Management of Dehydration and Special Issues

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Management of Dehydration and Special Issues

• Abdulwahab Telmesani
• FRCPC, FAAP
• Umm Al-Qura University

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Scientific Methodology

• Latest publications through best and well known
  search engines (Ovid, Blackwell, MD Consult,
  etc.)
• Cochrane Database of Systematic Reviews

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Management of Dehydration

• Why it is important?

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Management of Dehydration

• 2 million infant and child die every year in the
  developing countries

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Diarrhea

• Rota virus is a major worldwide cause of infant
  morbidity and mortality

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Rotavirus

• Rates of rotavirus illness among children in
  industrialized and less developed countries are
  similar, indicating that clean water supplies and
  good hygiene have little effect on virus
  transmission.
• 
  AAP

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Rotavirus

• Trials of pentavalent rotavirus vaccine in the
  United States and 10 other countries show
  efficacy rates of 98 for prevention of severe
  illness and 74 for prevention of
  rotavirus-induced diarrheal episodes of any
  severity.
• 
  AAP

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Rotavirus

• Rota Virus Live Oral Vaccine is out and soon
  available KSA

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Management of Dehydration

• Management at the primary health care centers
• By PHCC Physicians

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Who is our target patient?

• ?

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Who is our target patient?

• Previously well baby or child who has diarrhea
  with mild- moderate dehydration

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Who is our target patient?

• NOT
• Renal failure, cardiac patients, severely
  malnourished baby, toxic, etc.

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Degree of Dehydration

• Assess the degree of dehydration

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Degree of Dehydration

• Mild dehydration (3-5)
• Moderate dehydration (7-10)
• Sever dehydration (10-15)

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Degree of Dehydration

• Mild dehydration (3-5)
• -Normal P/E,
• -Normal or increased pulse rate
• -Decreased U/O and
• -Thirsty

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Degree of Dehydration

• Moderate dehydration (7-10)
• -Increased pulse rate
• -Decreased U/O and tears
• -Sunken eyes and fontanel
• -Dry mucous membrane.
• -Mild skin tenting, pale, cool periphery and
• -Decreased capillary refill.

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Degree of Dehydration

• Sever dehydration (10-15)
• -Rapid weak pulse.
• -Low BP, sunken eyes and fontanel
• -No tears or urine v. dry mucous membrane
• -Clear skin tenting. Cool mottled skin with
• delayed capillary refill.

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Fluid Maintenance

• ?

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Fluid Maintenance

• Body Wt Fluid per
  day
• 0 10 kg 100
  ml/kg
• 11 -20 kg 50
  ml/kg
• 20 kg
  20ml/kg

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e.g. a child of 25kg

• First 10 kg 1000 ml
• Second 10 kg 500 ml
• Remaining 5 kg 20 ml
• Total 1700 ml/ pay
• i.e. per hr 70 ml/ hr

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Calculate the deficit

• Percent of dehydration x Weight

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e.g. 7 dehydrated 10 kg baby

• 0.07 x 10 0.7 L i.e. 700 ml

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Lab work

• None Required

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Lab work

• Na and K
• Urea and creatinine
• pH/ Bicarb.
• Urinalysis

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ORS

• Oral Rehydration Solution

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ORS

• Developed 1940s in Dhaka Bangladesh

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ORS

• A revolution in the management of diarrhea
• 
  Olivier Fontaine Bulletin of WHO
• 
  Geneva 2001

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ORS

• Most important medical discovery of the 20th
  century
• 
  The
  Lancet

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ORS

• 5 million deaths / year
• After ORS
• 2 million deaths / year

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ORS components

• WHO/UNICEF
• Na 90 mmol/l
• k 20 mmlo/l
• cl 80 mmol/l
• glucose 111mmol/l
• Osmol 311 mmol/l

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WHO vs. Hypo-osmolar ORS

• WHO/UNICEF Hypo-osmolar
• Na 90 mmol/l Na
  60 mmol/l
• k 20 mmlo/l k
  20 mmlo/l
• cl 80 mmol/l cl
  50 mmol/l
• glucose 111mmol/l glucose 84 mmol/l
  
• Osmol 311 mmol/l Osmol 224
  mmol/l

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Hypo-osmolar ORS

• Many studies support the use of reduced
  osmolarity ORS but the debate is not resolved. It
  is preferred in severely malnourished (marasmic)
  child as the standard (old) WHO ORS may cause
  hypernatremia

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Hypo-osmolar ORS

• In May 2002 WHO moved to reduced osmolality ORS

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ORT vs. I/V Therapy

• ?

