- The patient, a child, presented with acute gastroenteritis characterized by vomiting, watery and foul-smelling diarrhea, and fever for 2 days. Laboratory investigations revealed dehydration as evidenced by elevated blood urea nitrogen and creatinine, hypokalemia, and metabolic acidosis. The child was treated supportively with intravenous fluids and electrolyte replacement. Serial monitoring showed improvement in dehydration parameters and normalization of electrolytes over the course of treatment.

1. CASE PRESENTATION
ON
AGE WITH MODERATE
DEHYDRATION

2. • Gastroenteritis, sometimes incorrectly called “stomach flu,” is the most
common digestive disorder among children.
• Gastroenteritis is usually caused by a viral, bacterial, or parasitic infection.
• The infection causes a combination of vomiting, diarrhoea, abdominal cramps,
fever, and poor appetite, which can lead to dehydration.
• One in 5 children die of diarrhea or diarrhea related complications every year
in India.
• Diarrheal disease is the second leading cause of child mortality; among
children younger than 5 years, it causes 1.5 to 2 millions death annually.

3. • Each year diarrhoea kills around 525 000 children under five.
• Globally, there are nearly 1.7 billion cases of childhood diarrhoeal
disease every year.
• Diarrhoea is a leading cause of malnutrition in children under five
years old.
• In developing countries, children experience between three to six
episodes of diarrhea annually.
• Despites easy & affordable treatment, most patients do not access
the recommended treatment.
• Timely use of ORS-Zinc can save over 133,000 lives by 2015.

4. Body water percentage charts
• For the first few months of life, nearly three-fourths of your body
weight is made up of water. That percentage starts to decline before
you reach your first birthday, however.
• The decreasing water percentage through the years is due in large
part to having more body fat and less fat-free mass as you age. Fatty
tissue contains less water than lean tissue, so your weight and body
composition affect the percentage of water in your body.
• The following charts represent the average total water in your body as
a percentage of body weight, and the ideal range for good health.

5. WATER PERCENTAGE OF BODY WEIGHT
For infant & children
Water as percentage of body weight in adults
Birth to 6 months 6 months to 1 year 1 to 12 years
Infants and children
average: 74%
range: 64%–84%
average: 60%
range: 57%–64%
average: 60%
range: 49%–75%
Adults Ages 12 to 18 Ages 19 to 50 Ages 51 and older
Male
average: 59
range: 52%–66%
average: 59%
range: 43%–73%
average: 56%
range: 47%–67%
Female
average: 56%
range: 49%–63%
average: 50%
range: 41%–60%
average: 47%
range: 39%–57%

6. • Where is all this water stored?
With all this water in your body, you may wonder where in your body it’s
stored. The following table shows how much water resides in your organs,
tissue, and other body parts.
In addition, plasma (the liquid portion of blood) is about 90 percent water.
Plasma helps carry blood cells, nutrients, and hormones throughout the body
Body part Water percentage
brain and heart 73%
lungs 83%
skin 64%
muscles and kidneys 79%
bones 31%

7. • About two-thirds of the body’s water is within the cells, while the remaining third
is in extracellular fluid. Minerals, including potassium and sodium, help maintain
ICF and ECF balances.
• DISTRIBUTION OF TOTAL BODY WATER

8. ANATOMY OF THE DIGESTIVE SYSTEM

9. ORGAN MAJOR FUNCTIONS OTHER FUNCTIONS
Mouth
•Ingests food
•Chews and mixes food
•Begins chemical breakdown of
carbohydrates
•Moves food into the pharynx
•Begins breakdown of lipids via lingual
lipase
•Moistens and dissolves food,
allowing you to taste it
•Cleans and lubricates the teeth and
oral cavity
•Has some antimicrobial activity
Pharynx
•Propels food from the oral cavity to the
esophagus
•Lubricates food and passageways
Esophagus •Propels food to the stomach •Lubricates food and passageways
Stomach
•Mixes and churns food with gastric juices
to form chyme
•Begins chemical breakdown of proteins
•Releases food into the duodenum as
chyme
•Absorbs some fat-soluble substances (for
example, alcohol, aspirin)
•Possesses antimicrobial functions
•Stimulates protein-digesting
enzymes
•Secretes intrinsic factor required for
vitamin B12 absorption in small
intestine

