2. ACUTE GASTROENTERITIS
• Acute gastroenteritis (AGE) is a leading cause of childhood morbidity and
mortality and an important cause of malnutrition.
• Cause dehydration and electrolytes loss -> may lead to death.
• Oral rehydration salts (ORS) is mainstay of treatment to treat dehydration
• However severe dehydration need intravenous fluid therapy.
3. DEFINITION
• Diarrhea: Defined as passage 3 or more loose or liquid stool per day OR
• More frequent passage than normal for the individual
• Acute Diarrhea: Typically < 7 days and not more than 14 days
• Chronic Diarrhea: > 14 days
4. CASE ILLUSTRATION 1
• 4 years old girl, NKMI, NKDFA
• Previous weight 18kg
• Vomiting diarrhea x 2/7
• Vomit >7x/day, loose stool >10x/day (Bristol 7)
• Reduce oral intake due to vomiting
• No history of outside food/sick contact
5. • Currently weighing 16.5kg
• Lethargic looking, sunken eyes, capillary refill time <2sec, pulse volume
rapid, still able to answer to questions, crying without tears, not
tachypneic, lips dry, tongue coated.
• Throat: mildly injected, tonsils grade 1, no exudate
• BP: 90/52, HR: 120bpm, RR: 20/min, Temp: 37, Spo2: 100% room air, DXT:
5.2mmol/L
• Lungs: clear, CVS: DRNM, Abdomen: soft, not distended, non tender
6. • Initial diagnosis from ETD – Acute gastroenteritis
• How do we decide the severity of the dehydration?
• What is the fluid regime we would like to start?
• How do we calculate?
• What fluids should we start with?
7. FLUID MANAGEMENT
WHO CHART
• The fluid management: Plan A, Plan B and Plan C according
to severity of dehydration
• Clinical assessment of hydration status and to look for any
sign of shock
• ORS is the mainstay of treatment for dehydration.
8.
9.
10.
11. PLAN A – NO DEHYDRATION
• Rule 1: Give Extra Fluids
• Breast feed more frequently
• Give additional ORS / water
• More food based fluids – soup / rice water
• Rule 2: Continue to feed the child
• Avoid good high in simple sugar as osmotic load may worsen the diarrhea
• Rule 3: Return to clinic or Hospital when:
• More GI Losses / Unable to tolerate orally / Become very thirsty
12. PLAN B – SOME DEHYDRATION
• Treat with ORS (can be done in ETD / ward)
• 75mls / kg over 4H and reassess
• Set goals for mother in each hour
• Frequent small sips
• If child vomits, wait for 10 minutes and continue but more slowly
• Reassess after 6H of rehydration, if improved then can go home with Plan
A
13. PLAN C – SEVERE DEHYDRATION
• Stabilization – A/B/C
• Start IVD immediately with +- Bolus 20mls/kg Isontonic 0.9% Normal
Saline
• Fluid deficit correction over 24-72H depending of Sodium Level
• Maintenance fluids – Holliday Segar Formula
14.
15. WHEN WE SHOULD START INTRAVENOUS
FLUIDS???
• Unconsious child
• Failed ORS treatments due to continuing rapid stool loss
• Failed ORS treatment due to frequent, severe vomiting and poor drinking
• Abdominal distention with paralytic ileus (secondary to anti-diarrheal
medications i.e. Loperamide or Hypokalemia)
16.
17. MAINTENANCE FLUIDS
• Children required higher maintenance fluids than adult:
• Higher metabolic rate that required greater caloric expenditure
• Higher body surface area to weight ratio (more water loss from skin)
• Higher respiratory rate (Especially Infant)
• Children required Dextrose Saline due to:
• Higher Metabolic rate
• Dextrose generally does not substantially affect tonicity as it is rapidly metabolized by insulin upon
entering into intravascular space unless diabetes exists.
• Solutions with a 1 to 1 glucose to sodium ratio (75 mEq/L according to WHO recommendations)
work with physiological glucose and sodium transporters to increase intestinal mucosa absorption.
22. ORAL REHYDRATION SALT
• ORS consists of 4 constituents:
• Sodium chloride - 3.5 grams
• Trisodium citrate dihydrate - 2.9 grams
• Potassium chloride - 1.5 grams
• Glucose - 20 grams
• ORS efficacy affected by ability of glucose to stimulate Na and fluid
absorption in the small intestine via a cyclic AMP-independent process
23.
24. CASE ILLUSTRATION 1
• 4 years old girl, NKMI, NKDFA
• Previous weight 18kg
• Vomiting diarrhea x 2/7
• Vomit >7x/day, loose stool >10x/day (Bristol 7)
• Reduce oral intake due to vomiting
• No history of outside food/sick contact
25. HOW DO WE DECIDE THE SEVERITY OF
THE DEHYDRATION?
• Previous weight 18kg
• Current weight 16.5kg
• Loss – 8.3% (Moderate)
26. WHAT IS THE FLUID REGIME WE WOULD
LIKE TO START?
