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Acute gastroenteritis (AGE)
• Common condition in childhood
• 5 million deaths per year <5 yo in developing
• 2 million deaths annually worldwide
• Rotavirus is the most important cause but other
intestinal viruses such as norwalk, noroviruses
and enteroviruses, bacteria (Salmonella, Shigella)
and Vibrio cholerae, protoza (such as
criyptosporidium) are also important causes
• The hallmark is diarrhea
• Change in bowel habit resulting in substantially more
frequent and/or looser stools
• Diarrhea may be associated with vomiting
• Two important clinical suggestions:
-diarrhea and/or vomiting can be non-specific
presenting signs in children with systemic sepsis e.g
meningococcal infection, septicemia and urinary tract
infection. Assess each child carefully
-if a child has vomiting alone consider the possibility of
other diagnoses e.g intestinal obstruction, diabetes or
Degree of dehydration in
• Clinical signs become apparent at 34%
• Minimal or no dehydration if <3%
• Mild to moderate if 3-8% dehydrated
• Severely dehydrated if >9%
Assessment of degree of dehydration
and recommended management
• Minimal or no deydration (<3%): no signs
-manage at home generally
-normal fluids, continue breast-feeding,
normal diet
-admit if very young, diagnosis in doubt,
or large losses
Assessment of degree of dehydration
and recommended management
• Mild to moderate dehydration (3-8%)
-general appearance abnormal (looks unwell)
- dry oral mucosa
-absent tears
-sunken eyes
-diminished skin turgor (skin recoil after pinching
skin>2s, capillary return >2s)
-Manage in hospital with ORS
-if ORS not tolerated, may require NG tube feeds or IV
-resume normal diet when tolerated
Assessment of degree of dehydration
and recommended management
• Severe dehydration (>9%):
-signs from mild to moderate +deep acidotic breathing
-altered neurological status(drowsiness, irritability)
-decreased peripheral perfusion
-circulatory collapse
-measure BUN, electrolytes, acid-base balance
-resuscitate with IV bolus if shocked
-rehydrate IV over 2-6 hrs with regular clinical and lab
Assessment of degree of dehydration
and recommended management
• Fluid requirement calculated as:
volume needed to replace the deficit
maintenance fluids
ongoing losses
Daily maintenance fluid requirement
Weight of the child
First 10 kg
Second 10 kg
50 ml/kg
20 ml/kg
if the child weighs 8 kg MFR is 800ml
İf the child weighs 12 kg MFR is(10x100)+(2x50):1100 ml
İf the child weihgs 23 kg MFR is
(10x100)+(10x50)+(3x20):1560 ml
Route of rehydration
• Question: is oral rehydration as effective and
safe as IV rehydration?
• Compared to children treated with IV
rehydration children treated with oral
rehydration has significantly fewer major
adverse events including death or seizures and
significant reduction in lenght of hospital stay
Fonseca BK, Holdgate A. Arch Pediatr Adolesc Med
2004;158:483-90 (meta analysis , 16 trials 1545 children)
Route of rehydration
A cochrane review of 17 trials, 1811 participants, all poor to
moderate quality
More treatment failures with ORT
No significant differences in weight gain, hyponatremia,
hypernatremia, duration of diarrhea or total fluid intake
ORT group stayed in the hospital for 1.2 days less
Phlebitis occured more often in the IVT group and paralytic
ileus in the ORT group
Six deaths occured in the IVT and two in the ORT group
For every 25 children treated with ORT one would fail and
require IVT
Hartling L, Bellemare S et al The Cochrane Database of Systematic Reviews
2006;(3) Art no CD004390
Route of rehydration
• Both oral and IV rehydration are safe and
• In developing countries where mothers nurse
their infants and give frequent oral feeds, ORT is
• In industrialized countries, ORT is cheaper and
with fewer adverse effects
• Parents and nursing staff should be encouraged
to give ORT and be informed that if they do so
the child will avoid IV line and get home quicker
Route of rehydration
• Rapid IV rehydration over 4 hrs was advocated by
WHO in 1980s for children in developing countries for
