CHAPTER 1

INTRODUCTION

1.1. Background

When young children suddenly experience the onset of diarrhoea, with or without vomiting, infective gastroenteritis is by far the most common explanation. A range of enteric viruses, bacteria and protozoal pathogens may be responsible. Viral infections account for most cases in the developed world. Gastroenteritis is very common, with many infants and young children experiencing more than one episode in a year.

The symptoms of gastroenteritis are unpleasant and the illness has an impact on both child and family. Vomiting causes distress and anxiety. Diarrhoea is often accompanied by abdominal pain. Infants and young children with severe symptoms may quickly become dehydrated. Dehydration is a serious and potentially life-threatening condition

Viewed from a global perspective, gastroenteritis in children is of enormous public health importance. Worldwide, approximately 1 billion people have no access to safe water and 2.6 billion people lack proper sanitation. About 10.6 million children still die every year before reaching their fifth birthday. Overwhelmingly, these deaths occur in low-income and middle income countries. Most deaths among children under 5 years are attributable to a very small number of infectious conditions. Undernutrition increases the risk of death from these disorders. Gastroenteritis alone is responsible for almost 20% of the deaths.

In the 1970s, there were almost 5 million childhood deaths worldwide from gastroenteritis each year. The use of oral rehydration therapy (ORT), arguably the greatest medical discovery of the 20th century, contributed to a marked reduction in this death rate. Nevertheless, gastroenteritis still causes between 1.6 and 2.6 million deaths in children younger than 5 years each year. Efforts at further reducing the death rate continue, with strategies focusing on prevention, nutrition and improved fluid management. Other interventions of major importance include the administration of zinc supplements and the use of antibiotic therapy for dysentery.

Deaths associated with gastroenteritis are now quite rare in developed countries. Nevertheless, gastroenteritis remains a potentially serious illness for the individuals affected and it poses a major burden for health services. In the USA in the 1990s, it was estimated that childhood diarrhoea was responsible for 200 000 hospitalisations and 300 deaths in children younger than 5 years each year, and had an economic cost of $2 billion1. A total of 402 symptomatic cases from Indonesian patients with acute gastroenteritis and 102 asymptomatic controls that tested negative for bacteria and parasites were screened for the presence of NLVs, rotavirus and adenovirus using the reverse transcriptase-polymerase chain reaction (RT-PCR), Rotaclone kits and Adenoclone kits. NLVs were detected in 45/218 (21%), rotavirus was detected in 170/402 (42%) and adenovirus was detected in 11/273 (4%) samples examined. Comparative data on patients showed that the incidence of rotavirus

infections was two times greater than the NLVs infections, and that adenovirus infections were the least prevalent. All of the control samples tested were negative for NLVs and adenoviruses, however 8/70 (11%) of the samples were positive for rotaviruses. The high incidence of enteric viral-related infections is a threat among acute diarrheic patients in Jakarta, Indonesia2.

CHAPTER 2

LITERATURE REVIEW

2.1. Gastroenteritis

2.1.1. Definition and Etiology

A uniform definition of acute gastroenteritis does not exist. The AAP defines acute gastroenteritis as “diarrheal disease of rapid onset, with or without accompanying symptoms or signs such as nausea, vomiting, fever or abdominal pain.” The hallmark of the disease is increased stool frequency with alteration of stool consistency3.

Diarrhea is caused by many different infectious or inflammatory processes in the intestine (Table 1.1). These processes directly affect enterocyte secretory and absorptive functions. Some of these processes act by increasing cyclic AMP levels (Vibrio cholerae, E. coli heat-labile toxin, vasoactive intestinal peptide-producing tumors). Other processes (Shigella toxin, congenital chloridorrhea) cause secretory diarrhea by affecting ion channels or by unknown mechanisms. Enteritis has many viral, bacterial, and parasitic causes (Table 1.2).

Diarrhea is the leading cause of morbidity and the second most common disease in children in the U.S. In the developing world, it is a major cause of childhood mortality. The epidemiology of gastroenteritis depends on the specific organisms. Some organisms are spread person to person, others are spread via contaminated food or water, and some are spread from animal to human. Many organisms spread by multiple routes. The ability of an organism to infect relates to its mode of spread, its ability to colonize the gastrointestinal tract, and the number of organisms required to cause disease.

Viral causes of gastroenteritis in children include rotaviruses, caliciviruses (including the noroviruses), astroviruses, and enteric adenoviruses (serotypes 40 and 41). Rotavirus invades the epithelium and damages villi of the upper small intestine and in severe cases involves the entire small bowel and colon. Rotavirus is the most frequent cause of diarrhea during the winter months. Vomiting may last 3 to 4 days, and diarrhea may last 7 to 10 days. Dehydration is common in younger children. Primary infection with rotavirus in infancy may cause moderate to severe disease but is less severe later in life.

Table 2.1. Mechanisms of Diarrhea

Primary Mechanism

Defect Stool Examination

Examples Comment

Secretory Decreased absorption, increased secretion: electrolyte transport

Watery, normal osmolality; osmols = 2 × (Na+ + K+)

Cholera, toxigenic Escherichia coli; carcinoid, VIP, neuroblastoma,

Persists during fasting; bile salt malabsorption also may increase

congenital chloride diarrhea, Clostridium difficile, cryptosporidiosis (AIDS)

intestinal water secretion; no stool leukocytes

Osmotic Maldigestion, transport defects, ingestion of unabsorbable solute

Watery, acidic, + reducing substances; increased osmolality; osmosis > 2 × (Na+ + K+)

Lactase deficiency, glucose-galactose malabsorption, lactulose, laxative abuse

Stops with fasting, increased breath hydrogen with carbohydrate malabsorption, no stool leukocytes

Increase motility

Decreased transit time

Loose to normal- appearing stool, stimulated by gastrocolic reflex

Irritable bowel syndrome, thyrotoxicosis, postvagotomy dumping syndrome

Infection also may contribute to increased motility

Decreased motility

Defect in neuromuscular unit(s)

Stasis (bacterial overgrowth)

Loose to normal- appearing stool

Pseudo-obstruction, blind loop

Possible bacterial overgrowth

Mucosal inflammation

Inflammation, decreased mucosal surface area and/or colonic reabsorption, increased motility

Blood and increased WBCs in stool

Celiac disease, Salmonella, Shigella, amebiasis, Yersinia, Campylobacter, rotavirus enteritis

Dysentery = blood, mucus, and WBCs

Shigella dysenteriae may cause disease by producing Shiga toxin, either alone or combined with tissue invasion. The incubation period is 1 to 7 days, and infected adults may shed organisms for 1 month. Infection is spread by person-to-person contact or by

the ingestion of contaminated food with 10 to 100 organisms. The colon is selectively affected. High fever and seizures may occur, in addition to diarrhea.