10. ORGAN MAJOR FUNCTIONS OTHER FUNCTIONS
Small intestine
•Mixes chyme with digestive juices
•Propels food at a rate slow enough
for digestion and absorption
•Absorbs breakdown products of
carbohydrates, proteins, lipids, and
nucleic acids, along with vitamins,
minerals, and water
•Performs physical digestion via
segmentation
•Provides optimal medium for
enzymatic activity
Accessory organs
•Liver: produces bile salts, which
emulsify lipids, aiding their digestion
and absorption
•Gallbladder: stores, concentrates,
and releases bile
•Pancreas: produces digestive
enzymes and bicarbonate
•Bicarbonate-rich pancreatic juices
help neutralize acidic chyme and
provide optimal environment for
enzymatic activity

11. ORGAN MAJOR FUNCTIONS OTHER FUNCTIONS
Large intestine
•Further breaks down food
residues
•Absorbs most residual water,
electrolytes, and vitamins
produced by enteric bacteria
•Propels feces toward rectum
•Eliminates feces
•Food residue is concentrated
and temporarily stored prior to
defecation
•Mucus eases passage of
feces through colon
The processes of digestion include six activities:
• Ingestion,
• Propulsion,
• Mechanical or physical digestion,
• Chemical digestion, absorption,
• Defecation.

12. • Gastroenteritis is inflammation of the digestive tract that results in
vomiting, diarrhoea, or both and is sometimes accompanied by fever
or abdominal cramps.
OR
• Acute gastroenteritis (AGE) is a diarrheal disease of rapid onset,
with or without accompanying symptoms and signs, such as nausea,
vomiting, fever or abdominal pain.
• Severe gastroenteritis causes dehydration and an imbalance of
blood chemicals (electrolytes) because of a loss of body fluids in the
vomit and stool.

13. BOOK PICTURE PRESENT IN BABY
Contaminated water & food √
Poor hygiene √
Nutritional deficiency √
Poor sanitation √
Immune deficient individual
Malnutrition √
Travel to endemic areas
Lack of breastfeeding √
Exposure to unsanitary conditions
Poor maternal education √

14. • RESERVOIR OF INFECTION:
Man is the main reservoir of enteric pathogens so most transmission
originates from human factors. For some enteric pathogens & viral agents
animals are the important reservoir.
• HOST FACTORS:
The disease is the most common in children especially those between 6
months to 2 years.
The incidence is highest during weaning period i.e. 6 to 11 months of age.
It occurs due to combined effects of reduced maternal antibodies, lack of
active immunity & introduction of contaminated food or direct spread
through child’s hands.
Diarrhea is more common in artificial feeding, specially with contaminated
cow’s milk or unhygienic preparation of tin milk.

15. Malnourished children are more prone to diarrhea.
Malnutrition leads to infection & infection leads to diarrhea., which is vicious cycle.
The predisposing factors of diarrhea include prematurity, immunodeficiency conditions,
lack of personal hygiene, inadequate food hygiene, incorrect infant feeding practices,
illiteracy, poor socioeconomic status. Etc.
• ENVIRONMENTAL FACTORS:
Is more frequently occur in summer & rainy season, whereas viral diarrhea (specially
rotavirus) found in water. Diarrheal disease are more commonly seen in unhygienic
environment.
• MODES OF TRANSMISSION:
Is mainly feco-oral route. It is water borne, food-borne disease or may transmit via
fingers, fomites, flies or dirt.

18. ETIOLOGY
 VIRAL
70- 85% of AGA in developed countries.
Rotavirus: 60% represents of all paediatric AGA hospitalization.
Is the most common cause of severe, dehydrating diarrhoea among infants and
children worldwide.
Rotavirus is highly contagious. Most infections are spread by fecal-oral
transmission. Infected infants may spread the infection to adults.
In temperate climates, rotavirus infections are most common in the fall and winter
months and are less common in the summer. In tropical climates, they can occur
year round
Presentation:
• Mild or moderate fever
• Vomiting followed by copious watery diarrhoea (up to 10-20 bowel movements
per day) usually non foul smelling.
• Diarrhoea persisting for 5-7 days.

19. • Astrovirus
Can infect people of all ages but usually infects infants and young
children.
Infection is most common in the winter and is spread by fecal-oral
transmission.
• Adenovirus
Most commonly affects children under the age of 2.
Infections occur year-round and increase slightly in the summer.
The infection is spread by fecal-oral transmission.

