The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians

doi:10.1016/j.jpeds.2009.07.065

The Journal of Pediatrics

Volume 156, Issue 2, February 2010, Pages 226-230

https://doi.org/10.1016/j.jpeds.2009.07.065 Get rights and content

Objective

To evaluate the applicability and efficacy of guidelines for the management of acute gastroenteritis (AGE) as used by pediatricians.

Study design

This was a national, open, randomized, controlled intervention trial. The intervention consisted of a 2-hour course based on the guidelines for management of AGE. Seventy-five randomly selected primary care pediatricians underwent training in AGE management (group A), and 75 pediatricians who were not specifically trained served as controls (group B). Each pediatrician enrolled 10 children age 1-36 months with acute-onset diarrhea. Outcome measures were guidelines applicability, duration of diarrhea, and difference in body weight between the first visit and 5-7 days later.

Results

The baseline features of the children were similar in groups A (n = 617) and B (n = 692). A total of 404 of the 617 children in group A (65.5%) were fully treated according to the guidelines, compared with 20 of the 692 children in group B (3%). Most violations involved administration of unnecessary drugs or diets. The duration of diarrhea was shorter in group A (intention-to-treat: 83.3 vs 90.9 hours; P < .001). Weight gain was marginally, but statistically significantly, higher in the children treated according to the guidelines (per-protocol analysis: +16.5 gr vs -13.5 gr; P < .05).

Conclusions

Guidelines for AGE have good applicability and excellent efficacy. Adjunctive medical interventions are associated with a longer duration of diarrhea.

Section snippets

Methods

This study was designed as an open, prospective, controlled, randomized intervention trial. The intervention consisted of a training course on the management of children with AGE based on the “nine pillars of good treatment of AGE” put forward by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Working Group on Acute Diarrhea.³

The study was performed in collaboration with the Federazione Italiana Medici Pediatri (FIMP), the largest association of primary

Results

Out of the 150 pediatricians enrolled, 149 (74 in group A and 75 in group B) completed the study. In terms of geographic distribution, 52% of the pediatricians were from southern Italy, 26.5% were from northern Italy, and 21.0% were from central Italy, and the distribution was similar in the 2 groups. Pediatrician work experience was similar in the 2 groups (group A: median, 16.6 years; range 2-30 years; group B: median, 17.1; range 1-31 years; P > .05). One pediatrician withdrew from the study.

Discussion

AGE is a frequent problem in early childhood and carries a correspondingly high burden of problems and costs for families and society as a whole.¹⁶ Optimal management of AGE should be a priority for all physicians in practice. This randomized controlled study evaluated the applicability and efficacy of global management of children with AGE.

Our study was based on a simple, inexpensive training course. The guidelines were based on the “option of doing the least”: ORS administration, early

