of dehydration.
10
Objective signs of dehydration
can be apparent with estimated uid decits below 5%
(2 signs). The presence of 3 or more signs had a sensitiv-
ity of 87% and a specicity of 82% for detecting a decit
of 5% or more, consistent with moderate dehydration.
10

Severe dehydration representing an estimated decit of
10% or greater was associated with the presence of 6 or
more signs. Using logistic regression modeling, a subset
of 4 clinical ndings with similar predictive characteristics
was identied: capillary rell > 2 seconds, dry mucous
membranes, absent tears, and abnormal general appear-
ance. Another group of clinical researchers have recently
developed a new 4-item, 8-point dehydration scale
(general appearance, eyes, mucous membranes, and tears)
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using a prospective cohort of 137 patients and formal
measurement methodology.
11
Although there are fewer
items, the scale is somewhat more complicated. The results
are similar to other studies, including a sensitivity of 74%
for mild dehydration, 33% for moderate dehydration, and
70% for severe dehydration.
9
Other physical ndings, such
as lack of tears and sunken eyes, were not strong, inde-
pendent predictors of dehydration.
9
This is probably due
to an absence of objective ways to measure these clinical
ndings. Urinary output, although frequently described
as an important indicator of dehydration, actually occurs
early during the course of becoming dehydrated, and has
a positive predictive value of only 17% for identifying
dehydration.
10,49
Diagnostic Studies
Laboratory Studies
In the vast majority of cases of gastroenteritis, the utility of
laboratory studies is limited. There are no gold standards
for conrming dehydration. Although the literature re-
ports over 30 different tests purportedly useful for aiding
in the determination of dehydration, none have performed
consistently well when applied to determining the severity
of dehydration.
8,24
In addition, there is signicant varia-
tion among test ordering in children with gastroenteritis,
leading to selection bias in many studies (particularly
retrospective studies), and there is no evidence that testing
leads to a change in patient outcome or family satisfac-
tion.
50
Ten Pitfalls To Avoid
1. A well-appearing child with no evidence of dehydration
gets a "PO challenge" that is given ad lib. The child guzzles
the entire 2 containers of apple juice immediately, and
shortly thereafter the child vomits, followed by the mother
proudly showing you the emesis. The mother and nurse
form a united front to insist that the child has conrmed the
need for an IV.
The fact that the child vomited is a normal part of the
disease process. It only demonstrates that he was given too
much to drink too quickly.
2. I thought vomiting was a contraindication to ORT.
Essentially all patients with gastroenteritis vomit. All atients
with mild or moderate dehydration are eligible to receive
ORT. The goal with ORT is to start with small amounts of
uid that are able to be absorbed by the gastric mucosa
before they are able to be vomited, and then increase as
tolerated. Even if vomiting occurs during rehydration, ORT
can continue and is often successful.
3. I didnt want to use oral rehydration because I thought it
would take too long, and putting in an IV would be quicker.
The data clearly support the use of oral rehydration over
intravenous rehydration, with an overall shorter length of
stay in the ED and fewer admissions.
4. I thought moderate dehydration was a contraindication
to oral rehydration.
Oral rehydration is indicated for mild or moderate
dehydration.
5. I know the kid was only 2-months old, but her mom had
the stomach u, too, so I gured she just had the stomach
u as well.
Not all that vomits is gastroenteritis. Gastroenteritis in very
young infants is relatively uncommon. In infants under
3 months of age, gastroenteritis is almost a diagnosis of
exclusion.
6. That 2-month-old looked fairly dry, but I tanked her up
pretty good, and I thought she looked great before she left.
Great care should be taken before sending home very
young infants after uid resuscitation. These young infants
have a lower likelihood of having typical gastroenteritis and
are more likely to have other causes to their vomiting. These
infants also have a higher risk for hypoglycemia due to poor
feeding, a high metabolic rate, and low glycogen stores.
7. I gave the parents old discharge instruction forms,
because thats all I had.
Older practice patterns, such as withholding all feeds, using
dilute formula, or exclusively using clear uids for days
on end, may still be printed on the discharge forms found
in some EDs. Patients and families require accurate and
updated information. Discharge instructions should include
specic information on appropriate rehydration uids and
techniques, as well as on the importance of rapid return to
realimentation as soon as possible. Exclusive administration
of oral rehydration solutions can be the cause of ongoing
diarrhea.
8. I thought his abdominal pain and tenderness were just
related to his gastroenteritis.
In the absence of typical symptoms, or in the presence
of other concerning symptoms, other causes should be
excluded (eg, surgical causes, such as acute appendicitis or
intussusception).
9. I though antiemetics were contraindicated in children.
Or, theyre too expensive, or have too many side effects.
The use of ondansetron, in particular, has been found to
be safe and effective, as an adjunct to ORT, to decrease
vomiting in patients with severe refractory vomiting.
10. There is no reason to develop a clinical pathway in our
ED.
Multiple studies have shown that the evaluation and
management of dehydration in children using a well-
developed clinical pathway is an excellent means of
streamlining care, reducing variation, and improving care.
Added benets include reducing admissions, saving money,
and improving satisfaction.
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Table 5. Essential Steps Of Oral Rehydration Therapy.
Select an appropriate uid (see text for a discussion of options)
Estimate the degree to which the child is dehydrated (See Table 2.)
Estimate the uid decit
Example:
10 kg child, estimated at 7% dehydrated, has a weight loss of: 0.07 x 10 = 0.7kg
Acute weight loss with vomiting and diarrhea is due to water loss (not bone, fat, etc.)
Since 1 L water weighs 1kg, 700 ml water weighs 0.7kg.
So, estimated total uid decit for this child is 700 ml.
Begin oral rehydration at a rate of 5 ml every 5 minutes (use a watch or clock for timing)
Increase the rate of intake as tolerated
Goals include replacing at least 10 ml/kg in the rst hour and having the total uid decit replaced within 4 hours
of gastroenteritis, even in the presence of severe dehydra-
tion.
Treatment
Oral Rehydration
Oral rehydration therapy (ORT) has been extensively
studied. ORT is known to be safe and effective as the
treatment of choice for mild and moderate dehydration.
57-
60
Morbidity and mortality can be greatly reduced with
the use of ORT.
12-17,61
Unlike most innovations that are
created in the developed world and then implemented in
the third world, ORT is an example of reverse technol-
ogy, whereby an innovation rst implemented in third
world countries is translated into use in more modern,
developed countries. In 1996 an expert panel estimated
that the use of ORT alone could decrease hospitalizations
by half (100,000/year).
61
A subsequent meta-analysis of 16
trials comparing 1545 children found that, for childhood
gastroenteritis, ORT is as at least as effective as intrave-
nous rehydration, is associated with fewer major adverse
events, and results in shorter hospital stays.
62
The data are
overwhelmingly positive.
In terms of implementation, it is probably best to
think of ORT as a distinct procedure. (See Table 5.) One of
the rst issues in initiating ORT involves the selection of
the uid to be used. For 2 decades the World Health Orga-
nization recommended an oral rehydration solution (ORS)
containing the following: sodium, 90 mmol/L; potassium,
20 mmol/L; chloride, 80 mmol/L; citrate, 10 mmol/L; and
glucose, 111 mmol/L. This solution has an osmolarity of
311 mOsm/L. A newer, lower osmolarity version is now
recommended and has been shown to reduce the amount
of diarrheal output, particularly in cases of cholera. It
contains sodium, 75 mmol/L; potassium, 20 mmol/L;
chloride, 65 mmol/L; citrate, 10 mmol/L and glucose, 75
mmol/L. This ORS has a total osmolarity of 245 mOsm/L.
This lower-osmolarity version has been shown to have im-
proved performance with severe diarrheal disease.
63
There
are a variety of ORS formulations available. (See Table 6.)
Two formulations of commercially available ORS one
glucose-based (Pedialyte
, Ross Products Division of

