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South Australian Paediatric Clinical Practice Guidelines 

Gastroenteritis in children 
  Department for Health and Wellbeing, Government of South Australia. All rights reserved. 

 

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Note

This guideline provides advice of a general nature.  This state-wide guideline has been prepared to promote and 
facilitate standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based 
on a review of published evidence and expert opinion.  

Information in this state-wide guideline is current at the time of publication.  

SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site 
and does not sponsor, approve or endorse materials on such links. 

Health practitioners in the South Australian public health sector are expected to review specific details of each 
patient and professionally assess the applicability of the relevant guideline to that clinical situation. 

If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must 
document in the patient s medical record, the decision made, by whom, and detailed reasons for the departure 
from the guideline. 

This state-wide guideline does not address all the elements of clinical practice and assumes that the individual 
clinicians are responsible for discussing care with consumers in an environment that is culturally appropriate and 
which enables respectful confidential discussion. This includes: 

  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining 

standards of professional conduct, and  
  Documenting all care in accordance with mandatory and local requirements 

 

Explanation of the aboriginal artwork: 
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. 
The horse shoe shape design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant 
woman. The smaller horse shoe shape in this instance represents the unborn child. The artwork shown before the specific statements within the document 
symbolises a footprint and demonstrates the need to move forward together in unison. 

 

 

 

 

 

 

 
 

 

 

 

 

 

The term  Aboriginal  is used to refer to people who identify as Aboriginal, Torres Strait Islanders, or both Aboriginal and Torres Strait 

Islander.  This is done because the people indigenous to South Australia are Aboriginal and we respect that many Aboriginal people prefer the 

term  Aboriginal .  We also acknowledge and respect that many Aboriginal South Australians prefer to be known by their specific language 

group(s). 

  Cultural safety enhances clinical safety.  

To secure the best health outcomes, clinicians must provide a culturally safe health 
care experience for Aboriginal children, young people and their families. Aboriginal 
children are born into strong kinship structures where roles and responsibilities are 
integral and woven into the social fabric of Aboriginal societies. 

Australian Aboriginal culture is the oldest living culture in the world, yet Aboriginal 
people currently experience the poorest health outcomes when compared to non-
Aboriginal Australians. 
 
It remains a national disgrace that Australia has one of the highest youth suicide 
rates in the world.  The over representation of Aboriginal children and young people 
in out of home care and juvenile detention and justice system is intolerable. 
 
The accumulative effects of forced removal of Aboriginal children, poverty, exposure 
to violence, historical and transgenerational trauma, the ongoing effects of past and 
present systemic racism, culturally unsafe and discriminatory health services are all 
major contributors to the disparities in Aboriginal health outcomes. 
 
Clinicians can secure positive long term health and wellbeing outcomes by making 
well informed clinical decisions based on cultural considerations. 

   

 



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Purpose and Scope of PCPG 

The Gastroenteritis in Children Clinical Guideline is primarily aimed at medical staff working in 
primary care or hospitals. It may however assist the care provided by other clinicians such as 
nurses. The information is current at the time of publication and provides a minimum standard 
for the assessment (including investigations) and management of gastroenteritis; it does not 
replace or remove clinical judgement or the professional care and duty necessary for each 
specific case. 

Flowchart for the management of gastroenteritis in children 
  

Child with Vomiting and Diarrhoea 

Dehydration or Shock present? 

Prevent Dehydration 

If low risk, discharge home with 
management advice and resources 

If high risk*, observe trial of oral 
fluids (6ml/kg/hr) 

Oral Rehydration Solution 

orally or via NG tube 

Give 25ml/kg/hr for 4 hours 

then reassess 

No Dehydration 

20ml/kg IV 0.9% Saline bolus 

Repeat bolus until circulation improved 

If &gt;40ml/kg bolus required consider 
other causes of shock and consult 
PICU 

Shock 

Trial of Oral Rehydration 

Hospital admission may be needed 

if child has large ongoing losses or 

is at high risk* of dehydration. 

Successful 

IV rehydration 

Give 0.9% Saline with 5% glucose at 10ml/kg/hr for 4-5 

hours then reassess. Change to oral or NG rehydration as 

soon as tolerated. 