21.  BACTERIAL
The bacteria that most commonly cause gastroenteritis include;
Campylobacter, Salmonella, Shigella, E. Coli, Clostridium difficile.
Children can contract bacterial gastroenteritis by
• Touching or eating contaminated foods, particularly raw or
inadequately cooked meats or eggs
• Eating contaminated shellfish
• Drinking unpasteurized milk or juice
• Touching animals that carry certain bacteria
• Swallowing contaminated water, such as from wells, streams, and
swimming pools

22. Presentation:
• High fever with shaking chills.
• Foul smelling stool
• Bloody bowel movements
• Abdominal cramping & fecal leucocytes

24.  PARASITIS
<10% of cases.
Gastroenteritis caused by parasites (such as Giardia intestinalis &
Cryptosporidium parvum is usually acquired by drinking contaminated
water or by fecal-oral transmission.
The parasite Entamoeba histolytica is a common cause of bloody diarrhea
in developing countries but is rare in the United States.
Presentation:
• Watery stools greenish, frothy stools
• Urgency of passing stools after meals
• Low grade fever

25.  Chemical toxins
• Gastroenteritis may result from ingesting chemical toxins.
• These toxins can be found in plants, such as poisonous mushrooms,
or in certain kinds of exotic seafood.
• Children who eat these substances may develop gastroenteritis.
Children also can develop gastroenteritis after drinking water or
eating food that is contaminated by chemicals such as arsenic, lead,
mercury, or cadmium.

26. PATHOPHYSIOLOGOCAL CHANGES
TYPES MECHANISM COMPLICATIONS
Secretory Acute watery diarrhea
Sodium pump failure
Rapid development of
dehydration
Electrolyte imbalance.
Invasive Microbes invades intestinal
mucosal cells
Blood & mucus in stools
Septicemia
Intestinal obstruction
Toxic maga-colon
Osmotic Injury to enterocytes
Brush border damage
Large, frothy, explosive, acidic
stools
Dehydration
hypernatremia

27. BOOK PICTURE PRESENT IN BABY
Nausea & Vomiting √
Diarrhoea √
Loss of appetite √
fever √
Abdominal pain √
Abdominal cramps
Bloody stool
Fainting & Weakness √
Dehydration √
Lethargic √

28. LABORATORY INVESTIGATION
• Careful history ( travel, blood in stool , water, contact, recent
antibiotics, fever, vomiting.
• Physical examination
• Stool analysis
• CBC
• Electrolytes

29. History
IN BOOK IN PATIENT
Onset, duration & number of episodes of
stools per day
Since 2 days , 4 - 7 episodes per day ,
watery greenish & foul smelling stool
Blood in stool
Episodes of vomiting per day Since 2 days, non- projectile
Presence of fever, cough, convulsions,
recent measles
High grade Fever since 2 days
Type & amounts of fluids taken Cow’s milk , 20- 40 cc every 3 hrly
Drug history NO
Immunization history Upto the age

30. PATIENT INVESTIGATIONS
BIOCHEMISTRY
Serum Electrolytes (16/10/19)
TEST DESCRIPTION OBSERVED VALUE NORMAL VALUE
Sr. Sodium 154.7 136 – 145 mmol/L
Sr. Potassium 3.62 3.5 – 5.1 mmol /L
Sr. Chloride 132.4 98 – 107 mmol /L
creatinine 2.22 0.3 – 1.0 mg/dl

31. • COMPLETE BLOOD COUNT (16/10/19)
TEST DESCRIPTION OBSERVED VALUE NORMAL RANGE
Hemoglobin 11.4 10.5 – 14.0 gm/dl
RBC 3.57 3.8 – 5.4 mill/cu.mm
Hematocrit 32.9 32 – 42 %
Mean Corpuscular vol. /MCV 92.16 72 - 88 Fl
Mean Corpuscular Hb /MCH 31.93 24 – 30 pg
MCHC 34.65 32.0 – 36.0 %
White blood cells 20500 6000 – 14000 /cmm
Neutrophils 70 40 – 75 %
Lymphocytes 23 35 – 69 %
Platelet count 525000 150000 – 450000/cmm

32. INVESTIGATIONS
• BOCHEMISTRY LAB REPORT (17/10/19)
PARAMETER RESULTS NORMAL RANGE
Blood Urea Nitrogen 66.3 10 - 15 mg%
Sr. Creatinine 2.0 01 - 02mg %
Blood Glucose (F/R) 76 60 - 100mg%
Sr. SGOT (AST) 34.0 Upto 40.0 U/L
Sr. SGPT (ALT) 44.0 UPTO 40.0 U/L
Sr. Sodium 140 132 - 144 mEq/L
Sr. Potassium 3.0 3.6 – 4.8 mEq/L
Sr. Chloride 130 96 – 105 mEq/L