moderate to severe dehydration
• In industrialized countries the practice of rapid IVT to
rehydrate children over 1-3 hrs and send them home if
they can tolerate oral fluids has been found to be safe
and effective
• The main potential danger is fluid overload and/or
electrolyte imbalance especially if the degree of
dehydration is overestimated which is common. There
is also risk of sending home some children who are in
need of hospital care
Route of rehydration
• Severe dehydration (>9%) is life
threatining and there is consensus
that one should rehydrate severely
dehydrated children using IV fluids
Choice of ORS
• Since 1980s the WHO has recommended a standart ORS
with relatively high Na and glucose content (90 mmol/L
Na, 111mmol/L glucose, total osmolality 311mmol/L)
• A number of studies compared standart ORS with reduced
osmolality ORS (rORS) (total osmolality 250 mmol/L)
• rORS Has been found to be associated with fewer
unscheduled IV infusions, lower stool output and less
vomiting. No additional risk of hyponatremia was found
• The WHO now recommends rORS for non-cholera diarrhea
Mode of delivery of ORS
• Giving ORS by a NG tube is increasingly common
in some industrialized countries
• NG tube feeds have the advantage of getting fluid
in if a child refuses to drink or is vomiting
• They are far less invasive, cheaper and less
traumatic then IV fluids
• On the other hand they are more invasive then
oral feeds, unpleasant and have not been shown
to have any advantage over oral rehydration
Choice of IV fluids
• In many industrialized countries N/2 or N/4
saline are chosen for IV fluids and they are
made isotonic by adding dextrose
• But as dextrose is rapidly metabolized the
fluid becomes rapidly hypotonic
• The use of low Na fluids has recently been
questioned following episodes of catastrophic
hyponatremia associated with IV rehydration
for AGE
Choice of IV fluids
• Hyponatremia is particularly likely to develop in
children who concurrently have the syndrome of
inappropriate ADH secretion (SIADH)
• Dehydration, vomiting and stress are potential
causes of SIADH and occur commonly in AGE
• Investigations showed that for resuscitation of
children with severe GE using IV fluids, normal
saline with or without added dextrose is
Antibiotics and AGE
• Antibiotics are not routinely recommended for
• Most episodes of AGE are caused by viruses
• Most episodes are self-limiting, including
those caused by bacteria and antibiotic use is
likely to select for antibiotic resistance
• Antibiotics might increase gastrointestinal
motility and cause bacterial overgrowth and
thus worsen diarrhea
Antiemetics in AGE
• Ondansetron and metoclopramide reduces
the number of episodes of vomiting in AGE in
children compared to placebo but increases
the incidence of diarrhea
• Use of antiemetics is not recommended in
childhood AGE
Diet in AGE
• There is widespread consensus that breast-fed
babies with dehydration from AGE should be
rehydrated orally or IV but continue breast
• Breast milk contains as much lactose as
formula feeds. Despite this, many people
advocate low lactose or lactose-free formulas,
supposedly because of risk of lactose
intolerance secondary to AGE
Diet in AGE
• A meta analysis of 29 trials (2215 patients) found
no advantage of lactose-free formulas over
lactose-containing formulas for the majority of
infants, although infants with malnutrition or
severe dehydration recovered more quickly when
given lactose-free formula
Brown KH, Peerson JM et al. Pediatrics 1994;93:17-2
• Using diluted food in children recovering from
AGE is not recommended because it is
unnecessary and also prolongs symptoms and
delays nutritional recovery
Diet in AGE
• Formulas containing soy fiber has been
reported to reduce liquid stools without
changing the stool output. This might reduce
diaper rash and encourage early resumption
of normal diet, but the benefits are probably
insufficient to merit its use as a standard of
Diet in AGE
• Children receiving semisolid or solid foods
should continue to receive their usual diet.
Routinely witholding food is inappropriate.