Abbott Laboratories) and one rice-based (Infalyte
, Mead
Although an elevated urine specic gravity does oc-
cur in dehydration, it occurs very early in the course of the
illness during the time of clinically insignicant uid
losses is a nonspecic nding, and does not correlate
with the overall degree of dehydration.
8
Among blood
tests, the blood urea nitrogen (BUN) (or the BUN/creati-
nine ratio) and bicarbonate concentrations appear to be
the most helpful, but only when markedly abnormal.
8,24

Given the lack of objective evidence and predictive capa-
bilities, laboratory studies should never be required as a
means of diagnosing dehydration. A reasonable strategy
seems to be using laboratory testing to conrm or verify
that there are no gross abnormalities, such as hypoglyce-
mia, hyperglycemia, or electrolyte disturbances. It should
also be remembered that different means of volume loss
(vomiting versus diarrhea) may have varying impact on
some of the laboratory studies that are assayed and mea-
sured (bicarbonate level), while others, such as the BUN,
are independent of how the uid is lost. Although perhaps
convenient to obtain, the data are conicting regarding
laboratory assessments in children for whom intravenous
rehydration is planned.
Stool studies are seldom indicated.
50
In well-appear-
ing, previously healthy patients with an acute onset of
vomiting and diarrhea, stool studies are unhelpful.
52-54
(See
Table 4.) Stool testing may be indicated for cases involv-
ing recent travel to the third world (suggestive of a higher
likelihood of bacterial illness), comorbidity, frankly bloody
stool, or diarrhea of 5 days duration, particularly if there is
a history of fever.
33,39,55
Recent antibiotic use raises the like-
lihood of Clostridium difcile infection. Selection criteria to
identify children for whom C. difcile testing is indicated
are not currently evidence-based.

Point-of-Care Testing
Hypoglycemia may be associated with diarrheal illness,
particularly in those who have an altered mental status,
are ill appearing, or are in early infancy, and therefore
have diminished fat reserves (ie, infants).
56

Radiography
There is no role for routine radiographic imaging in cases
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Johnson Nutritional Group) have been shown to be
equally efcacious.
18
In at least one study, however, rice-
based ORS reduced the failure rate of ORT (measured by
the surrogate variable of the rate of initiating intravenous
uid therapy) compared with the use of glucose-based
ORS.
64
Rice-based ORS appears to be effective at reducing
stool volume; however, according to the Cochrane collab-
orative review process, this effect is most prominent only
in patients with cholera.
65
Several points are clear: The
WHO and commercially available ORS solutions are the
best options, with nearly identical proportions of electro-
lyte constituents. Sports drinks contain a higher propor-
tion of sugars and lower proportions of sodium, but are
typically more palatable to older children. Fruit juices
and soda are inappropriate choices as ORS, based on their
constituents. This is not to be confused with having a child
who is not dehydrated or who is minimally dehydrated
drinking what they like. For the purposes of ORS, fruit
juices and soda should not be used. Plain water is an inap-
propriate choice for ORS, due to the absence of the neces-
sary electrolytes and glucose. Young infants given plain
water or dilute tea are at risk for developing hyponatremia
that may be severe enough to cause seizures. Again, there
is little reason to withhold a drink of water from a thirsty,
older child, but water should not be used for the specic
purposes of rehydration.
Despite excellent data supporting the use of ORT and
recommendations from well recognized organizations
emphasizing the use of ORT for rehydration in mild or
moderate dehydration, studies show that ORT is used in
less than 30% of the cases of diarrhea in the United States
for which it is indicated.
61,66,67
This underuse of ORT is as-
sociated with unnecessary ED visits and hospitalizations,
resulting in direct medical costs of greater than $1 billion
per year.
61
In another recent survey, nearly one third of
pediatric or general emergency physicians indicated that
they always used IV rehydration for mild dehydration,
something that clearly goes against all published recom-
mendations.
68
Even among academic pediatric emergency
medicine fellowship directors, who would otherwise be
expected to have an evidence-based practice as part of
their training program, the rate of ORT usage was low. In
one study, only 31% of respondents use ORT for mildly or
moderately dehydrated patients.
69