33. • BOCHEMISTRY LAB REPORT
18/10/19
PARAMETER RESULTS NORMAL RANGE
Blood Urea Nitrogen 27 10 - 15 mg%
Sr. Creatinine 0.8 01 - 02mg %
Blood Glucose (F/R) 121 60 - 100mg%
Sr. SGOT (AST) 22.0 Upto 40.0 U/L
Sr. SGPT (ALT) 59.0 UPTO 40.0 U/L
Sr. Sodium 143 132 - 144 mEq/L
Sr. Potassium 3.9 3.6 – 4.8 mEq/L

34. • 19/10/19
PARAMETER RESULTS NORMAL RANGE
Blood Urea Nitrogen 23.1 10 - 15 mg%
Sr. Creatinine 0.7 01 - 02mg %
Blood Glucose (F/R) 60 - 100mg%
Sr. SGOT (AST) Upto 40.0 U/L
Sr. SGPT (ALT) UPTO 40.0 U/L
Sr. Sodium 143 132 - 144 mEq/L
Sr. Potassium 3.7 3.6 – 4.8 mEq/L

35. 20/10/19
PARAMETER RESULTS NORMAL RANGE
Blood Urea Nitrogen 20.9 10 - 15 mg%
Sr. Creatinine 0.7 01 - 02mg %
Blood Glucose (F/R) 69 60 - 100mg%
Sr. SGOT (AST) Upto 40.0 U/L
Sr. SGPT (ALT) UPTO 40.0 U/L
Sr. Sodium 140.0 132 - 144 mEq/L
Sr. Potassium 3.2 3.6 – 4.8 mEq/L
Sr. chloride 127 96 – 105 mEq/L

36. 22/10/19
PARAMETER RESULTS NORMAL RANGE
Blood Urea Nitrogen 5.7 10 - 15 mg%
Sr. Creatinine 0.5 01 - 02mg %
Blood Glucose (F/R) 67.0 60 - 100mg%
Sr. SGOT (AST) Upto 40.0 U/L
Sr. SGPT (ALT) UPTO 40.0 U/L
Sr. Sodium 133 132 - 144 mEq/L
Sr. Potassium 4.6 3.6 – 4.8 mEq/L
Sr. chloride 119 96 – 105 mEq/L

37. ABG ANALYSIS
• 17/10/19
PARAMETER RESULTS
pH 7.14
pCO2 27 mmHg
pO2 37 mmhg
Na+ 156 mmol/L
K+ 2.1 mmol/L
Ca+ 0.86 mmol/L
Glu 94 mg/dl
Lac 1.2 mmol/L
HCT 44%
HCO3 9.4

38. ABG ANALYSIS
19/10/19 20/10/19
PARAMETER RESULTS
pH 7.26
pCO2 31 mmHg
pO2 31mmhg
Na+ 151 mmol/L
K+ 3.0 mmol/L
Ca+ 1.01 mmol/L
Glu 70 mg/dl
Lac 2.1 mmol/L
HCT 36%
HCO3 14.5
PARAMETER RESULTS
pH 7.29
pCO2 25 mmHg
pO2 68 mmhg
Na+ 142 mmol/L
K+ 2.7 mmol/L
Ca+ 1.02 mmol/L
Glu 67 mg/dl
Lac 3.0 mmol/L
HCT 35%
HCO3 12.0

39. 22/10/19
PARAMETER RESULTS
pH 7.37
pCO2 24 mmHg
pO2 62 mmhg
Na+ 145 mmol/L
K+ 3.5 mmol/L
Ca+ 0.81 mmol/L
Glu 53 mg/dl
Lac 0.8 mmol/L
HCT 26 %
HCO3 16.9 mmol/L

40. • BIOCHEMISTRY INVESTIGATION
18/10/19
PARAMETER RESULTS NORMAL RANGE
Calcium 11.8 9.0 – 11.0 mg%
Phosphorus 1.3 2.5 – 7.0 mg%
Alk. phosphatase 112.0 50 – 370 U/L
T. Billirubin 0.70 Upto 1.0 mg%
D. Billirubin 0.28 Upto 0.5 mg%
SGOT 70.0 Upto 40.0 U/L
SGPT 77.0 Upto 40.0 U/L

41. STOOL ROUTINE & MICROSCOPIC REPORT
PHYSICAL EXAMINATION
• Colour: green
• Consistency: semi-solid
• Adult worms: not seen
• Blood : absent
• Mucus: present
MICROSCOPIC EXAMINATION
• Ova: absent
• Cysts: absent
• Larvae: absent
• chemical examination: pH-6
• occult blood : present
• fat globules: present
• macrophages: absent