Seek expert advice 

Oral, NG or IV rehydration over 48 hours with 

frequent Na monitoring 

Aim for slow fall in Na (&lt;0.5mmol/l/hr)  

*Children at high risk of dehydration: 

Infants &lt;6months old 
Underlying chronic condition or immunodeficiency 
Persistent vomiting and/or high-output diarrhoea 
(&gt;8 episodes/day) 
Psycho-Social issues 

Investigations   Not routinely needed  

(details p6) 

Blood tests (EUC, blood gas and, BSL) indicated 
if: 

1. IVT started 
2. Shock or severe dehydration present 
3. Child has underlying condition which 

affects body water homeostasis. 
4. Altered conscious state 
5. HUS or hypernatremia suspected 

Stool culture indicated if: 
bloody stool 
recent travel to high-risk areas 
symptoms &gt;7days 
outbreaks in a school or childcare centre 

Medication 

Single dose of oral Ondansetron may assist oral 

hydration and ease nausea, reducing the need for 

admission. 

Measure EUC, blood gas and BSL 

Na&lt;145 

Na&gt;145 

Unsuccessful / IV 
indicated 



 Gastroenteritis in children 
 

 

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Table of Contents 
 
Flowchart for the management of gastroenteritis in children ............................................ 2 

Important Points ...................................................................................................................... 3 

Abbreviations ........................................................................................................................... 4 

Introduction .............................................................................................................................. 4 

Management summary ............................................................................................................ 4 

Assessment .............................................................................................................................. 5 

Management ............................................................................................................................. 7 

Medication .............................................................................................................................. 10 

References .............................................................................................................................. 12 

Information for parents ......................................................................................................... 12 

Acknowledgements ............................................................................................................... 13 

Appendices ............................................................................................................................. 14 

APPENDIX 1 - Differential diagnoses and warning signs of serious conditions mimicking 

gastroenteritis ...................................................................................................................... 14 

APPENDIX 2 - Oral rehydration solutions ........................................................................... 15 

APPENDIX 3   Fluid requirements and recommendations ................................................. 16 

APPENDIX 4 - Management decisions in gastroenteritis in children .................................. 17 

APPENDIX 5 - Ondansetron dosage guidelines ................................................................. 18 

APPENDIX 6   Management of Hypoglycaemia in the Paediatric Emergency Department

 ............................................................................................................................................. 19 

 

Important Points   

&gt; Gastroenteritis is a common infection of the gastrointestinal tract characterised by 
diarrhoea with or without vomiting and cramping abdominal pain. 

&gt; Most cases of gastroenteritis do not need hospital admission and can be managed using 
oral hydration. Enteral rehydration is preferable to intravenous (IV) hydration. 

&gt; Similar symptoms may occur in other illnesses which should be considered before the 
diagnosis of gastroenteritis is made. 

&gt; Dehydration and electrolyte abnormalities are the commonest complications requiring 
treatment. 

&gt; Electrolyte abnormalities such as hypernatraemia (Na &gt; 145mmol/L) and hypokalaemia 
are potentially dangerous and, if present, close monitoring is critical. 

&gt; Severe dehydration can cause life-threatening shock and should be managed with 
20ml/kg boluses of IV 0.9% sodium chloride. 

&gt; Prior to discharge ensure that the family can access timely medical review should the 
child deteriorate. 

  



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Abbreviations 
mg milligram 

kg kilogram 

hr hour 

ORS Oral rehydration solution 

EUC Electrolytes, Urea and Creatinine 

Na Sodium 

PICU Paediatric Intensive Care Unit 

WHO World Health Organisation 

LMO Local medical officer 

IV Intravenous  

NG Nasogastric 

NGT Nasogastric tube 

BSL Blood sugar level 

IO Intraosseous  

Introduction  

&gt; Gastroenteritis in children is usually caused by a viral infection but may be bacterial or 
parasitic in origin. Outbreaks in the community are seasonal and sporadic 

&gt; A number of potentially serious conditions have symptoms in common with gastroenteritis 
and must be considered before the diagnosis of gastroenteritis is made. Warning signs of 
other diagnoses must be recognised and investigated (See Appendix 1) 

&gt; Most children with gastroenteritis can be managed in the outpatient setting using oral 
fluids and parental education 

&gt; A small number of children become significantly dehydrated, requiring more aggressive 
rehydration under clinical supervision. Untreated or poorly treated dehydration can lead to 
shock and death 

&gt; The risks of treatment include iatrogenic over-hydration and cerebral oedema from the 
use of solutions with inadequate sodium concentrations 

&gt; Children with pre-existing conditions that make them more susceptible to dehydration or 
electrolyte derangement require close monitoring 

Management summary 

Establish diagnosis 

Vomiting is a non-specific symptom-exclude other illnesses before making the diagnosis of 

gastroenteritis (see Appendix 1).  

