Gastroenteritis in Children DR. OSAMA Y. KENTAB,M.D., FAAP, FACEP. CONSULTANT PEDIATRIC EMERGENCY...

Gastroenteritis in Children

DR. OSAMA Y. KENTAB,M.D., FAAP, FACEP.CONSULTANT PEDIATRIC EMERGENCY MEDICINE

KING ABDULAZIZ MEDICAL CITY - RIYADH

Fluid and Electrolytes

Case I 9 month old, 9 kg child with 2

days of vomiting and diarrheaT 38.5C, HR 158, RR 38, BP 90/50crying without tears, capillary refill 3

sec abdomen soft, non-tender, without

HSM

How dry is this child?

How dry is this child?

1. Mild Dehydration

2. Mod Dehydration

3. Severe Dehydration

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Dehydration

Infants are at higher risk for dehydration due to: larger baseline water content higher metabolic rate renal immaturity inability to meet own intake needs

Conventional Clinical Assessment of Dehydration

Gold standard for dehydration fluid deficit as percentage of body weight lost

Pre-illness weight - weight at presentation pre-illness weight

pre-illness weight rarely known, so use clinical findings to estimate

deficit

Infectious Etiologies Identified In Children Admitted For Dehydration

Description Viral enteritis

NOS Rotavirus Salmonella spp Shigella spp Bacterial

enteritis NOS Clostridium spp E. coli

(pathologic/invasive)

(%)

21.9

1.9

1.0

1.0

0.7

0.6

0.5

Assessment of dehydration

Severity Body FluidLost

% WeightLost

Shock State

Mild 50 ml/kg 5% Impending

Moderate 50 – 100 ml/kg 10% Compensated

Severe >100 ml/kg > 10% Uncompensated

Clinical Findings in Dehydration

% Skin Mucosa Pulse BloodPressure

0 Good Turgor Moist Normal Normal

5 Dry Dry, no tears Mildly Orthostatic

10 Tenting Very dry Mod , weak Mildly

15 Poorlyperfused

Parched Marked ,Thready

Markedly

First line of treatment is?

1. ORS in mild/mod with no vomiting

2. IV fluid

3. Anti diarrheal Drugs

4. Anti emetic drugs

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Guidelines for Managementof Dehydration

ORT is first line of treatment for mild/moderate dehydration

All medical facilities (office and ED) should have ORT available

Parents of Infants seeking care for diarrhea should be trained in use of ORT and early feeding

Symposium on ORT

Pediatrics , 1997; 100 (5): e10

Treatment of Dehydration in ChildrenOral Rehydrateon

Contraindications for ORT Severe dehydration / uncompensated shock

Preterm infant

Severe ongoing vomiting

High stool output (>20ml/kg/hr)

Poor compliance

Commonest Barriers to ORT in KSA?

1. Physician/staff knowledge/familiarity

2. Convenience

3. Availability of solutions

4. Parent/patient and physician attitudes

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Treatment of Dehydration in ChildrenOral Rehydrateon

Barriers to ORT in KSA Physician/staff knowledge/familiarity Convenience Availability of solutions Parent/patient and physician

attitudes Reimbursement issues

Treatment of Dehydration in ChildrenOral Rehydration

Procedure for oral rehydrationDetermine volume required:

replace entire deficit over 4 hours50 cc/kg for mild dehydration80-100 cc/kg for moderate to severe

ongoing losses5-10 cc/kg for each diarrheal stool 2 cc/kg for each episode of emesis

Essential Steps Of Oral Rehydration Therapy.

Select an appropriate fluid

Estimate the degree to which the child is dehydrated

Estimate the fluid deficit

Example: 10 kg child, estimated at 7% dehydrated, has a weight loss of: 0.07 x 10 = 0.7kg

Acute weight loss with vomiting and diarrhea is due to water loss

Since 1 L water weighs 1kg, 700 ml water weighs 0.7kg.

