CLINICAL GUIDELINES 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 ÃAlfredo Guarino (Coordinator), yShai Ashkenazi, zDominique Gendrel, ÃAndrea Lo Vecchio, yRaanan Shamir, and §Hania Szajewska ABSTRACT Results: Gastroenteritis severity is linked to etiology, and rotavirus is the most Objectives: These guidelines update and extend evidence-based indications severe infectious agent and is frequently associated with dehydration. for the management of children with acute gastroenteritis in Europe. Dehydration reflects severity and should be monitored by established score Methods: The guideline development group formulated questions, systems. Investigations are generally not needed. Oral rehydration with identified data, and formulated recommendations. The latter were graded hypoosmolar solution is the major treatment and should start as soon as with the Muir Gray system and, in parallel, with the Grading of possible. Breast-feeding should not be interrupted. Regular feeding should Recommendations, Assessment, Development and Evaluations system. continue with no dietary changes including milk. Data suggest that in the hospital setting, in non–breast-fed infants and young children, lactose-free feeds can be considered in the management of gastroenteritis. Active therapy Received March 17, 2014; accepted March 19, 2014. may reduce the duration and severity of diarrhea. Effective interventions From the ÃDepartment of Translational Medical Science, Section of include administration of specific probiotics such as Lactobacillus GG or Pediatrics, University of Naples Federico II, Naples, Italy, the Saccharomyces boulardii, diosmectite or racecadotril. Anti-infectious drugs ySchneider Children’s Medical Center, Tel-Aviv University, Tel-Aviv, should be given in exceptional cases. Ondansetron is effective against Israel, the zUniversity Paris 5 and Necker-Enfants-Malades, Paris, vomiting, but its routine use requires safety clearance given the warning § France, and the Medical University of Warsaw, Department of about severe cardiac effects. Hospitalization should generally be reserved for Pediatrics, Warsaw, Poland. children requiring enteral/parenteral rehydration; most cases may be managed Address correspondence and reprint requests to Prof Alfredo Guarino, MD, Department of Translational Medical Science, Section of Pediatrics, in an outpatients setting. Enteral rehydration is superior to intravenous University of Naples ‘‘Federico II,’’ Via Pansini 5, 80131 Naples, Italy rehydration. Ultrarapid schemes of intravenous rehydration are not superior (e-mail: [email protected]). to standard schemes and may be associated with higher readmission rates. Supplemental digital content is available for this article. Direct URL Conclusions: Acute gastroenteritis is best managed using a few simple, citations appear in the printed text, and links to the digital files are well-defined medical interventions. provided in the HTML text of this article on the journal’s Web site (www.jpgn.org). Key Words: acute gastroenteritis, child, children, definition of diarrhea, The work was supported by an unrestricted grant from the European Society guidelines for Pediatric Gastroenterology, Hepatology, and Nutrition. These guidelines are intended to provide a general indication and not as a (JPGN 2014;59: 132–152) definitive basis for diagnosis or treatment in any particular case. A.G. has been paid for consultancy and received speaker honoraria from Malesci Menarini and Milte. He has been paid by Dicofarm for the development of educational presentations; he received travel/accommo- 1. BACKGROUND dation grants to attend meetings from Dicofarm and Malesci Menarini; his institution received grant support from IPSEN France. S.A. has been n 2008, the European Society for Pediatric Gastroenterology, paid for consultancy on influenza vaccine by GlaxoSmithKline and he I Hepatology, and Nutrition (ESPGHAN) and the European received speaker honoraria for lectures on vaccines from Merck-Sharpe- Society of Pediatric Infectious Diseases (ESPID) jointly developed Dohme; his institution received grant support for a shigella vaccine study evidence-based guidelines for the management of acute gastroen- from the National Institutes of Health and is receiving grant support for a teritis (AGE) in children for practitioners at all levels of health rotavirus vaccine study from Merck-Sharpe-Dohme. A.L.V. has received care—primary care physicians, pediatricians, and family physi- speaker honoraria from Malesci Menarini. H.S. has participated as a cians—in Europe (1). The guidelines have had a major impact clinical investigator, and/or advisory board member, and/or