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CHILD WITH DIARRHEA AND
VOMITING
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OUTLINES (1)
• ACUTE GASTROENTERITIS ( AGE )
Definition of diarrhea and gastroenteritis
Differential diagnosis if AGE
Epidemiology of AGEEtiology
Short-term consequences of AGE
- Dehydration
- Electrolyte imbalance
- Metabolic acidosis
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(1) Definition
Acute gastroenteritis is a clinical syndrome ofdiarrhoea and/or vomiting of acute onset,often accompanied by fever, caused byinfectious agents or by bacterial toxins (eitheringested preformed in food or produced in thegut); and is not secondary to some primarydisease process outside the alimentary tract
Alternative name
Infectious diarrhoea; Acute diarrhoea
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DIARRHEA
Passage of loose watery stools
3 or more loose or watery stools/day
Alteration in normal bowel movement
characterized by decreased in consistency and
increased in frequency
Acute diarrhea < 14 days duration
Persistent diarrhea > 14 days
Chronic diarrhea > 30 days
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TYPES OF GASTROENTERITIS
1. Bacterial gastroenteritisi. Bacterial infectionii. Food poisoningiii. Antimicrobial Associated
(Pseudomembranous colitis -Clostridium difficile)
2. Viral gastroenteritis
3. Parasites gastroenteritis
4. Non-infectious
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( 2 )DIFFERENTIAL DIAGNOSIS
Differential
diagnosis
Infant Child Adolescent
Common -Gastroenteritis
-Systemic infection
-Antibiotic
associated-Overfeeding
-Gastroenteritis
-Food poisoning
-Systemic infection
-Antibioticassociated
-Gastroenteritis
-Food poisoning
-Antibiotic associated
Rare -Primary
disaccharidase
deficiency
-Hirschprung toxiccolitis
-Adrenogenital
syndrome
-Toxic ingestion -Hyperthyroidism
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• Although gastroenteritis consists of the triad of vomiting,
diarrhoea and fever, other conditions can present with the above
symptoms as well.
These include:-Acute appendicitis
-Strangulated hernia
-Intussusception or other causes of bowel
obstruction-Urinary tract infection
-Meningitis and other types of sepsis
-Any cause of raised intracranial pressure
-Diabetic ketoacidosis
-Inborn error of metabolism
-Haemolytic uraemic syndrome
-Inflammatory bowel disease
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!!!Always consider another diagnosis in the
presence of any of the following warningsigns:
#Abdominal distension
#Bile-stained vomiting
#Blood in vomitus or stool (in appropriateclinical setting)
#Severe abdominal pain
#Vomiting in the absence of diarrhoea
#Headache
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( 3 ) epidemiology
• Diarrheal diseases continue to be a major cause ofmorbidity and mortality in children in developingnations. In developed nations , they are an importantcause of hospital admission although mortality rates
may be lower. About 9% of all hospitalisations ofchildren younger than 5 years were reported to be aresult of diarrhoea.
• In Malaysia, the mortality of severe diarrhea in childrenrequiring hospital admission was low, with a case
fatality rate of 2.1/1000 admissions. Rotavirus andnontyphoidal salmonellae were the most common viraland bacterial pathogens causing severe diarrhea inchildren requiring hospital admission.
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( 4) ETIOLOGY
VIRUSES BACTERIA PARASITES
Rotavirus
Enteric
adenovurus Astrovirus
Calicivirus
Aeromonas
Bacillus cereus
Campylobacter jejuni
Clostridium
perfringes
E.coli
Salmonella spp.
Shigella spp. Vibrio Cholerae
Yersinia
enterocolitica
Blas hominis
Crypt. Parvum
Ent. histolytica
COMMON CAUSATIVE AGENTS OF GASTROENTERITIS
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WATERY DIARRHEA CAUSATIVE AGENTS
≤ 2 years old Rotavirus
Astrovirus
Calicivirus
Enteric adenovirus
Enteropathogenic Escherichia coli(EPEC), Enterotoxigenic Escherichia
coli (ETEC),
Vibrio cholerae
2-5 years old Enterotoxigenic Escherichia coli(ETEC)
Rotavirus
Shigella
Vibrio cholerae
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MUCOUSY / BLODDY CAUSATIVE AGENTS
≤ 2 years old Shigellashiga-toxin producing Escherichia
coli (STEC)
Campylobacter jejuni
2-5 years old Shigella
shiga-toxin producing Escherichia
coli (STEC)
non-typhoidal Salmonella
E. histolytica
!!! In Malaysia, major enteric viruses causing childhood AGE arerotavirus, norovirus, and enteric adenovirus. For bacterial
gastroenteritis, the most important causative agent is the non-
typhoidal Salmonella, followed by Campylobacter, Shigella and E.coli.
