Pre-admission management of acute gastroenteritis

Epidemiological studies on gastroenteritis in children in the Bannu district, Khyber Pakhtunkhwa, Pakistan

Aims

Gastroenteritis is a digestive disorder among children with symptoms of abdominal cramps, diarrhoea, and vomiting. This study aimed to determine the prevalence of gastroenteritis in children in the Bannu district in 2019, and also contributed for adopting preventive measures to reduce mortality in children.

Subject and methods

A retrospective study was conducted to determine the prevalence of gastroenteritis in children in Bannu. The data were collected from official registers of admission maintained in the children wards in the Women and Children Hospital, Bannu. Patients with symptoms of gastroenteritis at the outpatient department were admitted to one of the children wards.

Results

Overall, 1456 children—897 (61.4%) males and 559 (38.6%) females—suffered from gastroenteritis during the study period. The age group ≤6 months demonstrated the highest share (37.8%), followed by >6 m ≤ 1y (35.5%), >1y ≤ 2y (15.8%), >2y ≤ 5y (7.3%), >5 ≤ 10y (3.2%), and > 10y ≤ 15y (0.4%). Overall, 89.1% of cases were from children ≤2 years old and 96.4% of cases were attributed to children ≤ 5 years of age. April demonstrated the highest percentage of prevalence of 17.7, followed by May (13.5%), November (13%), June (11.7%), September (10.4%), October (9.8%), July (9.5%), August (8.4%), March (3.4%), and February (2.6%). The age group ≤6 m was the dominant group during February through May and was replaced by the age group >6 m ≤ 1y during August through November.

Conclusion

Gastroenteritis showed a reduced prevalence when shifted from lower to higher age groups. Being male and age group ≤6 m showed the highest prevalence of gastroenteritis with the peak of disease in April. Further research is needed to determine the cause-based prevalence of different gastroenteritis cases in the study area.

Diapers in war zones: ethnomedical factors in acute childhood gastroenteritis in Peshawar, Pakistan

This article considers ethnomedical knowledge and practices among parents related to contraction of acute gastroenteritis among children in Peshawar, Pakistan. Research methods included analysis of the Emergency Pediatric Services' admission register, a structured interview administered to 47 parents of patients seen in the Khyber Medical College Teaching Hospital, semi-structured interviews of 12 staff, and four home visits among families with children treated at the hospital. The use of native research assistants and participant observation contributed to the reliability of the findings, though the ethnographic, home-visit sample is small. Our research indicated that infection rates are exacerbated in homes through two culturally salient practices and one socioeconomic condition. Various misconceptions propagate the recurrence or perserverance of acute gastroenteritis including assumptions about teething leading to poor knowledge of disease etiology, rehydration solutions leading to increased severity of disease, and diaper usage leading to the spread of disease. In our Discussion, we suggest how hospital structures of authority and gender hierarchy may impact hospital interactions, the flow of information, and its respective importance to the patient's parents leading to possible propagation of disease. These ethnographic data offer a relatively brief but targeted course of action to improve the effectiveness of prevention and treatment efforts.

Emergency department revisits in children with gastroenteritis

OBJECTIVES

The aim of the study was to determine whether intravenous fluid administration is independently associated with a reduction in unscheduled emergency department (ED) revisits within 7 days.

METHODS

We conducted a single-center, retrospective observational cohort study in a pediatric ED in Toronto, Canada. Participants were younger than 18 years, diagnosed as having gastroenteritis, and discharged home between July 2003 and June 2008. Multivariable regression models were used to determine the associations between the exposures (intravenous rehydration, triage severity score, age) and ED revisits and revisits with intravenous rehydration. Accuracy was assessed using bootstrap analysis.

RESULTS

There were 22,125 potentially eligible visits; 3346 were included in our final cohort. A total of 497 children (15%) received intravenous rehydration and 543 (16%) had an unscheduled revisit. Regression analysis included 2874 children with complete data, and identified 5 independent predictors of an ED revisit: intravenous rehydration (odds ratio [OR] 1.76; 95% confidence interval [CI] 1.36-2.26); number of vomiting episodes (1.20; 95% CI 1.04-1.28/5 episode increase); days of diarrhea (OR 0.92; 95% CI 0.88-0.97/day increase); frequency of diarrhea (1.19; 95% CI 1.03-1.38/5 episode increase); and age (OR 0.94; 95% CI 0.91-0.98/year). Bootstrap methodology identified intravenous rehydration, age, number of vomiting episodes, days of diarrhea, and number of diarrheal stools a minimum of 500 of 1000 iterations.

