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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
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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
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
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
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
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
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
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
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 co-transport mechanism allowing efficient salt and water reabsorption
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
Physiologic Basis of ORT • Water passively follows the osmotic gradient • SGLT1- sodium glucose co-transporter which moves Na and glucose from the luminal membrane into the enterocyte
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
Physiologic Basis of ORT • Solutions with high concentration of the co-transporters decrease the water sodium transport into the bloodstream • Rehydration solutions with low osmolarity and 1:1 ration glucose to sodium perform optimally
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
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
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
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
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
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
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
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)
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
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%)
Management • Utility of Laboratory Evaluation • Supplementary labs, including serum electrolytes are unnecessary • Stool cultures are only indicated with bloody diarrhea
Management • ED management • Treatment should include two phases • Rehydration – fluid is replaced rapidly, over 3-4 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
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
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
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
Management • ED Management • Mild to Moderate Dehydration • Once dehydration is corrected further management can be implemented at home as long as the caregivers • 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
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
Management • 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
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
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
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
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
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
Dietary Therapy • Functional Foods • Probiotics • Two separate meta-analysis showed the probiotics are safe and efficacious in the treatment of infections and antibiotic-associated diarrhea • As probiotics are not regulated by the FDA, there may be great variability, wish make an informed recommendation rather challenging
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
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
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
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
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
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