Acute Gastroenteritis

Aroona Abdulla
Acute gastroenteritis
 AGE
 Pathophysiology,
 Clinical assessment and Investigations
 Assessment and management of dehydration
 Other aspects of managing a child with AGE
 Follow-up and prevention

 Complications
 Dysentery
 Persistent diarrhoea
 AGE with hypernatraemic dehydration
AGE - Definition
Acute disease of the GIT due to infective cause
leading to diarrhoea +/- vomiting of rapid onset
+/- other symptoms including:
Nausea, anorexia
Fever
Abdominal pain
Diarrhoea = passage of excessively liquid or
frequent stools with increased water content.
>3 loose stools /day
Wide variation in patterns of stool.
Diarrhoea → a change from the norm
Epidemiology

Worldwide:
3-5 billion cases of AGE in children <5
years
1.5 million deaths annually (WHO 2004)
ORT developed in late 1960’s
Deaths from diarrhoea in children <5
years
1979: 4.5 million
2002:of World Health
Bulletin
WHO: 1.6Organization
million
Causes
Viruses (about 70%)
 Rotaviruses
 Noroviruses (Norwalk-like
viruses)
 Enteric adenoviruses
 Caliciviruses
 Astroviruses
 Enteroviruses
Protozoa (<10%)
 Giardia lamblia
 Entamoeba histolytica
 Cryptosporidium
Bacteria (10-20%)
 Shiga toxin producing E. coli
 Vibrio cholerae
 Non-typhoid Salmonella spp
 Salmonella typhi and S
paratyphi
 Shigella spp
 Enteropathogenic E. coli
 Enteroinvasive E. coli
 Campylobacter jejuni
 Yersinia enterocolitica
 Clostridium difficile
Helminths
 Strongyloides stercoralis
Case 1

8 month old infant

Loose stools
Vomiting
Case 1- History
 Age –
 For DD (eg. 6 mths – intussusception,
 lower the age, higher the risk, ↑st in infants < 12mths
 Onset and duration:
 ↑duration →↑risk of dehydration and complications
 Constipation followed by diarrhoea – Salmonella
 Protracted diarrhoea – secondary lactose intolerance,
bacterial or protozoan infections
 Diarrhoea –
 Watery – Viral, profuse watery – cholera, enterotoxic E. coli
 Blood and mucus – Shigella, shigatoxin producing E. coli,
Campylobacter and enteroinvasive E. coli
 Frequency and amount – for assessment of dehydration and
risk (>8/day - ↑risk)
 Case 1- History
 Vomiting
 Frequency and amount - ↑risk of dehyration (>2/day - ↑risk), need
for iv fluid,
 DD – meningitis, systemic infections
 Blood stained vomitus – DHF, Mallory – Weiss
 Bilious vomiting, projectile vom. – surgical / int. obstruction
 Fever
 High fever – shigellosis, enteroinvasive E.coli, campylobacter,
other infections (UTI)
 High swinging fever - Salmonella typhi/paratyphi
 Persistent high fever – septicaemia, DF, other infections
 Abdominal pain
 Salmonella, Shigella, enteroinvasive bacteria, (+tenesmus)
 DD – Sx: intususception in infants, ac. Appendicitis, UTI
Case 1- History
Thirst – for assessment of dehydration
UOP (should be >1ml/kg/hr)
Frequency
Last passage of urine
LOC
for assessment of dehydration
DD – meningitis, encephalitis in Salmonella spp.
Systemic inquiry – for other infections, and other
problems
H/o antibiotic use
 AB induced diarrhoea, Clostridium difficile
Case 1- History

