Gastroenteritis

Mohamed Ahmed Fouad Lecturer of pediatrics

Jazan faculty of medicine

Objectives

bull Review the epidemiology and most common etiologies of diarrhea

bull Discuss specific characteristics of most common viral and bacterial pathogens

bull Recognize the most important aspects of the diagnosis a patient with diarrhea

bull Discuss proper laboratory evaluation and treatment of GE

Defention

bull Acute gastroenteritis (AGE) is a diarrheal disease of acute onset with or without accompanying symptoms and signs such as nausea vomiting fever or abdominal pain

bull Gastroenteritis Acute inflammation of the lining of the stomachintestines

bull 1048708Anorexia nausea vomiting diarrhea abdpain (hallmark is diarrhea)

bull According to the World Health Organization (WHO) AD is the passage of loose(Takes the shape of the container

bull ) or watery stools three times or more in a 24 hour period for upto14 days

bull In the breastfed infant the diagnosis is based on a change in usual stool frequency and consistency as reported by the mother

epidemiology

bull Gastroenteritis ranks with respiratory tract infection as the most common infectious disease syndrome of humans

bull Approximately five billion episodes of diarrhea occur worldwide annually accounting for 15 to 30 percent of all deaths in some countries

bull More than 20 viruses bacteria and parasites have been associated with acute diarhoea

bull Worldwide rotavirus is the commonest cause of severe dehydrating diarrhoea causing 06 million deaths annually 90 of which occur in developing countries

bull The incidence of specific pathogens varies between developed and developing countries

bull In developed countries about 40 of AD cases are due to rotavirus and only 10-20 are of bacterial origin while in developing countries 50-60 are caused by bacteria while 15-25 are due to rotavirus

Other viral agents bull Enteric

adenoviruses bull Astrovirus bull Human

calciviruses (norovirus and sapovirus)

Bacteria

bull E coli (EAEC EPEC EIEC)

bull Shigella spp

bull Staphylococcus spp

bull Salmonella spp

bull Yersinia enterocolitica

bull Campylobacter jejuni

bull Vibrio cholera

Parasites bull Entamoeba

histolitica bull Girdia lamblia bull Cryptosporidium bull Trichuris trichuria bull Strongyloides

stercoralis

Major two forms of Acute diarrhea

bull bull Acute watery diarrhea

bull ‐ Rotavirus worldwide 40 of hospitalized children lt 5 years

bull ‐ Enterotoxigenic Escherichia coli (ETEC) in older children

bull ‐ Vibrio cholerae in endemic areas

bull ‐ Norovirus

bull Invasive diarrhea

bull ‐ Shigella flexneri dysenteriae boydii sonnei

bull ‐ Salmonella enterica

bull ‐ Campylobacter spp Enterohemorrhagic E coli (EHEC)

bull Enteroinvasive E Coli (EIEC)

bull ‐ Protozoan Entamoeba histolytica

What is the causative organism bull Although accurate differentiation between bacterial viral and parasitic

gastroenteritis cannot be made except by stool analysis and stool culture the cause can be suggested in most cases by considering the character of the stool and the associated findings especially fever

bull 1 Bacterial gastroenteritis The possibility of bacterial gastroenteritis is considerable when the fever is above 385degC and the diarrhea is severe or bloody

bull Leucocytosis and elevated CRP level are common laboratory findings

bull 2 Viral gastroenteritis Fever is usually below 385degC and the diarrhea is usually watery and not severe The possibility is higher in the following situations (1) When there is preceding or associated viral respiratory infection (2) When the diarrhea is occurring in winter season

bull 3 Parasitic enteritis Clinical manifestations depend on the causative agent

bull With Giardia lamblia infection the diarrhea is usually watery foul smelling not severe and not associated with fever The possibility becomes greater when diarrhea persists for more than 10 days (giardia is the most common cause of mild persistent watery diarrhea)

bull With amoebiasis diarrhea is commonly bloody but fever is bull absent (important differentiating point from bacterial

gastroenteritis)

bull Accurate diagnosis is made by stool analysis Repeated stool analysis is important for the diagnosis of giardiasis because initial negative analysis does not exclude the possibility

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

Objectives

bull Review the epidemiology and most common etiologies of diarrhea

bull Discuss specific characteristics of most common viral and bacterial pathogens

bull Recognize the most important aspects of the diagnosis a patient with diarrhea

bull Discuss proper laboratory evaluation and treatment of GE

Defention

bull Acute gastroenteritis (AGE) is a diarrheal disease of acute onset with or without accompanying symptoms and signs such as nausea vomiting fever or abdominal pain

bull Gastroenteritis Acute inflammation of the lining of the stomachintestines

bull 1048708Anorexia nausea vomiting diarrhea abdpain (hallmark is diarrhea)

bull According to the World Health Organization (WHO) AD is the passage of loose(Takes the shape of the container

bull ) or watery stools three times or more in a 24 hour period for upto14 days

bull In the breastfed infant the diagnosis is based on a change in usual stool frequency and consistency as reported by the mother

epidemiology

bull Gastroenteritis ranks with respiratory tract infection as the most common infectious disease syndrome of humans

bull Approximately five billion episodes of diarrhea occur worldwide annually accounting for 15 to 30 percent of all deaths in some countries

bull More than 20 viruses bacteria and parasites have been associated with acute diarhoea

bull Worldwide rotavirus is the commonest cause of severe dehydrating diarrhoea causing 06 million deaths annually 90 of which occur in developing countries

bull The incidence of specific pathogens varies between developed and developing countries

bull In developed countries about 40 of AD cases are due to rotavirus and only 10-20 are of bacterial origin while in developing countries 50-60 are caused by bacteria while 15-25 are due to rotavirus

Other viral agents bull Enteric

adenoviruses bull Astrovirus bull Human

calciviruses (norovirus and sapovirus)

Bacteria

bull E coli (EAEC EPEC EIEC)

bull Shigella spp

bull Staphylococcus spp

bull Salmonella spp

bull Yersinia enterocolitica

bull Campylobacter jejuni

bull Vibrio cholera

Parasites bull Entamoeba

histolitica bull Girdia lamblia bull Cryptosporidium bull Trichuris trichuria bull Strongyloides

stercoralis

Major two forms of Acute diarrhea

bull bull Acute watery diarrhea

bull ‐ Rotavirus worldwide 40 of hospitalized children lt 5 years

bull ‐ Enterotoxigenic Escherichia coli (ETEC) in older children

bull ‐ Vibrio cholerae in endemic areas

bull ‐ Norovirus

bull Invasive diarrhea

bull ‐ Shigella flexneri dysenteriae boydii sonnei

bull ‐ Salmonella enterica

bull ‐ Campylobacter spp Enterohemorrhagic E coli (EHEC)

bull Enteroinvasive E Coli (EIEC)

bull ‐ Protozoan Entamoeba histolytica

What is the causative organism bull Although accurate differentiation between bacterial viral and parasitic

