CASE REPORT

With all due respect to:

To be presented on Monday, October 10th, 2022

ACUTE DIARRHEA WITH SEVERE DEHYDRATION,

COVID-19, MILD PROTEIN CALORIE MALNUTRITION IN A
CHILD

By:
Thadea Odilia Tandi

Supervised by:
Dr. dr. Jeanette I. Ch. Manoppo, Sp.A (K)

Department of Child Health

Faculty of Medicine Sam Ratulangi University
Prof. Dr. R.D. Kandou General Hospital Manado
2022
 TIMELINE

Agust 31st, 2022 Sept 1st, 2022 Sept 2nd, 2022 Sept 6th, 2022 Oct 10th, 2022

Patient
admitted in Initial Observation Final
Reporting
outpatient observation started Observation
department

1
 PATIENT’S RECORD

1. IDENTITY
1.1. IDENTITY OF PATIENT
Patient Name : T.P

Date of birth : October 21st 2021

Age : 10 months old
Gender : Female
Nationality : Indonesian

Date of admission : August 31st 2022

Registration Number : 15.09.19

1.2. PARENTS IDENTITY

FATHER MOTHER
Name : JP AB
Age : 39 years old 36 years old
Occupation : Private employees Housewife
Education : Senior high school Senior high school

2. HISTORY
(Allo-anamnesis from patient’s parents and medical record on August

31st ,2022)
Chief complaint
Liquid defecation since 3 days before and fever since 3 days before
hospital admission.

2.1 HISTORY OF PRESENT ILLNESS

The patient came brought by his parents to the Type C Hospital on
August 31, 2022 with complaints of liquid defecation since 3 days before
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 addmiting to the hospital, the frequency was more than 10 times per day,
there was no pulp, mucus or blood, the volume was half a glass of
bottled water. The patient also complained of fever since 3 days before
entering the hospital. High fever on touch, then the fever goes down
when given antipyretic drugs. According to the mother, the patient has
started drinks poorly since 1 day before.

2.2 HISTORY OF PAST ILLNESS

- There was no history of previous illness requiring hospitalization.
- History of allergy to food and drugs was denied.

2.3 FAMILY HISTORY OF ILLNESS

History of the same illness in the family was denied nor any other disease
that has the same symptoms as the patient.

FAMILY PEDIGREE

STRUCTURE OF FAMILY MEMBERS

No Name Relationship Sex Age Information
1. JP Father M 39 years Healthy
2. AB Mother F 36 years Healthy
3. JP Child M 17 years Healthy
4. AP Child F 14 years Healthy
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 5. FP Child M 5 years Healthy
6. TP Child F 10 months Patient

2.4. PERSONAL/SOCIAL HISTORY

A. HISTORY OF ANTENATAL CARE
The patient’s mother had nine times antenatal examinations at primary
health care, got Tetanus Toxoid immunization (TT) twice, and took iron
tablet routinely during the pregnancy. The patient’s mother was healthy
during the pregnancy.

B. HISTORY OF LABOR
The patient was born spontaneously, full term at primary health care,
2,600 grams, birth length unknown, cried immediately right after birth,
helped by midwife.

C. HISTORY OF POSTNATAL
No history of cyanotic or yellowish skin color. The patient was brought
for routine control and immunization at primary health care.

D. HISTORY OF FEEDING
The patient was breastfed until 6 months old. Formula milk was gives at
6 months old. Milk porridge was given at 6 until 8 months old, then
changed to soft rice at 8 months old, three times a day, and each plate
consists of rice, with fish, chicken, meat or egg, vegetables, and fruits.
Conclusion: No history of abnormal feeding or food allergy

E. DEVELOPMENTAL MILESTONES
The patient can hold his head up at 4 months of age. Turns around at 4
months of age. Sitting alone without support at 6 months of age.
Crawling at 8 months of age. Stand alone without handle 10 months old.
According to parents, his growth and development were equal to his
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 peers.
Conclusion: Patient’s growth and developmental milestones are normal
according to his age.

F. HISTORY OF VACCINATION
Patients received BCG vaccination with scar (+) on upper right arm, polio
4 times, DPT 3 times, Hepatitis B 4 times, and measles 1 time.
Conclusion: patients received basic immunization and booster
according to her age.

G. HISTORY OF BASIC NEEDS Physical-biomedic:

The patient received adequate primary needs (food, clothes and
shelter). He consumed home-cooked meal three times a day. When he
got sick, his parents took him to the nearest health facility in the area.

Emotional needs:
The patient received sufficient affection from both parents and other
family members. Parents accepted his medical condition, and give
adequate care and affection for his recovery.

Mental stimulation:
The patient gets stimulation at home from the patient's parents and
siblings

H. SOCIO-ECONOMIC AND ENVIRONMENT CONDITION

The patient’s father work as private employees and mother as midwife.
Medical treatment cost is covered by national health insurance class III.
The patient lives with his siblings and parents in semipermanent
house, with tin roofed house, board wall, and plank floor. The house has
three bedrooms, occupied by 6 persons, consists of 2 adults and 4
children. The bathroom / restroom is located outside the house. Drinking

5
 water source comes from refill water, and electricity source is provided
by government electricity company. Waste is handled by dumping them
outside the house and burned.
Conclusion: Social economic condition middle to lower family class.

PATIENT’S HOSPITAL ADMISSION SUMMARY

Prior to initial observation
(Patient’s history during hospitalization was provided by patient’s parents and
hospital medical record).
The patient came brought by his parents to the Type C Hospital on August
31, 2022 with complaints of liquid defecation since 3 days before addmiting
to the hospital, the frequency was more than 10 times per day, there was no
pulp, mucus or blood, the volume was half a glass of bottled water. The
patient also complained of fever since 3 days before entering the hospital.
High fever on touch, then the fever goes down when given antipyretic drugs.
According to the mother, the patient has started drinks poorly since 1 day
before.
From physical examination, the patient’s weight is 6.5 kg, height 71 cm,
based on WHO curves weight for age underweight, length for age in normal
stature, and weight for length wasted. The patient’s mental status was
lethargic, heart rate 120 beats/min (strong, adequate pulse), respiratory rate
28 cycles/min, temperature 38.0˚C (axillar). On head examination, there are
sunken eyes and sunken anterior fontanelle. On chest examination, there was
no retraction, clear breathing sound. On abdominal examination, there is
increased bowel sounds and skin turgor is slow to return. There was no
abnormality in genital examination. There was no edema on lower limbs.
From laboratory findings, leukocytes were 14,400 mm3, hemoglobin 12.6
g/dL, hematocrit 39.6%, platelets 543,000 mm3. the rapid test for the Anti-SARS
CoV-2 antigen was found to be positive. Chest x-ray shows pneumonia dextra.
Based on laboratory results, our patient was diagnosed with Covid-19, acute
bacterial infection, severe dehydration acute diarrhea. She is treated with

6
infusion Ringer Lactate 200 ml in 1 hour (30 ml/kg body weight) then 450 ml
in 5 hours (70 ml/kg body weight), injection of Ceftriaxone 500 mg every 24
hours IV, paracetamol 70 mg every 4-6 hours orally, zinc 20 mg every 24
hours orally, ORS ad libitum, and planned for SARS CoV-2 PCR swab.

PATIENT’S DATA AND CONDITION AFTER TAKEN AS A CASE REPORT

The examination was perfomed in the pediatric ward in August 31st, 2022
Complaint : Liquid defecation and fever
General condition : Looked ill
Consciousness : Lethargic

Anthropometric Status
Body weight : 6.9 kg (after rehydration)
Body length : 71 cm
Nutritional Status : wasted (according Weight for age birth to 2 years
(z-scores))
Weight / age : <-2 SD to -3 SD (underweight)
Length / age : -2 SD to 2 SD (normal)
Vital sign Pulse : 120 beat/ minutes
Respiratory rate : 28 cycle/ minutes
Temperature : 38.0 oC
Skin : Light brown colored, efflorescent (-), BCG scar (+) on upper
right arm.
Head and neck
Head : Normocephaly (head circumference 44 cm), no deformity, no
facial edema, black hair, not easily pulled out, sunken anterior
fontanelle.
Eyes : No anemic conjunctiva and no icteric sclera, pupils were
round, isocor, 3-3 mm, light reflex was normal, clear lenses,
normal eye movements to all directions, and sunken eyes.
Ears : Clear meatus acusticus externus, normal ear drums, no

