Slide 1	Title slide. “We are going to talk about a ubiquitous subject, diarrhea in kids.” Engage the audience asking for a show of hands who has treated pediatric diarrhea. Ask the audience to describe any remarkable cases they remember, any challenges with diagnosis or management, and why some patients went home versus which patients were admitted.
Slide 2	Key
Slide 3	By the end of this lecture, you should be able to: Identify viral causes and bacterial causes of gastroenteritis Classify the degree of dehydration in the child presenting with diarrhea Identify a well-nourished child from a malnourished child to determine best management of dehydration Outline World Health Organization Plans A, B, and C for treatment of dehydration Choose the appropriate treatment strategy for viral and bacterial gastroenteritis Anticipate complications of gastroenteritis
Slide 4	An introduction to a common presentation of a child with gastroenteritis. Read case aloud. Use this as an opportunity to discuss differential diagnosis, how sick child seems, what are the ways you can treat diarrhea (reassurance, oral rehydration, intravenous hydration, etc.) with the audience.
Slide 5	This case likely describes gastroenteritis. What is gastroenteritis? Technically, defined as 3 or more loose stools in 24 hours. It can be accompanied by other gastrointestinal (GI) symptoms such as vomiting, abdominal pain, or fever. Typical symptoms for acute gastroenteritis may last up to two weeks. The majority of cases are viral.
Slide 6	This slide discusses distinguishing between viral and bacterial causes of diarrhea. There is more concern for bacterial source if there is bloody diarrhea, high fever, or the child has a risk factor (eg, travel, contaminated foods, or water sick contacts).
Slide 7	For children under the age of 5, the most common etiologies of diarrhea included Rotavirus, E. coli, Shigella and Cryptosporidium in a study of over 20,000 children presenting for treatment in African and Southeast Asia (The Gambia, Mali, Mozambique, Kenya, Bangladesh, India, Pakistan). Liu J, Platts-Mills JA, Juma J, et al. Use of quantitative molecular diagnostic methods to identify causes of diarrhoea in children: a reanalysis of the GEMS case-control study. Lancet. 2016;388(10051):1291–1301. doi:10.1016/S0140-6736(16)31529-X
Slide 8	The two most common causes of viral gastroenteritis include rotavirus and norovirus. Rotavirus is most common in younger children and historically has been the most common cause of severe enough diarrhea that caregivers seek medical care, although rates of rotavirus diarrhea are (thankfully) decreasing due to vaccination campaigns. Norovirus is common across all ages and tends to be associated with outbreaks (eg, contaminated food, water). Rivera-Dominguez G, Ward R. Pediatric Gastroenteritis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; April 3, 2023.
Slide 9	Bacterial disease is more common in older children. Presentation will usually include bloody stools, high fever, and severe abdominal pain. The most common pathogens include E. coli, Shigella, Campylobacter, and Yersinia. Suspicion of particular bacteria will help guide antibiotic choices.
Slide 10	Food-borne gastroenteritis (“food poisoning”) is another common cause of diarrhea disease in children. Two major pathogens are S. aureus and Bacillus which produce enterotoxins which contaminate food and/or water. Due to the toxins, symptoms usually develop within hours after ingestion: acute onset nausea, vomiting, and diarrhea. Typically, the symptoms are self-limited and only require supportive care. S. aureus usually shows quicker onset than B. cereus but both tend to present within 16 hours Rivera-Dominguez G, Ward R. Pediatric Gastroenteritis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; April 3, 2023.
Slide 11	What are some questions you want to ask when a child presents with diarrhea? Request responses from the audience, and then review the list.
Slide 12	A rapid, focused exam can assess for shock or severe dehydration. It is important to also check for signs of anemia or liver dysfunction such as pallor, jaundice, or bruising.
Slide 13	Children do not typically present in shock the way adults or adolescents do. They tend to reach a tipping point and then crash when they can no longer compensate. Do not ignore delayed capillary refill, cool extremities, or a fast and weak pulse. One easy way to examine a child for this: touch is/her hand. If it is warm and capillary refill is normal (<2 seconds), the child is unlikely in shock. Remember that unlike adults, children will not be hypotensive until late in a shock state.
Slide 14	If you identify shock, STOP and TREAT immediately. Do not continue with your assessment.
Slide 15	Diarrhea accounts for more than 1/10 neonatal deaths worldwide! While common, it has significant mortality if danger signs are not recognized and treated. If a child is showing warning signs of severe illness such as shock, treatment should be initiated immediately. Liu L, Johnson HL, Cousens S, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000 [published correction appears in Lancet. 2012 Oct 13;380(9850):1308]. Lancet. 2012;379(9832):2151–2161. doi:10.1016/S0140-6736(12)60560-1
Slide 16	Two of the most immediate and quick physical exam findings for severe dehydration include the eyes and the skin. Sunken eyes can indicate severe dehydration but could also help identify malnutrition (should discuss chronicity of appearance with parents). A skin pinch which is slow to return to normal is a sign that can also indicate severe dehydration.