CONCLUSIONS

Intravenous rehydration is associated with unscheduled ED revisits after adjustment for clinical findings. Although children experiencing revisits were likely more unwell, our data do not support the provision of intravenous fluids to prevent unscheduled ED revisits in children with mild-to-moderate dehydration.

Acute gastroenteritis: from guidelines to real life

Acute gastroenteritis is a very common disease. It causes significant mortality in developing countries and significant economic burden to developed countries. Viruses are responsible for approximately 70% of episodes of acute gastroenteritis in children and rotavirus is one of the best studied of these viruses. Oral rehydration therapy is as effective as intravenous therapy in treating mild to moderate dehydration in acute gastroenteritis and is strongly recommended as the first line therapy. However, the oral rehydration solution is described as an underused simple solution. Vomiting is one of the main reasons to explain the underuse of oral rehydration therapy. Antiemetics are not routinely recommended in treating acute gastroenteritis, though they are still commonly prescribed. Ondansetron is one of the best studied antiemetics and its role in enhancing the compliance of oral rehydration therapy and decreasing the rate of hospitalization has been proved recently. The guidelines regarding the recommendation on antiemetics have been changed according to the evidence of these recent studies.

Pre-admission therapy for childhood acute diarrhoea--a hospital-based study

Acute gastroenteritis (AGE) is a common illness among infants and children contributing to significant mortality and morbidity. As such, appropriate treatment received prior to hospital admission is of utmost importance. This retrospective observational study aimed to determine preadmission management in paediatric patients prior to hospital admission. Two hundred and twenty-two case notes of paediatric AGE patients were reviewed over a 12-month period. One hundred and fifty-four patients received medications prior to admission with 143 (92.9%) patients received known classes of medications. Antipyretic agents were the most commonly prescribed (69.2%), followed by antibiotics (38.5%), anti-emetics (35.7%), oral rehydration salts (29.4%) and antidiarrhoeals (28.0%). The mean duration of stay in hospital was slightly shorter in patients, who received prior medications than those who did not (2.22 vs. 2.32 days respectively). Seventy per cent of children admitted for AGE were treated suboptimally prior to hospital admission with oral rehydration salts being largely under-utilized, despite their proven efficacy and safety. Sex, race and age had no influence on the type of preadmission treatment. A greater effort should be made to educate the general public in the appropriate treatment of AGE.

The burden of rotavirus gastroenteritis in children presenting to a paediatric hospital

The aim of this study was to determine the burden, management and outcomes of rotavirus infection in young children presenting to a tertiary paediatric hospital in Sydney, Australia. All laboratory-confirmed cases of rotavirus in children aged <5 years were identified and medical records reviewed. In 2004, 80 children aged <5 years presented to the hospital with rotavirus gastroenteritis confirmed by stool testing. Infants aged <24 months comprised 75% of cases, with more males than females affected. Most children (86%) acquired rotavirus infection in the community, with a mean length of hospital admission of 2·3 days. There were eight cases of nosocomial infection at a rate of 3/10 000 admissions. The rates of intravenous fluid management (46%) and antibiotic use (28%) were high, reflecting the severity of disease presenting in a hospital setting. These data will help inform the assessment of the recently introduced rotavirus vaccination programme in Australia.

Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting

Acute gastroenteritis is associated with significant morbidity in developed countries and each year is the cause of death of several million children in developing countries. Acute gastroenteritis is usually self-limiting. Oral rehydration therapy (ORT) is effective and successful in the majority of patients. Vomiting is common at the outset of viral gastroenteritis and can limit the effectiveness of ORT. Treatment with newer anti-emetic medications has been reported to facilitate ORT and to minimize the risk of dehydration and the need for intravenous hydration and hospitalization. The role of anti-emetic medications in the treatment of gastroenteritis-related vomiting is not clear. Some physicians agree with the use of anti-emetic medications because vomiting is unpleasant and distressing for the child and parents alike, and because vomiting can increase the likelihood of dehydration, electrolyte imbalance, and the need for intravenous hydration or hospitalization. Several surveys have shown that anti-emetic medications are commonly prescribed in the treatment of pediatric gastroenteritis and that adverse events are uncommon. Efficacy studies of the newer anti-emetic medications are now available and reveal that some are effective and help facilitate ORT. Other physicians disagree with the use of anti-emetic medications because acute gastroenteritis is a self-limiting condition, vomiting might help rid the body of toxic substances, there was previously a relative lack of published evidence of clinical benefit, and there are potential adverse events associated with the use of an anti-emetic medication. Anti-emetic medications that are currently available include ondansetron, granisetron, tropisetron, dolasetron, ramosetron, promethazine, dimenhydrinate, metoclopramide, domperidone, droperidol, prochlorperazine, and trimethobenzamide. Randomized, placebo-controlled trials suggest that ondansetron is efficacious and superior to other anti-emetic medications in the treatment of gastroenteritis-related vomiting. A recent double-blind clinical trial showed that a single oral dose of ondansetron reduces gastroenteritis-related vomiting and facilitates ORT without significant adverse events. Ondansetron shows promise as a first-line anti-emetic, and judicious use of this agent might increase the success of ORT, minimize the need for intravenous therapy and hospitalization, and reduce healthcare costs. Ondansetron should be considered in situations where vomiting hinders ORT, but a larger randomized, placebo-controlled trial is necessary before the medication can be routinely recommended for the treatment of gastroenteritis-related vomiting in children.