7
 secretion
Nose : No nasal flaring, no secrets
Mouth : No perioral cyanosis, dry buccal mucosa and lips, no tongue
papillae athrophy, no caries dentis
Throat : Tonsils T1-T1 no hyperemic, pharynx no hyperemic
Neck : Centered trachea, no enlargement lymph nodes
Chest : Normal shape, symmetrical chest expansion, no retraction

Heart :
Inspection : No visualization of ictus cordis.
Palpation : Ictus cordis not palpable.
Percussion : Left margin : linea midclavicularis sinistra
Right margin : linea parasternalis dextra
Upper margin : 2nd – 3rd intercostals spaces
Auscultation : The rhythm was regular, no murmur, no gallop

Lungs :
Inspection : Symmetrical respiration movement on the both side of
hemithorax
Palpation : Symmetrical vocal fremitus
Percussion : Sonor percussion
Auscultation : Symmetrical bronchovesicular breath sound, no rales, no
wheezing

Abdomen :
Inspection : Falt, no venectation
Auscultation : Increased bowel sounds
Palpation : Liver and spleen were not palpable, skin turgor is slow to return
Percussion : Tympanic percussion, no sign of ascites
Vertebrae : No deformity
Extremities : Warm, no cyanosis, CRT ≤ 2 seconds, eutonia, no spasticity

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Muscle : Normal muscle tone on all extremities
Neurological status
Reflexes : Normal physiological reflexes, no pathological reflexes.
Sensory : Normal
Motoric : 5 5
5 5

Cranial Nerves Examination :

NI = No olfactory problem
N II = Round, isocor pupils, positives direct and indirect light reflexes
N III, IV, VI = No strabismus, normal movements of the eyeballs.
NV = No abnormality
N VII = Symmetrical nasolabialis sulci, no lagophthalmos
N VIII = No hearing or balance problem
N IX = No swallow disorder
NX = No disorder
N XI = Can shrug shoulders and turn head against resistance
N XII = No tongue deviation

SUMMARY
The patient came brought by his parents to the Type C Hospital on August
31, 2022 with complaints of liquid defecation since 3 days before addmiting
to the hospital, the frequency was more than 10 times per day, there was no
pulp, mucus or blood, the volume was half a glass of bottled water. The
patient also complained of fever since 3 days before entering the hospital.
High fever on touch, then the fever goes down when given antipyretic drugs.
According to the mother, the patient has started drinks poorly since 1 day
before.
From physical examination, the patient’s weight is 6.5 kg, height 71 cm,
based on WHO curves weight for age underweight, length for age in normal
stature, and weight for length wasted. The patient’s mental status was

9
compos mentis, heart rate 120 beats/min (strong, adequate pulse), respiratory
rate 28 cycles/min, temperature 38.0˚C (axillar). On head examination, there
are sunken eyes and sunken anterior fontanelle. On chest examination, there
was no retraction, clear breathing sound. On abdominal examination, there is
increased bowel sounds and skin turgor is slow to return. There was no
abnormality in genital examination. There was no edema on lower limbs.
From laboratory findings, leukocytes were 14,400 mm3, hemoglobin 12.6
g/dL, hematocrit 39.6%, platelets 543,000 mm3. the rapid test for the Anti-SARS
CoV-2 antigen was found to be positive. Chest x-ray shows pneumonia dextra.
Based on laboratory results, our patient was diagnosed with acute diarrhea
with severe dehydration, Covid-19, mild protein calorie malnutrition, moderate
protein malnutrition. She is treated with infusion Ringer Lactate 200 ml in 1
hour (30 ml/kg body weight) then 450 ml in 5 hours (70 ml/kg body weight),
injection of Ceftriaxone 500 mg every 24 hours IV, paracetamol 70 mg every
4-6 hours orally, zinc 20 mg every 24 hours orally, ORS 50-100 ml each liquid
defecation, and planned for SARS CoV-2 PCR swab.

3. DIAGNOSIS
Acute Diarrhea with Severe Dehydration (E86.0)
Suspect Covid-19 (Z20.822)
Mild protein calorie malnutrition (E44.1)

4. LIST OF PROBLEM
Prognostic of a girl 10 months old with acute diarrhea with severe
dehydration, covid-19, mild protein calorie malnutrition, moderate
protein malnutrition

5. MANAGEMENT PLANS
1. Treatment plans Medication therapy:
- IVFD Ringer Lactate 200 ml in 1 hour (30 ml/kg body weight) then
450 ml in 5 hours (70 ml/kg body weight)

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 - Injection of Ceftriaxone 500 mg every 24 hours IV
- Paracetamol 70 mg every 4-6 hours orally
- Zinc 20 mg every 24 hours orally
- ORS 50-100 ml each liquid defecation
2. Pediatric Nutritional Care
A. Assessment:
10 months old girl: body weight 6.5 kg, height 71 cm, Ideal
weight: 8.5 kg
Nutritional status: wasted (according WHO curve weight for girl
age birth to 2 years (z-scores)).
B. Nutritional requirements according to the Recommended Daily
Allowance:
Energy : 98 kcal/kg/day = 833 kcal/day Protein: 1.5
g/kg/day= 12.7 g/day
Fat : 30% x 833 kcal = 249.9 kcal/day ~ 250 kcal/day
= 28 g/day
Fluid : 125 – 145 ml/kg/day = 850 – 986 ml/day
C. Nutritional route: per oral
D. Determination the mode of administration given in the polymeric
form:
Soft food 3 x 1 portion (@ 211 kcal, 38 g protein, 9 g fat)
 Porridge ½ cup (105 g) = 102 kcal, 2.1 g protein, 22.04 g
carbohydrate
 1 small drumstick = 81 kcal, 10.18 g protein, 4.2 g fat
 ½ cup vegetable soup = 49 kcal, 2.06 g protein, 6 g carbohydrate,
2.22 g fat
Snack 2 x 1 portion (@ 100 kcal)
 2 pieces of marie biscuit = 44 kcal, 0.8 g protein, 7.6 g
carbohydrate, 1.2 g fat
 1 slice of apple (80 g) = 41 kcal, 11.05 g carbohydrate

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 E. Monitoring and evaluation:
Monitoring of acceptability, food tolerance, adverse reactions
and body weight changes
3. Follow up and monitoring
 Monitoring of vital signs
 Monitoring nutrition and body weight
 Monitoring therapy, response, and drug adverse effect
4. Educations plans
 Describes the illnesses: causes, complications, treatment
plans, side effects, follow up, and prognosis.
 Educate proper feeding to meet nutritional needs and disease
 Educate to maintain oral hygiene and environment

6. Nursing care:
1. Monitoring of vital signs
2. General cleanliness of the patient
3. Hygiene monitoring for parents / caregivers, nurses, medical
personnel
4. Weight everyday
5. Input and output monitoring
6. Mental and emotional support

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7. FOLLOW UP
September 1st 2022 (1st observation day)
S Liquid defecation 3 times, no had fever
O General condition : looked ill, compos mentis
Respiratory rate : 24 cpm
Pulse : 92 bpm Temperature : 37.3oC (axilla)
Body weight : 6.8 kg (post rehydration)
Eyes : pink conjunctiva, anicteric sclera, no sunken eyes
ENT : normal form, secretions -/-, nasal flaring (-)
moistoral mucosa, T1 / T1 tonsils are not hyperemic,
non hyperemic pharyngeal wall
Neck : no palpable cervical lymphnodes, JVP not increase
Chest : no retraction
Lungs-heart : within normal limit
Abdomen : flat, soft, normo active bowel sound, no organomegaly,
quick return of skin turgor
Genitalia : female, normal
Extremities : warm, no edema on lower limbs, CRT < 2 seconds
A Acute Diarrhea with Severe Dehydration (E86.0)
Suspect Covid-19 (Z20.822)
Mild protein calorie malnutrition (E44.1)
P Therapeutic:
- IVFD Ringer Lactate (HS) 28 ml/hours
- Injection of Ceftriaxone 500 mg every 24 hours IV (2)
- Paracetamol 70 mg every 4-6 hours orally
- Zinc 20 mg every 24 hours orally (2)
- ORS 50-100 ml each liquid defecation

Monitoring and evaluation:

Vital signs, nutrition, therapy, response, and drug adverse effect

Pediatric nutritional care:

Caloric requirement 833 kcal/day, protein 12,7 g/day, fat 28 g/day, oral fluid intake
850 – 986 ml/day
- Serves soft food 3 x 1 portion (@ 211 kcal, 38 g protein, 9 g fat)
 Rice ½ cup (105 g) = 102 kcal, 2.1 g protein, 22.04 g carbohydrate
 1 small cut setamed fish (50 g)= 70 kcal, 13.17 g protein, 1.45 g fat
 ½ cup vegetable soup = 49 kcal, 2.06 g protein, 6 g carbohydrate, 2.22 g fat
- Snack 2 x 1 portion (@ 100 kcal)
 2 pieces of coconut biscuit = 52 kcal, 0.8 g protein, 7.6 g carbohydrate, 2 g fat

Nursing care:
Same as before

Planning:
- SARS CoV-2 PCR swab

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 September 2nd 2022 (2nd observation day)
S Liquid defecation 1 time, no had fever
O General condition : looked ill, compos mentis
Respiratory rate : 26 cpm
Pulse : 90 bpm Temperature : 36.8oC (axilla)
Eyes : palpebral edema (-), pink conjunctiva, anicteric sclera
ENT : normal form, secretions -/-, nasal flaring(-)
moistoral mucosa, T1 / T1 tonsils are not hyperemic,
non hyperemic pharyngeal wall
Neck : no palpable cervical lymphnodes, JVP not increase
Chest : no retraction
Lungs-heart : within normal limit
Abdomen : flat, soft, normo active bowel sound, no organomegaly
Genitalia : female, normal
Extremities : warm, no edema on lower limbs, CRT < 2 seconds
SARS CoV-2 swab result: positive (CT value: 25)
A Acute Diarrhea with Severe Dehydration (E86.0)
Covid-19 (B34.2)
Mild protein calorie malnutrition (E44.1)
P Therapeutic:
- IVFD Ringer Lactate (HS) 28 ml/hours
- Injection of Ceftriaxone 500 mg every 24 hours IV (3)
- Paracetamol 70 mg every 4-6 hours orally
- Zinc 20 mg every 24 hours orally (3)
- Vitamin C 50 mg every 24 hours
- Vitamin D3 400 IU every 24 hours
- ORS 50-100 ml each liquid defecation

Monitoring and evaluation:

Vital signs, nutrition, therapy, response, and drug adverse effect
Pediatric nutritional care:
Caloric requirement 833 kcal/day, protein 12,7 g/day, fat 28 g/day, oral fluid intake
850 – 986 ml/day
- Serves soft food 3 x 1 portion (@ 211 kcal, 38 g protein, 9 g fat)
 Porridge ½ cup (105 g) = 102 kcal, 2.1 g protein, 22.04 g carbohydrate
 1 small cut cooked fish (42.5 g)= 48 kcal, 9.9 g protein, 0.52 g fat
 ½ cup bean soup = 69 kcal, 4.26 g protein, 13.07 g carbohydrate, 0.21 g fat
- Snack 2 x 1 portion (@ 100 kcal)
 3 pieces of marie = 66 kcal, 1.2 g protein, 11.4 g carbohydrate, 1.8 g fat

Nursing care:
Same as before

Planning:
- Fecal routine
- Fecal culture

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 September 3rd 2022 (3rd observation day)
S Liquid defecation 2 times
O General condition : looked ill, compos mentis
Respiratory rate : 24 cpm
Pulse : 98 bpm Temperature : 36.8oC (axilla)
Eyes : pink conjunctiva, anicteric sclera, no sunken eyes
ENT : normal form, secretions -/-, nasal flaring (-)
moistoral mucosa, T1 / T1 tonsils are not hyperemic,
non hyperemic pharyngeal wall
Neck : no palpable cervical lymphnodes, JVP not increase
Chest : no retraction
Lungs-heart : within normal limit
Abdomen : flat, soft, normo active bowel sound, no organomegaly
Genitalia : female, normal
Extremities : warm, no edema on lower limbs, CRT < 2 seconds
Feces analysis (January, 03th 2015)
Macroscopic: consistency is tender, colour yellow, mucus (-), blood (-)
Microscopic: digestives residue: fat 6 BPF, carbohydrate (+), fiber (+), leucocyte (-),
erythrocyte (-), paracyte (-), worm egg (-), occult blood screen (-)
A Acute Diarrhea with Severe Dehydration (E86.0)
Covid-19 (B34.2)
Mild protein calorie malnutrition (E44.1)
P Therapeutic:
- IVFD Ringer Lactate (HS) 28 ml/hours
- Injection of Ceftriaxone 500 mg every 24 hours IV (4)
- Paracetamol 70 mg every 4-6 hours orally
- Zinc 20 mg every 24 hours orally (4)
- Vitamin C 50 mg every 24 hours
- Vitamin D3 400 IU every 24 hours
- ORS 50-100 ml each liquid defecation

Monitoring and evaluation:

Vital signs, nutrition, therapy, response, and drug adverse effect
Pediatric nutritional care:
Caloric requirement 833 kcal/day, protein 12,7 g/day, fat 28 g/day, oral fluid intake
850 – 986 ml/day
- Serves soft food 3 x 1 portion (@ 211 kcal, 38 g protein, 9 g fat)
 Rice ½ cup (105 g) = 102 kcal, 2.1 g protein, 22.04 g carbohydrate
 40 gr fried tempe = 78 kcal, 7.28 g protein, 4.55 g fat
 ½ cup vegetable soup = 49 kcal, 2.06 g protein, 6 g carbohydrate, 2.22 g fat
- Snack 2 x 1 portion (@ 100 kcal)
 1 piece of banana (100 g) = 90 kcal, 22 g carbohydrate, 1 g protein

Nursing care:
Same as before

Planning:
- Waiting for fecal culture

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 September 4th 2022 (4th observation day)
S Liquid defecation (-)
O General condition : looked ill, compos mentis
Respiratory rate : 24 cpm
Pulse : 102 bpm Temperature : 36.5oC (axilla)
Eyes : pink conjunctiva, anicteric sclera, no sunken eyes
ENT : normal form, secretions -/-, nasal flaring (-)
moistoral mucosa, T1 / T1 tonsils are not hyperemic,
non hyperemic pharyngeal wall
Neck : no palpable cervical lymphnodes, JVP not increase
Chest : no retraction
Lungs-heart : within normal limit
Abdomen : flat, soft, normo active bowel sound, no organomegaly
Genitalia : female, normal
Extremities : warm, no edema on lower limbs, CRT < 2 seconds
A Acute Diarrhea with Severe Dehydration (E86.0)
Covid-19 (B34.2)
Mild protein calorie malnutrition (E44.1)
P Therapeutic:
- IVFD Ringer Lactate (HS) 28 ml/hours
- Injection of Ceftriaxone 500 mg every 24 hours IV (5)
- Paracetamol 70 mg every 4-6 hours orally
- Zinc 20 mg every 24 hours orally (5)
- Vitamin C 50 mg every 24 hours
- Vitamin D3 400 IU every 24 hours
- ORS 50-100 ml each liquid defecation

Monitoring and evaluation:

Vital signs, nutrition, therapy, response, and drug adverse effect
Pediatric nutritional care:
Caloric requirement 833 kcal/day, protein 12,7 g/day, fat 28 g/day, oral fluid intake
850 – 986 ml/day
- Serves soft food 3 x 1 portion (@ 211 kcal, 38 g protein, 9 g fat)
 Rice ½ cup (105 g) = 102 kcal, 2.1 g protein, 22.04 g carbohydrate
 1 small cut cooked fish (42.5 g)= 48 kcal, 9.9 g protein, 0.52 g fat
 ½ cup bean soup = 69 kcal, 4.26 g protein, 13.07 g carbohydrate, 0.21 g fat
- Snack 2 x 1 portion (@ 100 kcal)
 2 pieces of coconut biscuit = 52 kcal, 0.8 g protein, 7.6 g carbohydrate, 2 g fat

Nursing care:
Same as before

Planning:
- Waiting for fecal culture

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 September 5th - 6th 2022 (5th - 6 th observation day)
S Liquid defecation (-)
O General condition : looked ill, compos mentis
Respiratory rate : 26 cpm
Pulse : 98 bpm Temperature : 36.7oC (axilla)
Eyes : pink conjunctiva, anicteric sclera, no sunken eyes
ENT : normal form, secretions -/-, nasal flaring (-)
moistoral mucosa, T1 / T1 tonsils are not hyperemic,
non hyperemic pharyngeal wall
Neck : no palpable cervical lymphnodes, JVP not increase
Chest : no retraction
Lungs-heart : within normal limit
Abdomen : flat, soft, normo active bowel sound, no organomegaly
Genitalia : female, normal
Extremities : warm, no edema on lower limbs, CRT < 2 seconds
Complete blood count (September 5th 2022): leukocytes were 15.500 mm3, hemoglobin
12.7 g/dL, hematocrit 37.7%, platelets 155,000 mm3
SARS CoV-2 swab result (September 6th 2022): negative
A Acute Diarrhea with Severe Dehydration (E86.0)
Covid-19 (B34.2)
Mild protein calorie malnutrition (E44.1)
P Therapeutic:
- IVFD Ringer Lactate (HS) 28 ml/hours
- Injection of Ceftriaxone 500 mg every 24 hours IV (6-7)
- Paracetamol 70 mg every 4-6 hours orally
- Zinc 20 mg every 24 hours orally (6-7)
- Vitamin C 50 mg every 24 hours
- Vitamin D3 400 IU every 24 hours
- ORS 50-100 ml each liquid defecation