Slide 17	This table is from the World Health Organization (WHO) Integrated management of childhood illness guidelines for assessing the degree of pediatric dehydration. You can see it progresses from left to right indicating no dehydration to severe dehydration. We can use these findings to objectively classify the degree of dehydration and select the appropriate treatment plan (Plan A, B or C).
Slide 18	Of note, if a child presents with a history of diarrhea or vomiting and is lethargic, please check their blood sugar early in the clinical course. Such children may be unable to keep up with their metabolic needs and may have altered mentation due to hypoglycemia. If you cannot check a blood sugar, err on the side of empirically administering glucose. Listed are the values of blood glucose that would indicate hypoglycemia.
Slide 19	How do you give glucose? An easy rule of thumb for intravenous intervention is the “Rule of 50s” wherein depending on the concentration of dextrose you have available, you can determine the appropriate pediatric weight-based dosing of glucose: Dose (mL/kg) × Concentration = 50 Therefore: D50%: 1 mL/kg D10%: 5 mL/kg D5%: 10 mL/kg The instructor can work through some examples of appropriate calculations with the learners.
Slide 20	It is critical to be able to assess the severity of dehydration because this determines your treatment plan.
Slide 21	The WHO divides diarrhea into three treatment plans based on severity of dehydration. Plan A = not dehydrated. These children can receive supportive care at home for diarrhea. Plan B = moderately dehydrated. These children should to be given fluids using the enteric system (orally or by gastric tube) in clinic or the emergency department and reassessed for appropriate disposition. Plan C= severely dehydrated. These children need to be transferred to a capable hospital and given intravenous (IV) fluids (if well nourished) and reassessed.
Slide 22	Plan A: if there are less than 2 features from Columns B or C, there is no evidence of dehydration.
Slide 23	This child can be managed at home, fed normally, and be given Oral Rehydration Solution (ORS) to take after each stool to compensate for losses.
Slide 24	Plan B: If there are 2 or more features from column B, then the child has some (moderate) dehydration and needs to be monitored in the clinic or emergency department.
Slide 25	This child should be started on oral or gastric fluids in clinic or in the emergency setting (75 ml/kg total over four hours) and then reassessed.
Slide 26	If you do not know the child’s weight, this table provides an estimate of the fluid to be given over the 4 hours based on the child’s age.
Slide 27	Plan C: If there are 2 or more features from column B, then the child has severe dehydration and needs to be referred to a capable hospital.
Slide 28	The heart of Plan C is IV fluids (for well-nourished children). This often requires a hospital setting. You will give an initial bolus (rate depends on child’s age) followed by maintenance fluids for the next five hours (see table).
Slide 29	How can you tell if a child is malnourished? Three main signs are wasting, edema, and decreased upper arm circumference. It is important to identify malnourished children not only because they need different treatment for dehydration but also because some of the typical signs of dehydration (eg, sunken eyes, delayed skin pinch, lethargy) are not reliable indicators of dehydration because they could just as well be due to malnutrition. Because they may have poor cardiac function associated with their chronic malnourishment, these children are susceptible to heart failure and could die if given rapid, unnecessary IV fluids.
Slide 30	If you have assessed the child and there are no signs of malnutrition, you can then begin IV fluids for severe dehydration. You will give 30 cc/kg over the first 0.5–1 hour (depending on age, see table) and another 70 cc/kg over the next 2.5–5 hours (again depending on age). Reassess the severely dehydrated child every 15–30 minutes and add oral rehydration solution as soon as the child will take it.
Slide 31	For malnourished children, you DO NOT GIVE IV FLUIDS UNLESS THEY ARE IN SHOCK. Why? Because their cardiac function is presumed poor, as is their protein status. Malnourished children given IV fluids too quickly can become fluid overloaded and die. Instead, start oral or gastric fluids with oral rehydration solution (ORS, Re-So-Mal) at 5 ml/kg every 0.5 hour for first 2 hours and then every 0.5–1 hour for the next 4 hours. These children need regular and frequent reassessment.
Slide 32	To summarize, for severe dehydration (i.e., Plan C) you are going to reassess frequently, give IV fluids if well-nourished, or oral or gastric fluids if malnourished. Well-nourished children can add ORS by mouth as soon as the child will take it. You then reevaluate/reclassify in 3 hours (older child) or 6 hours (infant).
Slide 33	What if you can’t obtain IV access? Another option for resuscitation is to place a nasogastric (NG) tube and start hydration that way as 10 ml/kg in a well-nourished child every 30 minutes with frequent reassessment. If you notice abdominal distention, slow down the rate of fluids resuscitation. Like the IV fluid plan previously, reassess and reclassify after 6 hours.
