Acute Gastroenteritis 2015

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1 Acute Gastroenteritis 2015 Disclosure Statement Joel S. Tieder, MD, MPH Clinical Advances in Pediatrics Symposium September 18, 2015 I have no relevant financial relationships with the manufacture(s) of any commercial product(s) and/or providers of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigate use of a commercial product/service in my presentation. Goals for this talk: Definitions Definitions Epidemiology Etiology Clinical assessment Management Strategies ORT Anti-emetics, probiotics SCH guideline An infection of the GI tract characterized by rapid onset of diarrhea with or without nausea, vomiting, fever, and abdominal pain. Diarrhea: the frequent passage of unformed liquid stool ( 3 or more loose, watery stools per day ) Dysentery: blood or mucous in the stool Definition Definition (exclusion criteria for SCH AGE pathway) Excluded from most discussions of AGE: Episodes lasting > 10 days Failure to thrive Significant comorbid conditions Vomiting with no accompanying diarrhea (?) Approximately 10% of children hospitalized for rotavirus infection have only fever and/or vomiting at the time of admission Toxic appearance (consider sepsis) Diarrhea >7 days (consider chronic disease, bacterial enteritis) Bloody diarrhea (consider HUS) Comorbid conditions (Medically complexity, renal failure, cardiac disease) Bilious emesis (consider bowel obstruction) On diuretic therapy Hyponatremia (<130) or Hypernatremia (>155) Hypoglycemia <50 (consider metabolic disease) Acute surgical abdomen 1

2 VOMICKING Differential Diagnosis V: Vestibular dysfunction O: Obstruction (volvulus, intussusception, megacolon) M: Metabolic (DKA, pregnancy, inborn errors) I: Infection (pneumonia, PID, UTI) C: CNS (mass, increased ICP, meningitis) K: Kidney (pyelonephritis, uremia, acute kidney injury) I: Itis (pancreatitis, hepatitis, appendicitis, milk/protein enteritis) N: Nasal drainage, noxious drugs G: Gastroenteritis, if none of the above Epidemiology Epidemiology: A Global Perspective Epidemiology: A Global Perspective Epidemiology: A Global Perspective Infectious diarrhea is the leading cause of infant mortality in developing countries 8000 children younger than 5 years die each day due to diarrhea and dehydration Accounts for 30% of worldwide deaths in infants and toddlers WHO/UN: incorporated ORT as the cornerstone of child-survival efforts Mortality has dropped sharply from 4.6 million (1970s), 3 million (1983), to 2.5 million (1990s) Use of ORS has increased from 15% (1984) to 40% (1993) 2

3 Epidemiology: US Perspective Etiology AGE remains a major cause of infant morbidity and hospitalization in developed countries Children < 5 have an average of 2 episodes of AGE per year (25 million episodes 2-3 million office visits per year Up to 10% of all pediatric hospital admissions (220,000 hospitalizations in the US) deaths per year among children (1997) 70-85% of all AGE in developed countries due to viruses 1/3-1/2 of AGE hospitalizations caused by rotavirus Changing: Vaccine and season Most common bacterial causes: SSYCCE Salmonella, Shigella, Yersinia, C. diff, Campylobacter, E. coli Parasitic agents cause < 10% of cases Clinical Assessment Clinical Assessment: Primary Objective What is your primary objective as provider? What components of HPI/PMFSHx and PE will help you best determine this objective? What laboratory studies will assist you in your medical decision making? Primary goal: assess degree of hydration Outpatient vs. inpatient Normal diet vs. ORT vs. IVF Need for anti-emetics, probiotics Clinical Assessment: History Clinical Assessment: Physical Examination (old way) HPI: weight loss (goal standard), amount/number of emesis/diarrhea SHx: sick contacts, daycare, animals, travel PMHx: recent infections, medications, and medical problems 3