Feeding history
Bottle-feeding and bottle washing / sterilizing
Contact history of diarrhoea in family /
household
Viral AGE more likely with good hygiene
practices
Hygiene practices
Handwashing, boiling of drinking water
 DD – AGE and complications
Infective AGE – Commonest
Acute watery diarrhoea (viral)
>3 stools/day
No blood in stools
Cholera
Diarrhoea with severe dehydration during cholera
outbreak
Stool culture +ve for Vibrio cholera O1 or O139
Dysentery – blood in the stool
Persistent diarrhoea – lasting > 14 days
Diarrhoea with severe malnutrition
Diarrhoea with AB use
 DD – less common
Other DD:
 Other infections
 Systemic: septicaemia, meningitis, DF
 Local: UTI, URTI, hepatitis A
 Surgical: intestinal obstruction
 vomiting, abd pain / crying attacks > diarrhoea
 pyloric stenosis, intussusception,
 acute appendicitis, necrotizing enterocolitis,
 Hirschprung disease
 Metabolic
 Diabetes mellitus/DKA and Inborn errors of metabolism
 Other
 coeliac dis, cows milk protein intolerance, adrenal insuf., Reyes synd
 Chronic constipation with overflow incont. – spurious
diarrhoea
Pathophysiology

Protective mechanisms of GIT

acid content of the stomach
IgA secreted by the small intestine
IgA in breast milk
→ Limit growth of bac in upper small
intestine
→ predominance of lactobacillus and
bifidobacteria in lower GIT
Pathophysiology - Viral
Rotavirus attacks mature enterocytes at
the tips of the small intestinal villi → killed
and shed into lumen
→ ↑of immature crypt-like cells +
shortening of villi (pic)
↓↓ absorptive and disaccharidase activity
+ Ca mediated active secretion of fluids
and electrolytes
→ DIARRHOEA
Pathophysiology - Bacterial
 Enterotoxic E. coli and Vibrio → enterotoxins
 → promote Cl- mediated active secretion of fluids + electrolytes
 profuse watery diarrhoea
 Na – linked co-transport preserved
 Enteropathogenic E. coli → adhere to the brush border membrane
of SI
 → severe mucosal damage
 May take many weeks to recover
 Shigella species and E. coli serotypes O124 and O164 → invade
colonic mucosa (enteroinvasive)
 Watery / mucoid diarrhoea and dysentery
 Blood and pus in stool
 Pain and tenesmus
 High fever (→ febrile convulsions)
 Clostridium difficile → prod. cytotoxins → direct toxic effect on
enterocytes
 Complications
 Dehydration
 Metabolic disturbances:
 Hypernatraemic dehydration
lethargy and irritability (particularly marked in hypernatremic
dehydration)
rapid correction with i.v. fluids → fluid shifts across BBB → cerebral
edema
→ convulsions or even death
 Hyponatraemia
Loss of HCO3- and K+ in stool, poor tissue perfusion, →
 Metabolic acidosis
 hypokalaemia
may have severe metabolic derangement
 hypoglycemia
 ketosis
 renal failure
Complications
Carbohydrate (lactose, glucose)
intolerance → milk intolerance
Bloody diarrhea (in Shigella, Salmonella,
Campylobacter and E. coli O157)
HUS (E. coli O157)
Iatrogenic complications from inappropriate
iv fluid
Susceptibility to re-infection
Death
Case 1
8 month old baby
2 day h/o:
Mod. fever, intermittent
Loose watery greenish stools x10 /d, mucus +, no
blood, mod. large amount
Vomiting 3 times – 1 day, no h’temesis, non-
bilious, food and fluids given, mod. amount
UOP fair, passed w stools
Mother is worried because baby is irritable and
not taking anything orally
Case 1
Examination:
*Weight – recent weight loss → deg. of dehydration
Temperature
LOC and general condition
Assess hydration
Abdomen: distension / mass / tenderness
Nutritional status – malnutrition
Systemic examination for other infections
Inspect stools for blood
 Assessment
Risk of dehydration
 age
 (highest in infants<12m)
 frequency of watery stools
(>8/day)
 vomiting (>2/day)
 Nutrition
 (malnutrition increases risk
of complications, esp.
electrolyte disturb.)
 Pathogen (Vibrio cholerae)
*signs of proved value [I,A]
Degree of dehydration
 *recent weight loss
 thirst
 oliguria
 Clinical examination:
 *altered LOC
 *prolonged “skin-pinch”,
 *dry oral mucosa,
 *sunken eyes
 tears
 sunken fontanelle
 CRT –
 ↓Sensitivity & specificity,
 <2sec - v. unlikely in severe
dehydration
 Haemodynamic status – tachycardia,
↓peripheral pulses, ↓BP, cold
peripheries (vasoconstriction)
 tachypnoea
signs of severe dehydration
 Assessment of Dehydration (AAP/CDC)
Degree Mild Moderate Severe dehydration
Weight loss 3-5% 6-9% >10%
Skin turgor normal (immed) *slow (<2 sec) *v. slow (>2 sec)
Fontanelle normal sunken sunken
Mucous mem. Slightly dry dry dry
Eyes normal *sunken orbits *deeply sunken
Extremities Normal CRT ↑ CRT > 2sec cool, mottled
Neuro status normal *normal to *normal to lethargic
listless or comatose
Pulse volume normal slightly ↓ mod. ↓
Heart rate normal ↑ ↑, (brady in v.sev.)
BP normal normal normal to ↓
UOPAdapted from Duggan
Sources: C, ↓
slightly Santosham M,< 1ml/kg/hr << 1ml/kg/hr
Glass RI. The management of acute diarrhea in
children: oral rehydration, maintenance, and nutritional therapy. MMWR 1992;41(No. RR-16):1–20;
Thirst slightly ↑ *mod.↑ - eager *very thirsty or too
and World Health Organization. The treatment of diarrhoea: a manual for physicians and other
senior health workers. Geneva, Switzerland: Worldto Health
drink Organization,
lethargic
1995. to indicate
 Assessment of Dehydration - WHO
Degree No or minimal Some dehydration Severe dehydration
Weight loss < 3% - 5% moderate (6-10%) (>10%) +/- shock

