Acute Gastroenteritis with dehydration

Medical case presentation on Acute Gastroenteritis with dehydration.

1. CASE PRESENTATION ON AGE WITH MODERATE DEHYDRATION

2. INTRODUCTION: Gastroenteritis , sometimes incorrectly called “stomach flu,” is the most common digestive disorder among children. Gastroenteritis is usually caused by a viral, bacterial, or parasitic infection. The infection causes a combination of vomiting, diarrhoea, abdominal cramps, fever, and poor appetite, which can lead to dehydration. One in 5 children die of diarrhea or diarrhea related complications every year in India . Diarrheal disease is the second leading cause of child mortality; among children younger than 5 years, it causes 1.5 to 2 millions death annually.

3. Each year diarrhoea kills around 525 000 children under five. Globally , there are nearly 1.7 billion cases of childhood diarrhoeal disease every year. Diarrhoea is a leading cause of malnutrition in children under five years old . I n developing countries, children experience between three to six episodes of diarrhea annually. Despites easy & affordable treatment, most patients do not access the recommended treatment. Timely use of ORS-Zinc can save over 133,000 lives by 2015.

4. Body water percentage charts For the first few months of life, nearly three-fourths of your body weight is made up of water. That percentage starts to decline before you reach your first birthday, however. The decreasing water percentage through the years is due in large part to having more body fat and less fat-free mass as you age. Fatty tissue contains less water than lean tissue, so your weight and body composition affect the percentage of water in your body . The following charts represent the average total water in your body as a percentage of body weight, and the ideal range for good health.

5. WATER PERCENTAGE OF BODY WEIGHT For infant & children Water as percentage of body weight in adults Birth to 6 months 6 months to 1 year 1 to 12 years Infants and children average: 74% range: 64%–84% average: 60% range: 57%–64% average: 60% range: 49%–75% Adults Ages 12 to 18 Ages 19 to 50 Ages 51 and older Male average: 59 range: 52%–66% average: 59% range: 43%–73% average: 56% range: 47%–67% Female average: 56% range: 49%–63% average: 50% range: 41%–60% average: 47% range: 39%–57%

6. Where is all this water stored ? With all this water in your body, you may wonder where in your body it’s stored. The following table shows how much water resides in your organs, tissue, and other body parts . In addition, plasma (the liquid portion of blood) is about 90 percent water . Plasma helps carry blood cells, nutrients, and hormones throughout the body Body part Water percentage brain and heart 73% lungs 83% skin 64% muscles and kidneys 79% bones 31%

7. About  two-thirds of the body’s water is within the cells, while the remaining third is in extracellular fluid. Minerals, including potassium and sodium, help maintain ICF and ECF balances . DISTRIBUTION OF TOTAL BODY WATER

8. ANATOMY OF THE DIGESTIVE SYSTEM

9. ORGAN MAJOR FUNCTIONS OTHER FUNCTIONS Mouth Ingests food Chews and mixes food Begins chemical breakdown of carbohydrates Moves food into the pharynx Begins breakdown of lipids via lingual lipase Moistens and dissolves food, allowing you to taste it Cleans and lubricates the teeth and oral cavity Has some antimicrobial activity Pharynx Propels food from the oral cavity to the esophagus Lubricates food and passageways Esophagus Propels food to the stomach Lubricates food and passageways Stomach Mixes and churns food with gastric juices to form chyme Begins chemical breakdown of proteins Releases food into the duodenum as chyme Absorbs some fat-soluble substances (for example, alcohol, aspirin) Possesses antimicrobial functions Stimulates protein-digesting enzymes Secretes intrinsic factor required for vitamin B 12  absorption in small intestine

10. ORGAN MAJOR FUNCTIONS OTHER FUNCTIONS Small intestine Mixes chyme with digestive juices Propels food at a rate slow enough for digestion and absorption Absorbs breakdown products of carbohydrates, proteins, lipids, and nucleic acids, along with vitamins, minerals, and water Performs physical digestion via segmentation Provides optimal medium for enzymatic activity Accessory organs Liver: produces bile salts, which emulsify lipids, aiding their digestion and absorption Gallbladder: stores, concentrates, and releases bile Pancreas: produces digestive enzymes and bicarbonate Bicarbonate-rich pancreatic juices help neutralize acidic chyme and provide optimal environment for enzymatic activity

11. ORGAN MAJOR FUNCTIONS OTHER FUNCTIONS Large intestine Further breaks down food residues Absorbs most residual water, electrolytes, and vitamins produced by enteric bacteria Propels feces toward rectum Eliminates feces Food residue is concentrated and temporarily stored prior to defecation Mucus eases passage of feces through colon The processes of digestion include six activities: Ingestion , Propulsion , Mechanical or physical digestion, Chemical digestion, absorption, D efecation .

