21.child with diarrhea and vomiting-seminar

8/12/2019 21.Child With Diarrhea and Vomiting-seminar

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CHILD WITH DIARRHEA AND

VOMITING



OUTLINES (1)

• ACUTE GASTROENTERITIS ( AGE )

Definition of diarrhea and gastroenteritis

Differential diagnosis if AGE

Epidemiology of AGEEtiology

Short-term consequences of AGE

- Dehydration

- Electrolyte imbalance

- Metabolic acidosis



(1) Definition

Acute gastroenteritis is a clinical syndrome ofdiarrhoea and/or vomiting of acute onset,often accompanied by fever, caused byinfectious agents or by bacterial toxins (eitheringested preformed in food or produced in thegut); and is not secondary to some primarydisease process outside the alimentary tract

Alternative name

Infectious diarrhoea; Acute diarrhoea



DIARRHEA

Passage of loose watery stools

3 or more loose or watery stools/day

Alteration in normal bowel movement

characterized by decreased in consistency and

increased in frequency

Acute diarrhea < 14 days duration

Persistent diarrhea > 14 days

Chronic diarrhea > 30 days



TYPES OF GASTROENTERITIS

1. Bacterial gastroenteritisi. Bacterial infectionii. Food poisoningiii. Antimicrobial Associated

(Pseudomembranous colitis -Clostridium difficile)

2. Viral gastroenteritis

3. Parasites gastroenteritis

4. Non-infectious



( 2 )DIFFERENTIAL DIAGNOSIS

Differential

diagnosis

Infant Child Adolescent

Common -Gastroenteritis

-Systemic infection

-Antibiotic

associated-Overfeeding

-Gastroenteritis

-Food poisoning

-Systemic infection

-Antibioticassociated

-Gastroenteritis

-Food poisoning

-Antibiotic associated

Rare -Primary

disaccharidase

deficiency

-Hirschprung toxiccolitis

-Adrenogenital

syndrome

-Toxic ingestion -Hyperthyroidism



• Although gastroenteritis consists of the triad of vomiting,

diarrhoea and fever, other conditions can present with the above

symptoms as well.

These include:-Acute appendicitis

-Strangulated hernia

-Intussusception or other causes of bowel

obstruction-Urinary tract infection

-Meningitis and other types of sepsis

-Any cause of raised intracranial pressure

-Diabetic ketoacidosis

-Inborn error of metabolism

-Haemolytic uraemic syndrome

-Inflammatory bowel disease



!!!Always consider another diagnosis in the

presence of any of the following warningsigns:

#Abdominal distension

#Bile-stained vomiting

#Blood in vomitus or stool (in appropriateclinical setting)

#Severe abdominal pain

#Vomiting in the absence of diarrhoea

#Headache



( 3 ) epidemiology

• Diarrheal diseases continue to be a major cause ofmorbidity and mortality in children in developingnations. In developed nations , they are an importantcause of hospital admission although mortality rates

may be lower. About 9% of all hospitalisations ofchildren younger than 5 years were reported to be aresult of diarrhoea.

• In Malaysia, the mortality of severe diarrhea in childrenrequiring hospital admission was low, with a case

fatality rate of 2.1/1000 admissions. Rotavirus andnontyphoidal salmonellae were the most common viraland bacterial pathogens causing severe diarrhea inchildren requiring hospital admission.



( 4) ETIOLOGY

VIRUSES BACTERIA PARASITES

Rotavirus

Enteric

adenovurus Astrovirus

Calicivirus

Aeromonas

Bacillus cereus

Campylobacter jejuni

Clostridium

perfringes

E.coli

Salmonella spp.

Shigella spp. Vibrio Cholerae

Yersinia

enterocolitica

Blas hominis

Crypt. Parvum

Ent. histolytica

COMMON CAUSATIVE AGENTS OF GASTROENTERITIS



WATERY DIARRHEA CAUSATIVE AGENTS

≤ 2 years old Rotavirus

Astrovirus

Calicivirus

Enteric adenovirus

Enteropathogenic Escherichia coli(EPEC), Enterotoxigenic Escherichia

coli (ETEC),

Vibrio cholerae

2-5 years old Enterotoxigenic Escherichia coli(ETEC)

Rotavirus

Shigella

Vibrio cholerae



MUCOUSY / BLODDY CAUSATIVE AGENTS

≤ 2 years old Shigellashiga-toxin producing Escherichia

coli (STEC)

Campylobacter jejuni

2-5 years old Shigella

shiga-toxin producing Escherichia

coli (STEC)

non-typhoidal Salmonella

E. histolytica

!!! In Malaysia, major enteric viruses causing childhood AGE arerotavirus, norovirus, and enteric adenovirus. For bacterial

gastroenteritis, the most important causative agent is the non-

typhoidal Salmonella, followed by Campylobacter, Shigella and E.coli.



