key: cord-0916096-k40ybxyv
authors: Leung, Alexander KC; Hon, Kam Lun
title: Paediatrics: how to manage viral gastroenteritis
date: 2021-03-26
journal: Drugs Context
DOI: 10.7573/dic.2020-11-7
sha: 8fd8111affe82c79067cb16e799de5ae47988983
doc_id: 916096
cord_uid: k40ybxyv

BACKGROUND: Viral gastroenteritis is the most common diarrhoeal disorder seen in general practice and emergency departments. This article aims to provide a narrative updated review on the evaluation and management of viral gastroenteritis in children. METHODS: A PubMed search was performed with Clinical Queries using the key term ‘viral gastroenteritis’. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to the English literature and the paediatric population. RESULTS: Acute viral gastroenteritis is usually self-limiting. However, it can lead to dehydration and electrolyte imbalance if not properly treated. Adequate fluids containing physiological concentrations of glucose and electrolytes should be provided to compensate for gastrointestinal losses and cover maintenance needs. Oral rehydration therapy is as effective as intravenous (IV) fluid therapy for rehydration for children with mild-to-moderate dehydration. Measurements of serum electrolytes, creatinine and glucose are usually not necessary and should only be considered in a subset of children with severe dehydration who require hospitalization and IV therapy. Judicious use of ondansetron can increase the success rate of oral rehydration therapy and minimize the need for IV therapy and hospitalization. CONCLUSION: Acute viral gastroenteritis is associated with substantial morbidity in developed countries and significant mortality in developing countries. Physicians should educate caregivers on proper personal hygiene and handwashing to prevent faecal to oral transmission of the pathogen as well as the importance of rotavirus vaccine in the prevention of rotavirus gastroenteritis. Several norovirus vaccines are currently undergoing clinical trials with promising results. It is hoped that development of an effective norovirus vaccine will further reduce the incidence of viral gastroenteritis.

Viral gastroenteritis is one of the most common causes of morbidity and mortality worldwide, especially in young children in developing countries. [1] [2] [3] [4] [5] Dehydration, which may be associated with electrolyte imbalance and metabolic acidosis, is the most frequent and dangerous complication. 6 

This article provides a narrative updated review on the evaluation, diagnosis and management of viral gastroenteritis in children. A PubMed search was performed in November 2020

with Clinical Queries using the key term 'viral gastroenteritis'. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews published within the past 10 years. The search was restricted to the English literature and children. The information retrieved from the above mentioned search was used in the compilation of the present article.

Worldwide, viruses account for approximately 75-90% of childhood acute gastroenteritis. 7 The most common viral pathogens are norovirus and rotavirus, followed by sapovirus,

The pathophysiology of viral gastroenteritis has been extensively studied with rotavirus. 12 Rotavirus preferentially infects enterocytes in the mature small intestine, leading to the destruction of these cells with impaired capacity for absorption of intestinal fluid and secondary disaccharidase deficiency. 12 The disaccharidase deficiency results in malabsorption of carbohydrates with resulting osmotic diarrhoea. Villous tips receive the most extensive damage with sparing of the crypts. Excessive secretion from the intestine may be secondary to the loss of villous tips and the filling of crypts with rapidly multiplying cells, leading to an imbalance between absorption and secretion and resulting in a net secretion (villous cells are largely absorptive and crypt cells are secretory). 12 In addition, the rotavirus nonstructural protein 4 (NSP4) functions as an enterotoxin, which can lead to hypersecretion of intestinal fluid. 12, 19 

The incubation period is usually 12-72 hours, depending on the causative viral pathogen. 1 The main clinical features of acute viral gastroenteritis include vomiting and diarrhoea, often accompanied by malaise, nausea, abdominal cramps, and fever. 1, 4 It is interesting to note that children with gastroenteritis caused by norovirus or sapovirus may present with isolated vomiting in the absence of diarrhoea. Vomiting is a prominent feature in most cases of rotavirus and norovirus gastroenteritis. 12, 32 Stools are typically loose to watery. Mucous and gross blood are uncommon. In rotavirus gastroenteritis, stools have a distinct odour. 12 The severity of the disease depends on the virulence of the virus, the viral load, the host immune system and comorbidities. 1 Diarrhoea usually lasts less than 7 days, most often improving after 1-3 days, and does not last longer than 14 days. 24 Diarrhoea that lasts longer than 14 days is considered chronic and therefore does not fit into the definition of acute gastroenteritis.