Monitoring and evaluation:

Vital signs, nutrition, therapy, response, and drug adverse effect
Pediatric nutritional care:
Caloric requirement 833 kcal/day, protein 12,7 g/day, fat 28 g/day, oral fluid intake
850 – 986 ml/day
- Serves soft food 3 x 1 portion (@ 211 kcal, 38 g protein, 9 g fat)
 Rice ½ cup (105 g) = 102 kcal, 2.1 g protein, 22.04 g carbohydrate
 2 pieces meatball tofu (50 g)= 84 kcal, 13.5 carbohydrate, 4 g protein, 1.5 g fat
 ½ cup vegetable soup = 49 kcal, 2.06 g protein, 6 g carbohydrate, 2.22 g fat
- Snack 2 x 1 portion (@ 100 kcal)
 2 slice of apple (160 g) = 82 kcal, 22.1 g carbohydrate

Nursing care:
Same as before

Planning:
- Waiting for fecal culture

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8. PROGNOSIS
Ad vitam : bonam
Ad functionam : dubia ad bonam
Ad sanationam : bonam

18
 COURSE OF THE DISEASE
When chosen
Follow Up
as a case

September 1st September 2nd September 3rd September 4th September 5th -
August 31st 2022
2022 2022 2022 2022 6th 2022

Liquid defecation since 3 days Liquid defecation 3 times Liquid defecation 1 time Liquid defecation 2 times Liquid defecation (-) Liquid defecation (-)
before, and fever since 3 days before
hospital admission. Poor intake since
1 day before
PE: BB: 6.9 kg (after PE: HR: 92 bpm, RR: 26 PE: HR: 98 bpm, RR: 24 PE: HR: 102 cpm, RR: 24 PE: HR: 98 cpm, RR: 26
rehydration), HR: 92 bpm, cpm, T: 36.8⁰C cpm, T: 36.8⁰C cpm, T: 36.5⁰C cpm, T: 36.7⁰C
PE: lethargic, HR: 120 bpm (strong, RR: 24 cpm, T: 37.3⁰C Head: sunken eyes (-) Head: sunken eyes (-) Head: sunken eyes (-) Head: sunken eyes (-)
adequate pulse), RR: 28 cpm, T: Head: sunken eyes (-) Abdomen: normal bowel Abdomen: normal bowel Abdomen: normal bowel Abdomen: normal bowel
38.0˚C (axillar). Abdomen: normal bowel sounds and skin turgor is sounds and skin turgor sounds and skin turgor sounds and skin turgor is
Head: sunken eyes (+), sunken sounds and skin turgor normal is normal is normal normal
anterior fontanelle (+) is normal
Abdominal: increased bowel sounds
and skin turgor is slow to return. SARS CoV-2 swab: Working diagnosis : Working diagnosis : Laboratory result: leukocytes
Working diagnosis : positive (CT value 25) Acute Diarrhea with Severe Acute Diarrhea with Severe were 15.500 mm3,
Acute Diarrhea with Severe Dehydration (E86.0) Dehydration (E86.0) hemoglobin 12.7 g/dL,
Laboratory result: leukocytes 14,400 mm3, Dehydration (E86.0) Covid-19 (B34.2) Covid-19 (B34.2) hematocrit 37.7%, platelets
hemoglobin 12.6 g/dL, hematocrit 39.6%, Suspect Covid-19 Working diagnosis : Mild protein calorie Mild protein calorie 155,000 mm3
platelets 543,000 mm3. Rapid test Anti- (Z20.822) Acute Diarrhea with Severe malnutrition (E44.1) malnutrition (E44.1) SARS CoV-2 swab result:
SARS CoV-2 reactive. Chest x-ray Mild protein calorie Dehydration (E86.0) negative
pneumonia dextra  malnutrition (E44.1) Covid-19 (B34.2)
Mild protein calorie Feces analysis: tender, Treatment :
 IVFD Ringer Lactate Working diagnosis :
malnutrition (E44.1) yellow, mucus (-), fat 6
Acute Diarrhea with Severe
Working diagnosis : Treatment : BPF, carbo (+), fiber (+),  Injection of Ceftriaxone
 IVFD Ringer Lactate Dehydration (E86.0)
Acute Diarrhea with Severe Dehydration leuco (-), erythro (-),  Paracetamol
Covid-19 (B34.2)
(E86.0)  Injection of Ceftriaxone Treatment : paracyte (-), worm egg (-  Zinc Mild protein calorie
Suspect Covid-19 (Z20.822)  Paracetamol  IVFD Ringer Lactate  Vitamin C
), occult blood (-) malnutrition (E44.1)
Mild protein calorie malnutrition (E44.1)  Zinc  Injection of Ceftriaxone  Vitamin D3
 ORS  Paracetamol  ORS
 Zinc Treatment :
Treatment : Treatment :
 Vitamin C  IVFD Ringer Lactate
 IVFD Ringer Lactate 200 ml in 1 hour  IVFD Ringer Lactate
 Vitamin D3  Injection of Ceftriaxone
(30 ml/kg body weight) then 450 ml in  Injection of Ceftriaxone
 ORS  Paracetamol
5 hours (70 ml/kg body weight)  Paracetamol
 Injection of Ceftriaxone 500 mg every  Zinc  Zinc
24 hours IV  Vitamin C  Vitamin C
 Paracetamol  Vitamin D3  Vitamin D3
 Zinc  ORS  ORS
 ORS

19
 CASE ANALYSIS

Risk Factor Female, 10 months old

Liquid defecation since 3 days before and fever since 3 days

Problem Gastrohepatology

Acute Diarrhea with Severe Dehydration

Diagnosis Suspect Covid-19
Mild protein calorie malnutrition

Reccurent liquid defecation

Clinical Dehydration
manifestation Viral infection
Weight loss

Supporting Lab: leukocytes 14,400 mm3, hemoglobin 12.6 g/dL, hematocrit 39.6%, platelets 543,000 mm3. SARS CoV-2
examination PCR positive. Chest x-ray pneumonia dextra. Fecal analysis: brown, soft, no blood, no leukocyte, no
mucous, no helminth egg, no parasites. 

Management IVFD Ringer Lactate, injection of Ceftriaxone, paracetamol, zinc, vitamin C, vitamin D3, ORS

Prognosis  Response to treatment Ad vitam : bonam

 Nutritional status Ad functionam : dubia ad bonam  Education plan
 Monitoring of drug side effects
 Complication Ad sanationam : bonam

1. Akobeng AK, et al. Gastrointestinal manifestations of COVID-19 in children: a systematic review and meta-analysis.
Frontline Gastroenterology 2021
2. Lo Vecchio, et al. Factors Associated With Severe Gastrointestinal Diagnoses in Children With SARS-CoV-2 Infection or
Multisystem Inflammatory Syndrome. JAMA Network Open. 2021
3. Vania G, et al. Gastrointestinal symptomps in severe COVID-19 children. Pediatr Infect Dis J. 2020
4. Bolia R, et al. Gastrointestinal Manifestations of Pediatric Coronavirus Disease and Their Relationship with a Severe Clinical
Course: A Systematic Review and Meta-analysis. J Trop Pediatr. 2021

