Management of Dehydration and Special Issues

2. Management of Dehydration and Special Issues Abdulwahab Telmesani FRCPC, FAAP Umm Al-Qura University

3. Scientific Methodology • Latest publications through best and well known search engines (Ovid, Blackwell, MD Consult, etc.) • Cochrane Database of Systematic Reviews

4. Management of Dehydration Why it is important?

5. Management of Dehydration 2 million infant and child die every year in the developing countries

6. Diarrhea Rota virus is a major worldwide cause of infant morbidity and mortality

7. Rotavirus Rates of rotavirus illness among children in industrialized and less developed countries are similar, indicating that clean water supplies and good hygiene have little effect on virus transmission. AAP

8. Rotavirus Trials of pentavalent rotavirus vaccine in the United States and 10 other countries show efficacy rates of 98% for prevention of severe illness and 74% for prevention of rotavirus-induced diarrheal episodes of any severity. AAP

9. Rotavirus Rota Virus Live Oral Vaccine is out and soon availableKSA

10. Management of Dehydration Management at the primary health care centers By PHCC Physicians

11. Who is our target patient? ?

12. Who is our target patient? Previously well baby or child who has diarrhea with mild- moderate dehydration

13. Who is our target patient? NOT Renal failure, cardiac patients, severely malnourished baby, toxic, etc.

14. Degree of Dehydration Assess the degree of dehydration

15. Degree of Dehydration • Mild dehydration (3-5%) • Moderate dehydration (7-10%) • Sever dehydration (10-15%)

16. Degree of Dehydration Mild dehydration (3-5%) -Normal P/E, -Normal or increased pulse rate -Decreased U/O and -Thirsty

17. Degree of Dehydration Moderate dehydration (7-10%) -Increased pulse rate -Decreased U/O and tears -Sunken eyes and fontanel -Dry mucous membrane. -Mild skin tenting, pale, cool periphery and -Decreased capillary refill.

18. Degree of Dehydration Sever dehydration (10-15%) -Rapid weak pulse. -Low BP, sunken eyes and fontanel -No tears or urine & v. dry mucous membrane -Clear skin tenting. Cool mottled skin with delayed capillary refill.

20. Fluid Maintenance ?

21. Fluid Maintenance Body Wt Fluid per day 0 – 10 kg 100 ml/kg 11 -20 kg 50 ml/kg • 20 kg 20ml/kg

22. e.g. a child of 25kg First 10 kg = 1000 ml Second 10 kg = 500 ml Remaining 5 kg = 20 ml Total = 1700 ml/ pay i.e. per hr = 70 ml/ hr

23. Calculate the deficit Percent of dehydration x Weight

24. e.g. 7% dehydrated 10 kg baby 0.07 x 10 = 0.7 L i.e. 700 ml

25. Lab work None Required

26. Lab work • Na and K • Urea and creatinine • pH/ Bicarb. • Urinalysis

28. ORS Oral Rehydration Solution

29. ORS Developed 1940s in Dhaka Bangladesh

30. ORS A revolution in the management of diarrhea Olivier Fontaine Bulletin of WHO Geneva 2001

31. ORS Most important medical discovery of the 20th century The Lancet

32. ORS 5 million deaths / year After ORS 2 million deaths / year

33. ORS components WHO/UNICEF Na = 90 mmol/l k = 20 mmlo/l cl = 80 mmol/l glucose = 111mmol/l Osmol = 311 mmol/l

34. WHO vs. Hypo-osmolar ORS WHO/UNICEF Hypo-osmolar Na = 90 mmol/l Na = 60 mmol/l k = 20 mmlo/l k = 20 mmlo/l cl = 80 mmol/l cl = 50 mmol/l glucose = 111mmol/l glucose = 84 mmol/l Osmol = 311 mmol/l Osmol = 224 mmol/l

35. Hypo-osmolar ORS Many studies support the use of reduced osmolarity ORS but the debate is not resolved. It is preferred in severely malnourished (marasmic) child as the standard (old) WHO ORS may cause hypernatremia

36. Hypo-osmolar ORS In May 2002 WHO moved to reduced osmolality ORS

37. ORT vs. I/V Therapy ?

38. ORT vs. I/V Therapy ORT is as effective as I/V fluid for rehydration of moderately dehydrated children due to G/E in the E/D. ORT Demonstrated no inferiority for successful rehydration at 4 hours and hospitalization rate. A randomized controlled trial by P Spandorfer et al Pediatrics Feb.2005

39. ORT vs. I/V Therapy Although no clinically important differences between ORT and IVT, the ORT group did have a higher rate of paralytic ileus, and the IVT group exposed to risk of intravenous therapy. For every 25 children treated with ORT one fail and require IVT L Hartlig The Cochrane Database of Systematic Reviews 2006 Issue 4

40. Reluctance to use ORT ?

41. Reluctance to use ORT • People do not consider ORT high-tech enough. • Physicians prefer I/V fluids. • It takes time to educate parents re ORT. • Time consuming for busy parents.

42. ORS Additives

43. ORS Additives Amylase-Resistant Starch

44. ORS Additives In children with acute diarrhea, the addition of amylase-resistant starch to glucose ORS significantly shortened duration of diarrhea compared with slandered treatment Randomized study By P Raghupathy J Ped Gastro & nut April 2006

45. ORS Additives Amino Acids

46. ORS Additives Adding amino acids to ORS found to improve it’s performance and help in the regeneration of the intestinal mucosa. G Nappert Nutition review Mar. 2000

47. ORS Additives Zinc

48. ORS Additives Zinc supplement(20 mg per day) reduced severity and duration of diarrhea T Bora et. al. Ped. Intern. October 2003 and many other publications

49. ORS Additives Probiotics in ORS proved effective