42. 17/10/19
• USG ABDOMEN
IMPRESSION: Minimal interbowel free fluid.
• RAPID DIAGNOSTIC TEST FOR MALARIA ANTIGEN REPORT
Result : Negative
• DENGUE NS1 Ag RAPID TEST:
Result: negative
• Dengue IgM/ IgM Rapid test:
Result: negative

43. • BLOOD EXAMINATION:
19/10/19
Hb: 8.0
PCV: 28.3
WBC: 8.500
Polymorphs: 63
Lymphocytes: 37%
21/10/19
Hb: 10.1
PCV: 31.9
WBC: 12,600
Polymorphs: 63
Lymphocytes: 33%

44. Assessment:
Goals :
1. Identify the type of diarrhea.
2. Look for dehydration & other complication.
3. Assess for malnutrition.
4. Assess feeding.

45. ASSESSMENT OF DEHYDRATION
• Dehydration is the important life threatening feature which is usually
associated with Diarrhea.
• Diarrheal stools are usually loose or watery in consistency. It may be
greenish or yellowish-green in color with offensive smell. It may be
contain mucus, pus or blood & may expelled with force, preceded by
abdominal pain.

46. A B C
1. Ask about
Diarrhea Less than 4 liquid stools per
day
4 to 10 liquid stools per day More than 10 liquid stools
Vomiting None/small amount Some Very frequent
Thirst Normal Greater than normal Unable to drink
Urine Normal A small amount and dark No urine for 6 hours
2. Look at
Condition Well, alert Restless, irritable, or sleepy Lethargic/ unconscious, floppy
Eyes Normal Sunken Very sunken & dry
Tears Present Absent Absent
Mouth & tongue Moist Dry Very dry
Breathing Normal Faster than normal Very fast & deep
3. Feel
Skin pinch Goes back quickly Goes back slowly Goes back very slowly
Pulse Normal Faster than normal Very fast, weak, cannot feel

47. A B C
Decide degree of
dehydration
The patient has no signs
of dehydration
If the patient has two or
more signs including at
least one sign there is
some dehydration.
If the patient has two or
more signs including at
least one sign there is
severe dehydration

48. CLINICAL FEATURE OF DEHYDRATION IN BOOK IN PATIENT
frequency of stools varies from 2 to 20 per day or more. √
low-grade fever, thirst, anorexia, with intermittent vomiting & abdominal distension. √
behavioural changes like irritability, restlessness, weakness, lethargy, sleepiness, delirium, stupor,
flaccidity usually are present.
√
Loss of weight √
Poor skin turgor √
Dry mucous membrane, dry lips, pallor, √
Sunken eyes √
Depressed fontanelles √
Decreased or absence of urinary output √
Vitals changes like low blood pressure, tachycardia, rapid respiration, cold limbs.

49. COMPARISON OF DEHYDRATION:
MILD (<5% body wt lost) MODERATE (5-9%) SEVERE (>10%)
MENTAL STATUS Alert Alert to listless Alert to comatose
FONTANELES Soft & flat Sunken Sunken
EYES Normal Mildly sunken orbits Deeply sunken orbits
ORAL MUCOSA Pink & moist Pale slightly dry Dry
SKIN TURGOR Elastic Decreased Tenting
HEART RATE Normal May be increased Increased, progressing to bradycardia
BLOOD PRESSURE Normal Normal Normal progressing to hypotension
EXTREMITIES Warm, pink, brisky capillary refill Delayed capillary refill Cool, mottled, Delayed capillary refill
URINE OUTPUT May be slightly decreased <1 ml /kg/hour Significantly <1 ml/kg/hr

50. AIM OF TREATMENT
• Assessment of fluid & electrolyte imbalance.
• oral Rehydration
• Maintenance fluid therapy
• Reintroduction adequate diet
• Symptom management

51. • FLUID MANAGEMENT:
Oral rehydration therapy : IV fluids in treatments of mild to moderate dehydration
oral reabsorption of sodium & water.
The management of AGE in a vast majority of children is best done with ORS solution
& continue feeding.
Oral rehydration therapy means drinking of solution of clean water, sugar & mineral
salts to replace the water & salt from the body during diarrhea especially when
accompanied by vomiting, i.e. gastroenteritis.
It is beneficial in three stages:
a) Prevention of dehydration
b) Rehydration of the dehydrated child
c) Maintenance of hydration after severely dehydrated patient has been
rehydrated with IV fluid therapy.