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ORT vs. I/V Therapy

• ORT is as effective as I/V fluid for
  rehydration of moderately dehydrated children due
  to G/E in the E/D. ORT Demonstrated no
  inferiority for successful rehydration at 4 hours
  and hospitalization rate.
• A randomized
  controlled trial by P Spandorfer et al
• 
  Pediatrics Feb.2005

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ORT vs. I/V Therapy

• Although no clinically important differences
  between ORT and IVT, the ORT group did have a
  higher rate of paralytic ileus, and the IVT group
  exposed to risk of intravenous therapy. For every
  25 children treated with ORT one fail and require
  IVT
• L Hartlig The Cochrane Database of
  Systematic Reviews 2006 Issue 4

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Reluctance to use ORT

• ?

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Reluctance to use ORT

• People do not consider ORT high-tech enough.
• Physicians prefer I/V fluids.
• It takes time to educate parents re ORT.
• Time consuming for busy parents.

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ORS Additives
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ORS Additives

• Amylase-Resistant Starch

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ORS Additives

• In children with acute diarrhea, the addition
  of amylase-resistant starch to glucose ORS
  significantly shortened duration of diarrhea
  compared with slandered treatment
• 
  Randomized study By P Raghupathy
• 
  J Ped Gastro nut April 2006

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ORS Additives

• Amino Acids

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ORS Additives

• Adding amino acids to ORS found to improve
  its performance and help in the regeneration of
  the intestinal mucosa.
• G
  Nappert Nutition review Mar. 2000

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ORS Additives

• Zinc

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ORS Additives

• Zinc supplement(20 mg per day) reduced
  severity and duration of diarrhea
• T
  Bora et. al. Ped. Intern. October 2003
• 
  and many other publications

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ORS Additives

• Probiotics in ORS proved effective

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Special Issues
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Antibiotics
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Antibiotics

• None Required

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Anti- emetics
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Anti- emetics

• Remains Controversial.

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Anti- emetics

• Small number of included trials provided some
  weak evidence in favor the use of ondansetron and
  metoclopromide
• D Alhashimi et. al. Cochrane
  Database of Systematic
• 
  Reviews March 2006

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Anti- emetics

• A single dose of oral Ondansetron (a serotonin
  antagonist anti-emetic) in children with G/E and
  dehydration reduces vomiting, facilitate oral
  rehydration and suitable for the use in emergency
  department
• Freedman New Eng. J
  of Med. April 2006

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Anti-diarrheal agents

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Anti-diarrheal agents

• Less Controversial

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Anti-diarrheal agents

• Antimotility drugs, slow intestinal transit
  but have little effect on the total stool volume
  and may have serous side effect including ileus.
  They are not advised for infants or children
• 
  G Nappert Nutition review Mar. 2000

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Anti-diarrheal agents

• Three studies have suggested that drugs that
  slow intestinal peristalsis are associated with
  increased risk of Hemolytic Uremic Syndrome or
  more sever complications when given to children
  with infectious diarrhea.
• 
  
• P
  Tarr et. al. Canad. Med Asso. J.
• 
  Apr. 1999

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Anti-diarrheal agents

• We strongly discourage their use in acute
  childhood diarrhea
• 
  
• P Tarr
  et. al. Canad. Med Asso. J.
• 
  Apr. 1999

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Probiotics and Diarrhea

• Ample Evidence

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Probiotics and Diarrhea

• Use of Probiotic as functional food in the
  treatment of diarrhea
• A strong evidence related to probiotics in
  prevention and treatment of Rotavirus-associated
  diarrhea
• Effective in prevention and treatment of
  antibiotic diarrhea

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Probiotics and Diarrhea

• Authors conclusion
• Probiotics appear to be a useful adjunct to
  rehydration therapy in treating acute infectious
  diarrhea in adult and children.
• Allen SJ Cochrane Database of
  Systematic Reviews
• 
  2006 Issue 4

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Diarrhea and dehydration Guidelines I

• CDC Guidelines for Treatment of Diarrhea and
  Dehydration
• (Endorsed by The American Academy of Pediatrics)
• R Sheth
• American Academy of Pediatrics
• publications Aug. 2004

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Diarrhea and dehydration Guidelines I

1. ORS should be used for dehydration.
2. Oral rehydration should be performed rapidly.
3. For rapid realimentation, age appropriate,
   unrestricted diet is recommended as soon as
   dehydration is corrected.
4. For breastfed infants, nursing should be
   continued.

