Regarding the assessment and classification of dehydration in children with acute gastroenteritis, which ONE of the following is TRUE?
Answer: C: A recent systematic review showed that prolonged capillary refill time, abnormal skin turgor and abnormal respiratory pattern were the three best clinical signs for identifying dehydration, whereas laboratory tests were often unhelpful and non-specific.
Historically, in the 1990s, the severity of dehydration was classified as 1) mild (3–5%), 2) moderate (6–9%) and 3) severe (>10%). However, increasing evidence shows that signs of dehydration can be imprecise and incorrect, making clinicians unable to predict the exact degree of dehydration, with the severity of dehydration frequently being under- or overestimated. Where it may be easy to recognise the patient at the extremes of the spectrum, that is, not dehydrated (<5%) or severely dehydrated/shocked (>10%), it is not that easy to distinguish between mild–moderate (5–10%) dehydration. This has led to the adoption of a new classification system for severity assessment in the early 2000s that divides patients into:
This estimate is employed to determine the initial need for therapy and the type of therapy to be administered. In 2009 the National Collaborating Centre for Women’s and Children’s Health reviewed the available evidence and adopted a new and even simpler clinical assessment scheme.6 Patients would be classified as:
This classification system was adopted by the National Institute for Health and Clinical Excellence (NICE) in 2009. This simplified scheme does not imply that the degree of dehydration is uniform but rather acknowledges the difficulty clinicians face in accurately assessing the degree of dehydration with the severity of dehydration frequently being under- or overestimated. At the same time, it further helps to:
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An 18-month-old boy is diagnosed with acute gastroenteritis. On examination he appears miserable but alert, has sunken eyes, dry mucous membranes and reduced skin turgor. His vital signs are normal with good peripheral pulses and capillary refill < 2 seconds. He refuses to drink oral rehydration solution (ORS) offered to him.
Which ONE of the following is the MOST appropriate next step?
Answer: D: This child has evidence of clinical dehydration (5–10%) without any features of poor perfusion or shock. Enteral (oral or nasogastric) rehydration is the treatment of choice in patients with clinical dehydration (LOE 1, A). It has been shown to be as effective as intravenous rehydration with the additional benefit that it has fewer complications, is more cost-effective, decreases admission rates, and has a shorter hospital stay and quicker return to normal diet and fluids. Children who are able to receive enteral rehydration therapy should not be given intravenous fluids (LOE 1, A). Intravenous therapy is reserved for those with evidence of poor peripheral perfusion or shock where an initial bolus of 10–20 mL/kg IV is indicated, as well as in children with clinical evidence of deterioration despite oral rehydration therapy. Furthermore, deficit can be safely replaced over 4 hours in most children and this ‘rapid rehydration’ is recommended. A slower rate is recommended in children with significant comorbidities such as renal failure, diuretic therapy and diabetes.
Hypotonic oral rehydration solutions (approximately 240 mOsm/L, sodium 60–90 mEq/L, carbohydrate: sodium ratio ~1:1, potassium ~20 mEq/L,) is the rehydration solution of choice as the properties of oral rehydration salts (ORS) promote its effective absorption (LOE 1, A). Commercially available solutions in Australia include Gastrolyte, Hydralyte, Pedialyte and Repalyte.
There are no published trials comparing clear fluids (water, carbonated drinks, fruit drinks) with glucose– electrolyte solutions for treating dehydration. However, physiological studies have shown that these drinks, which are low in sodium and ANSWERS ANSWERS 183 potassium and have a high sugar content and high osmolarity, may exacerbate diarrhoea and dehydration and cause electrolyte disturbance. Therefore, their use is not recommended in children with evidence of dehydration.
Regarding the management of children with acute gastroenteritis after successful rehydration, which ONE of the following statements is MOST appropriate?
Answer: D: Traditionally, a period of fasting has been recommended. However, current recommendations suggest early introduction of an age-appropriate diet with the early reintroduction of cow’s milk, milk formula or solid food as soon as the child is rehydrated. Early refeeding improves weight gain without increasing diarrhoea or vomiting and may shorten the duration of the diarrhoeal illness. Historically, a common practice in formula-fed infants has been to give diluted milk (half or quarter strength) and then gradually increase the concentration to full strength (graded feeding). However, the available evidence shows no benefit from diluted or graded feeding and giving full strength formula is likely to be beneficial in terms of nutrition and weight gain (LOE 1, A).