Assess level of dehydration 

Clinical assessment of dehydration allows an estimate of fluid deficit to be made, which 
guides the amount of fluid replacement to give. Regular reassessment is important, to assess 
adequacy of treatment and allow for ongoing losses. 

Rehydrate or prevent dehydration 

&gt; In mild or no dehydration oral administration of ORS (see Appendix 2) is recommended 
using frequent, small volumes. This can be successful even in the presence of ongoing 
vomiting. Short, frequent breast feeds can be used for breast fed infants. 

&gt; Moderate dehydration can be managed with oral, nasogastric or intravenous rehydration, 
either rapidly or over 24 hours. Choice of method will depend on a number of factors 
discussed below. 

&gt; Infants and children with severe dehydration should be resuscitated with IV crystalloid, 
oxygen and close monitoring. Once circulation has been restored rehydration can occur 
via the IV or enteral route. 

See Appendix 4 for a summary of management decisions 



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Assessment 

Primary care / outpatient history and examination 

History 

&gt; Suspect gastroenteritis if there is a sudden increase in stool frequency and a change in 
stool consistency to loose or watery. 

&gt; Early in the illness the only symptoms may be vomiting and fever. It is important to 
exclude other serious conditions that may present in this way (See appendix 1). 

In taking the history it is important to determine: 

&gt; Frequency and nature of vomiting and diarrhoea 

&gt; Fluid intake 

&gt; Urine output 

&gt; Recent antibiotics 

&gt; The presence of a similar illness in family members or close contacts 

&gt; The presence of bile-stained vomiting (volvulus or obstruction) or blood/mucous in the 
stool (intussusception or dysentery) should be specifically sought. 

Examination 

This should focus on detecting and quantifying the degree of dehydration (Table 1), as well 
as excluding other diseases 

&gt; Dehydration is expressed as a percentage of pre-illness body weight, using the 
assumption that 1kg of body weight approximates 1000ml water. 

&gt; Clinical estimation of dehydration is imprecise, even by experienced clinicians. The 
following signs have been found to be the most useful: (see Table 1). 

&gt; Comparison   of   body   weights, if available, is likely to be the most accurate. 

&gt; Note that in Hypernatraemic dehydration clinical estimation of dehydration may be 
more difficult, Consider hypernatremia in the presence of: 

o Lethargy 

o Irritability 

o A  doughy  skin consistency 

o Ataxia, tremor 

o Hyperreflexia, seizures, reduced conscious level 

Young infants usually present with non-specific symptoms and signs of illness and are 
more prone to developing significant dehydration rapidly. A higher level of surveillance 
should therefore be given to them. 

  



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Table 1: Clinical Estimation of Dehydration in Children with Diarrhoea and Vomiting  

Note: 

&gt; The degree of dehydration is an estimate and should be reassessed frequently while 
treatment is being given. 

&gt; Clusters of signs are more accurate than one or two signs alone. 

Investigations (Flowchart of management of gastroenteritis) 

EUC and blood gas (capillary or venous) measurements are not routinely required and 

do not add to the clinical estimate of degree of dehydration. 

Indications include: 

&gt; any child requiring intravenous therapy (IVT) 

&gt; any child with severe dehydration or profuse or prolonged losses 

&gt; altered conscious state or convulsions 

&gt; clinical suspicion of hypernatraemia -   doughy   skin,  lethargy  and irritability more than 
expected for degree of clinical dehydration 

&gt; suspicion of Haemolytic Uraemic Syndrome (bloody diarrhoea with  pallor, haematuria 
and poor urine output) 

&gt; children with pre-existing medical conditions that predispose to electrolyte abnormalities 
(e.g. cystic fibrosis, renal impairment) 

Blood Sugar Level (point of care) Young children with gastroenteritis are susceptible to 
hypoglycaemia. Measure the BSL in young infants, patients with large ketones in the urine 
and patients who are more lethargic than would be expected for their degree of 
dehydration. If BSL&lt;2.5 mmol/L give 2ml/kg 10% glucose after taking blood for 
hypoglycaemia screen.  (For WCH practitioners see Management of Hypoglycaemia in the 
Paediatric Emergency Department guideline - Appendix 6). Paediatric consultation is 
recommended. 

