Acute Diarrhea in Children

Case A 10 kg. male presents to your office with watery stools and a low grade fever. There is no blood in the stool and the child is approximately 5% dehydrated. How would workup and treat this child?

Evaluation of the child with diarrhea

  1. History
    1. recent travel history
    2. known exposures
    3. recent use of antibiotics
    4. attendance in daycare
    5. previous state of health
  2. Physical exam
    1. previous weight- often not available 
    2. Assess for level of dehydration 
      1. Mild dehydration( 3-5%)- mucous membranes are slightly dry but vital signs are normal and there is normal capillary refill and skin turgor. Tears are usually present and child is alert.
      2. Moderate dehydration (6-9%)- increased heart and respiratory rate and slightly prolonged capillary refill, and tenting of the skin. Lack of tears and the child isbecoming listless.
      3. Severe dehydration(>10%)- blood pressure is decreased and the child is very lethargic. Mucous membranes are very dry. Skin is cold and clammy.
Common etiologies of acute diarrhea
  1. Viral- usually watery diarrhea without blood. Often have accompanying vomiting and fever.
    1. Rotovirus-usually infants and toddlers.
    2. Norwalk virus
    3. Adenovirus
  2. Bacterial- either invasive or produce toxins
    1. Salmonella- invasive Causes short-lived illness with fever, vomiting, sometimes bloody stools. Usually doesn't require treatment
    2. Shigella- invasive. Causing bloody, mucousy stools. Usually requires antibiotic treatment. May be associated with seizures
    3. Campylobacteria- usually watery but also may cause bloody stools. May require antibiotic treatment in severe prolonged cases with Erythromycin
    4. Yersinia- 10% bloody diarrhea and often with accompanying systemic symptoms. No treatment necessary in most cases.
    5. E. Coli
    6. Staphylococcal-responsible for food poisoning. Toxin is in the food and symptoms frequentlyappear 6-12 hours after ingestion. Often with vomiting. Short lived. 
  3. Protozoan
    1. Cryptosporidium- watery stools usually without blood. Common in immunocompromised population,
    2. Giardia- often from contaminated water in certain areas. Bloating and abdominal pain is present Usually not bloody.
Treatment

Most cases of acute diarrhea do not require any laboratory investigations. If the child has bloody stools, cultures may be indicated and if the there is severe dehydration electrolytes should be checked.

Most cases can be treated with oral rehydration solutions. Exceptions are for severely dehyrated children, if there is persistent vomiting, or the child refuses to drink. Oral rehydration solutions should contain 75-90 meq of sodium, glucose, and potassium. The closest over-the -counter solution availabe are Pedialyte and Infalyte. The child's losses and maintenance requirements should be calculated and small amounts at a time should be offered to meet these requirements. If you give too much at one time you may induce vomiting. Soft drinks, juices, sport drinks, and tea should be avoided because they lack electrolytes and are hyperosmolar. They may induce more diarrhea. It is important to emphasize to the parents that this mode of treatment will not decrease the amount of stool initially. 

The child in the case has a deficit of 500cc (50cc/kg.). Maintenance requirement of 40cc/hr., and to correct the deficit after 6 hours, needs about 125cc./hr. 2 tbs./15 minutes will provide the child's needs. Ongoing losses should be corrected with 10cc/kg per stool. 

If the mother is nursing, breastfeeding shouldn't be interupted and if formula feeding may be continued. It has been shown that starving may lead to villous atrophy so feeding is recommended. The BRAT diet and other foods high in carbohydrates are recommended to enhance fluid and sodium absorption.

Any medication that slows intestinal motility and allow overgrowth of organisms should be avoided. Imodium and Lomotil can also cause ileus, bloating, respiratory depression, and drowsiness.

Pepto-Bismol has anti-secretory, anti-inflammatory, and anti-bacterial effects. Its use may under emphasize the role of fluid replacement.

Kao Pectate is an adsorbent and may lead to decreased intestinal motility, therefore it should be avoided.

Antimicrobials are usefull in certain situations 

Yogurt and Lactobaccillus- further investigation is needed before recommending it routinely, but some preliminary data show usefulness. 