52. • COMPOSITION OF ORS AS PER THE WHO & UNICEF
COMPONENT CONTENT PER LITER
WATER
SODIUM CHLORIDE 2.6 GM
POTASSIUM
CHLORIDE
1.5 GM
SODIUM CITRATE 2.9 GM
GLUCOSE
ANHYDROUS
13.5 GM
TOTAL 20.5
Dissociated into Mmo/L
GLUCOSE 75
SODIUM 75
CHLORIDE 65
POTASSIUM 20
CITRATE 10
TOTAL 245

53. THE APPROXIMATE AMOUNT OF ORS SOLUTION GIVEN IN THE FIRST
4 HRS AS FOLLOWS:
• Age less than 4 months or weight less than 5kg: 200-400 mL
• Age 4 to 11 months or weight 5 to 7.9 kg : 400-600 mL
• Age 12 to 23 months or weight 8 to 10.9 kg: 600-800 mL
• Age 2 to 4 years or weight 11 to 15.9 kg: 800-1200 mL
• Age 5 to 14 years or weight 16 to 29.9 kg: 1200-2200 mL
• Age 15 years or older or weight 30kg or more: 2200-4000 mL

54. PREPARATION FOR ORS

55. • NG FEEDING:
For children who do not tolerate feed or ORS by mouth, nasogatric feeding is
a safe & effective treatment.
• IV REHYDRATION:
IV access should be obtained in severe dehydration & patient should
administered a bolus of 20 – 30mL/kg lactated Ringer or NS solution over 60
minutes.
• DIET:
In general, children with gastroenteritis should be returned to a normal diet
as rapidly as possible; early feeding reduces illness duration & improves
nutritional status. the vicious circle of malnutrition and diarrhoea can be
broken by continuing to give nutrient rich foods, including breast milk during
an episode, and by giving a nutritious diet – including exclusive breastfeeding
for the first six months of life to children when they are well.

56. SYMPTOMATIC & PHARMACOLOGICAL MANAGEMENT
Symptomatic management of vomiting, fever, convulsion & abdominal distension to be done
with specific drug.
• Antiemetics: Ondansetron (0.1 to 0.2 mg/kg/dose) or metoclopramide to reduce vomiting.
• ANTIBIOTICS: usually not need but if stool culture shows Shigella then
Ciprofloxacin, (15mg/kg/day) for 5 days.
Alternatively Ceftriaxone (50 to 100 mg/kg/day) for 5 days.
For amoebic dysentery tinidazole / metronidazole can be used.
• Vaccines: In Feb 2006 the Food & Drug Administration (FDA) approved the RotaTeq vaccine
for the prevention of rotavirus gastroenteritis.
• Zinc: it is micro-nutrient & promotes immunity. It helps to reduces the fluid & salt loss in
stools by improving mucosal permeability. Accelerated regeneration of mucosa & increased
levels of brush-border enzymes. Also helps to absorption of ORS. Full dose for 14 days
protects against diarrhea & pneumonia foe the next 3 months.

57. Management of dehydration
• Plan A : Treatment of diarrhoea at
home
Counsel the mother on the 4 rules of
home treatment.
1. Give extra fluid
2. Give zinc supplements
3. Continue feeding
4. When to return
Danger signs to be explained to the
mother:
• Continuing diarrhea beyond 3 days
• increased stool volume/frequency
• Repeated vomiting
• Increasing thirst
• Increased irritability/lethargy
• refused to feed
• Fever & blood in stools

58. AMOUNT OF ORS
AGE AMOUNT OF ORS TO BE
GIVEN AFTER EACH LOOSE
STOOLS
AMOUNT OF ORS TO BE
PROVIDED AT HOME
<24 MONTHS 50 to 100ml 500/ day
2-10 YEARS 100 to 200ml 1000ml/day
>10 YEARS Ad lib 2000ml/day

59. Plan B Treatment for some dehydration with ORS
• Determine amount of ORS to give during first 4 hour
Age Up to 4 months 4 up to 12months 12 months up to
2 years
2 years up to 5
years
Weight <4 kg 6 -<10 kg 10-<12 kg 12-<20kg
Fluid in ML 200–450 450–800 800–960 960–1600

60. PLAN C
• Should be treated in hospital
• ideal fluid is RL with 5% dextrose, NS or plain RL can be used as alternative.
• total 100cc/kg fluid should be given.
• if severe dehydration is persistent repeat IV fluids & start rehydration by
the tube (NGT feeding).
• Hydration improved but some dehydration present shift to plan B.
• No hydration shift to plan A.
AGE 30ML/KG 70ML/KG
<12 months 1 hr 5 hrs
>12 months 30min 2 hrs 30 min