4 Clinical Assessment: PE Findings and the Literature Table 3. Gorelick 10-point scale. Individual findings generally have low sensitivity, high specificity abnormal skin elasticity CRT > 2 sec abnormal general appearance absent tears, abnormal respirations dry mucous membranes sunken eyes tachycardia decreased UOP (parent report of low UOP is sensitive but not specific) The presence of any three or more signs has sensitivity of 87% and specificity of 82% for detecting a deficit of 5% or more Gorelick, MH, 1997: Validity and Reliability of Clinical Signs in the Diagnosis of Dehydration in Children Steiner MJ 2004: Is This Child Dehydrated Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, et al. (2014) External Validation and Comparison of Three Pediatric Clinical Dehydration Scales. PLoS ONE 9(5): e doi: /journal.pone Clinical Assessment: Laboratory Studies Supplementary laboratory studies, including serum electrolytes and tests for specific pathogens (rotavirus and stool studies) should not be performed routinely Serum electrolytes are sometimes useful IF severe sodium or potassium abnormalities are suspected A normal bicarbonate may be useful to rule out dehydration but is unlikely to alter management Stool studies may be indicated for suspected cases of dysentery and infection control purposes Fluid management Fluid Management: ORT vs. IVF ORT potentially has less iatrogenic risks (The gut and kidney are smarter than you ) ORT is easier, painless, and considerably cheaper ORT (when accompanied by early re-feeding shortens duration of symptoms) Time to initiating therapy is shorter with ORT May give oral or NG 4

5 Fluid Management: ORT vs. IVF The single biggest obstruction to the use of ORT is US!!!! Oral rehydration therapy (ORT) has repeatedly been proven to be as effective as IV for mild to moderate dehydration both outpatient and inpatient. Studies have demonstrated that ORS vs. IVF decreased ED stays decreased duration of illness increased parent satisfaction no difference in hospitalization rate AND OUR DEPENDENCY ON TECHNOLOGY Fluid Management: ORT (oral rehydration therapy) Fluid Management: ORT ORT is based on the Na-glucose co-transport in the small intestine. This is maintained even during infection. It requires specific amounts and ratios of water, glucose, and electrolytes Oral rehydration solutions contain glucose plus electrolytes Many easily available solutions (e.g. Pedialyte) have mmol/l of sodium, which is at lower end of that studied These are best for maintenance fluids, but can be utilized for rehydration in otherwise healthy children. Clear liquids are not recommended as a routine substitute for (ORS) in the prevention or therapy of dehydration How to add your department name to this presentation Management: Return to regular diet 1. To add your department name, click on View > Master > Slide Master from the menu bar, then edit all of the Master slides. 2. Click on the Close Master View button The historical BRAT diet (consisting of bananas, rice, applesauce, and toast) is unnecessarily restrictive, but may be offered as part of the child's usual diet Clear liquids are not recommended as a routine substitute for oral rehydration solutions (ORS) or regular diets in the prevention or therapy of dehydration The vast majority of patients with AGE do not develop clinically important lactose intolerance. In selected patients with documented, persistent lactose intolerance, lactose-free formulas are recommended A meta-analysis of 16 studies found no significant clinical advantage to diluting milk or formula in the management of AGE 5

6 Management: Return to regular diet Management: Anti-emetics The historical BRAT diet (consisting of bananas, rice, applesauce, and toast) is unnecessarily restrictive, but may be offered as part of the child's usual diet Clear liquids are not recommended as a routine substitute for oral rehydration solutions (ORS) or regular diets in the prevention or therapy of dehydration The vast majority of patients with AGE do not develop clinically important lactose intolerance. In selected patients with documented, persistent lactose intolerance, lactose-free formulas are recommended A meta-analysis of 16 studies found no significant clinical advantage to diluting milk or formula in the management of AGE Selective serotonin (5-HT3) receptor antagonists Ondansetron (Zofran), Dolasetron; Tropisetron Was expensive but becoming cheaper Phenothiazines Prochlorperazine, Promethazine, Phenergan Side effects: drowsiness, respiratory depression, dystonic reactions Contraindicated under age 2 Management: Anti-emetics and anti-diarrheals Management: Probiotics Antiemetics are NOT routinely recommended, although ondansetron has been shown to be safe and effective therapy in the pediatric emergency department (ED), in addition to oral or IV rehydration therapy. Anti-diarrheal agents are NOT recommended in the routine management of children with AGE A Cochrane meta-analysis of 23 randomized controlled trials found mild therapeutic benefit from probiotics that was generally reproducible regardless of organism, quality of study design, or outcome measure Probiotics may be more effective for rotavirus diarrhea, compared to all - cause diarrhea The microorganisms used to culture yogurt, Streptococcus thermophilus and Lactobacillus bulgaricus, are not considered probiotics because they do not survive the acidity of the stomach to colonize the intestines Management: Probiotics The recommended strain of probiotic at SCH is Lactobacillus rhamnosus at a dose of colony forming units per day for a duration of 5 days. This recommendation comes from a Best Evidence Statement (BESt) from Cincinnati Children s Hospital Medical Center (CCHMR) and can be found at: QUIZ: Question 1 IVFs are easier, faster, and better than oral rehydration therapy (ORT) FALSE Studies consistently show ORT to be faster and cheaper than IVF. equal to or better than IVF for mild/moderate dehydration. ORT fails only 1 out of 25 times when used correctly 6