Complete Blood Examination may sometimes be helpful in the investigation of vomiting and 
fever without diarrhoea, or if the diagnosis is uncertain 

 Mild Moderate dehydration Severe dehydration 

Body 
Weight 

&lt;5% loss 5-9% loss &gt;9% loss 

Clinical 
signs 

None or minimal 
signs: 

? Normal level 
of alertness 

? Warm 

peripheries 

? Normal 

drinking 

? Normal pulse 

and 

respiratory 

rate 

? Thirst 

? Sunken eyes with 

minimal/ no tears 

? Dry mucous 

membranes (not 

accurate in mouth- 

breather) 

? Irritability or 

restlessness 

? Mild tachycardia 

? Increased capillary refill 

time 

Signs from mild-mod. 
Group (more marked) plus: 

? Abnormal drowsiness 
or lethargy 

? Capillary refill &gt;2s 

? Poor peripheral 

perfusion 

? Tachycardia and 

tachypnoea 

?  Acidotic  breathing 

(deep, rapid breaths) 

Pinch test 
for skin 
turgor 

Normal.  

Skin fold retracts 
immediately 

Slow.  

Skin fold visible &lt;2seconds 

Very slow.  

Skin fold visible &gt;2seconds 



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Most cases of gastroenteritis are viral (predominantly rotavirus or norovirus) and few bacterial 
causes benefit from antibiotic treatment. Routine stool examination is therefore not warranted 
when the presentation is typical. 

Microbiological examination of the stool may be useful in the following situations: 

&gt; bloody diarrhoea 

&gt; suspected food poisoning or epidemic 

&gt; prolonged (&gt;7-10 days) diarrhoea 

&gt; recent overseas travel 

&gt; child in residential institution/childcare 

&gt; any diagnostic uncertainty 

Management 

Minimal or no dehydration 

Discharge home with advice about providing adequate amounts of appropriate fluids and 
continuing a normal diet when tolerated. It is not necessary to pass a trial of oral rehydration 
under supervision. 

If ORS is refused dilute, unsweetened apple juice (1:4) can be used, but this is sub-optimal 
for rehydration as it has insufficient sodium. 

Written instructions, including a guide to fluid requirements and factors which should prompt a 
medical review, should be provided upon discharge. Consider referral for a home nursing 
review with Metropolitan Referral Unit: 1300 110 600/ Country Referral Unit: 1800 003 307 

Admission  

Patients should be admitted for 4-6 hours or transferred to an appropriate centre for a 
supervised trial of oral rehydration if: 

&gt; the diagnosis is uncertain 

&gt; they are in a high-risk group 

o infants less than six months of age 

o patients with co-existing medical problems 

o patients living in geographic isolation or with limited access to medical care 

o inability of caring adult to assess deterioration of child due to tiredness/ 
intellectual disability/ mind altered state 

o inability to return due to lack of transport or distance 

o re-presentations during the same illness. 

Moderate dehydration 

These children should either be referred to a centre offering paediatric care or specialist 
advice should be sought. 

Decide on the method of rehydration: 

Oral Rehydration 

Oral rehydration using a standard, hypo-osmolar oral rehydration solution (ORS) should be 
used as a first-line therapy. It is as effective as intravenous fluids in children with severe 
dehydration and is associated with significantly fewer adverse events and a shorter 
hospital stay. 

This may need to be explained to parents or carers, as misunderstandings about the place 
and importance of intravenous therapy are common. 

Fluid can be given in frequent, small amounts using a cup, syringe or spoon. 



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Nasogastric Rehydration 

This should be used when oral rehydration is not possible or fails, and before intravenous 
hydration. Most children stop vomiting after NG fluids are started. If vomiting continues, slow 
the infusion rate and give a dose of ondansetron, if this has not already been given. Check 
that the Nasogastric tube is in the stomach before commencing fluid. 

Nasogastric Infusion Rate and Volume 

Rapid rehydration is suitable for most children, although a slower rate may be preferred for 
infants under 6 months and those with comorbidities.  

Give 25ml/kg/hr ORS for 4 hours either orally or via NGT using a kangaroo pump for 
constant infusion.  Do not add maintenance fluid to this volume. 

Intravenous Rehydration 

Although enteral rehydration is preferred IV therapy is indicated if there is: 

&gt; Ongoing frequent vomiting of enteral fluids 

&gt; Shock 

&gt; Dehydration with altered level of consciousness 

&gt; Worsening dehydration or failure to improve despite oral or NG therapy 

&gt; Severe abdominal distension and ileus. 

IV rehydration rates 

Rapid rehydration, aiming to replace the fluid deficit and complete rehydration in 3-6 hours 

(WHO recommendation), is now the favoured method by many experts, as opposed to slow 
rehydration over 24 hours. Rapid replacement of extracellular fluids improves gastro-intestinal 
and renal perfusion, allows earlier feeding and results in a shorter duration of hospitalization.  

