Gastroenteritis en niños

What is gastroenteritis

Infective gastroenteritis in young children is characterised by the sudden onset of diarrhoea, with or without vomiting. Most cases are due to a viral infection but some are caused by bacterial or protozoal infections. The illness usually resolves without treatment within days but severe diarrhoea can rapidly cause dehydration, which may be life-threatening.¹

Vea también los artículos separados Gastroenteritis en adultos y niños mayores, diarrea del viajero y Diarrea infantil.

How common is gastroenteritis in children? (Epidemiology)

• Gastroenteritis is very common, with many children having more than one episode a year. Many children are treated by parents or other carers without seeking professional advice but approximately 10% of children younger than 5 years of age present with gastroenteritis to healthcare services each year. In a UK study, diarrhoeal illness accounted for 16% of medical presentations to a major paediatric emergency department.¹

• Worldwide, 2 billion cases of acute gastroenteritis and 1.9 million deaths occur each year in children aged under 5 years.²

• La gastroenteritis es causada por una variedad de patógenos virales, bacterianos y parasitarios. Un estudio longitudinal sobre enfermedades infecciosas intestinales en 2009 presentado a médicos generales del Reino Unido mostró que norovirus fue el organismo más común entre los casos que se presentaron al médico de cabecera (dos consultas por cada 1,000 personas-año). Rotavirus y el sapovirus también eran comunes (∼1.5 consultas por cada 1,000 personas-año). Uno de cada siete pacientes con campilobacteriosis consultaron a su médico de cabecera, resultando en aproximadamente una consulta por cada 1,000 personas-año según diagnósticos de cultivo. Otros organismos ocurrieron a tasas de menos de una consulta por cada 1,000 personas-año. Salmonelosis was uncommon (<0.2 consultations per 1,000 person-years), although one in three patients consulted their GP in England,

• Another infective cause of diarrhoea is the Ebola virus. The 2014 outbreak is one of the largest in history and the first in West Africa. Ebola should be considered in any child or young person who has developed diarrhoea, vomiting and weakness and who has arrived from countries where it is endemic or spent time in these countries within the previous 21 days. At the time of writing there are current outbreaks in Sudan and Tanzania (January 2025) and significant outbreaks in Guinea and the Democratic Republic of Congo occurred in February 2021. The latest information about outbreaks can be found on the GOV.UK website.³

• The causative agent for most cases of gastroenteritis is never isolated and the responsible agent never diagnosed.

Factores de riesgo

• Poor hygiene and lack of sanitation increase the incidence - for example, unclean water in low- and middle-income countries , and poor handwashing.

• Compromised immune system.

• Infection may arise from poorly cooked food, from cooked food that has been left too long at room temperature or from uncooked food. Insufficient reheating of food not only fails to kill bacteria but may speed up multiplication and increase the bacterial load ingested. Even if reheating of cooked food kills bacteria, enterotoxins such as staphylococcal exotoxin are not destroyed.

Evaluación¹

• Gastroenteritis should be suspected if there is a sudden change in stool consistency to loose or watery stools and/or a sudden onset of vomiting.

• If gastroenteritis is suspected then ask about recent contact with someone with acute diarrhoea and/or vomiting, exposure to a possible or known source of bowel infection (for example, contaminated water or food) and any recent travel abroad.

• Children are often febrile with any type of infective gastroenteritis.

• Los antibióticos pueden causar Clostridiodes difficile colitis.

• La diarrea con sangre generalmente es causada por Campylobacter spp. (mainly Campylobacter jejuni), donde la diarrea con sangre puede estar presente en hasta el 29% de los casos, y Escherichia coli O157 infections, where bloody diarrhoea may be present in over 70% of cases.⁴ Sin embargo, se debe tener en cuenta la posibilidad de Ébola debido a su propagación fuera de África. El consejo del Departamento de Salud es que el riesgo de contraer Ébola en el Reino Unido es actualmente muy bajo.³ El virus del Ébola generalmente causa fiebre (mayor de 38.6°C), dolor de cabeza severo, dolor muscular, debilidad, diarrea, vómitos, dolor abdominal, falta de apetito y sangrado o moretones inexplicables.

• Siempre considere otros posibles diagnósticos (por ejemplo, otras causas de fiebre) y siempre reevalúe el diagnóstico si el vómito o la diarrea se prolongan. Vea también el artículo separado Ill and feverish Child

• La mayoría de los niños no se deshidratan significativamente, pero always assess for the presence and degree of dehydration. Véase también el artículo separado Deshidratación en niños.

• Siempre realice un examen abdominal (incluyendo cualquier área de sensibilidad, masas, distensión y sonidos intestinales). Registre los hallazgos, incluso si son negativos. Siempre repita un examen exhaustivo si la situación cambia o no se resuelve como se esperaba.