consultant, on the management of gastroenteritis as judged by the number of and/or speaker for Arla, Biogaia, Biocodex, Danone, Dicofarm, Hipp, Nestle, Nestle Nutrition Institute, Nutricia, Mead Johnson, Merck, and citations (a total of 160) and by several articles addressing their Sequoia. The other authors report no conflicts of interest. quality and impact (2,3). In addition, an e-learning program was Copyright # 2014 by European Society for Pediatric Gastroenterology, created to implement their application. Hepatology, and Nutrition and North American Society for Pediatric We have now updated the guidelines to take account of the Gastroenterology, Hepatology, and Nutrition evidence accumulated over the last 5 years. The update differs from DOI: 10.1097/MPG.0000000000000375 the original guidelines in that we have rated the quality of evidence 132 JPGN Volume 59, Number 1, July 2014 Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. JPGN Volume 59, Number 1, July 2014 Evidence-Based Guidelines for Management of Gastroenteritis and the weight of recommendations using the Grading of Recom- 4. EPIDEMIOLOGY mendations, Assessment, Development and Evaluations (GRADE) system, which has advantages over other rating systems (4). To reflect the changes that have occurred, we have, however, retained, The incidence of diarrhea ranges from 0.5 to 2 episodes or wherever appropriate, revised, the Muir Gray rating that we used per child per year in children <3 years in Europe. 5 years ago (see ‘‘Methods for Guidelines Update Development’’). Gastroenteritis is a major reason for hospitalization in this Another novelty is a section on the management of children in range of age. hospital. This section addresses crucial issues in the management of Rotavirus is the most frequent agent of AGE; however, diarrhea, namely, enteral and parenteral rehydration, correction norovirus is becoming the leading cause of medically attended of hydroelectrolyte imbalance, complications, and monitoring the AGE in countries with high rotavirus vaccine coverage. course of the disease. The most common bacterial agent is either Campylobac- As in the case of the 2008 AGE guidelines, the tables of ter or Salmonella depending on country. evidence are an integral part of the update. Interested readers can Intestinal infections are a major cause of nosocomial access this material, which was used to produce the recommen- infection. dations, in the online version of the Journal of Pediatric Gastro- enterology and Nutrition (www.jpgn.org). Hospital- and population-based studies showed that 45% to 2. METHODS FOR GUIDELINES UPDATE 75% of children with AGE had a pathogenic enteric organism isolated from their stools. Rotavirus is the most common cause of DEVELOPMENT AGE in children in all European countries. A comprehensive We applied the same approach we had used to develop the literature search in Western Europe showed an incidence of previous guidelines (see the 2008 guidelines for details). In brief, rotavirus gastroenteritis as high as 1.33 to 4.96 cases/100 person the process started with specifying clinical questions that define the year. Hospitalization rates for rotavirus gastroenteritis ranged population for search purposes. from 7% to 81% in various countries. Nosocomial rotavirus These were defined as follows: previously healthy children gastroenteritis accounted for 50% to 70% of all cases of hospi- 5 years of age with clinically diagnosed AGE (diarrhea and/or tal-acquired gastroenteritis, and prolonged hospital stays by 4 to vomiting presumably of infectious origin), in- or outpatients living 12 days. This rate had a major impact on costs (7). Rotavirus in geographic Europe. Children with at-risk conditions, such as serotype predominance appears to change on a seasonal basis chronic disorders or immunodeficiency, are not covered. within each country and may even differ between regions of the Recommendations were formulated and graded according to same country. the Muir Gray (5) and Cook (6) (Table 1), and the GRADE system Two oral live rotavirus vaccines, Rotarix and RotaTeq, (4) (Table 2). See additional information about methods in the licensed in Europe in 2006, were found to have good safety and Online Repository. efficacy profiles in large clinical trials. A significant reduction of AGE-related hospital admissions has been reported in countries 3. DEFINITION with a routine rotavirus vaccination program (8). Although vacci- nation coverage in European countries is still low, changes in AGE Acute gastroenteritis is generally defined as a decrease epidemiology have been reported after the introduction of rotavirus in the consistency