Common condition in childhood 5 million deaths per year lt5 yo in developing countries 2 million deaths annually worldwide Rotavirus is the most ID: 646291
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Slide1
Acute gastroenteritis (AGE)
Common
condition
in
childhood
5
million
deaths
per
year
<5 yo in
developing
countries
2
million
deaths
annually
worldwide
Rotavirus
is
the
most
important
cause
but
other
intestinal
viruses
such
as
norwalk
,
noroviruses
and
enteroviruses
,
bacteria
(
Salmonella
,
Shigella
)
and
V
ibrio
cholerae
,
protoza
(
such
as
criyptosporidium
)
are
also
important
causesSlide2
AGE
The
hallmark
is
diarrhea
Change
in
bowel
habit
resulting
in
substantially
more
frequent
and
/
or
looser
stools
Diarrhea
may
be
associated
with
vomiting
Two
important
clinical
suggestions
:
-
diarrhea
and
/
or
vomiting
can be
non
-
specific
presenting
signs
in
children
with
systemic
sepsis
e.g
meningococcal
infection
,
septicemia
and
urinary
tract
infection
.
Assess
each
child
carefully
-
if
a
child
has
vomiting
alone
consider
the
possibility
of
other
diagnoses
e.g
intestinal
obstruction
,
diabetes
or
meningitisSlide3
Degree of dehydration in AGE
Clinical
signs
become
apparent
at 3-4%
Minimal
or
no
dehydration
if
<3%
Mild
to
moderate
if
3-8%
dehydrated
Severely
dehydrated
if
>9%Slide4
Assessment of degree of
dehydration
and
recommended
management
Minimal
or
no
deydration
(<3%): no
signs
-
manage
at
home
generally
-normal
fluids
,
continue
breast
-
feeding
, normal
diet
-
admit
if
very
young
,
diagnosis
in
doubt
,
or
large
lossesSlide5
Assessment of degree of
dehydration
and
recommended
management
Mild
to
moderate
dehydration
(3-8%)
-general appearance abnormal (looks unwell)
-
dry
oral
mucosa
-
absent
tears
-
sunken
eyes
-diminished skin turgor (skin recoil after pinching skin>2s, capillary return >2s)
-
Manage
in
hospital
with
ORS
-
if
ORS not
tolerated
,
may
require
NG
tube
feeds
or
IV
fluids
-
resume
normal
diet
when
toleratedSlide6
Assessment of degree of
dehydration
and
recommended
management
Severe
dehydration
(>9%):
-
signs
from
mild
to
moderate
+
deep
acidotic
breathing
-
altered
neurological
status
(
drowsiness
,
irritability
)
-
decreased
peripheral
perfusion
-
circulatory
collapse
-
measure
BUN,
electrolytes
,
acid
-
base
balance
-
resuscitate
with
IV
bolus
if
shocked
-
rehydrate
IV
over
2-6
hrs
with
regular
clinical
and
lab
reviewSlide7
Assessment of degree of
dehydration
and
recommended
management
Fluid
requirement
calculated
as:
volume
needed
to
replace
the
deficit
+
maintenance
fluids
+
ongoing
lossesSlide8
Daily maintenance
fluid
requirement
(MFR)
Weight
of
the
child
MFR
First
10 kg 100ml/kg
Second
10 kg 50 ml/kg
Subsequent
20 ml/kg
Example
:
if
the
child
weighs
8 kg MFR is 800ml
İf
the
child
weighs
12 kg MFR is(10x100)+(2x50):1100 ml
İf
the
child
weihgs
23 kg MFR is (10x100)+(10x50)+(3x20):1560 mlSlide9
Route of rehydration
Question
: is oral
rehydration
as
effective
and
safe
as IV
rehydration
?
Compared
to
children
treated
with
IV
rehydration
children
treated
with
oral
rehydration
has
significantly
fewer
major
adverse
events
including
death
or
seizures
and
significant
reduction
in
lenght
of
hospital
stay
Fonseca
BK,
Holdgate
A.
