CONTINOUS MEDICAL EDUCATION AGE IN PEDIATRIC

pediatric posting regular discussion cases

1. Acute Gastroenteritis Presenter: dr farra najwa Supervisor: dr MADIHAH Specialist: dr akma

2. introduction Leading cause of childhood morbidity and mortality Dehydration and electrolytes loss Important cause of malnutrition Oral rehydration solution (ORS) Safely and effective Severe dehydration may require intravenous fluid therapy Gastroenteritis is the inflammation of stomach & intestine (hallmark: increased stool frequency with alteration in stool consistency) Acute gastroenteritis (2 weeks duration ) Chronic gastroenteritis (>2 weeks duration)

3. First assess the state of perfusion of the child

4. Counsel the mother on the 3 rules of home treatment 1. Give extra fluid, 2. Continue feeding 3. When to return PLAN A: TREAT DIARRHOEA AT HOME

5. Give Extra Fluids ( as much as the child will take) Tell the mother: Breastfeed frequently and for longer at each feed. If exclusively breastfed, give Oral Rehydration Solution (ORS) or cooled boiled water in addition to breastmilk . If the child is not exclusively breastfed, give one or more of the following: ORS, food-based fluids (soup and rice water) or cooled boiled water. Give frequent small sips from a cup or spoon. If child vomits, wait 10 minutes, then continue but more slowly. Continue giving extra fluid until diarrhoea stops. It is especially important to give ORS at home when: The child has been treated with Plan B or Plan C during this visit.

6. Teach the mother how to mix and give ORS. Give her 8 sachets to use at home. Show mother how much ORS to give in addition to the usual fluid intake: Up to 2 years : 50 to 100ml after each loose stool 2 years or more : 100 to 200ml after each loose stool (If weight is available, give 10ml/kg of ORS after each loose stool)

7. Continue Feeding Continue nursing on demand. @ Continue their usual formula immediately on rehydration. Lactose-free or lactose-reduced formula usually are unnecessary. Continue to receive their usual food during the illness. Foods high in simple sugar should be avoided

8. When to Return (to clinic/hospital) •   Is not able to drink or breastfeed or drinking poorly. • Becomes sicker. •  Develops a fever. •  Has blood in stool.

9. PLAN B : TREAT SOME DEHYDRATION WITH ORS

10. Show the mother how to give ORS solution Frequent small sips from cup or spoon. Vomits wait 10 minutes, then continue but more slowly Continue breastfeeding

11. After 4 hours Reassess and classify the child for dehydration. Select the appropriate plan to continue treatment (Plan A, B or C). Begin feeding the child

12. If the mother must leave before completing treatment Show her how to prepare ORS solution at home. how much ORS to give to finish the 4-hour treatment at home. Give her enough ORS packets Explain the 3 Rules of Home Treatment (Plan A): GIVE EXTRA FLUID CONTINUE FEEDING WHEN TO RETURN

13. Important! O bserve the child at least 6 hours after re-hydration to be sure the mother can maintain hydration giving the child ORS solution by mouth. If there is an outbreak of cholera in your area, give an appropriate oral antibiotic after the patient is alert.

14. PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

15. Fluid deficit Percentage dehydration X body weight in grams (to be given over 4-6 hours).

16. indications for intravenous therapy Unconscious child. Failed ORS treatment due to continuing rapid stool loss ( >15-20ml/kg/ hr ). Failed ORS treatment due to frequent, severe vomiting, drinking poorly. Abdominal distension with paralytic ileus, usually caused by some antidiarrhoeal drugs (e.g. codeine, loperamide ) and hypokalaemia Glucose malabsorption , indicated by marked increase in stool output and large amount of glucose in the stool when ORS solution is given (uncommon).

