The two commonest causes are ?
infective gastroenteritis and antibiotic-induced diarrhoea.
Definition
An illness of acute onset, of less than 10 days duration
- associated with fever, diarrhoea and/or vomiting,
- where there is no other evident cause for the symptoms.
Prevention:
Rotavirus vaccine <6 mths
Causes
Viral (80%): mainly rotavirus, norovirus and adenovirus
Bacterial: C. jejuni & Salmonella sp. (two commonest), E. coli & Shigella sp.
Protozoal: Giardia lamblia, Entamoeba histolytica, Cryptosporidium
Food poisoning—staphylococcal toxin
Exclude acute appendicitis and intussusception in the very young.
What are the causes of death in GE?
Dehydration from gastroenteritis is an important cause of death,
- particularly in obese infants
- esp. if vomiting accompanies the diarrhoea
Symptoms
- Anorexia
- nausea
- poor feeding
- vomiting
- fever
- diarrhoea (fever and vomiting may be absent)
Fluid stools (often watery) 10–20/d
Crying due to pain, hunger, thirst or nausea
Bleeding uncommon (usually bacterial)
Anal soreness
Assessment of dehydration
The simplest way is by careful clinical assessment e.g.
- urine output
- vomiting
- level of thirst
- activity
- pinched skin test
The most accurate way is to weigh the child, preferably without clothes, on the same scale each time.
% loss of body weight is the best measure of dehydration.
It is usual to classify dehydration as:
1. Mild (up to 3% dehydration): normal signs, inc. urine output
2. Moderate (3 to 9%): irritable, lethargic, dry mucous membranes, decreased urine
3. Severe < 9% dehydration: very sick child, no urine output
Management
Management is rehydration based on the assessment and correction of fluid and electrolyte loss.
Avoid:
- Drugs—antidiarrhoeals, antiemetics and antibiotics
- Lemonade—osmotic load too high: can use if diluted 1:6 in water
To treat or not to treat at home
Treat at home—if family can cope, vomiting is not a problem and no dehydration
Admit to hospital—if dehydration or persisting vomiting or family cannot cope; infants <6 mths; high-risk patients
Severe dehydration
- Admit to hospital
- Urgent IV infusion of isotonic fluid
Keep child isolated from other children until settled; maintain hygiene, carers wash hands carefully and careful nappy disposal
Advice to parents (for mild-to-moderate diarrhoea)
General rules
- Give small amounts of fluids often
- Continue normal meals judiciously: no specific dietary restrictions necessary
- Continue breastfeeding (can be increased) or start bottle-feeding after 24 h
- Provide maintenance fluid and fluid loss
Day 1
Give fluids, a little at a time and often
- e.g. 5 mL every 1–2 mins by spoon or syringe or 50 mL every 15 mins if vomiting a lot
- A good method is to give 200 mL (about 1 cup) of fluid every time a watery stool is passed or a big vomit occurs.
Ideal fluid is Gastrolyte or New Repalyte.
Other suitable oral rehydration preparations are WHO recommended solutions Electrolade and Glucolyte.
Hydralyte, a solution as an ‘icy pole’ formulation.
Alternatives are:
- lemonade (not low-calorie): 1 part to 6 parts water
- sucrose (table sugar) or glucose: 1 to 120 mL water
- cordials (not low-calorie): 1 part to 16 parts water
- fruit juice: 1 part to 4 parts water
Day 2
Reintroduce the baby’s milk or full strength infant formula.
Day 3
- Normal strength milk and reintroduce the usual diet.
- Avoid excessive intake of fluids containing sugar.
Method of assessing fluid requirements
Fluid loss (mL) = % dehydration × body weight (kg) × 10
Maintenance (mL/kg/24 h): 1–3 mth: 120 mL; 4–12 mth: 100 mL; >12 mth: 80 mL
Allow for continuing loss, e.g. 8-mth 10-kg child with 5% dehydration:
- fluid loss = 5 × 10 × 10 = 500 mL
- maintenance = 100 × 10 = 1000 mL
Total 24-h requirement (minimum) = 1500 mL
Approximate average hrly requirement = 60 mL
Aim to give more (replace fluid loss) in the first 6 hrs
Rule of thumb: 100 mL/kg (infants) and 50 mL/kg (older children) in first 6 h
