Acute gastroenteritis in children

1. ACUTE
GASTROENTERITIS
IN CHILDREN
Moderated by Dr. Madhuri Engade
By Dr. Akshay Golwalkar

2. LEARNING OBJECTIVES
 Definitions of various types
 Common organisms & pathophysiology
 Identification of severity of dehydration & prompt
management
 Rationale behind ORS & its use
 Management of Acute diarrhea
 Management of Other complications
 Preventive measures

3. DEFINITIONS**
 Acute Diarrhea is the passage of loose* or watery stools,
three times or more in a 24 hour period for upto 14 days
 In the breastfed infant, the diagnosis is based on a
change in usual stool frequency and consistency as
reported by the mother
 Acute Diarrhea must be differentiated from “persistent
diarrhea which is of >14 days duration” and may begin
acutely.
*Takes the shape of the container
**World Health Organization, Global Burden of Disease estimates, 2004 update

4. MAGNITUDE OF PROBLEM
 One in 5* children die of diarrhea or diarrhea
related complications every year in India.
 Diarrheal illness is the second leading cause of
child mortality; among children younger than 5
years, it causes 1.5 to 2 million deaths annually.
 In developing countries, children experience
between three to six episodes of diarrhea annually.
*Predicting the distribution of under-five deaths by cause in countries without adequate vital registration systems
Saul S Morris,1 Robert E Black2 and Lana Tomaskovic3(International Journal of Epidemiology 2003;32:1041–1051)

5. MAGNITUDE OF PROBLEM
 In India,~380,000 *children die from diarrhea and its complications
every year.
 9.8 million child deaths each year, 2/3 of which are preventable with
low-cost interventions
 2 million child deaths from diarrhea, 88% of Diarrhea diseases are
preventable by easily available interventions.
 Diarrheal diseases are responsible for 18%** of deaths among children
under 5 years of age.
 Despite easy and affordable treatment, most patients do not access the
recommended treatment.
 Timely use of ORS-Zinc can save over 133,000 lives by 2015***
*World Health Organization, Global Burden of Disease estimates, 2004 update.
**Causes of Child Deaths - March 26, 2005 The Lancet
***Role of zinc administration in prevention of childhood diarrhea and pneumonia-a meta analysis,Agarwal I R,Sentz J,Miller M
A,Paediatrics 2007,June 119(6)

6. CAUSES OF CHILD DEATHS IN LOW-INCOME
COUNTRIES: DIARRHEA 18%*
*Causes of death among children under age of five years
UNICEF: Progress for children, 2007

7. CAUSES AND RISK FACTORS FOR ACUTE
DIARRHOEA
 Microbial, host and
environmental
factors interact to
cause Acute
Gastroenteritis
Host Factors
Environmental
Factors
Agent(Diarrheal
pathogens)

8.  Biological factors increase
susceptibility to Acute
Diarrhoea
 Malnutrition is associated with an
increased incidence, severity and
duration of diarrhoea
 Age
 Failure to get immunised against
rotavirus
 Failure of measles vaccination
 Selective IgA deficiency
 HIV
 Behavioral factors increase
the risk of Acute Diarrhoea
 Not breastfeeding exclusively for
6 months
 Using infant feeding bottles
 Not washing hands after
defecation, handling faeces or
before handling food
HOST FACTORS

9. DIARRHEA & MALNUTRITION
VICIOUS CYCLE
 Absorption
 Appetite
Voluntary restriction
 Immunity
 Mucosal integrity
Common
predisposing factors
 Losses
 Catabolism

10. ENVIRONMENTAL FACTORS
These include:
 Seasonality:The incidence of Acute
Diarrhea has seasonal variation in
many regions
 Poor domestic and environmental
sanitation especially unsafe water
 Poverty
An improved water supply in a
peri-urban setting

11. COMMON PATHOGENS
 More than 20 viruses, bacteria and parasites have been
associated with acute diarrhea
 Worldwide, rotavirus is the commonest cause of severe
dehydrating diarrhoea causing 0.6 million deaths annually,
90% of which occur in developing countries
Other viral agents
• Enteric
adenoviruses
• Astrovirus
• Human calciviruses
(norovirus and
sapovirus)
Bacteria
• E. coli (ETEC, EPEC,
EHEC, EAEC, EIEC*)
• Shigella species*
• Vibrio cholerae O1 &
O139
• Salmonella sp*
• Campylobacter jejuni*
• C. difficile
Parasites
• Entamoeba
histolitica*
• Girdia lamblia
• Cryptosporidium
• Trichuris trichuria
• Strongyloides
stercoralis
*causes diarrhea with or without dysentry

12.  Viral
70-85% of AGE in developed countries
Rotavirus: 60% of all pediatric AGE.
Seasonal variation: increased in winter and decreased
in summer.
Caliciviruses, astroviruses, and enteric adenoviruses
 Presentaion:
Low-grade fever
Vomiting followed by copious watery diarrhea (up to
10-20 bowel movements per day)
Usually non foul smelling
Symptoms persisting for 3-8 days
ETIOLOGY

13. ETIOLOGY
 Bacterial
• Campylobacter, Salmonella, Shigella, E. coli, Yersinia,
Clostridium difficile
 Presentation:
• High fevers with Shaking chills
• Foul smelling stools
• Bloody bowel movements (dysentery)
• Abdominal cramping & fecal leukocytes
*ETEC is unlikely to cause dysentery.

