AGE, ORS, IV FLUIDS

(Seminar 2)
14/4/2020
MARINAH MOHD OMAR - BMS17091287
NOR JANNATUL IRFANA – BMS17091289
Approach To A Child a With
Gastroenteritis
• inflammation of the gastrointestinal tract most commonly die to
infections with bacterial, viral or parasitic pathogens\
• most common manifestations are diarrhea and vomitting, associated
with abdominal pain or fever
Diarrhoea Dysentery
• frequent small stools
containing visible blood,
accompanied by fever,
abdominal cramps and pains,
usually resulting from disease
of large intestine
• Inflammatory disease of GIT
• Often associated with blood &
pus in faeces
• different from bloody diarrhea
(larger volume bloody stools
with less systemic illness)
Aetiology of AGE

Viruses (70-80%) Bacteria (10-20%) Protozoa (<10%) Pseudomembrano

us colitis
• Rotavirus A, B & • Salmonella sp. • Entamoeba • Clostridium
C • Shigella sp. histolytica difficile
• Enteric • E. coli • Giarda lamblia
adenovirus • Vibrio cholera
• Calicivirus • Campylobacter
(norovirus or jejuni
Norwalk virus) • Yersina
• Astrovirus enterocolitica
Differential Diagnosis of AGE
Typhoid fever • Constipation for week then diarrhoea, nausea and
vomiting
Urinary tract • Fever, vomiting, abdominal pain and poor feeding
infection (0 months  2 years)
Appendicitis • Abdominal pain followed by nausea & vomiting
• Diarrhoea & fever
Viral meningitis • Headache, dislike of bright lights, neck stiffness, fever
and nausea/vomiting.
• Individuals may also develop a rash or have muscle
pain.
• Normally recover without medical treatment
• The most accurate measure of dehydration is the degree of weight
loss
• The history and examination are used to assess the degree of
dehydration as:
- No clinically detectable dehydration (usually <5% loss of body weight)
-Clinical dehydration (usually 5–10%)
-Shock (usually >10%)
History Taking
• PERSONAL HISTORY
- age, name, sex, address, position in family
• CHIEF COMPLAINT:
- Diarrhea and/or Vomiting
• PRESENT HISTORY
• Diarrhea
• Onset-sudden/progressive, before/after meal, postprandial?, headache/dizziness(increase
in ICP)
• Duration
• Characteristic
• Quantity(the volume)
• Content(the colour, mucus/blood, foul-smell)
• Frequency
• Associated signs and symptoms
 • Vomiting
• Onset-acute/chronic, before/after meal, postprandial,
headache/dizziness(increase in ICP)
• Duration
• Characteristic(projectile motion?)
• Quantity(the volume)
• Content(colour, food particles, blood/mucus, foul-smelling)
• Frequency
• Associated signs and symptoms
• Systemic review
• PAST HISTORY
- history of current illness
-history of chronic illness
-history of surgical procedures

• Family History
• History of contact diarrhea
• chronic illnesses
• Social history
• Clean water supply at home, dengue area
• Drug history
• Allergy to antibiotics?, on any medication?
• PERINATAL HISTORY
-perinatal, natal, postnatal

• VACCINATION HISTORY

• NUTRITIONAL HISTORY
Physical Examination
• search for signs of comorbid conditions
• estimate of the level of dehydration

-careful general examination

-anthropometric measurements, weight change
-assess hydration status
Investigation
• Full blood count
• WBC count-infection
• Hb count-anemia due to blood loss
• Blood urea and serum electrolyte
• Indication of hydration
• Blood culture
• Salmonella typhi(thyphoid fever), nonthyhoidal Salmonella and E. coli enteritis
• Urine test
• Urine output and specific gravity
• Stool culture
• Mucus, blood and leukocytes indicate colitis in response to bacteria that diffusely
invade the colonic mucosa, such as Shigella, Salmonella, C. jejuni and invasive E. coli.
• Rotavirus antigen test.
• Evaluation of parasitic agents.
Treatment

Plan A: treat diarrhea at home

3 rules of home treatment

• Give extra fluid
• Continued feeding
• When to return
Giving extra fluids(as much as the child will take)

• Breastfeeding
• It should be done frequently and for longer at each feed.
• If the child is exclusively breastfed, give ORS or cooled boiled water in addition
of breast milk.
• Otherwise, give one or more of the following:
• ORS, food-based fluids(soup or rice water) or cooled boiled water

**Children receiving semi-solid or solid foods should continue to receive their

usual food during the illness.
**Food high in simple sugar should be avoided as osmotic load may worsen
the diarrhea.
• Oral Rehydration Solution(ORS)
• It should be given at home when
• The child has been treated with plan A or plan B during the visit.
• 8 sachets is given.
• Teach the mother how to mix and give ORS in addition to the usual
fluid intake.
• Up to 2 years: 50-100ml after each loose stool
• 2 years or more: 100-200ml after each loose stool
(if weight is available, give 10ml/kg of ORS after each loose stool)
• Ask the mother to
• Give frequent small sips from a cup or spoon
• If the child vomits, wait 10 minutes, then continue more slowly.
(Eg. 1 spoonful every 2-3 minutes)
• Continue giving extra fluid until diarrhea stops
When to return(to clinic/hospital)