Begin oral rehydration at a rate of 5 ml every 5 minutes (use a watch or clock for timing)

Increase the rate of intake as tolerated

Goals include replacing at least 10 ml/kg in the first hour and having the total fluid deficit replaced within 4 hours

Case 1

Moderately dehydrated 10% dehydrated 10kg child

Oral rehydration therapy 50 x l0 = 500cc deficit

(10 x 10)+(2 x 10) = 120 cc for ongoing losses

620 cc over 4 hours

155 cc/hr = one ounce every 15 minutes

= 10cc by syringe every 5 minutes

Appropriate oral rehydration solutions

1. 75-90 mmol/L of Na for Rehydration

2. 45-50 mmol/L for Rehydration

3. Base is 50 mmol/L

4. Glucose is 1.5%

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Treatment of Dehydration in ChildrenOral Rehydration

Appropriate oral rehydration solutions

Na:

75-90 mmol/L for rehydration

45-50 mmol/L for maintenance

base: 20-30 mmol/L

glucose (%): 2-2.5% (optimum glucose-Na cotransport)

Treatment of Dehydration in ChildrenOral Rehydration

Na (mEq/L)

K (mEq/L)

Cl (mEq/L)

Base (mEq/L)

Glu (gm/L)

Osm (mmol/L)

Rehydration WHO

Rehydralyte

90 75

20 20

80 65

10 10

20 25

310 305

Maintenance Pedialyte

45

20

35

10

25

250

Clear Liquid Cola

Apple Juice Chicken Broth

Gatorade

2 3

250 20

0.1 1 8 3

2 2

250 17

13 4 0 3

126 124

0 46

750 540 450 330

Can Oral Rehydration SolutionsBe Safely Flavored at Home

Solution Na K Cl Glu OSM

WHO 90 20 80 111 310

Pedialyte 45 20 35 140 250

Pedialyte (4 oz) plus2.5 cc unsweetened

Jello powder30 cc apple juice

30 cc orange juice

50

3938

20

2126

39

3035

138

141139

315

330312

Treatment of Dehydration in Children Alternative Oral Rehydration Solutions

Homemade ORS 1 liter of water 1/2 tsp. salt 5 tsp. table sugar 50 mEq/L Na, 2.1% CHO

Half-strength apple juice (8 oz) with 8 -10 saltine crackers 60 -70 mEq/L Na

Case 1: Isotonic Dehydration

Child has persistent vomiting and diarrhea. He is refusing PO’s. Na 140, K 4.8, Cl 108, HCO3 10, BUN 25,

Cr1.0, Glu 160

How would you treat him with IV fluids Which fluids? What rate? When to switch to maintenance (and

which fluids with what rate)?

Isotonic Dehydration

First 8 hours Emergency phase: 1/2 - 1 hour Replacement phase: 7-7.5 hrs

Deficit - 1/2 total in1st 8hrs(1/2 in next 16 hr.)

Maintenance - 1/3 daily requirement

Additional 10% for fever

Ongoing losses: determined per hour

Emergency Phase

20 cc/kg normal saline or ringer’s lactate bolus over 20-30 minutes

Re-assess Repeat 10 cc-20 cc/kg as needed 2-4 cc/kg D10 bolus for hypoglycemia

if needed

Goal: Normalized vital signs

Urine output

Replacement Phase

Quick Answer D5 1/2 NS at 2 times maintenance fluid rate

Quick Maintenance Rate Body Wt ml/kg/day ml/kg/hr

1st 10kg l00cc/kg/d 410-20 kg 50 cc/kg/d 2>20 kg 20 cc/kg/d 1

Case 1: Isotonic Dehydration

200cc NS bolus with HR l30 and urine output

Deficit = 100cc/kg = 1000cc Maintenance = 100cc x 10kg =

1000cc/day = 42cc/hr 1000 +1000 - 200 = 1800 = 1.8L in 24 hour.