• Fluid correction – 7.5%
• 7.5/100 x weight (g) = Fluid deficit(ml)
• Fluid deficit ÷ 24hr = Infusion/hr
• Fluid maintenance
• 100ml/kg x first 10kg
• 50ml/kg x next 10kg
• 20mls/kg for subsequent weight
• ORS 10ml/kg
27. WHAT FLUIDS SHOULD WE START WITH?
• For fluid correction
• Normal saline 0.9%
• Hartmann’s Solution
• For fluid maintenance
• Normal saline 0.9% in Dextrose 5%
• Orally
• ORS
28. CASE ILLUSTRATION 2
• 8 years old boy, underlying bronchial asthma, allergic to peanut
• Previous weight 27kg
• Presented with sudden onset vomiting for the past 4 days.
• Vomit post prandial up to 4x/day (non bilious, food and fluids)
• No loose stool, good oral intake, active as usual, no sick contact, no fever, no
URTI symptoms, no abdominal pain.
29. • Currently weighting 26.7kg
• Active looking, pink, no sunken eyes, crt <2sec, good pulse volume, good
hydration, GCS full
• BP: 100/60, HR: 100/min, RR: 20/min, Temp: 36.8, Spo2: 100%, DXT: 4.8
• Lungs: clear, CVS: DRNM, Abdomen: soft not distended, non tender
• Throat: Mildly injected, tonsils grade 2, no exudate.
• Initial diagnosis from ETD – 1. Acute gastroenteritis, 2. Acute tonsilitis
30. WHAT IS THE FLUID MANAGEMENT
1. Should we start IV fluids?
2. Should we admit patient?
3. What fluid regime should we use for this patient?
31. 1. There is no justification to start IV fluids regime
2. Clinically patient is well and good oral intake, no indication for
admission
3. Plan A is the most appropriate fluid management
1. Discharge with adequate ORS
2. Encourage orally as tolerated
3. Seek medical attention when not improving or worsening
32. REFERENCES
• The Malaysian Paediatric Association. (2019). Paediatric Protocols for Malaysian Hospitals, 4th Edition, 2019
[Updated] - The Malaysian Paediatric Association. Available at: https://mpaeds.my/paediatric-protocols-
for-malaysian-hospitals-4th-edition-2019/.
• Clinical Practice Guidelines : Intravenous fluids. (n.d.).
https://www.rch.org.au/clinicalguide/guideline_index/intravenous_fluids/
• Clinical Practice Guidelines : Gastroenteritis. (n.d.).
https://www.rch.org.au/clinicalguide/guideline_index/gastroenteritis/
• team, A. (2018) Treatment plan A - management of patients with no signs of dehydration (who
recommendations), GPnotebook. https://gpnotebook.com/pages/gastroenterology/who-(world-
health-organisation)-suggested-management-of-dehydration-secondary-to-diarrhoeal-
illness/treatment-plan-a-management-of-patients-with-no-signs-of-dehydration-(who-
recommendations)
5th Leading cause of mortality under 5 worldwide
2016, estimated 450,000 child under 5 death due to acute diarrhea
Also causes significant morbidity such as undernutrition and growth faltering
However, it is important to realize that frequent passing of formed stools is not diarrhea
Passing of loose, pasty stools in breastfed baby also not diarrhea
Aetiology of acute and chronic diarrhea may differ. Chronic diarrhea can divided into osmotic and secretory diarrhea and need to approach differently
Best measurement to assess the degree of dehydration is to document the % of body weight lost
Lethargy Vs Sleepy: Lethargy means mental state is dull and child cannot be fully awakened
Sunken eye: Some child is typically sunken, it is helpful to ask the mother if the child eye are normal or more sunken than usual OR can compare to recent photo
Assessment of degree of dehydration by physical examination is imprecise; repeated assessment is often necessary
Similary, assessment of degree of dehydration by blood ix are not precise as well
Paediatric Protocol had similar classification
However the term used is different compare to WHO
Mild Dehydration Vs No Dehydration
Moderate Dehydration Vs Some Dehydration
Management are same
HS Formula Developed in 1957 by Drs. Malcolm A. Holliday and William E. Segar while at the Indiana University School of Medicine, the researchers concluded a non-linear relationship between energy expenditure and weight alone to determine fluid requirements.
Primarily aimed at pediatric patients, the Holliday-Segar formula is the most commonly used estimate of daily caloric requirements.[2] To date, the formula continues to be recommended in the current clinical practice guidelines of the American Academy of Pediatrics, American Society of Parenteral and Enteral Nutrition, and National Health Service.[3][4][5]
Trisodium Citrate – Correct acidosis
Study show that ORS-citrate is as successful as that with ORS-bicarbonate in terms of its ability to rehydrate, correct the acidosis, and maintain electrolyte concentrations. Thus, trisodium citrate dihydrate, which has the a advantage of a longer shelf-life in hot and humid climates, can effectively replace sodium bicarbonate in the standard ORS solution