Early feeding reduces changes in intestinal
permeability caused by infection, reduces the
duration of illness, and improves nutrition
Zinc in diarrheal disease
• Severe zinc deficiency is associated with
diarrhea (acrodermatitis enteropathica)
• In developing countries, prophylactic dietary
oral zinc supplementation reduces the
incidence and severity of acute diarrheal
disease in childhood
• The WHO recommends that oral zinc is given
to children in developing countries at the
onset of diarrhea
Probiotics in AGE
• Probiotics are live microorganisms in
fermented foods or components of microbial
cells that have a beneficial effect on the health
and well-being of the host
• No serious adverse effects of probiotics have
been reported in well people, but infections
have been reported in people with impaired
immune systems
Probiotics in AGE
• In one systematic review, probiotics reduce the risk of
diarrhea lasting 3 or more days by 60% and reduce the
duration of diarrhea by 18 hrs
• A cochrane review on 1917 adult and pediatric patients
showed that probiotics reduced the risk of diarrhea at 3
days by 34% and the main duration of diarrhea by 30.5 hrs
• There is great variability among probiotics, further research
is needed to to determine the optimal type, dosage and
• Their routine use is not recommended in AGE in children
but it is likely that their benefit outweighs their harm
Antibiotic associated diarrhea
In most cases no pathogen is identified
Toxin producing C. difficile is responsible for a minority
Stopping antibiotics usually relieves the problem
Dietary manipulation may help
If it is not possible to stop the antibiotic, it is recommended
to change to a regimen less likely to cause diarrhea
• Amoxicillin, broad-spectrum cephalosporins, quinolones are
the antibiotics most commonly associated with diarrhea
• When C. difficile is identified, metronidazole 10 mg/kg (max
400 mg) orally 8 hourly for 7-10 days
Campylobacter enteritis
• Usually self-limited
• Antibiotics have relatively little clinical benefit and
because of the risk of resistance are not routinely
• Antibiotherapy is indicated only when there is high
fever or severe illness suggesting septicemia , usually in
• If antibiotics are indicated: eryhtromycin 10mg/kg PO
q6hrs or azitromycin 10 mg/kg PO daily
• For bacteriemia gentamicin <10y 7.5mg/kg IV daily;
>10 y 6mg/kg IV or ciprofloxacin 10mg/kg (max400mg)
IV q12hrs
• Rehydration is the basis of treatment and can usually
be achieved orally
• Standart ORS or rice-based ORS is recommended
• Antibiotic therapy reduces the volume and duration of
• Azitromycin 20mg/kg POI as a single dose or
doxycycline child>8yrs:2.5mg/kg (max100mg) PO
q12h x3d or ciprofloxacin 25 mg/kg (max 1 g) PO as a
single dose or erythromycin 12.5 mg/kg (max 500mg)
PO q6hx3d
EHEC enteritis
• Infection with some EHEC strains e.g 0157:H7 and
0111:H8 can lead to development of HUS and TTP
• The use of antibiotics is controversial because
they increase the release of shiga-like toxin and
increase the incidence of HUS and TTP in humans
• Studies do not show any benefit of antibiotic use
and some associate antibiotics with a higher risk
of HUS and/or longer duration of diarrhea
EPEC enteritis
• Most EPEC infections occur in developing
countries and organism is never cultured
• If serotype 0111:B4 is cultured mecillinam
(extd spectrum penicillin) showed a clinical