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Ibero-Latin American clinical practice guideline on the management of acute gastroenteritis in children under 5 years: Diagnosis and criteria for medical care
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Ibero-Latin American clinical practice guideline on the management of acute gastroenteritis in children under 5 years: Pharmacological treatment
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Treatment of acute gastroenteritis in private practice: A survey of 641pediatricians
2013, Archives de Pediatrie
Les recommandations sur la prise en charge des gastro-entérites aiguës (GEA) de l’enfant reposent sur la prise systématique de solution de réhydratation orale, une réalimentation précoce avec le régime antérieurement suivi, et une absence de traitement médicamenteux systématique. L’objectif principal de cette étude était d’évaluer les modalités de l’application de ces recommandations par les pédiatres libéraux en cas de GEA légère ou modérée. L’objectif secondaire était d’interroger les pédiatres sur leur pratique de la vaccination contre les rotavirus.
Un questionnaire anonyme a été envoyé par voie électronique en juin 2012, à 1187 pédiatres libéraux.
Les réponses de 641 pédiatres (54 %) ont été analysées. La quasi-totalité préconisait une réalimentation précoce après la prise de solution de réhydratation. Selon l’âge de l’enfant, 16 à 23 % d’entre eux proposaient un lait sans lactose, et 80 % conseillaient un régime anti-diarrhéique après l’âge de 6 mois. Seuls 18 % des médecins déclaraient prescrire jamais ou rarement un médicament. Les médicaments les plus prescrits étaient, par ordre décroissant, le racécadotril, le diosmectite, et les probiotiques. Prescrite parfois ou systématiquement par 90 % des pédiatres, la vaccination anti-rotavirus était en réalité moins pratiquée, puisque seulement 65 % des pédiatres pensaient vacciner plus de la moitié des enfants.
Cette étude montre une adhésion variable des pédiatres libéraux aux recommandations. Comparativement à une étude similaire faite 10 ans plus tôt, un lait sans lactose et des médicaments étaient moins souvent prescrits ; cependant, les modalités de la réalimentation diversifiée, après une prise de solution de réhydratation, étaient souvent éloignées des recommandations. Le vaccin contre les rotavirus, bien que largement prescrit, restait en pratique moins souvent administré.
Acute gastroenteritis (AGE) is a very common reason for pediatric consultations. Various expert committees have issued guidelines for its management, based on systematic use of an oral rehydration solution (ORS), early appropriate nutrition (most recent previous diet), and avoiding routine treatment with medication. The aim of the study was to assess the application of these guidelines by pediatricians in outpatient practice for mild to moderate AGE. A secondary objective was to question pediatricians about their practices for vaccination against rotavirus.
In June 2012, e-mail requests were sent to 1187 pediatricians in private practice, asking them to complete an anonymous questionnaire online at the website of the French Association of Pediatricians in Outpatient Practice.
A total of 641 (54%) responses could be analyzed. Nearly all the pediatricians recommended early resumption of nutrition after administration of ORS. Depending on the child's age, 16 to 23% reported they would recommend resuming feeding with lactose-free milk, and 80% would advise an antidiarrhea diet for children older than 6 months. The drugs prescribed most often were, in decreasing order, racecadotril (acetorphan), diosmectite, and probiotics. Although 90% of the pediatricians prescribed vaccination against rotavirus, 65% estimated that it was performed in more than half of all children.
This study of the management of moderate acute gastroenteritis shows variable adhesion to guidelines by pediatricians treating outpatients. Although ORS, maintenance of breastfeeding, and early nutrition after ORS are now widely applied, the type of nutrition recommended often failed to meet guidelines. Drug prescription is still too frequent. Anti-rotavirus vaccine is prescribed often but is administered much less frequently.
Parental knowledge of guidelines for treatment of paediatric acute gastroenteritis
2013, Public Health
Acute Diarrhea: A Field-randomized Trial on Primary Care Pediatricians
2011, Berman's Pediatric Decision Making: Expert Consult
Acute diarrhea
2011, Berman's Pediatric Decision Making

View all citing articles on Scopus

: Trial registration at anzctr.org.au (identifier: ACTRN12608000145303).

: The authors declare no conflicts of interest.

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Original ArticleThe Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

How to Read a Paper: The Basis of Evidence-Based Medicine

Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice parameter: the management of acute gastroenteritis in young children

Pediatrics

Practical guidelines for the management of gastroenteritis in children

J Pediatr Gastroenterol Nutr

Guidelines for managing acute gastroenteritis based on a systematic review of published research

Arch Dis Child

Guidelines for the approach to outpatient children with acute diarrhea

Acta Paediatr

Guidelines prepared by the ESPGAN Working Group on Acute Diarrhea: recommendations for feeding in childhood gastroenteritis

J Pediatr Gastroenterol Nutr

Management of acute gastroenteritis in Europe and the impact of new recommendations: a multicenter study

J Pediatr Gastroenterol Nutr

Treatment of infants with acute diarrhea: what's recommended and what's practiced

Pediatrics

Barriers to the use of oral rehydration therapy

Pediatrics

Management of acute gastroenteritis in Israel

Pediatrics

Original Article
The Applicability and Efficacy of Guidelines for the Management of Acute Gastroenteritis in Outpatient Children: A Field-Randomized Trial on Primary Care Pediatricians