Only certain strains of E. coli produce diarrhea. E. coli strains associated with enteritis are classified by the mechanism of diarrhea: enteropathogenic (EPEC), enterotoxigenic (ETEC), enteroinvasive (EIEC), entero-hemorrhagic (EHEC), or enteroaggregative (EAEC). EPEC is responsible for many of the epidemics of diarrhea in newborn nurseries and in daycare centers. ETEC produce heat-labile (cholera-like) enterotoxin, heat-stable enterotoxin, or both. ETEC causes 40% to 60% of cases of traveler's diarrhea. EPEC and ETEC adhere to the epithelial cells in the upper small intestine and produce disease by liberating toxins that induce intestinal secretion and limit absorption. EIEC invades the colonic mucosa, producing widespread mucosal damage with acute inflammation, similar to Shigella. EHEC, especially the E. coli O157:H7 strain, produce a Shiga-like toxin that is responsible for a hemorrhagic colitis and most cases of hemolytic uremic syndrome (HUS), which is a syndrome of microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. EHEC is associated with contaminated food, including unpasteurized fruit juices and especially undercooked beef. EHEC is associated with a self-limited form of gastroenteritis, usually with bloody diarrhea, but production of this toxin blocks host cell protein synthesis and affects vascular endothelial cells and the glomeruli, resulting in the clinical manifestations of HUS.

Campylobacter jejuni accounts for 15% of bacterial diarrhea. The infection is spread by person-to-person contact and by contaminated water and food, especially poultry, raw milk, and cheese. The organism invades the mucosa of the jejunum, ileum, and colon, producing enterocolitis

Yersinia enterocolitica is transmitted by pets and contaminated food, especially chitterlings. Infants and young children characteristically have a diarrheal disease, whereas older children usually have acute lesions of the terminal ileum or acute mesenteric lymphadenitis mimicking appendicitis or Crohn disease. Arthritis, rash, and spondylopathy may develop

Clostridium difficile causes C. difficile-associated diarrhea, or antibiotic-associated diarrhea secondary to its toxin. The organism produces spores that spread from person to person. C. difficile-associated diarrhea may follow exposure to any antibiotics, but is classically associated with clindamycin.

Entamoeba histolytica (amebiasis), Giardia lamblia, and Cryptosporidium parvum are important enteric parasites found in North America. Amebiasis occurs in warmer climates, whereas giardiasis is endemic throughout the U.S. and is common among infants in daycare centers. E. histolytica infects the colon; amebae may pass through the bowel wall and invade the liver, lung, and brain. Diarrhea is of acute onset, is bloody, and contains WBCs. G. lamblia is transmitted through ingestion of cysts, either from contact with an infected individual or from food or freshwater or well water contaminated with infected feces. The organism adheres to the microvilli of the duodenal and jejunal epithelium. Cryptosporidium causes mild, watery diarrhea in

immunocompetent persons that resolves without treatment. It produces severe, prolonged diarrhea in persons with AIDS4.

Table 1.2. Common Infectious Causes of Diarrhea and Their Virulence Mechanisms

Organisms Virulence PropertiesVirusesRotaviruses Damage to microvilliCaliciviruses Mucosal lesionAstroviruses Mucosal lesionEnteric adenoviruses (serotypes 40 and 41) Mucosal lesionBacteriaCampylobacter jejuni Invasion, enterotoxinClostridium difficile Cytotoxin, enterotoxinEscherichia coli  Enteropathogenic (EPEC) Adherence, effacement  Enterotoxigenic (ETEC) (traveler's diarrhea) Enterotoxins (heat-stable or heat-labile)  Enteroinvasive (EIEC) Invasion of mucosa  Enterohemorrhagic (EHEC) (includes O157:H7 causing HUS)

Adherence, effacement, cytotoxin

  Enteroaggregative (EAEC) Adherence, mucosal damageSalmonella Invasion, enterotoxinShigella Invasion, enterotoxin, cytotoxinVibrio cholera EnterotoxinVibrio parahaemolyticus Invasion, cytotoxinYersinia enterocolitica Invasion, enterotoxinParasitesEntamoeba histolytica Invasion, enzyme and cytotoxin production;

cyst resistant to physical destructionGiardia lamblia Adheres to mucosa; cyst resistant to physical

destructionSpore-forming intestinal protozoa Adherence, inflammation  Cryptosporidium parvum    Isospora belli    

Cyclospora cayetanensis

 

  Microsporida (Enterocytozoon bieneusi, Encephalitozoon intestinalis)

2.1.2 Pathophysiology

Adequate fluid balance in humans depends on the secretion and reabsorption of fluid and electrolytes in the intestinal tract; diarrhea occurs when intestinal fluid output overwhelms the absorptive capacity of the gastrointestinal tract. The 2 primary mechanisms responsible for acute gastroenteritis are damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to an osmotic diarrhea, and the release of toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhea.

However, even in severe diarrhea, various sodium-coupled solute co-transport mechanisms remain intact, allowing for the efficient reabsorption of salt and water. By providing a 1:1 proportion of sodium to glucose, classic oral rehydration solution (ORS) takes advantage of a specific sodium-glucose transporter (SGLT-1) to increase the reabsorption of sodium, which leads to the passive reabsorption of water. Rice- and cereal-based ORS may also take advantage of sodium-amino acid transporters to increase reabsorption of fluid and electrolytes5.

2.1.3 Clinical Manifestation

Gastroenteritis may be accompanied by systemic findings, such as fever, lethargy, and abdominal pain. Patients with diarrhea and possible dehydration should be evaluated to assess the degree of dehydration as evident from clinical signs and symptoms, ongoing losses, and daily requirements.

Viral diarrhea is characterized by watery stools, with no blood or mucus. Vomiting may be present, and dehydration may be prominent. Fever, when present, is low grade. Dysentery is diarrhea involving the colon and rectum, with blood and mucus, possibly foul smelling, and fever. Shigella is the prototype, which must be differentiated from infection with EIEC, EHEC, E. histolytica (amebic dysentery), C. jejuni, Y. enterocolitica, and nontyphoidal Salmonella. Gastrointestinal bleeding and blood loss may be significant. Enterotoxigenic disease is caused by agents that produce enterotoxins, such as V. cholerae and ETEC, the organism associated with 40% to 60% of cases of traveler's diarrhea. Fever is absent or only low grade. Diarrhea usually involves the ileum with watery stools without blood or mucus and usually lasts 3 to 4 days with four to five loose stools per day. Insidious onset of progressive anorexia, nausea, gaseousness, abdominal distention, watery diarrhea, secondary lactose intolerance, and weight loss is characteristic of giardiasis.