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( 5 ) short-term consequences of
AGE
A) Dehydration
1) Secretory diarrhea
- when secretion>absorption due to inflammation- recognized clinically by 4 features:
i) stools are large-volume, watery and often >1L/day
ii) diarrhea persists during fasting
iii) measured stool osmolar gap ( 290-((Na + K)) of <50m0sm/L
iv) don’t have excessive fat, blood or pus in their stool, but often developdepletion in fluid, Na and K
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2) Osmotic diarrhea
- due to invasion of the enterocytes by bacteria or viral will result
in reduced in absorption area
# eg: rotavirus infection
- can be due to after malabsorption of an ingested substances
which ‘pulls’ water into bowel lumen
# eg: laxatives, pancreatic insufficiency or lactose intolerance
- osmotic gap >50 m0sm/L
>>>By using these two mechanisms both will cause
rapid loss of fluid through stools which later
result in DEHYDRATION<<<>>>most serious complication is when dehydration
leading to shock<<<
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Types of dehydration
Isotonic
(isonatremic)
Hypertonic
(hypernatremic)
Hypotonic
(hyponatremic)Loses H2O = Na H2O > Na H2O < Na
Plasmaosmolality
Normal Increase Decrease
Serum Na Normal Increase Decrease
ECV
ICV
Decreasemaintained
Decrease
Decrease +++
Decrease +++
Increase
Thirst ++ +++ +/-
Skin turgor ++ Not lost +++
Mental state Irritable/lethargic Very irritable Lethargy/coma
shock In severe cases Uncommon Common
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B) Electrolytes imbalance
Sodium Imbalance
Most important electrolyte affected by dehydration
Hypernatremia
When body loses more water than electrolytes concentrating the amount of sodium
Sign of hyponatremia include thirst,confusion and seizure
Hyponatremia
Result when body loses more sodium than water especially in cases of severe vomitingand
diarrhea
Signs of hyponatremia include headache, confusion and lethargy
Potassium Imbalance
Potassium is mostly found inside the body’s cells so small changes in the potassium level
inthe bloodstream can have a significant impact on person with gastroenteritis
Hyperkalaemia
High potassium can cause dangerous arrhythmia or abnormal heart rhythm
Low potassium usually causes milder symptoms like muscle cramps, fatigue andconstipation
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• Metabolic Acidosis
Metabolic acidosis occurs when an acid other
than carbonic acid accumulate in the body
resulting in a fall in the plasma bicarbonate
Gastrointestinal base loss
Loss of bicarbonate in diarrhea, small bowel
fistula, urinary diversion procedure.
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Outlines ( 2 )
•
MANAGEMENT Assessment
i) History
ii) Clinical
Rehydration therapyi) Oral rehydration therapy
ii) Intravenous- overview
Nutritional therapy
Others- antibiotics, anti-diarrheal, anti-emetics,
probiotics, diosmectitie, zinc
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1) assessment
AIM
- Identify the presence of, the degree of, and type ofdehydration
- Identify the aetiological agent, if indicated andpossible
- Identify co-morbidity and complications
- To assess nutritional status
- To ascertain the most appropriate mode oftreatment
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c) Laboratory tests
• Blood: full blood count, blood urea andserum electrolytes ( BUSE )-if > 5%dehydration
• Septic workout: blood culture, dengueserology, BFMP, thyphidot
• Arterial blood gas
• Stool: viral studies, bacteriology (culture ifstool is profuse and watery, or containsblood and mucuos), microscopy (if stool isbloody/mucousy), reducing substances (ifwatery)
• Urine: specific gravity
• Blood glucose level in infants
d) Cli i l t f
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d) Clinical assessment of
dehydrationGoal of assessment
- to provide a starting point for treatment- to conservatively determine which:
> patient can safely be sent home for therapy
> patient should remain for observation
> patient needs immediate intensive therapy
Can be based on reliable previous weight-> The best measure of
dehydration is by the percentage loss of body weight.
But, if not available, the degree of dehydration can be assessed
clinically.
