Gastroenteritis in Children

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Gastroenteritis in Children

• Dr. Osama Y. Kentab,M.D., FAAP, FACEP.
• Consultant Pediatric Emergency Medicine
• King Abdulaziz medical city - riyadh

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Fluid and ElectrolytesCase I

• 9 month old, 9 kg child with 2 days of vomiting
  and diarrhea
• T 38.5C, HR 158, RR 38, BP 90/50
• crying without tears, capillary refill 3 sec
• abdomen soft, non-tender, without HSM
• How dry is this child?

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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

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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

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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

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Assessment of dehydration
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Clinical Findings in Dehydration
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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 Management of 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

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Treatment of Dehydration in ChildrenOral
Rehydrateon

• Contraindications for ORT
• Severe dehydration / uncompensated shock
• Preterm infant
• Severe ongoing vomiting
• High stool output (gt20ml/kg/hr)
• Poor compliance

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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

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Treatment of Dehydration in ChildrenOral
Rehydration

• Procedure for oral rehydration
• Determine volume required
• replace entire deficit over 4 hours
• 50 cc/kg for mild dehydration
• 80-100 cc/kg for moderate to severe
• ongoing losses
• 5-10 cc/kg for each diarrheal stool
• 2 cc/kg for each episode of emesis

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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

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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

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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)

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Treatment of Dehydration in ChildrenOral
Rehydration
0
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Can Oral Rehydration SolutionsBe Safely Flavored
at Home
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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

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Case 1 Isotonic Dehydration

• Child has persistent vomiting and diarrhea. He is
  refusing POs.
• 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)?

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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

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Emergency Phase

• 20 cc/kg normal saline or ringers 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

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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 4 10-20 kg 50 cc/kg/d 2 gt20
  kg 20 cc/kg/d 1

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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 hours
• 500 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

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Acute Dehydration (lt 3 Days)Total Body Water
Losses
ICF 20
ECF 80
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Acute Dehydration (gt 3 Days)Total Body Water
Losses
ICF 40
ECF 60
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Electrolytes
K ICF x 150 mEq/L
Na ECF x 140 mEq/L CL ECF x 110 mEq/L
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Electrolytes

• Maintenance
• Sodium 2-3 mEq/kg/day
• Chloride 2 mEq/kg/day
• Potassium 1-2 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)

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Case 1 Isotonic Dehydration

• Maintenance
• Sodium 30 mEq/day 10 mEq/8 hrs
• Potassium 20 mEq/day 6.7 mEq/8 hrs
• Deficit
• Sodium .8 x l000cc x 140 112 mEq
• Potassium .2 x 1000cc x 150 30 mEq

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Case 1 Isotonic Dehydration

• Potassium
• (Calculated per day)
• 20 mEq (maintenance)
• 15 mEq (1/2 of deficit)
• 35 mEq in 1.8L per day
• 20 mEq/L over 8 hrs
• with 20 mEq/L KCL

• Sodium
• (Calculated for 8 hrs)
• 10 mEq (1/3 of maint.)
• 56 mEq (1/2 of deficit)
• - 31 mEq (.2 L bolus NS)
• 35 mEq in .663 L
• 55 mEq/L over 8 hrs
• D5 1/3NS at 80cc/hr

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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?

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Signs and Symptoms ofHyponatremia

• Related to level and rate of fall of serum sodium
• Anorexia
• Nausea
• Lethargy/ disorientation
• Hypothermia
• Cheyne - Stokes respirations
• Seizures

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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

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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)

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Case 2 Hyponatremic Dehydration

• Emergency phase
• 2cc x 5kg 10 cc 3NS
• 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

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0
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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?

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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 gt 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

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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

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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

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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.

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Case 4
0

• 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

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Case 4 Pediatric BurnsBurn Management

• Full HP
• Prevent ileus (NPO,NO tube)
• Relieve pain
• Treat burn
• Tetanus
• Transfer to burn center as needed

• Stop Burning Process
• ABCs
• Obtain access
• Evaluate for major trauma
• Maintain body temperature (dry blankets)

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Case 4 Pediatric Burns

• Face 6.5
• Chest 6.5
• Arms 10
• Abdomen 6.5
• Total 29.5

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Case 4 Pediatric Burns

• Parkland Formula
• Accounts for deficits and ongoing losses
• Does not account for maintenance in children
  under 5 yrs
• For bums gt 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/Os very closely

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Case 4 Pediatric Burns

• Back to our patient
• (4 cc/kg ) (20 kg) (29.5 BSA) over 24 hours
• 2380 cc Ringers lactate over 24 hours
• 1180 cc in 8hours (150cc/hour)
• Add maintenance fluids
• Do not add potassium during early phase

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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

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Case 5

• Further examination
• RUQ mass
• Laboratory
• Na 127, K 2.5 , Cl 70, Co2 34
• 7.58/48/307/38/16

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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

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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

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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

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Case 5 Pyloric Stenosis

• Treatment
• D5 NS
• avoid hypotonic fluids
• high risk of hyponatremia
• add K when urine output adequate
• Surgical pyloromyotomy

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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

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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

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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

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Antidiarrheal agents

• Not recommended
• Serious side effects (e.g. paralytic ileus,
  sedation, worsening diarrhea)
• Murphy MS.Arch Dis Child 1998

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