Acute gastroenteritis in children – clinical picture and treatment options

Recommendations of an international expert commission for health professionals

Introduction

This publication was developed using the text of the gastroenteritis (GE) handout of the Herdecke Community Hospital Paediatric Department (1) as a general basis. In addition to a systematic literature search (2), a Delphi process with 50 experts in Anthroposophic Medicine was carried out (3). On this basis, an international panel of experts developed the following recommendations. 

Acute gastroenteritis is a common illness in children. It is mostly self-limiting. In an uncomplicated course it usually lasts 3-4 days, in a complicated course 5-7 days (4).

Triggers are usually norovirus, rotavirus or other viruses. Bacterial pathogens such as pathogenic E coli, shigella, salmonella and campylobacter are less common and are not discussed in detail here. Transmission routes are generally food, drinking water and contacts/animals.

Rare triggers such as heavy metals, chemotherapy, toxins, antibiotics or other drugs are not discussed in detail here either. 

Poverty, malnutrition and water-scarce regions are considered global risk factors for a severe course.  

Symptoms of acute gastroenteritis

  • Diarrhoea, nausea and vomiting, abdominal cramps
  • Fever, especially in infants and young children
  • Sucking weakness and exsiccosis (dry mucous membranes, reduced skin turgor)
  • In severe cases apathy, decreased diuresis, circulatory weakness, somnolence

A complicated course requiring rapid clinical intervention is indicated by bloody stools, somnolence, dehydration, electrolyte imbalance, acetonemic vomiting and circulatory disorders.  

Diagnosis

The diagnosis is based on the clinical picture and, if necessary, on the detection of the pathogen.

A medical examination is recommended:

  • in children under 2 years of age, especially in the first year of life, and obligatory in the first 6 months of life,
  • if the child vomits persistently and/or has frequent diarrhoea,
  • in febrile course of gastroenteritis under 2 years of age,
  • when increasing severity of the disease course is reported,
  • if other symptoms are reported that require clarification by rapid differential diagnostic,
  • complicating social circumstances.

Treatment

First of all, it is essential to decide whether the treatment should take place on an outpatient or inpatient basis.

Considerations for the decision on inpatient treatment:

  • Dehydration
  • Rapidly increasing symptoms
  • Reduced general health
  • Abnormal laboratory results
  • Age of the child
  • Willingness to cooperate and wish of parents.  

Conventional standard treatment

Oral, if necessary tube or parenteral rehydration with glucose electrolyte solution.

Conventional drug therapy:

  • Dimenhydrinate: occasionally to rarely
  • Antibiotics: only for special indication
  • Centrally acting antiemetics: seldom to never 

Principles of integrative treatment

  • Introduce and maintain warmth
  • Treatment of pain, vomiting, diarrhoea by external applications and medicines
  • Hydration or rehydration (fluid)
  • Adapted diet

Warmth

Little attention is generally paid to warmth in gastroenteritis. It reflects the general condition of the child, their circulatory stability, their reserves to cope with the illness, the inner physical and emotional cohesion. The function of the child’s warmth organisation is linked to social attachment. Therefore, if there is a lack of support/parental competence/resources, gastroenteritis can take a more critical course. It therefore makes sense to keep the child warm during acute gastroenteritis or to support their heat balance accordingly during a fever (see also https://www.anthromedics.org/PRA-0815-EN ).  

Antipyretic medication also slows down the immunological defence (5).
In oral rehydration, chilled solutions are often given, supposedly because children then tolerate the salty taste better. On the other hand, a cold stimulus can also provoke vomiting. Here a sensitive individualisation of the warmth that the child tolerates best makes sense. For tube, rectal (see below) or parenteral rehydration, solutions at body temperature are shown to be useful. Paying attention to warmth during treatment and instructing parents accordingly promotes the personal relationship with the child. 
 

Remedies in integrative treatment

1. Pharmaceuticals (6, 7, 8)

Infant (in the first year of life )

Baseline treatment:

  • Geum urbanum Rh D3 dil. WELEDA : 3–5 gtt 3–6 x/d,  with diarrhoea
  • Nux vomica D6 pillules : 3 pillules 3 x/d, with nausea and vomiting
  • Chamomilla Cupro culta, Radix Rh D3 dil. WELEDA : 3–5 gtt 3–6x/d, with abdominal cramps   

Toddler (1–5 years)

Baseline treatment:

  • Bolus alba comp. powder WALA : ½ teaspoon in a glass of water, drink in sips throughout the day or by tube, with diarrhoea and abdominal pain.
  • Nux vomica D6 pillules : 5 pillules 3–5 x/d, with nausea and vomiting
  • Colocynthis D6 pillules : 5 pillules as required, with colicky abdominal pain and diarrhoea

Other possibilities:

  • Geum urbanum Rh D3 dil. WELEDA : 5 gtt, 3–6x /d, with diarrhoea, especially if food and fluid intake triggers diarrhoea
  • Veratrum e radice D6 pillules WALA : 5 pillules 3x/d, with vomiting, diarrhoea with circulatory weakness, centralisation

School children and adolescents (6–18 years)