The explanation for the limited implementation of
ORT is not entirely clear. Reasons cited for failing to initi-
ate ORT when it is indicated include: extended length of
stay in the ED, increased staff time to implement ORT,
concerns over patient satisfaction, and potential failure
rates.
70
However, in a study designed specically to ad-
dress these commonly reported barriers to using ORT,
results indicated that ORT performed better than IV
therapy on all outcomes that were previously considered
to be barriers: length of ED stay, mean staff time, treatment
failure, rate of relapse, and satisfaction.
70
For whatever reasons, ORT remains underutilized for
the treatment of dehydration in the United States, both
at home and in the ED, despite multiple clinical trials
verifying its clinical efcacy and safety. The WHO has for-
mulated, endorsed, and perfected the exact composition
for premade packets of ORS, and these packets are quite
inexpensive (approximately $0.55 per packet). These pow-
dered formulations have been found to be safe and effec-
tive when combined with potable water, and they are very
easy to use.
71,72
Commercial variations are now produced
and available in the United States. They can be purchased
from Jianas Brothers (Kansas City, MO), Cera Products
(Jessup, MD), and Pharmacia & Upjohn, Inc (Peapack, NJ).
Other ORS formulations are commercially available, a-
vored, and are come in premixed and prepackaged bottles
at a cost of between $2 and $9 per liter. These formulations
are readily available in any grocery or convenience store,
but they are of course signicantly more costly than the
Table 6. Constituent Components & Recommendations For Oral Rehydration Solutions (ORS).
Osmolality
(mOsm/kg)
Glucose
(mmol/L)
Sodium
(mmol/L)
Potassium
(mmol/L)
Recommendation
as an ORS
WHO 331 111 90 20 Recommended for all ages
Low-Osmolarity
WHO
245 75 75 20 Recommended for all ages
Commercial ORS
(ie, Pedialyte)
250 130 45 20 Recommended for all ages
Sports Drink
(ie, Gatorade)
330 255 20 3 Not recommended for children
younger than 2 years of age
Cola 500 700 2 0.1 Not recommended
7-Up 388 500 4 0 Not recommended
Orange juice 687 680 1 486 Not recommended
Apple juice 694 690 0 27 Not recommended
*Source: Adapted from Sandhu BK; European Society of Pediatric Gastroenterology, Hepatology and Nutrition Working Group on Acute Diarrhoea. See
reference 17.
Continued on page 12
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NO
NO

The evidence for recommendations is graded using the following scale. For complete denitions, see back page. Class I: Denitely
recommended. Denitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III:
May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending
upon a patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2004 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any for-
mat without written consent of EB Practice, LLC.
Clinical signs of dehydration?
Administer 20 ml/kg
normal saline boluses
until perfusion is ad-
equate (and child is no
longer in physiologic
shock). (Class II)
Admit to Pediatric Inten-
sive Care Unit. (Transfer
according to local
resources.) (Class II)
1.
2.
NO
Discharge home with appropriate

discharge instructions. (See Sample
Discharge Instructions on next page.)
Follow up with primary care physician
Admit to basic pediatric ward bed or to
observation unit. (Class II)
Dehydration resolved and patient tolerating oral uids? YES
YES
Option 1
If oral rehydration failed due to persistent vomiting, initiate
intravenous rehydration and then reassess for dehydration.
(Class II)
Option 2
If oral rehydration failed due to persistent vomiting, may
administer antiemetic (eg, ondansetron) and reattempt oral
hydration. Reassess for dehydration. (Class II)
NO
YES
Clinical Pathway: Evaluation And Management Of Dehydration

Due To Gastroenteritis In Children Over 3 Months Of Age
Is the dehydration severe? YES
Option 1
Oral rehydration therapy. (Class II)
Option 2
Intravenous rehydration; then assess whether patient
is tolerating oral uids. (Class II)
Option 3
Nasogastric rehydration (Class III);
Then, reassess for dehydration.
Dehydration resolved and patient tolerating oral uids?
TM
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Sample Discharge Instructions
How to Prevent Your Child from Becoming Dehydrated
Use plenty of oral rehydration uids.
Acceptable uids include:
Over-the-counter oral rehydration solutions (Pedialyte, Infalyte, Rehydralyte).
If necessary, you may add a small amount of your childs favorite avoring or juice to the
oral rehydration solution, if that increases the childs interest in drinking the oral rehydra-
tion solution.
Freezer rehydration popsicles (do not use regular popsicles they are mainly just pure
sugar and do not contain the necessary salts and electrolytes).
Do not use:
Pure juices they have too much sugar and can cause worsening diarrhea.
Plain water does not have any sugar or salts and can cause electrolyte changes. Be espe-
cially careful about giving plain water to small babies, as it can sometimes cause changes
resulting in seizures.
Soda they are also just water and sugar and have the wrong concentration of salts and
electrolytes.
If your child is vomiting, start with small amounts of oral rehydration uid. Give 1 teaspoon (or
5cc in syringe) every 5 minutes, and then increase gradually, as tolerated by your child.
You should return to your childs normal diet as soon as possible
You do not need to stop milk or formula products.
You may continue breastfeeding.
You can still expect to see some vomiting and diarrhea. That is part of the normal disease process.
Your child still needs to continue to receive adequate nutrition.
Signs of Dehydration
Your child may appear less active, sleepy, or lethargic.
Your child cries, but has no tears.
Decreased frequency of urination, or wetting diapers
Sunken eyes
Cool, clammy skin
If these appear, you need to increase the amount and frequency of the oral rehydration solution
you are giving and speak with your doctor or clinic for a follow-up appointment.
You should return to the ED if your child:
Appears very sleepy, lethargic, or is difcult to arouse.
Has not urinated or wet a diaper in 8 hours.
Appears to be breathing either very fast, or has very deep and slow breathing.
If the vomiting or diarrhea becomes bloody.
If your childs abdomen becomes distended or appears to be tender or painful to the touch.
1.
2.
3.
1.
2.
3.
TM
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WHO packets. Due to the relatively high cost, parents may
be deterred from obtaining appropriate ORS. In at least 1
case report, lack of access to appropriate ORS was cited as
the specic cause for hypernatremia in an infant.
73
Parents
who used both WHO-ORS packets and commercially pre-
pared ORS preferred the WHO-ORS.
71
In another study,
providing ORS during ofce visits increased their use and
decreased subsequent unscheduled ofce visits.
74
Provid-
ing good anticipatory guidance during ED visits will not
only provide quality care during that visit, but also for all
future visits.
Intravenous Rehydration
Not all patients are good candidates for oral rehydration.
Patients in shock clearly require resuscitation with intrave-
nous (IV) uids. Patients whose dehydration falls into the
severe category, or in whom oral rehydration attempts are
failing, also benet from an initial bolus of IV rehydration.
Patients repeatedly vomiting despite appropriate attempts
at ORT also require IV therapy. Interestingly, IV rehydra-
tion in the ED leading to discharge home is a relatively
new concept. Debate continues as to how quickly the
uids should be given.
75

