Professional Documents
Culture Documents
Definition
>10ml/kg/d in infants/children (frequency) Watery, loose stools at least 3 times in 24hrs (consistency)
Epidemiology
Diarrheal disease and dehydration account for 1/3 of all deaths among infants and children under the age of 5 (worldwide) 1.5 million ED visits per year in the U.S. 200,000 hospitalizations and 300 deaths per year in the U.S. In developing countries- estimated 2 million deaths annually in children under 5
Etiology
Rotavirus- 1/3 of all gastroenteritis hospitalizations Others: Adenovirus (40/41), Norwalk, calicivirus, astrovirus
Bacterial:
Parasitic
Giardia, Cryptosporidium
OM, UTI, meningitis, pneumonia, sepsis, HIV Intussusception*, Hirschsprung disease*, partial bowel obstruction*, appendicitis* IBD, CF, celiac, lactase deficiency, IBS Congenital adrenal hyperplasia, hyperthyroidism Antibiotic-associated diarrhea, toxins, overfeeding
GI (anatomic) GI (functional)
Endocrine
Misc.
* Life-threatening conditions that should be considered during an evaluation of a child with diarrhea
Pathophysiology
Immature cells repopulate the villi which have decreased absorptive capacity (decreased enzyme activity) leading to diarrhea Stimulation of water and electrolyte secretion
Diagnosis of Gastroenteritis
C. Difficile if recently on antibiotics or prolonged hospitalization Viral studies (rotavirus, adenovirus) indicated for admission to the hospital (infection control)
Dehydration
Volume depletion or dehydration occurs when fluid is lost from the extracellular space at a rate that exceeds intake. The most common sites for extracellular fluid loss are:
Gastrointestinal tract (eg, diarrhea, vomiting) Skin (eg, fever, burns) Urine (eg, glucosuria, diuretic therapy, diabetes insipidus)
Dehydration
Infants w/ diarrhea are at increased risk for dehydration for the following reasons:
Higher body surface area-to-volume ratio when compared to older children or adults Higher metabolic rate Dependent on others for fluid
Clinical diagnosis:
Mild (3-5%)
Pre-illness weight to determine degree of dehydration is ideal but usually not realistic Determined by examiner and is based on clinical signs/symptoms Prospective study w/ 137 pts using 4 item dehydration scale (gen appearance, eyes, mucous membranes, tears). Sensitivity to predict dehydration:
Literature Review
Combinations of signs are markedly better than any individual sign in predicting dehydration Laboratory tests have only modest utility for assessing dehydration
bicarbonate was the most useful laboratory test. A value below 17 meq/L differentiated children with moderate and severe hypovolemia from those with mild hypovolemia
Diagnostic Studies
Laboratory studies: No gold standard for confirming dehydration BMP indicated in pt with moderate to severe dehydration requiring IVF therapy Urinalysis for urine specific gravity?
Not found to be significantly correlated with dehydration (Steiner, et al. Is this child dehydrated? JAMA 2004; 291)
Electrolyte abnormalities
Loss of potassium in stool can lead to hypokalemia; However, may be higher than expected if acidosis is present
Metabolic acidosis occurs from: loss of bicarbonate in stool, lactic acidosis from decreased tissue perfusion and decreased acid excretion from decreased renal perfusion
May be elevated secondary to decreased renal perfusion (BUN will increase before Cr due to incr. absorption of urea with Na and H20)
Estimate the degree to which the child is dehydrated (mild, moderate, severe) Estimate the fluid deficit:
Acute wt loss from diarrhea is due to water loss (not fat, bone, etc)