Isotonic is better than hypotonic saline for intravenous rehydration of children with gastroenteritis: a prospective randomised study

AIMS

To determine whether the risk of hyponatraemia in children with gastroenteritis receiving intravenous (IV) fluids is decreased by the use of 0.9% saline.

METHODS

A prospective randomised study was carried out in a tertiary paediatric hospital. A total of 102 children with gastroenteritis were randomised to receive either 0.9% saline + 2.5% dextrose (NS) or 0.45% saline + 2.5% dextrose (N/2) at a rate determined by their treating physician according to hospital guidelines and clinical judgement. Plasma electrolytes, osmolality, and plasma glucose were measured before (T(0)) and 4 hours after (T(4)) starting IV fluids, and subsequently if clinically indicated. Electrolytes and osmolality were measured in urine samples. Results were analysed according to whether children were hyponatraemic (plasma sodium <135 mmol/l) or normonatraemic at T(0).

RESULTS

At T(0), mean (SD) plasma sodium was 135 (3.3) mmol/l (range 124-142), with 37/102 (36%) hyponatraemic. At T(4), mean plasma sodium in children receiving N/2 remained unchanged in those initially hyponatraemic (n = 16), but fell 2.3 (2.2) mmol/l in the normonatraemic group. In contrast, among children receiving NS, mean plasma sodium was 2.4 (2.0) mmol/l higher in those hyponatraemic at baseline (n = 21) and unchanged in the initially normonatraemic children. In 16 children who were still receiving IV fluids at 24 hours, 3/8 receiving N/2 were hyponatraemic compared with 0/8 receiving NS. No child became hypernatraemic.

CONCLUSIONS

In gastroenteritis treated with intravenous fluids, normal saline is preferable to hypotonic saline because it protects against hyponatraemia without causing hypernatraemia.

High antidiuretic hormone levels and hyponatremia in children with gastroenteritis

OBJECTIVES

Nonosmotic antidiuretic hormone (ADH) activity can cause severe hyponatremia during involuntary fluid administration. We looked for evidence of this before and during intravenous (IV) fluid administration in children treated for gastroenteritis.

METHODOLOGY

In this prospective observational study, plasma ADH, electrolytes, osmolality, and glucose were measured in 52 subjects before (T0) and 4 hours after (T4) starting 0.45% saline + 2.5% dextrose and subsequently when indicated. Hormonal markers of stress were measured at T0. Urine samples were collected to measure electrolytes and osmolality.

RESULTS

The nonosmotic stimuli of ADH secretion that we identified were vomiting (50 of 52), dehydration (median: 5%; range: 3-8%), hypoglycemia (2 of 52), and raised hormonal markers of stress (mean +/- SD: cortisol, 1094 +/- 589 nmol/L; reverse triiodothyronine, 792 +/- 293 pmol/L). At T0, half the children were hyponatremic (plasma sodium concentration of < 135 mmol/L; n = 27). The median plasma ADH concentration at T0 was significantly elevated (median: 7.4 pg/mL; range: < 1.9-85.6 pg/mL). ADH was high in both hyponatremic and normonatremic children and remained high at T4 in 33 of the 52 children, 22 of whom were concurrently hyponatremic. At T4, mean plasma sodium concentration was unchanged in the hyponatremic children but was 2.6 mmol/L (+/-2.0) lower in those who were initially normonatremic. Urine tonicity was high compared with 0.45% saline in 16 of 19 children at baseline and in 20 of 37 children after 3 to 12 hours of IV fluids.

