ACUTE

GASTROENTERITIS

IN CHILDREN

Moderated by Dr. Madhuri Engade

By Dr. Akshay Golwalkar

LEARNING OBJECTIVES

Definitions of various types

Common organisms & pathophysiology

Identification of severity of dehydration & prompt management

Rationale behind ORS & its use

Management of Acute diarrhea

Management of Other complications

Preventive measures

DEFINITIONS**

Acute Diarrhea is the passage of loose* or watery stools,

three times or more in a 24 hour period for upto 14 days

In the breastfed infant, the diagnosis is based on a

change in usual stool frequency and consistency as

reported by the mother

Acute Diarrhea must be differentiated from “persistent

diarrhea which is of >14 days duration” and may begin

acutely.

*Takes the shape of the container

**World Health Organization, Global Burden of Disease estimates, 2004 update

MAGNITUDE OF PROBLEM

One in 5* children die of diarrhea or diarrhea

related complications every year in India.

Diarrheal illness is the second leading cause of

child mortality; among children younger than 5

years, it causes 1.5 to 2 million deaths annually.

In developing countries, children experience

between three to six episodes of diarrhea annually.

*Predicting the distribution of under-five deaths by cause in countries without adequate vital registration systemsSaul S Morris,1 Robert E Black2 and Lana Tomaskovic3(International Journal of Epidemiology 2003;32:1041–1051)

MAGNITUDE OF PROBLEM

In India,~380,000 *children die from diarrhea and its complications every year.

9.8 million child deaths each year, 2/3 of which are preventable with low-cost interventions

2 million child deaths from diarrhea, 88% of Diarrhea diseases are preventable by easily available interventions.

Diarrheal diseases are responsible for 18%** of deaths among children under 5 years of age.

Despite easy and affordable treatment, most patients do not access the recommended treatment.

Timely use of ORS-Zinc can save over 133,000 lives by 2015***

*World Health Organization, Global Burden of Disease estimates, 2004 update.**Causes of Child Deaths - March 26, 2005 The Lancet***Role of zinc administration in prevention of childhood diarrhea and pneumonia-a meta analysis,Agarwal I R,Sentz J,Miller M A,Paediatrics 2007,June 119(6)

CAUSES OF CHILD DEATHS IN LOW-INCOME

COUNTRIES: DIARRHEA 18%*

*Causes of death among children under age of five years

UNICEF: Progress for children, 2007

CAUSES AND RISK FACTORS FOR ACUTE

DIARRHOEA

Microbial, host and

environmental

factors interact to

cause Acute

Gastroenteritis

Host Factors

Environmental Factors

Agent(Diarrheal pathogens)

Biological factors increase

susceptibility to Acute

Diarrhoea

Malnutrition is associated with an

increased incidence, severity and

duration of diarrhoea

Age

Failure to get immunised against

rotavirus

Failure of measles vaccination

Selective IgA deficiency

HIV

Behavioral factors increase

the risk of Acute Diarrhoea

Not breastfeeding exclusively for

6 months

Using infant feeding bottles

Not washing hands after

defecation, handling faeces or

before handling food

HOST FACTORS

DIARRHEA & MALNUTRITION

VICIOUS CYCLE

Absorption

AppetiteVoluntary restriction

Immunity

Mucosal integrityCommon

predisposing factors

Losses

Catabolism

ENVIRONMENTAL FACTORS

These include:

Seasonality:The incidence of Acute

Diarrhea has seasonal variation in

many regions

Poor domestic and environmental

sanitation especially unsafe water

Poverty

An improved water supply in a peri-urban setting

COMMON PATHOGENS

More than 20 viruses, bacteria and parasites have been

associated with acute diarrhea

Worldwide, rotavirus is the commonest cause of severe

dehydrating diarrhoea causing 0.6 million deaths annually,

90% of which occur in developing countries

Other viral agents

• Enteric

adenoviruses

• Astrovirus

• Human calciviruses

(norovirus and

sapovirus)

Bacteria

• E. coli (ETEC, EPEC,

EHEC, EAEC, EIEC*)

• Shigella species*

• Vibrio cholerae O1 &

O139

• Salmonella sp*

• Campylobacter jejuni*

• C. difficile

Parasites

• Entamoeba

histolitica*

• Girdia lamblia

• Cryptosporidium

• Trichuris trichuria

• Strongyloides

stercoralis

*causes diarrhea with or without dysentry

Viral

70-85% of AGE in developed countries

Rotavirus: 60% of all pediatric AGE.

Seasonal variation: increased in winter and decreased in summer.