17. Indications for admission to Hospital Shock or severe dehydration. Failed ORS treatment and need for intravenous therapy. Concern for other possible illness or uncertainty of diagnosis. Patient factors, e.g. young age, unusual irritability/drowsiness, worsening symptoms. Caregivers not able to provide adequate care at home. Social or logistical concerns Lower threshold for children with obesity/ undernutrition due to possibility of underestimating degree of dehydration

18. Other problems associated with diarrhoea

19. ! Lactose intolerance formula-fed babies less than 6 months old Persistent loose/watery stool Abdominal distension Increased flatus Perianal excoriation Making the diagnosis Compatible history Check stool for reducing sugar (sensitivity of the test can be greatly increased by sending the liquid portion of the stool for analysis simply by inverting the diaper Treatment : A lactose free formula (preferably cow’s milk based) may be given. Normal formula can usually be reintroduced after 3-4 weeks.

20. ! Cow’s Milk Protein Allergy Known potentially serious complication following acute gastroenteritis. To be suspected when trial of lactose free formula fails in patients with protracted course of diarrhoea . Children suspected with this condition should be referred to a paediatric gastroenterologist for further assessment.

21. Nutritional Strategies No necessity to withold feeding. Undiluted vs diluted formula No dilution of formula is needed for children taking milk formula. Lactose free formula (cow’s milk-based or soy based) Not recommended routinely. Indicated only in children with lactose intolerance. Cow’s milk based lactose free formula is preferred.

22. 1. Antimicrobials 2. Antidiarrheoal 3. Antiemetic 4. Probiotic 5. Zinc supplement 6. Prebiotics PHARMACOLOGICAL AGENTS

23. FLUID AND ELECTROLYTE

24. Well children with Normal hydration Best use enteral (oral) route for fluids. Safe use of IV fluid therapy Accurate prescribing of fluids Careful monitoring Maintenance fluid requirements Holliday and segar formula based on weight. Only be used as a starting point Response to fluid therapy should be monitored closely Clinical observation, fluid balance, weight and a minimum daily electrolyte profile .

25. Prescribing Intravenous fluids

26. resuscitation

27. Fluid deficit (clinical shock) fluid bolus of 10-20mls/kg. reassess circulation - repeat boluses Look for the cause Fluid boluses of 10mls/kg diabetic ketoacidosis, intracranial pathology or trauma. •  cardiac conditions aliquots of 5-10mls/kg Avoid low sodium-containing (hypotonic) solutions Measure blood glucose treat hypoglycaemia with 2mls/kg of 10% Dextrose solution. Measure Na, K and glucose at the beginning and at least 24 hourly Rapid results of electrolytes can be obtained from blood gases measurements. Consider septic work-up or surgical consult

28. maintanance

29. Peri -or post-operative Require replacement of ongoing losses A plasma Na+ at lower range of normal (definitely if < 135mmol/L) intravascular volume depletion, Hypotension Central nervous system (CNS) infection Head injury Bronchiolitis Sepsis Excessive gastric or diarrhoeal losses Salt-wasting syndromes Chronic conditions such as diabetes, cystic fibrosis and pituitary deficits

30. Calculation of Maintanence Fluid Requirements

31. Flow Chart for Maintenance Intravenous Fluid Prescription

32. Deficit

33. drains , ileostomy, profuse diarrhoea Ongoing losses

34. best measured and replaced. fluid losses > 0.5ml/kg/ hr Calculation may be based on each previous hour, or each 4 hour period depending on the situation. For example; a 200mls loss over the previous 4 hours will be replaced with a rate of 50mls/ hr for the next 4 hours). Ongoing losses can be replaced with 0.9% Normal Saline or Hartmann’s solution. Fluid loss with high protein content leading to low serum albumin (e.g. burns) can be replaced with 5% Human Albumin

35. Management of electolyte Imbalance

36. Sodium balance in dehydration Daily [Na] requirement is 2-3 mmol /kg/day Normal [Na] is between 135-145 mmol /L Hypernatraemia defined as [Na] >150 mmol /L moderate : 150-160 mmol /L; severe >160 mmol /L) Hyponatraemia defined as [Na] < 135mmol/L

37. Calculated requirements can then be given from following available solutions dependent on availability & hydration status: 0.9 % NaCl (154 mmol /L), 3% NaCl (513 mmol /L)

38. Potassium disorders Daily potassium requirement: 1-2 mmol /kg/day Normal [K]: At birth - 2 weeks : 3.7-6.0 mmol /L 2 weeks - 3 months : 3.7-5.7 mmol /L Beyond 3 months : 3.5-5.0 mmol /L

39. Case sample Case 1

40. A 4 year old male boy, born term, first admission, immunize up to age with normal growth and development Presents to the emergency department with a history of vomiting and diarrhea for past 1 day 10 episodes of vomiting food content 8 episodes of diarrhea ( bristol 6) with mucus Diarrhea is watery, no blood or worms in stool. Foul smelling. Fever with a documented temperature of 40 degrees at home. At home taken some ors and went to ed immediately Associated with less active today and he looks slightly pale at times. He has only urinated twice in the last 15 hours.

