management of gastroenteritis

1. Marwa Elhady
Ass Prof of pediatrics – Al-Azhar university
Management of
Gastroenteritis

2. Diarrhea:
Passage of unusual loose or watery stool
>3 times in 24 h
 Consistency is more important than number
 Vomiting alone has many DD lastly GE
(It may be early presentation of rota virus)
 Greenish stool caused by bile pigment biliverdin due
to hurried intestinal motility (not GE)
 Breast feed infant often pass frequent loose stool
(normal habit)
 Do not mistake gastro-colic reflex as diarrheal
disorder

3. Diarrhea ± fever or vomiting
Acute onset
last <14 d
Acute onset
last >14 d
Insidious
last >14d
mucous +blood
pain+tenesmus

4. Evaluation

5. Management of GE
ttt of the
cause
Symptomatic
ttt
Prevent
complications

6. Bacterial
(pus in stool)
AB according to C/S
Empirical
3rd G cephalosporin
50-100mg/kg for 3-5d
Sulfa (TMP-SMZ) twice/d
5d
Ciprofloxacin
20-30mg/kg/d for7-10d
Parasite
(vegetative form in stool
analysis)
Metronidazole
25mg/kg/d for 7-10d
Nitazoxanide
Effective for bacterial,
parasite, rota v
7.5mg/kg/d for 3-5d

7. Kaolin/pectin
adsorpant
Probiotic
1x2x3d
Zinc
20mg/kg/d
1x2x10d
Mixtures
Hidrasec
1x2x5

8.  Cold fomentation
 Antipyretics
 Paracetamol 10-15mg/kg/dose/4-6h
 Ibuprofen 10-40mg/kg/day/6-8h
 Diclofenac 1-3mg/kg/d/8-12h
Fever
Vomiting
 Cold ORS at slow rate
 Antiemetics (centrally acting)
• Ondansetron (zofran, danset)
• Others (not recommended for use):
Alizapride (nausilex), Domperidone (Motilium), Metoclopramide
(Primperan), Cortiplex B6
• Antacids (for gastritis not for GE): Ranitidine, omeprazole

9. Dehydration (2nd commonest cause of death)

10. Plan A
(no dehydration)
Replace loss: ORS
Wt<10 kg: 60-120 ml &
Wt >10 kg:120-240 ml
for each diarrhea or
vomiting
Continue feeding
Come back if
• ↑↑watery stool
• ↑↑ vomiting
• ↑↑ fever
• ↑↑ thirst
• Poor feeding
• Blood in stool
• No improve > 3d
Plan B
(Mild to moderate
dehydration
Rehydration
(deficit ttt): ORS
50-100 (75) ml/kg
over 3-4 hr.
oral or NG tube
Replace loss
Feeding
Reevaluate
if persistent
vomiting , be sever
dehydrated so give
IV fluid
Plan C
(sever dehydration)
Rehydration: IVF
Shock ttt
Saline 0.9 (beast) or
Ringer lactate
20ml/kg over 15-20min
up to 60ml/kg over 1h
till perfusion & mental
status improve
Deficit & maintenance
ORS 100 ml/kg over 4h
Then replace loss
Or
IVF if not tolerate oral
(according to Na, K)

11. Normal saline 0.9% = Na 153mEq/l
Glucose 5% = 50gm Glucose/L (17cal/100 ml)
Ringer lactate = Na 131mEq/l + K + lactate
Pansol = G5%: saline 0.9 (2:1) + K
Pediament : G10% : saline (4:1) + K
Shock ttt : 20-60ml/kg within 1st h
Deficient (according to severity of dehydration) :
60-80ml/kg within 6h (except in hypernatremia)
Maintenance (according to electrolytes)
100ml/kg for 1st 10kg then 50ml/kg for 2nd 10kg then
20ml/kg/d
Replacement of ongoing lose (Replace ml/ml every 1-6 h):
diarrhea: D5½NS + 3mEq/100ml NaHCO3+ 2mEq/100ml KCl
Vomiting: normal saline + 1 mEq/100ml KCl
monitor Wt, UOP, and electrolytes

12. For shock ttt: Saline 0.9% is preferred than RL
Deficit & maintenance ttt: According to serum Na, K
Isonatremic (Na 135-145 mEq/l)
use G5:NS 2:1 or 4:1 + KCl 1-2cm/100ml fluids Or use Pansol
Hyponatremic (Na <130 mEq/l)
Use G5%: NS 1:1 + Kcl 1-2cm/100ml fluids
If Na<120 or CNS ≠: give NaCl 3% (desired Na – actual Na) x Wt
Hypernatremic (Na > 150 mEq/l)
Duration of correction according to initial serum Na
(difict+maintanance): 1.25-1.5 times maintenance
[Na] 145-157 mEq/L: 24 hr
[Na] 158-170 mEq/L: 48 hr
[Na] 171-183 mEq/L: 72 hr
[Na] 184-196 mEq/L: 84 hr
IVF : G5% ½ NS (+1-2mEq/100ml KCl) = 2:1
If Na decreases too slowly: ↓ Na conc in IVF =3 or 4:1
Na correction should not exceed 12 mEq/l/24 hr

13.  Fruit ‫تفاح‬/‫جوافه‬/‫كمثري‬/‫موز‬ /‫رمان‬
 Vegetables ‫جزر‬/‫كوسه‬ ‫بدون‬ ‫خضار‬ ‫شوربه‬
 Starch, CHO, cereals
‫بطاطس‬/‫بطاطا‬/‫ابيض‬ ‫دقيق‬ ‫مشتقات‬/‫نشا‬/‫الحبوب‬(‫ارز‬/‫قمح‬/‫ذره‬/‫شوفان‬/‫حمص‬)
 Drinks ‫سكر‬ ‫بدون‬ ‫خفيف‬ ‫شاي‬/‫عصيرليمون‬/‫زبادي‬
 Chicken, meat
Constipating diet
Avoid
Soft drinks
canned juice
high sugar or fat containing food
laxative diet ‫باقي‬‫ا‬‫لفواكه‬/‫كوسه‬/‫ملوخيه‬
Correct underlying malnutrition
additional meal for 2 weeks after diarrhea

14.  Promotion of Exclusive Breastfeeding
 Improved Water and Sanitary Facilities
 Good Hygiene (hand washing +soap)
 Improved Complementary Feeding Practices
 Improved Case Management of Diarrhea
 Rotavirus vaccination
 Rotarix : 2 doses at 1.5m,3m
 Rotateq :3 doses at 1.5,3,4.5m

15. Persistent diarrhea(>14 days)
Assessment and stabilization
IV or oral rehydration
Treat electrolyte imbalance
Screen and treat associated infections
Recovery Continued
Follow-up for growth Reevaluation
Continued breastfeeding
lactose free formula
Cereal (rice-based) diet
Replacement of milk with yogurt
zinc, vitamin A supplementation