20
CASE ANALYSIS
The coronavirus disease 2019 (COVID-19) is caused by single-stranded RNA
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The
disease was first described in Wuhan, China, in December 2019. Then the
virus spread rapidly worldwide, making the World Health Organization
declare the first pandemic of the 21st century in March 2020.1 On March 4,
2021, there were more than 114 million confirmed cases of COVID-19
worldwide, with nearly 3 million registered deaths.2 The clinical spectrum of
COVID-19 in children and adolescents ranges from asymptomatic/pauci
symptomatic infection to severe disease. Digestive symptoms related to
COVID-19 such as vomiting, diarrhea, and abdominal pain have emerged as
extrapulmonary manifestations, with SARS-CoV-2 RNA detected in the
faeces of people affected, suggesting faecal-oral transmission. Children with
gastrointestinal (GI) chronic diseases, including those undergoing
immunosuppressive or biological treatment, need to be strictly evaluated for
the risk of developing severe forms of COVID-19. GI involvement may play a
role in the presentation of symptoms in children affected by the multisystem
inflammatory syndrome (MIS-C) associated with COVID-19.3
COVID-19 is caused by SARS-CoV-2, previously known as the 2019
novel coronavirus (2019-nCoV). SARS-CoV-2 is a novel member of
coronaviruses which are a large class of highly diverse, enveloped, positive-
sense, single-stranded RNA viruses.4 Most reported cases of the disease are
adults, but the disease also affects children, including neonates.5 The first
reported paediatric case of COVID-19 was probably a 10-year-old boy from
Shenzhen, China, who was diagnosed with the condition in January 2020. 6
There have been a number of studies describing the clinical features of
COVID-19 since the disease was first reported in December 2019. While the
disease typically presents as acute respiratory disease and pneumonia, it has
been reported to impact other systems including the gastrointestinal tract.
Indeed, the recognition that the gastrointestinal tract may be a source of
transmission of SARS-CoV-2 has led to many endoscopy units having had to
21
postpone a large proportion of endoscopic procedures. A number of reports
on patients with COVID-19 mention gastrointestinal symptoms such as
diarrhoea, nausea, vomiting and abdominal pain.7 Despite these, the
gastrointestinal manifestations of the disease are not widely recognised by
clinicians. As COVID-19 continues to spread throughout the world, it is
essential for its gastrointestinal manifestations to be understood as they have
the potential of distracting the clinician from making a diagnosis of COVID-
19, especially in situations when the gastrointestinal symptoms precede the
typical respiratory symptoms. The aim of this systematic review and meta-
analysis is to describe the gastrointestinal manifestations of COVID-19 in
children and to determine the prevalence of such symptoms.
There are many mechanisms through which SARS-CoV-2 can interact
and damage the GI system. The first is a virus-induced cytopathic effect.
SARS-CoV-2 interacts with membrane receptors of the host cells through the
spike protein, which mediates the fusion of the virus and the cell membrane.8
Angiotensin-converting enzyme receptor 2 (ACE-2) and transmembrane
protease serine 2 (TMPRSS2) are both essential for the cellular entry process
of the virus. They are co-expressed at a high level both in the type II alveolar
cells of the lung, in the glandular cells of the gastric, duodenal, and rectal
epithelium, and in the enterocytes of ileum and colon.8 After viral entry, new
virions are synthesised in the cytoplasm of the GI cells and then are released
in the GI tract, causing direct disruption of enterocytes and the viral shedding
in the stool.9,10 As absorptive enterocytes are destroyed by SARS-CoV-2, this
changes the intestinal permeability, leading to malabsorption and unbalanced
intestinal secretion, resulting in the genesis of diarrhea.10-12 As ACE-2 is
equally expressed in liver and pancreas, the virus cytopathic effect can also
be detected in these organs. Hepatic distribution of ACE-2 is peculiar; it is
highly expressed in the endothelial layer of small blood vessels but not in the
sinusoidal endothelium.13 Its concentration on cholangiocytes’ surface is
higher than of the hepatocyte surface and is similar to the type II alveolar cells
of the lungs. SARS-CoV-2 may have the ability to infect cholangiocytes via
22
the ACE-2 receptor and directly dysregulate liver function.11,13 However, there
is no evidence of active virus replication in hepatocyte cells.12 A histological
examination of a liver biopsy obtained from a deceased COVID-19 patient
showed no viral inclusions, but rather a microvesicular steatosis and mild
lobular activity.11

Figure 1.14 Proposed model for SARS-CoV-2-associated diarrhea. SARS-CoV uses

ACE2 and the serine protease TMPRSS2 for entry in lung AT cells. ACE2 and
TMPRSS2 are not only expressed in lung, but also the small intestinal epithelia.
ACE2 is expressed in the upper esophagus, liver, and colon. ACE2 is also necessary
for the surface expression of amino acid transporters of the small intestine. Amino
acids, like tryptophan, regulate the secretion of antimicrobial peptides by Paneth cells
via mTOR pathway activation. Antimicrobial peptides impact the composition and
diversity of the microbiota. Disturbance of this pathway could drive inflammation
(enteritis) and ultimately diarrhea. SARS-CoV-2 rendering courtesy of Centers for
Disease Control and Prevention.

The second mechanism depends on immune-system activation.15

SARS-CoV-2-infected cells release a large number of inflammatory
mediators and chemokines such as interleukin (IL)-2, IL-7, granulocyte
colony-stimulating factor, interferon-γ inducible protein 10, monocyte
chemoattractant protein 1, macrophage inflammatory protein 1-α and tumour
necrosis factor-alpha (TNF-α). This “cytokine storm” causes neutrophil
aggregation and activates type 1 helper cells. This promotes the

23
accumulation of immune cells in the GI system;11 a large number of infiltrating
plasma cells and lymphocytes together with interstitial oedema have been
found in the inherent layers of the stomach, duodenum, and rectum in adult
COVID-19 patients.12 The cytokine overproduction correlates with disease
severity and multiple organ insufficiency development outside the lung, liver,
and pancreas.
SARS-CoV-2 may alter the intestinal microbiome even when only the
respiratory mucosa is involved (the “gut-lung axis”).9,10 Increased
inflammatory mediators lead to lung hyperpermeability so that the virus and
inflammatory mediators migrate to the intestine via circulation. SARS-CoV-2
and the inflammatory mediators disrupt the intestinal permeability leading to
the leakage of gut microbes and associated metabolites into circulation. The
leaked microbes and products migrate to organs including lungs and produce
abnormalities.
Children and adolescents with GI symptoms such as nausea, vomiting,
or diarrhea should be seriously evaluated for COVID-19, as the faecal-oral
route transmission of SARS-CoV-2 is extensively described (Figure 2). Oba
et al16 reported that GI signs and symptoms may affect 3% to 79% of children,
adolescents and adults with COVID-19. Various paediatric systematic
reviews evidenced similar results, 8,10,17curiously with different frequencies in
the United States and Europe compared to China (21.1% vs 12.9%).8
Manifestations include diarrhea (2%-50%), anorexia (40%-50%), vomiting
(4%-67%), nausea (1%-30%), abdominal pain (2%-6%) and GI bleeding (4%-
14%). Diarrhea and vomiting are the most common GI symptoms described,
sometimes as the first symptoms of disease, even before or in absence of
respiratory manifestations. Diarrhea, often watery, occurs from 1 d to 8 d after
the onset of COVID-19, with a median time of 3.3 d, and lasts for a mean of
4 d.16 Vomiting is more often reported in the paediatric population than in the
adult one.
Jin et al18 defined diarrhea as the passing of loose stools >3 times per
day. In their retrospective study, 53 of 651 patients (8.1%) had diarrhea at
24
onset and the median symptom duration was 4 days. The evidence presented
by Chan et al19 provided data from a family cluster with COVID-19. Two out of
7 patients experienced 3–4 days of diarrhea with several evacuations ranging
from 5 to 8 per day. The first known case of COVID-19 in the United States
also showed diarrheal symptoms for 2 consecutive days.20 A stool sample was
collected following loose bowel movements to verify the presence of the virus.
Importantly, the test was positive 7 days after the presumed onset of the
disease, showing a high viral load. Unfortunately, in the remaining studies
diarrhea was not well characterized and no data were available regarding the
total number of evacuations, consistency of the stools (Bristol scale), and
duration of symptoms.20
GI symptoms such as vomiting, abdominal pain and/or diarrhea are
typically present and considered diagnostic criteria in children with the
COVID-19-related MISC (71%-84% of the cases), along with fever lasting
more than 3 d, evidence of mucocutaneous inflammation (rash, conjunctivitis,
oromucosal changes), lymphopenia and high levels of circulating
inflammation.21-23

