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Management of Acute Gastroenteritis in Children.

DAVID M. BURKHART, M.D., Wright State University School of Medicine, Dayton, Ohio Am Fam Physician. 1999 Dec 1;60(9):25
by

EUSTACE KARO

on 15 November 2013

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Transcript of Management of Acute Gastroenteritis in Children.

Step 1
Step 2
Step 3
Management of Acute Gastroenteritis in Children
The traditional approach using
“clear liquids”
is inadequate.

Severe dehydration requires the prompt restoration of intravascular volume through the
intravenous
administration of fluids followed by oral rehydration therapy
(ORT)
.

When rehydration is achieved, an age-appropriate diet should be promptly resumed.
Task
DAVID M. BURKHART, M.D., Wright State University School of Medicine, Dayton, Ohio
Acute gastroenteritis is a common and costly clinical problem in children.


It is a largely self-limited disease with many etiologies.


The evaluation of the child with acute gastroenteritis requires a careful history and a complete physical examination to uncover other illnesses with similar presentations.


Minimal laboratory testing is generally required.
Treatment is primarily supportive &
is directed at preventing or treating dehydration.

When possible,
an age-appropriate diet and fluids should be continued.

Oral rehydration therapy

(ORT)

using a commercial pediatric oral rehydration

solution

(ORS)

is the preferred approach to mild or moderate dehydration.
Antiemetic
&
antidiarrheal
medications - -
are generally not indicated
&

may contribute to complications.

The use of antibiotics remains controversial.
PAEDIATRIC ACUTE GASTROENTERITIS

remains an important clinical illness
commonly encountered by family physicians.

IT'S ATTENDANT PROBLEMS of
vomiting, diarrhea & dehydration
continue to present significant risks to children &
are responsible for considerable health care
expenditures.
DIARRHOEAL DISEASES

are a leading cause

of childhood morbidity & mortality
in developing countries, & an important cause of malnutrition.


In 2001 an estimated
1.5 MILLION
below 5 years
died from diarrhoea.

Eight

out of
10
of these deaths
occur in the first two years of life.
ON AVERAGE,

children below 3 years of age

in developing countries experience

three episodes of diarrhoea each year.
In many countries diarrhoea,

including cholera,

is also an important cause of morbidity

among older children and adults.
MANY DIARRHOEAL DEATHS
ARE CAUSED BY DEHYDRATION.

Over the past two decades,
pediatric acute gastroenteritis
has been the subject of
considerable worldwide attention & effort.

After 20 years of research,
an improved ORS solution
has been developed.
Particular emphasis has been given
to the development & promotion of
inexpensive,
easy-to-use oral rehydration solutions (ORS)
for the treatment of dehydration,
the problem that is most responsible for
morbidity & mortality
in children with this illness.
ORS solution
is absorbed in the small intestine
even during copious diarrhoea,
thus replacing the water & electrolytes
lost in the faeces.

Despite the growing body of evidence
supporting the safety &
efficacy of oral re-hydration solutions (ORS),
they remain underutilized, &
the management of gastroenteritis
continues to vary considerably.
COMMON MANAGEMENT ERRORS INCLUDE :

CARE GIVERS

do not know
the current standards for oral rehydration therapy.

Even CARE GIVERS

who are familiar with these standards
do not necessarily use
oral rehydration therapy in their dehydrated pediatric pts.

CARE GIVERS

use oral rehydration solutions
1). in children with little or no dehydration,

2). administering intravenous rehydration therapy
to children with only moderate dehydration &
inappropriately withholding
oral rehydration solutions or
other feeding in children with vomiting
THE NEW ORS SOLUTION

reduces by 33%
the need for supplemental IV fluid therapy

after initial rehydration
when compared to
the previous standard WHO ORS solution.

Definition and Causes.

A uniform definition of acute gastroenteritis does not exist.

The AAP defines acute gastroenteritis as

“diarrheal disease of rapid onset,
with or without
accompanying symptoms or signs
such as
nausea, vomiting, fever or abdominal pain.”

The hallmark of the disease is
increased stool frequency with alteration of stool consistency.

CAUSES.