Caliciviruses, astroviruses, and enteric adenoviruses

Presentaion:

Low-grade fever

Vomiting followed by copious watery diarrhea (up to 10-20 bowel movements per day)

Usually non foul smelling

Symptoms persisting for 3-8 days

ETIOLOGY

ETIOLOGY

Bacterial

• Campylobacter, Salmonella, Shigella, E. coli, Yersinia,

Clostridium difficile

Presentation:

• High fevers with Shaking chills

• Foul smelling stools

• Bloody bowel movements (dysentery)

• Abdominal cramping & fecal leukocytes

*ETEC is unlikely to cause dysentery.

Parasitic

Giardia and Cryptosporidium

<10% of cases

Presentation:

Watery stools greenish, frothy stools

Urgency of passing stools after meals

Low-grade fever

differentiated from viral gastroenteritis by a protracted course

or history of travel to endemic areas

ETIOLOGY

PATHOGENESIS

ECF : ICF

Isonatremic vs Hyponatremic vs hypernatremic

dehydration

Electrolyte imbalance

PATHOGENESIS

Hemodynamic Changes

Skin turgor change

PATHOPHYSIOLOGICAL CHANGES*

Type Mechanism Complications

Secretory Acute watery diarrhea

Sodium pump failure

Rapid development of

dehydration

Electrolyte imbalance

Invasive Microbes invade Intestinal mucosal

cells

Blood & mucus in stools

Septicemia

Intestinal perforation

Toxic megacolon

HUS

Osmotic Injury to enterocytes

Brush border damage

Large, frothy, explosive, acidic stools

Dehydration

Hypernatremia

*IAP textbook of pediatrics 5th edition

CLINICAL TYPES

There are 2 main clinical types of Acute Diarrhoea

Each is a reflection of the underlying pathology and altered physiology

Clinical type Description Common

pathogens

Acute watery

diarrhoea

This is the most common. It is of recent onset,

commencing usually within 48 hours of

presentation. It is usually self limiting and most

episodes subside within 7 days. The main

complication is dehydration.

Rotavirus, E. coli,

Vibrio cholera

Acute bloody

diarrhoea

Also referred to as dysentery. This is the

passage of bloody stools. It is as a result of

damage to the intestinal mucosa by an invasive

organism. The complications here are sepsis,

malnutrition and dehydration.

Shigella spp,

Entamoeba

histolytica

ASSESSMENT

Goals :

i. Identify the Type of

diarrhea.

ii. Look for dehydration &

other complications

iii. Assess for malnutrition

iv. Rule out nondiarrheal

illnesses

v. Assess feeding

History :

i. Onset, duration & number of

stools per day.

ii. Blood in stools.

iii. Episodes of vomiting

iv. Presence of fever, cough,

convulsions, recent measles.

v. Type & amounts of fluids

taken.

vi. Drug history.

vii. Immunization history

EXAMINATION

Look at

Condition Well alert Restless, irritable Lethargic or

unconscious; floppy

Eyes Normal Sunken Very sunken & dry

Tears Present Absent Absent

Mouth &

tongue

Moist Dry Very dry

Thirst Drinks normally; not

thirsty

Thirsty; drinks eagerly. “Drinks poorly” or not

able to drink

Feel

Skin pinch Goes back quickly Goes back slowly Goes back very slowly

Decide No signs of

dehydration

If patient has two or more

signs then some

dehydration

If patient has two or

more signs then

severe dehydration

Treat Plan A Weigh patient if

possible Plan B

Weigh patient & use

Plan C urgently

PLAN A

may be treated at home.

Danger signs to be explained to the mother.

i. Continuing diarrhea beyond 3 days.

ii. Increased stool volume/ frequency.

iii. Repeated vomiting.

iv. Increasing thirst.

v. Increased irritability / lethargy

vi. Refusal to feed.

vii. Fever or blood in stools.

Age Amount of

ORS to be

given after

each loose

stool

Amount of ORS

to be provided

at home

<24

months

50 to 100 ml 500ml/day

2 – 10

years

100 to 200ml 1000ml/day

>10

years

Ad lib 2000ml/day

PLAN B

Should be treated in hospital.

75 ml/kg of ORS to be given in first 4 hours if not taken orally then NG tube can be used.

If after 4 hours if child still has some dehydration, again 75ml/kg of ORS to be given. (effective in 95% of the cases)

Ineffective in :i. High stool purge rate

ii. Persistent vomiting

iii. Paralytic ileus

iv. Incorrect preparation of ORS

When signs of dehydration disappears, ORS should be administered in volumes equal to diarrheal losses (max 10ml/kg)

Breast Feeding, semisolid foods continued after deficit replacement.

PLAN C Should be treated in hospital.