Arch
Pediatr
Adolesc
Med
2004;158:483-90 (meta
analysis
, 16
trials
1545
children
)Slide10
Route of rehydration
A
cochrane
review
of 17
trials
, 1811
participants
,
all
poor
to
moderate
quality
More
treatment
failures
with
ORT
No significant differences in weight gain, hyponatremia, hypernatremia, duration of diarrhea or total fluid intake
ORT
group
stayed
in
the
hospital
for
1.2
days
less
Phlebitis
occured
more
often
in
the
IVT
group
and
paralytic
ileus
in
the
ORT
group
Six
deaths
occured
in
the
IVT
and
two
in
the
ORT
group
For
every
25
children
treated
with
ORT
one
would
fail
and
require
IVT
Hartling
L,
Bellemare
S et al
The
Cochrane
Database
of
Systematic
Reviews
2006;(3) Art no CD004390Slide11
Route of rehydration
Both
oral
and
IV
rehydration
are
safe
and
effective
In
developing
countries
where
mothers
nurse
their
infants
and
give
frequent
oral
feeds
,
ORT is
preferred
In
industrialized
countries
, ORT is
cheaper
and
with
fewer
adverse
effects
Parents
and
nursing
staff
should
be
encouraged
to
give
ORT
and
be
informed
that
if
they
do
so
the
child
will
avoid
IV
line
and
get
home
quicker
Slide12
Route of rehydration
Rapid
IV
rehydration
over
4
hrs
was
advocated
by
WHO in 1980s
for
children
in
developing
countries
for
moderate
to
severe
dehydration
In industrialized countries the practice of rapid IVT to rehydrate children over 1-3 hrs and send them home if they can tolerate oral fluids has been found to be safe and effective
The main potential danger is fluid overload and/or electrolyte imbalance especially if the degree of dehydration is overestimated which is common.
There
is
also
risk of
sending
home
some
children
who
are
in
need
of
hospital
care
Slide13
Route of rehydration
Severe
dehydration
(>9%) is life
threatining
and
there
is
consensus
that
one
should
rehydrate
severely
dehydrated
children
using
IV
fluidsSlide14
Choice of ORS
Since 1980s
the
WHO has
recommended
a standart ORS
with
relatively
high
Na
and
glucose
content
(90
mmol
/L
Na
, 111mmol/L
glucose
, total
osmolality
311mmol/L)
A
number
of
studies
compared
standart ORS
with
reduced
osmolality
ORS (
rORS
) (total
osmolality
250
mmol
/L)
rORS
Has
been
found
to
be
associated
with
fewer
unscheduled
IV
infusions
,
lower
stool
output
and
less
vomiting
. No
additional
risk of
hyponatremia
was
found
The
WHO
now
recommends
rORS
for
non
-
cholera
diarrheaSlide15
Mode of delivery of ORS
Giving
ORS
by
a NG
tube
is
increasingly
common
in
some
industrialized
countries
NG
tube
feeds
have
the
advantage
of
getting
fluid
in
if
a
child
refuses
to
drink
or
is
vomiting
frequently
They
are
far
less
invasive
,
cheaper
and
less
traumatic
then
IV
fluids
On the other hand they are more invasive then oral feeds, unpleasant and have not been shown to have any advantage over oral rehydrationSlide16
Choice of IV fluids
In
many
industrialized
countries
N/2
or
N/4
saline
are
chosen
for
IV
fluids
and
they
are
made
isotonic
by
adding
dextrose
But as
dextrose
is
rapidly
metabolized
the
fluid
becomes
rapidly
hypotonic
The
use
of
low
Na
fluids
has
recently
been
questioned
following
episodes
of
catastrophic
hyponatremia
associated
with
IV
rehydration
for
AGESlide17
Choice of IV fluids
Hyponatremia
is
particularly
likely
to
develop
in
children
who
concurrently
have
the
syndrome
of
inappropriate
ADH
secretion
(SIADH)
Dehydration
,
vomiting
and
stress
are
potential
causes
of SIADH
and
occur
commonly
in AGE
Investigations
showed
that
for
resuscitation
of
children
with
severe GE
using