To somewhat oversimplify; uid replacement therapy
in children has historically been a process of calculat-
ing the uid decit and then replacing this volume of
uid over an extended time, commonly 24 hours or
more.
15,21,34,35,76-78
More recent developments include a
rapid rehydration approach, which recommends giving
IV uids relatively rapidly over a matter of a few hours,
and then switching to oral uids as soon as possible. This
alternative rapid approach has gained increasing favor,
and in the absence of any other complicating factors (ce-
rebral edema, altered mental status, comorbidity, or other
atypical presentation), has been found to be both safe and
effective.
19-23
With this approach, various investigators
have used anywhere from 20-60 ml/kg over 1-3 hours, fol-
lowed by institution of ORS.
19-23
Using a clinical pathway
that included rapid oral and IV rehydration resulted in
a reduction in admissions for moderately dehydrated
children from 96.3% to 55.8% and the number of chil-
dren discharged in 8 hours or less improved from 4% to
44%, compared to prior to the intervention.
23
In a compar-
ative trial of rapid oral and intravenous rehydration, the
oral rehydration group performed slightly better in terms
of weight gain, reintroduction of feedings, and reduction
of diarrhea.
79
According to a study to evaluate actual time
required to treat dehydration, the mean IV treatment time
was 5.4 hours, signicantly longer than the mean time for
treating other patients (1.2 hours).
80
The initial uid choice for rehydration should be
isotonic and dextrose-free. Normal saline or lactate ringers
are reasonable choices, given 40 mL/kg over 1-2 hours,
followed by ORS and realimentation as tolerated. There
are a couple of caveats. Patients in the mild or moderate
category with routine gastroenteritis and no other compli-
cating factors should be able to receive 40 mL/kg without
any contraindication. Infants are at slightly greater risk
of developing clinically important imbalances in serum
glucose and sodium. It has been recommended that young
Continued from page 9
Develop a multidisciplinary clinical guideline for use in your
department that can be initiated at triage and continued
throughout the patients course from their emergency stay
to discharge. Using a clinical pathway can have dramatic
effects. At the Childrens Hospital of Westmead in Australia,
the institution of an ED clinical pathway for dehydration-
rehydration resulted in a reduction in the rate of admissions
for moderately dehydrated children, from 96.3% to 55.8%,
and the number discharged in 8 hours or less was 44.2%,
compared to only 3.7% prior to the intervention.
23
In a
similar study at the Childrens Hospital Medical Center
in Cincinnati, the length of ED stay and percentage of
patients requiring admission also decreased following
implementation of an evidence-based acute gastroenteritis
guideline.
102,103
The guideline should take into consideration the
key assessment parameters, as described in the physical
examination section, and allow for consistent usage of
language and parameters commonly used. Ensure that
all stakeholders are involved in the development and
acceptance of the guideline. Once developed and approved,
it is essential that all caregivers are inserviced and that the
guideline becomes adopted into routine practice. It should
also become part of routine orientation for new nurses,
medical students and residents. It is also helpful to perform
quality improvement studies to evaluate performance of the
intervention. This can be accomplished in terms of patient
outcomes, such as length of stay, percent admissions,
return visits (treatment failures), and satisfaction. Referring
physicians should also be apprised of the changes, and their
satisfaction can also be tracked.
Patients without clinical evidence of dehydration do
not need any intervention and do not benet by attempts at
PO trials or laboratory evaluations. Patients with mild to
moderate dehydration are appropriate for oral rehydration
therapy (ORT). Patients with severe dehydration should
have an intravenous line inserted, and rapid intravenous
rehydration. Laboratory testing is best reserved for
patients under the age of 3 to 6 months, those with severe
dehydration, and those with atypical features.
Cost- And Time-Effective Strategies
For Managing Vomiting And Diarrhea In Children
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infants should have somewhat more liberal laboratory
testing and more frequent laboratory rechecks when un-
dergoing IV rehydration. Isotonic uid (eg, normal saline)
for initial rehydration is well tolerated, even in the case of
hypernatremia.
15,21,78
Hypotonic uids (eg, 0.45% saline or
0.2% saline) should be avoided, as they have higher rates
of adverse events, including fatal outcomes.
81
In addition,
in patients with hypernatremia specically, they should be
switched to ORS as soon as possible, as the rate of seizures
related to sodium disturbances are much lower when
ORS is added to IV rehydration.
13,82,83
Once intravascular
volume has been replenished (ie, once the patient has been
rehydrated), the patient can be converted, either orally
or intravenously, to a solution that contains some form of
dextrose.

Nasogastric Rehydration
In a study comparing rapid nasogastric and IV rehydra-
tion in pediatric patients, children received 50 mL/kg over
a 3-hour period. Results indicated that both were safe,
efcacious, and cost-effective alternatives to the standard
treatment for moderate dehydration in otherwise uncom-
plicated pediatric patients.
84
Probably few physicians have
tried to convince families to have their child undergo a na-
sogastric tube being placed instead of an IV. How success-
ful physicians are in convincing families to try nasogastric
rehydration remains unexplored.
Realimentation
There are signicant nutritional advantages to continu-
ing feeding during episodes of acute gastroenteritis. In
addition, the early initiation of feeding improves gastro-
intestinal structure and function and hastens intestinal
recovery.
36
Early realimentation is associated with reduced
duration of illness and improved weight gain.
36,56,85
Follow-
ing rehydration, realimentation should therefore be started
as soon as possible using an age-appropriate diet. The ap-
proach is simple and straightforward. The feeding should
be with the same foods or formula or breast milk the child
had been taking prior to the illness. In addition, there is no
evidence that removing milk from the diet, or recommend-
ing the routine dilution of milk during or following oral
rehydration therapy is necessary or helpful.
36,86
Breast milk
is similarly well tolerated and should not be restricted.
Breast-fed infants with diarrhea should continue nursing.
Given traditional approaches to gastroenteritis, including
avoiding feedings altogether, it may be difcult to con-
vince parents that early or continued feeding is benecial,
may decrease stool output, shorten duration of illness, and
improve nutrition for the child, but every attempt should
be made to do so.
Medications
Antiemetics
Most patients do well with oral rehydration alone. Oc-
casionally vomiting is quite severe, and antiemetics may
be helpful in getting control of the situation. In such cases,
administration of antiemetics may be helpful as an adjunct
to suppress vomiting and promote successful ORT. Al-
though antiemetics are commonly used in adults, clinical
experiences with antiemetics in children have historically
included side-effect proles with unacceptably high rates
of sedation, extrapyramidal effects, and, rarely, seizures.
Newer agents, such as ondansetron, a 5-HT3 receptor
antagonist, heralded great promise as being highly effec-
tive with few side effects. In ED settings, ondansetron has
been found to be safe and effective at decreasing vomiting
and the need for admission.
87,88
Although early experience
demonstrated success, concerns remained regarding the
high cost. The estimated cost of ondansetron is $26 per
4-mg vial. In comparison, the average cost per hospitaliza-
tion is $1900, excluding ED charges, and the estimated
number needed to treat is 8.5.
87
In other words, for every
8.5 children treated with ondansetron for gastroenteritis, 1
hospitalization would be prevented. Combining these re-
sults, ondansetron is cost-effective in reducing the need for
admissions in children with severe vomiting.
87-89
Although
not specically addressed in these relatively small studies,
ondansetron could be expected to be most cost-effective if
used either for patients receiving IV therapy or those most
at risk for admission, (ie, those with refractory vomiting).
These two groups would be most likely to benet from the
therapy.
Antidiarrheal Agents
In the past, agents such as loperamide and diphenoxylate
were used in the treatment of patients with acute diar-
rhea. Although the agents may slow intestinal transit time,
concern remains regarding adverse events, such as ileus,
abdominal distention, and sedation. These agents are no
longer recommended in the routine treatment of gastroen-
teritis in infants and young children.
90
Bismuth Salts
Bismuth subsalicylate (most commonly seen in products
such as Pepto-Bismol
) is a common constituent in many