12. DEFINITION Gastroenteritis is inflammation of the digestive tract that results in vomiting, diarrhoea, or both and is sometimes accompanied by fever or abdominal cramps. OR Acute gastroenteritis (AGE) is a diarrheal disease of rapid onset, with or without accompanying symptoms and signs, such as nausea, vomiting, fever or abdominal pain. Severe gastroenteritis causes dehydration and an imbalance of blood chemicals (electrolytes) because of a loss of body fluids in the vomit and stool.

13. CAUSES & HIGH RISK GROUP BOOK PICTURE PRESENT IN BABY Contaminated water & food √ Poor hygiene √ Nutritional deficiency √ Poor sanitation √ Immune deficient individual Malnutrition √ Travel to endemic areas Lack of breastfeeding √ Exposure to unsanitary conditions Poor maternal education √

14. RESERVOIR OF INFECTION: Man is the main reservoir of enteric pathogens so most transmission originates from human factors. For some enteric pathogens & viral agents animals are the important reservoir. HOST FACTORS: The disease is the most common in children especially those between 6 months to 2 years. The incidence is highest during weaning period i.e. 6 to 11 months of age. It occurs due to combined effects of reduced maternal antibodies, lack of active immunity & introduction of contaminated food or direct spread through child’s hands. Diarrhea is more common in artificial feeding, specially with contaminated cow’s milk or unhygienic preparation of tin milk.

15. Malnourished children are more prone to diarrhea. Malnutrition leads to infection & infection leads to diarrhea., which is vicious cycle. The predisposing factors of diarrhea include prematurity, immunodeficiency conditions, lack of personal hygiene, inadequate food hygiene, incorrect infant feeding practices, illiteracy, poor socioeconomic status. Etc. ENVIRONMENTAL FACTORS: Is more frequently occur in summer & rainy season, whereas viral diarrhea (specially rotavirus) found in water. Diarrheal disease are more commonly seen in unhygienic environment. MODES OF TRANSMISSION: Is mainly feco -oral route. It is water borne, food-borne disease or may transmit via fingers, fomites, flies or dirt.

16. PATHOPHYSIOLOGY

17. ETIOLOGY VIRAL 70- 85% of AGA in developed countries. Rotavirus: 60% represents of all paediatric AGA hospitalization. I s the most common cause of severe, dehydrating diarrhoea among infants and children worldwide. Rotavirus is highly contagious. Most infections are spread by fecal -oral transmission. Infected infants may spread the infection to adults. In temperate climates, rotavirus infections are most common in the fall and winter months and are less common in the summer. In tropical climates, they can occur year round P resentation: Mild or moderate fever V omiting followed by copious watery diarrhoea (up to 10-20 bowel movements per day) usually non foul smelling. Diarrhoea persisting for 5-7 days.

18. Astrovirus   C an infect people of all ages but usually infects infants and young children. Infection is most common in the winter and is spread by fecal -oral transmission . Adenovirus Most commonly affects children under the age of 2. Infections occur year-round and increase slightly in the summer. The infection is spread by fecal -oral transmission.

19. BACTERIAL The bacteria that most commonly cause gastroenteritis include; Campylobacter, Salmonella, Shigella, E. Coli, Clostridium difficile . Children can contract bacterial gastroenteritis by Touching or eating contaminated foods, particularly raw or inadequately cooked meats or eggs Eating contaminated shellfish Drinking unpasteurized milk or juice Touching animals that carry certain bacteria Swallowing contaminated water, such as from wells, streams, and swimming pools

20. Presentation: High fever with shaking chills. Foul smelling stool Bloody bowel movements Abdominal cramping & fecal leucocytes