Signs < 2 of * 2 or more of * 2 or more of **

Neuro status alert / active *restlessness / **abnormally sleepy or
irritability lethargic
Skin pinch normal (immed) *slow (<2 sec) **v. slow (>2 sec)
Eyes not sunken *sunken **sunken
Thirst normal *↑ - eager to drink ** poorly or not at all
AF normal not sunken sunken
CRT <2 sec ↑ > 2sec ↑ > 2sec
CVS stable stable circulatory collapse#
RR normal normal tachypnoea, deep br.
#
Weak rapid pulse, cool or blue extremities, ↓CRT, or hypotension
Skin pinch test showing laxity with dehydration
*Pitfall: Skin pinch may not be elicitable in hypernatremic dehydr.
Child with severe
dehydration
Poor GC
Drowsy
Sunken eyes
Chest risen due to
deep breathing in
response to acidosis
 Case 1
 8 month old baby
 2 day h/o:
 Mod. fever, intermittent
 Loose watery stools x10 /d, mucus +, no blood, mod. large amount
 Vomiting 3 times – 1 day, no h’temesis, food and fluids given, mod. amt
 UOP fair, passed with stools

 O/E:
 T 100F, irritable, feeding vigorously,
 eyes slightly sunken, no tears seen,
 tongue dry, skin pinch slightly lax (<2 sec),
 CRT =2 sec, pulse 140/min,
 p. pulses good vol, BP 85/ 50mmHg
 Abdomen soft, CVS, RS: NAD
 Weight 7.6 kg (5% ↓from 8kg)
Case 1
Assessment
AGE,
DD – UTI, Sepsis,
Some dehydration
Risk of dehydration +
Nutritional status –
Wt for age: 50th cent.