( 5 ) short-term consequences of

AGE

A) Dehydration

1) Secretory diarrhea

- when secretion>absorption due to inflammation- recognized clinically by 4 features:

i) stools are large-volume, watery and often >1L/day

ii) diarrhea persists during fasting

iii) measured stool osmolar gap ( 290-((Na + K)) of <50m0sm/L

iv) don’t have excessive fat, blood or pus in their stool, but often developdepletion in fluid, Na and K



2) Osmotic diarrhea

- due to invasion of the enterocytes by bacteria or viral will result

in reduced in absorption area

# eg: rotavirus infection

- can be due to after malabsorption of an ingested substances

which ‘pulls’ water into bowel lumen

# eg: laxatives, pancreatic insufficiency or lactose intolerance

- osmotic gap >50 m0sm/L

>>>By using these two mechanisms both will cause

rapid loss of fluid through stools which later

result in DEHYDRATION<<<>>>most serious complication is when dehydration

leading to shock<<<



Types of dehydration

Isotonic

(isonatremic)

Hypertonic

(hypernatremic)

Hypotonic

(hyponatremic)Loses H2O = Na H2O > Na H2O < Na

Plasmaosmolality

Normal Increase Decrease

Serum Na Normal Increase Decrease

ECV

ICV

Decreasemaintained

Decrease

Decrease +++

Decrease +++

Increase

Thirst ++ +++ +/-

Skin turgor ++ Not lost +++

Mental state Irritable/lethargic Very irritable Lethargy/coma

shock In severe cases Uncommon Common



B) Electrolytes imbalance

Sodium Imbalance

Most important electrolyte affected by dehydration

Hypernatremia

When body loses more water than electrolytes concentrating the amount of sodium

Sign of hyponatremia include thirst,confusion and seizure

Hyponatremia

Result when body loses more sodium than water especially in cases of severe vomitingand

diarrhea

Signs of hyponatremia include headache, confusion and lethargy

Potassium Imbalance

Potassium is mostly found inside the body’s cells so small changes in the potassium level

inthe bloodstream can have a significant impact on person with gastroenteritis

Hyperkalaemia

High potassium can cause dangerous arrhythmia or abnormal heart rhythm

Low potassium usually causes milder symptoms like muscle cramps, fatigue andconstipation



• Metabolic Acidosis

Metabolic acidosis occurs when an acid other

than carbonic acid accumulate in the body

resulting in a fall in the plasma bicarbonate

Gastrointestinal base loss

Loss of bicarbonate in diarrhea, small bowel

fistula, urinary diversion procedure.



Outlines ( 2 )

•

MANAGEMENT Assessment

i) History

ii) Clinical

Rehydration therapyi) Oral rehydration therapy

ii) Intravenous- overview

Nutritional therapy

Others- antibiotics, anti-diarrheal, anti-emetics,

probiotics, diosmectitie, zinc



1) assessment

AIM

- Identify the presence of, the degree of, and type ofdehydration

- Identify the aetiological agent, if indicated andpossible

- Identify co-morbidity and complications

- To assess nutritional status

- To ascertain the most appropriate mode oftreatment



c) Laboratory tests

• Blood: full blood count, blood urea andserum electrolytes ( BUSE )-if > 5%dehydration

• Septic workout: blood culture, dengueserology, BFMP, thyphidot

• Arterial blood gas

• Stool: viral studies, bacteriology (culture ifstool is profuse and watery, or containsblood and mucuos), microscopy (if stool isbloody/mucousy), reducing substances (ifwatery)

• Urine: specific gravity

• Blood glucose level in infants

d) Cli i l t f



d) Clinical assessment of

dehydrationGoal of assessment

- to provide a starting point for treatment- to conservatively determine which:

> patient can safely be sent home for therapy

> patient should remain for observation

> patient needs immediate intensive therapy

Can be based on reliable previous weight-> The best measure of

dehydration is by the percentage loss of body weight.

But, if not available, the degree of dehydration can be assessed

clinically.

