Download Management - Emory University Department of Pediatrics

Management of Acute
Gastroenteritis
(Oral Rehydration and
Nutritional Therapy)
Ricardo R. Jiménez, MD, FAAP
Pediatric Emergency Medicine
All Children’s Hospital
Objectives
 Dehydration assessment and diagnosis
 Oral Rehydration Therapy and Oral solutions
options
 Management of AGE at home and in the ED
 Dietary Therapy
 Pharmacological Therapy
2
Acute Gastroenteritis
 Acute Gastroenteritis (AGE) remains a major cause
of morbidity and mortality in the USA
• Over 1.5 million outpatient visits
• 200,000 hospitalizations
• 300 death a year
 Worldwide diarrheal disease is the leading cause of
morbidity and mortality
• 1.5-2.5 million deaths annually among children
younger than 5
3
Acute Gastroenteritis
 Direct medical cost in the US reach $ 250
million/year and is estimated to reach 1 billion
worldwide
 Even though the number of death associated to
AGE worldwide is still high, a decrease has been
noticed since the start of Oral Rehydration Therapy
(ORT) campaigns
4
Oral Rehydration Therapy
 ORT includes two phases:
• Rehydration Phase
 Water and electrolytes are provided via an oral
rehydration solutions (ORS) replacing existing
losses
• Maintenance Phase
 Replacement of ongoing fluid and electrolyte
losses and adequate dietary intake
5
Oral Rehydration Therapy
 The full benefits of ORT have not been realized in
developing countries
 One of the reasons for the low use of ORT is the
ingrained use of IV therapy
 The vast majority of pediatricians (30-49%) report
always using IVF to treat moderate dehydration and
1/3 report using IVF to treat mild dehydration
6
Oral Rehydration Therapy
 Randomized trials of ORT vs. IV hydration have
demonstrated
• Shorter ED stays
• Greater parental satisfactions
• As effective as IV in moderately dehydrated
children < 3 years
• Faster initiation of rehydration
• Lower hospitalization rate
7
Oral Rehydration Therapy
 Barriers for ORT
• Lack of parental knowledge
• Lack of training of medical professionals
• Cost of commercially available ORS
• Preferences among physicians
• The practice of continued feeding during
diarrheal disease have been hard to establish
8
Physiologic Basis of ORT
 The stool output in the adult is < 250ml/day, this
amount varies by age in children
 During diarrheal disease the intestinal output
increases greatly, overwhelming its reabsorptive
capacity
 Multiple studies done among cholera patient
demonstrated an intact Na-couple solute cotransport mechanism allowing efficient salt and
water reabsorption
9
Physiologic Basis of ORT
 This co-transport remains intact even in infections
of E. coli, salmonella, shigella and rotavirus
 The mechanism essential for the efficacy of oral
rehydration solution (ORS) is the couple transport
of sodium and glucose in the intestinal brush border
10
Physiologic Basis of ORT
 Water passively
follows the osmotic
gradient
 SGLT1- sodium
glucose cotransporter which
moves Na and
glucose from the
luminal membrane
into the enterocyte
11
Physiologic Basis of ORT
 GLUT2- glucose
transporter, moves
the glucose in the
enterocyte into the
blood
 Na+ K+ ATPase
provides the
gradient that drives
the process
12
Physiologic Basis of ORT
13
Physiologic Basis of ORT
 Solutions with high concentration of the cotransporters decrease the water sodium transport
into the bloodstream
 Rehydration solutions with low osmolarity and 1:1
ration glucose to sodium perform optimally
14
Choices of ORS
 In 1975 the WHO and UNICEF decided to promote
a single ORS (WHO-ORS)
• It contained (mmol/L) Na 90, K 20, CL 80, base
30 and Glu 111 with an Osm of 311
• This composition allowed for a single solution to
be use for treatment of diarrhea caused by a
multitude of agents
• Has been proven to be effective and safe for
over 25 year
15
Choices of ORS
 New multiple controlled trials has supported the
adoption of a lower osmolarity solution
 Lower osmolarity as been associated to less stool
output, less vomiting and reduced need of IV
among infants and children with non-cholera
diarrhea
16
Choices of ORS
 In 2002 the WHO announced a new ORS
formulation with a lower osmolarity
• 2002 WHO-ORS contains 75mEq/L of Na, 75
mmol/L of Glu and an Osm of 245
17
Choices of ORS
18
Solution
Carbs
(gm/L)
Sodium
(mmol/L
Potassium
(mmol/L)
Chloride