Worldwide, infectious agents (
viruses, bacteria and parasites
) are by far the most common causes of acute gastroenteritis.

VIRUSES
, primarily
ROTAVIRUS
species, are responsible for
70 to 80 percent of infectious diarrhea cases in the developed world,

various
BACTERIAL PATHOGENS
account for another
10 to 20 percent of cases &

PARASITIC
organisms such as Giardia species cause fewer than 10 percent of cases.
Factors that increase the risk of acute gastroenteritis in children include

climate and season
, as evidenced by the dramatic increase in rotavirus cases in the United States during the winter months

attendance
at day care centers &

impoverished
living conditions with poor sanitation.
Etiologic Agents for Pediatric Infectious Gastroenteritis.

Pathogens (Noninflammatory agents).

Rotavirus (most common)
Enteric adenovirus
Norwalk virus
Calicivirus
Astrovirus
Parvovirus
Etiologic Agents for Pediatric Infectious Gastroenteritis.

Pathogens (inflammatory agents).

Bacteria.
Salmonella (most common)
Toxigenic Escherichia coli(noninflammatory agent)
Shigella (second most common)
Campylobacter jejuni
Yersinia enterocolitica
(more common in Europe and Canada)
Hemorrhagic E. coli O157:H7
Clostridium difficile (iatrogenic)
Etiologic Agents for Pediatric Infectious Gastroenteritis.

Pathogens (non-inflammatory agents).

Parasites.

Giardia lamblia (most common)
Cryptosporidium.

NEW ORS SOLUTION.

SO CALLED
reduced (LOW) osmolarity ORS solution,
reduces by 33% the need for
supplemental IV fluid therapy
after initial rehydration
when compared to
the previous standard WHO ORS solution.

This new reduced (LOW) osmolarity ORS solution,
containing
a). 75 mEq/l of sodium
&
b). 75 mmol/l of glucose,
is now the ORS formulation officially recommended
by WHO & UNICEF.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.

The evaluation of the child with symptoms
of acute gastroenteritis begins with a careful history
to elicit information that might point to other illnesses with similar presentations.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.

Respiratory symptoms such as cough,
dyspnea or tachypnea may indicate
the presence of an underlying pneumonia.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.

a). Urinary frequency, urgency or pain may be symptoms of

PYELONEPHRITIS,

b). an earache may be a symptom of ACUTE OTITIS MEDIA, &

c). high fever and altered mental status may be signs of

MENINGITIS OR SEPSIS.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.

Factors such as

living in underdeveloped countries,
exposure to untreated drinking or washing water sources, contact with animals or birds,
day care center attendance,
recent antibiotic treatment or
a recent change in diet

may suggest other specifically treatable causes of vomiting & diarrhea.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.

A second goal of the history is to assess

a). the severity of the symptoms &
b). the risk of complications such as dehydration.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.

The presence or absence of fever,
the amount and type of oral intake, &
the frequency & estimated volume of emesis or stool are important factors to consider.

Fever increases insensible water loss.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.

a) Emesis,
b) Stool & urine volume in excess of intake

invariably leads to significant dehydration.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.

Stool characteristics such as the presence of blood
should prompt consideration of inflammatory bacterial disease &
a much more aggressive work-up & intervention
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT -- The physical examination.

The physical examination has two main functions:

a) a search for signs of comorbid conditions &
b) an estimate of the level of dehydration.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT -- The physical examination.

The first objective can be accomplished with a careful general examination.

The second objective is more difficult to achieve.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT -- The physical examination.

The primary tasks are :---

a) to assess the adequacy of perfusion &
b) to determine whether dehydration is severe enough
c) to cause hemodynamic instability.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT -- The physical examination.

It may be most helpful to compare
the patient's present weight
with the last recorded weight in the chart,

a) to assess the patient's orthostatic vital signs &
b) to carefully review the patient's recent oral fluid intake.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.
The physical examination--Clinical signs.

Table 1 Symptoms associated with dehydration.

Mental status Quality of Pulses Mouth & tongue

Thirst Breathing Skin fold
Mental Status Tears Capillary refill
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.
The physical examination--Clinical signs.

Extremeties.

Urine Output.
Table 1 Symptoms associated with dehydration.