Most useful signs for significant dehydration are:

Prolonged capillary refill time (normal < 2 seconds)

Reduced skin turgor

Abnormal respiratory pattern



Remember!!!!!

Young infants are at risk for dehydration:

-increased surface area: body volume ratio leading to increased insensible fluidlosses

- milk as main source of nutrition:

# large osmotic load promote osmotic diarrhea

# large protein load and high renal solute load- tendency to more severe vomiting and diarrhea

- unable to obtain fluids for themselves when thirsty

others risk factors for severe dehydration following AGE:

-failure to give ORS

- discontinuation of breast feeding- frequent stool (>8/day) or vomiting (>2/day)

- malnutrition

- Vibrio cholerae



Notes:1) In hypernatremic dehydration, signs of dehydration may

not be prominent because dehydration is mainly

intracellular. Skin is doughy in consistency and there is

abnormal behaviour.2) Repeated assessment is necessary, especially in infants and

young children.

3) Watery stools maybe mistaken as urine output.



REHYDRATION THERAPY



ORAL REHYDRATION THERAPY

Na (mmol/L) K (mmol/L) Cl (mmol/L) Base (mmol/L)

Child < 5 years

• Cholera

• Non- cholera

101

56

27

25

92

55

32

14

WHO ORS 75 20 65 10

Fluid not

suitable for oral

rehydration

• Cola

• Apple juice

1.6

0.4

-

44

-

45

13.4

-



Principles of ORT treatment

1. Adequate rehydration therapy using an

appropriate ORS

2. Replacement of ongoing fluid losses

from vomiting and diarrhea with ORS

3. Frequent feeding of appropriate foodsas soon as dehydration is corrected.



• ORT is recommended as first-line therapy for

both mildly and moderately dehydrated

children. ORT seems to be a preferred

treatment option for patients with moderatedehydration from gastroenteritis

• Preparation : 1 sachet in 250 ml / 8 oz water



Treatment for dehydration

• PLAN A

• PLAN B

•

PLAN C



PLAN AMild dehydration (5%)

• Treat diarrhea at home

1. Give extra fluid

- Breastfeed frequently & longer

- Add on ORS / cooled boiled water / food-based fluids

- ORS given for each loose stool

*If weight is available, give 10 ml/kg of ORS

- Give frequently small sips- If child vomits, wait 10 minutes then continue but more slowly

- Continue until diarrhea stops

- Give 8 sachets ORS to use at home

Age ORS (ml)

< 2 years 50 – 100

≥ 2 years 100 - 200



2. Continue feeding

- Breastfed / formula fed / semi-solid / solid foodshould continue

- Food high in simple sugar should be avoided asosmotic load may worsen the diarrhea

3. When to return (clinic / hospital)

- Not able to drink / breastfeed / drinking poorly

- Become sicker

- Develops fever- Has blood in stool



PLAN BModerate dehydration (7.5%)

• Give recommended amount ORS over 4-hour period

*Child’s weight (kg) x 75 If patient want more ORS than shown, give more

• Give frequently small sips

• If child vomits, wait 10 minutes then continue but more slowly

• Continue breastfeeding whenever the child wants

• After 4 hours

- reassess & classify the dehydration- select the appropriate plan to continue treatment (plan A, B / C)

- begin feeding the child

• If child refuse ORS, consider nasogastric tube

• Give IV fluid therapy if failed oral / nasogastric therapy, vomiting persist /impending shock

Age < 4 mo 4 – 12 mo 1 – 2 yr 2 – 5 yr

Weight (kg) < 6 6 - 9 10 - 11 12 – 19

ORS (ml) 200 - 400 400 - 700 700 - 900 900 - 1400



PLAN CSevere dehydration (10%)

•

Start IV / IO immediately.• If patient can drink, give ORS while drip is being set up. Check acid-base

electrolytes.

1. Resuscitate

Give bolus NS / Ringers lactate as fast as posible:

- neonate – 10 ml/kg

- pediatric – 20 ml/kg

• Reassess capillary filling after every bolus

• If not respond to rapid bolus rehydration – give inotropic agents

(dobutamine / dopamineto) to maintain perfusion. Consider otherunderlying problems.

• Stop the boluses once perfusion improve / fluid overload is suspected /max. amount of ORS

- neonate – 40 - 60 ml/kg

- pediatric – 60 - 80 ml/kg



• Assess every 1-2 hr during rehydration

• Give ORS (5 ml/kg/hr) as soon as child can drink (infant :after 3-4h, older child : 1-2h)

• Once child can take orally the rest of the fluid requirementcan be given by ORS.