(mmol/L
Base
(mmol/L)
Osmolarity
(mOsm/L)
WHO-ORS
(2002)
13.5
75
30
65
30
245
WHO-ORS
(1975)
20
90
20
80
30
311
Pedialyte
25
45
20
35
30
250
Enfalyte
30
50
25
45
34
200
Rehydralyte
25
75
20
65
30
305
CeraLyte
40
50-90
20
N/A
30
220
Gatorade
14
110
30
Apple Juice
120
0.4
44
45
N/A
730
Coca-Cola
112
1.6
N/A
N/A
13.4
650
290-303
Management
 Home Management
• Treatment with ORS is simple and enable
management of uncomplicated cases at home
• The caregiver must be instructed properly on the
signs of dehydration and is able to determine if
the child is responding or not to ORS
• Early administration of ORS leads to
 Fever office and emergency department visits
 Fever hospitalization and death
19
Management
 Home Management
• Caregivers should be encourage to start ORT
with commercially available ORS as soon as
diarrhea or vomiting commence
• The most important aspect of the home
management is to replace fluid losses and
maintain the nutritional intake
• Regardless of the fluid use an age-appropriate
diet should be continued, including breast
feeding
20
Management
 Home Management
• Severity Assessment
 Caregivers should be trained to recognize
signs of illness or ORT failure and to seek
medical assistant
 No guidelines have established a specific age
under which medical evaluation is imperative,
but the younger the child the lower the
threshold
21
Management
Recommendations for medical evaluation of children with
diarrheal illness
•Young age (< 6 months or < 8 kg)
•History of premature birth, chronic medical conditions or concurrent
illness
•Fever > 38°C for infants < 3 months or > 39°C aged 3-36 months
•Blood in stool or diarrhea lasting more than 2 wks
•High output diarrhea, including frequency and volume
•Caregiver’s report of signs consistent with dehydration
•Change in mental status
•Persistent vomiting
•Suboptimal response to ORT or inability of caregiver to provide ORT
22
Management
 Dehydration Assessment
• The goal is to provide a starting point and determine
intensity of therapy
• Clinical signs and symptoms that can quantify
dehydration
 Sunken anterior fontanel it can be unreliable or
misleading
 Decreased BP is a late finding and it heralds
shock, corresponds to >10% of fluids losses
 Tachycardia and decrease capillary refill are more
sensitive
 Decrease urine output is sensitive but nonspecific
 Increase of urine specific gravity can indicate
dehydration
23
Management
 Dehydration Assessment
• Prior guidelines, CDC’s 1992 and AAP’s 1996
grouped patient in 3 subgroups
 Mild dehydration (3%-5% fluid deficit)
 Moderate dehydration (6%-9% fluid deficit)
 Severe Dehydration ( >10% fluid deficit)
24
Management
 Dehydration Assessment
• New studies that evaluate the correlation of
clinical signs of dehydration and post treatment
weight gain indicate that
• First signs of dehydration might not be evident
until 3%-4% fluid loss
• Clinical signs more evident at 5% dehydration
• Severe dehydration signs not seen until 9%-10%
dehydration
25
Management
 Dehydration Assessment
• Distinguishing between mild or moderate
dehydration on the basis of clinical signs may be
difficult
• The new updated recommendations group
together patients with mild and moderate
dehydration and specify that signs of dehydration
may be apparent a wide range of fluid losses
(3%-9%)
26
Management
Symptom
27
Minimal or no
Dehydration (<3%)
Mild to Moderate
(3%-9%)
Severe
(>9%)
Mental Status
Alert
Normal, restless, irritable
Lethargic, unconscious
Thirst
Normal PO or refuses
Thirsty
Drinks poorly or unable
Heart Rate
Normal
Normal to increased
Tachycardia
Quality of pulses
Normal
Normal to decreased
Weak or impalpable
Breathing
Normal
Normal to fast
Deep
Eyes
Normal
Slightly sunken
Deeply sunken
Tears
Present
Decreased
Absent
Oral mucosa
Moist
Dry
Parched
Skin fold
Instant recoil
Recoil in < 2 sec
Recoil > 2sec
Capillary refill
Normal
Prolonged
Prolonged; minimal
Extremities
Warm
Cool
Cool, mottled, cyanotic
Urine output
Normal to decrease
Decreased
Minimal
Management
 Utility of Laboratory Evaluation
• Supplementary labs, including serum electrolytes
are unnecessary
• Stool cultures are only indicated with bloody
diarrhea
28
Management
 ED management
• Treatment should include two phases
 Rehydration – fluid is replaced rapidly, over 34 hr
 Maintenance – calories and fluids are