First 8 hours500 cc (1/2 1000cc deficit)

+ 333cc (1/3 of 1000 cc/day maintenance)

- 200cc (emergency phase bolus)

633 cc over 8 hours

80 cc/hr for 8 hours

Acute Dehydration (< 3 Days)Total Body Water Losses

ICF20%

ECF80%

ICFECF

ICF 20%

ECF 80%

Acute Dehydration (> 3 Days)Total Body Water Losses

ICF40%

ECF60%

ICFECF

ICF 40%

ECF 60%

Electrolytes

Na = % ECF x 140 mEq/LCl = % ECF x 110 mEq/L

K = % ICF x 150 mEq/L

ICFECF

K= %ICF x 150 mEq/L

Na= %ECF x 140 mEq/L

CL = %ECF x 110 mEq/L

Electrolytes

MaintenanceSodium 2-3 mEq/kg/dayChloride 2 mEq/kg/dayPotassium1-2 mEq/kg/day

Deficit Sodium %ECF x fluid deficit x 140 mEq/L Chloride %ECF x fluid deficit x 110 mEq/L Potassium %ICF x fluid deficit x 150 mEq/L

(replace only 1/2 of K deficit in 1st 24 hrs)

Case 2

3 month old infant with seizures. Full term infant with 2 day history of

watery stools. T 33.9C, HR 90, RR 20, BP 70/palp,

Wt 5kg Fontanelle sunken, dry mucus

membranes, cool extremities

What is your initial management?

Signs and Symptoms ofHyponatremia

Related to level and rate of fall of serum sodium

Anorexia

Nausea

Lethargy/ disorientation

Hypothermia

Cheyne - Stokes respirations

Seizures

Symptomatic Hyponatremia

Goal to increase Na to 125 mEq/L 3% NS = 0.5 mEq/cc Transient serum increase of 5-10

mEq/L 0.2 (plasma is 20% of TBW) x Wt x 5

- 10 mEq 1-2 mEq x kg 2-4 cc/kg 3% NS to raise serum Na 5-

10 mEq

Hyponatremic Dehydration

Emergency phase Treat CNS manifestations with 3% NS

Fluid resuscitation with 20 cc/kg NS

Replacement phase Replace fluid deficit

Replace Na deficit with goal of 135 mEq/I = ( l35mEq/l - actual Na) x 0.6 x kg

Increase Na 10 mEq/l per day

(risk of osmotic demylination syndrome)

Case 2: Hyponatremic Dehydration

Emergency phase 2cc x 5kg = 10 cc 3%NS 20cc/kg NS bolus x 2 = 200cc NS

Replacement phase (repeat serum Na = 125mEq/L) Na deficit = (135-125) x 0.6 x 5 = 30 mEq Add to “standard” Na deficit

=0.8 x 0.5 L x 140 = 56 mEq

Add to maintenance Na = 2 x 5 kg =10 mEq Total = 96 mEq/L = D5 1/2NS with 20mEq/L

KCL

Case 3

3 year old 15 kg child with profuse watery diarrhea increasing irritability T 38.70C, HR 150, RR 40, BP 95/55 doughy skin Na 160, K 3.5, Cl 120, CO2 10

What is your initial management?

Hypernatremic Dehydration

Emergency phase Fluid resuscitation with 20 cc/kg NS

Replacement phase Calculate free water deficit

4cc/kg for each l mEq/L of Na > l45mEq/l Replace free water deficit over 48 hours Lower serum Na 0.5-1 mEq/hr or 15

mEq/day Monitor for hypocalcemia and

hyperglycemia

Hypernatremic Dehydration

Hypertonic state causes free water movement from cells to ECF to decrease osmolality

Brain responds by making idiogenic osmoles to prevent intracellular dehydration

Rapid decline of osmolality will not allow time to “inactivate” idiogenic osmoles and may lead to cerebral edema

Case 3: Hypernatremic Dehydration

Emergency phase 20cc/kg NS bolus = 300cc NS

Replacement phase (to be given over 2 days) Total fluid deficit = 10% dehydrated

= 100cc/kg = 1500cc Free water deficit =

(160-l45mEq/L) x 4ml/kg x l5 kg = 900 ml

Solute containing solution = 1500 - 900 = 600cc

Case 3: Hypernatremic Dehydration

Fluid rate (calculated for 48 hours period) 1500cc deficit + 2500cc maintenance -

300cc emergency phase = 3700/48 hr = 77cc/hr

Na Na deficit = 0.8 x 0.6 L x 140 = 67mEq Add maintenance Na = 3 x l5 kg x 2

days = 90 mEq Less emergency NS bolus Na = 0.3 x 154

= 46 = 111 mEq/4.4L= 25 mEq/L D5 1/4NS with 20 mEq/Kcl at 77cc/hr Monitor serum Na, Ca, Glucose.

