Readings for scenario “No more tears for Henry”

King, C.K., Glass, R., Bresee, J.S., & Duggan, C. (2003). Managing acute gastroenteritis among children: Oral rehydration, maintenance, and nutritional therapy. MMWR: Morbidity & Mortality Weekly Report, 52(RR-16), 1-16. Retrieved from http://www.cdc.gov/mmwr/index.html

Summary

Acute Gastroenteritis:

- Common illness among infants and children in the world

- accounting for >1.5 million outpatient visits, 200,000 hospitalizations, and approximately 300 deaths/year

- Diarrhea is one of the common causes of mortality for children < 5 y o

- Oral Rehydration Therapy (ORT)

o Improved health outcomes among children in developing countries – decreased mortality

o Use has lagged in US

- Physicians recognize:

o Supplementation of zinc can reduce incidence and severity of diarrheal disease

o ORS of reduced osmolality (proportional reduced sodium nad glucose): recommended for global use

- This article updates recommendations of managing gastroenteritis

Introduction & Background

- ORT encompasses two phases of treatment: 1) a rehydration phase, in which water and electrolytes are administered as oral rehydration solution (ORS) to replace existing losses, and 2) a maintenance phase, which includes both replacement of ongoing fluid and electrolyte losses and adequate dietary intake

- The lag of ORT use in US is thought to be due to the ingrained use of IV therapy and reduced appeal of a technologically simple solution

o Many children with mild dehydration and vomiting have ORT withheld

- ORT use began in developing countries where IV availability is reduced

- NOW, ORT accepted as standard of care for the clinically efficacious and cost-effective management of acute gastroenteritis

Physiologic Basis for using ORS

- The adult intestinal epithelium must handle 6,500 mL of fluids/day, consisting of a combination of oral intake, salivary, gastric, pancreatic, biliary, and upper intestinal secretions. This volume is typically reduced to 1,500 mL by the distal ileum and is further reduced in the colon to a stool output of <250 mL/day in adults --- during diarrhea the volume of intestinal fluid output is substantially increased overwhelming the reabsorptive capacity of the GI tract

- Solutions with a high concentration of co-transporters increase the risk from hypertonic solutions that decrease rather than improve sodium and water transport into the bloodstream. However, solutions of lower osmolarity, but that maintain the 1:1 glucose to sodium ratio, perform optimally as oral solutions for diarrhea management (see Choice of ORS).

Home Management of Acute Diarrhea

Initiation of Therapy:

- All families should be encouraged to have a supply of ORS in the home at all times and to start therapy with a commercially available ORS product as soon as diarrhea begin

Need to recognize severity:

- Infants are more at risk for becoming dehydrated because of higher body-surface-to-volume ratio, higher metabolic rate, smaller fluid reserves and depend on others for fluid

- When fever is present: infants and children should be evaluated to rule out other serious illnesses (sepsis and meningitis)

- Box 1 provides a guide for when to seek medical evaluation:

Referral for Evaluation:

- This is the responsibility of the physician

- Focus on factors putting a child at risk of dehydration

o Number of days the child has been ill

o # of episodes of diarrhea or vomiting

o Volume of fluid output

o Mental status

o Past medical history

Clinical Assessment

- Diarrhea is 3 or more loose/ watery stools/day

o Volume of fluid lost through stools can vary from 5mL/kg body weight/day (normal) à >200 mL/ kg body weight/ day

- Dehydration and electrolyte losses associated with untreated diarrhea cause the primary morbidity of acute gastroenteritis.

- Diarrhea can be among the initial signs of non-gastrointestinal tract illnesses, including meningitis, bacterial sepsis, pneumonia, otitis media, and urinary tract infection.

- Vomiting alone can be the first symptom of metabolic disorders, congestive heart failure, toxic agent ingestion, or trauma.

- To rule out other serious illnesses, a detailed history and physical examination should be performed as part of the evaluation of all children with acute gastroenteritis.

History:

- onset, frequency, quantity, and character (i.e., the presence of bile, blood, or mucus) of vomiting and diarrhea

- Recent oral intake, including breast milk and other fluids and food; urine output; weight before illness; and associated symptoms, including fever or changes in mental status, should be noted.

- The past medical history should identify underlying medical problems, history of other recent infections, medications, and human immunodeficiency virus (HIV) status. A relevant social history can include the number and nature of caregivers, which can affect instructions regarding follow-up care.

Physical Examination

Things to gather:

- Body weight

- Vitals: T, HR, RR, BP

- special concern given to infants and children who appear listless, apathetic, or less reactive

- sunken eyes? Tearing?