Baseline treatment:

  • Bolus alba comp. powder WALA : ½ teaspoon in a glass of water, drink in sips throughout the day, with abdominal pain and diarrhoea. With vomiting, 1 saltsp of powder dry on the tongue, initially up to quarter hourly.
  • Nux vomica D6 pillules : 10 pillules 3–5 x/d, with vomiting and nausea
  • Colocynthis D6 pillules : 10 pillules as required, with colicky abdominal pain

Other possibilities:

  • Geum urbanum Rh D3 dil. WELEDA : 10 gtt 3–6 x/d, with diarrhoea especially if food and fluid intake causes diarrhoea
  • Gentiana Magen pillules WALA : 3 x 10 pillules, with vomiting and nausea
  • Veratrum e radice D6 pillules WALA : 5–10 pillules 3 x/d,  with additional circulatory weakness 

Composition of the medicinal products listed above: Bolus alba comp. powder: Acorus calamus e rhizoma ferm 33d, Anisi stellati aetheroleum, Arsenicum album dil. D4 aquos., Artemisia abrotanum ex herba ferm 33c, Carbo vegetabilis Trit. D1, Carvi aetheroleum, Chamomilla recutita e planta tota. Gentiana Magen pillules: Artemisia absinthium ex herba, Infusum Ø, Gentiana lutea e radice, Decoctum Ø, Strychnos nux-vomica e semine ferm 35b dil. D4, Taraxacum officinale e planta tota ferm.

2. External applications

In addition to the medicines listed above, the following external applications can be considered:

In the context of acute gastroenteritis, the abdominal pain, malaise and nausea can usually be relieved with the measures listed above. If nausea and vomiting persist, including with ketosis, glucose rehydration (intravenous or rectal) is key. 

3. Fluid and circulation

Rehydration

Rehydration is usually achieved orally. If this is not sufficiently possible, rectal rehydration with an enema can be performed quickly, uncomplicatedly and painlessly in infants and young children. If this is not possible, rehydration is usually carried out intravenously or by stomach tube in an inpatient setting. 

Oral rehydration with:

  • Tea (e.g. fennel or chamomile tea) with (grape) sugar and salt: e.g. 150 ml tea, 1 teaspoon (grape) sugar and 1 pinch of salt 
  • Ready-to-use glucose electrolyte solutions (according to WHO recommendation with 13.5 g/l glucose, 2.6 g/l sodium chloride, 1.5 g/l potassium chloride and 2.9 g/l sodium citrate)

Rectal rehydration (9) with:

Glucose electrolyte solutions at body temperature (see above): Infants 80–100 ml per enema, toddlers 100–200 ml per enema. Appropriate, reusable rubber enema syringes or an irrigator are practical. Not suitable are ready-to-use enemas for laxative measures. For very young children the supine position is suitable, for slightly older children also the left lateral position. The liquid administered is rapidly absorbed. A repeat is initially possible every 2–4 hours.

Intravenous rehydration:

Intravenous rehydration is carried out according to the guidelines with glucose electrolyte solutions that have been warmed up if possible. 

4. Nutrition

General nutritional recommendations (individual approach is advised):

  • Breastfeed infants.
  • For non-breastfed infants, oral rehydration solution if necessary and gradual transition to previously used powdered milk.
  • In case of sucking weakness, temporary tube feeding by stomach tube may be possible.
  • Tea preparations with plants containing bitter substances, e.g. yarrow, are suitable for strengthening the digestion; for a tendency to flatulence, caraway seeds; for diarrhoea blackberry leaves, raspberry leaves and dried blueberries. 
  • Young children: foods to avoid are milk and dairy products.
  • Abstain from highly sweetened or fatty foods.
  • After the symptoms have subsided, eat a restorative diet until the digestion has stabilised. 

5. Emotional and social aspects

What parents and children can learn from the disease:

  • Parents and child can learn to cope with illnesses or illness situations. Gastroenteritis is a disease that makes it easy to show parents that the natural way can be a reliable one in treatment, and that providing rest and care are important contributions they can make themselves. In this way, they experience self-efficacy and healing: even if the child thinks they are seriously ill, they can recover quickly. This develops trust in the child’s powers of recovery.
  • Parents and child can learn a conscious approach to food intake and regulation as well as strengthening the life sense through a mindful approach: hunger – appetite – repletion – feeling of fullness – nausea. Later, they experience joy again in sharing a nutritious meal together.
  • They can learn that sick children need fluids but not necessarily food. If they have no appetite and do not want to eat, they do not need to be forced to do so. This approach applies to most acute diseases and especially to febrile infections.