• Check hydration status & choose appropriate treatment(plan A/B)

• If fail to set IV / IO line, sent to nearest centre immediately – Try to give ORS (20 ml/kg/hr) over 6 hr

– Reassess every 1-2 hr

– If repeated vomiting / increasing abdominal distension, give thefluid more slowly

– Reassess after 6 hr, select the appropriate plan to continuetreatment (plan A,B/C)



2. Intravenous therapy

• Indication :- severe dehydration

- unconscious child- continuous rapid looses stool (>15-20 ml/kg/hr)

- frequent, severe vomiting, drinking poorly

- abdominal distension with paralytic ileus

- glucose malabsorption

(increase in stool output && large amount of glucose in the stool when ORS sol. given)

I. Fluid deficit

Fluid deficit (ml) = % dehydration x body weight (g)- mild dehydration – 5%

- moderate dehydration – 7.5%

- severe dehydration – 10%



II. Maintenance fluid therapy

Amount (ml/kg/day) x weight (kg)

• Total fluid require

= Maintenance + Deficit – Resuscitation

24 hours

Age Amount (ml/kg/day) Fluid

D1 60 Dextrose 10%

D2 80 1/5 NS + Dextrose 10%

D3 100 1/5 NS + Dextrose 10%

D4 120 1/5 NS + Dextrose 10%

D5 - D30 150 1/5 NS + Dextrose 10%

D31 - 6 month 150 1/5 NS + Dextrose 5%

6 month - 1 year 120 1/5 NS + Dextrose 5%

> 1 year 1st 10kg = 100 ml/kg

10 – 20kg = + 50 ml/kg for next 10 subsequent kg

20 kg = + 20 ml/kg for any subsequent kg

1/2 NS + Dextrose 5%

@

1/5 NS + Dextrose 5%



III. Treating metabolic acidosis

• Acidosis usually self corrects with rehydration ; correct only if pH < 7.1

• Sodium bicarbonate correction :

IV 8.4% NaHCO3 (mEq or ml) = 1/3 x base deficit x weightusually only half this volume (1/2 correction) is given

• Review with repeat blood gas

IV. Electrolyte requirement & replacement formulae

• Daily requirement of K+ = 2-3 mmol/kg/day x body weight (kg)

• Daily requirement of Na+ = 2-3 mmol/kg/day x body weight (kg)

Na+ deficit (mmol)

= (140 mmol/L – patient’s serum Na level) x 0.6 x wt (kg)

* 140 mmol/L : desired Na

+

level.0.6 : proportion of body weight for distribution of Na+



Type of dehydration

1. Hyponatraemic (< 130 mmol/L)

2. Isonatraemic (130 -150 mmol/L)

3. Hypernatraemic (> 150 mmol/L)

• Electrolyte disorder



• Electrolyte disorder

I. Hypernatraemia (serum Na > 150 mmol/l)

• This can result from ingestion of hypertonic liquids, such as over-concentrated milk feeds or home-made solutions to which salt is added, or loss of hypotonic fluids in the stool or urine. It is morecommon in hot weather.

a. Resuscitation

- If in shock, give NS / RL 20 ml/kg intravenously over ½ to 1 hour and repeat as

necessary

a. Rehydration

- if oral rehydration failed, start IV

- reduce serum Na slowly (not exceed 10 mmol/L/day) – dramatic fall result in cerebral edema,

seizures.- give total fluid in 48 – 72 hrs.

- use NS 5% dextrose : for fluid replacement ,

continue until serum NA < 145 mmol/l.

- then, use ½ NA 5% dextrose @ 1/5 NA 5% dextrose

- add KCl when child passes urine and review BUSE

- monitor BUSE 6 hourly

• Example: 10 month old child weighing 9kg is 5% dehydrated and not tolerating oral fluids. Serumsodium is above 150 mmol/l

- Fluid deficit = 5% of 9000g = 450 ml

- Maintenance at 120 ml/kg/24 h = 1080 ml/24 h

- To rehydrate over 48 hours, the rate of infusion should be

1/48 x (450 + 1080 + 1080) ml/hr = 54 ml/hour



When to prescribe antibiotics

Most causes of the gastroenteritis are due toviral infections; antibiotic is not necessary

Antibiotics are helpful only in children with

bloody diarrhea, probable shigellosis andsuspected cholera with severe dehydration