gastroenteritis cannot be made except by stool analysis and stool culture the cause can be suggested in most cases by considering the character of the stool and the associated findings especially fever

bull 1 Bacterial gastroenteritis The possibility of bacterial gastroenteritis is considerable when the fever is above 385degC and the diarrhea is severe or bloody

bull Leucocytosis and elevated CRP level are common laboratory findings

bull 2 Viral gastroenteritis Fever is usually below 385degC and the diarrhea is usually watery and not severe The possibility is higher in the following situations (1) When there is preceding or associated viral respiratory infection (2) When the diarrhea is occurring in winter season

bull 3 Parasitic enteritis Clinical manifestations depend on the causative agent

bull With Giardia lamblia infection the diarrhea is usually watery foul smelling not severe and not associated with fever The possibility becomes greater when diarrhea persists for more than 10 days (giardia is the most common cause of mild persistent watery diarrhea)

bull With amoebiasis diarrhea is commonly bloody but fever is bull absent (important differentiating point from bacterial

gastroenteritis)

bull Accurate diagnosis is made by stool analysis Repeated stool analysis is important for the diagnosis of giardiasis because initial negative analysis does not exclude the possibility

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

Defention

bull Acute gastroenteritis (AGE) is a diarrheal disease of acute onset with or without accompanying symptoms and signs such as nausea vomiting fever or abdominal pain

bull Gastroenteritis Acute inflammation of the lining of the stomachintestines

bull 1048708Anorexia nausea vomiting diarrhea abdpain (hallmark is diarrhea)

bull According to the World Health Organization (WHO) AD is the passage of loose(Takes the shape of the container

bull ) or watery stools three times or more in a 24 hour period for upto14 days

bull In the breastfed infant the diagnosis is based on a change in usual stool frequency and consistency as reported by the mother

epidemiology

bull Gastroenteritis ranks with respiratory tract infection as the most common infectious disease syndrome of humans

bull Approximately five billion episodes of diarrhea occur worldwide annually accounting for 15 to 30 percent of all deaths in some countries

bull More than 20 viruses bacteria and parasites have been associated with acute diarhoea

bull Worldwide rotavirus is the commonest cause of severe dehydrating diarrhoea causing 06 million deaths annually 90 of which occur in developing countries

bull The incidence of specific pathogens varies between developed and developing countries

bull In developed countries about 40 of AD cases are due to rotavirus and only 10-20 are of bacterial origin while in developing countries 50-60 are caused by bacteria while 15-25 are due to rotavirus

Other viral agents bull Enteric

adenoviruses bull Astrovirus bull Human

calciviruses (norovirus and sapovirus)

Bacteria

bull E coli (EAEC EPEC EIEC)

bull Shigella spp

bull Staphylococcus spp

bull Salmonella spp

bull Yersinia enterocolitica

bull Campylobacter jejuni

bull Vibrio cholera

Parasites bull Entamoeba

histolitica bull Girdia lamblia bull Cryptosporidium bull Trichuris trichuria bull Strongyloides

stercoralis

Major two forms of Acute diarrhea

bull bull Acute watery diarrhea

bull ‐ Rotavirus worldwide 40 of hospitalized children lt 5 years

bull ‐ Enterotoxigenic Escherichia coli (ETEC) in older children

bull ‐ Vibrio cholerae in endemic areas

bull ‐ Norovirus

bull Invasive diarrhea

bull ‐ Shigella flexneri dysenteriae boydii sonnei

bull ‐ Salmonella enterica

bull ‐ Campylobacter spp Enterohemorrhagic E coli (EHEC)

bull Enteroinvasive E Coli (EIEC)

bull ‐ Protozoan Entamoeba histolytica

What is the causative organism bull Although accurate differentiation between bacterial viral and parasitic

gastroenteritis cannot be made except by stool analysis and stool culture the cause can be suggested in most cases by considering the character of the stool and the associated findings especially fever

bull 1 Bacterial gastroenteritis The possibility of bacterial gastroenteritis is considerable when the fever is above 385degC and the diarrhea is severe or bloody

bull Leucocytosis and elevated CRP level are common laboratory findings

bull 2 Viral gastroenteritis Fever is usually below 385degC and the diarrhea is usually watery and not severe The possibility is higher in the following situations (1) When there is preceding or associated viral respiratory infection (2) When the diarrhea is occurring in winter season

bull 3 Parasitic enteritis Clinical manifestations depend on the causative agent

bull With Giardia lamblia infection the diarrhea is usually watery foul smelling not severe and not associated with fever The possibility becomes greater when diarrhea persists for more than 10 days (giardia is the most common cause of mild persistent watery diarrhea)

bull With amoebiasis diarrhea is commonly bloody but fever is bull absent (important differentiating point from bacterial

gastroenteritis)

bull Accurate diagnosis is made by stool analysis Repeated stool analysis is important for the diagnosis of giardiasis because initial negative analysis does not exclude the possibility

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

bull According to the World Health Organization (WHO) AD is the passage of loose(Takes the shape of the container

bull ) or watery stools three times or more in a 24 hour period for upto14 days

bull In the breastfed infant the diagnosis is based on a change in usual stool frequency and consistency as reported by the mother

epidemiology

bull Gastroenteritis ranks with respiratory tract infection as the most common infectious disease syndrome of humans

bull Approximately five billion episodes of diarrhea occur worldwide annually accounting for 15 to 30 percent of all deaths in some countries

bull More than 20 viruses bacteria and parasites have been associated with acute diarhoea

bull Worldwide rotavirus is the commonest cause of severe dehydrating diarrhoea causing 06 million deaths annually 90 of which occur in developing countries

bull The incidence of specific pathogens varies between developed and developing countries

bull In developed countries about 40 of AD cases are due to rotavirus and only 10-20 are of bacterial origin while in developing countries 50-60 are caused by bacteria while 15-25 are due to rotavirus

Other viral agents bull Enteric

adenoviruses bull Astrovirus bull Human

calciviruses (norovirus and sapovirus)