Needs Observation &

Rehydration
Investigations - Basic
 Stool RE – (if ?bacterial AGE, dysentery or protracted
diarrhoea)
 Pus cells – Shigella, Salmonella spp, enteropathogenic E.coli,
 RBC – Shigella, enteropathogenic and enteroinvasive E.coli,
Campylobacter, some Salmonella spp.
 Amoeba – E. hystolytica trophozoites with ingested rbc
 Giardia lamblia cysts or trophozoites
 Reducing substances (in protracted diarrhoea with ↑↑watery
stools and perianal excoriation) → lactose intolerance
 Urine RE (if ?UTI, esp. in infant < 1yr)
 WBC counts with DC + platelets (if systemic infection or
DF suspected
 CRP
 Electrolytes – Na, K, Cl
 If severe dehydration, high risk of dehydration or vomiting
Further Investigations – complications
 Blood gases for acid base status
 Urea, creatinine…………………. If severe dehydration +
 Stool culture
 If bloody diarrhoea / dysentery, HUS, stool pus cells,
diarrhoea in immunocompromised, persistent diarrhoea
 Blood culture
 If sepsis +ve clinically or Ix
 Hb / PCV / counts / Blood picture
 If HUS
 If surgical cause suspected
 Abdominal USG – pyloric stenosis, intussusception
 X-rays – intestinal obstruction
 Proctosigmoidoscopy
 If severe sympt. of colitis or cause of inflammatory
symptoms obscure after lab Ix
Management
Rehydration + replace ongoing losses
 ORT
 Iv fluids
Antiemetics
Probiotics
Nutritional management
Zinc supplementation
Antibiotics - role
Antidiarrhoeals – role
Physiology of Rehydration
 Enterotoxins inhibit GTPase
activity → ↑cAMP
 → ↑Cl- secretion
 → ↑Na+ and fluid loss

 Preserved reabsorption by
 Na+ -glucose co-transporter
(SGLT1)
 Amino acid stimulated Na+
co-transporter
 ORS

ORS components New Old* ORS New Old*

ORS ORS compo- ORS ORS
g/L g/L nents mmol/L mmol/L
Sodium chloride 2.6 3.5 Sodium 75 90
Chloride 65 80
Glucose, anhydrous 13.5 20 Glucose 75 110
Potassium chloride 1.5 1.5 Potassium 20 20
Trisodium citrate, 2.9 2.9 Citrate 10 10
dihydrate
Total 20.5 27.9 Total 245 310
*clinical trials → Less hyponatremia with ↑Na+ ORS in cholera, but not others
ORS (contd.)
Other formulations
 Rice-based ORS
Shown ↑efficacy in cholera diarrhoea
Provides more glucose for utilizing glucose coupled Na
co-transport
Provides amino acids for amino acid coupled NA co-
transport
Taste – not palatable, difficult to administer

Home prepared ORT solution

 Pinch of salt + 2 teaspoons sugar to 1 litre of boiled
cooled water
Important to prepare ORS following instructions
strictly
Case 2
 2 yr old child
 2 day h/o:
 High gr. fever, continuous
 Loose watery stools x10 /d, mucus +, no
blood, large amount
 Vomited 8 times – 1 day, no h’temesis,
taken breastfeeds and ↓fluids, but
vomited all
 UOP uncertain, ? with stools, last
noticed previous night (8hrs)
 O/E:
 T 101F, drowsy, refusing feeds, eyes
sunken, no tears seen, tongue dry, skin
pinch ↑(<2 sec),
 CRT >2 sec, pulse 150/min, p. pulses ↓
↓vol, cool peripheries
 Abdomen soft, RS: NAD
 CNS: no neck stiff., pupils ER
Case 2
 Wt: 10.8 kg
 No recent weight check

 Ix:
 TLC 25,000
 CRP 45mg/dl
 stool R/E: awaiting

 Assessment
 AGE with sepsis,
 Severe dehydration – circ. Shock +
 ↑Risk of further dehydration + complications
 ?Electrolyte abnorm, metab. Acidosis, ↓glycemia
 Nutritional status - ?10th cent.
 C. Resuscitation (Sev. dehyd >10%)
 Urgent IVF bolus 100 mL/kg of RL or n. saline
Age 30ml/kg 70ml/kg Total 100ml/kg
Infant <12mths Over 1 hr Over 5 hrs Over 6 hrs
1 – 5 yrs Over ½ hr Over 2½ hrs Over 3 hrs