Ideal fluid is RL with 5% dextrose, NS or plain RL can be used as alternative. NO 5% dextrose should be used.

Total 100cc/kg of fluid should be given

If severe dehydration is persistent repeat IV fluids

Hydration improved but some dehydration present, shift to plan B

If no dehydration shift to plan A.

Reassess patient every 15 to 30 min for pulses & hydration status.

Age 30ml/kg 70ml/kg

<12 months 1hr 5hrs

>12 months 30 min 2hrs 30 min

MANAGEMENT

Principles :

i. Rehydration & maintaining hydration.

ii. Ensuring adequate feeding.

iii. Oral supplementation of zinc.

iv. Early recognition of danger signs & treatment of

complications.

ORSORAL REHYDRATION

SOLUTION

PHYSIOLOGICAL BASIS FOR ORS

Glucose dependent sodium & water absorption.

Osmolarity lower than blood.

A shift from standard ORS to Low Osmolarity ORS.

LOW OSMOLARITY ORS

COMPOSITION

Ingredient g/LDissociates into mmol/L

Glucose,

anhydrous

13.5 Glucose 75

Sodium Chloride 2.6

Sodium 75

Chloride 65

Potassium

Chloride

1.5 Potassium 20

Trisodium

Citrate,dihydrate

2.9 Citrate 10

TOTAL 20.5 TOTAL 245

ORS-BENEFITS

Replaces water and salts lost during diarrhea.

Reduces dehydration and need for

hospitalization.

Decrease in severity of diarrhea and vomiting.

Decrease in duration of illness.

PREPARATION OF ORS

PREPARATION OF ORS

Acceptable home available fluids

Fluids that contain salt

(preferable)

Salted rice water, salted yoghurt drink,

vegetable or chicken soup with salt.

Fluids that don’t contain salt

(acceptable)

Plain water, unsalted rice water, unsalted soup,

yoghurt drink.

Unsuitable home available

fluids

Commercial carbonated beverages,

commercial fruit juices, sweetened tea.

WHAT IS ZINC?

What are it’s benefits?

WHAT IS ZINC?

Zinc is a micro-nutrient and promotes immunity.

It is an important antioxidant and preserves cellular membrane integrity.

Promotes the growth and development of the nervous system.

Rich sources of Zinc are foods of animal origin, such as meat and fish.

Zinc is also present in nuts, seeds, legumes, and whole grain cereal, but the high phytate content of these foods interferes with its absorption.

WHAT IS ZINC?

Zinc cannot be stored in the body, and zinc excretion through the gastrointestinal tract is increased during episodes of diarrhea.

Young children who have frequent episodes of diarrhea and have diets low in animal products and high in phytate-rich foods are most at risk of Zinc deficiency.

ZINC- BENEFITS

Zinc reduces the fluid and salt loss in stools by improving mucosal permeability.

Accelerated regeneration of mucosa

Increased levels of brush-border enzymes

Enhanced cellular immunity

Higher levels of secretary antibodies

Zinc improves absorption of ORS.

ZINC- BENEFITS

Reduces the severity and duration of illness.

Reduces need for antibiotics.

Reduces the chances of complications.

Full dose for 14 days protects against diarrhea and pneumonia for next 3 months.

Acts as a general tonic-improves appetite and promotes growth.

LONG TERM EFFECTS OF ZINC

Zinc supplementation for 10-14 has longer term effects on childhood illnesses in the 2-3 months after treatment

34% reduction in prevalence of diarrhea

26% reduction in incidence of pneumonia

Zinc Investigators’ Collaborative Group. Pediatrics. 1999.

DOSAGE OF ZINC

Available as ZINC Tablets/ syrup (20mg/5ml).

Given for 14 days for full benefits.

20 milligrams per day for children older than six months.

10 mg per day in those younger than six months.

SYMPTOMATIC TREATMENT

o Ondansetron (0.1 to 0.2 mg/kg/dose)

o For severe symptomatic hypokalemia

o Antisecretory agents like rececadotril

o Probiotics like lactobacillus

o No role of

i. binding agents like pectine, bismuth salts

ii. Antimotility agents like lopiramide.

USE OF ANTIBIOTICS

o Usually antibiotics not needed in most of the cases

o If stool culture shows shigella,

i. Ciprofloxacin(15mg/kg/day) for 5 days

ii. Alternatively ceftriaxone (50 to 100mg/kg/day) for 5 days

o For amoebic dysentery tinidazole or metronidazole can be used.

PREVENTION OF DIARRHEA & MALNUTRITION

o Proper nutrition

o Adequate sanitation

o Vaccination

i. Rota virus

ii. measles