Bacteria

bull E coli (EAEC EPEC EIEC)

bull Shigella spp

bull Staphylococcus spp

bull Salmonella spp

bull Yersinia enterocolitica

bull Campylobacter jejuni

bull Vibrio cholera

Parasites bull Entamoeba

histolitica bull Girdia lamblia bull Cryptosporidium bull Trichuris trichuria bull Strongyloides

stercoralis

Major two forms of Acute diarrhea

bull bull Acute watery diarrhea

bull ‐ Rotavirus worldwide 40 of hospitalized children lt 5 years

bull ‐ Enterotoxigenic Escherichia coli (ETEC) in older children

bull ‐ Vibrio cholerae in endemic areas

bull ‐ Norovirus

bull Invasive diarrhea

bull ‐ Shigella flexneri dysenteriae boydii sonnei

bull ‐ Salmonella enterica

bull ‐ Campylobacter spp Enterohemorrhagic E coli (EHEC)

bull Enteroinvasive E Coli (EIEC)

bull ‐ Protozoan Entamoeba histolytica

What is the causative organism bull Although accurate differentiation between bacterial viral and parasitic

gastroenteritis cannot be made except by stool analysis and stool culture the cause can be suggested in most cases by considering the character of the stool and the associated findings especially fever

bull 1 Bacterial gastroenteritis The possibility of bacterial gastroenteritis is considerable when the fever is above 385degC and the diarrhea is severe or bloody

bull Leucocytosis and elevated CRP level are common laboratory findings

bull 2 Viral gastroenteritis Fever is usually below 385degC and the diarrhea is usually watery and not severe The possibility is higher in the following situations (1) When there is preceding or associated viral respiratory infection (2) When the diarrhea is occurring in winter season

bull 3 Parasitic enteritis Clinical manifestations depend on the causative agent

bull With Giardia lamblia infection the diarrhea is usually watery foul smelling not severe and not associated with fever The possibility becomes greater when diarrhea persists for more than 10 days (giardia is the most common cause of mild persistent watery diarrhea)

bull With amoebiasis diarrhea is commonly bloody but fever is bull absent (important differentiating point from bacterial

gastroenteritis)

bull Accurate diagnosis is made by stool analysis Repeated stool analysis is important for the diagnosis of giardiasis because initial negative analysis does not exclude the possibility

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

epidemiology

bull Gastroenteritis ranks with respiratory tract infection as the most common infectious disease syndrome of humans

bull Approximately five billion episodes of diarrhea occur worldwide annually accounting for 15 to 30 percent of all deaths in some countries

bull More than 20 viruses bacteria and parasites have been associated with acute diarhoea

bull Worldwide rotavirus is the commonest cause of severe dehydrating diarrhoea causing 06 million deaths annually 90 of which occur in developing countries

bull The incidence of specific pathogens varies between developed and developing countries

bull In developed countries about 40 of AD cases are due to rotavirus and only 10-20 are of bacterial origin while in developing countries 50-60 are caused by bacteria while 15-25 are due to rotavirus

Other viral agents bull Enteric

adenoviruses bull Astrovirus bull Human

calciviruses (norovirus and sapovirus)

Bacteria

bull E coli (EAEC EPEC EIEC)

bull Shigella spp

bull Staphylococcus spp

bull Salmonella spp

bull Yersinia enterocolitica

bull Campylobacter jejuni

bull Vibrio cholera

Parasites bull Entamoeba

histolitica bull Girdia lamblia bull Cryptosporidium bull Trichuris trichuria bull Strongyloides

stercoralis

Major two forms of Acute diarrhea

bull bull Acute watery diarrhea

bull ‐ Rotavirus worldwide 40 of hospitalized children lt 5 years

bull ‐ Enterotoxigenic Escherichia coli (ETEC) in older children

bull ‐ Vibrio cholerae in endemic areas

bull ‐ Norovirus

bull Invasive diarrhea

bull ‐ Shigella flexneri dysenteriae boydii sonnei

bull ‐ Salmonella enterica

bull ‐ Campylobacter spp Enterohemorrhagic E coli (EHEC)

bull Enteroinvasive E Coli (EIEC)

bull ‐ Protozoan Entamoeba histolytica

What is the causative organism bull Although accurate differentiation between bacterial viral and parasitic

gastroenteritis cannot be made except by stool analysis and stool culture the cause can be suggested in most cases by considering the character of the stool and the associated findings especially fever

bull 1 Bacterial gastroenteritis The possibility of bacterial gastroenteritis is considerable when the fever is above 385degC and the diarrhea is severe or bloody

bull Leucocytosis and elevated CRP level are common laboratory findings

bull 2 Viral gastroenteritis Fever is usually below 385degC and the diarrhea is usually watery and not severe The possibility is higher in the following situations (1) When there is preceding or associated viral respiratory infection (2) When the diarrhea is occurring in winter season

bull 3 Parasitic enteritis Clinical manifestations depend on the causative agent

bull With Giardia lamblia infection the diarrhea is usually watery foul smelling not severe and not associated with fever The possibility becomes greater when diarrhea persists for more than 10 days (giardia is the most common cause of mild persistent watery diarrhea)

bull With amoebiasis diarrhea is commonly bloody but fever is bull absent (important differentiating point from bacterial

gastroenteritis)

bull Accurate diagnosis is made by stool analysis Repeated stool analysis is important for the diagnosis of giardiasis because initial negative analysis does not exclude the possibility

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

bull Worldwide rotavirus is the commonest cause of severe dehydrating diarrhoea causing 06 million deaths annually 90 of which occur in developing countries

bull The incidence of specific pathogens varies between developed and developing countries

bull In developed countries about 40 of AD cases are due to rotavirus and only 10-20 are of bacterial origin while in developing countries 50-60 are caused by bacteria while 15-25 are due to rotavirus

Other viral agents bull Enteric

adenoviruses bull Astrovirus bull Human

calciviruses (norovirus and sapovirus)

Bacteria

bull E coli (EAEC EPEC EIEC)

bull Shigella spp

bull Staphylococcus spp

bull Salmonella spp

bull Yersinia enterocolitica

bull Campylobacter jejuni

bull Vibrio cholera

Parasites bull Entamoeba

histolitica bull Girdia lamblia bull Cryptosporidium bull Trichuris trichuria bull Strongyloides

stercoralis

Major two forms of Acute diarrhea

bull bull Acute watery diarrhea

bull ‐ Rotavirus worldwide 40 of hospitalized children lt 5 years

bull ‐ Enterotoxigenic Escherichia coli (ETEC) in older children

bull ‐ Vibrio cholerae in endemic areas

bull ‐ Norovirus

bull Invasive diarrhea

bull ‐ Shigella flexneri dysenteriae boydii sonnei

bull ‐ Salmonella enterica

bull ‐ Campylobacter spp Enterohemorrhagic E coli (EHEC)

bull Enteroinvasive E Coli (EIEC)

bull ‐ Protozoan Entamoeba histolytica

What is the causative organism bull Although accurate differentiation between bacterial viral and parasitic

gastroenteritis cannot be made except by stool analysis and stool culture the cause can be suggested in most cases by considering the character of the stool and the associated findings especially fever

bull 1 Bacterial gastroenteritis The possibility of bacterial gastroenteritis is considerable when the fever is above 385degC and the diarrhea is severe or bloody

bull Leucocytosis and elevated CRP level are common laboratory findings

bull 2 Viral gastroenteritis Fever is usually below 385degC and the diarrhea is usually watery and not severe The possibility is higher in the following situations (1) When there is preceding or associated viral respiratory infection (2) When the diarrhea is occurring in winter season

bull 3 Parasitic enteritis Clinical manifestations depend on the causative agent

bull With Giardia lamblia infection the diarrhea is usually watery foul smelling not severe and not associated with fever The possibility becomes greater when diarrhea persists for more than 10 days (giardia is the most common cause of mild persistent watery diarrhea)

bull With amoebiasis diarrhea is commonly bloody but fever is bull absent (important differentiating point from bacterial

gastroenteritis)

bull Accurate diagnosis is made by stool analysis Repeated stool analysis is important for the diagnosis of giardiasis because initial negative analysis does not exclude the possibility