When the child

• Is not able to drink or breastfeed or drinking properly
• Becomes sicker
• Develops a fever
• Has blood in stool
 Plan B: treat some dehydration with ORS

Princple of Oral Rehydration Salt (ORS)

Glucose Na+ K+ Cl- HCO3

111 90 20 80 30
• Na+ is absorbed by the healthy intestinal wall is impaired in the
diarrhoeal state, causing water not able to be absorbed.
• In ORS, glucose is added to a saline solution.
• The glucose molecules absorption through the intestinal wall are
unaffected by the diarrhoeal disease state and in conjunction
sodium is carried through by a co-transport coupling
mechanism of sodium and glucose.
• This occurs in a 1:1 ratio, one molecule of glucose co-transporting
one sodium ion (Na+).
• It should be noted that glucose does not co-transport water, rather
it is the now increased relative concentration of Na+ across the
intestinal wall which pulls water through after it.
Dehydrarion Mild Moderate

Total ORS 50ml/kg over 4 hours by syringe, spoon or
cup
• Give 1ml/kg of ORS by syringe every 5
minute for 4 hours OR
• Give 3ml/kg of ORS every 15 minutes
for 4 hours
Reassessment at 4-hour intervals
100ml/kg over 4 hours
Infants:
• Give 30ml per hour of ORS
• Give 5-10ml (1-2tsp) every 15 minutes
Toddler:
• Give 60ml per hour of ORS
• Give 15ml (3tsp) every 15 minutes
Child:
• Give 90ml per hour of ORS
• Give 20-25ml every 15 minutes
• Give the recommended amount of ORS over 4-hour period:

1. Use the child’s age only when you do not know the weight.
2. The approximate amount of ORS required(in ml) can be calculated by
multiplying the child weight(in kg) x 75.
3. If the patient requires more ORS than shown, give more.
How to prepare ORS solution

• Empty the entire content of one ORS sachet into 250mls of cool boiled
water, and mix thoroughly.

• ORS should be given slowly but steadily to minimize vomiting.

• If vomiting occurs, pause feeding for 30-60 minutes
• May resume above diarrhea replacement after no vomiting for 30-
60minutes
• After 4 hours,
• Reassessed the child and classify the child for dehydration.
• Select the appropriate plan to continue treatment.
• Plan A, B or C
• If the mother must leave before completing treatment
• Show her how to prepare ORS solution at home.
• Show her how much ORS to give to finish the 4-hour treatment at home.
• Give her enough ORS packets to complete rehydration(at least 8 packets).
• Explain three rules of house treatment in Plan A
• Giving extra fluid, continued feeding and when to return
Plan C: treat severe dehydration quickly
• Start intravenous(IV) or intraosseous(IO) fluid immediately.
DEHYDRATION ASSESSMENT
• Dehydration is simply the excessive loss of body water resulting a
decrease in total body water.
• When a child comes with vomiting or diarrhoea always look for
dehydration.
• Infants are at a higher risk at developing dehydration because :
- High surface area to eight ratio
- High basal fluid requirement
- Immature renal tubular reabsorption process
- Inability
CLINICAL ASSESSMENT
INTRAVENOUS FLUID THERAPY
INDICATION OF INTRAVENOUS THERAPY
• Severe dehydration
• Unconscious child
• Frequent or severe vomiting, drinking poorly
• Glucose malabsorption, indicated by marked increase in stool output
• Continuing rapid stool loss ( > 15-20ml/kg/hour)
CALCULATION OF REQUIRED
THERAPY
1. Fluid deficit
= percentage dehydration x body weight in grams.
• Percentage dehydration is :
- < 5% for no signs of dehydration
- 5 – 10% for some dehydration
- > 10% for severe dehydration
2. Maintenance fluid therapy
• Types of fluid solution :
- 1/5 normal saline 5% dextrose solution or
½ saline 5% dextrose solution with or without added KCL
in the drip.
• Volume of fluid required:
- less than 6 months age : 150ml/kg/day
- 6 months to 1 year age : 120ml/kg/day
- more than 1 year of age :
* first 10kg = 100ml/kg
* 10 – 20kg = 1000ml for the first 10kg + 50ml/kg for the next
10 subsequent kg.
* > 20kg =1500ml for the first 20kg + 20ml/kg for any subsequent kg
3. Electrolyte requirement and replacement formulae
• Daily requirement of sodium = 2-3mmol/kg/day
x body weight (kg)
• Daily requirement of potassium = 2-3mmol/kg/day
x body weight (kg)

*It is important to measure serum electrolyte and blood glucose when

starting an IV fluids and atleast every 24 hours thereafter
References
• Illustrated Textbook Of Paediatrics-4th Edition
• Nelson Textbook of Paediatrics -21st Edition
• Paediatric Protocols for Malaysian hospitals -2nd edition