antidiarrheal medications available over the counter.
Medicolegal Issues
Although risks exist, even when least expected, medicolegal
risk can be incurred in a variety of ways. Issues or problems
may arise with any of the following:
The severely ill
Those with abnormal vital signs
Infants under the age of 3 to 6 months
Failing to include other diagnostic possibilities when the
case presentation does not match classic gastroenteritis
or includes other symptoms (abdominal distention,
headache, neurologic symptoms)
Failure to appreciate the potential for decompensation,
preexisting disease, or comorbidities
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Key Points For Managing Vomiting And Diarrhea In Children
Most children are not clinically dehydrated and do not
require PO trials in order to prove they can tolerate PO
prior to discharge.
Oral rehydration using an appropriate oral rehydration
solution (ORS) is the preferred method.
Rehydration should be performed rapidly (over less than 4
hours).
Once started, rehydration is continued in the ED and then
continued at home by the parents/guardians.
Successful ORT involves several phases:
Rehydration 1.
Maintenance and prevention of dehydration
Realimentation
Laboratory testing is seldom necessary.
Medications are usually not necessary.
Following rehydration, rapid realimentation involves using
an age-appropriate, unrestricted diet that should begin as
soon as possible.
Both formula- and breastfed infants should be
started back on their usual feedings as soon as
possible.
Partial dilution of formula and restriction of lactose
are not necessary.
2.
3.
Despite its widespread use in the treatment of diarrhea,

its mechanism of action is still incompletely understood.
The literature indicates that possible mechanisms of action
include a direct antimicrobial effect, binding and inactiva-
tion of enterotoxins, prevention of attachment of microor-
ganisms to the intestinal mucosa, and a direct antisecre-
tory effect. Data suggest that products containing bismuth
subsalicylate are a safe and effective adjunct to standard
ORT for infants and children with gastroenteritis. These
products result in decreased duration of diarrhea, amount
of stool output, and length of hospitalization.
90,91
However,
due to new labeling requirements by the Food and Drug
Administration, pediatric dosing will no longer appear
on antidiarrheal drugs containing bismuth subsalicylate.
92

