Gastroenteritis in Children

1. Gastroenteritis in Children Presented by: pourmirzaei (MD)

2. UpToDate References:

3. THE TYPES OF DIARRHEA IN CHILDREN: • ACUTE DIARRHEA : less than 14 days. • (PROLONGED DIARRHEA : 7 – 13 days.) • PERSISTENT DIARRHEA : lasts 14 days or more. • DYSENTERY : diarrhea with blood in the stool.

4. EPIDEMIOLOGY • 10% of childhood deaths. • 700 000 deaths per year . • Almost 1.7 billion episodes of diarrhea in children younger than 5 yr of age . • More than 80% of the episodes occurring in Africa and South Asia .

5. ETIOLOGY • Gastroenteritis is the result of infection acquired through the fecal–oral route or by ingestion of contaminated food or water . • Gastroenteritis is associated with poverty, poor environmental hygiene, and development indices.

6. In the United States, rotavirus and the noroviruses (such as Norwalk-like) are the most common viral agents, followed by sapoviruses, enteric adenoviruses. • Bacterial causes, which are most commonly Salmonella, Clostridium perfringens, Campylobacter, and Staphylococcus aureus, followed much less often by E. coli, Clostridium botulinum, Shigella, Cryptosporidium, Yersinia, Listeria, Vibrio, and Cyclosporaspecies .

7. RISK FACTORS FOR GASTROENTERITIS • Exposure to enteropathogens • Immune deficiency, measles, malnutrition • Lack of exclusive or predominant breast-feeding • Young age, • Vitamin A deficiency • Zinc deficiency

8. Mechanisms of Diarrhea • Osmotic Defect present: Digestive enzyme deficiencies Ingestion of unabsorbable solute Examples: Viral infection Lactase deficiency Sorbitol/magnesium sulfate Infections Comments: Stop with fasting No stool WBCs

9. Mechanisms of Diarrhea • Secretory: Defect: Increased secretion Decreased absorption Examples: Cholera Toxinogenic E.coli Comments: Persists during fasting No stool leukocytes

11. Mechanisms of Diarrhea • Exudative Diarrhea: Defects: Inflammation Decreased colonic reabsorption Increased motility Examples: Bacterial enteritis Comments: Blood, mucus and WBCs in stool

14. Usually cause explosive, watery diarrhoea • Typically last only 48-72hrs • Usually no blood and pus in stool Rotavirus Common Causes of Acute Diarrhoea • Infection – highly contagious • Viral gastroenteritis

15. E. Coli bacteria • Contaminated food or water • Usually affect small kids • Bacterial enterocolitis • Sign of inflammation – blood or pus in stool, fever

16. Salmonella enteritidis bact • In contaminated raw or undercooked chicken and eggs • Bacterial enterocolitis • Sign of inflammation – blood or pus in stool, fever

17. Shigella bacteria Campylobacter bacteria • Bacterial enterocolitis • Sign of inflammation – blood or pus in stool, fever

18. Cryptosporidium • in contaminated water – can survive chlorination • Giardia lamblia • in contaminated water • Usually not associated with inflammation • Parasites

19. Food Poisoning • Staphylococcus aureus • Produces toxins in food before it is eaten • Usually food contaminated left unrefrigerated overnight

20. Food Poisoning • Clostridium perfringens • Multiplies in food • Produces toxins after contaminated food is eaten

21. CLINICAL MANIFESTATION • Most of the clinical manifestations of diarrhea are related to the infecting pathogen. • Additional manifestations depend on the development of complications (e.g., dehydration and electrolyte imbalance)

23. Degree of Dehydration

24. Types of dehydration

25. HOW WILL YOU ASSESS DEHYDRATION? • 1- LOOK AT THE CHILD’S GENERAL CONDITION • lethargic or unconscious. restless and irritable • 2- LOOK FOR SUNKEN EYES • 3- LOOK: TO SEE HOW THE CHILD DRINKS • not able to drink ,drinking poorly. drinkingeagerly and acts thirsty • 4- PINCHING THE SKIN OF THE ABDOMEN