14.  Parasitic
 Giardia and Cryptosporidium
 <10% of cases
 Presentation:
Watery stools greenish, frothy stools
Urgency of passing stools after meals
Low-grade fever
differentiated from viral gastroenteritis by a protracted course
or history of travel to endemic areas
ETIOLOGY

15. PATHOGENESIS
 ECF : ICF
 Isonatremic vs Hyponatremic vs hypernatremic
dehydration
 Electrolyte imbalance

16. PATHOGENESIS
 Hemodynamic Changes
 Skin turgor change

17. PATHOPHYSIOLOGICAL CHANGES*
Type Mechanism Complications
Secretory Acute watery diarrhea
Sodium pump failure
Rapid development of
dehydration
Electrolyte imbalance
Invasive Microbes invade Intestinal mucosal
cells
Blood & mucus in stools
Septicemia
Intestinal perforation
Toxic megacolon
HUS
Osmotic Injury to enterocytes
Brush border damage
Large, frothy, explosive, acidic stools
Dehydration
Hypernatremia
*IAP textbook of pediatrics 5th edition

18. CLINICAL TYPES
 There are 2 main clinical types of Acute Diarrhoea
 Each is a reflection of the underlying pathology and altered physiology
Clinical type Description Common
pathogens
Acute watery
diarrhoea
This is the most common. It is of recent onset,
commencing usually within 48 hours of
presentation. It is usually self limiting and most
episodes subside within 7 days. The main
complication is dehydration.
Rotavirus, E. coli,
Vibrio cholera
Acute bloody
diarrhoea
Also referred to as dysentery. This is the
passage of bloody stools. It is as a result of
damage to the intestinal mucosa by an invasive
organism. The complications here are sepsis,
malnutrition and dehydration.
Shigella spp,
Entamoeba
histolytica

19. ASSESSMENT
 Goals :
i. Identify the Type of
diarrhea.
ii. Look for dehydration &
other complications
iii. Assess for malnutrition
iv. Rule out nondiarrheal
illnesses
v. Assess feeding
 History :
i. Onset, duration & number of
stools per day.
ii. Blood in stools.
iii. Episodes of vomiting
iv. Presence of fever, cough,
convulsions, recent measles.
v. Type & amounts of fluids
taken.
vi. Drug history.
vii. Immunization history

20. EXAMINATION
Look at
Condition Well alert Restless, irritable Lethargic or
unconscious; floppy
Eyes Normal Sunken Very sunken & dry
Tears Present Absent Absent
Mouth &
tongue
Moist Dry Very dry
Thirst Drinks normally; not
thirsty
Thirsty; drinks eagerly. “Drinks poorly” or not
able to drink
Feel
Skin pinch Goes back quickly Goes back slowly Goes back very slowly
Decide No signs of
dehydration
If patient has two or more
signs then some
dehydration
If patient has two or
more signs then
severe dehydration
Treat Plan A Weigh patient if
possible Plan B
Weigh patient & use
Plan C urgently

21. PLAN A
 may be treated at home.
 Danger signs to be
explained to the mother.
i. Continuing diarrhea
beyond 3 days.
ii. Increased stool volume/
frequency.
iii. Repeated vomiting.
iv. Increasing thirst.
v. Increased irritability /
lethargy
vi. Refusal to feed.
vii. Fever or blood in
stools.
Age Amount of
ORS to be
given after
each loose
stool
Amount of ORS
to be provided
at home
<24
months
50 to 100 ml 500ml/day
2 – 10
years
100 to 200ml 1000ml/day
>10
years
Ad lib 2000ml/day

22. PLAN B
 Should be treated in hospital.
 75 ml/kg of ORS to be given in first 4 hours if not taken orally then NG
tube can be used.
 If after 4 hours if child still has some dehydration, again 75ml/kg of ORS
to be given. (effective in 95% of the cases)
 Ineffective in :
i. High stool purge rate
ii. Persistent vomiting
iii. Paralytic ileus
iv. Incorrect preparation of ORS
 When signs of dehydration disappears, ORS should be administered
in volumes equal to diarrheal losses (max 10ml/kg)
 Breast Feeding, semisolid foods continued after deficit replacement.