Example of antibiotic with respective



Example of antibiotic with respectiveorganism

Organism Treatment

Salmonella typhi Ampicillin, cefotaxime,trimethoprim

Other Salmonella None; amoxicillin,

ampicillin,cefotaxime,trimethoprim

Shigella Trimethoprim,ampicillin

Escherichia coli



Escherichia coli

Toxigenic

Invasive / pathogenic

None if endemic; trimethoprim,

ciprofloxacin for Traveler’s diarrhea

Trimethoprim, neomycin

Campylobacter No treatment for mild disease,

erythromycin & azithromycin for diarrhea

Vibrio cholera Tetracycline, trimethoprim

Clostridium difficile Oral vancomycin

Giardia lamblia Quinacrine, furazolidone



Anti-diarrheal

• Should not be given to young children with diarrhea ordysentry.

• Most of the time, diarrhea doesn’t require treatment.It most often lasts only a couple of days whether treat

it or not. However, medicine can help to feel better,especially if patient also have cramping.

• When diarrhea is a symptom of an infection caused bybacteria or parasites, antidiarrheal medicines can

actually make the condition worse. This is because themedicine keeps body from getting rid of the bacteriaor parasite that is causing the diarrhea.



Common anti diarrhea

• Loperamide works by slowing down the speed of fluidsmoving through your intestines (bowels).

• Don’t give loperamide to children 6 years of age

• Bismuth subsalicylate works by balancing the way fluidmoves through intestines. It also reduces inflammationand keeps certain bacteria and viruses that causediarrhea from growing in the stomach and intestines.

• People who are allergic to aspirin or other salicylatemedicines should not take bismuth subsalicylate. Don’tgive bismuth subsalicylate to children 12 years of ageor younger.



Anti-emetics

• Prochlorperazine, promethazine, and metoclopramidehave a high incidence of side effects and should beavoided in patients less than 2 years old and used withextreme caution in children older than 2 years.In

limited studies, ondansetron when used as a singledose has shown to be safe in children with acutegastroenteritis.

• Oral ondansetron could be a consideration for children

with AGE who fail ORT to prevent the need forintravenous fluid (IVF), or as an adjunct to IVF to helpfacilitate ORT and prevent admission.

P bi ti



Probiotics are live microorganisms that

may confer a health benefit on the host.

•

The rationale for using probiotics is based on theassumption that they modify the composition ofcolonic microflora and counteract enteric pathogens.However, there are two main views as to howprobiotics counteract diarrhea. According to one

theory, probiotics act locally (at intestinal level).According to the other theory, probiotics act bymodulating the immune response.

• At local level, probiotics:

•

compete with pathogens for nutrients and receptors• induce hydrolysis of toxins and receptors

• induce production of antimicrobial substances(including peptides of the innate immune system)



Di tit



Diosmectite

Diosmectite (Brand names Smecta, Smecdral):

natural silicate of aluminium and magnesium us

ed as an intestinal adsorbent in the treatment of

several gastrointestinal diseases. It is insoluble in

water. Diosmectite is able to absorbing excess

water from intestinal tract.



• However anti-diarrhoeal drugs and anti-

emetics should not be given to young children

because it does not prevent dehydration and

some have dangerous, sometimes fatal sideeffects.



Zinc supplements

• It has been shown that zinc supplements

during an episode of diarrhoea reduce the

duration and severity of the episode and

lower the incidence of diarrhoea in thefollowing 2-3months. WHO recommends zinc

supplements as soon as possible after

diarrhoea has started. Dose up to 6 months ofage is 10 mg/day, and age 6 months and

above 20mg/day, for 10-14 days.



PRINCIPLES OF FLUID REPLACEMENT

VOLUME REQUIRED =

MAINTENANCE + DEFICIT + ONGOING LOSSES



? Calculate 24-Hour Maintenance Fluid

Body Weight (Kg) Volume Per Day

0-10 100 mL/kg

11-20 1000 mL +

50 mL/kg for each 1 kg > 10kg

20 1500 mL +

20 mL/kg for each 1 kg > 20 kg

? Calculate Fluid Deficit



? Calculate Fluid Deficit

% Dehydration X Patient’s Weight X 1000 mL

? Correction Of Ongoing Losses

Usually not a problem and correction is often

not necessary. Correction is mandatory in

patients with profuse watery stools, ( i.e

cholera) ; or in the following situations :

continuous nasogastric drainage, ileostomy,

etc.