Slide 34	How do you place an NG tube? Have an audience member who is familiar explain to the group. The facilitator should be prepared to describe how to place an NG tube: Measure the approximate distance depth of insertion from the nose to the ear to the epigastrium. Insert the NG tube through one of the patient’s nostrils using lubricant. Gently advance the NG tube through the nasopharynx. Continue to advance the NG tube. You can ask the patient to swallow some sips of water to facilitate advancement of the tube. Avoid giving patients a drink if their swallow is deemed unsafe due to the risk of aspiration. Once you reach the desired nasogastric tube insertion length, fix the NG tube to the nose with a dressing. Confirm placement by aspirating gastric contents, listening for borborygmi and/or getting a radiograph.
Slide 35	For all children, encourage breastfeeding if they were previously doing so before they became ill. Make sure caregivers know how to mix the ORS and administer it. Providers and caregivers can slowly reintroduce foods after several hours in older children and consider zinc supplementation. Ensure caregivers know how to mix Oral Rehydration Solution (ORS) and how much to give: Clean hands, utensils & water Mix 1 packet of ORS with 1L of clean water OR Mix 3.5g salt and 40g sugar in 1L of clean water (if ORS packets unavailable) Give ½ L/day to babies or toddlers or 1L/day to older children
Slide 36	Let’s briefly discuss some of the other therapies that can be helpful with diarrhea.
Slide 37	Probiotics have a modest effect on recovery, and they are most effective among patients who may have previously taken antibiotics contributing to the presentation of diarrhea. They may shorten the duration of illness. Guarino A, Lo Vecchio A, Canani RB. Probiotics as prevention and treatment for diarrhea. Curr Opin Gastroenterol. 2009;25(1):18–23. doi:10.1097/MOG.0b013e32831b4455
Slide 38	Zinc supplementation can be useful in areas where zinc deficiency or moderate malnutrition are high in children greater than 6 months of age. However, adding zinc may only shorten duration of diarrheal illness by about 1 day on average. Lazzerini M, Wanzira H. Oral zinc for treating diarrhoea in children. Cochrane Database Syst Rev. 2016;12(12):CD005436. Published 2016 Dec 20. doi:10.1002/14651858.CD005436.pub5
Slide 39	Zinc can be given in an oral electrolyte solution or as a tablet. It is administered as 10 mg (1/2 tablet) for children aged < 6 mo or 20 mg (1 tablet) in children >6 mo.
Slide 40	In general, antibiotics are not indicated for an acute diarrheal illness in children and can cause more severe disease, such as hemolytic uremic syndrome (HUS). DO NOT give antibiotics unless a specific pathogen has been isolated or highly suspected. Most children will improve with supportive care alone and time. Bajait C, Thawani V. Role of zinc in pediatric diarrhea. Indian J Pharmacol. 2011 May;43(3):232.
Slide 41	Hemolytic Uremic Syndrome (HUS) is a potentially fatal complication of bacterial enteritis. It is most common seen with E. coli O157:H7. It usually begins about a week after diarrheal onset and presents with a triad of: 1) hemolytic anemia, 2) thrombocytopenia, and 3) acute renal failure. Cody EM, Dixon BP. Hemolytic uremic syndrome. Pediatric Clinics. 2019 Feb 1;66(1):235–46.
Slide 42	The treatment for HUS is mostly supportive. If the child is anemic, you can transfuse packed red blood cells. If the child is thrombocytopenic, only transfuse if there is active bleeding, the patient needs to be medically optimized for an invasive procedure, or perhaps if platelets count is <10k. Recognize that the child may have impaired renal function and may not tolerate high volume fluids and show signs of fluid overload. What does that look like? Edema, jugular venous distention, hepatomegaly, splenomegaly, dyspnea, pulmonary basilar rales. In significant renal failure, some patients may even need emergency hemodialysis. Cody EM, Dixon BP. Hemolytic uremic syndrome. Pediatric Clinics. 2019 Feb 1;66(1):235–46.
Slide 43	Let us revisit our case. Ask audience to classify degree of dehydration and explain their decision-making.
Slide 44	Discuss case management, and review protocol for evaluating diarrhea and dehydration in children. Evaluate for signs of shock: Normal vitals, strong pulses Evaluate nutrition: Not malnourished Assess degree of dehydration: Sunken eyes, slow skin pinch, but alert and eagerly drinking Which Plan does child fall into? -Plan B: Some dehydration What is the treatment? −75 mL/kg over 4 hours of ORS You reassess in 4 hours; child is improved. Now what do you do? -Go to plan A, add zinc Cody EM, Dixon BP. Hemolytic uremic syndrome. Pediatric Clinics. 2019 Feb 1;66(1):235–46.
Slide 45	In summary: Diarrhea may have many causes, with viral gastroenteritis being the most common. Rehydration should be dependent on degree of dehydration and nutrition status. WHO Plans A, B, and C can be used to guide rehydration of well-nourished children with diarrhea and dehydration. Treatment of diarrhea is primarily supportive. HUS is a life-threatening complication.
Slide 46	References are provided here. Any questions?