A chief consideration in management of a child with diarrhea is to assess the degree of dehydration. The degree of dehydration dictates the urgency of the situation and the volume of fluid needed for rehydration. Mild dehydration (3% to 5%) is characterized by normal pulse rate or minimal tachycardia, decreased urine output, thirst, and normal physical examination. Moderate dehydration (5% to 10%) is characterized by tachycardia, little or no urine output, irritability or lethargy, sunken eyes and fontanel, decreased tears, dry mucous membranes, mild tenting of the skin, and delayed capillary refill (≤ 2 seconds) with cool and pale skin. Severe dehydration (10% to 15%) is characterized by tachycardia with a weak

pulse, hypotension and widened pulse pressure, no urine output, extremely sunken eyes and fontanel, no tears, parched mucous membranes, tenting of the skin, and extremely delayed capillary refill (≥ 3 seconds) with cold and mottled skin. As the degree of dehydration increases, the requirement to provide immediate medical intervention also increases. Mild to moderate dehydration usually can be treated with oral rehydration, whereas severe dehydration usually requires IV rehydration. Severe dehydration may require ICU admission4.

2.1.4 Diagnosis

The evaluation of the child with symptoms of acute gastroenteritis begins with a careful history to elicit information that might point to other illnesses with similar presentations. Respiratory symptoms such as cough, dyspnea or tachypnea may indicate the presence of an underlying pneumonia. Urinary frequency, urgency or pain may be symptoms of pyelonephritis, an earache may be a symptom of acute otitis media, and high fever and altered mental status may be signs of meningitis or sepsis. Factors such as travel to underdeveloped countries, exposure to untreated drinking or washing water sources, contact with animals or birds, day care center attendance, recent antibiotic treatment or even a recent change in diet may suggest other specifically treatable causes of vomiting and diarrhea.

A second goal of the history is to assess the severity of the symptoms and the risk of complications such as dehydration. The presence or absence of fever, the amount and type of oral intake, and the frequency and estimated volume of emesis or stool are important factors to consider. Fever increases insensible water loss. Emesis, stool and urine volume in excess of intake invariably leads to significant dehydration. Stool characteristics such as the presence of blood should prompt consideration of inflammatory bacterial disease and a much more aggressive work-up and intervention.

The physical examination has two main functions: a search for signs of comorbid conditions and an estimate of the level of dehydration. The first objective can be accomplished with a careful general examination. The second objective is more difficult to achieve. The primary tasks are to assess the adequacy of perfusion and to determine whether dehydration is severe enough to cause hemodynamic instability. It may be most helpful to compare the patient's present weight with the last recorded weight in the chart, to assess the patient's orthostatic vital signs and to carefully review the patient's recent oral fluid intake.

Clinical signs may also be used to classify the patient's dehydration as mild, moderate or severe. Evidence exists, however, that traditional clinical signs are not always reliable in determining the degree of dehydration. For example, capillary refill time can be affected by ambient temperature. One study found that only decreased peripheral perfusion, deep breathing and decreased skin turgor correlated with mild to moderate dehydration. Another study reported that prolonged skinfold time correlated best with the degree of dehydration, followed by altered mental status, sunken eyes and dry oral mucosa. Yet another study3 found that as many as 87 percent of children admitted to the hospital for dehydration on the

basis of clinical signs had mild or no dehydration based on a comparison of their weights on admission and discharge (when they were judged to be fully rehydrated); 82 percent of these patients received intravenous rehydration therapy.

Because of doubts about the accuracy of clinical signs of dehydration, family physicians need to remember that the dehydration categories are only an estimate. In assigning patients to a category, physicians should use all of the available clinical and historical information, not just the physical findings.

In the past, a number of laboratory studies were used to evaluate children with acute vomiting and/or diarrhea. Because oral rehydration therapy has become the preferred method of treating dehydration, routine laboratory testing is no longer necessary, although it may be helpful in individual patients or when oral replacement therapy fails.

High urinary specific gravity may indicate significant dehydration when combined with a history of decreased urine output. Serum chemistry measurements such as electrolyte, blood urea nitrogen and creatinine levels do not change the initial management approach in most patients.15 Hemodynamically stable children can be safely treated with oral rehydration therapy with only minimal risk of developing significant electrolyte abnormalities.16

Laboratory studies should be performed in children who are severely dehydrated and children who are receiving intravenous rehydration therapy. Serum electrolyte levels should also be obtained in children who show signs of hypernatremia or hypokalemia (Table 3), although evidence exists that these conditions, as well as hyponatremia, may resolve without complications when oral rehydration therapy is used.

Studies aimed at pinpointing causative agents are usually only marginally helpful in children with domestically acquired gastroenteritis. Yet the presence of gross or occult blood in the stool should raise suspicion of such pathogens as Shigella species, Campylobacter species and hemorrhagic Escherichia coli strains. Large numbers of leukocytes on a fecal smear may also indicate an inflammatory bacterial process. In the absence of gross blood or leukocytes, costly stool cultures usually have a very low yield and rarely change clinical management because most noninflammatory diarrheas are self-limited.6,18

Similarly, viral studies, such as rotavirus antigen tests, may confirm the causative agent but do not usually change management. Giardia antigen studies and smears for ova and parasites are generally not indicated unless the diarrheal illness lasts more than 10 days or a likely exposure history exists

2.1.6 Treatment

Most infectious causes of diarrhea in children are self-limited. Management of viral and most bacterial causes of diarrhea is primarily supportive and consists of correcting dehydration and ongoing fluid and electrolyte deficits and managing secondary complications resulting from mucosal injury. Antibiotic treatment is recommended for only some bacterial and parasitic causes of diarrhea (Table 1.3).

Treatment of fluid deficits requires an estimation of the degree of dehydration and the determination of any electrolyte imbalance. Hyponatremia is common, and hypernatremia is less common. Metabolic acidosis results from losses of bicarbonate in stool, lactic acidosis resulting from malabsorption or shock, and phosphate retention resulting from transient prerenal-renal insufficiency. Traditionally, therapy for 24 hours with oral rehydration solutions alone is effective for viral diarrhea. Therapy for severe fluid and electrolyte losses involves IV hydration, whereas less severe degrees of dehydration (<10%) in children without excessive vomiting or shock may be managed with oral rehydration solutions containing glucose and electrolytes. The World Health Organization oral rehydration solution contains 90 mEq/L of sodium, 20 mEq/L of potassium chloride, and 111 mEq/L of glucose.

Antibiotic treatment of mild illness with Salmonella does not shorten the clinical course, but does prolong bacterial excretion. Antibiotic therapy is necessary only for patients with S. typhi (typhoid fever) and sepsis or bacteremia with signs of systemic toxicity, metastatic foci, or age younger than 3 months with nontyphoidal salmonella.

Antibiotic treatment of Shigella produces a bacteriologic cure in 80% of patients after 48 hours, reducing the spread of the disease. Many Shigella sonnei isolates, the predominant strain affecting children, are resistant to amoxicillin and TMP-SMZ. Recommended treatment for children is an oral third-generation cephalosporin (ceftriaxone, cefixime, cefpodoxime) or a fluoroquinolone for persons 18 years old or older.