 Reassess every 15-30 min

 + ORS 5ml/kg/hr as soon as able to take orally
usually after 3-4 hrs
 Assess after 6 hrs
 Still severe dehydration, haemodynamically unstable, no
UOP → back to C (Resuscitation)
 CVS stable, moderate dehydration → Go to step B.
B. Replacement (Some dehyd 3-9%)
Age < 4 mths 4-12 mths 1-2 yrs 2-5 yrs
Weight < 6kg 6 - <10kg 10 - <12kg 12-19kg
ORS (ml) 200-400 400-700 700-900 900-1400
Min. amt
 If vomiting,
 wait 10 min and restart
 Antiemetics if repeated vomiting – ondansetron iv or oral
(not in WHO protocol but recent research → may be useful)
 Reassess hydration after 4 hrs
 Include weight check
 Categorize as no, some or severe dehydration
 → Treat as appropriate stage A, B or C
Case 2
A. Maintenance - Minimal dehydr. (<3%)
Replace ongoing stool loses with ORS
 WHO
< 2 yrs – 50-100ml for each loose stool
> 2 yrs – 100-200ml for each loose stool
 Other protocols
1 mL ORS for each 1gram loose stool or,
10 mL/kg body weight of ORS for each watery or loose
stool, and
2 mL/kg body weight for each episode of emesis.
Other fluids in between ORS –
 breastfeeds, coconut water, rice cunjee, soup, yogurt
drinks
 Fruit juices, cola and sports drinks are inappropriate
Continue age appropriate feeding
 IV Fluids
 Indications in Replacement phase:
 Mod dehydration and unable to retain oral fluids because of
persistent vomiting
 ↓LOC
 Ileus
 Inability to closely supervise or
give ORT

 Problems:
 Fluid overload
 Electrolytes disturbances
 ↑ occurrence of seizures
AAP - Practice Parameter: The management of Acute
gastroenteritis in young children. Pediatrics1996.97(3);424-435.
IV Fluids
Rehydration (algorhythm from BMJ)

BMJ review - Based on WHO

Repletion phase (Mod Dehyd. 6-9%) - AAP
 IVF or ORT by NG or oral at 100 mL/kg over 4-6 hrs.
 Which iv fluid? RLD or DNS, in infants <1yr – n/2+5%D
(½ DNS)
 Additional ORS to replace ongoing loss of stool*.
 1 mL ORS for each 1gram loose stool or,
 10 mL/kg body weight of ORS for each watery or loose stool,
 2 mL/kg body weight for each episode of emesis.
 Hourly reassess:
 hydration status -
 calculate continuing stool and emesis losses and add
ongoing losses to replacement.
 After 4 hrs reassess hydration. If mild dehydration (3-
5%) → go to mild dehydration
Repletion phase (mild-mod 3-5%) - AAP
 Repletion phase —
 ORS by mouth or NG (or IVF)
 at 50 mL/kg over 4 hours.
 Which iv fluid? RLD or DNS, in infants <1yr – ½ DNS
 Additional ORS to replace ongoing loss of stool*.
1 mL ORS for each 1gram loose stool or,
10 mL/kg body weight of ORS for each watery or loose stool,
and
2 mL/kg body weight for each episode of emesis.
 Reassess hydration and replacement of ongoing losses at
least 2 hourly.
 After 4 hrs – reassess hydration
 If no dehydration → go to Step A – Maintenance phase
Nutritional Management - Dos
 Feed as early as possible
 Milk
 Continue breastfeeding - ↑ freq
 Formula need not be diluted when reintroduced
 Other fluids -
 coconut water, rice cunjee, soup, yogurt drinks
 Resume normal (solid) diet when appetite returns
 Yogurt → lactobacillus
 Rice / cereal - complex carbohydrates → more glucose and
amino acids ↑ fluid reabsorption and ↓stool volume
 Banana, fruit → K+, high energy, fibre ↑stool bulk - ↑solid
 Vegetables → fibre
 Fish / lean meat (proteins) → amino acids help fluid
reabsorption
 Mix with 1-2 teaspoons of vegetable oil
Nutritional Management – Dont’s
Avoid foods high in fat and sugars
 Commercial fruit juices, cola and sports drinks are
inappropriate - ↑sugar content, ↓Na
Don’t add sugar or glucose to coconut water
Fruit juices should be prepared without adding
sugar as far as possible
All these can worsen diarrhoea
Pharmacological measures

Antiemetics
Probiotics
Zinc
Antibiotics – limited role
Antidiarrhoeals – no role
 Antiemetics
 Ondansetron - useful in reducing vomiting over 8 hrs
 ↓vomiting, ↑oral intake, ↓need for iv fluids, ↓hospital admission
 A/E: ↑diarrhoeal episodes and representation after discharge.