Most useful signs for significant dehydration are:
Prolonged capillary refill time (normal < 2 seconds)
Reduced skin turgor
Abnormal respiratory pattern
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Remember!!!!!
Young infants are at risk for dehydration:
-increased surface area: body volume ratio leading to increased insensible fluidlosses
- milk as main source of nutrition:
# large osmotic load promote osmotic diarrhea
# large protein load and high renal solute load- tendency to more severe vomiting and diarrhea
- unable to obtain fluids for themselves when thirsty
others risk factors for severe dehydration following AGE:
-failure to give ORS
- discontinuation of breast feeding- frequent stool (>8/day) or vomiting (>2/day)
- malnutrition
- Vibrio cholerae
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Notes:1) In hypernatremic dehydration, signs of dehydration may
not be prominent because dehydration is mainly
intracellular. Skin is doughy in consistency and there is
abnormal behaviour.2) Repeated assessment is necessary, especially in infants and
young children.
3) Watery stools maybe mistaken as urine output.
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REHYDRATION THERAPY
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ORAL REHYDRATION THERAPY
Na (mmol/L) K (mmol/L) Cl (mmol/L) Base (mmol/L)
Child < 5 years
• Cholera
• Non- cholera
101
56
27
25
92
55
32
14
WHO ORS 75 20 65 10
Fluid not
suitable for oral
rehydration
• Cola
• Apple juice
1.6
0.4
-
44
-
45
13.4
-
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Principles of ORT treatment
1. Adequate rehydration therapy using an
appropriate ORS
2. Replacement of ongoing fluid losses
from vomiting and diarrhea with ORS
3. Frequent feeding of appropriate foodsas soon as dehydration is corrected.
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• ORT is recommended as first-line therapy for
both mildly and moderately dehydrated
children. ORT seems to be a preferred
treatment option for patients with moderatedehydration from gastroenteritis
• Preparation : 1 sachet in 250 ml / 8 oz water
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Treatment for dehydration
• PLAN A
• PLAN B
•
PLAN C
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PLAN AMild dehydration (5%)
• Treat diarrhea at home
1. Give extra fluid
- Breastfeed frequently & longer
- Add on ORS / cooled boiled water / food-based fluids
- ORS given for each loose stool
*If weight is available, give 10 ml/kg of ORS
- Give frequently small sips- If child vomits, wait 10 minutes then continue but more slowly
- Continue until diarrhea stops
- Give 8 sachets ORS to use at home
Age ORS (ml)
< 2 years 50 – 100
≥ 2 years 100 - 200
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2. Continue feeding
- Breastfed / formula fed / semi-solid / solid foodshould continue
- Food high in simple sugar should be avoided asosmotic load may worsen the diarrhea
3. When to return (clinic / hospital)
- Not able to drink / breastfeed / drinking poorly
- Become sicker
- Develops fever- Has blood in stool
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PLAN BModerate dehydration (7.5%)
• Give recommended amount ORS over 4-hour period
*Child’s weight (kg) x 75 If patient want more ORS than shown, give more
• Give frequently small sips
• If child vomits, wait 10 minutes then continue but more slowly
• Continue breastfeeding whenever the child wants
• After 4 hours
- reassess & classify the dehydration- select the appropriate plan to continue treatment (plan A, B / C)
- begin feeding the child
• If child refuse ORS, consider nasogastric tube
• Give IV fluid therapy if failed oral / nasogastric therapy, vomiting persist /impending shock
Age < 4 mo 4 – 12 mo 1 – 2 yr 2 – 5 yr
Weight (kg) < 6 6 - 9 10 - 11 12 – 19
ORS (ml) 200 - 400 400 - 700 700 - 900 900 - 1400
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PLAN CSevere dehydration (10%)
•
Start IV / IO immediately.• If patient can drink, give ORS while drip is being set up. Check acid-base
electrolytes.
1. Resuscitate
Give bolus NS / Ringers lactate as fast as posible:
- neonate – 10 ml/kg
- pediatric – 20 ml/kg
• Reassess capillary filling after every bolus
• If not respond to rapid bolus rehydration – give inotropic agents
(dobutamine / dopamineto) to maintain perfusion. Consider otherunderlying problems.
• Stop the boluses once perfusion improve / fluid overload is suspected /max. amount of ORS
- neonate – 40 - 60 ml/kg
- pediatric – 60 - 80 ml/kg
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• Assess every 1-2 hr during rehydration
• Give ORS (5 ml/kg/hr) as soon as child can drink (infant :after 3-4h, older child : 1-2h)
• Once child can take orally the rest of the fluid requirementcan be given by ORS.
