Professional Documents
Culture Documents
Acute Gastroenteritis
(including management of dehydration, bloody diarrhoea and cholera)
Important Points in History
Diarrhoea
o frequency of stools, number of days, blood or mucous in stools
local reports of cholera outbreak or other contacts unwell
recent antibiotic or other drug treatment
attacks of crying with pallor in an infant
feeding history
fever
local mankhwala
Relevant Investigations
Drug Treatment
60
Assessing hydration
For all children with diarrhoea, hydration status should be classified as severe dehydration,
some dehydration or no dehydration and appropriate treatment given.
Classification
Severe
Dehydration
Some
Dehydration
No dehydration
Signs or Symptoms
Two or more of the following signs:
Lethargy/unconsciousness
Sunken Eyes
Unable to drink/drinks poorly
Skin pinch goes back very slowly
( 2 seconds)
Two or more of the following signs:
Restlessness/irritability
Sunken eyes
Drinks eagerly/thirsty
Skin pinch goes back slowly
Treatment
Give fluid for severe
dehydration
PLAN C
<12 months
>12 months
61
Age *
<4 months
4 12 months
12 months 2 years
2 5 years
5 15 years
* Use the childs age only when you do not know the weight. The approximate amount of
ORS required (in ml) can also be calculated by multiplying the childs weight (in kg) by 75.
If the child wants more to drink, give more.
Show the mother how to give ORS solution.
o a teaspoonful every 12 minutes if the child is under 2 years;
o frequent sips from a cup for an older child.
o If the child vomits, wait 10 minutes. Then continue, but more slowly.
o Continue breastfeeding whenever the child wants.
After 4 hours:
o Reassess the child and classify the child for dehydration.
o If the child has improved and the situation allows, most children can be
discharged after this time.
o Select the appropriate plan (A, B or C) to continue treatment.
o Begin feeding the child.
Fluid management of NO deydration (Plan A)
Children with diarrhoea but no dehydration should receive extra fluids to prevent
dehydration. They should continue to receive an appropriate diet for their age, including
continued breastfeeding. Most of these children can be discharged with advice as below:
1. Give extra Fluid (as much as the child will take)
Tell the Mother:
Breastfeed frequently and for longer at each feed.
If the child is exclusively breastfed, give ORS or clean water in addition to
breast milk.
If the child is not exclusively breastfed, give one or more of the following:
ORS solution, food-based fluids (such as soup, rice water, and yoghurt
drinks), or clean water.
It is especially important to give ORS at home when:
the child has been treated with Plan B or Plan C during this visit.
the child cannot return to a clinic if the diarrhoea gets worse.
Teach the Mother how to mix and give ORS. Give the Mother 2 packets of ORS
to use at Home. Show the Mother how much fluid to give in addition to the
usual fluid intake:
Up to 2 years 50 to 100 ml after each loose stool
2 years or more 100 to 200 ml after each loose stool
62
2. Zinc Supplements
These are recommended by WHO, but usually not locally available.
If you are prescribing Zinc, the dose is:
Up to 6 months 1/2 tablet (10 mg) per day for 1014 days
6 months and more 1 tablet (20 mg) per day for 1014 days
Show the Mother how to give the Zinc:
Infants, dissolve the tablet in a small amount of clean water, expressed milk
or ORS in a small cup or spoon; Older children, tablet can be chewed or
dissolved in a small amount of clean water in a cup or spoon.
Remind the Mother to give the Zinc supplements for the full 10-14 days.
3. Continue Feeding
4. When to Return
Return if the child develops any of the following signs:
drinking poorly or unable to drink or breastfeed
becomes more sick
develops a fever
has blood in the stool.