Extraintestinal manifestations, such as respiratory symptoms, may occur with rotavirus infection and headache and myalgia may occur with norovirus infection. 1 

A detailed history and a thorough physical examination are essential to establish the diagnosis of acute gastroenteritis and to exclude other causes of vomiting and/or diarrhoea. 4 In viral gastroenteritis, the incubation period is usually longer than 12 hours, vomiting is prominent, fever is usually low grade, stools usually do not contain blood, and the entire illness usually lasts less than 7 days. However, the differentiation of viral gastroenteritis from bacterial gastroenteritis based on clinical manifestations alone is often difficult. Red-flag symptoms and clinical signs suggestive of acute bacterial gastroenteritis include bilious or bloody vomiting, blood or mucus in stool, excessive irritability, inconsolable crying, high fever, toxic appearance, tachypnoea, cyanosis, poor peripheral perfusion, petechial rash, neck stiffness and altered sensorium. 7

The history should focus on the age of the child and the onset, duration, number of episodes and quantity of the diarrhoea and vomiting as well as on the amount and type of fluid intake. 4, 5, 7 The character of vomiting (e.g. projectile, bilious) and diarrhoea (e.g. presence of blood and mucus) should be noted.

The child's weight before onset of the illness, associated symptoms (e.g. such as fever, abdominal cramps, tenesmus), overall activity level, consumption of contaminated foods or fluid, concurrent illness in family members, exposure to individuals with gastroenteritis, outbreak of gastroenteritis in the community, day-care attendance, medical history (e.g. comorbid disease, immunodeficiency), recent travel to a diarrhoea-endemic area, recent infection, recent use of antibiotics, duration of breastfeeding, and immunization status should be noted. [33] [34] [35] Physical examination

The general condition of the patient, vital signs (temperature, weight, heart rate, respiratory rate, blood pressure), and the severity of dehydration should be assessed. 4, 5, 28 Although loss in body weight is a useful indicator of dehydration, it should always be corroborated by changes in clinical signs because weight measurement is susceptible to many potential errors (such as the use of different scales or unstandardized measurement techniques). 4 Additionally, weight may change significantly depending on whether the child has recently eaten, defecated or voided. 36 A thorough physical examination may help to exclude other causes of vomiting and/or diarrhoea.

The diagnosis of acute gastroenteritis is a clinical one based on the presence of diarrhoea (usually no blood in the stools), often accompanied by vomiting, fever and abdominal pain. Acute viral gastroenteritis refers to acute gastroenteritis caused by a viral pathogen. A presumptive diagnosis of acute viral gastroenteritis can be made in the absence of atypical features such as high fever, bilious vomiting, projective vomiting, gross blood or mucus in stool, persistence of diarrhoea more than 7 days without improvement, recent antibiotic use, severe dehydration, focal abdominal tenderness, marked abdominal distension, and absent bowel sounds. 24

Acute viral gastroenteritis should be differentiated from bacterial causes of acute gastroenteritis (e.g. Salmonella, Shigella, diarrhoeagenic Escherichia coli, Campylobacter jejuni, Clostridium difficile), parasitic causes of acute gastroenteritis (e.g. Giardia intestinalis, Entamoeba histolytica, Cryptosporidium species), food poisoning, antibiotic-associated diarrhoea, acrodermatitis enteropathica, parenteral diarrhoea (e.g. otitis media, urinary tract infection), haemolytic uremic syndrome, malabsorption syndromes (e.g. celiac disease, cystic fibrosis, disaccharidase deficiency) and inflammatory bowel disease (e.g. Crohn's disease, ulcerative colitis). 24 Gross blood or mucus in the stool are unusual in viral gastroenteritis, the presence of which should prompt consideration of other aetiologies.