21. PARASITIS <10% of cases. Gastroenteritis caused by parasites (such as  Giardia intestinalis & Cryptosporidium parvum is usually acquired by drinking contaminated water or by fecal -oral transmission. The parasite  Entamoeba histolytica  is a common cause of bloody diarrhea in developing countries but is rare in the United States . Presentation: Watery stools greenish, frothy stools Urgency of passing stools after meals Low grade fever

22. Chemical toxins Gastroenteritis may result from ingesting  chemical toxins. These toxins can be found in plants, such as poisonous mushrooms, or in certain kinds of exotic  seafood. Children who eat these substances may develop gastroenteritis . Children also can develop gastroenteritis after drinking water or eating food that is contaminated by chemicals such as arsenic, lead, mercury, or cadmium.

23. PATHOPHYSIOLOGOCAL CHANGES TYPES MECHANISM COMPLICATIONS Secretory Acute watery diarrhea Sodium pump failure Rapid development of dehydration Electrolyte imbalance. Invasive Microbes invades intestinal mucosal cells Blood & mucus in stools Septicemia Intestinal obstruction Toxic maga -colon Osmotic Injury to enterocytes Brush border damage Large, frothy, explosive, acidic stools Dehydration hypernatremia

24. CLINICAL FEATURES BOOK PICTURE PRESENT IN BABY Nausea & Vomiting √ Diarrhoea √ Loss of appetite √ fever √ Abdominal pain √ Abdominal cramps Bloody stool Fainting & Weakness √ Dehydration √ Lethargic √

25. LABORATORY INVESTIGATION Careful history ( travel, blood in stool , water, contact, recent antibiotics, fever, vomiting. P hysical examination S tool analysis CBC Electrolytes

26. H istory IN BOOK IN PATIENT Onset, duration & number of episodes of stools per day Since 2 days , 4 - 7 episodes per day , watery greenish & foul smelling stool Blood in stool Episodes of vomiting per day Since 2 days, non- projectile Presence of fever, cough, convulsions, recent measles High grade Fever since 2 days Type & amounts of fluids taken Cow’s milk , 20- 40 cc every 3 hrly Drug history NO Immunization history Upto the age

27. PATIENT INVESTIGATIONS BIOCHEMISTRY Serum Electrolytes (16/10/19) TEST DESCRIPTION OBSERVED VALUE NORMAL VALUE Sr. Sodium 154.7 136 – 145 mmol /L Sr. Potassium 3.62 3.5 – 5.1 mmol /L Sr. Chloride 132.4 98 – 107 mmol /L creatinine 2.22 0.3 – 1.0 mg/dl

28. COMPLETE BLOOD COUNT (16/10/19) TEST DESCRIPTION OBSERVED VALUE NORMAL RANGE Hemoglobin 11.4 10.5 – 14.0 gm /dl RBC 3.57 3.8 – 5.4 mill/cu.mm Hematocrit 32.9 32 – 42 % Mean Corpuscular vol. / MCV 92.16 72 - 88 Fl Mean Corpuscular Hb /MCH 31.93 24 – 30 pg MCHC 34.65 32.0 – 36.0 % White blood cells 20500 6000 – 14000 / cmm Neutrophils 70 40 – 75 % Lymphocytes 23 35 – 69 % Platelet count 525000 150000 – 450000/ cmm

29. INVESTIGATIONS BOCHEMISTRY LAB REPORT (17/10/19) PARAMETER RESULTS NORMAL RANGE Blood Urea Nitrogen 66.3 10 - 15 mg% Sr. Creatinine 2.0 01 - 02mg % Blood Glucose (F/R) 76 60 - 100mg% Sr. SGOT (AST) 34.0 Upto 40.0 U/L Sr. SGPT (ALT) 44.0 UPTO 40.0 U/L Sr. Sodium 140 132 - 144 mEq /L Sr. Potassium 3.0 3.6 – 4.8 mEq /L Sr. Chloride 130 96 – 105 mEq /L

30. BOCHEMISTRY LAB REPORT 18/10/19 PARAMETER RESULTS NORMAL RANGE Blood Urea Nitrogen 27 10 - 15 mg% Sr. Creatinine 0.8 01 - 02mg % Blood Glucose (F/R) 121 60 - 100mg% Sr. SGOT (AST) 22.0 Upto 40.0 U/L Sr. SGPT (ALT) 59.0 UPTO 40.0 U/L Sr. Sodium 143 132 - 144 mEq /L Sr. Potassium 3.9 3.6 – 4.8 mEq /L