Mental status
Thirst
Heart rate
---------------------------------------------------------
Quality of Pulses
Breathing
Eyes
----------------------------------------------------------
Tears
Mouth & tongue
Skin fold
---------------------------------------------------------
Capillary refill
Extremeties.
Urine Output.
Table 1 Symptoms associated with
Minimal or no
dehydration.
(<3% loss body wt)
Minimal or no Dehydration
Symptoms (< 3% loss body wt

Mental status Well; alert
Thirst Drinks normally; might refuse liquids.
Heart rate Normal.
---------------------------------------------------------------------------
-----------------------------
Quality of Pulses Normal
Breathing Normal
Eyes Normal
---------------------------------------------------------------------------
------------------------------
Tears Present
Mouth & tongue Moist
Skin fold Instant recoil.
---------------------------------------------------------------------------
-----------------------------
Capillary refill Normal
Extremeties. Warmth
Urine Output. Normal to decreased.
Table 1 Symptoms associated with
Mild to Moderate
dehydration.
(3-9 % loss body wt)
Mild to Moderate dehydration
Symptom 3%-9% of body weight
Mental status Normal, fatigued or restless, irritable
Thirst Thirsty, eager to drink
Heart rate Normal to increased
---------------------------------------------------------
--------------------------------------------------
Quality of Pulses Normal to decreased
Breathing Normal; fast
Eyes Slightly sunken
----------------------------------------------------------
-------------------------------------------------
Tears Decreased
Mouth & tongue Dry
Skin fold Recoil in < 2 seconds
---------------------------------------------------------
--------------------------------------------------
Capillary refill Prolonged
Extremeties. Cool
Urine Output. Decreased
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.
The physical examination--Clinical signs.

Evidence exists, however,
that traditional clinical signs are not always reliable in determining the degree of dehydration.

For example, capillary refill time can be affected by ambient temperature.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.
The physical examination--Clinical signs.

One study13 found that only ::--

1) decreased peripheral perfusion,
2) deep breathing &
3) decreased skin turgor

correlated with mild to moderate dehydration.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.
The physical examination--Clinical signs.

Another study14 reported that
prolonged skinfold time correlated best
with the degree of dehydration,
followed by altered mental status,
sunken eyes &
dry oral mucosa.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.
The physical examination--Clinical signs.

Yet another study found that as many as 87 percent of children admitted to the hospital for dehydration
on the basis of clinical signs had mild or no dehydration
based on a comparison of their weights on admission & discharge (when they were judged to be fully rehydrated);
82 percent of these patients received intravenous rehydration therapy.
Evaluation of the child with symptoms
of acute gastroenteritis.

CLINICAL ASSESSMENT.
The physical examination--Clinical signs.

Because of doubts about the accuracy of clinical signs of dehydration, family physicians need to remember that the dehydration categories are only an estimate.

In assigning patients to a category, physicians should use all of the available clinical and historical information, not just the physical findings.
Table 1 Symptoms associated with
severe
dehydration.

Severe dehydration
Symptom (>9% of body weight)

Mental status Apathetic, lethargic, unconscious
Thirst Drinks poorly; unable to drink
Heart rate Tachypnoea, with bradycardia in most
severe cases.
---------------------------------------------------------
---------------------------------------------
Quality of Pulses Weak, thready, or impalpable
Breathing Deep.
Eyes Deeply sunken.
----------------------------------------------------------
--------------------------------------------
Tears Absent
Mouth & tongue Parched
Skin fold Recoil in > 2 seconds
---------------------------------------------------------
---------------------------------------------
Capillary refill Prolonged; Minimal
Extremeties. Cold; Mottled; Cyanotic
Urine Output. Minimal.
Evaluation of the child with symptoms
of acute gastroenteritis.

LABORATORY ASSESSMENT.

In the past,
a number of laboratory studies were used
to evaluate children with acute vomiting and/or diarrhea.
Evaluation of the child with symptoms
of acute gastroenteritis.

LABORATORY ASSESSMENT.

Because oral rehydration therapy
has become the preferred method of treating dehydration,

routine laboratory testing is no longer necessary,
although it may be helpful in individual patients or
when oral replacement therapy fails.
Evaluation of the child with symptoms
of acute gastroenteritis.