 Some other antiemetics suggested:1

 Dopamine antagonists –
 domperidone
 metoclopramide - not recommended for use in neonates (in any form).
 A/E: may increase gut motility
 Promethazine
 (not recommended for children <2 years in any form)
 A/E: drowsiness and complicates assessment
 When to give: during oral replacement / iv replacement
1. Marc Bevan, et al. Proposal for the inclusion of anti-emetic medications (for children) in the who model list of
essential medicines. Report - Second Meeting of the Subcommittee of EC on the Selection and Use of
Essential Medicines, Geneva, 29 September to 3 October 2008.

2. Elliott EJ, et al. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents.
Cochrane Database Syst Rev 2006;(3):CD005506. Evidence-Based Child Health 2006 (in press). Cited in
Elizabeth Jane Elliott. Acute gastroenteritis in children. BMJ 2007;334;35-40.
Probiotics

Found to ↓ duration of diarrhoea and daily

frequency of stools1
Lactobacillus rhamnosus and a mix of L.
delbrueckii var bulgaricus, Streptococcus
thermophilus, L. acidophilus, and
Bifidobacterium bifidum2
Saccharomyces boulardii not shown significant
difference 2
1. Allen SJ, Okoko B, Martinez E, Gregorio G, Dans LF. Probiotics for treating
infectious diarrhoea. Cochrane Database Syst Rev 2003;(4):CD003048.
2.Canani BC et al. Probiotics for treatment of acute diarrhoea in children:
randomised clinical trial of five different preparations. BMJ 2007;335;340;online
Zinc supplementation
WHO recommends:
> 6 months: 20 mg /day
for infants < 6 months: 10 mg /day 1
of zinc suppl. for 10–14 days
Reduce severity and duration of diarrhoea2
Prevents re-infection3
1.WHO/UNICEF Joint statement – Clinical Management of Acute Diarrhoea
2.Bahl, R., et al., ‘Effect of zinc supplementation on clinical course of acute diarrhoea‘ –
Report of a Meeting, New Delhi, 7-8 May 2001.
Journal of Health, Population and Nutrition, vol. 19, no. 4, December 2001, pp. 338-346.
3.Bhutta Z.A., Black, R.E., Brown K. H., et al., ‘Prevention of diarrhoea and pneumonia by
zinc supplementation in children in developing countries: Pooled analysis of randomized
controlled trials’, Zinc Investigators’ Collaborative Group, Journal of Paediatrics, vol. 135,
no. 6, December 1999, pp. 689-697.
 Role of antibiotics
Most AGE do not require nor benefit from AB
A/E: AB diarrhoea, prolonged Salmonella excretion
Indicated for
AGE complicated by septicaemia with some
bacterial infections
Protozoal infections – Giardia, Amoebic desentery
Evidence of other systemic or severe local bacterial
infection, eg. UTI, pharyngitis, otitis media,
septicaemia, meningitis

WHO 2005. Management of Common illnesses with Limited Resources (Paediatric) - WHO 2005
Elizabeth Jane Elliott. Acute gastroenteritis in children. BMJ 2007;334;35-40.
M S Murphy. Guidelines for managing acute gastroenteritis based on a systematic review of
published research. Arch. Dis. Child. 1998;79;279-284
 Role of antibiotics - Indications
Organism Indication AB
Shigella All ampi, cipro / oflox,
ceftrioxone
Vibrio cholerae All doxycyline,
tetracycline
Campylobacter Early erythromycin
Salmonella Inf<3mth, typhoid,
cefotaxime,
bacteraemia, ceftrioxone,
localized ampicillin,
suppuration chloramphenicol,
cotrim
Clostridium difficile Mod-severe illness metronid, vanco
WHO 2005. Management of Common illnesses with Limited Resources (Paediatric) - WHO 2005
 Role of antibiotics - Indications
Organism Indication AB
E. coli - Severe prolonged cotrimoxazole
enterotoxigenic illness
E. coli - Nursery epidemics, cotrimoxazole
enteropathogenic life threatening
E. coli - All cotrimoxazole
enteroinvasive
Aeromonas Dysentery, prolonged cotrimoxazole
diarrhoea
Giardia lamblia If stool → Giardia metronidazole
cysts or trophozoites
Entamoeba If stool → amoebic metronidazole
histolytica trophozoites in rbc
WHO 2005. Management of Common illnesses with Limited Resources (Paediatric) - WHO 2005
Role of antidiarrheals