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

Other viral agents bull Enteric

adenoviruses bull Astrovirus bull Human

calciviruses (norovirus and sapovirus)

Bacteria

bull E coli (EAEC EPEC EIEC)

bull Shigella spp

bull Staphylococcus spp

bull Salmonella spp

bull Yersinia enterocolitica

bull Campylobacter jejuni

bull Vibrio cholera

Parasites bull Entamoeba

histolitica bull Girdia lamblia bull Cryptosporidium bull Trichuris trichuria bull Strongyloides

stercoralis

Major two forms of Acute diarrhea

bull bull Acute watery diarrhea

bull ‐ Rotavirus worldwide 40 of hospitalized children lt 5 years

bull ‐ Enterotoxigenic Escherichia coli (ETEC) in older children

bull ‐ Vibrio cholerae in endemic areas

bull ‐ Norovirus

bull Invasive diarrhea

bull ‐ Shigella flexneri dysenteriae boydii sonnei

bull ‐ Salmonella enterica

bull ‐ Campylobacter spp Enterohemorrhagic E coli (EHEC)

bull Enteroinvasive E Coli (EIEC)

bull ‐ Protozoan Entamoeba histolytica

What is the causative organism bull Although accurate differentiation between bacterial viral and parasitic

gastroenteritis cannot be made except by stool analysis and stool culture the cause can be suggested in most cases by considering the character of the stool and the associated findings especially fever

bull 1 Bacterial gastroenteritis The possibility of bacterial gastroenteritis is considerable when the fever is above 385degC and the diarrhea is severe or bloody

bull Leucocytosis and elevated CRP level are common laboratory findings

bull 2 Viral gastroenteritis Fever is usually below 385degC and the diarrhea is usually watery and not severe The possibility is higher in the following situations (1) When there is preceding or associated viral respiratory infection (2) When the diarrhea is occurring in winter season

bull 3 Parasitic enteritis Clinical manifestations depend on the causative agent

bull With Giardia lamblia infection the diarrhea is usually watery foul smelling not severe and not associated with fever The possibility becomes greater when diarrhea persists for more than 10 days (giardia is the most common cause of mild persistent watery diarrhea)

bull With amoebiasis diarrhea is commonly bloody but fever is bull absent (important differentiating point from bacterial

gastroenteritis)

bull Accurate diagnosis is made by stool analysis Repeated stool analysis is important for the diagnosis of giardiasis because initial negative analysis does not exclude the possibility

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

Major two forms of Acute diarrhea

bull bull Acute watery diarrhea

bull ‐ Rotavirus worldwide 40 of hospitalized children lt 5 years

bull ‐ Enterotoxigenic Escherichia coli (ETEC) in older children

bull ‐ Vibrio cholerae in endemic areas

bull ‐ Norovirus

bull Invasive diarrhea

bull ‐ Shigella flexneri dysenteriae boydii sonnei

bull ‐ Salmonella enterica

bull ‐ Campylobacter spp Enterohemorrhagic E coli (EHEC)

bull Enteroinvasive E Coli (EIEC)

bull ‐ Protozoan Entamoeba histolytica

What is the causative organism bull Although accurate differentiation between bacterial viral and parasitic

gastroenteritis cannot be made except by stool analysis and stool culture the cause can be suggested in most cases by considering the character of the stool and the associated findings especially fever

bull 1 Bacterial gastroenteritis The possibility of bacterial gastroenteritis is considerable when the fever is above 385degC and the diarrhea is severe or bloody

bull Leucocytosis and elevated CRP level are common laboratory findings

bull 2 Viral gastroenteritis Fever is usually below 385degC and the diarrhea is usually watery and not severe The possibility is higher in the following situations (1) When there is preceding or associated viral respiratory infection (2) When the diarrhea is occurring in winter season

bull 3 Parasitic enteritis Clinical manifestations depend on the causative agent

bull With Giardia lamblia infection the diarrhea is usually watery foul smelling not severe and not associated with fever The possibility becomes greater when diarrhea persists for more than 10 days (giardia is the most common cause of mild persistent watery diarrhea)

bull With amoebiasis diarrhea is commonly bloody but fever is bull absent (important differentiating point from bacterial

gastroenteritis)

bull Accurate diagnosis is made by stool analysis Repeated stool analysis is important for the diagnosis of giardiasis because initial negative analysis does not exclude the possibility

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

What is the causative organism bull Although accurate differentiation between bacterial viral and parasitic

gastroenteritis cannot be made except by stool analysis and stool culture the cause can be suggested in most cases by considering the character of the stool and the associated findings especially fever

bull 1 Bacterial gastroenteritis The possibility of bacterial gastroenteritis is considerable when the fever is above 385degC and the diarrhea is severe or bloody

bull Leucocytosis and elevated CRP level are common laboratory findings

bull 2 Viral gastroenteritis Fever is usually below 385degC and the diarrhea is usually watery and not severe The possibility is higher in the following situations (1) When there is preceding or associated viral respiratory infection (2) When the diarrhea is occurring in winter season

bull 3 Parasitic enteritis Clinical manifestations depend on the causative agent

bull With Giardia lamblia infection the diarrhea is usually watery foul smelling not severe and not associated with fever The possibility becomes greater when diarrhea persists for more than 10 days (giardia is the most common cause of mild persistent watery diarrhea)

bull With amoebiasis diarrhea is commonly bloody but fever is bull absent (important differentiating point from bacterial

gastroenteritis)

bull Accurate diagnosis is made by stool analysis Repeated stool analysis is important for the diagnosis of giardiasis because initial negative analysis does not exclude the possibility

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

bull 3 Parasitic enteritis Clinical manifestations depend on the causative agent

bull With Giardia lamblia infection the diarrhea is usually watery foul smelling not severe and not associated with fever The possibility becomes greater when diarrhea persists for more than 10 days (giardia is the most common cause of mild persistent watery diarrhea)

bull With amoebiasis diarrhea is commonly bloody but fever is bull absent (important differentiating point from bacterial

gastroenteritis)

bull Accurate diagnosis is made by stool analysis Repeated stool analysis is important for the diagnosis of giardiasis because initial negative analysis does not exclude the possibility

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

Complications of acute gastroenteritis

bull 1 Dehydration

bull 2 Shock

bull 3 Acute renal failure

bull 4 Metabolic acidosis

bull 5 Hypokalemia

bull 6 Hypocalcemia

bull 7 Convulsions

bull 8 Bleeding

bull 9 Persistent diarrhea

bull 10 Malnutrition Kwashiorkor (with one attack) and marasmus (with repeated attacks)