23. PLAN C
 Should be treated in hospital.
 Ideal fluid is RL with 5% dextrose, NS or plain RL can be used
as alternative. NO 5% dextrose should be used.
 Total 100cc/kg of fluid should be given
 If severe dehydration is persistent repeat IV fluids
 Hydration improved but some dehydration present, shift to plan
B
 If no dehydration shift to plan A.
 Reassess patient every 15 to 30 min for pulses & hydration
status.
Age 30ml/kg 70ml/kg
<12 months 1hr 5hrs
>12 months 30 min 2hrs 30 min

24. MANAGEMENT
 Principles :
i. Rehydration & maintaining hydration.
ii. Ensuring adequate feeding.
iii. Oral supplementation of zinc.
iv. Early recognition of danger signs & treatment of
complications.

25. ORS
ORAL REHYDRATION
SOLUTION

26. PHYSIOLOGICAL BASIS FOR ORS
 Glucose dependent sodium & water absorption.
 Osmolarity lower than blood.
 A shift from standard ORS to Low Osmolarity ORS.

27. LOW OSMOLARITY ORS
COMPOSITION
Ingredient g/L
Dissociates into mmol/L
Glucose,
anhydrous
13.5 Glucose 75
Sodium Chloride 2.6
Sodium 75
Chloride 65
Potassium
Chloride
1.5 Potassium 20
Trisodium
Citrate,dihydrate
2.9 Citrate 10
TOTAL 20.5 TOTAL 245

28. ORS-BENEFITS
 Replaces water and salts lost during diarrhea.
 Reduces dehydration and need for
hospitalization.
 Decrease in severity of diarrhea and vomiting.
 Decrease in duration of illness.

29. PREPARATION OF ORS

30. PREPARATION OF ORS
Acceptable home available fluids
Fluids that contain salt
(preferable)
Salted rice water, salted yoghurt drink,
vegetable or chicken soup with salt.
Fluids that don’t contain salt
(acceptable)
Plain water, unsalted rice water, unsalted soup,
yoghurt drink.
Unsuitable home available
fluids
Commercial carbonated beverages,
commercial fruit juices, sweetened tea.

31. WHAT IS ZINC?
What are it’s benefits?

32. WHAT IS ZINC?
 Zinc is a micro-nutrient and promotes immunity.
 It is an important antioxidant and preserves cellular membrane
integrity.
 Promotes the growth and development of the nervous system.
 Rich sources of Zinc are foods of animal origin, such as meat
and fish.
 Zinc is also present in nuts, seeds, legumes, and whole grain
cereal, but the high phytate content of these foods interferes
with its absorption.

33. WHAT IS ZINC?
 Zinc cannot be stored in the body, and zinc excretion through
the gastrointestinal tract is increased during episodes of
diarrhea.
 Young children who have frequent episodes of
diarrhea and have diets low in animal products
and high in phytate-rich foods are most at risk
of Zinc deficiency.

34. ZINC- BENEFITS
 Zinc reduces the fluid and salt loss in stools by improving
mucosal permeability.
 Accelerated regeneration of mucosa
 Increased levels of brush-border enzymes
 Enhanced cellular immunity
 Higher levels of secretary antibodies
 Zinc improves absorption of ORS.

35. ZINC- BENEFITS
 Reduces the severity and duration of illness.
 Reduces need for antibiotics.
 Reduces the chances of complications.
 Full dose for 14 days protects against diarrhea and
pneumonia for next 3 months.
 Acts as a general tonic-improves appetite and promotes
growth.

36. LONG TERM EFFECTS OF ZINC
Zinc supplementation for 10-14 has longer
term effects on childhood illnesses in the 2-3
months after treatment
34% reduction in prevalence of diarrhea
26% reduction in incidence of pneumonia
Zinc Investigators’ Collaborative Group. Pediatrics. 1999.

37. DOSAGE OF ZINC
 Available as ZINC Tablets/ syrup (20mg/5ml).
 Given for 14 days for full benefits.
 20 milligrams per day for children older than six months.
 10 mg per day in those younger than six months.

38. SYMPTOMATIC TREATMENT
o Ondansetron (0.1 to 0.2 mg/kg/dose)
o For severe symptomatic hypokalemia
o Antisecretory agents like rececadotril
o Probiotics like lactobacillus
o No role of
i. binding agents like pectine, bismuth salts
ii. Antimotility agents like lopiramide.

39. USE OF ANTIBIOTICS
o Usually antibiotics not needed in most of the cases
o If stool culture shows shigella,
i. Ciprofloxacin(15mg/kg/day) for 5 days
ii. Alternatively ceftriaxone (50 to 100mg/kg/day) for 5 days
o For amoebic dysentery tinidazole or metronidazole can be used.

40. PREVENTION OF DIARRHEA & MALNUTRITION
o Proper nutrition
o Adequate sanitation
o Vaccination
i. Rota virus
ii. measles