Not recommended
Can mask dehydration and ongoing
losses
Inadequate evidence on safety
Medicines under research
Racecadotril – antisecretory agent
 an enkephalinase inhibitor
 preserves the antisecretory activity of enkephalins
 does not slow intestinal transit or promote bacterial
overgrowth
 Promising as an adjunctive in ↓stool output in clinical
trials
Current guidelines do not emphasize use
 →not required in most cases, may be used only as an
adjunct
 as mainstay of treatment is rehydration
On discharge advice
Prescribe
 ORS
 Zinc supplements
 Probiotics
How to prepare and give ORS
Continue to feed
 – breastfeeds, fluids and dietary advice
Hygeine
 – handwashing, avoiding bottle feeds, boiled water for
drinking
How to recognize danger signs of dehydration
 WHO– lethargy/ irritability, thirst, sunken eyes, skin pinch
When to follow-up
Follow-up after discharge
Bring child immediately if:
Sick
Lethargic, ↓LOC
Unable to drink or breast-feed May need
Poor drinking hospital
↓UOP admission
Develops fever
Blood in stool
Not improving for 5 days
Prevention
 Prevention
Intervention area Reduction of diarrhoea
frequency
Hygiene 37%
Sanitation 32%
Water supply 25%
Water quality 31%
Multiple 33%

WHO 2006. Ref:

Fewtrell L et al. Water, sanitation, and hygiene interventions to reduce
diarrhoea in less developed countries: a systematic review and
metaanalysis. The Lancet Infectious Diseases, 2005, 5(1):42–52.
Summary
 Mainstay of treatment is rehydration – saves lives
 Antiemetics – useful in reducing vomiting, but may ↑
diarrhoea
 Probiotics – useful in ↓diarrhoea duration and freq
 Nutrition – early feeding improves outcome and ↓re-
infection
 Zinc supplementation - ↓severity and duration of
diarrhoea and ↓re-infection
 Antibiotics –
 not required and does not benefit in most cases [1A]
 Indicated for Shigella dysentery and septicaemia
complicating other bacterial AGE
 Antidiarrhoeals – should not be used
 Literature
 Pocket Book of Hospital Care for Children – Guidelines for the Management of Common
Illnesses with Limited Resources - WHO 2005
 Review of Medical Physiology – WF Ganong
 Nelsons Paediatrics -
 Forfar & Arneil’s Textbook of Paediatrics – 6th ed
 Elizabeth Jane Elliott. Acute gastroenteritis in children. BMJ 2007;334;35-40.
 M S Murphy. Guidelines for managing acute gastroenteritis based on a systematic review
of published research. Arch. Dis. Child. 1998;79;279-284
 Practice Parameter: The management of Acute gastroenteritis in young children.
Pediatrics1996.97(3);424-435.
 Managing Acute Gastroenteritis Among Children - Oral Rehydration, Maintenance, and
Nutritional Therapy. CDC MMWR. November 21, 2003 / Vol. 52 / No. RR-16
 WHO/UNICEF Joint statement. Clinical Management of Acute Diarrhoea. May 2004
 Allen SJ, Okoko B, Martinez E, Gregorio G, Dans LF. Probiotics for treating infectious
diarrhoea. Cochrane Database Syst Rev 2003;(4):CD003048.
 Canani BC et al. Probiotics for treatment of acute diarrhoea in children: randomised clinical
trial of five different preparations. BMJ 2007;335;340;online
 Marc Bevan, Elizabeth Seil, Robin Bell and Jane Robertson. Proposal for the inclusion of
anti-emetic medications (for children) in the WHO model list of essential medicines. Report
- Second Meeting of the Subcommittee of the Expert Committee on the Selection and Use
of Essential Medicines, Geneva, 29 September to 3 October 2008