LABORATORY ASSESSMENT.

High urinary specific gravity
may indicate significant dehydration
when combined with a history of decreased urine output.
Evaluation of the child with symptoms
of acute gastroenteritis.

LABORATORY ASSESSMENT.

Serum chemistry measurements such as electrolyte, blood urea nitrogen & creatinine levels do not change the initial management approach in most patients.

Hemodynamically stable children can be safely treated with oral rehydration therapy with only minimal risk of developing significant electrolyte abnormalities.
Evaluation of the child with symptoms
of acute gastroenteritis.

LABORATORY ASSESSMENT.

Laboratory studies should be performed in children who are severely dehydrated and children who are receiving intravenous rehydration therapy.
Evaluation of the child with symptoms
of acute gastroenteritis.

LABORATORY ASSESSMENT.

Serum electrolyte levels should also be obtained in children who show signs of
hypernatremia or hypokalemia (Table 3),
although evidence exists that these conditions,
as well as hyponatremia, may resolve without complications when oral rehydration therapy is used.
TABLE 3

Signs of Hypernatremia and Hypokalemia in Dehydration

HYPERNATREMIA.

1) Cutaneous signs ::--
-Warm, “doughy” texture

Possibly decreased skinfold tenting in severe dehydration, thereby giving appearance of lower level of dehydration

2) Neurologic signs ::--
-Hypertonia
-Hyperreflexia
-Lethargy common, but marked irritability when touched

HYPOKALEMIA.

1) Weakness
2) Ileus with abdominal distention
3) Cardiac arrhythmias.
Evaluation of the child with symptoms
of acute gastroenteritis.

LABORATORY ASSESSMENT.

Studies aimed at pinpointing causative agents are usually only marginally helpful in children with domestically acquired gastroenteritis.

Yet the presence of gross or occult blood in the stool should raise suspicion of such pathogens as ::---

Shigella species,
Campylobacter species &
Hemorrhagic Escherichia coli strains.
Evaluation of the child with symptoms
of acute gastroenteritis.

LABORATORY ASSESSMENT.

Studies aimed at pinpointing causative agents are usually only marginally helpful in children with domestically acquired gastroenteritis.

Large numbers of leukocytes on a fecal smear may also indicate an inflammatory bacterial process.

In the absence of gross blood or leukocytes, costly stool cultures usually have a very low yield &
rarely change clinical management because most noninflammatory diarrheas are self-limited.
Evaluation of the child with symptoms
of acute gastroenteritis.

LABORATORY ASSESSMENT.

Studies aimed at pinpointing causative agents are usually only marginally helpful in children with
domestically acquired gastroenteritis.

Similarly, viral studies, such as rotavirus antigen tests, may confirm the causative agent but do not usually change management.

Giardia antigen studies and smears for ova and parasites are generally not indicated unless the diarrheal illness lasts more than 10 days or a likely exposure history exists
Managing Acute Gastroenteritis Among Children.

Management of Dehydration.

Fluid Management

Oral rehydration therapy has repeatedly been proven
to be as effective as intravenous fluids in treatment
of mild to moderate dehydration both outpatient & inpatient.

Methods of delivery include PER ORAL & NASAL-GASTRIC.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration.

Fluid Management -- Rehydration protocols:

Mild:


50cc/kg of ORS plus replacement over 4 hour
s
**
begin with 5cc aliquots q1-2 min with volumes increasing as tolerated

Moderate:

100cc/kg of ORS plus replacement over 4 hours
As for mild, but should be in supervised setting (A&E, or office)

Severe:

20cc/kg of isotonic IV fluids over one hour
Repeat as necessary
Continue replacement for stools

** ongoing losses can be matched at approximately 10cc/kg for each stool
Managing Acute Gastroenteritis Among Children.

Management of Dehydration.

The management of acute gastroenteritis (AGE)
is directed at preventing or treating
THE DEHYDRATION
that so often accompanies this disease.
Summary of AAP Recommendations for ORT
in Children Based on Estimated Degree of Dehydration.

