A CUTE

G ASTROENTERITIS
I N C HILDREN

Moderated by Dr. Madhuri Engade

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

Environmental
Factors
 HOST FACTORS

 Biological factors increase  Behavioral factors increase

susceptibility to Acute the risk of Acute Diarrhoea
Diarrhoea
 Malnutrition is associated with an  Not breastfeeding exclusively for
increased incidence, severity and 6 months
duration of diarrhoea  Using infant feeding bottles
 Age
 Failure to get immunised against  Not washing hands after
rotavirus defecation, handling faeces or
 Failure of measles vaccination before handling food
 Selective IgA deficiency
 HIV
DIARRHEA & MALNUTRITION
VICIOUS CYCLE

 Immunity
 Mucosal integrity  Losses
Common  Catabolism
predisposing factors

 Absorption
 Appetite
Voluntary restriction
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
 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 Bacteria Parasites

• Enteric • E. coli (ETEC, • Entamoeba
adenoviruses EPEC, EHEC, histolitica*
EAEC, EIEC*)
• Astrovirus • Girdia lamblia
• Shigella species*
• Human • Vibrio cholerae O1 & • Cryptosporidium
calciviruses O139 • Trichuris trichuria
(norovirus and • Salmonella sp* • Strongyloides
sapovirus) • Campylobacter stercoralis
jejuni*
• C. difficile

*causes diarrhea with or without dysentry

ETIOLOGY
 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
 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.
ETIOLOGY
 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
PATHOGENESIS
 ECF : ICF

 Isonatremic vs Hyponatremic vs hypernatremic

dehydration

 Electrolyte imbalance
PATHOGENESIS

 Hemodynamic Changes

 Skin turgor change

PATHOPHYSIOLOGICAL CHANGES*
Type Mechanism Complications
Secretory Acute watery diarrhea Rapid development of
Sodium pump failure dehydration
Electrolyte imbalance

Invasive Microbes invade Intestinal Septicemia

mucosal cells Intestinal perforation
Blood & mucus in stools Toxic megacolon
HUS

Osmotic Injury to enterocytes Dehydration

Brush border damage Hypernatremia
Large, frothy, explosive, acidic
stools

*IAP textbook of pediatrics 5th edition

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 This is the most common. It is of recent onset, Rotavirus, E. coli,
diarrhoea commencing usually within 48 hours of Vibrio cholera
presentation. It is usually self limiting and
most episodes subside within 7 days. The
main complication is dehydration.

Acute bloody Also referred to as dysentery. This is the Shigella spp,

diarrhoea passage of bloody stools. It is as a result of Entamoeba
damage to the intestinal mucosa by an histolytica
invasive organism. The complications here
are sepsis, malnutrition and dehydration.
ASSESSMENT
 Goals :  History :
i. Identify the Type of i. Onset, duration & number
diarrhea. of stools per day.
ii. Look for dehydration & ii. Blood in stools.
other complications iii. Episodes of vomiting
iii. Assess for malnutrition
iv. Presence of fever, cough,
iv. Rule out nondiarrheal convulsions, recent measles.
illnesses v. Type & amounts of fluids
v. Assess feeding taken.
vi. Drug history.
vii. Immunization history
EXAMINATION
Look at
Condition Well alert Restless, irritable Lethargic or
unconscious; floppy
Eyes Normal Sunken Very sunken & dry
Tears Present Absent Absent
Mouth & Moist Dry Very dry
tongue
Thirst Drinks normally; not Thirsty; drinks eagerly. “Drinks poorly” or not
thirsty able to drink
Feel
Skin Goes back quickly Goes back slowly Goes back very slowly
pinch
Decide No signs of If patient has two or If patient has two or
dehydration more signs then some more signs then
dehydration severe dehydration

Treat Plan A Weigh patient if Weigh patient &

possible Plan B use Plan C urgently
PLAN A
 may be treated at home. Age Amount of Amount of
ORS to be ORS to be
given after provided at
 Danger signs to be each loose home
explained to the stool
mother.
<24 50 to 100 ml 500ml/day
i. Continuing diarrhea months
beyond 3 days.
ii. Increased stool 2 – 10 100 to 200ml 1000ml/day
volume/ frequency. years
iii. Repeated vomiting.
>10 Ad lib 2000ml/day
iv. Increasing thirst.
years
v. Increased irritability /
lethargy
vi. Refusal to feed.
vii. Fever or blood in
stools.
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.
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
Age 30ml/kg 70ml/kg
<12 months 1hr 5hrs
>12 months 30 min 2hrs 30 min
 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.
MANAGEMENT
 Principles :
i. Rehydration & maintaining hydration.

ii. Ensuring adequate feeding.

iii. Oral supplementation of zinc.

iv. Early recognition of danger signs & treatment of

complications.
 ORS
ORAL REHYDRATION
SOLUTION
PHYSIOLOGICAL BASIS FOR ORS

 Glucose dependent sodium & water absorption.

 Osmolarity lower than blood.

 A shift from standard ORS to Low Osmolarity

ORS.
 LOW OSMOLARITY ORS
COMPOSITION
Dissociates into mmol/L
Ingredient g/L

Glucose, 13.5 Glucose 75

anhydrous
Sodium 75
Sodium Chloride 2.6

Chloride 65

Potassium 1.5 Potassium 20

Chloride
Trisodium 2.9 Citrate 10
Citrate,dihydrate
TOTAL 20.5 TOTAL 245
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.

PREPARATION OF ORS
PREPARATION OF ORS
Acceptable home available fluids

Fluids that contain salt Salted rice water, salted yoghurt drink,
(preferable) vegetable or chicken soup with salt.

Fluids that don’t contain salt Plain water, unsalted rice water, unsalted
(acceptable) soup, yoghurt drink.

Unsuitable home available Commercial carbonated beverages,

fluids commercial fruit juices, sweetened tea.
 WHAT IS ZINC?

What are it’s benefits?

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.
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.
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.

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.
LONG TERM EFFECTS OF ZINC

 Zincsupplementation 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.

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.

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.
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.

PREVENTION OF DIARRHEA &
MALNUTRITION
o Proper nutrition

o Adequate sanitation

o Vaccination
i. Rota virus
ii. measles