• Arrange emergency transfer to secondary care for children with symptoms or signs suggesting shock.
• Consider further assessment in secondary care in the following circumstances:
• Signs consistent with dehydration.
• Changing mental status.
• Visible blood in stool.
• Young age (less than 6 months of age or less than 8 kg body weight).
• History of premature birth, chronic medical conditions (for example severe cardiac or renal disease), or concurrent illness.
• Fever 38°C or more for infants younger than 3 months of age, or more than 39°C for children 3–36 months of age.
• High output diarrhoea including frequent and substantial volumes.
• Persistent vomiting or persistent fever.
• Suboptimal response to oral rehydration therapy.
• No improvement in 48 hours, or overall condition that is worsening.
• Decide whether monitoring the response to rehydration therapy can be carried out safely in the home setting and if so under what level of supervision (for example general practitioner, community children's nurse). If there are concerns about the parent's ability to monitor their child's condition and to provide appropriate care, consider admission to hospital.

Shock

• This recommendation is based on the National Institute for Health and Clinical Excellence (NICE) guideline Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment, and management in children younger than 5 years [NICE, 2009].

Consideration of admission

• This recommendation is based on suggested indications for in-patient care from an expert consensus guideline [World Gastroenterology Organisation, 2008].
• Following a recent outbreak of E coli 0157 at an open farm in the UK, the Health Protection Agency has reminded prescribers that children with bloody diarrhoea should be admitted to hospital, to confirm the diagnosis and prevent the spread of infection to others in the household [Independent Investigation Committe, 2010].
• Taking into account social factors when deciding whether to admit to hospital is discussed in a UK guideline commissioned on behalf of NICE [National Collaborating Centre for Women's and Children's Health, 2009].