InpatientCurriculum20052006

ACUTE GASTROENTERITIS
Introduction In1992,theCentersforDiseaseControlpreparedthefirstnationalguidelinesformanagingpediatricdiarrheaand publishedtheminMMWR.In1996,theSubcommitteeonAcuteGastroenteritis,oftheProvisionalCommitteeon QualityImprovementoftheAAP,publishedapracticeparameterforthemanagementofacutegastroenteritisin youngchildren(ages1moto5yo).Subsequently,in 2003theCDC publishedanupdatetotheiroriginal recommendations,whichtheAAPendorsedin2004. StatisticsintheUnitedStates: accountsfor>1.5millionoutpatientvisits/year accountsfor200,000hospitalizations/year accountsfor300deaths/year estimatedresponsiblefor9%of all hospitalizations ofchildren<5yo incidenceofdiarrheainchildren<3yoestimatedat1.32.3episodes/child/year **higherforchildrenindaycare StatisticsWorldwide: diarrhealdiseaseisleadingcauseofpediatricmorbidityandmortality 1.5(35) billionepisodesannuallyinchildren<5yo 1.52.5milliondeathsannuallyinchildren<5yo **thesenumbersareasignificant improvement! DefinitionsandTerms: Acute Gastroenteritis (AGE):diarrhealdiseaseofrapidonset,withorwithout accompanyingsymptoms,signs,suchasnausea,vomiting,fever,orabdominalpain Diarrhea:thefrequentpassageofunformedliquidstools (3ormoreloose,waterystool perday) Dysentery:bloodormucusinstools ExcludedfrommostdiscussionsofAGE: o episodesofdiarrhealasting>10days o diarrheaaccompanyingfailuretothrive o vomitingwithnoaccompanyingdiarrhea Etiologies: 7085%ofAGEindevelopedcountriesareduetoviruses Rotavirusaccountsfor1/3ofallpediatricAGEhospitalizationsinU.S. Mostcommonbacterialcauses:Campylobacter,Salmonella,Shigella,E.coli,Yersinia, andC.difficile(iatrogenic) Parasiticagents(e.g.Giardia)causelessthan10%ofcases Early Intervention Homeinterventionsareanimportantaspectofearlymanagementofacutegastroenteritis. Physicianscantriage mostpatientsviaphoneorofficeexamination.

Reasonsforearlymedicalevaluationofchildrenwithacutediarrhea:

youngage(<6moor<8kg) h/oprematurity,chronicmedicalcondition,concurrentillness temperature>37.9if<3mo,or>38.9in336mo visiblebloodinstool highoutput persistentemesis caregiverreportofsignsofdehydration changeinmentalstatus(includingirritability,apathyorlethargy) suboptimalresponsetooralrehydrationattempts

Clinical Assessment Athoroughandrelevanthistorymustbetaken,includingonset,frequency,characterandquantityofstools,aswell asintake.Socialhistory(e.g.caregivers,daycare)andpastmedicalhistory(e.g.recentinfections,medications, and medical problems)arealsonecessary. Ideally,amountofacutechangeinweightisthebestwaytodeterminedegreeofdehydration.However,ifapre illnessweightisnotavailable,clinicalsignsandsymptomscanbeutilizedtodeterminedegreeofdehydration.

Laboratory Management RoutinecasesofAGEdonotrequireextensivelaboratoryworkup. Stoolculturesareindicatedincasesofdysenteryorwherethe diagnosisofAGEisunclear. Serumelectrolytesshouldbeconsideredincasesofmoderatetoseveredehydration, whenthe caseisnotstraightforward, orwhenIVfluidsarerequired Alsoconsiderelectrolytesifsymptomsofhyernatremia (irritability,doughyskin)