IV
fluids
, normal
saline
with
or
without
added
dextrose
is
recommended
Slide18
Antibiotics and AGE
Antibiotics
are
not
routinely
recommended
for
AGE
Most
episodes
of AGE
are
caused
by
viruses
Most
episodes
are
self-
limiting
,
including
those
caused
by
bacteria
and
antibiotic
use
is
likely
to
select
for
antibiotic
resistance
Antibiotics
might
increase
gastrointestinal
motility
and
cause
bacterial
overgrowth
and
thus
worsen
diarrheaSlide19
Antiemetics in AGE
Ondansetron
and
metoclopramide
reduces
the
number
of
episodes
of
vomiting
in AGE in
children
compared
to
placebo
but
increases
the
incidence
of
diarrhea
Use
of
antiemetics
is not
recommended
in
childhood
AGESlide20
Diet in AGE
There
is
widespread
consensus
that
breast
-fed
babies
with
dehydration
from
AGE
should
be
rehydrated
orally
or
IV but
continue
breast
feeding
Breast
milk
contains
as
much
lactose
as
formula
feeds
.
Despite
this
,
many
people
advocate
low
lactose
or
lactose
-
free
formulas
,
supposedly
because
of risk of
lactose
intolerance
secondary
to
AGESlide21
Diet in AGE
A meta analysis of 29 trials (2215 patients) found no advantage of lactose-free formulas over lactose-containing formulas for the majority of infants, although infants with malnutrition or severe dehydration recovered more quickly when given lactose-free formula
Brown KH,
Peerson
JM et al.
Pediatrics
1994;93:17-2
Using
diluted
food
in
children
recovering
from
AGE is not
recommended
because
it is
unnecessary
and
also
prolongs
symptoms
and
delays
nutritional
recoverySlide22
Diet in AGE
Formulas
containing
soy fiber has
been
reported
to
reduce
liquid
stools
without
changing
the
stool
output
.
This
might
reduce
diaper
rash
and
encourage
early
resumption
of normal
diet
, but
the
benefits
are
probably
insufficient
to
merit
its
use
as a
standard
of
careSlide23
Diet in AGE
Children
receiving
semisolid
or
solid
foods
should
continue
to
receive
their
usual
diet
.
Routinely
witholding
food
is
inappropriate
.
Early
feeding
reduces
changes
in
intestinal
permeability
caused
by
infection
,
reduces
the
duration
of
illness
,
and
improves
nutrition
Slide24
Zinc in diarrheal disease
Severe
zinc
deficiency
is
associated
with
diarrhea
(
acrodermatitis
enteropathica
)
In
developing
countries
,
prophylactic
dietary
oral
zinc
supplementation
reduces
the
incidence
and
severity
of
acute
diarrheal
disease
in
childhood
The
WHO
recommends
that
oral
zinc
is
given
to
children
in
developing
countries
at
the
onset
of
diarrheaSlide25
Probiotics in AGE
Probiotics are live microorganisms in fermented foods or components of microbial cells that have a beneficial effect on the health and well-being of the host
No
serious
adverse
effects
of
probiotics
have
been
reported
in
well
people
, but
infections
have
been
reported
in
people
with
impaired
immune
systemsSlide26
In
one
systematic
review
, probiotics reduce
the
risk of
diarrhea
lasting
3
or
more
days
by
60%
and
reduce
the
duration
of
diarrhea
by
18
hrs
A
cochrane
review
on 1917
adult
and
pediatric
patients
showed
that probiotics reduced the risk of diarrhea at 3 days by 34% and the main duration of diarrhea by 30.5 hrsThere is great variability among probiotics, further research is needed to to determine the optimal type, dosage and regimenTheir routine use is not recommended in AGE in children but it is likely that their benefit outweighs their harm
Probiotics
in AGESlide27
Antibiotic associated diarrhea
In
most
cases
no
pathogen
is
identified
Toxin
producing
C.