Rapid rehydration is suitable for most patients but should not be used if: 

&gt; The patient is less than 6 months old  

&gt; The patient is severely dehydrated (10%) or shocked  

&gt; The patient has an altered level of consciousness  

&gt; The serum sodium, if known, is &lt;130 or &gt;145 mmol/L.  

Commence IV [0.9% sodium chloride +5% glucose]* at 10ml/kg/hr for 4-5 hours then stop the 
infusion and reassess the patient. *See Appendix 3 for how to make up this solution. Do not 
add maintenance fluid to this volume.  

Although this volume of replacement fluid represents a 5% deficit without the inclusion of 
maintenance fluids or ongoing losses it is usually sufficient to allow improvement.  

During the infusion oral fluids can be offered and, once tolerated, the intravenous fluids 
should be ceased, with rehydration continuing orally. 

Slow Rehydration 

Patients who do not fit the criteria for rapid rehydration should be rehydrated over 24 hours. 
Calculate the sum of: Deficit + maintenance + ongoing losses. 

The fluid deficit is calculated using the formula: 

Fluid deficit in ml = % dehydration x weight in kg x 10 

Replace the Fluid deficit over eight hours or more slowly in consultation with the relevant 
specialist unit. 

See Appendix 3 for maintenance rates and fluid. 

  



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Ongoing losses can be estimated to be 2ml/kg/hour in acute rotavirus. 

ORS either orally or via NGT is preferable but IV [0.9% sodium chloride + 5% glucose] may 
be used if ORS is not tolerated.  

Once the child is tolerating oral fluids IV therapy should be discontinued and rehydration 
completed orally. 

Severe dehydration 

These children should be referred to a centre offering paediatric care for assessment or 
seek specialist advice using the 13STAR (137 827) number. 

&gt; Dehydration with shock constitutes a medical emergency 

&gt; Once the airway and breathing have been assessed and supported as required, with 
high-flow oxygen being given, IV or IO access should be secured 

&gt; Take blood for EUC, venous gas, and Glucose 

&gt; Consider other causes for shock and manage accordingly 

&gt; Give a fluid bolus of 20ml/kg of IV 0.9% sodium chloride solution (do not use solutions 
containing glucose or potassium for boluses). Reassess. If shock persists; repeat the fluid 
bolus. Once the circulation is restored commence rehydration, assuming a fluid deficit of 
10% (see guidance above for slow rehydration). Although this is usually done over 24 
hours it need not be solely by the intravenous route. If there is no improvement seek 
specialist advice 

&gt; The patient should be weighed at least daily. 

Monitoring of Rehydration  

Given that the degree of dehydration, and therefore fluid deficit, is an estimate which is prone 
to inaccuracy, careful review is essential. 

Review the patient at 4-6 hours and once the rehydration volume has been given. Look 
particularly for: 

&gt; Weight change 

&gt; Clinical signs of dehydration 

&gt; Urine output 

&gt; Ongoing losses &amp; 

&gt; Signs of fluid overload, such as puffy face and extremities 

Clinical improvement is expected after 4-6 hours so if this has not occurred careful 
consideration of the accuracy of the diagnosis and consultation with a paediatrician is 
recommended. 

Once the child is rehydrated continue fluids orally (this is preferable) or at maintenance + 
ongoing losses. Potassium may be added to IV solutions once the child has passed urine 

and the serum potassium is known. 

Monitor electrolytes regularly if IV rehydration is being used. 

Discharge considerations 

&gt; If the child is rehydrated and tolerates oral fluids (aim for 6mL/kg/hr) then discharge home 
with advice sheet and LMO follow-up. Consider referral for a home nursing review with 
Metropolitan Referral Unit tel: 1300 110 600/ Country Referral Unit tel: 1800 003 307 

&gt; If living circumstances indicate limited access to medical attention should child s condition 
deteriorate, caution is recommended. Consider further observation and monitoring 

&gt; If the rapid rehydration finishes late at night and the child has improved clinically it is 
reasonable to continue observations and allow the child to sleep, with oral fluids 
commencing in the morning 



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&gt; If dehydration persists the child will need overnight admission and continued rehydration. 
Commence maintenance fluids as ORS [or 0.9% sodium chloride + 5% glucose] (for rates 
see Appendix 3), plus fluid to correct the remaining deficit over the next 4 hours, plus 
2mL/kg/hr to replace ongoing diarrhoeal losses. Reassess again once the deficit volume 
has been given. 

Feeding may commence once oral fluids are tolerated or once the child is hungry. Full-
strength milk/formula may be given to infants. 