• Check hydration status & choose appropriate treatment(plan A/B)
• If fail to set IV / IO line, sent to nearest centre immediately – Try to give ORS (20 ml/kg/hr) over 6 hr
– Reassess every 1-2 hr
– If repeated vomiting / increasing abdominal distension, give thefluid more slowly
– Reassess after 6 hr, select the appropriate plan to continuetreatment (plan A,B/C)
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2. Intravenous therapy
• Indication :- severe dehydration
- unconscious child- continuous rapid looses stool (>15-20 ml/kg/hr)
- frequent, severe vomiting, drinking poorly
- abdominal distension with paralytic ileus
- glucose malabsorption
(increase in stool output && large amount of glucose in the stool when ORS sol. given)
I. Fluid deficit
Fluid deficit (ml) = % dehydration x body weight (g)- mild dehydration – 5%
- moderate dehydration – 7.5%
- severe dehydration – 10%
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II. Maintenance fluid therapy
Amount (ml/kg/day) x weight (kg)
• Total fluid require
= Maintenance + Deficit – Resuscitation
24 hours
Age Amount (ml/kg/day) Fluid
D1 60 Dextrose 10%
D2 80 1/5 NS + Dextrose 10%
D3 100 1/5 NS + Dextrose 10%
D4 120 1/5 NS + Dextrose 10%
D5 - D30 150 1/5 NS + Dextrose 10%
D31 - 6 month 150 1/5 NS + Dextrose 5%
6 month - 1 year 120 1/5 NS + Dextrose 5%
> 1 year 1st 10kg = 100 ml/kg
10 – 20kg = + 50 ml/kg for next 10 subsequent kg
20 kg = + 20 ml/kg for any subsequent kg
1/2 NS + Dextrose 5%
@
1/5 NS + Dextrose 5%
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III. Treating metabolic acidosis
• Acidosis usually self corrects with rehydration ; correct only if pH < 7.1
• Sodium bicarbonate correction :
IV 8.4% NaHCO3 (mEq or ml) = 1/3 x base deficit x weightusually only half this volume (1/2 correction) is given
• Review with repeat blood gas
IV. Electrolyte requirement & replacement formulae
• Daily requirement of K+ = 2-3 mmol/kg/day x body weight (kg)
• Daily requirement of Na+ = 2-3 mmol/kg/day x body weight (kg)
Na+ deficit (mmol)
= (140 mmol/L – patient’s serum Na level) x 0.6 x wt (kg)
* 140 mmol/L : desired Na
+
level.0.6 : proportion of body weight for distribution of Na+
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Type of dehydration
1. Hyponatraemic (< 130 mmol/L)
2. Isonatraemic (130 -150 mmol/L)
3. Hypernatraemic (> 150 mmol/L)
• Electrolyte disorder
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• Electrolyte disorder
I. Hypernatraemia (serum Na > 150 mmol/l)
• This can result from ingestion of hypertonic liquids, such as over-concentrated milk feeds or home-made solutions to which salt is added, or loss of hypotonic fluids in the stool or urine. It is morecommon in hot weather.
a. Resuscitation
- If in shock, give NS / RL 20 ml/kg intravenously over ½ to 1 hour and repeat as
necessary
a. Rehydration
- if oral rehydration failed, start IV
- reduce serum Na slowly (not exceed 10 mmol/L/day) – dramatic fall result in cerebral edema,
seizures.- give total fluid in 48 – 72 hrs.
- use NS 5% dextrose : for fluid replacement ,
continue until serum NA < 145 mmol/l.