These recommendations are based on two major conclusions:---

Oral rehydration therapy should be the initial treatment because it is as effective as intravenous therapy in rehydrating and replacing electrolytes in children with mild to moderate dehydration.

An age-appropriate diet should be continued in children with diarrhea who are not dehydrated, &
an age-appropriate diet should be resumed as soon as rehydration is accomplished in children with
mild to moderate dehydration.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration - NO DEHYDRATION.


Some evidence exists showing that complex carbohydrates, lean meats, yogurt, fruits and vegetables are better tolerated than fatty foods or foods with a high simple sugar content (e.g., juices and soft drinks)
Managing Acute Gastroenteritis Among Children.

Management of Dehydration- NO DEHYDRATION.


Children who have diarrhea without vomiting &
who have been determined not to be dehydrated
based on the physical examination
may be safely continued on an age-appropriate diet.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration- NO DEHYDRATION.

As long as signs or symptoms of malabsorption
do not develop during the treatment period,
it is not necessary to withhold specific foods,
including
full-strength milk & other dairy products.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-NO DEHYDRATION.

Adding an oral rehydration solution to
the regular feeding routine provides no extra benefit, although the solution may be accepted
by a child who refuses other foods and fluids.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.

Children with diarrhea and mild to moderate dehydration on clinical evaluation should be treated with one of the commercially available oral rehydration preparations.

The numerous formulations available in the market differ primarily in their sodium content & osmolality.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.
All contain glucose or glucose polymers as their carbohydrate. The World Health Organization oral rehydration formulation, not readily available in the United States, has the highest sodium content as well as the highest osmolality.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.
No evidence exists to show that one formula is superior to another in effecting rehydration.

All of the preparations are equally safe, even in children with known electrolyte abnormalities,
once they are hemodynamically stable.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.
The cost of commercial oral rehydration preparations is often cited as a barrier to their use.

This expense is usually not covered by insurance plans.

However, cost varies widely among brands and preparations and should not preclude the use of these products.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.

The time-honored “clear liquids” most often used by parents or recommended by physicians in the past are not appropriate for use in oral rehydration therapy.

Drinks such as colas, ginger ale, apple juice and even commercial sports drinks (e.g., Gatorade) are inappropriately high in carbohydrates and osmolality.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.

They can cause osmotic worsening of diarrhea, and their low sodium content may contribute to the development of hyponatremia.

Tea should not be used because of its low sodium content, and chicken broth is contraindicated because of its high sodium content.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.

Furthermore,
food should not be arbitrarily withheld
because continued feeding or
the early resumption of feeding improves outcome.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.

Even children who are vomiting can usually be treated with oral rehydration therapy.

When an oral solution is administered by the caregiver in controlled amounts (one or two teaspoons every one to two minutes, with gradual increases in amount as tolerated), the familiar regimen of “frequent small sips” can deliver a volume significant enough to achieve rehydration and maintain hydration in more than 90 percent of children with acute gastroenteritis.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.

As long as ileus has been ruled out, an oral rehydration solution may be given through a nasogastric feeding tube in a child who is hemodynamically stable but unwilling or unable to drink adequately because of continued vomiting.25

Specific recommendations for the amount of oral rehydration solution that should be given and the schedule for its administration are summarized in table above.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.

Occasionally, no caregiver is available to administer the labor-intensive oral rehydration therapy to a child who is moderately to severely dehydrated but hemodynamically stable.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration-MILD TO MODERATE DEHYDRATION
.

In this situation, outpatient rapid intravenous hydration followed by oral rehydration maintenance therapy may be used and may prevent the need for hospitalization.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration - SEVERE DEHYDRATION
.

Intravenous therapy is usually reserved for use in children with severe dehydration, which is marked by the presence of shock or near-shock.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration - SEVERE DEHYDRATION
.

Signs of hemodynamic instability,
including profound lethargy,
markedly delayed capillary refill and tachycardia with severe orthostatic blood pressure changes,
represent a medical emergency and
require immediate and aggressive intravenous therapy to restore intravascular volume.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration - SEVERE DEHYDRATION
.

Normal saline solution or Ringer's lactate should be given in a rapid intravenous bolus of 20 mL per kg.