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

bull Infection with Shiga toxin producing Escherichia coli (E coli 0157 H7 )or Shigella dysenteriae may cause haemorrhagic colitis (with severe bloody diarrhoea) which may be complicated by haemolytic uraemic syndrome

bull This syndrome is endemic worldwide and characterised by acute onset of microangiopathic haemolytic anaemia thrombocytopenia acute renal impairment and multisystem involvement

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

DD bull Other causes that can cause acute diahrea

bull 1 Dietetic diarrhea It may follow recent change in the type of milk concentrated formula or recent addition of new foods not suitable for the age of the infant

bull 2 Drug induced diarrhea Most oral antibiotics especially ampicillin can cause acute diarrhea (antibiotic-associated diarrhea)

bull 3 Parenteral diarrhea It is a diarrhea that occurs secondary to infections outside the gastrointestinal tract as respiratory and urinary tract infection

bull 4Spurious diarrhoea for example in chronic constipation with overflow incontinence

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

Investigations bull If the child is not dehydrated nor the stools bloody investigations

are not generally necessary unless the child is hospitalized or has been exposed to others with proven bacterial gastroenteritis

bull Samples also should be taken during outbreaksmdashespecially in childcare school hospital or residential settingsmdashwhere there is a public health imperative to identify the pathogen and establish its source

bull Stool microscopy and culture is needed if there is blood and mucus

in the diarrhoea

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

Rotavirus can be detected by stool immunoassay If extra - gastrointestinal infection is suspected confirmation may be required from blood and urine cultures or X - ray Investigations to be considered are shown in this table

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

Measurement of UreaampCreatinine and Electrolytes can be

considered in

bull Severe dehydration or shock

bull Children on IV fluid

bull Children with severe malnutrition

bull Suspected cases of hypernatreamic dehydration

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

How is dehydration assessed

bull It is important to assess hydration in gastroenteritis as hydration status determines the immediate management of this condition

bull The infant or child with profuse watery diarrhoea and frequent vomiting is most at risk

bull Clinical signs are usually not present until a child has lost at least 5 of his or her body weight

bull Documented recent weight lost is a good indicator of the degree of dehydration but this information is rarely available

bull The best clinical indicators of more than 5 dehydration are prolonged capillary refill abnormal skin turgor and absent tears

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

bull AAP guideline classifies patients as mild (3-5) moderate (6-9) and severe (gt10) dehydration

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

Management

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

bull Prevention of dehydration is the cornerstone of gastroenteritis treatment in children

bull Encourage the childrsquos preferred usual and age appropriate diet to

prevent or limit dehydration also early refeeding reduces the duration of diarrhoea

bull if breastfeeding continue if formula feeding do not dilute or switch formulas

bull As soon as the dehydration is corrected a regular diet should resume

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

bull Restrictive regimens like The BRAT diet are not recommended (bananas rice applesauce and toast) is too restrictive Published guidelines recommend early reintroduction of milk and solids including complex carbohydrates lean meats yogurt and vegetables

bull If the child is vomiting offer frequent (every 10 to 60 minutes) small feedings

bull for the child with some dehydration treat with commercial oral rehydration solution (ORS) for a period of 4 to 6 hours or until an adequate degree of rehydration is achieved

bull Early oral rehydration therapy using an oral rehydration solution (ORS) before the child becomes more severely dehydrated is important and can be done at home

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

bull Clear liquids such as water sodas chicken broth and apple juice should not replace an ORS because they are hyperosmolar and do not adequately replace potassium bicarbonate and sodium

bull These fluids especially water and apple juice can cause hyponatremia

bull An adult ORS also should not be used

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

ORS

bull Lancet- potentially the most important medical advance this centuryldquo

World Health Organization estimates that 90 of diarrheal deaths worldwide could be prevented with appropriate treatment with ORS

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

ORS-principle

ndash Na+ absorption is impaired in the diarrhoeal state

ndash if the Na+ is not absorbed water cannot be absorbed

ndash Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens

ndash Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism

ndash This occurs in a 11 ratio one molecule of glucose co-transporting one sodium ion (Na+)

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

Reduced osmolarity ORS

41 less need for IV fluids

Less stool output

Less vomiting

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

bull The key to success with ORT is frequent small amounts of an approved Oral Rehydration Solution (ORS) given over a 4-6 hour time period ORT will be initiated within the hospitals and clinics However the patient may be discharged prior to the completion of total rehydration The entire guideline follows

bull Calculate total volume deficit

ndash Mild dehydration (lt5)

bull 50 mLkg + 10 mLkg additional volume for each diarrhea stool

ndash Moderate dehydration (5-10)

bull 100 mLkg + 10 mLkg additional volume for each diarrhea stool

bull First hour of therapy Administer 5 mL of ORS every two minutes for an hour

bull If the patient vomits suspend ORT for 15 minutes and resume first hour of therapy

bull After first hour of therapy Allow patient to rest for 15 minutes

bull Second hour of therapy Increase ORS amount to 6-10 mL (amount is determined by the size of the child) of ORS every two minutes for an hour

bull If patient tolerates total volume instruct parent to introduce normal diet for age when patient is considered rehydrated

bull If patient does not tolerate normal diet continue ORS for another four to eight hours and advance to normal diet as soon as possible

bull If vomiting persists three or more times during first two hours of ORS attempt consider insertion of small nasogastric tube or IV hydration

What is the role of drugs

bull Drugs are rarely needed

bull Antiemetic agents are not recommended for routine use Although new generation antiemetics (such as the serotonin antagonist ondansetron) do not have extrapyramidal effects and reduce the duration and frequency of vomiting they also increase diarrhoea

bull Antimotility agents (such as loperamide) decrease the duration of diarrhoea but they have potential severe adverse effects Vitamin A does not influence the course of acute gastroenteritis

Zinc bull zinc is lost during diarrhoea

bull Zinc deficiency is associated with impaired electrolyte and water absorption

decreased brush border enzyme activity and impaired cellular and humoral

immunity

bull Treatment with zinc reduces the duration and severity of AD and also

reduces the frequency of further episodes during the subsequent 2-3

months

bull WHO recommends that children from developing countries with diarrhoea

be given zinc for 10-14 days ndash 10mg daily for children lt6 months

ndash 20 mg daily for children gt6 months

and Barry GorbachSherwood (Probiotics)1985Goldin

High-dose (1010-1012CFU) Lactobacillus GG helpful Basu J Clin Gastroenterol 43208 2009