- then, use ½ NA 5% dextrose @ 1/5 NA 5% dextrose
- add KCl when child passes urine and review BUSE
- monitor BUSE 6 hourly
• Example: 10 month old child weighing 9kg is 5% dehydrated and not tolerating oral fluids. Serumsodium is above 150 mmol/l
- Fluid deficit = 5% of 9000g = 450 ml
- Maintenance at 120 ml/kg/24 h = 1080 ml/24 h
- To rehydrate over 48 hours, the rate of infusion should be
1/48 x (450 + 1080 + 1080) ml/hr = 54 ml/hour
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When to prescribe antibiotics
Most causes of the gastroenteritis are due toviral infections; antibiotic is not necessary
Antibiotics are helpful only in children with
bloody diarrhea, probable shigellosis andsuspected cholera with severe dehydration
Example of antibiotic with respective
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Example of antibiotic with respectiveorganism
Organism Treatment
Salmonella typhi Ampicillin, cefotaxime,trimethoprim
Other Salmonella None; amoxicillin,
ampicillin,cefotaxime,trimethoprim
Shigella Trimethoprim,ampicillin
Escherichia coli
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Escherichia coli
Toxigenic
Invasive / pathogenic
None if endemic; trimethoprim,
ciprofloxacin for Traveler’s diarrhea
Trimethoprim, neomycin
Campylobacter No treatment for mild disease,
erythromycin & azithromycin for diarrhea
Vibrio cholera Tetracycline, trimethoprim
Clostridium difficile Oral vancomycin
Giardia lamblia Quinacrine, furazolidone
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Anti-diarrheal
• Should not be given to young children with diarrhea ordysentry.
• Most of the time, diarrhea doesn’t require treatment.It most often lasts only a couple of days whether treat
it or not. However, medicine can help to feel better,especially if patient also have cramping.
• When diarrhea is a symptom of an infection caused bybacteria or parasites, antidiarrheal medicines can
actually make the condition worse. This is because themedicine keeps body from getting rid of the bacteriaor parasite that is causing the diarrhea.
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Common anti diarrhea
• Loperamide works by slowing down the speed of fluidsmoving through your intestines (bowels).
• Don’t give loperamide to children 6 years of age
• Bismuth subsalicylate works by balancing the way fluidmoves through intestines. It also reduces inflammationand keeps certain bacteria and viruses that causediarrhea from growing in the stomach and intestines.
• People who are allergic to aspirin or other salicylatemedicines should not take bismuth subsalicylate. Don’tgive bismuth subsalicylate to children 12 years of ageor younger.
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Anti-emetics
• Prochlorperazine, promethazine, and metoclopramidehave a high incidence of side effects and should beavoided in patients less than 2 years old and used withextreme caution in children older than 2 years.In
limited studies, ondansetron when used as a singledose has shown to be safe in children with acutegastroenteritis.
• Oral ondansetron could be a consideration for children
with AGE who fail ORT to prevent the need forintravenous fluid (IVF), or as an adjunct to IVF to helpfacilitate ORT and prevent admission.
P bi ti
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Probiotics are live microorganisms that
may confer a health benefit on the host.
•
The rationale for using probiotics is based on theassumption that they modify the composition ofcolonic microflora and counteract enteric pathogens.However, there are two main views as to howprobiotics counteract diarrhea. According to one
theory, probiotics act locally (at intestinal level).According to the other theory, probiotics act bymodulating the immune response.
• At local level, probiotics:
•
compete with pathogens for nutrients and receptors• induce hydrolysis of toxins and receptors
• induce production of antimicrobial substances(including peptides of the innate immune system)
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Di tit
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Diosmectite
Diosmectite (Brand names Smecta, Smecdral):
natural silicate of aluminium and magnesium us
ed as an intestinal adsorbent in the treatment of
several gastrointestinal diseases. It is insoluble in
water. Diosmectite is able to absorbing excess
water from intestinal tract.
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• However anti-diarrhoeal drugs and anti-
emetics should not be given to young children
because it does not prevent dehydration and
some have dangerous, sometimes fatal sideeffects.
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Zinc supplements
• It has been shown that zinc supplements
during an episode of diarrhoea reduce the
duration and severity of the episode and
lower the incidence of diarrhoea in thefollowing 2-3months. WHO recommends zinc
supplements as soon as possible after
diarrhoea has started. Dose up to 6 months ofage is 10 mg/day, and age 6 months and
above 20mg/day, for 10-14 days.
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PRINCIPLES OF FLUID REPLACEMENT
VOLUME REQUIRED =
MAINTENANCE + DEFICIT + ONGOING LOSSES
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? Calculate 24-Hour Maintenance Fluid
Body Weight (Kg) Volume Per Day
0-10 100 mL/kg
11-20 1000 mL +
50 mL/kg for each 1 kg > 10kg
20 1500 mL +
20 mL/kg for each 1 kg > 20 kg
? Calculate Fluid Deficit
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? Calculate Fluid Deficit
% Dehydration X Patient’s Weight X 1000 mL
? Correction Of Ongoing Losses
Usually not a problem and correction is often
not necessary. Correction is mandatory in
patients with profuse watery stools, ( i.e
cholera) ; or in the following situations :
continuous nasogastric drainage, ileostomy,
etc.