Extended understanding of disease from the perspective of Anthroposophic Medicine

Infectious diseases of the digestive tract arise from various causes. If a foreign microbial quality enters the digestive system and weakens its integrity as a result of the dysfunction that occurs, acute gastroenteritis develops. There is then a weakness in the digestive tract with regard to breaking down the food substance and the microorganisms absorbed with it from the environment in such a way that its own microbiome is stabilised and the food substance is converted and built up into own living substance. Developing infants and toddlers have a particular susceptibility in this respect. Disorders of the microbiome composition, e.g. as a result of primary caesarean section, antibiosis, lack of breastfeeding or nutritional deficiency, increase susceptibility. Constitutionally, the digestive system’s own activity – and thus, as a rule, the organism’s own microbiome – can be inherently weak. Lack of exercise and a one-sided strain on the nervous and sensory system reinforce such a tendency. In the infant and toddler, an individual immune system, an individual “I-organisation” develops only over time through to an individualised microbiome. In the context of acute gastroenteritis, the organism develops a defensive reaction to prevent the dissolution of boundaries and the penetration of microorganisms, food antigens, etc. into the interior of the organism. From this point of view, the gastroenteritic symptoms as “catarrh of the intestine”, up to and including the activation of the immune system in a fever, primarily represent a reasonable reaction of the organism in the sense of “self-cleansing”. In principle, it is important to support and regulate these therapeutically in such a way that damage to the organism is prevented and, at the same time, the overcoming of the factors that trigger the disease and the alleviation of the symptoms are promoted. The stabilisation of the child’s warmth organisation is a basic prerequisite for this. Antibiotics and other anti-infectives have no place in the treatment of acute uncomplicated gastroenteritis in children (4).

Pain, nausea, vomiting and hyperperistalsis are expressions of an increased intervention of the sentient organisation. In gastroenteritis, the gastrointestinal system can become an “internal wound”. The associated discomfort and vegetative reactions affect the child and result in vital debilitation with loss of fluid and weight, hypotension, etc. Therapeutically, it is important to regulate the sentient organisation in a calming way through appropriate measures. This can usually be achieved within the framework of integrative therapy without analgesics and conventional antiemetics. A decisive role in managing the children is also played by the inner calm and purposeful actions of the adult caregivers and professionals. The aim is to restore the normal, unconscious intervention of the sentient organisation in the digestive process, which as a rule quickly leads to an abatement of the distressing symptoms. In cases of failure to thrive, malnutrition and similar physical disorders, acute gastroenteritis in childhood can be more severe and can quickly become a life-threatening disease in low-resource health systems. The life organisation, which physiologically establishes and differentiates itself in the first seven years of life, is often underdeveloped here in its self-regulatory competence and loses control and regulation of the fluid balance all the more easily.

1 Schwermer M, Fetz K, Vagedes J, Krüger M, Längler A, Ostermann T, Zuzak T. An expert consensus-based guideline for the integrative anthroposophic treatment of acute gastroenteritis in children. Complementary Therapies in Medicine 2019;45:289–294. DOI: https://doi.org/10.1016/j.ctim.2019.04.001. [Crossref]

2 Schwermer M, Längler A, Fetz K, Ostermann T, Zuzak TJ. Management of Acute Gastroenteritis in Children: A Systematic Review of Anthroposophic Therapies. Complementary Medicine Research 2018;25:321-330. DOI: https://doi.org/10.1159/000488317. [Crossref]

3 Schwermer M, Fetz K, Wopker P, Sommer S, Vagedes J, Krüger M, Martin D, Ostermann T, Längler A, Zuzak T. Entwicklung von wissenschaftsbasierten Behandlungsempfehlungen in der anthroposophisch erweiterten Kinderheilkunde. Der Merkurstab 2018;71(3):226-228.

4 Posovszky C, Buderus S, Classen M, Lawrenz B, Keller K-M, Koletzko S. Acute Infectious Gastroenteritis in Infancy and Childhood. Deutsches Ärzteblatt International 2020;117(37):615-624. DOI: https://doi.org/10.3238/arztebl.2020.0615. [Crossref]

5 Szőke H,  Bókkon I, Martin D, Vagedes J, Kiss Á, Kovács Z, Fekete F, Kocsis T, Szijjártó L, Dobrylovsky Á, Mussler O, Kisbenedek A. The Innate Immune System and Fever under Redox Control: A Narrative Review. Current Medicinal Chemistry 2022;29(25):4324-4362. DOI: https://doi.org/10.2174/0929867329666220203122239. [Crossref]

6 Association of Anthropsophic Physicians in Germany (GAÄD) and Medical Section of the School of Spiritual Science (Eds) (2017): Vademecum Anthroposophische Arzneimittel. 4th edition. Munich: GAÄD; 2017.

7 Soldner G, Stellmann HM. Individual Paediatrics. Physical, emotional and spiritual aspects of diagnosis and counselling. Anthroposophic-homoeopathic therapy. 4th edition. Boca Raton, FL: CRC Press; 2014.

8 Schönau E, Naumann EG, Längler A, Beuth J (Eds). Pädiatrie integrativ. Konventionelle und komplementäre Therapie. Munich: Urban & Fischer Verlag; 2004.

9 Szőke H, Szőke J, Martin D, Jan V, Kiss Á, Kovács Z, Dobrylovsky A, Mussler O, Kisbenedek A, Verzár Z, Szőke R. Proctoclysis for rehydration in children – A scoping review and a pilot survey among medical doctors. Complementary Therapies in Medicine 2022;71:102902. DOI: https://doi.org/10.1016/j.ctim.2022.102902. [Crossref]


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