administered
– Rapid realimentation, the patient should continue an
age-appropriate diet as tolerated
– Breastfeeding should continue
– Lactose restriction is usually not necessary
29
Management
Basic guidelines for the management of dehydration
30
•
ORS should be use for rehydration
•
Oral rehydration should be performed within 3-4 hr
•
Rapid realimentation, an age-appropriate unrestricted diet is
recommended as soon as dehydration is corrected. Gut rest is not
indicated
•
In breastfeed infants, nursing should continue
•
Diluted formula or special formulas are not indicated
•
Additional ORS can be administer for ongoing losses
•
No unnecessary labs or medications (i.e. antidiarrheals)
Management
 ED management
• Minimal Dehydration
 Provide adequate fluid and age appropriate
diet
 ORS should be encourage
 Fluid intake should be increased to
compensate for emesis or diarrhea
– 10 ml/kg of additional fluid per every diarrhea or 2
ml/kg per every emesis
– As an alternative in children < 10 kg provide 2-4 oz
of ORS per diarrhea or emesis and 4-8 oz in children
> 10 kg
31
Management
 ED Management
• Mild to Moderate Dehydration
 The fluid losses should be estimated and
rapidly replaced
 Administer 50-100 ml of ORS/kg during 2-4 hr
 Additional ORS should be administer for
ongoing losses
 Smaller volumes should be offered first and
increase as tolerated using (i.e. 5 ml)
 More may be offered if the child wants more,
but larger amounts have been associated with
vomiting
32
Management
 ED Management
• Mild to Moderate Dehydration
 Clinical trials support the use NG feeding for
those patients with persistent vomiting
 When compared to IV, NG feedings were
found to be more cost effective and associated
with fewer complications
 Hydration status should be assess on a
regular basis
 Those children who do not improved with ORT
or with high output should be held for
observation
33
Management
 ED Management
• Mild to Moderate Dehydration
 Once dehydration is corrected further
management can be implemented at home as
long as the caregivers
–
–
–
–
34
Have demonstrated comprehension of ORT
Understand indications to seek medical attention
Have means to seek medical attention
Have agreed to follow up with their primary care
physician
Management
 ED Management
• Mild to Moderate Dehydration
 A new study demonstrated an increase ORT
failure among mild-moderate dehydrated
children associated with large ketones in the
urine and mental status changes
 Also children with tachycardia at discharge or
with history of severe vomiting are more likely
to require a second visit to the ED
35
Management
 ED Management
• Severe Dehydration
 Constitutes a medical emergency and requires
immediate IV rehydration
 20 ml/kg of Lactated Ringers or Normal Saline
should be administered until pulse, perfusion
and mental status returns to normal
 Electrolytes, BUN, Cr and glucose should be
obtained
 Vitals should be assess on a regular basis
36
Management
37
 ED Management
• Severe Dehydration
 Multiple administrations of fluid in a short
amount of time may be necessary
 Severe edema is rare as long as appropriate
weight based amounts are provided with close
observation
 With frail or severely malnourish infants
smaller amounts (10ml/kg) are recommend
because of their reduced ability of increasing
the cardiac output
 No response to IV hydration should raise
suspicion for septic shock, metabolic, cardiac
or neurologic disorders
Management
 ED Management
• Severe Dehydration
 As soon as the signs of severe dehydration
have resolved the patient may be started on
ORT
 Early institution of ORT will encourage earlier
resumption of feeding
 Some studies have shown more rapid
resolution of acidosis with ORT than IV
38
Limits of ORT
 In children with abdominal ileus or signs of
intestinal obstruction ORT should be held until
surgical evaluation
 1% of infants will have carbohydrate malabsorption,
were diarrhea may be worsen by ORS or solutions
with simple sugars
39
Dietary Therapy
 Withholding food for 24 hr is unnecessary
 Once rehydration is achieved patient should
continue with their age-appropriate diets
 Lactose-free or lactose-reduced formulas are not
necessary, except in children with severe
malnutrition
 Low ph or reducing substances in the stool without