Lactobacillus GG (6x106CFU) not effective Basu J Paediatr Child Health 43837

2007

Probiotic ldquoBifilacrdquo useful Narayanappa Indian J Pediatr 75709

2008

Sohellip Continue studying ndash formulations populations

antibiotics

bull Even though bacterial pathogens are the commonest cause of AD in

developing countries there should be cautious and rational use of

antibiotics to discourage development of microbial resistance avoid side

effects and reduce cost

bull Antibiotics should be used for(is there is need to mention names of ab)

ndash Severe invasive bacterial diarrhoea eg Shigellosis

ndash Cholera

ndash GirdiasisImmunocompromised children

Antibiotics are contraindicated in

bull E coli 0157 H7 because they increase the risk of Haemolytic Uraemic

syndrome (HUS)

bull Uncomplicated salmonella enteritis because they prolong bacteria shedding

Is a lactose-free diet necessary

bull The vast majority of patients with AGE do not develop clinically important lactose intolerance

bull In selected patients with documented persistent lactose intolerance lactose-free formulas are recommended

When to discharge the patient

bull It is recommended that for children receiving care in a hospital setting prompt discharge be considered when the following levels of recovery are reached

bull sufficient rehydration achieved as indicated by weight gain andor clinical status

bull bull IV or NG fluids not required

bull bull oral intake equals or exceeds losses

bull bull adequate family teaching has occurred and

bull bull medical follow up is available via telephone or office visit

How to prevent

This involves intervention at two levels

bull Primary prevention (to reduce disease transmission)

ndash Rotavirus and measles vaccines

ndash Handwashing with soap

ndash Providing adequate and safe drinking water

ndash Environmental sanitation

bull Secondary prevention (to reduce disease severity)

ndash Promote breastfeeding

ndash Vitamin A supplementation

ndash Treatment of episodes of AD with zinc

Post-gastroenteritis syndrome

bull Infrequently following an episode of gastroenteritis the introduction of a normal diet results in a return of watery diarrhoea

bull Temporary lactose intolerance may have developed

bull In such circumstances a return to an oral rehydration solution for 24 h followed by a further introduction of a normal diet is usually successful

bull In very severe cases a period of parenteral nutrition is required to enable the injured small intestinal mucosa to recover sufficiently to absorb luminal nutrients

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use

bull If patient tolerates total volume instruct parent to introduce normal diet for age when patient is considered rehydrated

bull If patient does not tolerate normal diet continue ORS for another four to eight hours and advance to normal diet as soon as possible

bull If vomiting persists three or more times during first two hours of ORS attempt consider insertion of small nasogastric tube or IV hydration

What is the role of drugs

bull Drugs are rarely needed

bull Antiemetic agents are not recommended for routine use Although new generation antiemetics (such as the serotonin antagonist ondansetron) do not have extrapyramidal effects and reduce the duration and frequency of vomiting they also increase diarrhoea

bull Antimotility agents (such as loperamide) decrease the duration of diarrhoea but they have potential severe adverse effects Vitamin A does not influence the course of acute gastroenteritis

Zinc bull zinc is lost during diarrhoea

bull Zinc deficiency is associated with impaired electrolyte and water absorption

decreased brush border enzyme activity and impaired cellular and humoral

immunity

bull Treatment with zinc reduces the duration and severity of AD and also

reduces the frequency of further episodes during the subsequent 2-3

months

bull WHO recommends that children from developing countries with diarrhoea

be given zinc for 10-14 days ndash 10mg daily for children lt6 months

ndash 20 mg daily for children gt6 months

and Barry GorbachSherwood (Probiotics)1985Goldin

High-dose (1010-1012CFU) Lactobacillus GG helpful Basu J Clin Gastroenterol 43208 2009

Lactobacillus GG (6x106CFU) not effective Basu J Paediatr Child Health 43837

2007

Probiotic ldquoBifilacrdquo useful Narayanappa Indian J Pediatr 75709

2008

Sohellip Continue studying ndash formulations populations

antibiotics

bull Even though bacterial pathogens are the commonest cause of AD in

developing countries there should be cautious and rational use of

antibiotics to discourage development of microbial resistance avoid side

effects and reduce cost

bull Antibiotics should be used for(is there is need to mention names of ab)

ndash Severe invasive bacterial diarrhoea eg Shigellosis

ndash Cholera

ndash GirdiasisImmunocompromised children

Antibiotics are contraindicated in

bull E coli 0157 H7 because they increase the risk of Haemolytic Uraemic

syndrome (HUS)

bull Uncomplicated salmonella enteritis because they prolong bacteria shedding

Is a lactose-free diet necessary

bull The vast majority of patients with AGE do not develop clinically important lactose intolerance

bull In selected patients with documented persistent lactose intolerance lactose-free formulas are recommended

When to discharge the patient

bull It is recommended that for children receiving care in a hospital setting prompt discharge be considered when the following levels of recovery are reached

bull sufficient rehydration achieved as indicated by weight gain andor clinical status

bull bull IV or NG fluids not required

bull bull oral intake equals or exceeds losses

bull bull adequate family teaching has occurred and

bull bull medical follow up is available via telephone or office visit

How to prevent

This involves intervention at two levels

bull Primary prevention (to reduce disease transmission)

ndash Rotavirus and measles vaccines

ndash Handwashing with soap

ndash Providing adequate and safe drinking water

ndash Environmental sanitation

bull Secondary prevention (to reduce disease severity)

ndash Promote breastfeeding

ndash Vitamin A supplementation

ndash Treatment of episodes of AD with zinc

Post-gastroenteritis syndrome

bull Infrequently following an episode of gastroenteritis the introduction of a normal diet results in a return of watery diarrhoea

bull Temporary lactose intolerance may have developed

bull In such circumstances a return to an oral rehydration solution for 24 h followed by a further introduction of a normal diet is usually successful

bull In very severe cases a period of parenteral nutrition is required to enable the injured small intestinal mucosa to recover sufficiently to absorb luminal nutrients

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use

What is the role of drugs

bull Drugs are rarely needed

bull Antiemetic agents are not recommended for routine use Although new generation antiemetics (such as the serotonin antagonist ondansetron) do not have extrapyramidal effects and reduce the duration and frequency of vomiting they also increase diarrhoea

bull Antimotility agents (such as loperamide) decrease the duration of diarrhoea but they have potential severe adverse effects Vitamin A does not influence the course of acute gastroenteritis

Zinc bull zinc is lost during diarrhoea

bull Zinc deficiency is associated with impaired electrolyte and water absorption

decreased brush border enzyme activity and impaired cellular and humoral

immunity

bull Treatment with zinc reduces the duration and severity of AD and also

reduces the frequency of further episodes during the subsequent 2-3

months

bull WHO recommends that children from developing countries with diarrhoea

be given zinc for 10-14 days ndash 10mg daily for children lt6 months

ndash 20 mg daily for children gt6 months

and Barry GorbachSherwood (Probiotics)1985Goldin

High-dose (1010-1012CFU) Lactobacillus GG helpful Basu J Clin Gastroenterol 43208 2009