31. 19/10/19 PARAMETER RESULTS NORMAL RANGE Blood Urea Nitrogen 23.1 10 - 15 mg% Sr. Creatinine 0.7 01 - 02mg % Blood Glucose (F/R) 60 - 100mg% Sr. SGOT (AST) Upto 40.0 U/L Sr. SGPT (ALT) UPTO 40.0 U/L Sr. Sodium 143 132 - 144 mEq /L Sr. Potassium 3.7 3.6 – 4.8 mEq /L

32. 20/10/19 PARAMETER RESULTS NORMAL RANGE Blood Urea Nitrogen 20.9 10 - 15 mg% Sr. Creatinine 0.7 01 - 02mg % Blood Glucose (F/R) 69 60 - 100mg% Sr. SGOT (AST) Upto 40.0 U/L Sr. SGPT (ALT) UPTO 40.0 U/L Sr. Sodium 140.0 132 - 144 mEq /L Sr. Potassium 3.2 3.6 – 4.8 mEq /L Sr. chloride 127 96 – 105 mEq /L

33. 22/10/19 PARAMETER RESULTS NORMAL RANGE Blood Urea Nitrogen 5.7 10 - 15 mg% Sr. Creatinine 0.5 01 - 02mg % Blood Glucose (F/R) 67.0 60 - 100mg% Sr. SGOT (AST) Upto 40.0 U/L Sr. SGPT (ALT) UPTO 40.0 U/L Sr. Sodium 133 132 - 144 mEq /L Sr. Potassium 4.6 3.6 – 4.8 mEq /L Sr. chloride 119 96 – 105 mEq /L

34. ABG ANALYSIS 17/10/19 PARAMETER RESULTS pH 7.14 pCO2 27 mmHg pO2 37 mmhg Na+ 156 mmol /L K+ 2.1 mmol /L Ca + 0.86 mmol /L Glu 94 mg/dl Lac 1.2 mmol /L HCT 44% HCO3 9.4

35. ABG ANALYSIS 19/10/19 20/10/19 PARAMETER RESULTS pH 7.26 pCO2 31 mmHg pO2 31mmhg Na+ 151 mmol /L K+ 3.0 mmol /L Ca + 1.01 mmol /L Glu 70 mg/dl Lac 2.1 mmol /L HCT 36% HCO3 14.5 PARAMETER RESULTS pH 7.29 pCO2 25 mmHg pO2 68 mmhg Na+ 142 mmol /L K+ 2.7 mmol /L Ca + 1.02 mmol /L Glu 67 mg/dl Lac 3.0 mmol /L HCT 35% HCO3 12.0

36. 22/10/19 PARAMETER RESULTS pH 7.37 pCO2 24 mmHg pO2 62 mmhg Na+ 145 mmol /L K+ 3.5 mmol /L Ca + 0.81 mmol /L Glu 53 mg/dl Lac 0.8 mmol /L HCT 26 % HCO3 16.9 mmol /L

37. BIOCHEMISTRY INVESTIGATION 18/10/19 PARAMETER RESULTS NORMAL RANGE Calcium 11.8 9.0 – 11.0 mg% Phosphorus 1.3 2.5 – 7.0 mg% Alk . phosphatase 112.0 50 – 370 U/L T. Billirubin 0.70 Upto 1.0 mg% D. Billirubin 0.28 Upto 0.5 mg% SGOT 70.0 Upto 40.0 U/L SGPT 77.0 Upto 40.0 U/L

38. STOOL ROUTINE & MICROSCOPIC REPORT PHYSICAL EXAMINATION Colour: green Consistency: semi-solid Adult worms: not seen Blood : absent Mucus: present MICROSCOPIC EXAMINATION Ova: absent Cysts: absent Larvae: absent chemical examination: pH-6 occult blood : present fat globules: present macrophages: absent

39. 17/10/19 USG ABDOMEN IMPRESSION: Minimal interbowel free fluid. RAPID DIAGNOSTIC TEST FOR MALARIA ANTIGEN REPORT Result : Negative DENGUE NS1 Ag RAPID TEST: Result: negative Dengue IgM / IgM Rapid test: Result: negative

40. BLOOD EXAMINATION: 19/10/19 Hb : 8.0 PCV: 28.3 WBC: 8.500 Polymorphs: 63 Lymphocytes: 37% 21/10/19 Hb : 10.1 PCV: 31.9 WBC: 12,600 Polymorphs: 63 Lymphocytes: 33%

41. Assessment: G oals : 1. Identify the type of diarrhea. 2. Look for dehydration & other complication. 3. A ssess for malnutrition. 4. Assess feeding.