Electrolyte Disturbances 

Hypernatraemic dehydration (Na &gt; 145mmol/L) is potentially dangerous and close 
monitoring is critical. 

If Na &gt; 145mmol/L speak to a specialist. Aim to replace deficit slowly (over 48 hours) to 
minimise risk of cerebral oedema. Admission to a unit where the patient can be closely 
monitored is preferable and sodium levels need to be measured 4 hourly. Fluid choice 
(usually 0.9% sodium chloride+/- 5% Glucose) and rate should be in discussion with a 
Paediatric specialist. Nasogastric rehydration using ORS is a safe option in many cases. 

Medication  
Avoid the use of unnecessary medication in gastroenteritis 

Antiemetics 

&gt; Oral Ondansetron in wafer or syrup form is available and has been shown to be safe and 
effective for children with gastroenteritis down to 6 months of age. IV ondansetron is not 

recommended and arrhythmias have been reported with repeat IV dosing. 

&gt; Ondansetron can reduce admission rates and improve the success of oral rehydration. It 
also relieves nausea, which facilitates feeding. Only one dose is required. Ondansetron 
can increase the volume and frequency of diarrhoea. Conditions in appendix 1 should be 
excluded prior to administering Ondansetron. See Appendix 5 for dosage schedule. 

&gt; Metoclopramide (Maxolon ) and Prochlorperazine (Stemetil ) are not recommended as 
there is a risk of extra-pyramidal side-effects and they are often ineffective in children with 
gastroenteritis. 

Anti-diarrhoeal agents and anti-motility agents 

These are not recommended as their efficacy is not proven and there is a risk of adverse 

effects 

Antibiotics 

These are rarely required, even in bacterial gastroenteritis. Choice of antibiotic depends on 
the organism isolated (See Table 2). 

Consultation with a paediatrician or infectious diseases specialist is recommended. 

  



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Table 2: Pathogens and recommended treatments 

Pathogen 
Indication for  

Treatment 
Rationale for 

Treatment 
Recommended Agent 

Shigella 
Culture proven 

dysentry 
Reduces length of 

illness 
Azithromycin for 5 days 

Salmonella 
Infants&lt;3months, 
Immunodeficiency 

Reduce risk of 
bacteremia and 

extra-intestinal focal 
infection 

Ceftriaxone 

50-100mg/kg/day 

Campylobacter 
Culture proven 

dysentry 

Reduce transmission 
in child care centres 

and institutions 

Azithromycin 
10mg/kg/day for 3 days 

or 30mg/kg as single 
dose 

Clostridium Difficile 
Moderate to severe 

cases 
Reduce duration of 

illness 
Metronidazole 

30mg/kg/day for 10 days 

Probiotics and Zinc 

Zinc has not been shown to be of benefit in developed countries, where zinc deficiency is 
rare. 

Probiotics containing Lactobacillus rhamnosus GG or S boulardii may reduce the duration of 
diarrhoea and could be considered as an adjunct to rehydration therapy. 

  



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References 

1. 2017 IDSA Guidelines for the Diagnosis and Management of Infectious Diarrhea. 
Shane et al, Clinical Infectious Diseases  2017;XX(00):1 36  

2. European Society for Pediatric Gastroenterology, Hepatology, and 
Nutrition/European Society for Pediatric Infectious Diseases Evidence-Based 
Guidelines for the Management of Acute Gastroenteritis in Children in Europe: 
Update 2014 , Guarino et al.JPGN [Volume 59, Number 1]:July 2014.  

3. Guidelines for the management? of acute gastroenteritis in children in Europe  

4. Whyte LA, Al-? Araji RA, McLoughlin LM. Arch Dis Child Educ Pract Ed 
2015;100:308 312.  

5. Das et al. The effect of antiemetics in childhood gastroenteritis, BMC Public Health 
2013, 13(Suppl 3):S9 http://www.biomedcentral.com/1471-2458/13/S3/S9  

6. The Diagnostic Accuracy of Clinical Dehydration Scale in Identifying Dehydration in 
Children With Acute Gastroenteritis: A Systematic Review, Falszewska et al, 
Clinical Pediatrics? 2014, Vol. 53(12) 1181 1188?  