61. Patient treatment
21/10/19
• Inj. Cefotaxime (150mkd) 150mg IV TDS
• Inj. PCM 25 mg/kg/day (5ml =125mg) 2ml sos for fever
• Syp. zinc 2.5 ml OD
• Syp. MVBC 2.5 ml BD
• Syp. Cal D 3 ml BD
• Syp. Metronidazole (10 mg/kg/day ) 5 ml=100mg TDS

62. DRUG NAME AVAILABLE
DOSE
ORDERED
DOSE
ACTION SIDE EFFECT
Inj. Cefotaxime 1 gm 150mg Broad spectrum antibiotic (third generation
cephalosporin) with acting against numerous
gram positive & gram negative bacteria.
Inhibits bacterial cell wall synthesis by
binding to one/ more penicillin binding
protein.
Swelling, redness, or
pain at the injection site
may occur. Rash,
itching, fever, nausea,
Vomiting, stomach pain,
headache, diarrhea etc.
Inj. PCM 60 ml 2ml Exact action is not known. Paracetamol (anti-
inflammatory) is thought to relieve pain by
reducing the production of prostaglandins in
the brain and spinal cord.
Paracetamol toxicity is
the foremost cause
of acute liver failure.
Syp. zinc 50 ml 2.5 ml Zinc restores mucosal barrier integrity &
enterocyte brush border enzyme activity, it
promotes the production of antibodies &
circulating lymphocyte against intestinal
pathogens.
Nausea, vomiting
gastric irritation,
neurologic
deterioration

63. DRUG NAME AVAILABLE
DOSE
ORDERED
DOSE
ACTION SIDE EFFECT
Syp. MVBC 100 ml 2.5 ml Multivitamins are used to provide vitamins that
are not taken in through the diet. Multivitamins
are also used to treat vitamin deficiencies (lack
of vitamins) caused by illness, pregnancy, poor
nutrition, digestive disorders, and many other
conditions.
upset stomach,
headache; or
unusual or unpleasant
taste in your mouth
Syp. Cal D3 200 ml 3 ml used for Calcium supplementation, Deficiency of
vitamin d, Low magnesium levels and other
conditions.
Abdominal pain
Constipation
Headache
Loss of appetite
Nausea, Vomiting
Stomach ache
Feeling of sickness
Excessive thirst
Syp. Metronidazole 60 ml 5 ml=100mg brand name Flagyl, it is an antibiotic and anti-
protozoal medication.It inhibits nucleic acid
synthesis by disrupting the DNA of microbial cells
Dizziness, headache,
stomach upset, nausea,
vomiting, loss of
appetite, diarrhea, constip
ation, or metallic
taste in mouth may occur.
Darker urine.

64. COMPLICATIONS:
• Dehydration
 Excessive loss of fluids & minerals (electrolytes) from the body & electrolyte
deficiency.
 Electrolyte disturbances : Hypokalemia; Hypocalcemia; Hyponatremia.
 Metabolic acidosis
 Acute renal failure
• Systemic infection (meningitis, arthritis, pneumonia) especially
with Salmonella infections
• Sepsis (Salmonella, Yersinia, Campylobacter organisms)
• Toxic megacolon
• Convulsion due to; Hypogycemia, CNS infection, Hypocalcemia, Brain edema.
• Shock
• Guillain-Barré syndrome (Campylobacter organisms)

65. Dehydration can lead to more serious problems, such as:
• Heat Injury If don’t have enough fluids while you’re physically active,
you could have a life-threatening heatstroke.
• Urinary and Kidney Issues A long or repeated episode of dehydration
can trigger kidney stones, urinary tract infections (UTIs), or kidney
failure.
• Seizures When your electrolytes are out of whack, could develop
seizures.
• Hypovolemic Shock This life-threatening condition happens when low
blood volume causes a drop in blood pressure and the amount of
oxygen in body.

66. Prevention
• Key measures to prevent diarrhoea include:
• Access to safe drinking-water;
• Use of improved sanitation;
• Hand washing with soap;
• Exclusive breastfeeding for the first six months of life;
• Good personal and food hygiene;
• Health education about how infections spread; and
• Rotavirus vaccination.