Figure 2. Gastrointestinal involvment in coronavirus disease 2019. 24

Prompt diagnosis of SARS-CoV-2 infection can determine treatment

strategies and influence the outcome of the disease in children. Suggestive

25
symptoms together with the history of a close contact with a COVID-19 patient
are the most useful criteria for a suspicion of infection. Diagnosis is confirmed
by SARS-CoV-2 isolation in patient samples, while auxiliary examinations are
useful to determine the severity of the disease and organ involvement in
infected children.25
Nucleic acid testing is the method of choice for virus identification.
SARS-CoV-2 RNA can be detected in sputum, lower respiratory tract
secretions, urine, stool, tears, and blood samples by real-time polymerase
chain reaction (RT-PCR) technology or by viral gene sequencing. RT-PCR
on nose-pharyngeal swab (NPS) is the diagnostic method of choice in
children. However, paediatric patients tested for SARS-CoV-2 by RT-PCR on
a rectal swab or stool returned a positive result in 89% of cases, despite not
presenting with any GI symptoms. Moreover, COVID-19 children may have a
stool SARS-CoV-2 RT-PCR positive result more frequently than adults in
spite of a negative respiratory swab; RT-PCR on stool samples seems to be
as accurate as those performed on the NPS in order to identify SARS-CoV-
2.26,27
The diagnosis in this patient was based on the results of the SARS
CoV-2 PCR swab examination and the results were positive. The patient also
has symptoms of fever and diarrhea. so that the patient's covid manifests in
the gastrointestinal tract. the patient did not do a PCR examination of the
feces.
As the faecal-oral route is confirmed as a way for SARS-CoV-2
transmission, all children with digestive tract symptoms should be tested for
SARS-CoV-2 on faeces.15,28 RT-PCR on stool becomes positive from 2 d to
2 wk after the respiratory specimen ones, and 23%-82% of patients continue
to have positive faecal test for approximately 1-16 d after their NPS turn
negative.27,29 The interval to stool negativisation may be prolonged,
exceeding 70 d in healthy children, longer in patients treated with
corticosteroids.29

26
 Therefore, despite major evidence being necessary to consider a
negative RT-PCR on faeces as one of the discharge criteria, it may be
important to recommend isolation at home for at least 2 wk after hospital
discharge.29
Generally, COVID-19 paediatric patients require symptomatic care,
both because the great majority of them has mild symptoms and also because
all virus-targeted therapies are employed exclusively in clinical trial settings.29
Supportive care included fever treatment, oxygen therapy in patients with
respiratory complications with or without airway management, and
nasogastric or intravenous hydration in children unable to tolerate oral fluids
such as those with severe GI symptoms.30
COVID-19 children are at higher risk of developing malnourishment
during criticalillness, which has been associated with increased morbidity and
mortality; therefore, nutritional therapy plays a significant role in these
children.16 The European Society of Paediatric and Neonatal Intensive Care
cornerstones for nutrition recommend commencing early enteral feeding
within 24 h of hospital admission in critically ill children unless
contraindicated. Energy requirements need not exceed resting energy
expenditure during the acute phase and an increase in enteral nutrition in a
stepwise fashion is recommended until the goal for delivery is achieved.
Overfeeding harms critically ill children, especially during the acute phase.31
In children with severe GI COVID-19 and MIS-C, enteral nutrition
support may be continued for a long time into the recovery phase until
sufficient oral intake is consistently achieved to support physical and
nutritional rehabilitation.32 Enteral nutrition is also recommended in critically
ill children on hemodynamic support with a stable clinical condition; parenteral
nutrition has to be withheld during the first 7 d of admission.16,31 However, in
children who continue to require fluid resuscitation or escalating doses of
vasoactive agents with evidence of severe GI dysfunction and MIS-C, enteral
nutrition may be withheld for up to 7 d.32

27
 Acute diarrhea is the most frequent gastrointestinal disorder and the
main cause of dehydration in childhood.33 It is characterized by a sudden
occurrence of three or more watery or loose stools daily.33,36,37 In addition, the
initial phase of the disease is often accompanied by anorexia, vomiting,
abdominal pain and elevated body temperature. 34 Acute diarrhea primarily
occurs in children during the first five years after birth, and particularly in the
second half-year and in small children.35 Although it is present worldwide, the
highest incidence is recorded in the developing countries.

Table 1. Classify the child's level of dehydration38

Classification Signs or symptoms Treatment
Severe Two or more of the Give fluids for severe
dehydration following signs: dehydration.
 Lethargy or
unconsciousness
 Sunken eyes
 Unable to drink or
drinks poorly
 Skin pinch goes back
very slowly (≥ 2 s)
Some dehydration Two or more of the following - Give fluid and food for
signs: some dehydration
 Restlessness, - After rehydration,
irritability advise mother on home
 Sunken eyes treatment and when to
 Drinks eagerly, thirsty return immediately
 Skin pinch goes back - Follow up in 5 days if
slowly not improving.
No dehydration Not enough signs to - Give fl uid and food to
classify as some or severe treat diarrhoea at home
dehydration - Advise mother on when
to return immediately

28
 - Follow up in 5 days if
not improving.

Key measures to treat diarrhoea include the following:38

 Rehydration: with oral rehydration salts (ORS) solution. ORS is a mixture
of clean water, salt and sugar. It costs a few cents per treatment. ORS is
absorbed in the small intestine and replaces the water and electrolytes
lost in the faeces.
 Zinc supplements: zinc supplements reduce the duration of a diarrhoea
episode by 25% and are associated with a 30% reduction in stool volume.
 Rehydration: with intravenous fluids in case of severe dehydration or
shock.
 Nutrient-rich foods: the vicious circle of malnutrition and diarrhoea can be
broken by continuing to give nutrient-rich foods – including breast milk –
during an episode, and by giving a nutritious diet – including exclusive
breastfeeding for the first six months of life – to children when they are
well.
 Consulting a health professional, in particular for management of
persistent diarrhoea or when there is blood in stool or if there are signs
of dehydration.
The patient was found to be lethargic, cow's eye, slow skin turgor, and
the patient was not drinking enough, so the patient was diagnosed with
severe dehydration. Then the patient was treated with therapy C and given
IVFD Ringer lactate 100 ml/kg which was divided into 2 stages, namely 30
ml/kg in the first 1 hour and then 70/kg in the next 5 hours. The patient was
also given zinc 20 mg orally.

29
Figure 3. Chart diarrhoea treatment plan C: Treat severe dehydration
quickly38

The unprecedented global social and economic crisis triggered by the

COVID-19 pandemic poses grave risks to the nutritional status and survival

30
of young children in low-income and middle-income countries (LMICs). Of
particular concern is an expected increase in child malnutrition, including
wasting, due to steep declines in household incomes, changes in the
availability and affordability of nutritious foods, and interruptions to health,
nutrition, and social protection services.39 One in ten deaths among children
younger than 5 years in LMICs is attributable to severe wasting because
wasted children are at increased risk of mortality from infectious diseases.40
Before the COVID-19 pandemic, an estimated 47 million children younger
than 5 years were moderately or severely wasted, most living in sub-Saharan
Africa and south Asia.41
Malnutrition is the primary cause of immunodeficiency worldwide, with
infants, children, adolescents, and the elderly most affected. There is a strong
relationship between malnutrition and infection and infant mortality, because
poor nutrition leaves children underweight, weakened, and vulnerable to
infections, primarily because of epithelial integrity and inflammation.42
Balanced nutritional intake during the progression of and recovery
from any illness is important for improvement in health outcomes.43-45
Terefore, it is expected that malnutrition may have deleterious efects on the
prognosis of the novel Coronavirus Disease 2019 (COVID-19) and therefore
require proper attention.46-51
Anthony K Akobeng, Ciaran Grafton-Clarke, Ibtihal Abdelgadir, Erica
Twum-Barimah,Morris Gordon,52 in a systematic review and meta-analysis of
269 citations found 13 studies (nine case series and four case reports)
comprising data for 284 patients were included. Four studies as having a low
risk of bias, eight studies as moderate and one study as high risk of bias. In
a meta-analysis of nine studies, comprising 280 patients, the pooled
prevalence of all gastrointestinal symptoms was 22.8% (95% CI 13.1% to
35.2%; I2=54%). Diarrhoea was the most commonly reported gastrointestinal
symptom followed by vomiting and abdominal pain. (Level of Evidance 1A,
recommendation A)