Diagnóstico diferencial

Not all diarrhoea or vomiting is gastroenteritis, especially in children, and other causes must be considered, including the following:

• Otros sitios de infección - por ejemplo, infección del tracto urinario, otitis media, meningitis, neumonía, influenza.

• Diarrea en niños pequeños.

• Estreñimiento con desbordamiento.

• Acute appendicitis (niños mayores) pero otras condiciones pueden presentarse de manera similar, incluyendo adenitis mesentérica y malrotación del intestino.

• Invaginación intestinal produce una heces de 'gelatina de grosella roja'; sin embargo, los padres pueden reportarlo como diarrea con sangre.

• Enfermedad celíaca.

• Los padres a menudo usan las palabras 'vómito en proyectil' de manera inapropiada, pero la edad de los niños con estenosis pilórica es característico y la fuerza del vómito en tales casos es muy impresionante.

• Los bebés pueden estar experimentando regurgitación, expulsión o incluso reflujo gastroesofágico.

• Cetoacidosis diabética.

• Enfermedad de Addison.

Diagnosing gastroenteritis in children (investigations)¹

• Stool samples - for microscopy (include ova, cysts and parasites), culture and sensitivity. Usually samples are not required but should be sent for microbiological investigation in outbreaks - for example, in schools, or if:

  • Septicaemia is suspected.

  • There is blood and/or mucus in the stool.

  • The child is immunocompromised.

  • The child has recently been abroad.

  • The diarrhoea has not improved by day seven.

  • Hay incertidumbre sobre el diagnóstico de gastroenteritis.

• Blood tests - FBC, renal function and electrolytes for patients in the hospital setting.

• Perform a blood culture if giving antibiotic therapy.

• Niños con E. coli La infección por O157 requiere asesoramiento especializado para el monitoreo del síndrome urémico hemolítico.

• Other tests will depend on the individual case and the need to rule out other possible diagnoses.

Management of gastroenteritis in children¹

During remote (for example, telephone) assessment:

• Arrange emergency transfer to secondary care for children with symptoms suggesting shock.

• Arrange face-to-face assessment for children:

  • With symptoms suggesting an alternative serious diagnosis.

  • At high risk of dehydration.

  • With symptoms suggesting clinical dehydration.

  • Whose social circumstances make remote assessment unreliable.

• Consider repeat face-to-face assessment or referral to secondary care for children:

  • With symptoms and/or signs suggesting an alternative serious diagnosis.

  • With red flag symptoms and/or signs.

  • Whose social circumstances require continued involvement of healthcare professionals.

• Provide a safety net for children who will be managed at home, including:

  • Information for parents and carers on how to recognise developing red flag symptoms.

  • Information on how to get immediate help from an appropriate healthcare professional if red flag symptoms develop.

  • Arrangements for follow-up at a specified time and place, if necessary.

Fluid management

In children with gastroenteritis but without clinical dehydration:

• Continue breastfeeding and other milk feeds.

• Encourage fluid intake.

• Discourage the drinking of carbonated drinks, especially in those at increased risk of dehydration. Fruit juices should also be avoided in severe dehydration, but the use of dilute apple juice as an alternative to electrolyte solution in the initial management of mildly dehydrated children has gained some support.⁵

• Offer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration.

In children with clinical dehydration, including hypernatraemic dehydration:

• Use low-osmolarity ORS solution (240-250 mOsm/L).

• Give 50 ml/kg for fluid deficit replacement over four hours as well as maintenance fluid for oral rehydration therapy.

• Give the ORS solution frequently and in small amounts.

Racecadotril is an intestinal antisecretory enkephalinase inhibitor that inhibits the breakdown of endogenous enkephalins. It reduces the hypersecretion of water and electrolytes into the intestine. It is licensed for the complementary symptomatic treatment of acute diarrhoea in infants aged over 3 months, together with oral rehydration and the usual support measures (dietary advice and increased daily fluid intake), when these measures alone are insufficient to control the clinical condition.

Consider supplementation with their usual fluids (including milk feeds or water but not fruit juices or carbonated drinks) if they refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs.

Consider giving the ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently.

Monitor the response to oral rehydration therapy by regular clinical assessment.

When to use fluid management

Use intravenous fluid therapy for clinical dehydration if:

• Shock is suspected or confirmed.

• A child with red flag symptoms or signs (see 'Red flags' box, above) shows clinical evidence of deterioration despite oral rehydration therapy.

• A child persistently vomits the ORS solution, given orally or via a nasogastric tube.

If intravenous fluid therapy is required for rehydration (and the child is not hypernatraemic at presentation):

• Use an isotonic solution, such as 0.9% sodium chloride, or 0.9% sodium chloride with 5% glucose, for both fluid deficit replacement and maintenance.