Antibiotic treatment of E. coli enteritis is indicated for infants younger than 3 months old with EPEC and patients who remain symptomatic (see Table 1.3). Antibiotic treatment is not recommended for patients with E. coli O157:H7 or HUS because release of toxin may precipitate or worsen the course of HUS.

Most patients with Campylobacter recover spontaneously before the diagnosis is established. Treatment with erythromycin, azithromycin, or ciprofloxacin (for persons > 18 years old) initiated within 5 days of the onset of illness speeds recovery and reduces the duration of the carrier state.

The course of Y. enterocolitica usually is self-limited, lasting 3 days to 3 weeks. The efficacy of antibiotic treatment is questionable, but children with septicemia or focal infection, such as mesenteric lymphadenopathy, should be treated with cefotaxime. Treatment of C. difficile includes discontinuation of the antibiotic and, if diarrhea is severe, oral metronidazole or vancomycin. E. histolytica dysentery is treated with metronidazole followed by a luminal agent, such as iodoquinol. The treatment of G. lamblia is with albendazole, metronidazole, furazolidone, or quinacrine. No specific treatment is recommended for Cryptosporidium in otherwise healthy persons. Drugs such as loperamide, paregoric, and diphenoxylate are potentially dangerous and have no place in the management of acute infectious diarrhea in children4.

Table 1.3. Antibiotic Therapy for Infectious Diarrhea

Organism Treatment Comment

Salmonella typhi, Salmonella paratyphi

Ampicillin,† chloramphenicol,† TMP-SMZ, cefotaxime, ciprofloxacin‡

Invasive, bacteremic disease (typhoid fever or enteric fever)

Nontyphoidal Salmonella

Usually none (if ≥ 3 months old); ampicillin, cefotaxime, ciprofloxacin‡

Treatment indicated if < 3 months old, malignancy, sickle cell disease, HIV/AIDS, or evidence of nongastrointestinal foci of infection is present

Shigella Children: Third-generation cephalosporin, TMP-SMZ†

High prevalence of resistance to amoxicillin

  Adults: fluoroquinolones‡ Increasing prevalence of resistance to TMP-SMZ

    Treatment reduces infectivity and improves outcome

Escherichia coli      Enterotoxigenic Usually none if endemic; TMP-

SMZ or ciprofloxacin for traveler's diarrhea

Prevention of traveler's diarrhea with bismuth subsalicylate, doxycycline, or ciprofloxacin‡

  Enteroinvasive TMP-SMZ, ampicillin if susceptible

 

  Enteropathogenic TMP-SMZ or an aminoglycoside    Enterohemorrhagic Usually none No treatment if HUS is suspected  Enteroaggregative TMP-SMZ or an aminoglycoside  Campylobacter jejuni Mild disease needs no treatment;

erythromycin or azithromycin for diarrhea; aminoglycoside, ciprofloxacin,‡ meropenem, or imipenem for systemic illness

If started early (days 1-3), treatment reduces symptoms and fecal organisms

Yersinia enterocolitica

None for uncomplicated diarrhea; TMP-SMZ; gentamicin or cefotaxime for extraintestinal disease

Value of treatment of mesenteric lymphadenitis with antibiotics is not established

Vibrio cholerae Tetracycline, doxycycline, TMP-SMZ

Fluid maintenance crucial

Clostridium difficile Oral metronidazole,§ oral vancomycin

C. difficile is agent of antibiotic-associated diarrhea (pseudomembranous colitis)

Entamoeba histolytica Metronidazole§ followed by iodoquinol to treat luminal infection

Treatment determined by degree of tissue invasion

Giardia lamblia Metronidazole,§ quinacrine, furazolidone, others

Furazolidone is only preparation available in liquid form

Cryptosporidium parvum

None; azithromycin or paromomycin and octreotide in persons with HIV/AIDS

A serious infection in immunocompromised persons

2.2 Dehydration

Use the chart in Table 1.4 to determine the degree of dehydration and select the appropriate plan to treat or prevent dehydration. The signs typical of children with no signs of dehydration are in column A, the signs of some dehydration are in column B, and those of severe dehydration are in column C. If two or more of the signs in column C are present, the child has "severe dehydration". If this is not the case, but two or more signs from column B (and C) are present, the child has "some dehydration". If this also is not the case, the child is classified as having "no signs of dehydration". Signs that may require special interpretation are accompanied by footnotes in Table 1.46.

Table 1.4 Assessment of diarrhoea patients for dehydration

A B C

LOOK AT: CONDITIONa

EYESb

THIRST

Well, alert

Normal

Drinks normally, notthirsty

Restless, irritable

Sunken

Thirsty, drinks eagerly

Lethargic or unconscious

Sunken

Drinks poorly, or not ableto drink

FEEL: SKIN PINCHc Goes back quickly Goes back slowly Goes back very slowly

DECIDE The patient hasNO SIGNS OFDEHYDRATION

If the patient has two ormore signs in B, there isSOME DEHYDRATION

If the patients has two ormore signs in C, there isSEVEREDEHYDRATION

TREAT Use Treatment Pan A

Weigh the patient, ifpossible, and useTreatment Plan B

Weigh the patient and useTreatment Plan CURGENTLY

a Being lethargic and sleepy are not the same. A lethargic child is not simply asleep: the child's mental state is dull

and the child cannot be fully awakened; the child may appear to be drifting into unconsciousness.b In some infants and children the eyes normally appear somewhat sunken. It is helpful to ask the mother if thechild's eyes are normal or more sunken than usual.c The skin pinch is less useful in infants or children with marasmus or kwashiorkor, or obese children.

2.2.1 Treatment Plan A: home therapy to prevent dehydration and malnutritionChildren with no signs of dehydration need extra fluids and salt to replace their losses of water and electrolytes due to diarrhoea. If these are not given, signs of dehydration may develop. Mothers should be taught how to prevent dehydration at home by giving the child more fluid than usual, how to prevent malnutrition by continuing to feed the child, and why these actions are important. They should also know what signs indicate that the child should be taken to a health worker.

Give the child more fluids than usual, to prevent dehydration. Many countries have designated recommended home fluids. Wherever possible, these should include at least one fluid that normally contains salt (see below). Plain clean water should also be given. Other fluids should be recommended that are frequently given to children in the area, that mothers consider acceptable for children with diarrhoea, and that mothers would be likely to give in increased amounts when advised to do so.