7. Freedman SB, Pasichnyk D, Black KJL, Fitzpatrick E, Gouin S, Milne A, et al. 
(2015) Gastroenteritis Therapies in Developed Countries: Systematic Review and 
Meta-Analysis. PLoS ONE 10(6): e0128754. doi:10.1371/journal.pone.0128754  

8. Guidelines on acute Gastroenteritis in children: a critical appraisal of their quality 
and applicability in primary care. van den Berg and Berger BMC Family Practice 
2011, 12:134  

9. The Royal Children s Hospital Melbourne, Clinical practice guidelines: 
Gastroenteritis 

10. Powell CVE, Priestley SJ, Young S, Heini RG. Pediatrics 2011;128:e771. 
Randomized Clinical Trial of Rapid Versus 24-Hour Rehydration for Children With 
Acute Gastroenteritis  

Several Guideline sites were consulted for existing guidelines regarding  diarrhoea , 
 vomiting  and  gastroenteritis  including: 

&gt; National Guideline Clearing House www.guideline.gov  

&gt; National Institute for Health and Clinical Excellence (NICE) 
www.nice.org.uk/guidance/published  

&gt; UK NHS www.evidence.nhs.uk/search?q=guidelines+finder 

&gt; National Institute of Clinical Studies www.nhmrc.gov.au/guidelines/search  

&gt; National Health and Medical Research Council 
www.nhmrc.gov.au/publications/index.htm 

The following guidelines were found to be suitable for adaptation using the AGREE tool  
https://www.agreetrust.org/?s=agree+instrument&amp;submit=Go 

&gt; The Greater Eastern and Southern NSW Child Health Network Clinical Practice 
Guidelines for Gastroenteritis  
www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2014_024.pdf  

&gt; The NICE guideline: Diarrhoea and vomiting caused by gastroenteritis: diagnosis, 
assessment and management in children younger than 5 years 
www.nice.org.uk/guidance/cg84  

Information for parents 

Women s and Children s Health Network: Parenting and Child Health (2017):[Sited 12/17] 
URL: www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&amp;np=303&amp;id=1845  
 

  












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Acknowledgements 

The South Australian Paediatric Clinical Practice Guidelines gratefully acknowledge the 
contribution of clinicians and other stakeholders who participated throughout the guideline 
development process particularly:  

 
Write Group Lead 
Dr Jacquie Schutz 
 

SAPCPG Reference Group Members 

Dr Gavin Wheaton 

Dr Mark Thesinger 

Dr Malcolm Higgins 

Dr Brett Ritchie 

Dr Brian Coppin 

Dr Noha Soliman 

Dr David Thomas 

Dr Keiko Morioka 

Dr Gillian Watterson  

Dr Shirley Sthavan 

Carol La Vanda 

Chelsea Meintjes 

Jayne Wilkie 

Susan Cameron 

Document Ownership &amp; History 

Developed by: SA Child &amp; Adolescent Health Community of Practice 

Contact: Health.PaediatricClinicalGuidelines@sa.gov.au 

Endorsed by: SA Safety and Quality Strategic Governance Committee 

Next review due:  20/09/2023   

ISBN number:  978-1-74243-902-0 

PDS reference:  CG102 

Policy history: Is this a new policy (V1)?  N 

 Does this policy amend or update and existing policy?   Y  

 If so, which version? V2 

 Does this policy replace another policy with a different title?  N 

 If so, which policy (title)? 
 

Approval 

Date 
Version 

Who approved 

New/Revised Version 
Reason for Change 

20/09/18 V3 
SA Health Safety &amp; Quality 
Strategic Governance 
Committee 

Formally reviewed in line with 1-5 
year scheduled timeline for review. 

06/05/14 V2 
SA Health Safety &amp; Quality 
Strategic Governance 
Committee 

Formally reviewed in line with 1-3 
year scheduled timeline for review. 

08/10/13 V1 
SA Health Safety &amp; Quality 
Strategic Governance 
Committee 

Original SA Health Safety &amp; Quality 
Strategic Governance Committee 
approved version. 




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Appendices 

APPENDIX 1 - Differential diagnoses and warning signs of serious conditions 
mimicking gastroenteritis 

Vomiting alone although a common presenting feature in early gastroenteritis is a symptom of 
many other illnesses. 

Beware - very young children or malnourished children are likely to be more severely 
ill or have another diagnosis. 