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Diarrhea and dehydration Guidelines I

1. For formula-fed infants, diluted formula is not
   recommended, and special formula usually is not
   necessary.
2. Additional ORS should be administered for ongoing
   losses through diarrhea.
3. No unnecessary laboratory tests or medications
   should be administered.

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Diarrhea and dehydration Guidelines II

• An Evidence Based and Consensus Based Guideline
  for Acute Diarrhea Management
• K Armon et al
• Archives of Disease in Childhood
• Aug. 2001

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Diarrhea and dehydration Guidelines II

• Intended to aid doctors in recognizing
  children who need admission for observation and
  treatment and those who may safely go home

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Diarrhea and dehydration Guidelines II

• Differential diagnosis of child presenting with
  diarrhea
• (Intussusception, surgical abdomen,
  hemolytic uremic syndrome)
• Look for Red Flags

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Diarrhea and dehydration Guidelines II

• A. Red Flags
• Abdominal pain with tenderness, with or
• without guarding
• Pallor, jaundice, oligo/anuria, bloody
• diarrhea
• Systemically unwell, out of proportion to
• the level of dehydration
• Shock

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Diarrhea and dehydration Guidelines II

• B. Estimation of severity of dehydration
• Mild dehydration (3-5)
• Moderate dehydration (7-10
• Sever dehydration (10-15)

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Diarrhea and dehydration Guidelines II

• C. Blood Tests
• It is thus unnecessary to measure electrolytes
  in those children who will be rehydrated with
  ORS.

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Diarrhea and dehydration Guidelines II

• D. Management of Rehydration
• ORS is safer than I/V (failure rate 3.6)
• in mild to moderate dehydration.
• Small frequent aliquots (5 ml or more
• if welling and no vomiting over 3-4 HRs)
• N/G or I/V over night or when parents
• are not welling to carry ORT.

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Diarrhea and dehydration Guidelines II

• E. Composition of ORS (UK)
• Na 60 mmol/l
• K 20 mmol/l
• Glucose 74-111 mmol/l

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Diarrhea and dehydration Guidelines II

• Maintenance of hydration
• Allow free fluids.
• Encourage drinking more than usual.

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Diarrhea and dehydration Guidelines II

• G. Refeeding following rehydration
• Brest fed infant should continue.
• Formula should be restarted as soon as
• the child is rehydrated (HRs.)

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Diarrhea and dehydration Guidelines II

• H. Criteria for admission of children with
• Gastroenteritis
• Sever dehydration
• Mild- moderate dehydration observed (3-4
  hrs)
• ensure success rehydration.
• High risk patients e.g. infants less than
  6 months,
• frequent watery diarrhea (8/day) or
  persistent
• vomiting

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Diarrhea and dehydration Guidelines II

• I. Role of medications
• Infants and children with acute
• gastroenteritis should not be
• treated with antidiarrheal agents.

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Telmesani Guidelines III
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Facts

• The body possess thermostat in the Gut and the
  Kidneys (feed back regulation)
• Electrolyte deficit even in Hypernatremic
  dehydration
• We are dealing with health mildly-moderately
  dehydrated baby/child

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ADH and Gastroenteritis

• Nonosmotic stimuli of ADH secretion are
  frequent in children with gastroenteritis.
• The use of hypotonic saline for deficit
  replacement needs to be reassessed
• 
  K Nevile et al Pediatrics Dec 2005

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Rapid rehydration in moderate dehydration

• Using
• ½ NS 2.5 dextrose at rate of 20 ml/kg for 2
  hrs. via I/V.
• Gastrolyte at the same rate via N/G
• It reduced admission and length of stay in E/D
• SJ
  Phin J of Ped. And Child health July 2003

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Telmesani Guidelines III
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Telmesani Guidelines III

• Resolve parents anxiety.
• Explain what is G/E.
• Use ORS, Zamzam, Water, De-carbonated soda or
  Coconut water.
• Use small frequent oral fluids if vomiting.
• Use yogurt (better with probiotics).
• Start feed once able (antidiarrheal food)

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Telmesani Guidelines III

• In moderate dehydration and vomiting
• Child/ anxious parents
• NPO patient.
• Use the rapid rehydration (20 ml/kg/hr x 2 hrs).
  OR give twice maintenance x 2 hrs.
• Use ½ N.S (caution in adding k).
• Start ORT afterward as above.

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Telmesani Guidelines III

• Cautious and rare use of anti-emetics.
• Do not use antidiarrheal agents