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Gastroenteritis in Infancy & Childhood. Dr Jonny Taitz Sydney Children’s Hospital, Randwick April 2003. Introduction. Very common problem in Paediatrics Causes Diarohea, vomiting & fever Usually viral Rotavirus, Adenovirus, Enterovirus Bacterial

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gastroenteritis in infancy childhood

Gastroenteritis in Infancy & Childhood

Dr Jonny Taitz

Sydney Children’s Hospital, Randwick

April 2003

introduction
Introduction
  • Very common problem in Paediatrics
  • Causes Diarohea, vomiting & fever
  • Usually viral
    • Rotavirus, Adenovirus, Enterovirus
  • Bacterial
    • E-coli, Shigella, Salmonella, Yersinia, Campylobacter
  • Parasitic
    • Giardia, Entomeba
what is gastroenteritis
What is Gastroenteritis?
  • Damage to gut mucosa
  • Disturbance of balance between mechanisms controlling secretion & absorption
  • Net effect = Diarohea
  • Most cases self limiting with full recovery
  • BUT small proportion 
    • Severe dehydration +
    • Electrolyte abnormalities
    • Shock, cerebral oedema +
    • Death
review of dehydration
Review of Dehydration
  • Weight changes are still the most accurate
  • 3% Mild (oral, breast, gastrolyte)
    • Thirst is first
    •  Urine output
    • Dry mucous membranes
  • 5% Moderate(oral/nasogatric, breast/gastrolyte, consider IV)
    •  Urine output
    • Obviously dry mucous membranes
    • Sunken eyes & fontanelle
    • Tachycardia (mild)
review of dehydration contd
Review of Dehydration (contd)
  • 7% Moderate-Severe (IV N/2 or N saline)
    • Severe tachycardia
    • Apathetic
    •  Turgor
    • Sunken eyes & fontanelle

10% Severe (N saline bolus 10-20 mls/kg then n/2 or N saline)

    • = Shock
    • Circulatory failure
    • Altered consciousness
    • Small volume pulses
    • NB hypotension is a late sign
principles of fluid management
Principles of Fluid Management
  • Enteral route preferable to parenteral route for mild/moderate dehydration
  • Oral rehydration therapy (oral or nasogastric)
  • Breast, dilute fruit juice
  • Hydrolyte ice-block & parent’s chart
  • Aim
    • 1 ml/kg every 10 mins or 5 ml/kg very hour
  • For moderate or severe dehydration IV access & fluids required
principles of fluid management7
Principles of Fluid Management
  • Shock
    • Rx aggressively
      • 10 – 20 mls/kg IV Bolus over 10-20 mins
      • Use normal saline
      • DO NOT USE ½ or ¼ saline !!!
principles of fluid management8
Principles of Fluid Management
  • Rehydration
    • This can be done slowly usually over 24 hrs
    • If hyponatremic aim for 48 hrs
    • AVOID RAPID FLUID SHIFTS !!!
  • No magic bullet
  • Careful regular assessment is the key
3 fluid types
3 Fluid Types
  • Maintenance
  • Rehydration
  • Ongoing losses
maintenance
Maintenance
  • Age & weight dependent
  • 1st yr - 120 mls/kg/day
  • 2nd yr - 100 mls/kg/day
  • 2-4 yrs - 85 mls/kg/day
  • 4-6 yrs - 70 mls/kg/day
  • > 6 - adult
  • I.e 1 yr old 10kg infant

Needs  120 mls x 10kg x 24 hrs

= 1200 mls maintenance

rehydration
Rehydration
  • Depends on fluid deficit
  • 5% = 50 mls/kg/day
  • 3% = 30 mls/kg/day
  • Same 10kg infant 5% dry

= 50 mls x 10 x 24 hrs

= 500 mls/day rehydration fluid

ongoing losses
Ongoing Losses
  • Not part of guidelines
  • But in profuse, watery diarohea add 10-20 mls/kg/day to account for regular losses
which rehydration fluid to use
Which Rehydration Fluid to Use
  • SIMPLE
    • N/2
    • N Saline
  • New evidence
    • N saline probably the best (SCH)
  • Na+  130 mmols  N Saline
what about electrolyte imbalance
What about Electrolyte Imbalance
  • Initially EUC, BSL if 5% or more dehydrated
  • VBG if shocked
  • Repeat if markedly abnormal / child not improving
  • Na+ < 132 mmol/l or > 145 mmol/l
  • K+ < 3 or > 5.5 mmol/l
pitfalls
Pitfalls
  • Watch the salt !!!
    • Evidence that SIADH occurs with gastroenteritis
    • Changes to serum Na+ can lead to cerebral oedema, seizures & death
  • Do not forget the Potassium
    • Once urine passed  add 3 mmol/kg/day
    • May require up to 5mml/kg/day if hypokalaemic
    •  Add 10 mmol KCl / 500 mls fluid
pitfalls continued
Pitfalls (continued)
  • Be Sweet  add Dextrose
    • Particularly in younger children
    • New evidence 2.5% Dex should be sufficient
  • Milk (if tolerated) is better then intravenous fluid for the patient and the gut mucosa
medications
Medications
  • No indications for
    • Anti-vomiting
    • Anti-diaroheal
    • Anti-motility
  • Antibiotics only for proven bacterial gastroenteritis
differential diagnosis
Differential Diagnosis
  • Think of other options:
    • Abdo distension
    • Bile stained vomiting
    • Fever > 39oC
    • Vomiting, but NO Diarohea
    • Blood in Urine/stool

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Bowel obstruction strangulated hernia

- Sepsis, Meningitis, Dysentry, UTI

- UTI, Meningitis, DKA, raised intracranial pressure

- IBD, HUS, Dysentry