Contents of Modified ORS and ReSoMal
Glucose (mmol/L)
Sodium (mmol/L)
Potassium (mmol/L)
Chloride (mmol/L)
Citrate (mmol/L)
Magnesium (mmol/L)
Zinc (mmol/L)
Copper (mmol/L)
WHO ORS
75
75
20
65
ReSoMal
125
45
40
70
7
3
0.3
0.045
Cholera
Suspect cholera in children over 2 years old who have acute watery diarrhoea and signs of
severe dehydration, if cholera is occurring in the local area. Cholera outbreaks are
particularly seen in the rainy season. Cholera classically causes profuse diarrhoea (ricewater stool) with a characteristic odour and vomiting. It leads rapidly to severe dehydration
and patients may be shocked.
For all children with suspected cholrea
Assess and treat dehydration and shock as for other acute diarrhoea.
Try to accurately estimate losses and replace appropriately with ORS.
Monitor response to rehydration and adjust accordingly
Children with cholera often need large amounts of IV fluids. Several litres is not
unusual.
Give erythromycin 12.5mg/kg qds for 3 days to shorten disease and reduce infectivity
Guardian advice
Give accurate directions re volumes of ORS to give.
Advise about sanitation precautions.
63
64
Diarrhoea with or without blood that persists for at least 14 days or more
Usually follows an episode of acute gastroenteritis
SEVERE persistent diarrhoea = PD + some or severe dehydration
Duration of diarrhoea
Presence of blood in stool
Use of antibiotics and other drugs
Usual feeding practices
VCT
Stool microscopy Giardia, Entamoeba histolytica, isospora
Relevant tests for associated infections
Treatment
(a) Assessment, resuscitation and early stabilisation
Oral rehydration is usually effective (WHO treatment plan B)
IV fluids (WHO plan C) only if essential e.g. worsening diarrhoea with ORS, vomiting,
severe dehydration with acidosis
Screen and treat associated secondary infections
Persistent bloody diarrhoea treat with Nalidixic acid 12.5 mg/kg
Treat amoebiasis with metronidazole: 7.5 mg/kg, 3 times a day.
If Giardia seen/ suspected, give metronidazole 5 mg/kg 3 times a day
If HIV+ consider treatment for isospora (high dose cotrimoxazole) and helminthiasis
(stat albendazole) see HIV guidelines
(b) Feeding
Many children will have poor appetite until diarrhoea lessens and serious infection
has been treated. Special diets are therefore required. Besides giving child energy
and nutrition feeding will also speed up gut recovery.
65
Discuss and address underlying risk factors with guardian appropriate feeding
(breast feeding, supplementary feeding); environmental hygiene and sanitation; HIV
Consider referral to community supplementary feeding program
Reference:
WHO Pocket Book of Hospital Care for Children (Geneva 2005)
WHO The treatment of diarrhoea a manual for physicians and senior health workers
(Geneva 2005)
66
Fluid Management
Before Giving IV fluids THINK does this child need IV fluids?
Be particularly careful with infants and in severe malnutrition
(avoid if possible)
Includes:
a. Maintenance fluids
b. Calculating how fast the IVI should drip
c. How to make up fluids containing 5% or 10% Dextrose
d. Glucose and electrolyte content of IV fluids.
Does not include:
e. Treatment of Shock
- Well nourished/Severely Malnourished child (see shock protocol)
f. Management of Dehydration
- Well-nourished child (see acute gastroenteritis protocol)
- Severely malnourished child (see malnutrition protocol)
- Hypernatraemic dehydration (see acute electrolyte imbalance protocol)
g. Maintenance fluids for neonates (see neonatal protocols)
1. Maintenance Fluids
Calculating fluid requirement for 24 hours: Assuming no dehydration and no extra losses
(e.g. from a surgical drain or from an NGT) a child will require over 24 hours:
100mls/kg for the first 10kg of body weight
+ 50mls/kg for the second 10kg of body weight
+ 20mls/kg for every kg thereafter
Example. A 14 kg boy will need
100mls x 10kg for his first 10kg
+ 50mls x 4kg for his next 4kg
=
1000mls
=
200mls
=
1200mls over 24hours
Which is 50mls per hour (1200mls / 24hours)
Example A 35kg girl will need
100mls/kg for her first 10kg
+ 50mls/kg for her next 10kg
+ 20mls/kg for her last 15kg
=
1000mls
=
500mls
=
300mls
=
1800mls over 24 hours
Which is 75mls per hour (1800mls / 24hours)
If there are other ongoing losses (e.g. from and NGT or from a drain) these should be added
to the total daily fluid requirements
These fluid requirements are the same whether the child takes the fluid orally, by NGT or IV
drip.