Most fluids that a child normally takes can be used. It is helpful to divide suitable fluids into two group Fluids that normally contain salt, such as: ORS solution, salted drinks (e.g. salted rice water or a salted yoghurt drink), vegetable or chicken soup with salt. Teaching mothers to add salt (about 3g/l) to an unsalted drink or soup during diarrhoea is also possible, but requires a sustained educational effort. A home-made solution containing 3g/l of table salt (one level teaspoonful) and 18g/l of common sugar (sucrose) is effective but is not generally recommended because the recipe is often forgotten, the ingredients may not be available or too little may be given. Fluids that do not contain salt, such as: plain water, water in which a cereal has been cooked (e.g. unsalted rice water), unsalted soup, yoghurt drinks without salt, green coconut water, weak tea (unsweetened), unsweetened fresh fruit juice.

A few fluids are potentially dangerous and should be avoided during diarrhoea. Especially important are drinks sweetened with sugar, which can cause osmotic diarrhoea and hypernatraemia. Some examples are: commercial carbonated beverages, commercial fruit juices, sweetened tea. Other fluids to avoid are those with stimulant, diuretic or purgative effects, for example: coffee, some medicinal teas or infusions.

The general rule is: give as much fluid as the child or adult wants until diarrhoea stops. As a guide, after each loose stool, give:

children under 2 years of age: 50-100 ml (a quarter to half a large cup) of fluid; children aged 2 up to 10 years: 100-200 ml (a half to one large cup);

older children and adults: as much fluid as they want.

Give supplemental zinc (10 - 20 mg) to the child, every day for 10 to 14 daysZinc can be given as a syrup or as dispersible tablets, whichever formulation is available and affordable. By giving zinc as soon as diarrhoea starts, the duration and severity of the episode as well as the risk of dehydration will be reduced. By continuing zinc supplementation for 10 to 14 days, the zinc lost during diarrhoea is fully replaced and the risk of the child having new episodes of diarrhoea in the following 2 to 3 months is reduced.

Continue to feed the child, to prevent malnutritionThe infant usual diet should be continued during diarrhoea and increased afterwards. Food should never be withheld and the child's usual foods should not be diluted. Breastfeeding should always be continued. The aim is to give as much nutrient rich food as the child will accept. Most children with watery diarrhoea regain their appetite after dehydration is corrected, whereas those with bloody diarrhoea often eat poorly until the illness resolves. These children should be encouraged to resume normal feeding as soon as possible. When food is given, sufficient nutrients are usually absorbed to support continued growth and weight gain. Continued feeding also speeds the recovery of normal intestinal function, including the ability to digest and absorb various nutrients. In contrast, children whose food is restricted or diluted lose weight, have diarrhoea of longer duration, and recover intestinal function more slowly.

What foods to give depends on the child's age, food preferences and pre-illness feeding pattern; cultural practices are also important. In general, foods suitable for a child with diarrhoea are the same as those required by healthy children.Specific recommendations are given below.• Infants of any age who are breastfed should be allowed to breastfeed as often and as long as they want. Infants will often breastfeed more than usual; this should be encouraged.• Infants who are not breastfed should be given their usual milk feed (or formula) at least every three hours, if possible by cup. Special commercial formulas advertised for use in diarrhoea are expensive and unnecessary; they should not be given routinely. Clinically significant milk intolerance is rarely a problem.• Infants below 6 months of age who take breastmilk and other foods should receive increased breastfeeding. As the child recovers and the supply of breastmilk increases, other foods should be decreased. (If fluids other than breastmilk are given, use a cup, not a bottle.) This usually takes about one week. If possible, the infant should become exclusively breastfed

There is no value in routinely testing the stools of infants for pH or reducing substances. Such tests are oversensitive, often indicating impaired absorption of lactose when it is not clinically important. It is more important to monitor the child's clinical response (e.g. weight gain, general improvement). Milk intolerance is only clinically important when milk feeding causes a prompt increase in stool volume and a return or worsening of the signs of dehydration, often with loss of weight.

If the child is at least 6 months old or is already taking soft foods, he or she should be given cereals, vegetables and other foods, in addition to milk. If the child is over 6 months and such foods are not yet being given, they should be started during the diarrhoea episode or soon after it stops. Recommended foods should be culturally acceptable, readily available, have a high content of energy and provide adequate amounts of essential micronutrients. They should be well cooked, and mashed or ground to make them easy to digest; fermented foods are also easy to digest. Milk should be mixed with a cereal. If possible, 5-10 ml of vegetable oil should be added to each serving of cereal7. Meat, fish or egg should be given, if available. Foods rich in potassium, such as bananas, green coconut water and fresh fruit juice are beneficial.

Offer the child food every three or four hours (six times a day). Frequent, small feedings are tolerated better than less frequent, large ones. After the diarrhoea stops, continue giving the same energy-rich foods and provide one more meal than usual each day for at least two weeks. If the child is malnourished, extra meals should be given until the child has regainednormal weight-for-height.

Take the child to a health worker if there are signs of dehydration or other Problems The mother should take her child to a health worker if the child:• starts to pass many watery stools;• has repeated vomiting;• becomes very thirsty;• is eating or drinking poorly;• develops a fever;• has blood in the stool; or• the child does not get better in three days.

2.2.2 Treatment Plan B: oral rehydration therapy for children with some dehydrationChildren with some dehydration should receive oral rehydration therapy (ORT) with ORS solution in a health facility following Treatment Plan B, as described below. Children with some dehydration should also receive zinc supplementation as described above.

If the child's weight is known, this should be used to determine the approximate amount of solution needed. The amount may also be estimated by multiplying the child's weight in kg times 75 ml. If the child's weight is not known, select the approximate amount according to the child's age. The exact amount of solution required will depend on the child's dehydration status. Children with more marked signs of dehydration, or who continue to pass frequent watery stools, will require more solution than those with less marked signs or who are not passing frequent stools. If a child wants more than the estimated amount of ORS solution, and there are no signs of over-hydration, give more. Oedematous (puffy) eyelids are a sign of over-hydration. If this occurs, stop giving ORS solution, but give breastmilk or plain water, and food. Do not give a diuretic. When the oedema has gone, resume giving ORS solution or home fluids according to Treatment Plan A.

A family member should be taught to prepare and give ORS solution. The solution should be given to infants and young children using a clean spoon or cup. Feeding bottles should not be used. For babies, a dropper or syringe (without the needle) can be used to put small amounts of solution into the mouth. Children under 2 years of age should be offered a teaspoonful every 1-2 minutes; older children (and adults) may take frequent sips directly from the cup. Vomiting often occurs during the first hour or two of treatment, especially when children drink the solution too quickly, but this rarely prevents successful oral rehydration since most of the fluid is absorbed. After this time vomiting usually stops. If the child vomits, wait 5-10 minutes and then start giving ORS solution again, but more slowly (e.g. a spoonful every 2-3 minutes).

Check the child from time to time during rehydration to ensure that ORS solution is being taken satisfactorily and that signs of dehydration are not worsening. If at any time the child develops signs of severe dehydration, shift to Treatment Plan C. After four hours, reassess the child fully, following the guidelines in Table 1.4 Then decide what treatment to give next. If signs of severe dehydration have appeared, intravenous (IV) therapy should be started

following Treatment Plan C. This is very unusual, however, occurring only in children who drink ORS solution poorly and pass large watery stools frequently during the rehydration period.