Measurements of serum electrolytes, creatinine and glucose are usually not necessary in most immune-competent children with typical findings of acute viral gastroenteritis as the results do not change the management. 33, 37 These tests should only be considered in a subset of children with severe dehydration who require hospitalization and intravenous (IV) therapy. 34, 38 Routine aetiologic testing of viral pathogens is typically not necessary but may be employed during outbreaks for epidemiological purposes. Faecal leukocytes and stool cultures should be considered in children with bloody diarrhoea, high fever and severe abdominal cramps as these symptoms are not consistent with uncomplicated viral gastroenteritis. 27, 33 Complete blood cell count and appropriate cultures should be considered when sepsis is suspected.

Dehydration and electrolyte imbalance are the most common complications. If the dehydration is severe enough, it can lead to shock, coma and even death. Children with poor nutrition status are at increased risk. 6 Shock and acute renal failure may result from severe dehydration. 39 Other complications include irritant diaper dermatitis, hypoglycaemia, carbohydrate intolerance, renal tubular damage, renal stone, hyperuricaemia, impaired liver functions and seizures. [40] [41] [42] [43] [44] [45] [46] [47] Gastroenteritis is associated with enormous costs either directly through medical expenses or indirectly through loss of working hours by parents of sick children because of the frequency of the disease. 48, 49 

The goal of treatment is to maintain adequate hydration of the child with gastroenteritis. 50, 51 Adequate fluids should be provided to compensate for gastrointestinal losses and cover maintenance needs. 4 Children weighing <10 kg should receive 60-120 mL of an oral rehydration solution (ORS) per episode of vomiting or diarrhoeal stool whilst those weighing >10 kg should receive 120-240 mL of ORS per episode of vomiting or diarrhoeal stool in addition to their normal daily requirements. 24 The daily fluid maintenance requirement is 100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent kilogram over 20 kg. 4 It has been shown that oral rehydration therapy (ORT) is as effective as, if not better than, IV fluid therapy for rehydration for children with mild-to-moderate dehydration. [52] [53] [54] [55] Compared with IV therapy, ORT is less traumatic, easier to administer, cheaper and can be administered in a variety of settings, including the home. 2, 50, 53, 54 ORSs containing physiological concentrations of glucose and electrolytes should be used. 36, 37, 56 Fluids containing nonphysiological concentrations of glucose and electrolytes, such as carbonated drinks and sweetened fruit juices, are discouraged because these drinks have a high carbohydrate content, very low electrolyte content, and high osmolarity. 6, 36 The administration of such hyperosmolar solutions in large amounts may produce osmotic diarrhoea. On the other hand, plain water should not be used for rehydration as intake of large amounts of plain water may lead to hypoglycaemia and hyponatraemia. 36 For infants who are breastfed, breastfeeding should be continued. 7, 57 It is not necessary to dilute formula or to give lactose-free formula in refeeding non-breastfed infants. 34 Children with mild-to-moderate dehydration can be managed as outpatients with ORT as mainstay of treatment. 2, 7, 58 For children refusing ORS, the key is to give small amounts of ORS at frequent intervals and the volume should be gradually increased until the child can drink as desired. 59 Using a dropper or syringe for very small infants and spoon for older infants and young children can significantly increase the success rate. 7, 36 In a child who refuses to drink, squirting the ORS into the mouth with a syringe may help. 36 Flavoured ORS or ORS popsicles, which may be more acceptable to some children, may also be tried. If children refuse to drink by any of the above measures, nasogastric gavage should be considered before IV hydration is attempted. 60 Nasogastric rehydration provides the physiological benefits of enteral rehydration and avoids the potential complications of IV therapy. 61 For children with severe dehydration, Ringer's lactate or normal saline (20 mL/kg) should be given intravenously over 1 hour. 37, 62, 63 Vital signs should be monitored and the patient reassessed on a regular basis. Boluses of IV fluid may have to be given until pulse, perfusion and mental status return to normal. 34 IV rehydration should also be considered in children with protracted vomiting despite small and frequent feedings and on those undergoing antiemetic treatment or with impaired consciousness, paralytic ileus, and severe acidosis. 34, 37 Hypotonic saline solutions are inappropriate for IV rehydration as administration of large volume of hypotonic solution might lead to dilutional hyponatraemia. 4 ORT should be started when the child's condition is stable. 61 Early refeeding