42. ASSESSMENT OF DEHYDRATION Dehydration is the important life threatening feature which is usually associated with Diarrhea. Diarrheal stools are usually loose or watery in consistency. It may be greenish or yellowish-green in color with offensive smell. It may be contain mucus, pus or blood & may expelled with force, preceded by abdominal pain.

43. A B C 1 . Ask about Diarrhea Less than 4 liquid stools per day 4 to 10 liquid stools per day More than 10 liquid stools Vomiting None/small amount Some Very frequent Thirst Normal Greater than normal Unable to drink Urine Normal A small amount and dark No urine for 6 hours 2. Look at Condition Well, alert Restless, irritable, or sleepy Lethargic/ unconscious, floppy Eyes Normal Sunken Very sunken & dry Tears Present Absent Absent Mouth & tongue Moist Dry Very dry Breathing Normal Faster than normal Very fast & deep 3. Feel Skin pinch Goes back quickly Goes back slowly Goes back very slowly Pulse Normal Faster than normal Very fast, weak, cannot feel

44. A B C Decide degree of dehydration The patient has no signs of dehydration If the patient has two or more signs including at least one sign there is some dehydration. If the patient has two or more signs including at least one sign there is severe dehydration

45. CLINICAL FEATURE OF DEHYDRATION IN BOOK IN PATIENT frequency of stools varies from 2 to 20 per day or more. √ low-grade fever, thirst, anorexia, with intermittent vomiting & abdominal distension. √ behavioural changes like irritability, restlessness, weakness, lethargy, sleepiness, delirium, stupor, flaccidity usually are present. √ Loss of weight √ Poor skin turgor √ Dry mucous membrane, dry lips, pallor, √ Sunken eyes √ Depressed fontanelles √ Decreased or absence of urinary output √ Vitals changes like low blood pressure, tachycardia, rapid respiration, cold limbs.

46. COMPARISON OF DEHYDRATION: MILD (<5% body wt lost) MODERATE (5-9%) SEVERE (>10%) MENTAL STATUS Alert Alert to listless Alert to comatose FONTANELES Soft & flat Sunken Sunken EYES Normal Mildly sunken orbits Deeply sunken orbits ORAL MUCOSA Pink & moist Pale slightly dry Dry SKIN TURGOR Elastic Decreased Tenting HEART RATE Normal May be increased Increased, progressing to bradycardia BLOOD PRESSURE Normal Normal Normal progressing to hypotension EXTREMITIES Warm, pink, brisky capillary refill Delayed capillary refill Cool, mottled , Delayed capillary refill URINE OUTPUT May be slightly decreased <1 ml /kg/hour Significantly <1 ml/kg/ hr

47. MANAGEMENT AIM OF TREATMENT Assessment of fluid & electrolyte imbalance. oral Rehydration Maintenance fluid therapy R eintroduction adequate diet Symptom management

48. FLUID MANAGEMENT: Oral rehydration therapy : IV fluids in treatments of mild to moderate dehydration oral reabsorption of sodium & water. The management of AGE in a vast majority of children is best done with ORS solution & continue feeding. Oral rehydration therapy means drinking of solution of clean water, sugar & mineral salts to replace the water & salt from the body during diarrhea especially when accompanied by vomiting, i.e. gastroenteritis. It is beneficial in three stages: Prevention of dehydration R ehydration of the dehydrated child Maintenance of hydration after severely dehydrated patient has been rehydrated with IV fluid therapy.