28. HOW DO YOU CLASSIFY DEHYDRATION? • 1. SEVERE DEHYDRATION • 2. SOME DEHYDRATION • 3. NO DEHYDRATION

34. Complications of Diarrhea • Dehydration • Metabolic Acidosis • Gastrointestinal complications • Nutritional complications

35. STOOL EXAMINATION Fecal leukocytes are indicative of bacterial invasion of colonic mucosa, although some Patients with shigellosis have minimal leukocytes at an early stage of infection , as do patients infected with Shiga toxin-producing E. coli and E. histolytica

36. XTAG GPP • An FDA-approved gastrointestinal pathogen panel using multiplexed nucleic acid technology that detects Campylobacter, C. difficile, E. coli 0157, enterotoxigenic E. coli, Salmonella, Shigella, Shiga-like toxin E. coli, norovirus, rotavirus , Giardia, and Cryptosporidium.

37. Stool culture In children with bloody diarrhea in whom stool microscopy indicates fecal leukocytes; in outbreaks with suspected hemolytic-uremic syndrome (HUS); and in immunosuppressed children with diarrhea.

38. Important comment • In most previously healthy children with uncomplicated watery diarrhea, no laboratory evaluation is needed except for epidemiologic purposes.

39. Management • Non-specific • Oral Rehydration Solution (ORS): • Effective in all types & all degrees of dehydration. • Can prevent dehydration if given early in the disease. • Cheap, easy to administer; can be given by mother at home. • No chance of overhydration or electrolyte overdose. • Methods of administration: spoon, cup, dropper, syringe, naso-gastric tube .

40. Types of ORS New WHO (ORS) containing 75 mEq of sodium, 64 mEq of chloride, 20 mEq of potassium, and 75 mmol of glucose per liter, with total osmolarity of 245 mOsm/L

41. HOW WILL YOU TEACH THE CAREGIVER TO GIVE ORS IN THE CLINIC? • 1. DETERMINE AMOUNT of ORS to give during first 4 hours. • 2. SHOW THE MOTHER HOW TO GIVE ORS SOLUTION. • Tell her how much • Show her the amount in units • Sit with her while she gives the child the first few sips from a cup or spoon. Ask her if she has any questions.

45. Risks that might necessitate IV Therapy • age <6 mo • Prematurity • chronic illness • fever >38°C if younger than 3 mo • fever >39°C if 3-36 mo of age • bloody diarrhea • persistent emesis; poor urine output • sunken eyes • depressed level of consciousness.

46. Antimotility drugs • Opiate receptor agonists, such as loperamide and diphenoxylate-atropine combinations, reduce intestinal luminal motility. • These drugs have significant side effects, including lethargy, paralytic ileus, toxic megacolon, central nervous system depression, coma, and even death . • In addition, because they delay transit time, they prolong the course of bacterial diarrheas, such as Shigella and Escherichia coli

47. Indications for hospitalization ●Shock ●Severe volume depletion ●Moderate volume depletion with refusal of oral fluids ●Clinical deterioration ●Neurologic abnormalities (eg, lethargy, seizures) ●Intractable or bilious vomiting ●Failure of oral rehydration ●Possibility of severe illness or condition other than acute gastroenteritis that requires specific therapy

48. ENTERAL FEEDING AND DIET SELECTION • Breast-feeding or non diluted regular formula should be resumed as soon as possible . • Fatty foods or foods high in simple sugars (juices, carbonated sodas) should be avoided. • An energy intake of a minimum of 100 kcal/kg/day and a protein intake of between 2 and 3 g/kg/day. . .

49. Although children with persistent diarrhea are not lactose intolerant, administration of a lactose load exceeding 5 g/kg/day may be associated with higher purging rates and treatment failure. Alternative strategies for reducing the lactose load while feeding malnourished children who have prolonged diarrhea include addition of milk to cereals and replacement of milk with fermented milk products such as yogurt.

50. For persistent diarrhea • In addition to rice-lentil formulations, the addition of green banana or pectin to the diet has also been shown to be effective in the treatment of persistent diarrhea.