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TYPES OF DEHYDRATION
Can be classified according to serumsodium concentration
HYPONATRAEMIC < 130 mmol/L
ISONATRAEMIC = 130 – 150 mmol/ L
HYPERNATRAEMIC > 150 mmol/L
? Correct Isonatraemic Dehydration
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? Correct Isonatraemic Dehydration
18 months old girl
Weight on admission = 10kg
Dehydration estimated on admission = 10 %Initial serum Na+ = 142 mmol/L
Rapid Phase (Resuscitation)
20ml/kg bolus NS over 1 hour
20ml X 10 kg = 200 ml over 1 hour
Replacement
Volume required = maintenance + deficit + ongoing losses
= 1000 ml + 1000ml
= 2000ml
Maintenance = 10 kg X 100 ml/kg = 1000ml
Deficit = 10/100 X 10kg X 1000ml = 1000ml
On going losses not included
2000ml – 200ml(resuscitation) = 1800 ml
78 ml/hour X 23 hours
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? Correct Hyponatraemic Dehydration
Sodium deficit (mmol) =
(140mmol/L - patient’s serum Na level x 0.6 x body weight kg)
140 mmol/L = desired Na+ level
0.6 = proportion of body weight for distribution of sodium
EX : Child 15 kg, Na+ level = 120 mmol/L
Sodium deficit = (140-120)mmol/L X 0.6 X 15kg
= 180 mmol/L
Correction = Deficit above (180 mmol/L) + daily maintenance
Asymptomatic Hyponatraemic dehydration = treatment is similar to isonatraemic
dehydration.
In symptomatic hyponatraemia, use hypertonic saline ( e.g NACL 3%) to increase serum
sodium by 0.5 mmol/L per hour
(RAPID CORRECTION POTENTIALLY DANGEROUS. RECOMMENDED RATE OF CORRECTION
APP 1-2 mmol/L )
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Hypernatremic dehydration
• 1yr old (10kg) female child presented withfever since 4 days ago.
• It is associated with vomiting and diarrhea
more than 7 times per day• On examination, patient appear Lethargic,
cold, weak rapid pulse, low BP, sunken eyes,dry eyes, parched mucous membranes,capillary refill 5 sec, marked tenting of skin
• Na = 175, K+ = 3.2, HC03 = 20
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• Feature of patient with
hypernatremic dehydration:
Skin has a characteristic doughy feelAnterior fontanelle may not be sunken
Late sign of shock
#Difficult to recognize clinically ( sign of dehydration less obvious – water shift
from ICF to ECF
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Management
• The hypovolemic child requires fluid replacement and aslow correction of her fluid deficit over 48 to 72 hours.
• Any patient who has hypernatremia needs to bemonitored for seizure activity.
•Generally, the serum sodium level should decrease at arate no faster than 10 mmol/L/h, because rapidcorrection of hypernatremia can lead to fluid shiftsfrom the ECF to the ICF and the development ofcerebral edema and seizure
• Patients must be monitored for the signs andsymptoms of cerebral edema throughout the course oftheir treatment
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• Severe dehydration
1. Rapid phase (resuscitate)
20ml/kg bolus NS over 30-60 min
20x 10=200ml over 30-60 min
2. Replacement
Total fluid needed= deficit+maintenance+loss
deficit
15%x10x1000= 1500ml
Maintenance
10kgx 1000ml/kg=1000ml
# thus fluid needed in =maintenance+ deficit+loss
=1000+ [1500-200]=2300ml of ½ NS 5% Dextrose over 48-72 hour
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ORS (Oral Rehydration Solution)
- First line therapy for mild to moderate diarrheal
dehydration
- less expensive than IV therapy with lower complicationrate
( IV therapy may still be required for patient with
severe dehydration ; patients with uncontrollable
vomiting; patients unable to drink because of extremefatigue, stupor, or coma; or patients with gastric or
intestinal distention. )
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ORSRepletion phase
Administer 50 mL/kg of ORS over 4 hours to patients with milddehydration.
Administer 100ml/kg of ORS over 4 hours to patient with moderatedehydration.
Additional 10ml/kg ORS to replace ongoing loss from diarrhea /
emesis.
Reassess patient's hydration status
• Maintenance phase –
when rehydration is complete, maintenance therapy : 100 ml/kg in24 hours until diarrhea stops. Feeding and fluids should be started.