Management of acute gastroenteritis in children

Acute gastroenteritis remains one of the leading causes of death in the under 5-age group in the developing world. Over 2 million deaths per year occur in this group which is much improved compared to the 1980’s when there were in the region of 4.5 million deaths per year. In the UK, gastrointestinal illness is rarely fatal but in 2007, it accounted for almost 32,000 admissions to hospital in the under 5-age group and so is a major economic burden. There is still a huge variation in practice and the NICE guidelines were published in April 2009 to develop a more unified approach to the management of acute gastroenteritis. In this article, I have tried to identify some of the key points from the NICE guidelines with regard to history taking, assessment of dehydration and fluid management. The NICE guidelines also looked at therapeutic options such as probiotics and antiemetics but were unable to find evidence to recommend them. More recent references were sought for further proof of efficacy of these agents. Adherence to guidelines for acute gastroenteritis in the past has been poor and variation related to institution. Data on adherence to the NICE guidelines is limited.     

Pre-admission management of acute gastroenteritis

Objective : Acute gastroenteritis contributes to significant morbidity and need for hospital admission. The current literature suggests outpatient management is often inappropriate. This study examines the pre-admission management of children admitted with acute gastroenteritis to a major children's hospital.
Methodology : Information was obtained from parental questionnaires and the medical notes for 164 children.
Results : Parents were poorly informed regarding appropriate home management Over 70% sought professional advice prior to admission, usually from their general practitioner. Although 58% received advice on fluid therapy, an oral rehydration solution was recommended for only 32%. and only 9% actually used one before admission. Advice regarding fluid requirements was usually inadequate. Inappropriate medications were prescribed for 22% of children, including antibiotics (15.4%). antidiarrhoeals (1.2%) and anti-emetics (5.5%). Hospitalized children were generally well nourished with minimal dehydration and electrolyte disturbance.
Conclusions : Oral rehydration therapy is utilized rarely and medications are over-utilized in home management of gastroenteritis. Education of parents, general practitioners and hospital doctors is essential to optimize outpatient management The impact of optimal outpatient management on hospital admission rates and morbidity requires formal assessment.     

Stool electrolytes in acute dehydrating gastroenteritis.

Stool electrolytes were studied in 100 cases of gastroenteritis. The duration of illness was 24-48 hours in 32% and 72-96 hours in 28% of the cases. On stool culture, 43% children had no growth, 23% had Enteropathogenic E. coli and 10% had cholera and rotavirus each. The stool sodium loss was more in cholera and shigella cases, diarrhea of shorter duration and in children between 24-30 months of age. Potassium loss in the stool was more in shiegella cases, diarrhea of short duration and in children between 30-36 months of age. In cases of gastroenteritis with severe malnutrition, stool sodium loss was less; stool potassium loss was not affected by the nutritional status. Total electrolytes lost in stools can be estimated by knowing purging rate and rehydration therapy can be planned accordingly.     

Dietary treatment of acute gastroenteritis in infants

Two prospective studies compare the dietary treatment of acute diarrhoea (gastroenteritis in infancy with either partially adapted formula or with special formula (HN 25) with a low lactose content (1.8%), or virtually free of lactose (0.05%), including only infants with acute diarrhoea, a loss in weight not exceeding 8%, and without parenteral fluid intake. There is no difference in the duration of hospitalization. However, the time until normalization of the stools was significantly shorter when lactose-reduced formula or formula virtually free of lactose was fed (4.4 resp. 3.1 vs. 5.1 days). There were 9 relapses in the control group fed partially adapted formula, and none in the trial group fed special formula. The present results show that in mild and moderate diarrhoea a dietary treatment with lactose-reduced formula should be preferred to a treatment with infant formula.     

