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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, Alfredo (Coordinator)*; Ashkenazi, Shai; Gendrel, Dominique; Lo Vecchio, Andrea*; Shamir, Raanan; Szajewska, Hania§

Journal of Pediatric Gastroenterology & Nutrition: July 2014 - Volume 59 - Issue 1 - p 132–152
doi: 10.1097/MPG.0000000000000375

Objectives: These guidelines update and extend evidence-based indications for the management of children with acute gastroenteritis in Europe.

Methods: The guideline development group formulated questions, identified data, and formulated recommendations. The latter were graded with the Muir Gray system and, in parallel, with the Grading of Recommendations, Assessment, Development and Evaluations system.

Results: Gastroenteritis severity is linked to etiology, and rotavirus is the most severe infectious agent and is frequently associated with dehydration. Dehydration reflects severity and should be monitored by established score systems. Investigations are generally not needed. Oral rehydration with hypoosmolar solution is the major treatment and should start as soon as possible. Breast-feeding should not be interrupted. Regular feeding should 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 may reduce the duration and severity of diarrhea. Effective interventions include administration of specific probiotics such as Lactobacillus GG or Saccharomyces boulardii, diosmectite or racecadotril. Anti-infectious drugs should be given in exceptional cases. Ondansetron is effective against vomiting, but its routine use requires safety clearance given the warning about severe cardiac effects. Hospitalization should generally be reserved for children requiring enteral/parenteral rehydration; most cases may be managed in an outpatients setting. Enteral rehydration is superior to intravenous rehydration. Ultrarapid schemes of intravenous rehydration are not superior to standard schemes and may be associated with higher readmission rates.

Conclusions: Acute gastroenteritis is best managed using a few simple, well-defined medical interventions.

*Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy

Schneider Children's Medical Center, Tel-Aviv University, Tel-Aviv, Israel

University Paris 5 and Necker-Enfants-Malades, Paris, France

§Medical University of Warsaw, Department of Pediatrics, Warsaw, Poland.

Address correspondence and reprint requests to Prof Alfredo Guarino, MD, Department of Translational Medical Science, Section of Pediatrics, University of Naples “Federico II,” Via Pansini 5, 80131 Naples, Italy (e-mail:

Received 17 March, 2014

Accepted 19 March, 2014

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (

The work was supported by an unrestricted grant from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

These guidelines are intended to provide a general indication and not as a 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/accommodation grants to attend meetings from Dicofarm and Malesci Menarini; his institution received grant support from IPSEN France. S.A. has been paid for consultancy on influenza vaccine by GlaxoSmithKline and he received speaker honoraria for lectures on vaccines from Merck-Sharpe-Dohme; his institution received grant support for a shigella vaccine study from the National Institutes of Health and is receiving grant support for a rotavirus vaccine study from Merck-Sharpe-Dohme. A.L.V. has received speaker honoraria from Malesci Menarini. H.S. has participated as a clinical investigator, and/or advisory board member, and/or consultant, and/or speaker for Arla, Biogaia, Biocodex, Danone, Dicofarm, Hipp, Nestle, Nestle Nutrition Institute, Nutricia, Mead Johnson, Merck, and Sequoia. The other authors report no conflicts of interest.

© 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,