31
 Lo Vecchio, et al53 found 685 children (386 boys [56.4%]; median age,
7.3 [IQR, 1.6-12.4] years) were included. Of these children, 628 (91.7%) were
diagnosed with acute SARS-CoV-2 infection and 57 (8.3%) with MIS-C. The
presence of GI symptoms was associated with a higher chance of
hospitalization (OR, 2.64; 95% CI, 1.89-3.69) and intensive care unit
admission (OR, 3.90; 95% CI, 1.98–7.68). Overall, 65 children (9.5%) showed
severe GI involvement, including disseminated adenomesenteritis (39.6%),
appendicitis (33.5%), abdominal fluid collection (21.3%), pancreatitis (6.9%),
or intussusception (4.6%). Twenty-seven of these 65 children (41.5%)
underwent surgery. Severe GI manifestations were associated with the child’s
age (5-10 years: OR, 8.33; 95% CI, 2.62-26.5; >10 years: OR, 6.37; 95% CI,
2.12-19.1, compared with preschool-age), abdominal pain (adjusted OR
[aOR], 34.5; 95% CI, 10.1-118), lymphopenia (aOR, 8.93; 95% CI, 3.03-26.3),
or MIS-C (aOR, 6.28; 95% CI, 1.92-20.5). Diarrhea was associated with a
higher chance of adenomesenteritis (aOR, 3.13; 95% CI, 1.08-9.12) or
abdominal fluid collection (aOR, 3.22; 95% CI, 1.03-10.0). (Level of Evidance
1A, recommendation A)
Vania G, et al54 reported, differently to published data, that a history of
gastrointestinal (GI) was positively correlated with a worst severity score
(severe and critical) and a higher ICU admission rate. The presence of GI
symptoms at the admission was differently distributed throughout severity
classes (P = 0.006). Having GI symptoms was more frequently associated
with severe and critical phenotype (P = 0.029). (Level of Evidance 2A,
recommendation B)
Bolia R, et al55 total of 811 studies were identified through a systematic
search of which 55 studies (4369 patients) were included in this systematic
review. The commonest GI symptoms were diarrhea-19.08% [95%
confidence interval (CI) 10.6-28.2], nausea/vomiting 19.7% (95% CI 7.8-33.2)
and abdominal pain 20.3% (95% CI 3.7-40.4). The presence of diarrhea was
significantly associated with a severe clinical course with a pooled OR of 3.97
(95% CI 1.80-8.73; p < 0.01). Abdominal pain and nausea/vomiting were not
32
associated with disease severity. Diarrhea, nausea/vomiting or abdominal
pain are present in nearly one-fifth of all children with COVID-19. The
presence of diarrhea portends a severe clinical course. (Level of Evidance
1A, recommendation A)

33
REFERENCES

1. World Health Organization. WHO Coronavirus Disease (COVID-19)

pandemic. [cited 4 March 2021]. In: World Health Organization
[Internet]. Available from: https:// covid-19.who.int/1
2. World Health Organization. WHO Coronavirus Disease (COVID-19)
dashboard. [cited 4 March 2021]. In: World Health Organization
[Internet]. Available from: https://covid-19.who.int/2
3. Miller J, Cantor A, Zachariah P, Ahn D, Martinez M, Margolis KG.
Gastrointestinal Symptoms as a Major Presentation Component of a
Novel Multisystem Inflammatory Syndrome in Children That Is Related
to Coronavirus Disease 2019: A Single Center Experience of 44 Cases.
Gastroenterology 2020; 159: 1571-1574. e2
4. He F, Deng Y, Li W. Coronavirus disease 2019: what we know? J Med
Virol 2020;92:719–25.
5. Lai C-C, Liu YH, Wang C-Y, Wang Y-H, Hsueh S-C, Yen M-Y, et al.
Asymptomatic carrier state, acute respiratory disease, and pneumonia
due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-
2): facts and myths. J Microbiol Immunol Infect 2020;53:404–12.
6. Chan JF-W, Yuan S, Kok K-H, To K K-W, Chu H, Yang J, et al. A
familial cluster of pneumonia associated with the 2019 novel
coronavirus indicating person-to-person transmission: a study of a
familycluster. Lancet 2020;395:514–23.
7. Gu J, Han B, Wang J. COVID-19: gastrointestinal manifestations and
potential fecal-oral transmission. Gastroenterology 2020;158:1518–9.
8. Wang JG, Cui HR, Tang HB, Deng XL. Gastrointestinal symptoms and
fecal nucleic acid testing of children with 2019 coronavirus disease: a
systematic review and meta-analysis. Sci Rep 2020; 10:17846.

34
9. Matthai J, Shanmugam N, Sobhan P; Indian Society of Pediatric
Gastroenterology, Hepatology and Nutrition; Pediatric Gastroenterology
Chapter of Indian Academy of Pediatrics. Coronavirus Disease
(COVID-19) and the Gastrointestinal System in Children. Indian Pediatr
2020; 57: 533-535
10. Chiappini E, Licari A, Motisi MA, Manti S, Marseglia GL, Galli L, Lionetti
P. Gastrointestinal involvement in children with SARS-COV-2 infection:
An overview for the pediatrician. Pediatr Allergy Immunol 2020; 31
Suppl 26: 92-95
11. Patel KP, Patel PA, Vunnam RR, Hewlett AT, Jain R, Jing R, Vunnam
SR. Gastrointestinal, hepatobiliary, and pancreatic manifestations of
COVID-19. J Clin Virol 2020; 128: 104386
12. Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H. Evidence for
Gastrointestinal Infection of SARSCoV-2. Gastroenterology 2020; 158:
1831-1833. e3
13. Jothimani D, Venugopal R, Abedin MF, Kaliamoorthy I, Rela M. COVID-
19 and the liver. J Hepatol 2020; 73: 1231-1240
14. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic
characterisation and epidemiology of 2019 novel coronavirus:
implications for virus origins and receptor binding. Lancet
2020;395:565–574.
15. Lei HY, Ding YH, Nie K, Dong YM, Xu JH, Yang ML, et al. Potential
effects of SARS-CoV-2 on the gastrointestinal tract and liver. Biomed
Pharmacother 2021; 133: 111064
16. Oba J, Carvalho WB, Silva CA, Delgado AF. Gastrointestinal
manifestations and nutritional therapy during COVID-19 pandemic: a
practical guide for pediatricians. Einstein (Sao Paulo) 2020;
18:eRW5774

35
17. Xu Y, Li X, Zhu B, Liang H, Fang C, Gong Y, et al. Characteristics of
pediatric SARS-CoV-2 infection and potential evidence for persistent
fecal viral shedding. Nat Med 2020; 26: 502-505
18. Jin X, Lian J-S, Hu J-H, Gao J, Zheng L, Zhang Y-M et al.
Epidemiological, clinical and virological characteristics of 74 cases of
coronavirus-infected disease 2019 (COVID-19) with gastrointestinal
symptoms. Gut 2020;69:1002–1009
19. Chan JF-W, Yuan S, Kok K-H, To K K-W, Chu H, Yang J, et al. A
familial cluster of pneumonia associated with the 2019 novel
coronavirus indicating person-to-person transmission: a study of a
family cluster. Lancet 2020;395:514–523
20. Song Y, Liu P, Shi XL, Chu Y. L, Zhang J, Xia J, et al. SARS-CoV-2
induced diarrhoea as onset symptom in patient with COVID-19. Gut
2020;69:1143–1144
21. Nakra NA, Blumberg DA, Herrera-Guerra A, Lakshminrusimha S. Multi-
System Inflammatory Syndrome in Children (MIS-C) Following SARS-
CoV-2 Infection: Review of Clinical Presentation, Hypothetical
Pathogenesis, and Proposed Management. Children (Basel) 2020; 7
22. Radia T, Williams N, Agrawal P, Harman K, Weale J, Cook J, et al.
Multi-system inflammatory syndrome in children & adolescents (MIS-C):
A systematic review of clinical features and presentation. Paediatr
Respir Rev 2020
23. Vogel TP, Top KA, Karatzios C, Hilmers DC, Tapia LI, Moceri P, et al.
Multisystem inflammatory syndrome in children and adults (MIS-C/A):
Case definition & guidelines for data collection, analysis, and
presentation of immunization safety data. Vaccine 2021
24. Calitri C, Fumi I, Ignaccolo MG, Banino E, Benetti S, Lupica MM, et al.
Gastrointestinal involvement in paediatric COVID-19 — from
pathogenesis to clinical management: A comprehensive review. World
J Gastroenterol 2021 June 21; 27(23): 3303-3316