CONCLUSIONS

Nonosmotic stimuli of ADH secretion are frequent in children with gastroenteritis. Their persistence during IV-fluid administration predisposes to dilutional hyponatremia. The use of hypotonic saline for deficit replacement needs to be reassessed.

2. Acute infectious diarrhoea and dehydration in children

Gastroenteritis in children is still a common reason for consulting a general practitioner and for hospital admission. Rotavirus is the most common cause of gastroenteritis in children and accounts for half of all hospital admissions for severe acute infectious diarrhoea. Most children with gastroenteritis do not develop dehydration and can be treated at home. Children with mild to moderate dehydration should be treated with low osmolarity oral rehydration solutions, and those with severe dehydration or shock need to be admitted for administration of intravenous fluids. Lactose-free feeds should not be routinely used after acute gastroenteritis, but there is some evidence that a lactose-free diet may reduce the duration of diarrhoea. Antimotility drugs are rarely indicated in children with gastroenteritis, as the potential risks outweigh the benefits. The development of a rotavirus vaccine would provide huge public health benefits and cost savings. Other preventive strategies include educating people about personal and food hygiene and encouraging breastfeeding.

Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration

OBJECTIVE

To assess the safety, efficacy, and cost-effectiveness of rapid nasogastric hydration (RNG) and rapid intravenous hydration (RIV) administered in the emergency department (ED) to young children suffering with uncomplicated, acute moderate dehydration.

METHODS

Ninety-six children aged 3 to 36 months, who presented with signs and symptoms of uncomplicated, acute moderate dehydration caused by vomiting and/or diarrhea, presumed to be caused by viral gastroenteritis, were randomly assigned to receive either RNG with a standard oral rehydration solution or RIV with normal saline. Each solution was administered at a rate of 50 mL/kg of body weight, delivered over a 3-hour period in our urban pediatric ED. All participants were weighed pretreatment and posttreatment and underwent initial and final measurements of their serum electrolytes, blood urea nitrogen, creatinine, and glucose levels, along with urine chemistry and urine specific gravity. Telephone follow-up by completion of a standardized questionnaire was obtained approximately 24 hours after discharge from the ED.

RESULTS

Ninety-two of 96 enrolled patients completed the study. Three patients failed treatment (2 RIV and 1 RNG) and were excluded and hospitalized because of severe, intractable vomiting, and 1 patient was withdrawn secondary to an intussusception. Among 92 evaluable patients, 2 were found to be severely dehydrated (>10% change in body weight) and were excluded from analysis, leaving 90 patients (RNG: N = 46 and RIV: N = 44), who completed the study. Both RNG and RIV were found to be a safe and efficacious means of treating uncomplicated, acute moderate dehydration in the ED. Determinations of electrolytes, blood urea nitrogen, creatinine, or glucose were not found to be of value on an intent-to-treat basis in the care of these patients. The urine specific gravity and incidence of ketonuria declined from levels commensurate with moderate dehydration in the RNG group, but not as consistently so in the RIV group. Both RNG and RIV were substantially less expensive to administer than standard care with intravenous fluid deficit therapy in-hospital, and RNG was more cost-effective to administer over RIV in the outpatient setting.

CONCLUSION

RNG and RIV administered in the ED are safe, efficacious, and cost-effective alternatives to the standard treatment for uncomplicated, acute moderate dehydration in young children. RNG is as efficacious as RIV, is no more labor intensive than RIV, and is associated with fewer complications. In addition, we found that most routine laboratory testing is of little value in these patients and should be avoided, except when clearly clinically indicated.

Fetal oxygen saturation monitoring in labour: an analysis of 118 cases

Fetal oxygen saturation (FSpO2) was recorded during labour to determine the relationship between FSpO2 and indicators of fetal well-being, including umbilical blood gases, xanthine (X), hypoxanthine (Hx) and Apgar scores. This is one of the largest reported series of fetal pulse oximetry, with 118 fetuses monitored for over 329 hours. Mean FSpO2 for all cases was 46.9% (SD = 9.1%). There was no correlation between FSpO2 during the last 10 minutes of monitoring and arterial pH, Hx or X. A mean FSpO2 > or = 30% was associated with a 5 minute Apgar score of > or = 7 in the majority of cases. One fetus had a mean FSpO2 < 30% during the final 10 minutes of monitoring and an umbilical arterial pH < 7.20, while there were 10 fetuses with an umbilical arterial pH < 7.20, and mean FSpO2 > or = 30%. As these numbers are small, a larger series is necessary to further characterize the small number of fetuses who are significantly hypoxic.