Early refeeding with an age-appropriate diet has been shown to induce digestive enzymes, promote the recovery of disaccharidases, improve the absorption of nutrients, enhance enterocyte regeneration, decrease the intestinal permeability changes induced by infection, reduce the duration of diarrhoea, improve nutritional outcomes and maintain growth. 64, 65 Foods high in complex carbohydrates (e.g. rice, cereals, bread, wheat and potatoes), fruits and vegetables, and lean meat are better tolerated than foods containing high levels of simple sugar and fats. 57 Foods high in simple sugars should be avoided as they may cause osmotic diarrhoea. 57 With the exception of a subset of children with transient secondary disaccharidase deficiency, most children with acute gastroenteritis are able to tolerate milk and lactose-containing diets.

Judicious use of ondansetron can increase the success rate of ORT and decrease the need for IV therapy and hospitalization. 58, 64, [66] [67] [68] In a meta-analysis of 24 randomized clinical trials comparing the antiemetic effects of ondansetron, dimenhydrinate, domperidone, granisetron, metoclopramide and dexamethasone, ondansetron was the only intervention that revealed an effect on the cessation of vomiting. 69 Compared to placebo, ondansetron increased the proportion of children with cessation of vomiting (OR 0.28; 95% CI 0.16-0.46; high quality of evidence) and decreased the proportion of children with the need for hospitalization (OR 0.93; 95% CI 1.69-6.18; moderate quality of evidence). 69 The recommended IV dose of ondansetron is 0.1-0.5 mg/kg, with a maximum of 4 mg. 4 The recommended oral dose is 2 mg for children weighing 8-15 kg, 4 mg for children weighing >15 kg to ≤30 kg, and 8 mg for children >30 kg. [70] [71] [72] A single dose of oral ondansetron is usually sufficient for the treatment of gastroenteritis-related vomiting. 64, 66, 71 The dose may be repeated if the child vomits within 15 minutes after taking the medication. 7 However, the use of ondansetron is associated with increased risk of diarrhoea. 54, 73 Ondansetron should be avoided in children who are at risk for malignant hyperthermia and those with prolonged QT interval. 57, 74 Other antiemetics such as dimenhydrinate, promethazine, metoclopramide, droperidol, domperidone, prochlorperazine, trimethobenzamide, and dexamethasone are not recommended for use in children either because of lack of efficacy data or because of the significant adverse events associated with their use. 2, 57 Antidiarrhoeal medications Racecadotril, an antisecretory drug, exerts its antidiarrhoeal effects by inhibiting intestinal endopeptidase (also known as enkephalinase), which helps to prevent the breakdown of enkephalins in the gastrointestinal tract and reduce the secretion of electrolytes and water into the gastrointestinal tract without affecting its motility. 75, 76 A 2007 systematic review of three randomized controlled studies (238 children in the treatment group; 233 children in the control group) showed a reduction in the stool output and duration of diarrhoea in treated children with acute gastroenteritis. 76 In a 2018 systematic review and meta-analysis of 24 randomized controlled trials, racecadotril reduced the time to cessation of diarrhoea from 106.2 hours to 78.2 hours (mean reduction 28.0 hours; p<0.0001). 77 More studies are needed before the routine use of racecadotril in the treatment of acute gastroenteritis can be recommended.