Calculating oral fluids requirements per feed:
Example A 7 kg baby who is too breathless to breast feed, but is able to drink expressed
milk from a spoon or cup will require:
100mls x 7kg = 700mls per 24 hours
If the mother is feeding the child every 3 hours, then there will be a total of 8 feeds
per day
67
To work out how fast the IVI should drip the first you need to first determine two things:
1) What type of giving set do you have?
There are three types of giving sets available at QECH
Standard paediatric 60 drops in 1 ml
Standard adult 20 drops in 1ml
Other adult 15 drops in 1ml
Every time you set up an IVI you should check on the giving set package
to determine what type you are using
2) What rate do you want the fluids to run at in mls/hr
You can now work out how many drops per minute the IVI should drip:
Formula:
Examples
Maintenance fluids for a 7.2kg boy. With a 60 drops per 1 ml giving set.
o His maintenance fluid requirements are 7.2kg x 100mls = 720mls per 24 hours
o This is 30mls per hour
o (ml/hr = drops per min for 60 drops per 1ml giving set)
o 30mls per hour means that the IVI should be dripping at 30 drops per minute
o This is 1 drop every 2 seconds
Maintenance fluids for a 33kg girl. With a 20 drops per 1 ml giving set.
o Her maintenance fluid requirements are
(10kg x 100mls) + (10kg x 50mls) + (13kg x 20mls) = 1760mls per 24 hours
o This is 73.3mls per hour
o (Desired rate ml/hr 3 = no. of drops per min for 20 drops per 1ml giving set)
o 73 3 means that the IVI should be dripping at 24 drops per minute
o This is 4 drops every 10 seconds.
3. How to make up fluids containing 5% or 10% Dextrose
If you want to give a child IV fluids containing 5% dextrose or 10% dextrose and there is no
suitable fluid available you will have to make it up by mixing 50% Dextrose and another IV
fluid.
68
Desired Dextrose
Concentration
5% Dextrose
10% Dextrose
10% Dextrose
Amount of 50%
Dextrose
1 part 50 % Dextrose
1 part 50 % Dextrose
1 part 50% Dextrose
Examples:
To make up 100 mls of R/L with 10% dextrose in a burette:
Put 80ml of fluid (Normal Saline/Ringers Lactate) in burette.
Draw up 20ml of 50% Dextrose and add to burette. (80 4 = 20 ml)
This makes 100ml of Normal Saline/Ringers Lactate with 5% Dextrose.
Label the burette using white tape, writing the type of fluid, time of commencement
and rate to be given at.
To make up 400 ml of R/L with 5% dextrose without a burette.
Take a 1L bag of Ringers Lactate and drain it until 360 ml remain.
Draw up 40ml of 50% dextrose and add it to the bag. (360 9 = 40 ml)
This makes 400 ml of Ringers Lactate with 5 % Dextrose.
Label the bag using white tape, writing the type of fluid, time of commencement and
rate to be given at.
4. Glucose and Electrolyte content of IV fluids (contents per litre)
Strength
Darrows / 5%
Dextrose
Ringers
Lactate
Normal Saline
0.9%
5% dextrose
Sodium Potassium
mmol/l mmol/l
61
17
Dextrose
50g
Energy
kcal/l
200
130
50g
200
111
154
154
69
29
Hepatic Disease
1. Infective Hepatitis
2. Cirrhosis
3. Drugs
4. Malignancy
5. Metabolic disease
6. Schistosomiasis (late
stage)
Posthepatic
(Obstructive)
1. Biliary atresia
2. Gallstones
3. Choledochal cyst
4. Worms (ascaris in
common bile duct)
Investigations
70
Blood film
Liver function tests:
o Conjugated bilirubin in liver disease or biliary obstruction,
o Unconjugated bilirubin in haemolysis or hepatitis.
o Transaminases raised in hepatitis
Abdominal ultrasound (shrunken liver in cirrhosis, large bright inflamed liver in
hepatitis, tumours of liver, biliary atresia, choledochal cysts or gallstones)
Hepatitis B serology if hepatitis is considered.