difficile
is
responsible
for
a
minority
Stopping
antibiotics
usually
relieves
the
problem
Dietary
manipulation
may
help
If it is not possible to stop the antibiotic, it is recommended to change to a regimen less likely to cause diarrhea
Amoxicillin
,
broad
-
spectrum
cephalosporins
,
quinolones
are the antibiotics most commonly associated with diarrheaWhen C. difficile is identified, metronidazole 10 mg/kg (max 400 mg) orally 8 hourly for 7-10 days Slide28
Campylobacter enteritis
Usually
self-
limited
Antibiotics
have
relatively
little
clinical
benefit
and
because
of
the
risk of
resistance
are
not
routinely
indicated
Antibiotherapy
is
indicated
only
when
there
is
high
fever
or
severe
illness
suggesting
septicemia
, usually in infants. If antibiotics are indicated: eryhtromycin 10mg/kg PO q6hrs or azitromycin 10 mg/kg PO dailyFor bacteriemia gentamicin <10y 7.5mg/kg IV daily; >10 y 6mg/kg IV or ciprofloxacin 10mg/kg (max400mg) IV q12hrsSlide29
cholera
Rehydration
is
the
basis
of treatment
and
can
usually
be
achieved
orally
Standart ORS
or
rice
-
based
ORS is
recommended
Antibiotic therapy reduces the volume and duration of diarrhea
Azitromycin
20mg/kg POI as a
single
dose
or
doxycycline
child
>8yrs:2.5mg/kg (max100mg) PO q12h x3d
or
ciprofloxacin
25 mg/kg (
max
1 g) PO as a
single
dose
or
erythromycin
12.5 mg/kg (
max 500mg) PO q6hx3dSlide30
EHEC enteritis
Infection
with
some
EHEC strains e.g 0157:H7
and
0111:H8 can
lead
to
development
of HUS
and
TTP
The
use
of
antibiotics
is
controversial
because
they
increase
the
release
of
shiga
-
like
toxin
and
increase
the
incidence
of HUS
and
TTP in humansStudies do not show any benefit of antibiotic use and some associate antibiotics with a higher risk of HUS and/or longer duration of diarrheaSlide31
EPEC enteritis
Most
EPEC
infections
occur
in developing
countries
and
organism
is
never
cultured
If serotype 0111:B4 is cultured mecillinam (extd spectrum penicillin) showed a clinical cure 79%, trimethoprim-sulfamethoxazole 73% and placebo only 7%
The
main
significance
is
for
traveler’s
diarrheaSlide32
Non-typhoid
Salmonella
enteritis
(NTS)
NTS
infections
are
food
-
borne
Extraintestinal
complications
such
as
septicemia
,
meningitis
and
osteomyelitis
are
rare
Outbreaks
are
associated
especially
with
infected
meat
or
eggs
,
cattle
or pigsIn developing countries, particularly tropical Africa, NTS are important cause of invasive extraintestinal diseaseSlide33
Non-typhoid
Salmonella
enteritis
(NTS)
Antibiotics
result
more
negative
stool
cultures
during
the
1st
week
but
cause
more
frequent
clinical
relapses
and
prolongation
of
detection
of
salmonella
in
stools
after
3
wks
Adverse
drug
reactions are more common with antibioticsAntibiotics are not indicated for asymptomatic short-term carriersAntibiotics are indicated for suspected or proven septicemia (infants<3m , malnourished infants or immunocompromised children with bloody diarrhea and fever and /or Salmonella isolated from fecesSlide34
Non-typhoid
Salmonella
enteritis
(NTS)
Antibiotics are also recommended for Salmonella infection occurring in association with chronic gastrointestinal disease, malignant neoplasms, hemoglobinopathies or severe colitis
Amoxicillin
is
preferred
if
the
organism
is
susceptible
For
empiric
therapy
ciprofloxacin
10 mg/kg POq12h OR
azithromycin
20mg/
kgPO
1st
day
and
10mg/kg
daily
If
PO not
tolerated
ciprofloxacin
10 mg/kg (
max
400mg)IV q12h OR
ceftriaxone
50mg/kg (
max
2g) IV
dailySlide35
Typhoid and paratyphoid
fevers
S.
typhi
and
S,
paratyphi
are
endemic
in
many
developing
countries
.