Smectite/diosmectite, an adsorbent, has been used for the treatment of diarrhoea in many European countries. 57 gastroenteritis, pending on the results of future well-designed, randomized, placebo-controlled studies. 79 Other antidiarrhoeal medications such as bismuth subsalicylate, attapulgite, kaolin-pectin, diphenoxylate-atropine and loperamide are not recommended either because of lack of efficacy data or the potentially severe adverse events associated with their use. 57 Antimicrobial agents

Generally, antimicrobial agents are not indicated in the treatment of viral gastroenteritis. 57 Nitazoxanide, a broadspectrum antiparasitic and antiviral agent, has been shown to reduce the duration of diarrhoea in children with viral gastroenteritis in several studies. [80] [81] [82] Well-designed, largescale, randomized, double-blind and placebo-controlled studies are necessary to confirm the efficacy of nitazoxanide in order to make formal recommendations regarding their use in the management of viral gastroenteritis in children.

Probiotics such as Lactobacilli reuteri, Lactobacilli rhamnosus GG, Saccharomyces boulardii, Bifidobactium bifidum and Streptococcus thermophilus have been used in the treatment of viral gastroenteritis with varying success. [83] [84] [85] [86] Presumably, probiotics work by improving the barrier function of the intestine, competing for nutrients necessary for the survival of pathogens, competitive blockage of receptor sites, enhancement of the immune response and the production of substances that inactivate viral particles. 86 A 2020 systematic review and meta-analysis showed that, in patients with acute viral gastroenteritis, probiotics can shorten the duration of diarrhoea (mean difference 0.7 day; 95% CI 0.31-1.09 days; n=740, 10 trials) and the duration of hospitalization (mean difference 0.76 day; 95% CI 0.61-0.92 day; n=329, 4 trials). 87 Well-designed, large-scale, randomized, double-blind and placebo-controlled studies are necessary to determine the specific strains and optimal dosages of probiotics that are most helpful.

Zinc supplementation in children with diarrhoea in developing countries leads to reduced duration and severity of diarrhoea. [88] [89] [90] [91] [92] One way of administering zinc during acute diarrhoea is to mix it with ORS. The recommended dose is 20 mg zinc supplements per day for 10-14 days for children with acute diarrhoea (10 mg per day for infants younger than 6 months of age). 93 In a recent study conducted in India and Tanzania, 4500 children aged 6-59 months with acute diarrhoea were randomized to receive 5 mg, 10 mg and 20 mg of zinc sulphate orally for 14 days. 94 The mean number of diarrhoeal stool was 10.7, 10.9 and 10.8 in the 20-mg, 10-mg and 5-mg groups, respectively. Vomiting within 30 minutes after administration of zinc sulphate occurred in 19.3%, 15.6% and 13.7% of children in the 20-mg, 10-mg and 5-mg groups, respectively. The authors concluded that lower doses of zinc have non-inferiority efficacy for the treatment of children with acute diarrhoea and have less vomiting than the standard 20-mg dose. 94 A 2016 Cochrane review found that zinc supplementation may be of benefit in the treatment of diarrhoea in children aged 6 months and older in areas where the prevalence of zinc deficiency or malnutrition is high. 95 The current evidence does not support the routine use of zinc supplementation in children less than 6 months of age, in well-nourished children and children in areas at low risk of zinc deficiency. 95 Given the effectiveness of traditional ORS and the increased cost of zinc supplementation, zinc supplementation is not routinely recommended in developed countries. 4

A preliminary study showed that oral administration of human serum immunoglobulin to hospitalized immunocompromised children with acute diarrhoea reduced stool output by 50%. 96 Well-designed, large-scale, randomized controlled trials are needed to support the routine use of oral human serum immunoglobulin in hospitalized immunocompromised children with acute diarrhoea.

Good personal hygiene is of utmost importance to prevent the spread of pathogens. This includes frequent handwashing with soap, careful diaper disposal, and proper preparation and storage of food and drinking water. Contaminated objects and surfaces should be properly disinfected.