TYPES OF DEHYDRATION

Can be classified according to serumsodium concentration

HYPONATRAEMIC < 130 mmol/L

ISONATRAEMIC = 130 – 150 mmol/ L

HYPERNATRAEMIC > 150 mmol/L

? Correct Isonatraemic Dehydration



? Correct Isonatraemic Dehydration

18 months old girl

Weight on admission = 10kg

Dehydration estimated on admission = 10 %Initial serum Na+ = 142 mmol/L

Rapid Phase (Resuscitation)

20ml/kg bolus NS over 1 hour

20ml X 10 kg = 200 ml over 1 hour

Replacement

Volume required = maintenance + deficit + ongoing losses

= 1000 ml + 1000ml

= 2000ml

Maintenance = 10 kg X 100 ml/kg = 1000ml

Deficit = 10/100 X 10kg X 1000ml = 1000ml

On going losses not included

2000ml – 200ml(resuscitation) = 1800 ml

78 ml/hour X 23 hours



? Correct Hyponatraemic Dehydration

Sodium deficit (mmol) =

(140mmol/L - patient’s serum Na level x 0.6 x body weight kg)

140 mmol/L = desired Na+ level

0.6 = proportion of body weight for distribution of sodium

EX : Child 15 kg, Na+ level = 120 mmol/L

Sodium deficit = (140-120)mmol/L X 0.6 X 15kg

= 180 mmol/L

Correction = Deficit above (180 mmol/L) + daily maintenance

Asymptomatic Hyponatraemic dehydration = treatment is similar to isonatraemic

dehydration.

In symptomatic hyponatraemia, use hypertonic saline ( e.g NACL 3%) to increase serum

sodium by 0.5 mmol/L per hour

(RAPID CORRECTION POTENTIALLY DANGEROUS. RECOMMENDED RATE OF CORRECTION

APP 1-2 mmol/L )



Hypernatremic dehydration

• 1yr old (10kg) female child presented withfever since 4 days ago.

• It is associated with vomiting and diarrhea

more than 7 times per day• On examination, patient appear Lethargic,

cold, weak rapid pulse, low BP, sunken eyes,dry eyes, parched mucous membranes,capillary refill 5 sec, marked tenting of skin

• Na = 175, K+ = 3.2, HC03 = 20



• Feature of patient with

hypernatremic dehydration:

Skin has a characteristic doughy feelAnterior fontanelle may not be sunken

Late sign of shock

#Difficult to recognize clinically ( sign of dehydration less obvious – water shift

from ICF to ECF



Management

• The hypovolemic child requires fluid replacement and aslow correction of her fluid deficit over 48 to 72 hours.

• Any patient who has hypernatremia needs to bemonitored for seizure activity.

•Generally, the serum sodium level should decrease at arate no faster than 10 mmol/L/h, because rapidcorrection of hypernatremia can lead to fluid shiftsfrom the ECF to the ICF and the development ofcerebral edema and seizure

• Patients must be monitored for the signs andsymptoms of cerebral edema throughout the course oftheir treatment



• Severe dehydration

1. Rapid phase (resuscitate)

20ml/kg bolus NS over 30-60 min

20x 10=200ml over 30-60 min

2. Replacement

Total fluid needed= deficit+maintenance+loss

deficit

15%x10x1000= 1500ml

Maintenance

10kgx 1000ml/kg=1000ml

# thus fluid needed in =maintenance+ deficit+loss

=1000+ [1500-200]=2300ml of ½ NS 5% Dextrose over 48-72 hour



ORS (Oral Rehydration Solution)

- First line therapy for mild to moderate diarrheal

dehydration

- less expensive than IV therapy with lower complicationrate

( IV therapy may still be required for patient with

severe dehydration ; patients with uncontrollable

vomiting; patients unable to drink because of extremefatigue, stupor, or coma; or patients with gastric or

intestinal distention. )



ORSRepletion phase

Administer 50 mL/kg of ORS over 4 hours to patients with milddehydration.

Administer 100ml/kg of ORS over 4 hours to patient with moderatedehydration.

Additional 10ml/kg ORS to replace ongoing loss from diarrhea /

emesis.

Reassess patient's hydration status

• Maintenance phase –

when rehydration is complete, maintenance therapy : 100 ml/kg in24 hours until diarrhea stops. Feeding and fluids should be started.

21.child with diarrhea and vomiting-seminar

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