Some of the differential diagnoses to consider are: 

Surgical &gt; intestinal obstruction (e.g. Volvulus or intussusception) 

&gt; acute appendicitis 

&gt; raised intracranial pressure 

Medical &gt; urinary tract infection 

&gt; FPIES (food protein-induced enterocolitis syndrome) 

&gt; pneumonia 

&gt; meningitis 

&gt; sepsis 

&gt; metabolic (e.g. Diabetes mellitus, urea cycle defects) 

 

WARNING SIGNS that should be recognised and prompt further investigation include: 

? Abdominal distension 

? Localised abdominal tenderness or severe abdominal pain 

? Bile-stained vomiting 

? Fever &gt;39 C 

? Blood or mucus in stool 

? Headache 

? Neck stiffness 

? Bulging fontanelle 

? Non-blanching rash 

? Shortness of breath 

  



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APPENDIX 2 - Oral rehydration solutions 

Fig 1: Oral Rehydration Solution Composition 

Name 
Sodium 
mmol/L 

Potassium 
mmol/L 

Chloride 
mmol/L 

Citrate 
mmol/L 

Glucose 
mmol/L 

Osmolarity 
mOsm/L 

Glucose-electrolyte solutions 

WHO 90 20 80 10 111 311 

Gastrolyte  
powder 

60 20 60 10 90 240 

Hydralyte  45 20 45 30 80 240 

Repalyte / 
ChemmartORS / 
Restore ORS  

60 20 60 10 90 240 

Pedialyte  45 20 35 10 126 246 

Rice-based solutions 

Gastrolyte  R 60 20 50 10 
6g pre- 
cooked 
rice/L 

226 

European Society of Paediatric Gastroenterology, Hepatology and Nutrition 
recommendation 

 
60 20 Not &lt;30 10 74-111 200-250 

Fig 2: Composition of other Oral Fluids 

 
Sodium mmol/L 

Carbohydrate 
mmol/L 

Osmolarity mOsm/L 

Apple Juice 3 690 730 

Soft Drinks ~2 ~700 ~750 

Sports drinks ~20 ~255 ~330 

 

  



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APPENDIX 3   Fluid requirements and recommendations 

Maintenance Fluids 

0-6months: 120-140 ml/kg/day 
 
&gt; 6months: 

Body Weight Fluid requirement ml/day Fluid requirement ml/hr 

First 10kg 100ml/kg 4ml/kg/hr 

Second 10kg + 50ml/kg +2ml/kg/hr 

Subsequent kg + 20ml/kg +1ml/kg/hr 

   

E.g. 25kg child: maintenance rate is 40+20+5 = 65 ml/hr. 

Rehydration Fluids 

&gt; Oral Rehydration Solution 

&gt; IV 0.9% sodium chloride for resuscitation 

&gt; IV 0.9% sodium chloride for IV rehydration (with or without 5% glucose)* 

&gt; IV 0.9% sodium chloride + 5% glucose for maintenance 

N.B. Do not give 4% glucose + 0.18% sodium chloride or 5% glucose 

* Note: 0.9% sodium chloride with 5% glucose is a commercially available solution.  

If unavailable: to make 0.9% sodium chloride with 5% glucose: 

? Remove 100ml of 0.9% sodium chloride from a 1000ml bag of 0.9% sodium chloride and 
add 100ml of 50% glucose 

  



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APPENDIX 4 - Management decisions in gastroenteritis in children 

When to treat at home: 

&gt; Family able to cope 

&gt; Absence of dehydration 

&gt; Vomiting not interfering with fluid intake 

When to consult: 

&gt; Diagnosis in doubt 

&gt; Therapy in doubt 

&gt; Infant under six months of age 

&gt;  Severe dehydration present  

&gt; Electrolyte disturbance present 

&gt; Failure to respond to therapy 

&gt; Pre-existing disease 

o Diabetes 

o Cyanotic heart disease 

o Chronic renal disease 

o Previous bowel resection 

o Malnutrition 

When not to treat at home 

&gt; Moderate Dehydration 

&gt; Diagnosis in doubt 

&gt; Family unable to cope 

&gt; Deterioration 

&gt; Persistent vomiting 

&gt; Profuse diarrhoea 

  



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APPENDIX 5 - Ondansetron dosage guidelines 

Oral Ondansetron is recommended for children over 2 years of age with frequent vomiting 
likely to be due to gastroenteritis to assist in oral rehydration and relief of nausea. 

Some studies have used the medication safely for children from 6 months of age. Dose is 
0.15 mg/kg as mixture 

If wafers are used: 

&gt; 2mg (  wafer) for children 8-15kg 

&gt; 4mg for children 15-30kg 

&gt; 8mg for children &gt;30kg 

Adverse effects are unusual but some studies suggest that its use may prolong the duration 
of diarrhoea. Ondansetron should not be used in children with prolonged QT syndrome 

 

  



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APPENDIX 6   Management of Hypoglycaemia in the Paediatric Emergency 
Department 

 
 


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