Presumably, this is due to concerns over the rare devel-
opment of Reyes syndrome in febrile children who take
aspirin-like products.
Antimicrobial Therapy
The use of empiric antibiotics is not recommended. Most
cases of gastroenteritis are due to viruses, and therefore
the children will not benet from antibiotics. Although
there is a select group of bacterial entities in which anti-
microbial therapy is recommended, even most bacterial
gastroenteritis does not require or benet from antibiotic
treatment.
93,94
(See Table 4.) This is because antimicrobial
therapy may prolong the course of the illness in some
cases and has been associated with increased rates of other
complications.
95
Special Circumstances
Clinical guidelines are intended for previously healthy
patients with classic, uncomplicated gastroenteritis. Care
must be individualized for other children. In particular,
patients with known or suspected underlying cardiovas-
cular, renal, endocrine, or central nervous system dis-
eases who may be at risk for signicant uid overload or
cardiovascular decompensation should not undergo rapid
rehydration.
Controversies/Cutting Edge
One area of controversy involves the use of a PO chal-
lenge before discharging patients from the ED. There is
no literature to support the practice of trials of drinking
uids prior to discharge to home. This time-honored
approach is wide open for study and cannot be recom-
mended based on the available evidence.
Although oral rehydration has been well supported
and has very good supporting evidence, the routine use of
oral rehydration therapy in the ED remains controversial.
These perceived barriers have been discussed above. (See
Treatment, Oral Rehydration on page 8.) Most clinicians
agree that more emphasis should be placed on oral rehy-
dration and the prevention of dehydration, rather than on
intravenous rehydration. In many ways, this may just be
lip service. Although multiple experts have been advo-
cating for the increased use of enteral rehydration for over
30 years as the preferred treatment for the acute replace-
ment of uid and electrolyte losses, the widespread use of
this simple technology still seems to elude most practitio-
ners.
Racecadotril, an enkephalinase inhibitor with anti-
secretory and antidiarrheal properties, has been tested
for use in children. Data suggest that when compared to
placebo, racecadotril lowers stool output by up to 50% in
patients with profuse, watery diarrhea.
96,97
Racecadotril
appears to be well tolerated and may prove to be a useful
adjuvant to standard oral rehydration therapy in infants
and children with acute gastroenteritis, particularly those
with severe diarrheal illnesses, such as those caused by ro-
tavirus. Currently, however, it has not gained widespread
use in the United States.
There are some limited data to suggest that lactobacil-
lus therapy may have some usefulness in acute infectious
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diarrhea in children; however, its effect seems to be fairly
small, and it has failed to gain any widespread acceptance
in the United States.
98,99
Disposition
Children who demonstrate no evidence of dehydration
should be discharged with instructions on how to recog-
nize and prevent dehydration. (See Sample Discharge In-
structions on page 11.) In terms of discharge instructions,
handing out preprinted instruction sheets alone is not
sufcient. Discharge instructions must be designed to be
culturally sensitive and related at basic cognitive levels for
the populations being served. They must also be readily
available in all languages appropriate for the population
of patients seen in the catchment area of the ED. Both inac-
curate information and improper instructions are potential
causes for signicant error and patient harm.
100
Parents of infants with gastroenteritis and dehydra-
tion need, at minimum, both verbal and written instruc-
tions in the use of ORS. Those receiving ORT in the ED,
will not only see ORT, but will also actually participate in
the process. Parents and caregivers vary in their precon-
ceived notions and their ability to understand and retain
information.
101
Patients with severe dehydration should
receive rapid IV rehydration, followed by ORT. Patients
should be reassessed after initial therapy to determine
response and ability to proceed to realimentation and
discharge. The data are unclear regarding specic admis-
sion criteria, either to the pediatric intensive care unit or to
the pediatric ward.
17,30
Although evidence-based admis-
sion criteria have not been fully developed, it is probably
prudent to admit children with any of the following: ill
appearance, atypical presentation, age less than 3 months,
high probability of outpatient failure (eg, high ongoing
losses, social reasons, complications), comorbid condi-
tions, and failure of ED rehydration.
Summary
Gastroenteritis is a common pediatric complaint. Whereas
dehydration has the potential to become a sequela of the
disease process, it does not always occur. Dehydration, by
itself, is not an indication for IV rehydration or hospital-
ization. Oral rehydration is the preferred therapy for mild
and moderate dehydration, and intravenous therapy is
best reserved for refractory moderate or severe dehydra-
tion. A simple approach to the ED management of these
patients, focusing on objective dehydration assessment
and ORS, can greatly streamline care. Optimal nutritional
therapy, with continued feeding during illness, should
be considered of paramount importance in the overall
management of acute gastroenteritis. Involving all care
providers, including parents, nurses, and primary care
physicians, in a coordinated process of rehydration will
result in the greatest likelihood of success in managing
these all too common cases.
Calculating And Replacing Fluid Decits
Ive given a couple of 20 ml/kg boluses of normal
saline. Now what?!?
One area of interest to many emergency physicians is the
management of dehydrated children over many hours. At
times, primarily due to hospital overcrowding, emergency
physicians nd that their pediatric referral hospitals are
unable to accept transfers for prolonged periods, or admit-
ted children spend hours (if not days) in the ED before
being moved up into a hospital bed. Alternatively, it is
becoming more common for children with typical gastro-
enteritis to be admitted to 23-hour observation units and
managed by emergency physicians. In order to help emer-
gency physicians in these circumstances, this brief section
will provide the details of how to calculate and replace
uid decits over 24 hours.
Example
A 2-year-old boy weighing 12 kg has persistent vomiting
and copious watery diarrhea. A trial of oral rehydration
has failed due to unremitting vomiting, even after the
administration of an oral dissolving table of ondansetron.
The boy is moderately dehydrated (See Table 2). The boy
receives a 250 ml (20.8 ml/kg) bolus of normal saline. The
vomiting persists. After deciding to admit the child to the
observation unit, the emergency physician also decides to
calculate the uid decit and replace the uid decit over
24 hours. Remember that 1 L of water weighs 1 kg.
Step 1 - Calculate the total uid decit
If you assume that the child is in the more severe part
of the moderate dehydration category, then this would
suggest that the child is around 8% or 9% dehydrated.
For ease of calculation, selecting 10% as overhydrating
a child by 1% or 2% shouldnt have a negative effect on a
previously healthy child. So, if a 12-kg child is thought to
have lost 10% of their body weight, this would be 1.2 kg. If
this is all water-weight loss (which it is), this would be 1.2
L, or 1,200 ml.
Step 2 - Calculate the hourly rate and front load
Replace the rst half of the uid decit over the rst 8
hours and the second half of the uid decit over the next
16 hours. So, 1,200 ml divided by 2 = 600 ml. Giving 600
ml over 8 hours = 75 ml per hour. For the next 16 hours,
the rate would be 38 ml per hour (600 ml divided by 16 =
37.5).
Step 3 - Pick a uid
Unless the child is an infant in the rst few months of life,
a reasonable choice is D
5
0.45NS, with 20 mEq KCl per
liter. For the younger infants, D
5
0.2NS with 20 mEq KCl
per liter is typically chosen.
TM
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Step 4 - Write the order
D
5
0.45NS with 20 mEq KCl per liter at 75 ml/hour IV
for the rst 8 hours, and then 38 ml/hour for the next 16
hours.
Dosing Ondansetron
Since the use of ondansetron is off-label, emergency
physicians may have difculty nding information about
the dosing of ondansetron for use in the setting of gas-
troenteritis. In the study by Ramsook et al,
88
the authors
administered the oral solution every 8 hours and gave 1.6
mg per dose for children 6 to 12 months of age, 3.2 mg to
children 1 to 3 years of age, and 4 mg to children 4 to 12
years of age. Reeves et al
87
administered 0.15 mg/kg of the
intravenous preparation, up to a maximum of 8 mg in a
single dose. The oral dissolving tablets (ODT) are available
in 4-mg and 8-mg preparations. For this reason, it may be
reasonable to dose ondansetron as follows:
Infants and Toddlers 2 mg (1/2 a 4-mg ODT)
Young School Aged Children 4 mg
Older Children and Adolescents 8 mg.
References
Evidence-based medicine requires a critical appraisal of
the literature based upon study methodology and number
of subjects. Not all references are equally robust. The nd-
ings of a large, prospective, randomized, and blinded trial
should carry more weight than a case report.
To help the reader judge the strength of each refer-
ence, pertinent information about the study, such as the
type of study and the number of patients in the study, will
be included in bold type following the reference, where
available. In addition, the most informative references
cited in the paper, as determined by the authors, will be
noted by an asterisk (*) next to the number of the refer-
ence.
1. Dorland WA. Dorlands Illustrated Medical Dictionary. 30th Edition. Phila-
delphia, Pa: WB Saunders Company; 2003:758.
2.* Finberg L. The early history of the treatment of dehydration. Arch Pedi-
atr Adolesc Med 1998;152:71-73. (Review)
3. No authors listed. Clinical policy: critical issues for the initial evaluation
and management of patients presenting with a chief complaint of
nontraumatic acute abdominal pain. Ann Emerg Med 2000;36(4):406-
415. (Clinical policy)
4. Parashar U, Quiroz ES, Mounts AW, et al. Norwalk-like viruses: public
health consequences and outbreak management. MMWR Recomm Rep
2001 Jun 1:50(RR-9);1-17. (Review)
5.* No authors listed. Practice parameter: the management of acute gastro-
enteritis in young children. American Academy of Pediatrics, Provi-
sional Committee on Quality Improvement, Subcommittee on Acute
Gastroenteritis. Pediatrics 1996 Mar;97(3):424-435. (Practice guideline)
6. World Health Organization. The treatment of diarrhoea. A manual
for physicians and other senior health workers. 1995. Available at:
http://www.who.int/child-adolescent-health/New_Publications/
CHILD_HEALTH/WHO_FCH_CAH_03.7.pdf. Accessed December
30, 2004. (Policy/Guideline)
7. Guerrant RL, Van Gilder T, Steiner TS, et al. Infectious Diseases Society of
America. Practice guidelines for the management of infectious diar-
rhea. Clin Infect Dis 2001 Feb 1;32(3):331-351. (Practice guideline)
8.* Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA
2004;291(22):2746-2754. (Review)
9.* Duggan C, Refat M, Hashem M, et al. How valid are clinical signs of
dehydration in infants? J Pediatr Gastroenterol Nutr 1996;22:56-61.
(Prospective cohort; 135 patients)
10.* Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical
signs in the diagnosis of dehydration in children. Pediatrics 1997;99(5):
e6. (Prospective cohort; 186 patients)
11. Friedman JN, Goldman RD, Srivastava R, et al. Development of a clini-
cal dehydration scale for use in children between 1 and 36 months of
age. J Pediatr 2004;145:201-207. (Prospective cohort; 137 patients)
12. Duggan C, Santosham M, Glass RI. The management of acute diarrhea
in children: oral rehydration, maintenance, and nutritional therapy.
MMWR Recomm Rep 1992;41(RR-16):1-20. (Review)
13.* Shari J, Ghavami F, Nowrouzi Z, et al. Oral versus intravenous rehy-
dration therapy in severe gastroenteritis. Arch Dis Child 1985;60:856-
60. (Prospective, randomized; 470 patients)
14. Issenman RM, Leung AK. Oral and intravenous rehydration of children.
Can Fam Physician 1993;39:2129-2136. (Prospective; 42 patients)
15. Holliday M. The evolution of therapy for dehydration: should decit
therapy still be taught? Pediatrics 1996;98:171-177. (Review)
16. Rahman O, Bennish ML, Alam AN, et al. Rapid intravenous rehydra-
tion by means of a single polyelectrolyte solution with or without
dextrose. J Pediatr 1988;113:654-660. (Prospective, randomized; 67
patients)
17. Sandhu BK; European Society of Pediatric Gastroenterology, Hepatol-
ogy and Nutrition Working Group on Acute Diarrhoea. Practical
guidelines for the management of gastroenteritis in children. J Pediatr
Gastroenterol Nutr 2001;33(Suppl 2):S36-S39). (Review/Guideline)
18. Cohen MB, Mezoff AG, Laney DW Jr, et al. Use of a single solution for
oral rehydration and maintenance therapy of infants with diarrhea
and mild to moderate dehydration. Pediatriacs 1995;95:639-645. (Pro-
spective randomized trial; 60 patients)
19.* Reid SR, Bonadio WA. Outpatient rapid intravenous rehydration to
correct dehydration and resolve vomiting in children with acute gas-
troenteritis. Ann Emerg Med 1996;28(3):318-323. (Prospective cohort;
58 patients)
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21. Holliday MA, Friedman AL, Wassner SJ. Extracellular uid restora-
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74. Duggan C, Lasche J, McCarty M, et al. Oral rehydration solution for
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75. Rosenstein BJ, Baker MD. Pediatric outpatient intravenous rehydration.
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76. Feld LG, Kaskel FJ, Schoeneman MJ. The approach to uid and electro-
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77. De Bruin WJ, Greenwald BM, Notterman DA. Fluid resuscitation in
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92. Pepto-Bismol
Web site. Frequently Asked Questions. Available at:

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Physician CME Questions
65. Ondansetron is a safe and effective antiemetic for
children with gastroenteritis.
a. True
b. False
66. Laboratory testing is indicated for most children
with gastroenteritis.
a. True
b. False
67. Children without clinical evidence of dehydration
do not need any intervention other than parental
education in the ED.
a. True
b. False
68. Antibiotics are indicated for most children with
gastroenteritis.
a. True
b. False
69. The decision on whether or not to use intravenous
rehydration is primarily based on urine specic
gravity.
a. True
b. False
70. Urine output is typically decreased in moderate
dehydration.
a. True
b. False
71. Oral rehydration is indicated for moderately dehy-
drated, vomiting, young children.
a. True
b. False
72. When compared to intravenous therapy, oral rehy-
dration therapy leads to longer ED stays.
a. True
b. False
73. The best uid for intravenous rehydration in young
infants is normal saline.
a. True
b. False
74. Formula diluted with water until it is half strength
should be avoided in treated gastroenteritis.
a. True
b. False
75. A PO challenge is no longer recommended in the
routine ED management of gastroenteritis.
a. True
b. False
76. Nasogastric uid administration is a viable option
for rehydrating children with dehydration due to
gastroenteritis.
a. True
b. False
77. Severe dehydration is a contraindication to oral
rehydration therapy.
a. True
b. False
78. Rectal exams are rarely indicated in the evaluation
of children with gastroenteritis.
a. True
b. False
79. No single physical nding is sufciently accurate to
be used in determining the degree to which a child
is dehydrated.
a. True
b. False
80. Decreased urinary output has a positive predictive
of about 90% for identifying dehydration in chil-
dren with gastroenteritis.
a. True
b. False
TM
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Pediatric Emergency Medicine Practice is not afliated with any pharmaceutical rm or medical device manufacturer.
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Publisher: Robert Williford. Executive Editor: Cheryl Strauss.
Coming in Future Issues:
Unexplained Crying Accidental Poisoning
This test concludes the August through December 2004
semester testing period of Pediatric Emergency Medicine
Practice. The answer form for this semester and a return
envelope have been included with this issue. Please refer
to the instructions printed on the answer form. All paid
subscribers are eligible to take this test.