Lactobacillus GG (6x106CFU) not effective Basu J Paediatr Child Health 43837

2007

Probiotic ldquoBifilacrdquo useful Narayanappa Indian J Pediatr 75709

2008

Sohellip Continue studying ndash formulations populations

antibiotics

bull Even though bacterial pathogens are the commonest cause of AD in

developing countries there should be cautious and rational use of

antibiotics to discourage development of microbial resistance avoid side

effects and reduce cost

bull Antibiotics should be used for(is there is need to mention names of ab)

ndash Severe invasive bacterial diarrhoea eg Shigellosis

ndash Cholera

ndash GirdiasisImmunocompromised children

Antibiotics are contraindicated in

bull E coli 0157 H7 because they increase the risk of Haemolytic Uraemic

syndrome (HUS)

bull Uncomplicated salmonella enteritis because they prolong bacteria shedding

Is a lactose-free diet necessary

bull The vast majority of patients with AGE do not develop clinically important lactose intolerance

bull In selected patients with documented persistent lactose intolerance lactose-free formulas are recommended

When to discharge the patient

bull It is recommended that for children receiving care in a hospital setting prompt discharge be considered when the following levels of recovery are reached

bull sufficient rehydration achieved as indicated by weight gain andor clinical status

bull bull IV or NG fluids not required

bull bull oral intake equals or exceeds losses

bull bull adequate family teaching has occurred and

bull bull medical follow up is available via telephone or office visit

How to prevent

This involves intervention at two levels

bull Primary prevention (to reduce disease transmission)

ndash Rotavirus and measles vaccines

ndash Handwashing with soap

ndash Providing adequate and safe drinking water

ndash Environmental sanitation

bull Secondary prevention (to reduce disease severity)

ndash Promote breastfeeding

ndash Vitamin A supplementation

ndash Treatment of episodes of AD with zinc

Post-gastroenteritis syndrome

bull Infrequently following an episode of gastroenteritis the introduction of a normal diet results in a return of watery diarrhoea

bull Temporary lactose intolerance may have developed

bull In such circumstances a return to an oral rehydration solution for 24 h followed by a further introduction of a normal diet is usually successful

bull In very severe cases a period of parenteral nutrition is required to enable the injured small intestinal mucosa to recover sufficiently to absorb luminal nutrients

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use

Zinc bull zinc is lost during diarrhoea

bull Zinc deficiency is associated with impaired electrolyte and water absorption

decreased brush border enzyme activity and impaired cellular and humoral

immunity

bull Treatment with zinc reduces the duration and severity of AD and also

reduces the frequency of further episodes during the subsequent 2-3

months

bull WHO recommends that children from developing countries with diarrhoea

be given zinc for 10-14 days ndash 10mg daily for children lt6 months

ndash 20 mg daily for children gt6 months

and Barry GorbachSherwood (Probiotics)1985Goldin

High-dose (1010-1012CFU) Lactobacillus GG helpful Basu J Clin Gastroenterol 43208 2009

Lactobacillus GG (6x106CFU) not effective Basu J Paediatr Child Health 43837

2007

Probiotic ldquoBifilacrdquo useful Narayanappa Indian J Pediatr 75709

2008

Sohellip Continue studying ndash formulations populations

antibiotics

bull Even though bacterial pathogens are the commonest cause of AD in

developing countries there should be cautious and rational use of

antibiotics to discourage development of microbial resistance avoid side

effects and reduce cost

bull Antibiotics should be used for(is there is need to mention names of ab)

ndash Severe invasive bacterial diarrhoea eg Shigellosis

ndash Cholera

ndash GirdiasisImmunocompromised children

Antibiotics are contraindicated in

bull E coli 0157 H7 because they increase the risk of Haemolytic Uraemic

syndrome (HUS)

bull Uncomplicated salmonella enteritis because they prolong bacteria shedding

Is a lactose-free diet necessary

bull The vast majority of patients with AGE do not develop clinically important lactose intolerance

bull In selected patients with documented persistent lactose intolerance lactose-free formulas are recommended

When to discharge the patient

bull It is recommended that for children receiving care in a hospital setting prompt discharge be considered when the following levels of recovery are reached

bull sufficient rehydration achieved as indicated by weight gain andor clinical status

bull bull IV or NG fluids not required

bull bull oral intake equals or exceeds losses

bull bull adequate family teaching has occurred and

bull bull medical follow up is available via telephone or office visit

How to prevent

This involves intervention at two levels

bull Primary prevention (to reduce disease transmission)

ndash Rotavirus and measles vaccines

ndash Handwashing with soap

ndash Providing adequate and safe drinking water

ndash Environmental sanitation

bull Secondary prevention (to reduce disease severity)

ndash Promote breastfeeding

ndash Vitamin A supplementation

ndash Treatment of episodes of AD with zinc

Post-gastroenteritis syndrome

bull Infrequently following an episode of gastroenteritis the introduction of a normal diet results in a return of watery diarrhoea

bull Temporary lactose intolerance may have developed

bull In such circumstances a return to an oral rehydration solution for 24 h followed by a further introduction of a normal diet is usually successful

bull In very severe cases a period of parenteral nutrition is required to enable the injured small intestinal mucosa to recover sufficiently to absorb luminal nutrients

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use

and Barry GorbachSherwood (Probiotics)1985Goldin

High-dose (1010-1012CFU) Lactobacillus GG helpful Basu J Clin Gastroenterol 43208 2009

Lactobacillus GG (6x106CFU) not effective Basu J Paediatr Child Health 43837

2007

Probiotic ldquoBifilacrdquo useful Narayanappa Indian J Pediatr 75709

2008

Sohellip Continue studying ndash formulations populations

antibiotics

bull Even though bacterial pathogens are the commonest cause of AD in

developing countries there should be cautious and rational use of

antibiotics to discourage development of microbial resistance avoid side

effects and reduce cost

bull Antibiotics should be used for(is there is need to mention names of ab)

ndash Severe invasive bacterial diarrhoea eg Shigellosis

ndash Cholera

ndash GirdiasisImmunocompromised children

Antibiotics are contraindicated in

bull E coli 0157 H7 because they increase the risk of Haemolytic Uraemic

syndrome (HUS)

bull Uncomplicated salmonella enteritis because they prolong bacteria shedding

Is a lactose-free diet necessary

bull The vast majority of patients with AGE do not develop clinically important lactose intolerance

bull In selected patients with documented persistent lactose intolerance lactose-free formulas are recommended

When to discharge the patient

bull It is recommended that for children receiving care in a hospital setting prompt discharge be considered when the following levels of recovery are reached

bull sufficient rehydration achieved as indicated by weight gain andor clinical status

bull bull IV or NG fluids not required

bull bull oral intake equals or exceeds losses

bull bull adequate family teaching has occurred and

bull bull medical follow up is available via telephone or office visit

How to prevent

This involves intervention at two levels

bull Primary prevention (to reduce disease transmission)

ndash Rotavirus and measles vaccines

ndash Handwashing with soap

ndash Providing adequate and safe drinking water

ndash Environmental sanitation

bull Secondary prevention (to reduce disease severity)

ndash Promote breastfeeding

ndash Vitamin A supplementation

ndash Treatment of episodes of AD with zinc

Post-gastroenteritis syndrome

bull Infrequently following an episode of gastroenteritis the introduction of a normal diet results in a return of watery diarrhoea

bull Temporary lactose intolerance may have developed

bull In such circumstances a return to an oral rehydration solution for 24 h followed by a further introduction of a normal diet is usually successful

bull In very severe cases a period of parenteral nutrition is required to enable the injured small intestinal mucosa to recover sufficiently to absorb luminal nutrients