Almost
all
infection
in
industrialzed
countries
are
acquired
by
travelers
It
is a
septicemic
illness
rather
then
diarrheal
illness
Fever, hepatomegaly, abdominal pain, diarrhea, vomiting, cough, malaise and headache are prominent findings. Rose spots and bradycardia are rare in childrenFebrile convulsions, jaundice, ileus, perforation and impaired consciousness are other manifestationsHematologic abnormalities include neutropenia, leucopenia and thrombocytopeniaSlide36
Typhoid and paratyphoid
fevers
For
antibiotherapy
:
ciprofloxacin
15mg/kg (max500mg) PO q12hx 7-10d OR
Azithromycin
20mg/kg (max1g)x5d
If
PO not
tolerated
ciprofloxacin
10mg/kg (max400mg) IV q12hx 7-10d OR
Azithromycin
20mg/kg (max1g) IVx5d
If
clinical
response
delayed
ceftriaxone
50mg/kg (
max
2g) IV
dailySlide37
Shigellosis
Antibiotic
therapy
is
recommended
for
children
with
shigella
dysentery
,
even
if
mild
,
for
public
health
reasons
because
a
very
low
inoculum
causes
infection
Effective
antibiotics
,
if
the
organism
is sensitive include quinolones, ceftriaxone, azithromycin, cefixime, and cotrimoxazoleciprofloxacin 15mg/kg (max500mg) PO q12hx 3d OR Azithromycin 20mg/kg (max1g)x5d OR Cotrimoxazole 4+20mg/kg PO q12hx5dSlide38
Traveler’s diarrhea
At
least
11
million
people
develop
traveler’s
diarrhea
worldwide
Passage
3
or
more
unformed
stools
over
24h
with
symptoms
sterting
during
or
shortly
after
a
foreign
travel
,
nausea
,
vomiting
,
abdominal
pain, fever, tanesmus, and blood or mucus in stoolsAbout 85% are bacteria and ETEC is the most common one, campylobacter jejuni is responsible in 30% of cases, salmonella and shigella each accounts for 15%2/3 of ETEC produce a heat-labile toxin similar to cholera toxin which induces secretory diarrheaFor prevention boil
it,
cook
it,
peel
it
or
forget
it.
Avoid
drinking
local
water
,
consider
tap
water
and
ice
cubes
as
contaminated
.
Bottled
water
is not
always
safe
.
Swimming
pool
is
also
a
potential
riskSlide39
Althogh there
are
no
efficacy
data in
children
, an oral, killed, recombinant
B-
sub
-
unit
,
whole
-
cell
vaccine
against
cholera
and
ETEC is
available
.