- lips, mouth, and tongue will yield critical clues regarding the degree of dehydration

- Deep respiration can be indicative of metabolic acidosis

- Faint or absent bowel sounds can indicate hypokalemia

- general perfusion and capillary refill

- check skin turgor

Dehydration Assessment

This table provides a guideline for a starting point for treatment and who can be sent home for therapy

Lab Evaluation

- stool cultures should be gathered in there is dysentery but not for acute, watery diarrhes for immunocompetent pt

- CBC and urine and blood cultures might be indicated when sepsis or UTIs are a concern

Acute Gastroenteritis Therapy based on degree of dehydration

- 7 principles guide optimal treatment in Box 2

- Treatment should include two phases: rehydration and maintenance.

- Rehydration phase: the fluid deficit is replaced quickly (i.e., during 3--4 hours) and clinical hydration is attained.

- Maintenance phase: maintenance calories and fluids are administered. Rapid realimentation should follow rapid rehydration, with a goal of quickly returning the patient to an age-appropriate unrestricted diet, including solids

- Breastfeeding should be continued at all times

- Diet: increased as soon as tolerated to compensate for lost caloric intake during the acute illness.

o Lactose restriction is usually not necessary (although it might be helpful in cases of diarrhea among malnourished children or among children with a severe enteropathy), and changes in formula usually are unnecessary

- During both phases, fluid losses from vomiting and diarrhea are replaced in an ongoing manner

- Antidiarrheal medications are not recommended for infants and children

Minimal Dehydration

- treatment is aimed at providing adequate fluids and continuing an age-appropriate diet

- use of ORS should be encouraged: 1 mL of fluid should be administered for each gram of output

- In hospital: weigh soiled diapers (without urine)

- If unable to measure: children weighing <10 kg should be administered 60--120 mL (2--4 ounces) ORS for each episode of vomiting or diarrheal stool, and those weighing >10 kg should be administered 120--240 mL (4--8 ounces)

Mild – Moderate Dehydration

- should have their estimated fluid deficit rapidly replaced - administering 50--100 mL of ORS/kg body weight during 2--4 hours using additional ORS to replace continued losses

- Using a teaspoon, syringe, or medicine dropper, limited volumes of fluid (e.g., 5 mL or 1 teaspoon) should be offered at first, with the amount gradually increased as tolerated

- Nasogastric (NG) feeding allows continuous administration of ORS at a slow, steady rate for patients with persistent vomiting or oral ulcers

o More cost-effective and well-tolerated than IV rehydration

- If ORT doesn’t improve child’s dehydration keep them until signs of dehydration subside

- After dehydration is corrected, further management can be implemented at home, provided that the child's caregivers demonstrate comprehension of home rehydration techniques (including continued feeding)

Severe Dehydration

- constitutes a medical emergency requiring immediate IV rehydration

- LR, NS/ similar solution administered until pulse, perfusion and mental status return to normal

- Serum electrolytes, bicarbonate, blood urea nitrogen, creatinine, and serum glucose levels should be obtained

- Hypotonic solutions should not be used for acute parenteral rehydration

- Watch for overhydration

- Hydration status should be reassessed frequently to determine the adequacy of replacement therapy

- As soon as the severely dehydrated patient's level of consciousness returns to normal, therapy usually can be changed to the oral route, with the patient taking by mouth the remaining estimated deficit. An NG tube can be helpful for patients with normal mental status but who are too weak to drink adequately.

Clinical management in the hospital

Inpatient care is indicated for children if

caregivers cannot provide adequate care at home;
substantial difficulties exist in administrating ORT, including intractable vomiting, ORS refusal, or inadequate ORS intake;
concern exists for other possible illnesses complicating the clinical course;
ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes;
severe dehydration (>9% of body weight) exists;
social or logistical concerns exist that might prevent return evaluation, if necessary, or
such factors as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation.

Limitations of ORT:

- children in hemodynamic shock – their airway protective reflexes might be impaired

- Ab ileus: don’t give fluids until BS are audible

- Bowel obstruction

- A limited percentage of infants (<1%) with acute diarrhea experience carbohydrate malabsorption. This is characterized by a dramatic increase in stool output after intake of fluids containing simple sugars (e.g., glucose), including ORS

Hypernatremic Dehydration

- serum sodium concentration >145 mEq/L

- Respond well to ORT

Dietary Therapy

- Breastfed infants: feed on demand

- Formula-fed infants should continue their usual formula immediately upon rehydration in amounts sufficient to satisfy energy and nutrient requirements

- Not necessary to use lactose free formulas (unless lactose intolerant)

- Children receiving semisolid or solid foods should continue to receive their usual diet during episodes of diarrhea. Foods high in simple sugars should be avoided because the osmotic load might worsen diarrhea; therefore, substantial amounts of carbonated soft drinks, juice, gelatin desserts, and other highly sugared liquids should be avoided.