cure 79%, trimethoprim-sulfamethoxazole
73% and placebo only 7%
• The main significance is for traveler’s diarrhea
Non-typhoid Salmonella enteritis(NTS)
• NTS infections are food-borne
• Extraintestinal complications such as
septicemia, meningitis and osteomyelitis are
• Outbreaks are associated especially with
infected meat or eggs, cattle or pigs
• In developing countries, particularly tropical
Africa, NTS are important cause of invasive
extraintestinal disease
Non-typhoid Salmonella enteritis(NTS)
• Antibiotics result more negative stool cultures during the
1st week but cause more frequent clinical relapses and
prolongation of detection of salmonella in stools after 3
• Adverse drug reactions are more common with antibiotics
• Antibiotics are not indicated for asymptomatic short-term
• Antibiotics are indicated for suspected or proven
septicemia (infants<3m , malnourished infants or
immunocompromised children with bloody diarrhea and
fever and /or Salmonella isolated from feces
Non-typhoid Salmonella enteritis(NTS)
• Antibiotics are also recommended for Salmonella
infection occurring in association with chronic
gastrointestinal disease, malignant neoplasms,
hemoglobinopathies or severe colitis
• Amoxicillin is preferred if the organism is susceptible
• For empiric therapy ciprofloxacin 10 mg/kg POq12h
OR azithromycin 20mg/kgPO 1st day and 10mg/kg
• If PO not tolerated ciprofloxacin 10 mg/kg (max
400mg)IV q12h OR ceftriaxone 50mg/kg (max 2g) IV
Typhoid and paratyphoid fevers
• S. typhi and S, paratyphi are endemic in many
developing countries. Almost all infection in
industrialzed countries are acquired by travelers
• It is a septicemic illness rather then diarrheal illness
• Fever, hepatomegaly, abdominal pain, diarrhea,
vomiting, cough, malaise and headache are prominent
findings. Rose spots and bradycardia are rare in
• Febrile convulsions, jaundice, ileus, perforation and
impaired consciousness are other manifestations
• Hematologic abnormalities include neutropenia,
leucopenia and thrombocytopenia
Typhoid and paratyphoid fevers
• For antibiotherapy: ciprofloxacin 15mg/kg
(max500mg) PO q12hx 7-10d OR Azithromycin
20mg/kg (max1g)x5d
• If PO not tolerated ciprofloxacin 10mg/kg
(max400mg) IV q12hx 7-10d OR Azithromycin
20mg/kg (max1g) IVx5d
• If clinical response delayed ceftriaxone
50mg/kg (max 2g) IV daily
• Antibiotic therapy is recommended for children
with shigella dysentery, even if mild, for public
health reasons because a very low inoculum
causes infection
• Effective antibiotics, if the organism is sensitive
include quinolones, ceftriaxone, azithromycin,
cefixime, and cotrimoxazole
• ciprofloxacin 15mg/kg (max500mg) PO q12hx 3d
OR Azithromycin 20mg/kg (max1g)x5d OR
Cotrimoxazole 4+20mg/kg PO q12hx5d
Traveler’s diarrhea
• At least 11 million people develop traveler’s diarrhea worldwide
• Passage 3 or more unformed stools over 24h with symptoms
sterting during or shortly after a foreign travel, nausea,
vomiting, abdominal pain, fever, tanesmus, and blood or mucus
in stools
• About 85% are bacteria and ETEC is the most common one,
campylobacter jejuni is responsible in 30% of cases, salmonella
and shigella each accounts for 15%
• 2/3 of ETEC produce a heat-labile toxin similar to cholera toxin
which induces secretory diarrhea
• For prevention boil it, cook it, peel it or forget it. Avoid drinking
local water, consider tap water and ice cubes as contaminated.