Two
doses
given
at
least
one
week
apart
create
immunization
one
week
after
the
second doseVaccine is licenced in only a few countries including Sweden and CanadaProphylactic antibiotics are recommended only in immunucompromised child traveling for a short period of time, in which case ciprofloxacin may be the antibiotic of chioceTraveler’s diarrheaSlide40
Traveler’s diarrhea
All trials reported a significant reduction in duration
of diarrhea in participants treated with antibiotics
compared with placebo
The most effective antibiotics
for empiric
t
herapy
from trials are
quinolones
,
azithromycin, and rifaximin
All patients should
take fluids and electrolytes. Rehydration with ORS is
particularly important for young children
Antimotility
drugs, such as
loperamide
, should be
avoided in children, because of the danger of causing
paralytic
ileus
. Mild cases do not usually need
antibiotics
For moderate to severe disease,
azithromycin
20 mg/kg (max 1 g) orally, as a
single dose OR
ciprofloxacin 20 mg/kg (max 750 mg) orally, as a
single dose OR
norfloxacin
20 mg/kg (max 800 mg) orally, as a
single dose OR trimethoprim+sulfamethoxazole 4+20 mg/kg
(max 160+800 mg) orally, 12-hourly for 3 days
OR
rifaximin
10 mg/kg orally, 12-hourly for 3 daysSlide41
Amebiasis
E. histolytica infection can cause non-invasive intestinal
infection, which can be
symptomatic or cause
amebic dysentery or colitis, a
meboma
,
a
nd
/or liver
abscess
Passage of
Entamoeba
cysts or
trophozoites
in the absence of acute dysenteric illness does
not warrant antimicrobial therapy
Patients with amebic colitis characteristically present
with dysenteric symptoms of bloody diarrhea, abdominal
pain, and tenderness. Children can have rectal
bleeding without diarrhea. The onset can be gradual,
with several weeks of symptoms: often multiple, small
volume,
mucoid
stools, but sometimes profuse, watery
diarrhea Slide42
Amebiasis
Toxic megacolon complicates
amebic colitis in about 0.5% of patients
Amebomas are localized
inflammatory,
annular masses of the
cecum
or
ascending colon which can cause obstruction and be
confused with carcinomas
The diagnosis of amebic colitis rests on the demonstration
of
E.
histolytica
in the stool or colonic mucosa
of patients with diarrhea.
Commercially available ELISA assays
are more sensitive and less user-dependent
than microscopySlide43
Amebiasis
Serum antibodies against
amebae
are detected by
indirect
hemagglutination in >70% of patients
w
ith
symptomatic
E.
histolytica
infection
and are particularly
sensitive (>94%) in amebic liver abscess
For acute amebic dysentery, the
nitroimidazoles
(metronidazole, tinidazole, ornidazole) are
>90%
effective
metronidazole 15 mg/kg (max 600 mg) orally,
8-ourly for 7–10 days OR
tinidazole
50 mg/kg (max 2 g) orally, daily for 3
daysSlide44
Cryptosporidium
Cryptosporidium parvum infection causes frequent,
watery diarrhea, without blood in
immunocompetent
children.
Other prominent symptoms include
crampy
abdominal pain, fever, and vomiting. Asymptomatic
infection is rare. Infections are often waterborne;
the cysts are resistant to chlorine, and contaminated
water
and swimming pools have been the source
of large outbreaks.
In
immunocompetent
children,
infection usually
r
esolves
after 10 days (range 1–20)
and requires no specific treatment.
In contrast,
Cryptosporidium
infection can be life-
t
hreatening
in
immunocompromised children. To treat
Cryptosporidium infection in immunocompromised
children,
nitazoxanide
1–3 years: 100 mg 12-hourly; 4–11
years: 200 mg 12-hourly; 12 years or older:
500 mg orally 12-hourly, for 3 daysSlide45
Giardiasis
Giardia lamblia
is a flagellate protozoan parasite with
a worldwide distribution. Infection is primarily waterborne,
and although humans are the main reservoir
of infection, animals such as dogs and cats can
contaminate water with infectious cysts.
Infection can
be asymptomatic, can be acute with watery diarrhea
and abdominal pain, or protracted with chronic or
intermittent foul-smelling stools, abdominal distension,
flatulence, and anorexiaSlide46
Giardiasis
Diagnosis is by detecting
cysts in stool.
A
lthough
ELISA tests on stool are
slightly more sensitive than direct microscopy for ova
and parasites,
one study suggested that both tests
need to be
p
erformed
to achieve a sensitivity >90%.
Diagnosis
in difficult cases may require
e
xamination
of
aspirated duodenal fluid.
M
ost
authorities agree that treatment
of patients with asymptomatic passage of
Giardia
cysts
is unwarranted. The traditional treatment of symptomatic
patients is with
metronidazole
5 mg/kg (max 250 mg) orally, 8-hourly for 5 days
, which is 80–
95%effective
For immunocompetent
children who fail therapy, it is usual to repeat
the original course while investigating whether
reinfection
may have occurred from a family member
or water source