symptoms is not indicative of lactose intolerance
40
Dietary Therapy
 Clinical trials have indicated that the use of diluted
formulas is associated with prolongation of
symptoms and delayed nutritional recovery
 Soy formulas have been marketed to reduce
diarrhea, but the added soy reduce the liquid stools
without changing the actual output volume
41
Dietary Therapy
 Children receiving a solid or semisolid diet should
continue their usual diet
 Avoid foods with high simple sugars, which may
cause osmotic diarrhea
 BRAT diets are unnecessary restrictive and provide
suboptimal nutrition
42
Dietary Therapy
 Functional Foods
• Foods that have an effect on physiologic
processes separate from their nutritional function
• Probiotics are live microorganisms in fermented
foods promote improved balance in intestinal
microflora
 Most common species studied included
Lactobacilli and nonpathogenic
Saccharomyces boulardii
 Mechanism of action include, enhancing host
defenses, competition of pathogenic flora for
receptor sites and production of antibiotic
substances
43
Dietary Therapy
 Functional Foods
• Probiotics
 Two separate meta-analysis showed the
probiotics are safe and efficacious in the
treatment of infections and antibioticassociated diarrhea
 As probiotics are not regulated by the FDA,
there may be great variability, wish make an
informed recommendation rather challenging
44
Dietary Therapy
 Functional Foods
• Prebiotics are complex carbohydrates that
stimulate the growth of health promoting
intestinal flora
 The oligosaccharides contained in breast milk
are the prototypic prebiotic
 Data have associated the oligosaccharides in
breast milk to the lowered incidence of acute
diarrhea in the breast feed infant
45
Pharmacologic Therapy
 Antimicrobials
• Viruses are the predominant source of AGE in
developed countries
• Antimicrobials wastes resources and may
increases antimicrobial resistance
• Even when the cause is suspected to be
microbial, usually antibiotics are not indicated as
these disease processes tend to be self-limited
• Children with special needs or severe disease
may benefit from antibiotics if microbial etiology
is suspected
46
Pharmacologic Therapy
 Nonatimicrobial therapies
 Limited data exist about the efficacy of
antimotility agents like loperamide
 Side effects are well described including
–
–
–
–
Ileus
Nausea
Drowsiness
Atropine effects
 Loperamide has been linked to cases of
severe abdominal distention and even death
47
Pharmacologic Therapy
 Nonatimicrobial therapies
• Bismuth subsalicylate has limited efficacy in
treating diarrhea in children
• Ondasetron, a serotonin antagonist antiemetic
 Effective in decreasing vomiting and facilitates
ORT
 Proven efficacious and safe in children > 6
months
 Shown to shorten the ED stay
 Reduction of cost, with one 4 mg ODT tablet
costing around $35 and the placement on an
IV around $ 124
48
Pharmacologic Therapy
 Nonatimicrobial therapies
• Promethazine, non-selective antihistamine
 One of the most prescribed antiemetic
 Not studied in children
 Increase side effects including drowsiness,
respiratory depression, dystonia and
neuroleptic malignant syndrome
 The AAP does not recommend its use in
children younger than 2 years
49
Summary
 The use of appropriate ORS have shown to be
effective for the treatment of mild to moderated
dehydration
 Severe dehydration is a medical emergency and IV
fluids should not be held
 Continuation of age-appropriate diet is more
effective for the treatment of AGE than gut rest
 Ondasetron is safe and efficacious for the treatment
of AGE in children
50
QUESTIONS?
51
References
1.
2.
3.
4.
5.
52
King C K, Glass R, et al. Managing Acute Gastroenteritis
Among Children. CDC MMWR, Nov 2003;52:16
Freedman FB, Adler M, et al. Oral Ondasetron for
Gastroenteritis in a Pediatric Emergency Department. The
New England Journal of Medicine 2006;354:1698-705
Spanddorfer PR, Alessandrini EA, et al. Oral Versus
Intravenous Rehydration of Moderately Dehydrated
Children: A Randomized Controlled Trial. Pediatrics
2005;115:295-301
Ozuah PO, Avener JR, et al. Oral Rehydration, Emergency
Physicians and Practice Parameters: A National Survey.
Pediatrics 2002;109:259-261
Freedman SB, Powel E, Seshadri R. Predictors of
Outcomes in Pediatric Enteritis: A Prospective Cohort
Study. Pediatrics 2009;123:e9-e16