7 QUIZ: Question 2 QUIZ: Question 2 Parents and families prefer IVF over ORT as a treatment option Parents and families prefer IVF over ORT as a treatment option FALSE Most families don t know ORT is an option Patient satisfaction is equal or better with ORT ORT offers families the skills and confidence to manage their child s illness at home Medical personnel are the real obstruction to ORT QUIZ: Question 3 QUIZ: Question 3 The most successful form of ORT is to offer Pedialyte or a popsicle to a patient The most successful form of ORT is to offer Pedialyte or a popsicle to a patient FALSE ORT is a therapy with specific methodological and physiological basis that predict its successful use ORT must be administered QUIZ: Question 4 QUIZ: Question 4 If a child vomits, then that means he or she has failed ORT? If a child vomits, then that means he or she has failed ORT? FALSE Vomiting is part of gastroenteritis. We should not expect it to go away with rehydration therapy. Most children can be successfully rehydrated with ORT despite vomiting. Ondansetron (Zofran) has been demonstrated to be safe and successful at decreasing emesis and LOS and increasing the success of ORT. 7

8 QUIZ: Question 5 QUIZ: Question 5 Which of the following is the best intervention to improve the symptoms of AGE? a) Clear liquids and gut-rest b) BRAT diet c) Diluted formulas or juices d) Avoidance of lactose f) None of the above Which of the following is the best intervention to improve the symptoms of AGE? a) Clear liquids and gut-rest b) BRAT diet c) Diluted formulas or juices d) Avoidance of lactose f) None of the above Studies consistently show exactly the opposite. The above strategies prolong symptoms and delay return of normal physiology. QUIZ: Question 6 QUIZ: Question 6 The following management strategies will improve diarrhea in AGE The following management strategies will improve diarrhea in AGE a) Early refeeding b) Yogurt c) Probiotics d) Zofran e) a, b, c f) a and c a) Early refeeding b) Yogurt c) Probiotics d) Zofran e) a, b, c f) a and c Regular yogurt does not contain the correct lactobacillus QUIZ: Question 9 QUIZ: Question 9 The mainstay of inpatient treatment is: The mainstay of inpatient treatment is: a) IVF until not vomiting and stool studies result b) Education and toleration of ORT c) Daily electrolytes to monitor dehydration d) Zofran, popsicles, and the snack cart e) Address caregiver s refusal to leave a) IVF until not vomiting b) Education and toleration of ORT c) Daily electrolytes to monitor dehydration d) Zofran, popsicles, and the snack cart e) Parents refuse to leave ORT = QUALITY EVIDENCE-BASED CARE It is the only proven therapy to reduce symptoms of AGE 8

9 Take Home Point #1 Take Home Point #2 Not every patient that vomits (without diarrhea) has AGE! Need to carefully consider a broad differential when presented with a child who has vomiting without diarrhea Oral rehydration therapy (ORT) has repeatedly been proven to be as effective as IV for mild to moderate dehydration both outpatient and inpatient Take Home Point #3 Thanks! When it comes to AGE, less is more: less testing (less blood work, less stool studies) less interventions (less IVF) less medication use (no antibiotics, no antidiarrheals) less crazy diets (use ORT or regular diet) Joel.tieder@seattlechildrens.org Don t just do something, stand there Table 1. Clinical dehydration scale (CDS). Table 2. World health organization scale. Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, et al. (2014) External Validation and Comparison of Three Pediatric Clinical Dehydration Scales. PLoS ONE 9(5): e doi: /journal.pone Jauregui J, Nelson D, Choo E, Stearns B, Levine AC, et al. (2014) External Validation and Comparison of Three Pediatric Clinical Dehydration Scales. PLoS ONE 9(5): e doi: /journal.pone