Fluid Management

Oralrehydrationtherapyhasrepeatedlybeenproventobeaseffectiveasintravenousfluidsintreatmentofmildto moderatedehydrationbothoutpatientandinpatient. Methodsofdeliveryincludepoandng. Somestudies havedemonstrateddecreasedERstaysandincreasedparentsatisfactionwithORStherapyoverIV therapy.Thereisnodifference,however,indurationofillnessorhospitalizationrates. Oralrehydrationsolutionscontainglucosepluselectrolytes.Many easilyavailablesolutions(e.g.Pedialyte)have45 50mmol/Lofsodium,whichisatlowerendofthatstudied.Thesearebestformaintenancefluids,butcanbeutilized forrehydrationinotherwisehealthychildren. Rehydration protocols: Mild: 50cc/kgofORSplusreplacementover4hours** beginwith5ccaliquotsq12minwithvolumesincreasingastolerated Moderate: 100cc/kgofORSplusreplacementover4hours Asformild,butshouldbeinsupervisedsetting(ER,office) Severe: 20cc/kgofisotonicIVfluidsoveronehour Repeatasnecessary Continuereplacementforstools **ongoinglossescanbematchedatapproximately10cc/kgforeachstool

Dietary, Medical and Other Adjuvant Therapy

 DietaryTherapy Allchildrenshouldbereturnedtoageappropriatedietsuponinitialrehydration Restingthegutisaninappropriateapproachearlyrefeedinghasbeenshowntoreduce illnessduration,improvenutritionaloutcomesanddecreasechangestointestinal permeability Dilutingformulahasbeenshowntoprolongsymptomsanddelaynutritionalrecovery Lactosefreeformulasarelargelyunnecessaryametaanalysisconcludedthatatleast 80%ofchildrencouldtoleratefullstrengthmilk. BRATdietandotherrestrictivedietsareunnecessaryandprovidesuboptimalnutrition Foodshighinsimplesugarsshouldbeavoidedduetoosmoticload(see:carbonatedsoft drinks,juice,gelatindesserts, etc) Medications Antidiarrheals(e.g.loperamide,opiates,bismuthsubsalicylate)arenotrecommendedfor useinAGE.Opiatesarecontraindicated,andtheothershavelimitedscientificevidence tooutweighrisks) Antiemeticscurrentlyantiemeticsare notrecommendedinthetreatmentofAGE. Thoughsomeclinicalstudieshavedemonstratedthatondansetroncandecreasevomiting andhospitalization. Probiotics Normally,gutflora(saccharolyticbacteria)fermentdietarycarbohydratesthathavenot been absorbed.Diarrheareducesfecalflora. Probiotics(e.g. LactobacillusGG) alterthecompositionofgutfloraandassistin restoring normalgutfunction. Morestudiesaresupportingtheuseofprobiotics,specifically LactobacillusGG,asan adjuvanttherapyinAGE.

References AmericanAcademyofPediatricsProvisionalCommitteeonQualityImprovementSubcommitteeonAcute Gastroenteritis.Practiceparameter:themanagementofacutegastroenteritisinyoungchildren. Pediatrics. 1996 97:42435. BorowitzSM.Areantiemeticshelpfulinyoungchildrensufferingfromacuteviralgastroenteritis? ArchDisChild. 200590:6468. GrunenbergN.Isgradualintroductionoffeedingbetterthanimmediatenormalfeedinginchildrenwith gastroenteritis? ArchDis Child. 200388:4557. Guandalini S,etal.LactobacillusGGadministeredinoralrehydrationsolutiontochildrenwithacutediarrhea:a multicentereuropeantrial. JPediatrGastroenterolNut. 200030:5460. KingCK,GlassR,BreseeJS,DugganC.Managingacutegastroenteritisamongchildren:oralrehydration, maintenance,andnutritionaltherapy. MMWR. 200352(RR16):116. SandhuBK.Rationaleforearly feedingin childhoodgastroenteritis. JPediatrGastroenterolNut. 200133:S13S16. Szajewska HandMrukowiczJ.Probioticsinthetreatmentandpreventionofacuteinfectiousdiarrheaininfantsand children:asystematicreviewofpublishedrandomized,doubleblind,placebocontrolledtrials. JPediatr GastroenterolNut. 200133:S17S25.