Gastroenteritis

Treatment of diarrhea changed in the mid-1960s with the introduction of oral rehydration solution (ORS) as an alternative to administration of IV fluids. Although ORS is still not universally used in the United States, it has been proven to be effective and to result in fewer complications than IV therapy. ORS successfully rehydrates 90 percent of children in whom it is used.11

The majority of children with diarrhea and vomiting who become dehydrated may be treated with ORS (Fig 122-1). This treatment capitalizes on the fact that glucose-coupled sodium and water absorption remains sufficiently intact during most infections. Glucose-electrolyte solutions, like Pedialyte, are commonly available in the United States. The glucose concentration of these solutions does not exceed the sodium concentration in millimolar units by more than 2:1. In addition, the osmolality of commercial hydration solution is relatively low and about 310 mosm/L. In contrast, other clear fluids, such as soft drinks, juices, and Jell-O water, are largely carbohydrate based, are typically deficient in Na + and Cl+, and have osmolalities ranging from 510 to 1225. The routine use of such highly osmolar sugar-based solutions to treat acute diarrhea will predictably amplify net small intestinal fluid secretion and increase diarrhea.

FIG. 122-1. Evaluation and treatment of diarrhea in children.

Vomiting is not a contraindication to administering ORS. The key in the treatment of vomiting children is to give small volumes of glucose-electrolyte solution, often starting with 5 mL at a time given every couple of minutes. ORS may also be given in the form of a popsicle. Giving ORS in this manner is labor intensive, though, and, if parents or staff are not available, then IV therapy may be necessary. For IV rehydration, between 20 and 40 mL/kg of Ringer's lactate or normal saline may be given over 1 to 3 h. Following parenteral rehydration, many children may be discharged home for regular feedings and supplemental ORS solution, provided follow-up is available, they do not appear toxic, and the caregiver is reliable. The daily volume of ORS should not exceed 150 mL/kg/day. 12 Breast milk or infant formula should be used if additional fluid is needed to satisfy thirst.

Children who have mild diarrhea and no dehydration may continue age-appropriate feedings and supplemental fluids as needed to replace ongoing stool loss (10 mL/kg/stool). ORS may be used to replace stool loss: although the solution is salty and may be refused, children who are dehydrated rarely refuse ORS. Mild dehydration (3 to 5 percent) may be treated by giving 50 mL/kg ORS plus replacement of ongoing losses over a 4-h period. Moderate dehydration (6 to 9 percent) is treated with 100 mL/kg plus replacement of ongoing losses over 4 h. Age-appropriate feedings should be reintroduced after a child is rehydrated. Severe dehydration (more than 10 percent) is a medical emergency, and the child should be given bolus IV fluids (20 mL/kg) using normal saline. The bolus may be repeated as needed to restore circulating volume and the child admitted to the hospital.

In general, reinstatement of food should begin after the 4-h rehydration phase is completed and never delayed more than 24 h. Recent studies have shown that the introduction of full-strength formula or unrestricted diet immediately following rehydration is associated with decreased duration of diarrhea, positive nitrogen balance, and increased weight gain. Breast-feeding should be routinely continued for infants with acute gastroenteritis. Infants who have been receiving formula feedings and who are not dehydrated may rapidly return to their feeding. There is no need to give dilute formula. Some practitioners have recommended the BRAT diet (bananas, rice, applesauce, and toast), but this diet does not provide adequate energy, fat, or protein. Instead, complex carbohydrates, lean meats, yogurt, fruits, and vegetables should be encouraged. Fatty foods and foods high in simple sugars like juices and soft drinks should be avoided. Some ethnic groups may prefer to use traditional home remedies like herbal teas or rice water. Since the osmolality of these solutions is variable, they may worsen the diarrhea. Finally, there is little evidence to support a lactose-free diet. Over 80 percent of children with acute diarrhea can tolerate full-strength milk safely. 13

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