49. COMPOSITION OF ORS AS PER THE WHO & UNICEF COMPONENT CONTENT PER LITER WATER SODIUM CHLORIDE 2.6 GM POTASSIUM CHLORIDE 1.5 GM SODIUM CITRATE 2.9 GM GLUCOSE ANHYDROUS 13.5 GM TOTAL 20.5 Dissociated into Mmo /L GLUCOSE 75 SODIUM 75 CHLORIDE 65 POTASSIUM 20 CITRATE 10 TOTAL 245

50. THE APPROXIMATE AMOUNT OF ORS SOLUTION GIVEN IN THE FIRST 4 HRS AS FOLLOWS: A ge less than 4 months or weight less than 5kg: 200-400 mL Age 4 to 11 months or weight 5 to 7.9 kg : 400-600 mL Age 12 to 23 months or weight 8 to 10.9 kg: 600-800 mL Age 2 to 4 years or weight 11 to 15.9 kg: 800-1200 mL Age 5 to 14 years or weight 16 to 29.9 kg: 1200-2200 mL Age 15 years or older or weight 30kg or more: 2200-4000 mL

51. PREPARATION FOR ORS

52. NG FEEDING: For children who do not tolerate feed or ORS by mouth, nasogatric feeding is a safe & effective treatment. IV REHYDRATION: IV access should be obtained in severe dehydration & patient should administered a bolus of 20 – 30mL/kg lactated Ringer or NS solution over 60 minutes. DIET: In general, children with gastroenteritis should be returned to a normal diet as rapidly as possible; early feeding reduces illness duration & improves nutritional status. the vicious circle of malnutrition and diarrhoea can be broken by continuing to give nutrient rich foods, including breast milk during an episode, and by giving a nutritious diet – including exclusive breastfeeding for the first six months of life to children when they are well.

53. SYMPTOMATIC & PHARMACOLOGICAL MANAGEMENT Symptomatic management of vomiting, fever, convulsion & abdominal distension to be done with specific drug. Antiemetics : Ondansetron (0.1 to 0.2 mg/kg/dose) or metoclopramide to reduce vomiting. ANTIBIOTICS : usually not need but if stool culture shows Shigella then Ciprofloxacin, (15mg/kg/day) for 5 days. Alternatively Ceftriaxone (50 to 100 mg/kg/day) for 5 days. For amoebic dysentery tinidazole / metronidazole can be used. Vaccines : In Feb 2006 the Food & Drug Administration (FDA) approved the RotaTeq vaccine for the prevention of rotavirus gastroenteritis. Zinc: it is micro-nutrient & promotes immunity. It helps to reduces the fluid & salt loss in stools by improving mucosal permeability. Accelerated regeneration of mucosa & increased levels of brush-border enzymes. Also helps to absorption of ORS. Full dose for 14 days protects against diarrhea & pneumonia foe the next 3 months.

54. Management of dehydration Plan A : Treatment of diarrhoea at home Counsel the mother on the 4 rules of home treatment . 1. Give extra fluid 2. Give zinc supplements 3. Continue feeding 4. When to return Danger signs to be explained to the mother: Continuing diarrhea beyond 3 days increased stool volume/frequency Repeated vomiting Increasing thirst Increased irritability/lethargy refused to feed Fever & blood in stools

55. AMOUNT OF ORS AGE AMOUNT OF ORS TO BE GIVEN AFTER EACH LOOSE STOOLS AMOUNT OF ORS TO BE PROVIDED AT HOME <24 MONTHS 50 to 100ml 500/ day 2-10 YEARS 100 to 200ml 1000ml/day >10 YEARS Ad lib 2000ml/day

56. Plan B Treatment for some dehydration with ORS Determine amount of ORS to give during first 4 hour Age Up to 4 months 4 up to 12months 12 months up to 2 years 2 years up to 5 years Weight <4 kg 6 -<10 kg 10-<12 kg 12-<20kg Fluid in ML 200–450 450–800 800–960 960–1600

57. PLAN C Should be treated in hospital ideal fluid is RL with 5% dextrose, NS or plain RL can be used as alternative. total 100cc/kg fluid should be given. if severe dehydration is persistent repeat IV fluids & start rehydration by the tube (NGT feeding). Hydration improved but some dehydration present shift to plan B. No hydration shift to plan A. AGE 30ML/KG 70ML/KG <12 months 1 hr 5 hrs >12 months 30min 2 hrs 30 min