Bottled water is not always safe. Swimming pool is also a
potential risk
Traveler’s diarrhea
• Althogh there are no efficacy data in children, an
oral, killed, recombinant B-sub-unit, whole-cell
vaccine against cholera and ETEC is available. Two
doses given at least one week apart create
immunization one week after the second dose
• Vaccine is licenced in only a few countries
including Sweden and Canada
• Prophylactic antibiotics are recommended only in
immunucompromised child traveling for a short
period of time, in which case ciprofloxacin may
be the antibiotic of chioce
Traveler’s diarrhea
• All trials reported a significant reduction in duration of diarrhea
in participants treated with antibiotics compared with placebo
• The most effective antibiotics for empiric therapy from trials are
quinolones, azithromycin, and rifaximin
• All patients should take fluids and electrolytes. Rehydration with
ORS is particularly important for young children
• Antimotility drugs, such as loperamide, should be avoided in
children, because of the danger of causing paralytic ileus. Mild
cases do not usually need antibiotics
• For moderate to severe disease, azithromycin 20 mg/kg (max 1
g) orally, as a single dose OR ciprofloxacin 20 mg/kg (max 750
mg) orally, as a single dose OR norfloxacin 20 mg/kg (max 800
mg) orally, as a single dose OR trimethoprim+sulfamethoxazole
4+20 mg/kg (max 160+800 mg) orally, 12-hourly for 3 days OR
rifaximin 10 mg/kg orally, 12-hourly for 3 days
• E. histolytica infection can cause non-invasive intestinal
infection, which can be symptomatic or cause amebic
dysentery or colitis, ameboma, and/or liver abscess
• Passage of Entamoeba cysts or trophozoites in the absence
of acute dysenteric illness does not warrant antimicrobial
• Patients with amebic colitis characteristically present with
dysenteric symptoms of bloody diarrhea, abdominal pain,
and tenderness. Children can have rectal bleeding without
diarrhea. The onset can be gradual, with several weeks of
symptoms: often multiple, small volume, mucoid stools,
but sometimes profuse, watery diarrhea
• Toxic megacolon complicates amebic colitis in about
0.5% of patients
• Amebomas are localized inflammatory, annular
masses of the cecum or ascending colon which can
cause obstruction and be confused with carcinomas
• The diagnosis of amebic colitis rests on the
demonstration of E. histolytica in the stool or colonic
mucosa of patients with diarrhea.
• Commercially available ELISA assays are more
sensitive and less user-dependent than microscopy
• Serum antibodies against amebae are detected by
indirect hemagglutination in >70% of patients with
symptomatic E. histolytica infection and are
particularly sensitive (>94%) in amebic liver abscess
• For acute amebic dysentery, the nitroimidazoles
(metronidazole, tinidazole, ornidazole) are >90%
• metronidazole 15 mg/kg (max 600 mg) orally, 8-ourly
for 7–10 days OR tinidazole 50 mg/kg (max 2 g) orally,
daily for 3 days
• Cryptosporidium parvum infection causes frequent, watery
diarrhea, without blood in immunocompetent children. Other
prominent symptoms include crampy abdominal pain, fever, and
vomiting. Asymptomatic infection is rare. Infections are often
waterborne; the cysts are resistant to chlorine, and
contaminated water and swimming pools have been the source
of large outbreaks.
• In immunocompetent children, infection usually resolves after
10 days (range 1–20) and requires no specific treatment.
• In contrast, Cryptosporidium infection can be life-threatening in
immunocompromised children. To treat Cryptosporidium
infection in immunocompromised children, nitazoxanide 1–3
years: 100 mg 12-hourly; 4–11 years: 200 mg 12-hourly; 12 years
or older: 500 mg orally 12-hourly, for 3 days
• Giardia lamblia is a flagellate protozoan parasite with
a worldwide distribution. Infection is primarily
waterborne, and although humans are the main
reservoir of infection, animals such as dogs and cats
can contaminate water with infectious cysts.
• Infection can be asymptomatic, can be acute with
watery diarrhea and abdominal pain, or protracted
with chronic or intermittent foul-smelling stools,
abdominal distension, flatulence, and anorexia
• Diagnosis is by detecting cysts in stool. Although ELISA tests
on stool are slightly more sensitive than direct microscopy for
ova and parasites, one study suggested that both tests need
to be performed to achieve a sensitivity >90%. Diagnosis in
difficult cases may require examination of aspirated duodenal
• Most authorities agree that treatment of patients with
asymptomatic passage of Giardia cysts is unwarranted. The
traditional treatment of symptomatic patients is with
metronidazole 5 mg/kg (max 250 mg) orally, 8-hourly for 5
days, which is 80–95%effective
• For immunocompetent children who fail therapy, it is usual to
repeat the original course while investigating whether
reinfection may have occurred from a family member or
water source
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