- Early feeding decreases changes in intestinal permeability caused by infection, reduces illness duration, and improves nutritional outcomes

- Recommended foods include age-appropriate unrestricted diets, including complex carbohydrates, meats, yogurt, fruits, and vegetables.

Pharmacological Therapy

Antimicrobial

- antimicrobial therapy is not usually indicated among children because the majority of cases of acute diarrhea are self-limited and not shortened by antimicrobial agents. Exceptions to these rules involve special needs of individual children

Nonantimicrobial Drug Therapies

- Nonspecific antidiarrheal agents (e.g., adsorbents such as kaolin-pectin), antimotility agents (e.g., loperamide), antisecretory drugs, and toxin binders (e.g., cholestyramine), are commonly used among older children and adults, but data are limited regarding their efficacy.

Supplemental Zinc Therapy

- severe zinc deficiency (e.g., acrodermatitis enteropathica) is associated with diarrhea, milder deficiencies of zinc might play a role in childhood diarrhea, and zinc supplementation might be of benefit either for improved outcomes in acute or chronic diarrhea or as prophylaxis against diarrheal disease

- # of trials have been shown that zinc supplements help in treating diarrheal disease but this needs further evaluation

Probiotics

- Further human trials are needed before making specific recommendations

Acute Bloody Diarrhea (Dysentery)

- Oral rehydration therapy is critical in managing specific types of diarrheal diseases.

- Dysentery: acute bloody diarrhea caused by invasive microbial infection.

o Doesn’t include occult blood (detected by guaiac card only) or streaks of blood on the surface of formed stool

- Tx of dehydration in dysentery follows the same principles as treatment of acute watery diarrhea.

- Child with bloody diarrhea is at higher risk for complications, including sepsis and other systemic diseases - threshold for admission of such children to the hospital for close observation is lower.

- Stool cultures are needed for guiding therapy. Food should not be withheld for children with dysentery any more than in other cases of diarrhea. More frequent, smaller meals might be better tolerated, and higher protein intakes

- In the majority of cases, empiric antimicrobial agents should not be administered while awaiting culture results, because antimicrobial therapy might not be indicated even when culture results are positive. Amoebiasis is an unusual cause of bloody diarrhea in young children, even in less-developed countries. Treatment for amoebiasis should be reserved for those cases in which trophozoites are detected on microscopic examination of the stools

Choice of ORS:

- In 1975, WHO and the United Nations Children's Fund (UNICEF) agreed to promote a single ORS (WHO-ORS) containing (in mmol/L) sodium 90, potassium 20, chloride 80, base 30, and glucose 111 (2%) for use among diverse populations – single solution to be used for diarrhea treatment with a variety of electrolytes losses

- Further studies have shown ORS of lower osmolality is better than ORT

Barriers

- Cultural practices

- Lack of parental knowledge

- Lack of training for HCP

- Cost

- Among physicians, preference for IV hydration, even where evidence indicates improved results from oral rehydration = major barrier

Conclusion:

Treatment of acute diarrhea has relied upon simple and effective therapy of oral rehydration. The critical co-principle in case management of early resumption of feeding of children immediately upon rehydration has also gained wide acceptance. More recent advances in the science of diarrhea treatment include recognition for the role of zinc supplementation in reducing disease severity and occurrence, and development of an oral rehydration solution of lower osmolarity for global use. The combination of oral rehydration and early nutritional support promises to safely and effectively assist a patient through an episode of diarrhea. If the principles of therapy outlined in this report are accepted by all levels of the medical community and if education of parents includes teaching them to begin ORT at home, numerous deaths and unnecessary clinic visits and hospitalizations can be avoided. ORT is suitable for use among children throughout the world

Toddlers (18months – 3 yrs old)

Important stages of growth, development and maturation:

Physical

- Growth is slower

- Growth in spurts

- Wide gait and walk hesitantly

- Fine and gross motor skills progress quickly

- Fine Motor skills: reaching, grasping, manipulating small objects

- Gross Motor skills: balance and coordination continuously improve, most are walking alone by 18months, tend to experiment with skills

Cognitive

- Relationships between objects and actions

- Imitate adults

- Develop a number sense, match colours and shapes

- Engage in symbolic play (object-use and make-believe)

Social/ Emotional

- Egocentric

- Autonomous and independent

- No conscience

- Demonstrate negativism

- Enjoy ritualism

- Experience separation anxieties

- Tantrums as coping mechanism

- Early toddlers: solitary play

- Early preschoolers: associative play

Common Concerns/Hazards

- Illnesses: chickenpox, viruses

- Hazards: most deaths are a result of accidents (from their curiosity): falls, chemicals, burns, drowning, choking, and MVA

Communication Techniques:

- Demonstrate and use play to teach a procedure

- Provide visuals

- Simplify vocabulary: clear and firm instructions

- Offer limited options: don’t offer a choice when there is none

- Praise a child for a job well done

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