If the child still has signs indicating some dehydration, continue oral rehydration therapy by repeating Treatment Plan B. At the same time start to offer food, milk and other fluids, as described in Treatment Plan A, and continue to reassess the child frequently.

If there are no signs of dehydration, the child should be considered fully rehydrated. When rehydration is complete:- the skin pinch is normal;- thirst has subsided;- urine is passed;- the child becomes quiet, is no longer irritable and often falls asleep.

Teach the mother how to treat her child at home with ORS solution and food following Treatment Plan A. Give her enough ORS packets for two days. Also teach her the signs that mean she should bring her child back

While treatment to replace the existing water and electrolyte deficit is in progress the child's normal daily fluid requirements must also be met. This can be done as follows: Breastfed infants: Continue to breastfeed as often and as long as the infant wants, even

during oral rehydration. Non breastfed infants under 6 months of age: If using the old WHO ORS solution

containing 90 mmol/L of sodium, also give 100-200ml clean water during this period. However, if using the new reduced (low) osmolarity ORS solution containing 75mmol/L of sodium, this is not necessary. After completing rehydration, resume full strength milk (or formula) feeds. Give water and other fluids usually taken by the infant.

Older children and adults: Throughout rehydration and maintenance therapy, offer as much plain water to drink as they wish, in addition to ORS solution.

If the mother and child must leave before rehydration with ORS solution is completed: show the mother how much ORS solution to give to finish the four-hour treatment at home; give her enough ORS packets to complete the four hour treatment and to continue oral rehydration for two more days, as shown in Treatment Plan A; show her how to prepare ORS solution; teach her the four rules in Treatment Plan A for treating her child at home.

With the previous ORS, signs of dehydration would persist or reappear during ORT in about 5% of children. With the new reduced (low) osmolarity ORS, it is estimated that such treatment “failures” will be reduced to 3%, or less. The usual causes for these “failures” are: continuing rapid stool loss (more than 15-20 ml/kg/hour), as occurs in some children with cholera; insufficient intake of ORS solution owing to fatigue or lethargy; frequent, severe vomiting. Such children should be given ORS solution by nasogastric (NG) tube or Ringer's Lactate Solution intravenously (IV) (75 ml/kg in four hours), usually in hospital. After confirming that the signs of dehydration have improved, it is usually possible to resume ORT successfully. Rarely, ORT should not be given. This is true for children with: abdominal distension with paralytic ileus, which may be caused by opiate drugs (e.g. codeine, loperamide) and hypokalaemia; glucose malabsorption, indicated by a marked increase in stool output when ORS solution is given, failure of the signs of dehydration to improve and a large amount of glucose in the stool when ORS solution is given. In these situations, rehydration should be given IV until diarrhoea subsides; NG therapy should not be used.

Begin to give supplemental zinc, as in Treatment Plan A, as soon the child is able to eat following the initial four hour rehydration period. Except for breastmilk, food should not be given during the initial four-hour rehydration period. However, children continued on Treatment Plan B longer than four hours should be given some food every 3-4 hours as described in Treatment Plan A. All children older than 6 months should be given some food before being sent home. This helps to emphasize to mothers the importance of continued feeding during diarrhoea.

2.2.3 Treatment Plan C: for patients with severe dehydrationThe preferred treatment for children with severe dehydration is rapid intravenous rehydration, following Treatment Plan C. If possible, the child should be admitted to hospital. Guidelines for intravenous rehydration are given in Table 1.5 Children who can drink, even poorly, should be given ORS solution by mouth until the IV drip is running. In addition, all children should start to receive some ORS solution (about 5 ml/kg/h) when they can drink without difficulty, which is usually within 3-4 hours (for infants) or 1-2 hours (for older patients). This provides additional base and potassium, which may not be adequately supplied by the IV fluid.

Table 1.5 Guidelines for intravenous treatment of children and adults with severe dehydration

Start IV fluids immediately. If the patient can drink, give ORS by mouth

until the drip is set up. Give 100 ml/kg. Ringer's Lactate Solutiona divided as follows:Age First give

30 ml/kg in:Then give70 ml/kg in:

Infants(under 12 months)

1 hoursb 5 hours

Older ½ hoursb 2 ½ hours

Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly. After six hours (infants) or three hours (older patients), evaluate the patient using the assessment chart. Then choose the appropriate Treatment Plan (A, B or C) to continue treatment.

a If Ringer's Lactate Solution is not available, normal saline may be used. b Repeat once if radial pulse is still very weak or not detectable.

Patients should be reassessed every 15-30 minutes until a strong radial pulse is present. Thereafter, they should be reassessed at least every hour to confirm that hydration is improving. If it is not, the IV drip should be given more rapidly. When the planned amount of IV fluid has been given (after three hours for older patients, or six hours for infants), the child's hydration status should be reassessed fully, as shown in Table 1.4. Look and feel for all the signs of dehydration: If signs of severe dehydration are still present, repeat the IV fluid infusion as outlined in Treatment Plan C. This is very unusual, however, occurring only in children who pass large watery stools frequently during the rehydration period. If the child is improving (able to drink) but still shows signs of some dehydration, discontinue the IV infusion and give ORS solution for four hours, as specified in Treatment Plan B. If there are no signs of dehydration, follow Treatment Plan A. If possible, observe the child for at least six hours before discharge while the mother gives the child ORS solution, to confirm that she is able to maintain the child's hydration. Remember that the child will require therapy with ORS solution until diarrhoea stops. If the child cannot remain at the treatment centre, teach the mother how to give treatment at home following Treatment Plan A, give her enough ORS packets for two days and teach her the signs that mean she should bring her child back

If IV therapy is not available at the facility, but can be given nearby (i.e. within 30 minutes), send the child immediately for IV treatment. If the child can drink, give the mother some ORS solution and show her how to give it to her child during the journey. If IV therapy is not available nearby, health workers who have been trained can give ORS solution by NG tube, at a rate of 20 ml/kg body weight per hour for six hours (total of 120 ml/kg body weight). If the abdomen becomes swollen, ORS solution should be given more slowly until it becomes less distended. If NG treatment is not possible but the child can drink, ORS solution should be given by mouth at a rate of 20 ml/kg body weight per hour for six hours (total of 120 ml/kg body weight). If this rate is too fast, the child may vomit repeatedly. In that case, give ORS solution more slowly until vomiting subsides. Children receiving NG or oral therapy should be reassessed at least every hour. If the signs of dehydration do not improve after three hours, the child must be taken immediately to the nearest facility where IV therapy is

available. Otherwise, if rehydration is progressing satisfactorily, the child should be reassessed after six hours and a decision on further treatment made as described above for those given IV therapy. If neither NG nor oral therapy is possible, the child should be taken immediately to the nearest facility where IV or NG therapy is available.