VDRL
If there is ascites, a diagnostic/ therapeutic tap may be necessary.
If clotting screen is necessary discuss with Johns Hopkins lab (near Lepra)
Treatment
Pre hepatic (Haemolysis)
o Blood transfusion if PCV 15% or less.
o Treat underlying cause of haemolysis including sepsis and malaria
o Treat with quinine/LA for malaria even if malaria parasites are negative and
the child has evidence of haemolysis (jaundice, low PCV), and fever.
o Sickle cell crisis: (see sickle cell p45)
Hepatic disease
o Blood sugar level - daily and more frequently if the child has a decreased
conscious state maintain BSL between 4-9 mmol/l.
o Vitamin K: iv if bleeding actively have a low threshold for its use if chronic
liver disease (longstanding jaundice, bruising, signs of chronic liver disease).
o Vitamin A - if chronic liver disease is suspected.
o Diet: Low protein, high carbohydrate. Feed 2 hourly.
o Fluid balance monitoring if encephalopathic need approximately 2/3
maintenance fluid requirement. Monitor daily weight.
o Antibiotics if febrile and jaundiced and MPs are negative. Give Quinine in this
situation.
o Surgical review if varices and GI bleeding. Crossmatch blood.
o In chronic liver disease consider prophylactic ranitidine, nystatin PO
o Avoid Paracetamol. Use ibuprofen if required.
Complications
Haemolysis
o Cardiac failure secondary to severe anaemia
Liver disease
o GIT bleeding from varices, hemorrhoids secondary to portal hypertension
o Oedema due to hypoproteinaemia
o Fat-soluble (ADEK) vitamin deficiency
o Hepatic encephalopathy
o Hypoglycaemia
o Hepatorenal syndrome
o Pancreatitis
o Sepsis particularly gram negative sepsis
71
Length of the history: ask presenting complaint and complaints from the preceding
3/12 period. When last completely well playing / smiling?
Feeding history: Breast Fed (exclusive for how long), weaning (age and with what?),
energy density and frequency of present diet?
Availability and type of food at home?
Anorexia or lack of appetite (< 75% of expected food intake in 20 minutes)?
Vomiting or diarrhoea (and if so duration, aspect, quantity and frequency)?
Previous Illnesses: especially chronic cough (duration & contacts), and persistent
diarrhoea? Chronic otitis media, night sweats, thrush?
Growth chart in Child Health Passport: please copy onto CCP and MOYO CCP!
Oedema distribution and duration; when did it start and what preceded it?
Photophobia (did the child have a recent measles contact)?
Lethargy & apathy/irritability?
Developmental delay (both as a cause and effect of malnutrition)?
Vaccinations up to date (especially measles)?
Mothers HIV status and that of other members of the nucleus family and compliant to
Co-trim and HAART?
Social, Economic and Family History (clues of immune suppression), deaths of other
sibs, orphaned, disruption of family-, economic- or care provision, other difficulties?
72
Relevant Investigations
Blood Sugar (if lethargic, irritable, low BCS, diarrhoea or vomiting, hypothermic),
MPS (malaria apparently not common in oedematous malnourished children),
PCV
Urinalysis (if unsure if diagnosis = kwash)
Blood Culture (low threshold)
Faecal samples for ova and parasites,
HIV testing should be done as soon as possible
Mantoux test: suppressed in severe malnutrition as in HIV infection. If >5 mm
positive, suggests tuberculosis infection
Chest X ray.