Rotavirus gastroenteritis: impact on young children, their families and the health care system

OBJECTIVE

To assess the impact of rotavirus gastroenteritis on young children attending a paediatric hospital, their families and the health care system.

DESIGN

Cross-sectional descriptive survey.

SETTING

New Children's Hospital (Royal Alexandra Hospital for Children), Sydney, New South Wales, 15 July to 4 October 1996.

PARTICIPANTS

Children aged under three years attending the Emergency Department with acute diarrhoea as the presenting symptom.

OUTCOME MEASURES

Cases of rotavirus infection confirmed by enzyme-linked immunosorbent assay by age; rotavirus serotype; gastroenteritis severity score; estimated costs to parents (lost pay or leave, travel, medication and other expenses) and to the health care system (visits to Emergency Department and other health care workers, hospital admissions).

RESULTS

280 children were recruited (73% of 384 children who met the inclusion criteria and 27% of the 1037 aged under three years with acute gastroenteritis). Rotavirus was detected in 188 of the 280 (67%); most isolates were serotype G1 (86% of the 174 serotyped). Of the 188 children with confirmed rotavirus infection 78% were aged 7-24 months and 82% visited at least one other health care worker, usually a general practitioner. Seventy (37% of the 188) were admitted to hospital; 33 of these (47%) were aged 13-24 months. Estimated mean total cost per episode of rotavirus gastroenteritis was $1744 for children admitted to hospital and $441 for children not admitted. The mean cost to families was $493 for children admitted to hospital and $228 for children not admitted.

CONCLUSIONS

Rotavirus gastroenteritis has a significant impact on young children, their families and the health care system. Prevention of severe disease through routine infant vaccination would be potentially cost-effective.

Oral rehydration solution in the year 2000: pathophysiology, efficacy and effectiveness

The use of oral rehydration solution (ORS) with early refeeding forms the basis of therapy for dehydration secondary to diarrhoea ORS has produced such positive results in dehydrated patients that no further scientific demonstration is needed to confirm its efficacy. This review presents several issues that remain unsettled or controversial. They include the following. 1. The mechanism of water handling by the intestine is discussed; this is more complex than initially thought, at the epithelial, cellular and molecular level. 2. The composition of ORS which has been successfully adapted for the most frequent conditions, except for severely malnourished children, is described. 3. In contrast to the strong scientific basis and obvious efficacy in rehydration of ORS, its consequences for growth, nutrition and mortality are difficult to demonstrate, unless adequate long-term nutritional support is also provided in addition to ORS. 4. Finally, discrepancies between the recommendations and the practice of oral rehydration therapy are now well documented. Analysis of the causes of these discrepancies may participate in improving public health campaigns.

Management of childhood gastroenteritis in the community

OBJECTIVE

To examine general practitioners' (GPs') management of childhood gastroenteritis and their perceptions about barriers to optimal management in the community.

DESIGN

Cross-sectional postal survey in which GPs' self-reported practices were assessed by a paediatric gastroenterologist for compliance with published guidelines.

SETTING

Hunter region of NSW, mid 1994.

PARTICIPANTS

All 422 urban and rural GPs practising in the Hunter region were sent questionnaires; 289 (243 urban and 46 rural) GPs responded.

RESULTS

Nearly all GPs (97%) recommended clear fluids in the management of childhood gastroenteritis, with 195 (67%) recommending oral electrolyte solution. Management practices were assessed as: optimal, 170 GPs (59%); acceptable, 33 GPs (11%); inappropriate or potentially dangerous, 38 GPs (13%); and too vague to classify, 48 GPs (17%). Multiple logistic regression analysis showed that better management strategies were associated with being younger and practising in rural areas. GPs perceived the main barriers to effective management of gastroenteritis were: inadequate parenting skills, 131 GPs (45%); lack of parental understanding about the illness, 118 GPs (41%); other social problems, 67 GPs (23%); parental anxiety, 57 GPs (20%); and conflicting advice given by others, 42 GPs (15%). Only 33 GPs (11%) identified the taste and 16 (6%) the cost of oral electrolyte solution as major barriers.

CONCLUSIONS

Most GPs reported management of gastroenteritis was acceptable, although not necessarily optimal. GPs need to ensure that parents fully understand the nature of their child's illness and their recommendations for management at home.