Breastfeeding is recommended for the first year of life with exclusive breastfeeding for the first 6 months. 35 Human milk may reduce the incidence of gastroenteritis and shorten the duration of diarrhoea. 7 Studies have shown that rotavirus vaccination is both efficacious and effective in the prevention of rotavirus-related diarrhoea and rotavirus-related hospitalizations as well as in the reduction of diarrhoea-associated healthcare utilization and costs. [97] [98] [99] [100] The rotavirus vaccination was licensed in 2006; 97 10 years after vaccine licensure, a systematic review of 57 articles from 27 countries showed that emergency department visits and hospitalizations due to rotavirus gastroenteritis were reduced by a median of 67% overall and 60%, 59% and 71% in countries with high, medium and low child mortality, respectively. 97 Universal immunization of infants as early as 6 weeks of age and completion of the schedule by 8 months of age with rotavirus vaccine is recommended and will substantially reduce the incidence of rotavirus gastroenteritis and associated morbidity and mortality. 101 A novel multiepitope subunit vaccine is under development for the prevention of norovirus gastroenteritis and the outlook is promising. 102 The vaccine still requires ISSN: 1740-4398 REVIEW -Paediatrics: how to manage viral gastroenteritis drugsincontext.com

Acute viral gastroenteritis is associated with substantial morbidity in developed countries and has a significant mortality in developing countries. Norovirus has surpassed rotavirus as the most common aetiologic agent in regions where rotavirus vaccination is included in the routine childhood immunization programmes. Physicians should educate caregivers on proper personal hygiene and handwashing to prevent the faecal-oral transmission of the pathogen as well as on the importance of rotavirus vaccine in the prevention of rotavirus gastroenteritis.

validation to ensure its safety and effectiveness against norovirus gastroenteritis. Several norovirus vaccines are currently undergoing clinical trials with promising results. [103] [104] [105] [106] [107] [108] [109] It is hoped that development of an effective norovirus vaccine will further reduce the incidence of viral gastroenteritis.

The prognosis is good. In most cases, acute viral gastroenteritis is self-limited. • Rehydration therapy with fluids containing physiological concentrations of glucose and electrolytes is required to compensate for gastrointestinal losses and cover maintenance needs. • Oral rehydration therapy is as effective as intravenous (IV) fluid therapy for rehydration for children with mild-tomoderate dehydration. • Measurements of serum electrolytes, creatinine and glucose should only be considered in children with severe dehydration who require hospitalization and IV therapy. • Antiemetic medications such as ondansetron can increase the success rate of oral rehydration therapy and minimize the need for IV therapy and hospitalization. • The recommended IV dose of ondansetron is 0.1-0.5 mg/kg, with a maximum of 4 mg. The recommended oral dose of ondansetron is 2 mg for children weighing 8-15 kg, 4 mg for children weighing >15 to ≤30 kg, and 8 mg for children >30 kg. A single dose is usually sufficient but may be repeated if the child vomits within 15 minutes after administration. • Antidiarrhoeal medications are not currently recommended in children.

• The antimicrobial nitazoxanide requires further study to be recommended for use in children.

• Proper personal hygiene and handwashing to prevent faecal to oral transmission of the pathogen is required. • Norovirus is currently the most common cause of viral gastroenteritis in children; an effective norovirus vaccine should further reduce the incidence of viral gastroenteritis.

Viral gastroenteritis

Acute gastroenteritis: from guidelines to real life

Viral gastroenteritis in children

Viral gastroenteritis

Pediatric viral gastroenteritis

Acute gastroenteritis in children

Gastroenteritis in children

Epidemiology and clinical features of rotavirus, adenovirus, and astrovirus infections and coinfections in children with acute gastroenteritis prior to rotavirus vaccine introduction in Meerut, North India

Eight different viral agents in childhood acute gastroenteritis

Viral gastroenteritis

Antiviral activities of resveratrol against rotavirus in vitro and in vivo

Rotavirus gastroenteritis

Occurrence of human astrovirus associated with gastroenteritis among Congolese children in Brazzaville, Republic of Congo

Astrovirus infection and diarrhea in 8 countries

Sapovirus prevalence in children less than five years of age hospitalised for diarrhoeal disease in South Africa

Prevalence, risk factors, and clinical characteristics of rotavirus and adenovirus among Lebanese hospitalized children with acute gastroenteritis

Aichivirus in children with diarrhea in Northern Italy

Etiology of viral gastroenteritis in children <5 years of age in the United States

