Patient Presentation
An 8-month-old male came to clinic with a 24 hour history of diarrhea that was described as loose, watery, and running out the diapers. He had the diarrhea 6 times. He also had 3 episodes of emesis.
There was no blood in the emesis or diarrhea. He was drinking various fluids somewhat, but not his normal amounts. He had had 3 wet diapers, but his father said that it was difficult to tell how wet they were because of the diarrhea.
He was tired, but not otherwise unwell. He had a large, watery stool prior to the physician going into the room, and his father was giving him a sports drink.
The review of systems found him to be in a daycare center that had recent diarrhea in his classroom.
The pertinent physical exam revealed an alert male who appeared tired. His weight was the same as a previous weight 1 month prior. His mucous membranes were moist, with 1-2 seconds of capillary refill.
His abdomen was soft and non-tender but with active bowel sounds.
His buttocks were red with no skin breakdown. The rest of his examination was normal.
The diagnosis of gastroenteritis was made. The patient appeared hydrated and the father was educated about how to give frequent fluids during a gastroenteritis episode.
The father was also counseled about not giving the sports drink or other similar fluid because they don’t contain the correct amount of fluid and electrolytes. He was told to use a commercially prepared, oral rehydration salt (ORS) solution or ORS solution packets which could be mixed.
The father was also given instruction of signs and symptoms to monitor for dehydration or other problems, and when to call or return to the clinic.
Discussion
Gastroenteritis is a common ailment around the world. It is defined as inflammation of the lining of the stomach and the intestine and thus has diarrhea as its major symptom. Vomiting may also occur.
Gastroenteritis is most commonly caused by viruses, usually by rotavirus, or enteric adenovirus. A variety of bacteria can also cause it including Salmonella, Shigella, Campylobacteriacae and Yersinia.
Diarrhea is the second leading cause of childhood death with more than 1.9 million childrens’ deaths worldwide/year. Most symptoms last for 3-5 days. After this time or if symptoms are severe, a patient should seek help from a healthcare provider.
Oral rehydration salt (ORS) solution is the mainstay of treatment world-wide.
ORS solution is easy to make, use and is the most economical treatment. ORS solution is absorbed in the intestines and can quickly replace the water and electrolytes lost through vomiting and diarrhea.
ORS solution should be combined with appropriate education on feeding practices. Continued breastfeeding through acute episodes of diarrhea protects against dehydration and reduces protein and calorie consumption thus decreasing dehydration and malnutrition. Providing zinc supplements (20 mg of zinc per day for 10 to 14 days) is also recommended in some countries, but generally not in the United States.
The United Nations Children’s Fund (UNICEF) recommends that each child drinks as much as possible but “at least a quarter to a half of a large cup of the ORS drink after each watery stool” for a child less than 2 years of age, and “at least a half to a whole large cup of the ORS drink after each watery stool” for a child more than 2 years of age.
UNICEF further recommends that “if the child vomits, the caregiver should wait for 10 minutes and then begin again to give the drink to the child slowly, small sips at a time.”
One study in the US in an urban pediatric continuity clinic found that mixing ORS solution from packets was better tolerated and more well liked by the parents than commercially prepared ORS ready-to-drink solution.
Learning Point
In March 2006, the World Health Organization recommended a new ORS solution formulation.
The newest ORS formula has less glucose and sodium with a total concentration of 245 mOsm/L compared to the previous 311 mOsm/L.
The lower concentration allows quicker fluid absorption in the small intestine which decreases the need for intravenous fluids. Therefore there will be less need for hospitalization in the emergency room or on the wards.
The new formulation contains:
Sodium chloride (NaCl) = 2.6 g
Trisodium citrate dihydrate (C6H5Na3O7,2H2O) = 2.9 g
Potassium chloride (KCl) = 1.5 g
Anhydrous glucose (C6H12O6)= 13.5 g
The contents of each packet should be dissolved in 1 litre of clean water.
The ORS solution should be discarded after 24 hours.
Questions for Further Discussion
1. What is the differential diagnosis of bloody diarrhea?
2. How often should an infant or child urinate normally or if dehydrated?
3. Where can ORS solution packets be purchased?
4. What vaccines are available for rotavirus?
Related Cases
- Disease
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Gastroenteritis
and at Pediatric Common Questions, Quick Answers for this topic: Vomiting and Diarrhea
To view current news articles on this topic check Google News.
Landinsky, et al. Archives of Pediatrics and Adolescent Medicine 2000;154:700-705.
World Health Organization. Improved formula for oral rehydration salts to save children’s lives. Available from the Internet at http://www.who.int/mediacentre/news/releases/2006/pr14/en/index (rev. 03/23/2006, cited 11/22/06).
World Health Organization. Oral Rehydration Salts (ORS). Available from the Internet at http://www.who.int/medicines/publications/pharmacopoeia/ors/en/ ( cited 11/22/2006).
Unicef. Facts for Life. Available from the Internet at http://www.unicef.org/ffl/07/1.htm ( cited 11/22/06).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
December 18, 2006
Pediatric Education 