Case 4

5yo child 2nd and 3rd degree bums from car radiator

T 37.9C, HR 150, RR 36, BP 105/65 bums on face, chest, arms, and abdomen

Case 4: Pediatric BurnsBurn Management

Stop Burning Process

ABC’s Obtain access Evaluate for

major trauma Maintain body

temperature (dry blankets)

Full H&P Prevent ileus

(NPO,NO tube) Relieve pain Treat burn Tetanus Transfer to

burn center as needed

Case 4: Pediatric Burns

Face 6.5%

Chest 6.5%

Arms 10%

Abdomen 6.5%

Total 29.5%

Case 4: Pediatric Burns

Parkland Formula Accounts for deficits and ongoing losses Does not account for maintenance in

children under 5 yrs For bums > 20% BSA

2-4 cc/kg/%BSA over 24 hours 1/2in first 8hours from burn; 1/2 in next l6

hrs Objective - At least 0.5 to 1 cc/kg/hr urine

output Follow vital signs and I/O’s very

closely

Case 4: Pediatric Burns

Back to our patient (4 cc/kg ) (20 kg) (29.5% BSA) over 24 hours

2380 cc Ringer’s lactate over 24 hours

1180 cc in 8hours (150cc/hour)

Add maintenance fluids

Do not add potassium during early phase

Case 5

6 week old male History

projectile vomiting poor weight gain abnormal breathing pattern

Physical periodic breathing with 15 sec pauses HR 190, HP 90/44 sunken fontanelle; tenting of skin CR 3 sec

Case 5

Further examination

RUQ mass

Laboratory

Na 127, K 2.5 , Cl 70, Co2 34

7.58/48/307/38/+16

Case 5 : Pyloric Stenosis

Initial resuscitation with 20cc/kg of NS Patient with HR 190, BP 89/40 Repeat 20cc/kg NS (40cc/kg total) HR 180, BP 85/40 Repeat 20cc/kg NS bolus (80cc/kg total) Reassess

Case 5 : Pyloric Stenosis

Narrowing of the pyloric canal due to hypertrophy

First born male Age at onset: 2 to 5weeks Clinically well for the first weeks of life Vomiting becomes more prominent and forceful

Case 5 : Pyloric Stenosis

An olive may be felt Gastric peristaltic waves may be

seen Profound hypochloremic

metabolic alkalosis gastric losses high serum bicarb Chloride often 65 -75 Acidosis develops when critically ill

Case 5 : Pyloric Stenosis

Treatment D5 NS

avoid hypotonic fluids

high risk of hyponatremia

add K when urine output adequate

Surgical pyloromyotomy

Intravenous Rehydration

Rapid rehydration approach Found to be both safe and effective rapid oral and IV rehydration

reduction in admissions for moderately dehydrated children — from 96.3% to 55.8%

discharged in 8 hours or less improved from 4% to 44%

Holliday MA,etal Pediatr Nephrol 1999

Sunoto.Paediatr Indones 1990

Phin SJ etal, J Paediatr Child Health 2003

Nasogastric Rehydration

Rapid nasogastric VS IV rehydration 50 mL/kg over a 3-hour period Both were safe Cost-effective alternatives to the

standard treatment for moderate dehydration

Nager AL etal,Pediatrics 2002

Realimentation

Improves gastrointestinal structure and function

Reduced duration of illness and improved weight gain

The same foods or formula or breast milk the child had been taking prior to the illness

Removing milk or routine dilution of milk is not necessary

Duggan C etal,J Pediatr 1997

Brown KH etal, Pediatrics 1994

Antidiarrheal agents

Not recommended Serious side effects (e.g. paralytic

ileus, sedation, worsening diarrhea)

Murphy MS.Arch Dis Child 1998