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IN CHILDREN
Epidemiology of acute diarrhea:
developed versus developing
countries.
Per year Estimated Hospitalizatio Deaths
episodes of ns
acute
diarrhea
Bacteremia - osteomyelitis
- meningitis
- endocarditis
Common pathogens
Campylobacter
Salmonella
Shigella
Yersinia
Pathogenic E.coli
Parasitic agents
Giardia intestinalis, Cryptosporidium
parvum, Entamoeba histolytica, and
Cyclospora cayetanensis most commonly
cause acute diarrheal illness in children.
These agents account for a relatively small
proportion of cases of infectious diarrheal
illnesses among children in developing
countries.
Clinical evaluation
The initial clinical evaluation of the
patient should focus on:
Assessing the severity of the illness
and the need for rehydration
Identifying likely causes on the
basis of the history and clinical
findings
ONSET
Approach to Peds Dehydration
1) Initial Resuscitation
2) Determine % dehydration
3) Define the type of dehydration
4) Determine the type and rate of
rehydration fluids
Degree of Dehydration
Blood pressure N N
hypotensive
Urine
Theoutput N to down
best 3 individual examination signs are: down minimal
Prolonged Cap refill time
Abnormal Skin turgor
Abnormal resp pattern
Three major classes of dehydration
based on relative losses of Na and
Water
Acidosis
CBC
Inflamatory tests
Stool analysis of leucocytes
Stool cultures
Measurement of serum electrolytes is only required in
children with severe dehydration or with moderate
dehydration (hypernatremic dehydration requires specific
rehydration methods irritability and a doughy feel to
the skin are typical manifestations and should be sought
specifically)
Tests such as BUN and bicarbonate are only helpful when
results are markedly abnormal
A normal bicarbonate concentration reduces the
likelihood of dehydration
No lab test should be considered definitive for
dehydration
DIFFERENTIAL DG
DIFFERENTIAL DG
Meningitis
Bacterial sepsis
Pneumonia
Otitis media
Urinary tract infection
Prevention
Safe food:
Cooking eliminates most pathogens from foods
Exclusive breastfeeding for infants
Weaning foods are vehicles of enteric infection
WHO
formulatio
n 330 110 90 80 30 20
Pedialyte 270 140 45 35 30 20
AJ 730 690 5 x x 32
Sports
drink 330 255 20 x 3 3
D5W /
0.45%
saline 454 300 77 77 0 0
ORT
Oral rehydration therapy
Appropriate for mild to moderate dehydration
Safer
Less costly
Administered in various clinical settings
Fluid replacement should be over
3-4hrs
50ml/kg for mild dehydration
100ml/kg for moderate dehydration
10ml/kg for each episode of vomiting or
watery diarrhea
Minimal or no dehydration.
Mild to moderate
dehydration
ORT
Contraindications to ORT
Severe dehydration (10%)
Ileus or intestinal obstruction
Unable to tolerate (Persistent vomiting)
Signs of shock
Decreased LOC (Level of consciousness) or
unconscious
Unclear diagnosis
Psychosocial situations
Severe dehydration.
Resuscitation
Emergency resuscitation phase
+
Maintenance fluids
Calculation :
100ml/kg first 10 kg
50ml/kg next 10kg
25ml/kg for each kg above 20kg
Hyponatremia
Treat if Na < 125
Calculate Na deficit = (Desired Na Measured Na) x 0.6 x kg
Safe rate of change = 12mmol/L rise / day
Hypernatremia
pure free water deficit
Calculate [(Na 145) /2]x [4ml/kg] x wt (kg)
Safe rate of change = 12mmol/L decline/day
Severe Dehydration
Management of severe dehydration
requires IV fluids
Fluid selection and rate should be
dictated by
The type of dehydration
The serum Na
Clinical findings
Aggressive IV NS bolus remains the
mainstay of early intervention in all
subtypes
Isonatremic Dehydration
Calculate the fluid deficit
Deficit (ccs) = % dehydration x body wt
D5NS is fluid of choice
( deficit the bolus) over the first 8hrs
Add maintenance and any ongoing losses to
above
Further the deficit replaced over the next 16hrs
Monitor electrolytes and U/O
Hypernatremic Dehydration
Fluid deficit =
(Current Na/Desired Na 1) x 0.6 x body wt
Replace with D50.2%NS
Replace over 48hrs
Reduce sodium by no more than 10mEq/L/24hrs
( deficit the bolus) over the first 24hrs
Add maintenance and any ongoing losses to
above
Further the deficit replaced over the next 24hrs
Hyponatremic dehydration
Na deficit =
(Nadesired- Nacurrent) x 0.6 x Weight (kg)
Divide above by Na in mEq/L within
the replacement fluid
154 mEq in NS
77 mEq in D5 NS
513 in 3% saline
divide by deficit x 2 to determine
rate at 0.5mEq/L/hr
Hyponatremic Dehydration
If seizing
Correct with 3% Saline bolus
Target a Na of 120
Further correction beyond this with D5 NS
If not Seizing
Correct with D5 NS
Target a Na of 130
Watch for Central Pontine Myelinolysis
More likely in chronic hypo-Na with less Sx
Correct slowly at rate of 0.5mEq/L/hr
Alternative antimicrobials for treating
cholera in children are TMP-SMX (5
mg/kg TMP + 25 mg/kg SMX, b.i.d.
for 3 days), furazolidone (1.25
mg/kg, q.i.d. for 3 days), and
norfloxacin.
CAMPYLOBACTER