Feed volumes and types are calculated and prescribed daily using the tables and
charts in Moyo
Place NGT if the child finishes less than 75% of the formula milk for 2 consecutive
feeds. Other reasons for inserting an NGT are reduced level of consciousness,
lethargy or convulsions, pneumonia with rapid breathing, painful lesions in the mouth
or cleft palate or deformity. The NGT should be removed when the child takes 75% of
the days diet orally, or takes 2 consecutive feeds fully by mouth.
F75 contains 75 kcal/0.9g protein/100mls, F100 contains 100kcal/2.9g
protein/100mls. Both contain extra minerals and vitamins
If possible, continue breastfeeding (including HIV exposed children). To ensure good
lactation, the mother should breastfeed before the child is fed with F75.
73
Phase I Resuscitation/Stabilisation
a. High risk for hypothermia, hypoglycaemia and infections.
b. All children are initially put on F-75 feeds 8 times per day. Volume =
130mls/kg day (100 mls/kg if very oedematous)
c. If appetite is returning, child is more active and alert, complications are
treated and oedema visibly decreasing THEN change to transition phase.
2. Transition (TR) phase
a. Prescribe F100 in the same frequency and volume as it was given with F75.
b. If the child takes this well, increase the volume daily by 10%. If this is
accepted for a period of 4 days without increase in stool frequency or
diarrhoea then assume the small bowel mucosa can accommodate larger
carbohydrate loads and begin RUTF (Chiponde).
c. When on chiponde F100 is switched back to F75 in the same volumes.
Prescribe amount of chiponde as per charts and tables in Moyo
3. Rehabilitation and Catch-Up Phase (II)
a. Begin when consistently gaining weight and finishing at least 50% of
Chiponde target amount, when active, alert and free of complications.
b. During this final catch-up phase in the NRU, the child receives Likuni Phala at
6 a.m. and 6 p.m. instead of F75, and F75 & RUTF for the remaining 6 feeds.
4. When to move back a phase?
a. If worsening of vomiting or diarrhoea, increasing oedema or signs of fluid
overload, loss of appetite move back to phase I and review the same day.
b. These children have a high risk of cardio-vascular compromise while
appearing hypovolaemic.
Complications of Malnutrition
a. Hypoglycaemia (blood sugar < 3mmol/l)
Give 1ml/kg of 50% dextrose. If alert give orally or by NGT. If lethargic by iv
Feed with F75 immediately (avoid rebound hypoglycaemia)
Give 1/6 of the 3 hourly amount of F75 every half-an-hour
Repeat a blood sugar after 30 minutes: if it is >3mmol/l change to 3 hourly feeds
If still low, make sure antibiotics have been given, and continue half-hourly F75.
Transition F75 feeds from half hourly to two hourly feeds
Emphasise the importance of night feeds
b. Hypothermia (axillary temperature of below 350C)
Prevent by giving free blanket, closing windows and discouraging baths in
early morning. Preferably wash just with a wet cloth at lunchtime in the sun,
after a feed and immediately dry in a warm blanket.
Cover the child, including the head
Move the child away from windows
Change wet clothing promptly
Encourage the mother to practice kangaroo care
Use a heater or lamp
Monitor temperature until> 350 C
c. Hypovolaemic- and or septic shock
Defined in malnourished children if lethargic, obtunding/unconscious, cold hands,
plus either slow-capillary refill (>2sec) or a weak or fast pulse, and gallop rhythm.
Give Oxygen and broad spectrum antibiotics. Check glucose
Keep the child warm (preferably on resuscitaire with overhead heater/lamp)
Carefully monitor pulse and respiratory rate
74
d. Dehydration
Use only RESOMAL in malnourished children. Do NOT use regular ORS
Give ReSoMal as follows (see acute gastroenteritis p63 for constituents)
How often to give ReSoMal
Every 30 minutes for first 2 hours
Alternate hours (with F75 at the usual volume) for
up to 10 hours
Amount to Give
5ml/kg
5 10ml/kg
If the child has already received IV fluids for shock and is switching to ReSoMal, omit
the first 2 hour treatment with ReSoMal and start with the amount for the next period
of 10 hours.