36
25. Miao H, Li H, Yao Y, Wu M, Lu C, Wang J, et al. Update on
recommendations for the diagnosis and treatment of SARS-CoV-2
infection in children. Eur J Clin Microbiol Infect Dis 2020; 39: 2211-2223
26. Xu CLH, Raval M, Schnall JA, Kwong JC, Holmes NE. Duration of
Respiratory and Gastrointestinal Viral Shedding in Children With SARS-
CoV-2: A Systematic Review and Synthesis of Data. Pediatr Infect Dis
J 2020; 39: e249-e256
27. Zhang L, Peres TG, Silva MVF, Camargos P. What we know so far
about Coronavirus Disease 2019 in children: A meta-analysis of 551
Laboratory-confirmed cases. Pediatr Pulmonol 2020; 55: 2115-2127
28. Tian Y, Rong L, Nian W, He Y. Review article: gastrointestinal features
in COVID-19 and the possibility of faecal transmission. Aliment
Pharmacol Ther 2020; 51: 843-851
29. Wang JG, Cui HR, Tang HB, Deng XL. Gastrointestinal symptoms and
fecal nucleic acid testing of children with 2019 coronavirus disease: a
systematic review and meta-analysis. Sci Rep 2020; 10:17846
30. Chan K, Beck C, Chauvin-Kimoff L, Gripp K, Krmpotic K, Thakore S, et
al; Acute Care Committee. The acute management of COVID-19 in
paediatrics. Paediatr Child Health. 2021 Nov 11;26(7):438-439.
31. Tume LN, Valla FV, Joosten K, Jotterand Chaparro C, Latten L, Marino
LV, et al. Nutritional support for children during critical illness: European
Society of Pediatric and Neonatal Intensive Care (ESPNIC)
metabolism,endocrine and nutrition section position statement and
clinical recommendations. Intensive Care Med 2020; 46: 411-425
32. Marino LV, Valla FV, Tume LN, Jotterand-Chaparro C, Moullet C,
Latten L, et al. Considerations for nutrition support in critically ill
children with COVID-19 and paediatric inflammatory multisystem
syndrome temporally associated with COVID-19. Clin Nutr 2021; 40:
895-900

37
33. Guandalini S, Kahn SA, Kleinman RE, Sanderson IR, Goulet O,
Sherman PM, et al. Acute diarrhea in Children. Walker’s Pediatric
Gastrointestinal Disease. 5th ed. Hamilton: BC Decker Inc; 2008.
p.253-64.
34. Koletzko S, Osterrieder S. Acute infectious diarrhea in children. Dtsch
Arztebl Int. 2009; 106(33):539-47
35. Farthing M, Salam MA, Lindberg G, Dite P, Khalif I, Salazar-Lindo E, et
al.; WGO. Acute diarrhea in adults and children: a global perspective. J
Clin Gastroenterol. 2013; 47(1):12-20.
36. Bhutta ZA. Gastroenteritis in children. In: Kliegman RM, Stanton BF,
Schol NF, St Geme III JW, Behrman RE, editors. Nelson Textbook of
Pediatrics. 19th ed. Philadelphia: Elsevier; 2011. p.1323-39.
37. Guarino A, Albano F, Ashkenazi S, Gendrel D, Hoekstra JH, Shamir R,
et al; European Society for Paediatric Gastroenterology, Hepatology;
Nutrition/European Society for Paediatric Infectious Diseases.
European Society for Paediatric Gastroenterology, Hepatology, and
Nutrition/European Society for Paediatric Infectious Diseases evidence-
based guidelines for the management of acute gastroenteritis in
children in Europe. J Pediatr Gastroenterol Nutr. 2008; 46(Suppl
2):S81-122.
38. World Health Organization. Improving the quality of care for maternal,
newborn and child health: implementation guide for national, district
and facility levels [Internet]. Geneva: World Health Organization; 2022
[cited 2022 Sep 23]. Available from:
https://apps.who.int/iris/handle/10665/353738
39. Akseer N, Kandru G, Keats EC, Bhutta ZA. COVID-19 pandemic and
mitigation strategies: implications for maternal and child health and
nutrition. Am J Clin Nutr 2020; published online June 19. https://doi.org/
10.1093/ajcn/nqaa171.

38
40. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M,
et al. Maternal and child undernutrition and overweight in low-income
and middle-income countries. Lancet 2013; 382: 427–51.
41. UNICEF, WHO, World Bank Group. Joint malnutrition estimates, 2020
edition. 2020. https://www.who.int/publications/i/item/jme-2020- edition
(accessed September 13, 2022).
42. Better nutrition could save millions of kids—study. Reuters, 17 June
2004
43. Slawson DL., Fitzgerald N, Morgan KT. Position of the Academy of
Nutrition and Dietetics: the role of nutrition in health promotion and
chronic disease prevention. J. Acad. Nutr. Diet. 113, 972–979 (2013).
44. Hendricks KM, Duggan C, Gallagher L, Carlin AC, Richardson DS,
Collier SB, et al. Malnutrition in hospitalized pediatric patients: current
prevalence. Arch. Pediatr. Adolesc. Med. 1995 Oct;149(10), 1118–22.
45. Allred CRG, Voss AC, Finn SC, McCamish MA. Malnutrition and clinical
outcomes: the case for medical nutrition therapy. J. Am. Diet. Assoc.
96, 361–369 (1996).
46. Barazzoni R, Bischoff SC, Breda J, Wickramasinghe K, Krznaric Z,
Nitzan D, et al. ESPEN expert statements and practical guidance for
nutritional management of individuals with SARS-CoV-2 infection. Clin.
Nutr. 39, 1631–1638 (2020).
47. Bedock D, Lassen PB, Mathian A, Moreau P, Couffignal J, Ciangura C,
et al. Prevalence and severity of malnutrition in hospitalized COVID-19
patients. Clin. Nutr. ESPEN. 2020 Dec;214–19
48. Handu D, Moloney L, Rozga M, Cheng F. Malnutrition Care during the
COVID-19 Pandemic: Considerations for Registered Dietitian
Nutritionists Evidence Analysis Center. J. Acad. Nutr. Diet. (2020).
49. Tibault R, Coeffier M, Joly F, Bohe J, Schneider SM, Dechelotte P. How
the Covid-19 epidemic is challenging our practice in clinical nutrition—
feedback from the feld. Eur. J. Clin. Nutr. 2021 Mar;75(3):407-16

39
50. Tibault R, Seguin P, Tamion F, Pichard C, Singer P. Nutrition of the
COVID-19 patient in the intensive care unit (ICU): a practical guidance.
Crit. Care. 2020 Jul 19;24(1):447
51. Rouget A, Vardon-Bounes F, Lorber P, Vavasseur A, Marion O,
Marcheix B, et al. Prevalence of malnutrition in COVID-19 inpatients:
the Nutricov study. Br. J. Nutr. 2021 Nov 14;126(9):1296-1303

EVIDENCE-BASED REFERENCES

52. Akobeng AK, Grafton-Clarke C, Abdelgadir I, Twum-Barimah E, Gordon

M. Gastrointestinal manifestations of COVID-19 in children: a
systematic review and meta-analysis. Frontline Gastroenterology
2021;12:332–7.
53. Lo Vecchio A, Garazzino S, Smarrazzo A, Venturini E, Poeta M,
Berlese P, et al. Factors Associated With Severe Gastrointestinal
Diagnoses in Children With SARS-CoV-2 Infection or Multisystem
Inflammatory Syndrome. JAMA Network Open. 2021;4(12):e2139974
54. Vania G, Lucia B, Marta S, Emma L, Laura F, Alessandro L, et al.
Gastrointestinal symptomps in severe COVID-19 children. Pediatr
Infect Dis J. 2020 Oct;39(10):e317-e320.
55. Bolia R, Goel AD, Badkur M, Jain V. Gastrointestinal Manifestations of
Pediatric Coronavirus Disease and Their Relationship with a Severe
Clinical Course: A Systematic Review and Meta-analysis. J Trop
Pediatr. 2021 May 17;67(2):fmab051.

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ABBREVIATIONS

BCG Bacillus Calmette Guerin

DPT Diphtheria Pertussis Tetanus
SARS Severe Acute Respiratory Syndrome
kg kilogram
cm centimeter
BW Body Weight
g Gram
g/dL Gram per deciliter
Hb Hemoglobin
Ht Hematocrit
IVFD Intravenous Fluid Drips
Kg Kilo gram
WHO World Health Organization
KgBW Kilo gram Body Weight
kcal Kilocalories
cpm cycle per minute
bpm beat per minute
JVP Jugular Venous Pressure
PCR Polymerase chain reaction
RNA Ribonucleic acid
GI gastrointestinal
ACE-2 Angiotensin-Converting Enzyme receptor 2
TMPRSS2 transmembrane protease serine 2
IL Interleukin
TNF- α tumour necrosis factor-alpha
CRP C-reaction protein
PCT procalcitonin
ICU intensive care unit
LMICs low-income and middle-income countries

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Appendix
Patient’s Photo

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Growth Chart

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