• For those who required initial rapid intravenous fluid boluses for suspected or confirmed shock, add 100 ml/kg for fluid deficit replacement to maintenance fluid requirements and monitor the clinical response.

• For those who were not shocked at presentation, add 50 ml/kg for fluid deficit replacement to maintenance fluid requirements and monitor the clinical response.

• Measure plasma sodium, potassium, urea, creatinine and glucose at the outset, monitor regularly and alter the fluid composition or rate of administration if necessary.

• Consider providing intravenous potassium supplementation once the plasma potassium level is known.

Nutritional management

During rehydration therapy:

• Continue breastfeeding.

• Do not give solid foods.

• In children without red flag symptoms or signs, do not routinely give oral fluids other than ORS solution; however, consider supplementation with the child's usual fluids (including milk feeds or water but not fruit juices or carbonated drinks) if they consistently refuse ORS solution.

• In children with red flag symptoms or signs, do not give oral fluids other than ORS solution.

After rehydration:

• Give full-strength milk straightaway.

• Re-introduce the child's usual solid food.

• Avoid giving fruit juices and carbonated drinks until the diarrhoea has stopped.

Medicamentos

• Antibiotic therapy should not be used routinely but should be given:

  • For suspected or confirmed septicaemia.

  • With extra-intestinal spread of bacterial infection.

  • When younger than 6 months with salmonella gastroenteritis.

  • In those who are malnourished or immunocompromised with salmonella gastroenteritis.

  • Donde hay C. difficile-associated pseudomembranous enterocolitis, giardiasis, bacillary dysentery, amoebiasis or cholera.

  • For children who have recently been abroad, seek advice from the local health protection team about antibiotic therapy.

• Advice from the local health protection team should also be sought regarding the need for antibiotic treatment or stool testing for microbiological clearance, particularly in a child:

  • Younger than 6 months of age with salmonella infection, or who is malnourished or immunocompromised with salmonella infection.

  • Con producción de toxina Shiga E. coli Infección por (STEC).

• Antiemetics, zinc supplements, and probiotics are not recommended in primary care.⁶

Information and advice for parents and carers

Advise parents, carers and children that:

• Washing hands with soap (liquid if possible) in warm running water and careful drying are the most important factors in preventing the spread of gastroenteritis.

• Hand washing immediately after going to the toilet or changing nappies (parents/carers) and before preparing, serving or eating food is vital.

• Towels used by infected children should not be shared.

• Children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis.

• Children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting.

• Children should not swim in swimming pools for two weeks after the last episode of diarrhoea.

Complications of gastroenteritis in children

• There is an increased risk of dehydration in:¹

  • Children younger than 1 year, particularly those younger than 6 months.

  • Infants who were of low birth weight.

  • Children who have passed more than five diarrhoeal stools in the previous 24 hours.

  • Children who have vomited more than twice in the previous 24 hours.

  • Children who have not been offered or have not been able to tolerate supplementary fluids before presentation.

  • Infants who have stopped breastfeeding during the illness.

  • Children with signs of malnutrition.

• Síndrome urémico hemolítico es una complicación grave.

• Pérdida de lactasa del intestino (causando intolerancia a la lactosa) puede ocurrir, especialmente después de una infección viral. Esto es bastante común, pero generalmente no es un problema. Vea también el artículo separado Intolerancia a la lactosa.

Pronóstico¹

• Usually there is uneventful recovery. Diarrhoea usually lasts for 5-7 days and in most it stops within two weeks. Vomiting usually lasts for 1-2 days and in most it stops within three days.

• The number of deaths from rotavirus in children in England and Wales is probably no more than three or four a year, although it will be much greater in low- and middle-income countries. Worldwide the number was 235,331 in 2019.⁷ Las estadísticas de vigilancia del rotavirus demuestran una disminución constante en la incidencia en el Reino Unido desde la introducción de una vacuna contra el rotavirus. ⁸

• Infants and those with immunological compromise are more likely to have more severe disease and to require admission to hospital for rehydration. In severe cases, hypovolaemic shock and even death can occur.

Prevention of gastroenteritis in children

• Breastfeeding confers some protection against gastroenteritis. One study found that exclusive breastfeeding, compared with not breastfeeding, protects against hospitalisation for diarrhoea and lower respiratory tract infection; this is especially important in low and middle-income countries.⁹

• There is now an effective rotavirus vaccine available.⁷

• La inmunización rutinaria contra el rotavirus se ha añadido al calendario de vacunación del Reino Unido y estuvo disponible desde septiembre de 2013. Rotarix® se administra por vía oral a los 2 y 3 meses de edad.¹⁰