Monitor carefully. If there are signs of over hydration e.g. emerging oedema around
eyes, stop ReSoMal.
If the hydration status improves give RESOMAL only after loose stools:
o For children <2 years, give 50 100 ml. after each loose stool
o For children >2 years, give 100 200 ml. after each loose stool
GIVE
1st Line AB treatment = Co-trimoxazole
120 mg if < 5kg 5 BD
240 mg if > 5 kg BD
2nd Line AB treatment (prescribed to
most admitted children)
Chloramphenicol 25 mg/kg t.d.s. i.v. and
Gentamicin 7.5 mg/kg o.d. i.v. /i.m.
Give Ciprofloxacin 10 mg/kg b.d .p.o as
2nd line alternative drug.
3rd Line AB treatment
Ceftriaxone 100 mg/kg OD IV/IM for 7
days
Or if the child can swallow, and Gram
Negative-sepsis is suspected then
Ciprofloxacin 10 mg/kg OD PO 7 days
(and in case NTS infection for 14 days).
75
f.
g. Anaemia (PCV<12%)
Only transfuse children with a PCV<12%, and then preferably with fresh whole blood.
If stable await senior review,
If unstable give a blood transfusion with whole blood (10-15 ml/kg in 6 hours),
Frusemide (1mg/kg) should be given to all children receiving a blood transfusion,
If no signs of cardiac failure, infuse 10-15 mls/kg of blood over 3-6 hours,
If signs of congestive cardiac failure, infuse 7-10 mls/kg of blood over 3-6 hours
NB Only give Fe therapy (3 mg elemental Fe/kg/day) in catch-up growth phase on discharge
h. Photophobia, Xerosis, Bitots spots, xerophtalmia and corneal ulceration
give vitamin A immediately and repeat at day 2 and 14 (see formulary for dose)
In case of ulceration and or keratomalacia:
One drop of Atropine 1% should be instilled into each eye, three times a day,
Chloramphenicol or tetracycline eye ointment 2-3 hourly for 7/7 in each eye,
Eye pads and advise mother to keep the child out of bright sunlight.
Seek ophthalmological advice as soon as possible,
Failure to respond to treatment
1. Definition: During rehabilitation/catch-up phase (phase II) the childs expected weight
gain is about 10-15 g/kg per day. Hence, a child who does not gain at least 5g/kg per
day for 3 consecutive days should be reviewed carefully for failure.
2. The most common causes for not reaching the expected weight gains are:
Inadequate dietary intake (insufficient amount of F75, F100 or Chiponde, the
prescribed (night-) feeds are not given as prescribed, spillage [easily 10% of
prescribed volume], vomiting, anorexia). CONSIDER NGT
Glossitis due to thrush or folate deficiency
Chronic diarrhoea, and malabsorption
Lack of supervisory staff, and/or exhausted guardians from feeding every 3 hours
Inaccurate or faulty recording and weighing
3. Manage treatment failure by:
Review the exact amount of food that the child is taking and calculate the caloric
intake per day (should be > 150 kcal/kg/d).
Treating HIV infection (the decision to start HAART should be discussed with senior
staff)
76
Correct micronutrient deficiencies: is the child receiving a catch-up diet which does
not contain adequate amounts of micronutrients (K, Fe etc.),
Look for underlying occult infection (e.g. TB, HIV, bacteraemia, UTI, Otitis, Thrush),
TB infection should be suspected in any child who does not gain weight for more
than 7 days on AB, who has a TB contact, or symptoms or signs suggestive of TB.
Treat the treatable conditions and increase the caloric intake by increasing the
amount of F100 and or RUTF/Chiponde.
Play
Severely malnourished children often have a delayed mental and behavioural development.
Half an hour focussed and well directed play per day has proven to significantly increase
catch-up growth in height and the childs cognitive development. Play activities dont need
fancy equipment and examples how to make simple, but effective, toys from daily household
cleaning materials can be found with the nursing or Umodzi staff. Children on Moyo should
be seen by the play therapist every day.
77