CHAPTER 3CASE REPORT

Name : YASAge : 1 years 1 monthSex : MaleDate of Admission : September, 27th 2013

Main complain : Diarrhea

History : Patient had diarrhea since 2 days ago, frequency 5x/day, volume + ½ cup/diarrhea, more water from the dregs, mucus (-), blood (-). Patient also had vomiting since 2 days ago after meal, content of what he eats and drinks. Fever (+) since 2 days ago, fever fluctuate, currently no fever and relieved by consumption of anti-pyretic drugs. Seizure (-), history of seizures (-). Cough (+) since 5 days ago, sputum (-), history of contact with an infected adult with cough (-). Urination (+) normal.

History of previous illness: none

History of birth : Spontaneous birth with help of midwife, cried immediately, cyanosis (-), body weight at birth XXXXg

History of pregnancy : XX baby, age of the mother during pregnancy is years old, fever (-), hypertension (-), DM (-), history of taking medications (-).

History of growth and development :

History of feeding : from birth till now, the baby just got formula milk because there’re no production of milk from the mother, 6 month till now small plate of rice with side dish like fish and egg.

History of immunization : BCG (+), DPT 3 times, Hepatitis B 3 times, Polio 3 times, Campak not yet.

Physical ExaminationBody weight : 8,3 kg

Height : 73 cm

Presence statusSens. GCS 12 (E3V3M6), Body temperature: 38 oC, Pulse: 128 bpm, Respiratory Rate: 48 bpm.

Localized status

1. Head : deformity (-) Eye : Sunken eyes (-/-), Light reflexes(+/+), isochoric pupil, conjunctiva palpebra inferior ane (-/-), icteric (-/-) , Ear : Normal appereance, Mouth : Sianosis (-), dry mucosal (+) , Nose: Normal appereance.

2. Neck : Lymph node enlargement (-)3. Thorax : Symmetrical fusiformis. Epigastria retraction (-).

HR:128 bpm, regular, murmur (-) RR 48 bpm, regular. Crackles (-/-).4. Abdomen : Soepel (+), symmetrical, Peristaltic movement (+) increase in

frequence . Liver/Hepar/Lien undeterminate. Skin pinch : Goes back slowly

5. Extremities : Pulse 128 bpm, regular, adequate pressure and volume, warm extremities, CRT< 2”. BP : 110/80 mmHg.

Laboratory Result:September, 27th 2013Complete blood count(CBC)Hemoglobin (HGB) g% 11.50 11.3 - 14.1Eritrosit (RBC) 106/ mm3 4.37 4.40 - 4.48Leukosit (WBC) 103/ mm3 8.14 6.0 - 17.5Hematokrit % 33.30 37 – 41Trombosit (PLT) 103/ mm3 378 217- 497MCV fL 76.2 81 – 95MCH Pg 26.3 25 – 29MCHC g% 34.50 29 - 31RDW % 13.90 11.6 – 14.8PDW % 10.5MPV Fl 9.40 7.20-10.0WBC CountNeutrofil % 31.20 37 – 80Limfosit % 55.00 20 – 40Monosit % 13.30 2 – 8Eosinofil % 0.1 1 – 6Basofil % 0.4000 0 – 1Carbohydrate MetabolismBlood Glucose ad random mg/dL 71.30 <200ElectrolyteNatrium (Na) mEq/L 135 135 – 155 Kalium (K) mEq/L 3.7 3.6 – 5.5Cloride (Cl) mEq/L 111 96 – 100

Working Diagnosis : Gastroenteritis with severe dehydration.

Diffential Diagnosis : Gastroenteritis with severe dehydration.

Medication : - IVFD RL 70 cc/kgBW = 581 cc for 2 ½ hours 23 gtt/i micro start at 03.00 pm up to 05.40 pm.- Zinc 1 X 20 mg- Paracetamol 3 X 100 mg (if needed)- Diet filter chicken porridge (M3) 830 kkal with 17 gr protein- Treat in RB4 infection room (R III.6)

Follow up post rehydration:Subjective : Diarrhea (+) frequency 1 time, volume ± ¼ cup/diarrhea, more water from the dregs. Objective : Sensorium : GCS 15 (E4V5M6) , body temperature 37,4ºC. Body Weight before rehydration : 8,3 kg , Body Weight after rehydration : 8,4 kg

Head : deformity (-) Eye : Sunken eyes (-/-), Light reflexes(+/+), isochoric pupil, conjunctiva palpebra inferior ane (-/-), icteric (-/-) , Ear : Normal appereance, Mouth : Sianosis (-), dry mucosal (-) , Nose: Normal appereance. Neck : Lymph node enlargement (-)Thorax : Symmetrical fusiformis. Epigastria retraction (-). HR:114 bpm, regular, murmur (-) RR 42 bpm, regular. Crackles (-/-).Abdomen : Soepel (+), symmetrical, Peristaltic movement (+) increase in frequence. Liver/Lien/Kidney undeterminate. Skin pinch goes back quicklyExtremities : Pulse 114 bpm, regular, adequate pressure and volume, warm extremities, CRT< 3”. Urine Output : 1,6 cc/kgBW/hours (3 hours)

Assessment : Gastroenteritis without dehydrationMedication : - IVFD RL maintenance 840 cc/24 hours , 35 gtt/i micro.

- Zinc 1 X 20 mg- Paracetamol 3 X 100 mg if needed- Diet filter chicken porridge (M3) 830 kkal with 17 gr protein- Pedialyte 50-100 cc/vomite-diarrhea

Follow Up

September, 28th 2013 S: Diarrhea (+) frequency often, volume ± ¼ cup/diarrhea, more water from the dregs. Vomite (-). Urine (+) Normal.O: Sens: CM, Temp: 37 oC . Last body weight : 8.4 kg , BB at 06.00 am : 7.8 kgHead Face : deformity (-). Eye : Sunken eyes (+/+), Light reflexes(+/+), isochoric

pupil, conjunctiva palpebra inferior ane (-/-), icteric (-/-) , Ear : Normal appereance, Mouth : Sianosis (-), dry mucosal (+), Nose: Normal appereance.

NeckThorax

Lymph node enlargement (-)Symmetrical fusiformis. Retracsi (-). HR: 120 bpm, reguler, murmur (-) RR: 28 bpm, reguler. Crackles (-/-)

Abdomen Symmetrical, soepel. Peristaltic (+) increase in frequence.Liver/Lien/Kidney undeterminate. Skin pinch goes back quickly

Extremities Pulse 120 bpm, regular, adequate pressure and volume, warm acral, CRT< 3”.