Furthermore, the routine use of a lactose-free diet is not recommended because the vast majority of young children with AGE can safely continue to receive lactose-containing milk formula. The number of treatment failures is negligible versus children with acute diarrhoea on a lactose-free diet (LOE 1, A). Temporary lactose intolerance may develop in some children with acute gastroenteritis due to damage to the small intestinal mucosa by pathogens. In a child with prolonged watery diarrhoea (>7 days) associated with perianal excoriation, carbohydrate malabsorption should be excluded by testing the stool for reducing substances and, if confirmed, lactose-free feeds may be indicated.
Weaned children should be fed whatever they eat normally. Full feeding of appropriate-for-age foods are well tolerated and are definitely better than the practice of withholding food (better weight gain without increasing complication rates or treatment failures). The BRAT diet of bread, rice, apples and toast is a limited diet low in energy density, protein and fat that was formerly empirically recommended, although no studies have ever evaluated its safety or efficacy. It is recommended though that fatty foods or foods high in simple sugars should be avoided.
A 4-year-old boy presents with two episodes of bloody diarrhoea in the preceding 24 hours. He is apyrexial and clinically well with no travel history. His mother has just recovered from gastroenteritis.
Which ONE of the following is the MOST appropriate answer?
Answer: C: Bloody diarrhoea in children usually results from toxigenic and invasive intestinal bacterial infections. Other non-infective conditions are rarer but should always be considered because they can be serious and even life threatening. These include:
Potential pathogens of invasive bacterial enterocolitis include:
The most likely causative agents in Australia are Salmonella and Campylobacter. In the developing world, shigella and parasitic infections with Entamoeba histolitica (amoebic dysentery) are important and should be considered in patients whio have recently travelled overseas.
Bacterial gastroenteritis is usually self-limiting and antibiotics are needed only in selected cases. Empirical antibiotic treatment for bloody diarrhoea should be approached with caution, especially in children, as it may increase the risk of haemolytic uremic syndrome. Empiric antibiotics should, however, be considered in all children presenting with symptoms of systemic infection (high fever, tachycardia). The choice of antimicrobial agent depends on local prevalence and resistance pattern. Parenteral antibiotics are preferred in patients with toxic appearance, underlying immune deficiency and febrile infants <3 months. A blood culture should be performed before administration of antibiotics and a stool sample should be collected. Children with acute (<7 days’ duration) and mild–moderate disease (<6 stools per day) who are systemically well may be managed as an outpatient after stool has been collected for microscopy, culture and sensitivity (MCS) including E. coli O157:H7, pending results.
Alternatively, the patient can be admitted for observation. All children with severe disease (≥ 6 stools per day), who are systemically unwell (fever, tachycardia) or with abdominal complications, should be admitted. Children with persistent (>7 days) of bloody diarrhoea should be referred for further investigation of other causes, including IBD.
A 23-year-old female presents with 2 days’ history of watery, non-bloody diarrhoea. She is otherwise well. She has recently returned from a visit to SouthEast Asia and will return there in 1 month on an important business trip.
Which ONE of the following is TRUE?
Answer: A: The causes of travellers’ diarrhoea depend on the destination, setting and season.
Despite the fact that antibiotic prophylaxis seems to be effective in preventing travellers’ diarrhoea, it is not currently recommended for healthy travellers, including children. There are several reasons for this including the lack of data on the safety and efficacy of antibiotics given for >2 weeks. In addition, early self-treatment of travellers’ diarrhoea is highly efficacious. Chemoprophylaxis can be considered for travellers with underlying conditions that make progression to severe and/or complicated diarrhoea more likely (e.g. immunodeficiency, type 1 diabetes, active IBD, cardiac or renal failure). Expert opinion supports the use of prophylactic antibiotics when a trip is vitally important or the consequences of watery diarrhoea would be difficult to manage (e.g. after colostomy or ileostomy). In this scenario, prophylactic antibiotics might therefore be considered as she has an important business trip coming up.
As traveller’s diarrhoea is usually self-limiting, antibiotic treatment is not indicated in mild cases. For moderate to severe disease, antibiotics have been shown to be effective and may be combined with loperamide in adults. Antimotility drugs should be avoided in children or where fever or bloody diarrhoea is present. A single large dose of antibiotics is usually effective. Recommended regimens include azithromycin orally, as a single dose or norfloxacin orally, as a single dose. The rapid emergence of quinolone resistance in gram-negative pathogens, particularly in South Asia, is likely to reduce the effectiveness of norfloxacin and ciprofloxacin.
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