Evaluation of infant feeding in acute gastroenteritis

Sixty-eight bottle-fed babies under 9 months of age with mild acute gastroenteritis were observed to evaluate current feeding regimens following acute gastroenteritis in infancy. All babies were fed for 24 h with a glucose-electrolyte mixture (GEM) and then randomly assigned to either a gradual reintroduction to their normal milk, i.e., slow regrade; immediate return to full-strength formula; or a rapid regrade to a hypoallergenic whey hydrolysate formula. All groups were well matched for age, sex, ethnic origin, nutritional state, and degree of hydration. There was no significance difference in stool frequency or reducing substances, vomiting, and duration of hospital stay between the three groups. Many infants (6/24) refused to take the whey hydrolysate formula, presumably because of unpalatability. Weight gain was more rapid when full-strength milk was given. Clinical relapse developed in 12 (17%) of patients. An enteric pathogen was detected in eight of this group and cow's milk protein intolerance in three (one from each feeding group). No infant had clinically significant lactose intolerance, in marked contrast to previous experience at Queen Elizabeth Hospital. In this group of previously healthy, well-nourished babies with mild acute gastroenteritis, there was no advantage in regrading slowly to milk or a hypoallergenic formula. An immediate return to normal formula 24 h after GEM feeding was well tolerated and simpler for parents.     

Sugar intolerance complicating acute gastroenteritis.

Sugar intolerance occurred in 31 of 200 children admitted to hospital with acute gastroenteritis. In 28 this was transient and settled rapidly, but in the remaining three it indicated a more serious and persistent problem. The most important predisposing factor was viral infection, in particular with rotavirus. The current regimen for the management of sugar intolerance complicating acute gastroenteritis at this hospital is outlined.     

Increased protein absorption after acute gastroenteritis in children

We investigated the intestinal absorption of the macromolecule human alpha-lactalbumin during and after an episode of acute gastroenteritis in children. Twenty children were studied in the acute phase and 17 excreted rotavirus. Eleven children were studied again 5-8 weeks later (convalescent phase). Human alpha-lactalbumin serum concentrations in the acute phase were similar but in the convalescent phase they were significantly (p less than 0.001) higher than those in the reference children. The serum concentrations were also higher in the convalescent than in the acute phase (p = 0.021). This study suggests that there is an increased absorption of proteins from the gut into the circulation 5-8 weeks after rotavirus gastroenteritis.     

Ultrasonography findings and symptoms in acute rotavirus gastroenteritis

Background: The aim of the present study was to better understand how clinical events in acute rotavirus gastroenteritis are depicted on ultrasonography. Methods: The relationship between abdominal ultrasonography and clinical course and symptoms was evaluated in 92 patients with acute rotavirus gastroenteritis (51 boys, 41 girls) with an average age of 30.7 ± 24.6 months. Results: Significant correlations were observed between ultrasonography score and duration of illness after ultrasonography (P= 0.0232). It was also interesting that ultrasonography findings (score: 3.1 ± 1.0 vs 3.6 ± 1.2; P= 0.0118), clinical symptoms (3.1 ± 1.7 score vs 3.8 ± 1.8 score, P= 0.0293), and duration of illness after ultrasonography (4.4 ± 1.4 days vs 3.8 ± 1.1 days, P= 0.0301) were significantly different between patients examined on ultrasonography <1 day after illness onset (n= 50, but duration of illness after ultrasonography followed only in 42) and those examined ≥2 days after onset (n= 42, but duration of illness after ultrasonography followed only in 35). Conclusion: The ability of abdominal ultrasonography to indicate severity of disease makes abdominal ultrasonography an important guide to therapy.     

Serum zinc levels in children with acute gastroenteritis

BACKGROUND: The aim of the present study was to determine the serum zinc levels on admission and 7-10 days after clinical recovery from acute gastroenteritis of <8 days' duration. METHODS: This prospective study included 82 infants aged 2-24 months who had no associated bacterial infection, chronic disease, prior antibiotic use, moderate or severe malnutrition or dysentery. Forty-one healthy children formed the control group. RESULTS: The mean serum zinc level on admission (Zn1) was 11.85 +/- 2.83 micromol/L and at 7-10 days after recovery (Zn2) was 10.92 +/- 2.17 micromol/L; mean serum zinc level of the control group was 11.81 +/- 3.45 micromol/L. Zn2 was significantly lower than Zn1, but there was no statistical difference between the mean of the control group and Zn1 and Zn2. When dehydrated patients were excluded from the patient group, Zn1 and Zn2 did not differ. Although asymptomatic, 39% of the control group had low zinc. Serum zinc levels were not affected by sex, age, clinical characteristics of the patients or severity of gastroenteritis. CONCLUSION: Serum zinc levels of the patients admitted with acute gastroenteritis without any other disease and without moderate or severe malnutrition were not affected by disease state. Gastroenteritis did not further decrease serum zinc levels in patients with asymptomatic or subclinical zinc deficiency.