58. Patient treatment 21/10/19 Inj. Cefotaxime (150mkd) 150mg IV TDS Inj. PCM 25 mg/kg/day (5ml =125mg) 2ml sos for fever Syp. zinc 2.5 ml OD Syp. MVBC 2.5 ml BD Syp. Cal D 3 ml BD Syp. Metronidazole (10 mg/kg/day ) 5 ml=100mg TDS

59. DRUG NAME AVAILABLE DOSE ORDERED DOSE ACTION SIDE EFFECT Inj. Cefotaxime 1 gm 150mg Broad spectrum antibiotic (third generation cephalosporin) with acting against numerous gram positive & gram negative bacteria. Inhibits bacterial cell wall synthesis by binding to one/ more penicillin binding protein. Swelling, redness, or pain at the injection site may occur.  Rash, itching , fever, nausea, Vomiting , stomach pain, headache , diarrhea etc. Inj. PCM 60 ml 2ml Exact action is not known. Paracetamol (anti-inflammatory) is thought to relieve pain by reducing the production of prostaglandins in the brain and spinal cord. Paracetamol toxicity is the foremost cause of  acute liver failure. Syp. zinc 50 ml 2.5 ml Zinc restores mucosal barrier integrity & enterocyte brush border enzyme activity, it promotes the production of antibodies & circulating lymphocyte against intestinal pathogens. Nausea , vomiting gastric  irritation, neurologic deterioration

60. DRUG NAME AVAILABLE DOSE ORDERED DOSE ACTION SIDE EFFECT Syp. MVBC 100 ml 2.5 ml Multivitamins are used to provide  vitamins that are not taken in through the diet. Multivitamins are also used to treat vitamin deficiencies (lack of  vitamins ) caused by illness, pregnancy, poor nutrition, digestive disorders, and many other conditions. upset stomach, headache; or unusual or unpleasant taste in your mouth Syp. Cal D3 200 ml 3 ml used for  Calcium supplementation ,  Deficiency of vitamin d , Low magnesium levels and other conditions. Abdominal pain Constipation Headache Loss of appetite Nausea, Vomiting Stomach ache Feeling of sickness Excessive thirst Syp. Metronidazole 60 ml 5 ml=100mg brand name  Flagyl , it is an  antibiotic  and  anti- protozoal medication .It inhibits nucleic acid synthesis by disrupting the DNA of microbial cells Dizziness ,  headache ,   stomach  upset,  nausea, vomiting , loss of appetite,  diarrhea ,  constipation , or  metallic taste  in  mouth may occur. Darker urine .

61. COMPLICATIONS : Dehydration E xcessive loss of fluids & minerals (electrolytes) from the body & electrolyte deficiency. E lectrolyte disturbances : Hypokalemia ; Hypocalcemia ; Hyponatremia . M etabolic acidosis Acute renal failure Systemic infection (meningitis, arthritis, pneumonia) especially with  Salmonella  infections Sepsis ( Salmonella, Yersinia, Campylobacter  organisms ) Toxic megacolon Convulsion due to; Hypogycemia , CNS infection, Hypocalcemia , Brain edema . Shock Guillain-Barré syndrome  ( Campylobacter  organisms )

62. Dehydration can lead to more serious problems, such as: Heat Injury   If don’t have enough fluids while you’re physically active, you could have a life-threatening heatstroke. Urinary and Kidney Issues  A long or repeated episode of dehydration can trigger kidney stones, urinary tract infections (UTIs), or kidney failure. Seizures  When your electrolytes are out of whack, could develop seizures. Hypovolemic Shock  This life-threatening condition happens when low blood volume causes a drop in blood pressure and the amount of oxygen in body.

63. Prevention Key measures to prevent diarrhoea include: Access to safe drinking-water; Use of improved sanitation; Hand washing with soap; Exclusive breastfeeding for the first six months of life; Good personal and food hygiene; Health education about how infections spread; and Rotavirus vaccination.

64. HEALTH EDUCATION Make sure before feeding to baby or preparing feed for baby washes your hands regularly, especially after the use the toilet and after you change your child’s nappies. Wash your hands with warm water and soap. Utensils should be cleaned with warm water. Continue the breastfeeding & also give additional fluid like ORS it will help to replace water lost by diarrhoea and vomiting , give the water needed for normal health & provide some sugars and salts that children need to keep their strength up. Never give baby unpasteurized milk or untreated water. Watch for signs of dehydration like; baby has a dry mouth and tongue or he is not passing urine (dry nappies), not taking feed, has sunken eyes, has cold hands and feet & is more sleepy than usual. H ave your child immunized for rotavirus. Checked for the anal region for any infection.