A: Gastroenteritis with mild-moderate dehydrationP: - IVFD RL 75 cc/kgBW = 625 cc for 4 hours, 156 gtt/i micro.

- Zinc 1 X 20 mg- Paracetamol 3 X 100 mg if needed- Diet filter chicken porridge (M3) 830 kkal with 17 gr protein- Pedialyte 50-100 cc/vomite-diarrhea

September, 29th 2013 S: Diarrhea (+) frequency 1 time, volume ± 1/8 cup/diarrhea, more water from the dregs. Vomite (-). Urine (+) Normal.O: Sens: CM, Temp: 37 oC . Head Face : deformity (-). Eye : Sunken eyes (-/-), Light reflexes(+/+), isochoric

pupil, conjunctiva palpebra inferior ane (-/-), icteric (-/-) , Ear : Normal appereance, Mouth : Sianosis (-), dry mucosal (-), Nose: Normal appereance.

NeckThorax

Lymph node enlargement (-)Symmetrical fusiformis. Retracsi (-). HR: 116 bpm, reguler, murmur (-) RR: 24 bpm, reguler. Crackles (-/-)

Abdomen Symmetrical, soepel. Peristaltic (+) increase in frequence.Liver/Lien/Kidney undeterminate. Skin pinch goes back quickly

Extremities Pulse 116 bpm, regular, adequate pressure and volume, warm acral, CRT< 3”.

A: Gastroenteritis without dehydrationP: - IVFD RL 30gtt/i micro.

- Zinc 1 X 20 mg- Paracetamol 3 X 100 mg if needed- Diet filter chicken porridge (M3) 830 kkal with 17 gr protein- Pedialyte 50-100 cc/vomite-diarrhea

Plan :- Check Complete Blood Count- Urinalisa and Feces culture- Electrolyte

September, 30th 2013 S: Diarrhea (+) frequency 1 time, volume ± 1/8 cup/diarrhea, more water from the dregs. Vomite (-). Urine (+) Normal.O: Sens: CM, Temp: 37.5 oC . Head Face : deformity (-). Eye : Sunken eyes (-/-), Light reflexes(+/+), isochoric

pupil, conjunctiva palpebra inferior ane (-/-), icteric (-/-) , Ear : Normal appereance, Mouth : Sianosis (-), dry mucosal (-), Nose: Normal appereance.

NeckThorax

Lymph node enlargement (-)Symmetrical fusiformis. Retracsi (-). HR: 112 bpm, reguler, murmur (-) RR: 24 bpm, reguler. Crackles (-/-)

Abdomen Symmetrical, soepel. Peristaltic (+) increase in frequence.Liver/Lien/Kidney undeterminate. Skin pinch goes back quickly

Extremities Pulse 112 bpm, regular, adequate pressure and volume, warm acral, CRT< 3”.

A: Gastroenteritis without dehydrationP: - IVFD RL 30gtt/i micro.

- Zinc 1 X 20 mg- Paracetamol 3 X 100 mg if needed- Diet filter chicken porridge (M3) 830 kkal with 17 gr protein- Pedialyte 50-100 cc/vomite-diarrhea

October, 1st 2013 S: Diarrhea (+) frequency 1 time, volume ± 1/10 cup/diarrhea, more water from the dregs. Vomite (-). Urine (+) Normal.O: Sens: CM, Temp: 36,9 oC . Head Face : deformity (-). Eye : Sunken eyes (-/-), Light reflexes(+/+), isochoric

pupil, conjunctiva palpebra inferior ane (-/-), icteric (-/-) , Ear : Normal appereance, Mouth : Sianosis (-), dry mucosal (-), Nose: Normal appereance.

NeckThorax

Lymph node enlargement (-)Symmetrical fusiformis. Retracsi (-). HR: 110 bpm, reguler, murmur (-) RR: 24 bpm, reguler. Crackles (-/-)

Abdomen Symmetrical, soepel. Peristaltic (+) normal.Liver/Lien/Kidney undeterminate. Skin pinch goes back quickly

Extremities Pulse 110 bpm, regular, adequate pressure and volume, warm acral, CRT< 3”.

A: Gastroenteritis without dehydrationP: - IVFD RL 30gtt/i micro.

- Zinc 1 X 20 mg- Paracetamol 3 X 100 mg if needed- Diet filter chicken porridge (M3) 830 kkal with 17 gr protein- Pedialyte 50-100 cc/vomite-diarrhea

October, 2nd 2013 S: Diarrhea (-).Vomite (-). Urine (+) Normal.O: Sens: CM, Temp: 36,7 oC . Head Face : deformity (-). Eye : Sunken eyes (-/-), Light reflexes(+/+), isochoric

pupil, conjunctiva palpebra inferior ane (-/-), icteric (-/-) , Ear : Normal appereance, Mouth : Sianosis (-), dry mucosal (-), Nose: Normal appereance.

NeckThorax

Lymph node enlargement (-)Symmetrical fusiformis. Retracsi (-). HR: 118 bpm, reguler, murmur (-) RR: 24 bpm, reguler. Crackles (-/-)

Abdomen Symmetrical, soepel. Peristaltic (+) normal.Liver/Lien/Kidney undeterminate. Skin pinch goes back quickly

Extremities Pulse 118 bpm, regular, adequate pressure and volume, warm acral, CRT< 3”.

A: Gastroenteritis without dehydrationP: - IVFD RL 30gtt/i micro.

- Zinc 1 X 20 mg- Paracetamol 3 X 100 mg if needed- Diet filter chicken porridge (M3) 830 kkal with 17 gr protein- Pedialyte 50-100 cc/vomite-diarrhea if needed

October, 3rd 2013 S: Diarrhea (-).Vomite (-). Urine (+) Normal.O: Sens: CM, Temp: 36,7 oC . Head Face : deformity (-). Eye : Sunken eyes (-/-), Light reflexes(+/+), isochoric

pupil, conjunctiva palpebra inferior ane (-/-), icteric (-/-) , Ear : Normal appereance, Mouth : Sianosis (-), dry mucosal (-), Nose: Normal appereance.

NeckThorax

Lymph node enlargement (-)Symmetrical fusiformis. Retracsi (-). HR: 112 bpm, reguler, murmur (-) RR: 22 bpm, reguler. Crackles (-/-)

Abdomen Symmetrical, soepel. Peristaltic (+) normal.Liver/Lien/Kidney undeterminate. Skin pinch goes back quickly

Extremities Pulse 112 bpm, regular, adequate pressure and volume, warm acral, CRT< 3”

A: Gastroenteritis without dehydrationP: - IVFD RL 30gtt/i micro.

- Zinc 1 X 20 mg- Paracetamol 3 X 100 mg if needed- Diet filter chicken porridge (M3) 830 kkal with 17 gr protein- Pedialyte 50-100 cc/vomite-diarrhea if needed

CHAPTER 4

DISCUSSION

CHAPTER 4

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