41. Exam VS T 38.2 degrees P 110 R 45 , BP 90/65 Spo2 100 % in room air. Weight = 18 kg. GPE Alert and cooperative, but not very active. Not toxic or irritable. Eyes are not sunken. Oral mucosa is moist Hear and lung exams are normal except for tachycardia. Abdomen is soft and non-tender. Bowel sounds are present normoactive . Slightly pale, capillary refill time is 2 seconds over chest, and skin turgor feels somewhat diminished.

42. 18kg BOLUS 18X10 : 180CC/30min 18x20 : 360cc/1hr Deficit (5/100 x (18x1000)) 900cc/4hr 225cc/ hr 2. Maintanance 10 (1000) – 8 (160) 1160cc/day 48cc/ hr

43. Clinically assessed to be 5% dehydrated by clinical criteria. An IV is started and a investigation taken at the same time. His chemistry panel shows Na 135, K 3.4 , U 3.0 Cr 30, bicarb 23. During the first hour of the IV fluid infusion, he says that he feels much better. More awake and color improves. During the second hour of IV fluid infusion, child falls asleep. At the end of the two hours, he is awakened and since he feels better, he is discharged coming morning with instructions to rest and continue oral hydration efforts.

44. Three days later, his rectal swab is growing Salmonella. His parents are called. They indicate that he still has some diarrhea, but only about two episodes per day and his vomiting has stopped. He is on a regular diet and continues to improve. Because he has improved, no antibiotic treatment is started. However , vigorous hand washing and hygiene regarding dishes/utensils for all family members is recommended.

45. Case sample Case 2

46. 18 month old female is directly admitted to the hospital from KK Kuala Nerang . History of 15 episodes of diarrhea and 5 episodes of vomiting daily for past 3 day daily Mom claimed change diaper more than 10 time in a day, and unable to tolerate food and fluid due to vomit Loose stool bristol 6, yellowsish , no mucus, no blood, no worm seen Vomit food content, non bilious, no blood, not projective

47. History of visit to KK 3 day ago , but discharge after assessing children condition to be stable, with ors and advice to come back If worsening condition Today has fever max recorded 40x2, at home and KK, Mom claimed today child weak, pale and her eyes are sunken. Other wise no altered behaviour , no abnormal movement, no ho travelling, taking outside food Has history of sick contact with sister 5y/o, just discharge 1 day ago due to AGE with moderate dehydration Her weight is 11.0 kg which is decreased from her weight in the kk ie 11.6 kg just three days ago Urine output is difficult to assess because of the diarrhea.

48. Exam VS T 39.8 , P 110, RR 40, BP 100/60, oxygen saturation 100% in room air. Weight 11.0 kg. GPE alert , drowsy not toxic and not irritable. eyes might be slightly sunken. dry oral mucosa and coated tongue Heart regular, no murmurs. Lungs are clear. Abdomen is scaphoid, soft and non-tender with hyperactive bowel sounds . skin turgor is diminished, but no tenting is present. Capillary refill time is 3 seconds over her thighs. Her extremities are cool in her feet, but warm elsewhere.

49. 11kg BOLUS 11X10 : 110CC/30min 11x20 : 220cc/1hr Deficit (10/100 x (11x1000)) 1100cc/4hr 275cc/ hr 2. Maintanance 10 (1000) – 1(50) 1050cc/day 44cc/ hr

50. An IV is started and a blood ix is taken A stool investigation is done She is given 220 cc of normal saline IV over one hour and she feels much better. The appearance of her eyes have normalized and she is more active. Her chemistry panel shows Na 134, K 3.4, U 20 Cr 40 , bicarb 12.