65. NURSING DIAGNOSIS 1. Diarrhea related to bacterial or viral infection as evidenced by increase frequency of loose motion. 2. Risk for fluid deficient volume related to refused to take feed, diarrhea & vomiting. 3. Imbalanced nutrition status less than body requirement related to decrease oral intake. 3. Impaired skin integrity related to irritation caused by frequent, loose stools. 4. Knowledge deficient related to disease condition as evidenced by mother is not taking proper care. 5. Hyperthermia related to infection as evidenced by temperature 100.2 & dehydration

66. RESEARCH ARTICLES Ashwini Dedwal , MD, Sae Pol, PhD , et al (2016) conducted study on Microbial Etiology of Acute Gastroenteritis in Pediatric Patients in Western India. One hundred stool samples were collected from children admitted with acute diarrhea of 72 hours or less duration in 1–60 months of age over a period of 1 year. Bacteria were identified by standard Microbiological methods and Serotyping of isolated  E. coli  was done.  Rotavirus  antigen was detected by ELISA followed by genotyping by RT-PCR and multiplex PCR. Parasitic identification was done by microscopy . Seventy-four percent of children with diarrhea were in the age group of 7 to 12 months. Watery diarrhea (94%) was the commonest clinical presentation, followed by vomiting (78%), fever (78%), and dehydration (74%). Pathogenic bacteria were isolated in 51% of samples.  Escherichia coli  was most common (48%) followed by  Shigella flexneri  (2%) and  Vibrio cholerae  (1%).

67. The most prevalent  E. coli  type was  Enterotoxigenic Escherichia Coli  (20.8%) followed by  Enteropathogenic Escherichia Coli  (16.7%),  Enterohemorrhagic Escheria Coli  (4.1%), and  Shiga Toxin producing EC  (2.1%). The most prevalent serotypes of  ETEC  were O27, O23, and O169. Among  EPEC  most prevalent serotypes were O90, O26. The most prevalent  EHEC  strain found in this study was O71.  Rotavirus  was detected in 35% of patients. Most prevalent  Rotavirus geno type was G9P[4] (28.6%) followed by G2P[4] (21.4%), G1P[8] (21.4%), G12P[6] (14.3%), G9P[8] (7.1%). Parasitic etiology was detected in 5% of cases. infection of  E. coli  and  Rotavirus  was detected in 23% of children. Rotavirus was most commonly associated with  EPEC  (25.7%) followed by ETEC (17.1%). This study concluded as E . coli  was the commonest microorganism followed by  Rotavirus . Thus, the importance of safe water and food hygiene would be most important intervention to prevent acute gastroenteritis in children along with  Rotavirus  vaccine.

68. Ritika ghosh (2017) conducted A Study of Electrolyte Disturbances in a Child Presenting with Acute Gastroenteritis, with Special Emphasis on Hyponatremic Dehydration. To study the electrolyte changes in moderate and severe dehydration in AGE in children. (2) To study the incidence and clinical features of Hyponatremic dehydration. Materials and A cross-sectional type of observational study of 200 children admitted with AGE with moderate to severe dehydration was conducted at M R Banglur hospital, Kolkata. AGE constituted 18% of the total admissions. 22% had Hyponatremia , 71.5% had Isonatremia and 6.5% had Hypernatremia. Out of 30 children who were suffering from Hyponatremic dehydration and had ORS before admission, 83.3% were given diluted ORS. Clinical features significantly associated with Hyponatremia were increased frequency of diarrhea, absence of thirst, tachycardia, abdominal distension and severe dehydration. Conclusion : Hyponatremic dehydration is the second most common type of dehydration next to Isonatremic dehydration, but it is more common in children who took diluted ORS. Hyponatremic dehydration may be suspected from the history and clinical features. Increased awareness regarding ORS preparation may help in preventing Hyponatremia in AGE. What is already known: Isonatremic dehydration is the most common electrolyte abnormality found in AGE. What this study adds: Hyponatremic dehydration is the most common electrolyte abnormality found in those suffering from AGE, who have taken inappropriately diluted Oral Rehydration Solution (ORS).