Monthly online CME testing is available for subscribers at
no extra charge at http://www.empractice.net
Class I
Always acceptable, safe
Denitely useful
Proven in both efcacy and ef-
fectiveness
Level of Evidence:
One or more large prospective stud-
ies are present (with rare exceptions)
High-quality meta-analyses
Study results consistently positive
and compelling
Class II
Safe, acceptable
Probably useful
Level of Evidence:
Generally higher levels of evidence
Non-randomized or retrospective
studies: historic, cohort, or case-
control studies
Less robust RCTs
Results consistently positive
Class III
May be acceptable
Possibly useful
Considered optional or alternative
treatments
Level of Evidence:
Generally lower or intermediate
levels of evidence
Case series, animal studies, consen-

sus panels
Occasionally positive results
Indeterminate
Continuing area of research
No recommendations until further
research
Level of Evidence:
Evidence not available
Higher studies in progress
Results inconsistent, contradictory
Results not compelling
Signicantly modied from: The
Emergency Cardiovascular Care
Committees of the American Heart As-
sociation and representatives from the
resuscitation councils of ILCOR: How
to Develop Evidence-Based Guidelines
for Emergency Cardiac Care: Quality of
Evidence and Classes of Recommenda-
tions; also: Anonymous. Guidelines for
cardiopulmonary resuscitation and
emergency cardiac care. Emergency
Cardiac Care Committee and Subcom-
mittees, American Heart Association.
Part IX. Ensuring effectiveness of com-
munity-wide emergency cardiac care.
JAMA 1992;268(16):2289-2295.
Class Of Evidence Denitions

Each action in the clinical pathways section of Pediatric Emergency Medicine
Practice receives a score based on the following denitions.
Target Audience: This enduring material is designed for emergency medicine
physicians.
Needs Assessment: The need for this educational activity was determined by
a survey of medical staff, including the editorial board of this publication;
review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP;
and evaluation of prior activities for emergency physicians.
Date of Original Release: This issue of Pediatric Emergency Medicine Practice
was published December 31, 2004. This activity is eligible for CME credit
through December 1, 2007. The latest review of this material was December
29, 2004.
Discussion of Investigational Information: As part of the newsletter, faculty
may be presenting investigational information about pharmaceutical
products that is outside Food and Drug Administration approved labeling.
Information presented as part of this activity is intended solely as continuing
medical education and is not intended to promote off-label use of any
pharmaceutical product. Disclosure of Off-Label Usage: In this issue of Pediatric
Emergency Medicine Practice the use of ondansetron, as described for the use
of nausea and vomiting associated with gastroenteritis, is an off-label use.
The labeling for oral preparations of ondansetron, including the ODT Orally
Disintegrating Tablets and the Oral Solution marketed under the brand name
Zofran, includes prevention of nausea and vomiting associated with cancer
chemotherapy, radiotherapy involving whole body or abdominal irradiation,
and postoperative care. The labeling for the intravenous preparation of
ondansetron, marketed under the brand name Zofran, includes prevention
of nausea and vomiting associated with cancer chemotherapy and
postoperative care.
Faculty Disclosure: In compliance with all ACCME Essentials, Standards, and
Guidelines, all faculty for this CME activity were asked to complete a full
disclosure statement. The information received is as follows: Dr. Hostetler, Dr.
Nakanishi, and Dr. Whiteman report no signicant nancial interest or other
relationship with the manufacturer(s) of any commercial product(s) discussed
in this educational presentation.
Accreditation: Mount Sinai School of Medicine is accredited by the
Accreditation Council for Continuing Medical Education to sponsor
continuing medical education for physicians.
Credit Designation: Mount Sinai School of Medicine designates this
educational activity for up to 4 hours of Category 1 credit toward the AMA
Physicians Recognition Award. Each physician should claim only those
hours of credit actually spent in the educational activity. Pediatric Emergency
Medicine Practice is approved by the American College of Emergency
Physicians for 48 hours of ACEP Category 1 credit (per annual subscription).
This continuing medical education activity has been reviewed by the
American Academy of Pediatrics and is acceptable for up to 48 AAP Credits.
These credits can be applied toward the AAP CME/CPD Award available to
Fellows and Candidate Fellows of the American Academy of Pediatrics.
Earning Credit: Two Convenient Methods
Print Subscription Semester Program: Paid subscribers with current and
valid licenses in the United States who read all CME articles during each
Pediatric Emergency Medicine Practice six-month testing period, complete the
post-test and the CME Evaluation Form distributed with the December and
June issues, and return it according to the published instructions are eligible
for up to 4 hours of Category 1 credit toward the AMA Physicians Recogni-
tion Award (PRA) for each issue. You must complete both the post-test and
CME Evaluation Form to receive credit. Results will be kept condential. CME
certicates will be delivered to each participant scoring higher than 70%.
Online Single-Issue Program: Paid subscribers with current and valid
licenses in the United States who read this Pediatric Emergency Medicine
Practice CME article and complete the online post-test and CME Evaluation
Form at EMPractice.net are eligible for up to 4 hours of Category 1 credit
toward the AMA Physicians Recognition Award (PRA). You must complete
both the post-test and CME Evaluation Form to receive credit. Results will be
kept condential. CME certicates may be printed directly from the Web site
to each participant scoring higher than 70%.
Physician CME Information
This CME enduring material is sponsored by Mount Sinai School of Medicine
and has been planned and implemented in accordance with the Essentials
and Standards of the Accreditation Council for Continuing Medical Education.
Credit may be obtained by reading each issue and completing the printed
post-tests administered in December and June or online single-issue post-tests
administered at EBMedPractice.net.
TM
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Gastroenteritis An Evidence Based Approach To Typical Vomiting, Diarrhea, and Dehydration

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Gastroenteritis An Evidence Based Approach To Typical Vomiting, Diarrhea, and Dehydration

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December 2004

, Ross Products Division of

Discharge home with appropriate

Clinical Pathway: Evaluation And Management Of Dehydration

) is a common constituent in many

Despite its widespread use in the treatment of diarrhea,

Web site. Frequently Asked Questions. Available at:

Case series, animal studies, consen-

Class Of Evidence Denitions

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