The patient is then reevaluated and, if needed, the treatment is repeated.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration - SEVERE DEHYDRATION
.

When necessary, an intraosseous line may be used in a child of suitable age (i.e., up to six years old27).
Managing Acute Gastroenteritis Among Children.

Management of Symptoms.
Parents and older patients often request specific medications for the most prominent symptoms of acute gastroenteritis (vomiting and diarrhea).

Although such agents are commonly prescribed, their use remains controversial.

An AAP subcommittee reported a consensus opinion that because of the self-limited nature of the vomiting and its tendency to improve with the correction of dehydration, antiemetic agents are not needed in children with acute gastroenteritis.
Managing Acute Gastroenteritis Among Children.

Management of Dehydration - SEVERE DEHYDRATION
.

If intravenous access cannot be obtained in a timely manner, administration of an oral rehydration solution through a nasogastric tube may also be considered if the child is conscious and ileus has been ruled out.
Managing Acute Gastroenteritis Among Children.

Management of Symptoms.

Physicians were therefore advised to use discretion
in prescribing antiemetic agents
because of the potential for adverse effects,
including ::--
1) allergic reactions,
2) sedation,
3) acute dystonic reactions &
4) other extrapyramidal symptoms.
Managing Acute Gastroenteritis Among Children.

Management of Symptoms.

Antidiarrheal medications include drugs that ::----

1) alter intestinal secretion (bismuth subsalicylate [e.g., Pepto-Bismol]) or
2) intestinal motility (loperamide [Imodium]),
3) adsorbents (kaolin/pectin [e.g., Kaopectate]) &
4) preparations containing “beneficial bacteria” (Lactobacillus [e.g., yogurt]).

These agents are generally not indicated in children with acute gastroenteritis because of lack of convincing evidence that they are effective &
because of concerns that adverse effects may outweigh any benefits.
Managing Acute Gastroenteritis Among Children.

Management of Symptoms.

Diarrhea in children should not be treated with opiate-anticholinergic combinations or opiates other than loperamide because of the high potential for toxic side effects.

Antidiarrheal medications also have the potential to worsen the course of inflammatory bacterial enteritis,
leading to toxic megacolon & colonic hemorrhage.
Managing Acute Gastroenteritis Among Children.

Management of Symptoms. ANTIBIOTICS USE.

The use of antibiotic therapy in children with acute gastroenteritis remains controversial.

Although treatment may shorten the course of some diarrheal illnesses (e.g., Shigella or traveler's diarrhea), most bacterial diarrheas are self-limited and will be resolving before the causative organism is identified.

Empiric therapy should be directed at the organism thought most likely to be involved.
Managing Acute Gastroenteritis Among Children.

Management of Symptoms.

For some bacteria, such as noninvasive Salmonella species, treatment may prolong the carrier period
after the symptoms have resolved.
Managing Acute Gastroenteritis Among Children.

Management of Symptoms.

For others, such as Campylobacter jejuni and Yersinia enterocolitica, the efficacy of antibiotics in hastening recovery is doubtful.
Managing Acute Gastroenteritis Among Children.

Management of Symptoms.

Empiric antibiotic therapy may even lead to the development of Clostridium difficile–associated enterocolitis and a worsening of symptoms.
Final Comment.

The development of safe,
effective oral rehydration solutions
as an alternative to home remedies of doubtful benefit or the use of intravenous regimens
has dramatically changed the management of acute gastroenteritis in young children.

Final Comment.

Nonetheless, oral rehydration therapy is still underutilized in the developed world.

Family physicians have the opportunity to change this situation by becoming familiar with the guidelines for oral rehydration therapy and instructing their patients in its appropriate use.

Final Comment.

With patient education, the reduction of medication use &
the application of oral rehydration therapy in their clinical practices, family physicians can reduce outpatient morbidity &
lessen the inconvenience &
costs associated with emergency department &
inpatient treatment of acute gastroenteritis.
THE NEW ORS SOLUTION
IS CALLED
reduced (LOW)
osmolarity ORS solution.
THE NEW ORS SOLUTION


also reduces
the incidence of
a). vomiting by 30%
&
b). stool volume by 20%.
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