1 Liter = 1 Kg; therefore 700ml = 0.7kg Estimated fluid deficit is 700ml to be replaced over 3-4 hours.
Physiologic Basis:
Intestine sees 6500ml/fluid/day, which is reduced to <100ml/day of formed stool due to a large capacity to absorb water. Water absorption is passive and depends on the osmotic gradient created by sodium/carbohydrate transport
Na/H exchangers Electrochemical gradient (Na/K ATPase) Sodium-coupled transport with carrier solutes (i.e glucose)
Rapid replacement of fluid deficit over 3-4 hours Begin at 5ml Q5min and increase as tolerated Mild (3-5%): 50ml/kg ORS over 4hrs Moderate (6-9%): 100ml/kg ORS over 4hrs
Maintain maintenance fluid requirements *Rapid realimentation w/ age appropriate unrestricted diet
Continued feeding slows the progression of dehydration by adding to overall available fluids and promotes mucosal recovery and improves fluid absorption Use of diluted or special formulas is unjustified
Ongoing Losses:
Replace 1cc per cc stool loss OR 10ml/kg per stool and/or 2ml/kg per emesis
Limitations to ORT
Altered mental status with concern for aspiration Abdominal Ileus Underlying disorder that limits intestinal absorption of ORT (i.e short gut, malabsorption)
If there is severe and persistent vomiting, and inadequate intake of ORS If stool output continues to be excessive, and ORT is unable to adequately rehydrate the child.
Enteral Rehydration for mild and moderate dehydration has been shown to have:
Fewer side effects Lower cost Shorter treatment times Fewer admissions
IVF Rehydration
Indicated for severe dehydration or moderate dehydrated pt failing ORT Rapid rehydration approach:
Rapid IV replacement with 0.9NS or LR using 20-60ml/kg over 1-3hrs, followed by introduction of ORS This approach should ONLY be used in pts w/ routine gastroenteritis w/out complicating factors (CHF, renal disease, increased ICP, DKA, etc)
IVF Rehydration
Standard IVF Therapy w/Replacement over 24hrs Initial fluid resuscitation: 20ml/kg bolus w/ normal saline or LR
Example: 12kg patient with estimated 10% dehydration Weight loss= 12 X 0.1= 1.2kg 1.2kg= 1.2L or 1200ml fluid deficit to replace over 24hrs
Replace first (600ml) over first 8hrs Replace second (600ml) over next 16hrs Remember to replace ongoing losses
Anti-emetics
Generally not used in pediatrics secondary to high side-effect profile Ondansetron has been found to be safe and effective in decreasing vomiting and need for admission
Slows intestinal transit time Side Effects: Ileus, abdominal distention, sedation
? Prevention of attachment of microorganisms to the intestinal mucosa Pediatric dosing no longer on labels due to concerns of salicylate toxicity and/or Reye syndrome
Antimicrobials
Exceptions: Giardia, Shigella, cholera, amoebiasis, ETEC Can prolong carrier state in some infections
References:
Behrman: Nelson Textbook of Pediatrics, 17th ed. 2004. Deficit Therapy: 245-251 Davidson G, Barnes G, Bass D, Cohen M, Fasano A, Fontaine O, Guandalini S. Infectious Diarrhea in Children: Working Group Report of First World Congress of Pediatric Gastroenterology, Hepatology and Nutrition. JPGN 2002;35:S143-S150 Farthing, MJ. Oral Rehydration: An Evolving Solution. JPGN 2002;34:S64-S67. Findberg, L. Dehydration in Infancy and Childhood. Pediatrics in Review 2002;23(8)277-282. Hoekstra, JH. Acute Gastroenteritis in Industrialized Countries: Compliance with Guidelines for Treatment. JPGN 2001;33:S31-S33. Hostetler, MA. Gastroenteritis: An Evidence-Based Approach to Typical Vomiting, Diarrhea and Dehydration. Pediatric Emergency Medicine Practice. 2004;1(5):1-17 King CK, Glass R, Bresee J, Duggan C. Managing Acute Gastroenteritis Among Children. Oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003;52(RR-16):1-14 Roberts, KB. Fluid and Electrolytes: Parental Fluid Therapy. Pediatrics in Review 2001;22(11):380-387 Steiner MJ, Dewalt DA, Byerley JS. Is this child dehydrated? JAMA 2004;291(22):2746-2754.