The role of torovirus in nosocomial viral gastroenteritis at a large tertiary pediatric centre

Email: aleung@ucalgary.ca Provenance: Invited; externally peer reviewed. Submitted

Drugs in Context is published by BioExcel Publishing Ltd. Registered office: Plaza Building, Lee High Road

BioExcel Publishing Limited is registered in England Number 10038393. VAT GB 252 7720 07. For all manuscript and submissions enquiries, contact the Editorial office editorial@drugsincontext.com For all permissions, rights and reprints

REVIEW -Paediatrics: how to manage viral gastroenteritis drugsincontext

Human bocavirus in children with acute gastroenteritis in Albania

Epidemiology of Aichi virus in fecal samples from outpatients with acute gastroenteritis in Northwestern Spain

Saffold virus infection in elderly people with acute gastroenteritis in Sweden

Acute viral gastroenteritis in children in in resource-rich countries: clinical features and diagnosis

The role of human coronavirus infection in pediatric acute gastroenteritis

Control and prevention of viral gastroenteritis

FL: StatPearls Publishing; 2020. 28. Nutrition and Gastroenterology Committee, Canadian Paediatric Society. Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis

Outbreaks of acute gastroenteritis transmitted by person-to-person contact, environmental contamination, and unknown modes of transmission--United States

An acute gastroenteritis outbreak associated with person-to-person transmission in a primary school in Shanghai: first report of a GI.5 norovirus outbreak in China

Detection and quantification of airborne norovirus during outbreaks in healthcare facilities

Considerations in assessing the clinical course and severity of rotavirus gastroenteritis

Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy

Breast is best for babies

Acute diarrhea in children. What to do and what not to do

Practice parameter: the management of acute gastroenteritis in young children

Clinical practice guideline for the treatment of pediatric acute gastroenteritis in the outpatient setting

Postrenal failure due to urinary stones associated with acute viral gastroenteritis: three case reports

Acute kidney injury due to rotavirus gastroenteritis-associated obstructive uric acid stones in a Japanese infant harboring a heterozygous W258X mutation

Hypertransaminasaemia in children with viral gastroenteritis

Uric acid and dehydration in children with gastroenteritis

Acidosis with hyperuricemia and renal tubular damage in viral gastroenteritis

Bilateral hydronephrosis due to obstructive ureteral stone associated with norovirus gastroenteritis

Hypoglycaemia was common in acute gastroenteritis in a prospective hospital-based study, but electrolyte imbalances were not

Rotavirus gastroenteritis-associated urinary tract calculus in an infant

Clinical characteristics of seizures associated with viral gastroenteritis in children

Cost of illness for childhood diarrhea in low-and middle-income countries: a systematic review of evidence and modelled estimates

Cost of gastroenteritis in Australia: a healthcare perspective

Oral rehydration therapy: a review

Travelers' diarrhea: a clinical review

Oral rehydration versus intravenous therapy for treating dehydration due to gastroenteritis in children: a meta-analysis of randomized controlled trials

Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials

Gastroenteritis therapies in developed countries: systematic review and meta-analysis

Oral and intravenous rehydration of children

Efficacy and safety of two oral solutions as maintenance therapy for acute diarrhea. A double-blind, randomized, multicenter trial

Acute viral gastroenteritis in children in in resource-rich countries: management and prevention

Acute gastroenteritis: evidence-based management of pediatric patients

In children with vomiting related to gastroenteritis, are anti-emetic medications an effective adjunct to fluid and electrolyte therapy? Part B: clinical commentary. Paediatr Child Health

Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration

Acute diarrhea: evidence-based management

Rapid intravenous rehydration of children with acute gastroenteritis and dehydration: a systematic review and meta-analysis

Rapid intravenous rehydration therapy in children with acute gastroenteritis: a systematic review

Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis

European Society of Paediatric Gastroenterology, Hepatology and Nutrition Working Group on Acute Diarrhoea. Rationale for early feeding in childhood gastroenteritis

Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting

The role of oral ondansetron in children with vomiting as a result of acute gastritis/ gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial

Systematic review with meta-analysis: ondansetron for vomiting in children with acute gastroenteritis

Antiemetics in children with acute gastroenteritis: a meta-analysis

Antiemetic therapy in pediatric emergency department

Oral ondansetron for gastroenteritis in a pediatric emergency department

REVIEW -Paediatrics: how to manage viral gastroenteritis drugsincontext

Acute infectious pediatric gastroenteritis: beyond oral rehydration therapy

Ondansetron for gastroenteritis in children and adolescents

Effect of intravenous ondansetron on QTc interval in children with gastroenteritis

Is racecadotril effective for acute diarrhea in children? First update

Systematic review: racecadotril in the treatment of acute diarrhea in children

Racecadotril in the treatment of acute diarrhea in children: a systematic, comprehensive review and meta-analysis of randomized controlled trials

Smectite for acute infectious diarrhoea in children: a Cochrane review summary

Smectite for acute infectious diarrhoea in children

Effect of nitazoxanide for treatment of severe rotavirus diarrhoea: randomised double-blind placebo-controlled trial

Nitazoxanide in the treatment of viral gastroenteritis: a randomized double-blind placebocontrolled clinical trial

Nitazoxanide vs. probiotics for the treatment of acute rotavirus diarrhea in children: a randomized, single-blind, controlled trial in Bolivian children

Feeding of Bifidobacterium bifidum and Streptococcus thermophilus to infants in hospital for prevention of diarrhoea and shedding of rotavirus

Hepatology, and Nutrition. Probiotics and prebiotics in pediatrics

Lactobacillus therapy for acute infectious diarrhea in children: a metaanalysis

Probiotics in infectious diarrhea in children: are they indicated?

A systematic review and meta-analysis: the effectiveness of probiotics for viral gastroenteritis

Efficacy of zinc-fortified oral rehydration solution in 6-to 35-month-old children with acute diarrhea

Zinc with oral rehydration therapy reduces stool output and duration of diarrhea in hospitalized children: a randomized controlled trial

Zinc supplementation for acute gastroenteritis

Therapeutic evaluation of zinc and copper supplementation in acute diarrhea in children: double blind randomized trial

Meta-analysis: zinc supplementation for acute gastroenteritis in children

Zinc and diarrhea in children under 5 years: WHO recommendations implemented in Switzerland

Lower-dose zinc for childhood diarrhea -a randomized, multicenter trial

Oral zinc for treating diarrhoea in children

The role of oral administration of immunoglobulin in managing diarrheal illness in immunocompromised children

REVIEW -Paediatrics: how to manage viral gastroenteritis drugsincontext

Global impact of rotavirus vaccination on childhood hospitalizations and mortality from diarrhea

Rotavirus vaccines and health care utilization for diarrhea in US children

A systematic review of the effect of rotavirus vaccination on diarrhea outcomes among children younger than 5 years

Rotavirus vaccine effectiveness in preventing hospitalizations due to gastroenteritis: a descriptive epidemiological study from Germany

Effect of rotavirus vaccine implementation on the prevalence of coinfections with enteric viruses in Norway

Development of multi-epitope subunit vaccine for protection against the norovirus' infections based on computational vaccinology

NOR-201 Study Group. Rapid responses to 2 virus-like particle norovirus vaccine candidate formulations in healthy adults: a randomized controlled trial

Vaccines against norovirus: state of the art trials in children and adults

Norovirus vaccine against experimental human GII.4 virus illness: a challenge study in healthy adults

Broad blockade antibody responses in human volunteers after immunization with a multivalent norovirus VLP candidate vaccine: immunological analyses from a phase I clinical trial

Robust mucosal-homing antibody-secreting B cell responses induced by intramuscular administration of adjuvanted bivalent human norovirus-like particle vaccine

A novel intramuscular bivalent norovirus virus-like particle vaccine candidate -reactogenicity, safety, and immunogenicity in a phase 1 trial in healthy adults

Recent advances in human norovirus research and implications for candidate vaccines

None.