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use

antibiotics

bull Even though bacterial pathogens are the commonest cause of AD in

developing countries there should be cautious and rational use of

antibiotics to discourage development of microbial resistance avoid side

effects and reduce cost

bull Antibiotics should be used for(is there is need to mention names of ab)

ndash Severe invasive bacterial diarrhoea eg Shigellosis

ndash Cholera

ndash GirdiasisImmunocompromised children

Antibiotics are contraindicated in

bull E coli 0157 H7 because they increase the risk of Haemolytic Uraemic

syndrome (HUS)

bull Uncomplicated salmonella enteritis because they prolong bacteria shedding

Is a lactose-free diet necessary

bull The vast majority of patients with AGE do not develop clinically important lactose intolerance

bull In selected patients with documented persistent lactose intolerance lactose-free formulas are recommended

When to discharge the patient

bull It is recommended that for children receiving care in a hospital setting prompt discharge be considered when the following levels of recovery are reached

bull sufficient rehydration achieved as indicated by weight gain andor clinical status

bull bull IV or NG fluids not required

bull bull oral intake equals or exceeds losses

bull bull adequate family teaching has occurred and

bull bull medical follow up is available via telephone or office visit

How to prevent

This involves intervention at two levels

bull Primary prevention (to reduce disease transmission)

ndash Rotavirus and measles vaccines

ndash Handwashing with soap

ndash Providing adequate and safe drinking water

ndash Environmental sanitation

bull Secondary prevention (to reduce disease severity)

ndash Promote breastfeeding

ndash Vitamin A supplementation

ndash Treatment of episodes of AD with zinc

Post-gastroenteritis syndrome

bull Infrequently following an episode of gastroenteritis the introduction of a normal diet results in a return of watery diarrhoea

bull Temporary lactose intolerance may have developed

bull In such circumstances a return to an oral rehydration solution for 24 h followed by a further introduction of a normal diet is usually successful

bull In very severe cases a period of parenteral nutrition is required to enable the injured small intestinal mucosa to recover sufficiently to absorb luminal nutrients

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use

Is a lactose-free diet necessary

bull The vast majority of patients with AGE do not develop clinically important lactose intolerance

bull In selected patients with documented persistent lactose intolerance lactose-free formulas are recommended

When to discharge the patient

bull It is recommended that for children receiving care in a hospital setting prompt discharge be considered when the following levels of recovery are reached

bull sufficient rehydration achieved as indicated by weight gain andor clinical status

bull bull IV or NG fluids not required

bull bull oral intake equals or exceeds losses

bull bull adequate family teaching has occurred and

bull bull medical follow up is available via telephone or office visit

How to prevent

This involves intervention at two levels

bull Primary prevention (to reduce disease transmission)

ndash Rotavirus and measles vaccines

ndash Handwashing with soap

ndash Providing adequate and safe drinking water

ndash Environmental sanitation

bull Secondary prevention (to reduce disease severity)

ndash Promote breastfeeding

ndash Vitamin A supplementation

ndash Treatment of episodes of AD with zinc

Post-gastroenteritis syndrome

bull Infrequently following an episode of gastroenteritis the introduction of a normal diet results in a return of watery diarrhoea

bull Temporary lactose intolerance may have developed

bull In such circumstances a return to an oral rehydration solution for 24 h followed by a further introduction of a normal diet is usually successful

bull In very severe cases a period of parenteral nutrition is required to enable the injured small intestinal mucosa to recover sufficiently to absorb luminal nutrients

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use

When to discharge the patient

bull It is recommended that for children receiving care in a hospital setting prompt discharge be considered when the following levels of recovery are reached

bull sufficient rehydration achieved as indicated by weight gain andor clinical status

bull bull IV or NG fluids not required

bull bull oral intake equals or exceeds losses

bull bull adequate family teaching has occurred and

bull bull medical follow up is available via telephone or office visit

How to prevent

This involves intervention at two levels

bull Primary prevention (to reduce disease transmission)

ndash Rotavirus and measles vaccines

ndash Handwashing with soap

ndash Providing adequate and safe drinking water

ndash Environmental sanitation

bull Secondary prevention (to reduce disease severity)

ndash Promote breastfeeding

ndash Vitamin A supplementation

ndash Treatment of episodes of AD with zinc

Post-gastroenteritis syndrome

bull Infrequently following an episode of gastroenteritis the introduction of a normal diet results in a return of watery diarrhoea

bull Temporary lactose intolerance may have developed

bull In such circumstances a return to an oral rehydration solution for 24 h followed by a further introduction of a normal diet is usually successful

bull In very severe cases a period of parenteral nutrition is required to enable the injured small intestinal mucosa to recover sufficiently to absorb luminal nutrients

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use

How to prevent

This involves intervention at two levels

bull Primary prevention (to reduce disease transmission)

ndash Rotavirus and measles vaccines

ndash Handwashing with soap

ndash Providing adequate and safe drinking water

ndash Environmental sanitation

bull Secondary prevention (to reduce disease severity)

ndash Promote breastfeeding

ndash Vitamin A supplementation

ndash Treatment of episodes of AD with zinc

Post-gastroenteritis syndrome

bull Infrequently following an episode of gastroenteritis the introduction of a normal diet results in a return of watery diarrhoea

bull Temporary lactose intolerance may have developed

bull In such circumstances a return to an oral rehydration solution for 24 h followed by a further introduction of a normal diet is usually successful

bull In very severe cases a period of parenteral nutrition is required to enable the injured small intestinal mucosa to recover sufficiently to absorb luminal nutrients

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use

Post-gastroenteritis syndrome

bull Infrequently following an episode of gastroenteritis the introduction of a normal diet results in a return of watery diarrhoea

bull Temporary lactose intolerance may have developed

bull In such circumstances a return to an oral rehydration solution for 24 h followed by a further introduction of a normal diet is usually successful

bull In very severe cases a period of parenteral nutrition is required to enable the injured small intestinal mucosa to recover sufficiently to absorb luminal nutrients

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use

Conclusion

bull Prescribe ORS for all ages

bull Continue Breast feeding and diet

bull Explain danger signals

bull 20 mg10 mg of elemental zinc

bull probiotics doubtable value

bull Judicious use of antibiotics for dysentery and systemic infections

bull No anti-motility agents

bull Anti-emitic drugs not for routine use