Use of lactose free formula has not been proven of value nor has I/2 strength formulas 

References
1. Lasche and Dugan.  Managing Acute Diarrhea Contemporary Pediatrics February 1999
2. American Academy of Pediatrics. Practice Parameter: the management of acute gastroenteritis in young children. Pediatrics 1996 97 424-436
3. Atherly-John Yvonne, et al. A Randomized Trial of Oral vs. Intravenous Rehydration in a Pediatric Emergency Room. Archivive of Pediatrics and Adolescent Medicine. Dec 2002 Page 1240
4. Shilkofski N. Escherichia coli 0157:H7 Pediatrics in Review February 2004
5. MMWR. Managing Acute Gastroenteritis Among Children. Oral Rehydration, Maintenance, and Nutritional TherapyPediatrics August 2004
6. Thielman NM, Guerrant RL. Clinical Practice. Acute infectious diarrhea. N Engl J Med. 2004. Jan 1; 350(1):38-47. Review
7. Spandofer P. Oral Versus Intravenous Rehydration of Moderately Dehydrated Children: A Randomized Controlled Trial . Pediatrics Feb. 2005
8. Keating J. Chronic Diarhhea.  Pediatrics in Review.  January 2005
9. Vernacchio L. et al.  Diarrhea in American Infants and Young Children in the Community Setting: Incidence, Clinical Presentation, and Microbiology.  Pediatric Infectious Disease Journal  Vol 25(1) Jan. 2006
10. Dennehy P. Rotavirus.  Contemporary Pediatrics December 2005
11. Bass E et al.  Rotavirus.  Pediatrics in Review May 2007
12. Hyponatremia  Pediatrics in Review November 2007
13. DuPont H.  Bacterial Diarrhea.  NEJM Oct 15, 2009

 

 

Uptake, Impact, and Effectiveness of Rotavirus Vaccination in the United States: Review of the First 3 Years of Postlicensure Data

Tate, Jacqueline E. PhD; Cortese, Margaret M. MD; Payne, Daniel C. PhD; Curns, Aaron T. MPH; Yen, Catherine MD, MPH; Esposito, Douglas H. MD; Cortes, Jennifer E. MD; Lopman, Benjamin A. PhD; Patel, Manish M. MSc, MD; Gentsch, Jon R. PhD; Parashar, Umesh D. MB BS, MPH

 

Author Information

From the Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA.

Accepted for publication September 28, 2010.

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention (CDC).

Address for correspondence: Jacqueline E. Tate, PhD, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS-A47, Atlanta, GA 30333. E-mail: jqt8@cdc.gov.

 

Source: Pediatr.Infect.Dis.J., 2011, 30, 1 Suppl, S56-60

 

Abstract

 

Background: Rotavirus vaccine was recommended for routine use in US infants in 2006. Before the introduction of vaccine, rotavirus was the most common cause of severe gastroenteritis in children <5 years of age in the United States.

 

Methods: We reviewed published data to summarize the US experience during the first 3 years of its rotavirus vaccination program.

 

Results: Rotavirus seasons have been delayed and diminished in magnitude during the postvaccine era compared with the prevaccine era. Hospitalizations, emergency department visits, and outpatient visits due to gastroenteritis have declined dramatically in children <5 years of age including in children age-ineligible to have received vaccine, suggesting indirect benefits of vaccination. Rotavirus vaccine has been widely accepted by pediatricians. Vaccine coverage is steadily increasing but remains lower than coverage levels of other routine infant immunizations.

 

Conclusions: The implementation of routine childhood immunization against rotavirus has rapidly and dramatically reduced the large health burden of rotavirus gastroenteritis in US children. Continued monitoring of rotavirus diarrhea is needed to determine if immunity wanes as vaccinated children get older and to better quantify the indirect benefits of vaccination. Ongoing surveillance will also enable monitoring of the long-term impact of vaccination on rotavirus epidemiology.

 

 

 

 

Diarrhea-Associated Hospitalizations Among US Children Over 2 Rotavirus Seasons After Vaccine Introduction

Catherine Yen, MD, MPHa,b, Jacqueline E. Tate, PhDb, Joshua D. Wenk, BAc, J. Mitchell Harris, II, PhDc, Umesh D. Parashar, MBBS, MPHb

a Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, and
b National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; and
c National Association of Children's Hospitals and Related Institutions, Alexandria, Virginia

 

Source: Pediatrics, 2011, 127, 1, e9-e15

 

OBJECTIVE After implementation of rotavirus vaccination in 2006, large decreases in rates of severe diarrhea among US children occurred in 2007–2008. We ascertained whether these decreases were sustained in 2008–2009.

 

METHODS We examined hospital discharge data from a national network of pediatric hospitals and compared all-cause diarrhea-related and rotavirus-specific hospitalizations in 3 prevaccine rotavirus seasons (2003–2006) with those in 2 postvaccine seasons (2007–2008 and 2008–2009) among children <5 years of age. We defined rotavirus seasons using data from a national laboratory surveillance network.