67. • Make sure before feeding to baby or preparing feed for baby washes your
hands regularly, especially after the use the toilet and after you change your
child’s nappies. Wash your hands with warm water and soap.
• Utensils should be cleaned with warm water.
• Continue the breastfeeding & also give additional fluid like ORS it will help to
replace water lost by diarrhoea and vomiting, give the water needed for normal
health & provide some sugars and salts that children need to keep their
strength up. Never give baby unpasteurized milk or untreated water.
• Watch for signs of dehydration like; baby has a dry mouth and tongue or he is
not passing urine (dry nappies), not taking feed, has sunken eyes, has cold
hands and feet & is more sleepy than usual.
• Have your child immunized for rotavirus.
• Checked for the anal region for any infection.

68. NURSING DIAGNOSIS
1. Diarrhea related to bacterial or viral infection as evidenced by increase
frequency of loose motion.
2. Risk for fluid deficient volume related to refused to take feed, diarrhea &
vomiting.
3. Imbalanced nutrition status less than body requirement related to
decrease oral intake.
3. Impaired skin integrity related to irritation caused by frequent, loose
stools.
4. Knowledge deficient related to disease condition as evidenced by mother
is not taking proper care.
5. Hyperthermia related to infection as evidenced by temperature 100.2 &
dehydration

69. RESEARCH ARTICLES
Ashwini Dedwal, MD, Sae Pol, PhD, et al (2016) conducted study on
Microbial Etiology of Acute Gastroenteritis in Pediatric Patients in Western
India. One hundred stool samples were collected from children admitted
with acute diarrhea of 72 hours or less duration in 1–60 months of age
over a period of 1 year. Bacteria were identified by standard
Microbiological methods and Serotyping of isolated E. coli was
done. Rotavirus antigen was detected by ELISA followed by genotyping by
RT-PCR and multiplex PCR. Parasitic identification was done by
microscopy.
Seventy-four percent of children with diarrhea were in the age group of 7
to 12 months. Watery diarrhea (94%) was the commonest clinical
presentation, followed by vomiting (78%), fever (78%), and dehydration
(74%). Pathogenic bacteria were isolated in 51% of samples. Escherichia
coli was most common (48%) followed by Shigella flexneri (2%) and Vibrio
cholerae (1%).

70. The most prevalent E. coli type was Enterotoxigenic Escherichia
Coli (20.8%) followed by Enteropathogenic Escherichia
Coli (16.7%), Enterohemorrhagic Escheria Coli (4.1%), and Shiga Toxin
producing EC (2.1%). The most prevalent serotypes of ETEC were O27,
O23, and O169. Among EPEC most prevalent serotypes were O90, O26.
The most prevalent EHEC strain found in this study was
O71. Rotavirus was detected in 35% of patients. Most
prevalent Rotavirus geno type was G9P[4] (28.6%) followed by G2P[4]
(21.4%), G1P[8] (21.4%), G12P[6] (14.3%), G9P[8] (7.1%). Parasitic
etiology was detected in 5% of cases. infection of E.
coli and Rotavirus was detected in 23% of children. Rotavirus was most
commonly associated with EPEC (25.7%) followed by ETEC (17.1%).
This study concluded as E. coli was the commonest microorganism
followed by Rotavirus. Thus, the importance of safe water and food
hygiene would be most important intervention to prevent acute
gastroenteritis in children along with Rotavirus vaccine.

71. • Ritika ghosh (2017) conducted A Study of Electrolyte Disturbances in a Child
Presenting with Acute Gastroenteritis, with Special Emphasis on Hyponatremic
Dehydration. To study the electrolyte changes in moderate and severe dehydration in
AGE in children. (2) To study the incidence and clinical features of Hyponatremic
dehydration. Materials and A cross-sectional type of observational study of 200
children admitted with AGE with moderate to severe dehydration was conducted at
M R Banglur hospital, Kolkata.
• AGE constituted 18% of the total admissions. 22% had Hyponatremia, 71.5% had
Isonatremia and 6.5% had Hypernatremia. Out of 30 children who were suffering
from Hyponatremic dehydration and had ORS before admission, 83.3% were given
diluted ORS. Clinical features significantly associated with Hyponatremia were
increased frequency of diarrhea, absence of thirst, tachycardia, abdominal distension
and severe dehydration.
• Conclusion: Hyponatremic dehydration is the second most common type of
dehydration next to Isonatremic dehydration, but it is more common in children who
took diluted ORS. Hyponatremic dehydration may be suspected from the history and
clinical features. Increased awareness regarding ORS preparation may help in
preventing Hyponatremia in AGE. What is already known: Isonatremic dehydration is
the most common electrolyte abnormality found in AGE. What this study adds:
Hyponatremic dehydration is the most common electrolyte abnormality found in
those suffering from AGE, who have taken inappropriately diluted Oral Rehydration
Solution (ORS).