Case Study: Management of Acute Gastroenteritis in 3-Month-Old Twins

Case at a Glance

A mother of 3-month-old male and female twins presented with concerns about sequential-onset diarrhea in both infants. After receiving conflicting advice from an after-hours clinic to supplement with an oral rehydration solution, she sought a second opinion. This case highlights the appropriate management of mild viral gastroenteritis in young, non-dehydrated infants and the potential risks of inappropriate use of oral rehydration solutions.

Patient's Story

The patients are 14-week-old (9.5 weeks adjusted) male and female twins, weighing approximately 13 lbs and 11 lbs, respectively. They are combination-fed with breast milk and standard infant formula (approximately 50/50). A change in their formula brand was made three weeks prior to presentation. The household is non-smoking, and the infants are not on any medications.

The female twin (Patient A) developed diarrhea eight days prior to the consultation. The mother described multiple daily stools that were yellow/green, watery, and contained mucus. Six days after the onset of symptoms in Patient A, the male twin (Patient B) developed diarrhea with similar characteristics.

Despite the diarrhea, the mother reported that both infants remained active, were feeding well, drooling, and producing a normal number of wet diapers, with no overt signs of dehydration.

Initial Assessment

On the fourth day of symptoms for Patient A, the mother took her to an emergency department. The infant was assessed, deemed to be well-hydrated, and the family was advised to continue monitoring at home.

Four days later, with Patient A still experiencing diarrhea and Patient B now symptomatic, the mother took both infants to an after-hours clinic. The examining family physician assessed both infants as clinically hydrated. The physician provided a requisition for stool sample analysis and recommended a change in the feeding plan: cease all formula feeding, breastfeed exclusively, and supplement with a commercial oral rehydration solution (Pedialyte). The mother expressed concern, noting her breast milk supply was insufficient to meet the twins' full nutritional needs.

The Diagnostic Journey

The recommendation to supplement with an oral rehydration solution in non-dehydrated infants of this age was concerning to the mother. She sought a second opinion via an online medical forum, where a pediatrician reviewed the case history.

The pediatrician advised that administering an oral rehydration solution like Pedialyte to a non-dehydrated infant under six months is not recommended and carries a risk of causing electrolyte imbalances and potential renal distress. The sequential onset of illness between the twins was highly suggestive of a viral etiology, making a formula intolerance less likely.

The primary diagnostic indicators were the clinical presentation and the sequential nature of the illness. Stool studies were pending, but the immediate clinical decision-making was based on the infants' hydration status.

Final Diagnosis

Presumptive Acute Viral Gastroenteritis.

Treatment Plan

Based on the pediatric consultation, the following plan was established:

1. Discontinue the previous advice: The recommendation to stop formula and supplement with an oral rehydration solution was to be disregarded.
2. Maintain Nutrition and Hydration: Continue the existing combination feeding regimen of breast milk and formula. The primary goal is to provide adequate calories and fluids through their usual milk source.
3. Vigilant Monitoring: The parents were instructed to closely monitor for any signs of dehydration, including a decrease in the number of wet diapers (fewer than 4-6 in 24 hours), lethargy, sunken fontanelle, dry mouth, or persistent vomiting.
4. Escalation Plan: If any signs of dehydration were to develop, the instruction was to seek immediate care at a pediatric emergency department.

Outcome and Follow-up

The mother confirmed her intention to follow the pediatrician's advice, maintain the current feeding schedule, and monitor the twins closely. An appointment was made with their primary care provider (nurse practitioner) for follow-up and to review the results of the stool studies. The acute gastroenteritis was expected to be self-limiting and resolve within 7-14 days, with supportive care focused on preventing dehydration being the cornerstone of management.