 

RESULTS At 62 consistently reporting hospitals, a median of 15 645 diarrhea-related hospitalizations (range: 14 881–16 884 hospitalizations) occurred each rotavirus season among children <5 years of age in 2003–2006. Compared with this median, all-cause diarrhea-related hospitalizations decreased by 50% (n = 7760) in 2007–2008 and by 29% (n = 11 039) in 2008–2009. In 2007–2008, reductions of 47% to 55% were seen for all age groups, including vaccine-ineligible children 2 years of age (48%). In 2008–2009, these reductions decreased in magnitude, especially among children 2 years of age (17%). Decreases in 2007–2008 and 2008–2009 were similar in the Northeast and West, but decreases were smaller in 2008–2009, compared with 2007–2008, in the Midwest and South.

 

CONCLUSIONS Compared with prevaccine seasons, decreases in diarrhea- and rotavirus-associated hospitalizations seen in 2007–2008 were sustained in 2008–2009 but were somewhat smaller. Given the variability in diarrhea-related hospitalization trends over the 2 postvaccine seasons according to age group and region, continued surveillance is required for full assessment of the impact of rotavirus vaccination.

 

 

Rehydration & Refeeding After Diarrheal Illness

Say no to sports drinks and the BRAT diet.

Source: Adv.NPs PAs, 2010, 1, 3, 35-6, 38, 40

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Beverages such as apple juice, chicken broth, colas and sports drinks are not appropriate for rehydration therapy due to their insufficient composition of necessary nutrients (Table 2). It is important to educate parents and guardians that such beverages can complicate and worsen diarrhea due to their high osmolarity and low molecular bases. Moreover, sports drinks were formulated based on water and electrolyte losses from diaphoresis, not diarrhea. Therefore, watering down such drinks reduces the amount of needed electrolytes. One meta-analysis found that solutions containing lower concentrations of sodium and glucose may be even more effective, but more research is needed in this area.20

 

Refeeding

The CDC, the European Society of Pediatric Gastroenterology Hepatology and Nutrition and the European Society for Paediatric Infectious Disease recommend early resumption of feeding with an unrestricted, age-appropriate diet as soon as rehydration is complete.

 

The BRAT diet (bananas, rice, applesauce, toast) was historically advocated by healthcare providers for its low fiber. This support stemmed from the belief that a high-fiber diet would cause an increase in gastrointestinal upset. Providers continue to recommend this diet based on the fact that a bland diet will not exacerbate GI distress either. But this diet should no longer be recommended to caregivers of children with diarrhea for many reasons.6

 

First, foods in the BRAT diet are thought to act as "binders" that can help reverse the diarrhea by causing constipation. But if the loose stools are caused by infectious agents, the diarrhea should be allowed to run its course to rid the body of the toxins. This is important information for the parent who may be more concerned with the amount of loose stools and frequent diaper changes.

 

Second, the BRAT diet provides less than optimal nutrition and is unnecessarily restrictive (Table 3). Third, no scientific evidence proves that the BRAT diet helps recovery from diarrhea. Foods rich in complex carbohydrates, lean meats, yogurt, fruits and vegetables are the preferred diet therapy.

 

Children who exhibit signs of severe dehydration (10% or greater volume loss) are not candidates for ORT. Severe dehydration is a medical emergency requiring IVT to prevent ischemic tissue damage. These patients present with hypotension, prolonged capillary refill (greater than 3 seconds), cool and mottled extremities, lethargy and tachypnea.

 

Other scenarios requiring referral for emergent treatment include diarrhea persisting more than 72 hours with no response to ORT; hypernatremia; severe complications such as seizures, hypotonia, hematemesis, hematochezia, and anuria for more than 12 hours; or an immunocompromised host.21

 

ORT for First-Line Care

Research has shown that ORT is the best first-line treatment for mild to moderate dehydration in infants and children with acute diarrhea. It is cost effective, easy to use and supported by published evidence. More research is needed to evaluate reduced osmolarity ORS compared to WHO standard ORS. Early refeeding is mutually important in the treatment of infants and children with diarrhea. Previously accepted rehydration practices, such as use of the BRAT diet and sports beverages, should be avoided because they provide suboptimal nutrition and may exacerbate dehydration.

 

Article re-posted from: http://nursing.advanceweb.com/regional-content/articles/rehydration-refeeding-after-diarrheal-illness.aspx?CP=2