Tuesday, February 26, 2013

Diarrhea, Its Classifications, Manifestations And Detailed Rehydration Therapy



Diarrhea (AmE) (or diarrhoea) (BrE)  is the condition of having three or more loose or liquid bowel movements per day. It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause dehydration and electrolyte disturbances such as potassium deficiency or other salt imbalances.
In 2009 diarrhea was estimated to have caused 1.1 million deaths in people aged 5 and over and 1.5 million deaths in children under the age of 5. Oral rehydration solutions (ORS) with modest amounts of salts and zinc tablets are the treatment of choice and have been estimated to have saved 50 million children in the past 25 years. In cases where ORS is not available, homemade solutions are often used.

Diarrhea Classification

Diarrhea's type
Diagnostic's criteria
Severity
Main clinical syndrome
Invasive (bacterial)
Liquid excrements with pathological admixture (mucus, verdure, blood)

Mild

Moderate

Severe
·        Primary toxicosis (neurotoxicosis)
·        Toxicosis with dehydration I, II and III degree
·        Infectious-toxic shock
·        Toxic-dystrophic syndrome
·        Hemolytic-uremic syndrome

Secretor (watery)
Excrements are liquid, massive, without pathological admixtures
Prolonged
Long-lasting diarrhea (more 2 weeks) with pathological admixtures
Chronic enzyme-associated
 Watery, don’t fermentated excrements without signs of the inflammation in koprogram, associated with food ingredients

Criteria of the Diarrhea Severity
Criteria
Mild current
Moderate current
Severe current

 Local manifestations

regurgitation, vomiting 1-2 times per day, excrements less than 7-8 times per day, changed nature with small amount of mucus, but with increase of  stools, moderate metheorism

Multiple vomiting, as a rule after receiving the food, excrements to 15 times per day, liquid, with much mucus, can be bloody mucus, metheorism

Multiple vomiting not only after receiving the food, but also independent, can be with bile, sometimes - as coffee lees, excrements - more 15 times per day, sometimes - with each diaper, much mucus, there is blood, sometimes - an intestinal bleeding

General manifestations

General condition is broken little, falls appetite, body temperature is normal or subfebrile, deceleration or delay of the body weight, visible signs of toxicosis and dehydration are absent

General condition is moderately broken, malaise or excitement, appetite is reduced, poor sleeping, moderate signs of toxicosis and dehydration, body temperature is 38-39º С, body weight decreases

General condition is sharply worsened, changes in all organs and systems, quite often - sopor, loss of the consciousness, cramps, expressed toxicosis and dehydration, significant weight loss

Differential diagnosis should be performed among acute non infection diarrheas, salmonellosis, shigellosis, staphylococcal diarrhea, viral diarrhea, and cholera.
Diagnosis example:
E.coli infection (caused by Enterotoxigenic strain), typical form, severe degree.
Complication: hypertonic dehydration, 3rd degree.

Treatment
Therapy of an acute intestinal infection for children has 4 constituents: diet, rehydration therapy, antibacterial therapy and auxiliary therapy (enerosorption, probiotics).
Dehydration: Dehydration means the body does not have enough fluids to function at an optimal level. Dehydration can be caused by fluid loss (through vomiting, diarrhea or excessive urination), inadequate intake, or a combination of both. The most common cause of dehydration in infants and children is acute gastroenteritis, with its associated vomiting and diarrhea.

 




1. Rehydration therapy
Timely and adequate rehydration therapy is a near-term and most essential link in treatment of an acute intestinal infection, both secretory and invasive. Early application of adequate rehydration therapy is the main condition of rapid and successful treatment. Rehydration therapy is done according the severity of child’s dehydration (Table 1).
Table 1
 Clinical signs of dehydration severity (present 2 or more from the noted signs)
Sign

Mild (1st  degree)

Moderate (2nd  degree)

Severe (3rd  degree)

Loss of body weight

Children aged before yrs
3-5%
6-9%
10% and more
Children aged 3-14 years
To 3%
3-6%
6-9%
General condition
Disturbance
Disturbance or somnolence
Languor, somnolence
Thirst
Drinks voraciously
Drinks voraciously
Does not drink
Anterior fontanel
Not changed
Slightly sunken
Sunken  
Eyeballs
Not changed
Soft
Sunken expressively
Mucus membranes of the mouth
Moist
Slightly dry
Dry
Skin fold
Disappears at once
Disappears slowly

It can disappear slowly (> 2 sec.) or does not disappear at all
Arterial pressure
Norm
Hypotonia  
Severe hypotonia
Urination

Normal

Decreased

Considerably decreased to 10 ml/kg day

Oral rehydration (by mouth)

 

Oral rehydration is most effective, when is performed from the first hours of the disease. Oral rehydration must be the first aid at home when the disease begins. It doesn’t have any contraindications.
In accordance with recommendations of WHO optimum composition of solutions for oral rehydration is:
sodium - 60 mmol/l;
potassium - 20 mmol/l;
bicarbonates - 10 mmol/l;
glucose - 110 mmol/l;
osmolarity is - 250 mosmol/l.
Content of sodium and potassium in solutions for oral rehydration must correspond their average losses at an acute intestinal infection. The concentration of glucose in them must help water resorption not only in an intestine but also in kidneys. Because high osmolarity it is not recommended to give fruit juices, sweet drinks (Coca-cola, and others like that) during the oral rehydration.
The method of oral rehydration have to start immediately, because dehydration begins after the first liquid, watery emptying, yet long before appearance of clinical signs of dehydration. Valuable rehydration therapy is performed in 2 stages.
The 1st stage is rehydration therapy which is carried out during 4-6 hours for proceeding of the lost liquid volume. During the mild dehydration – 30-50 ml/kg, at moderate degree - 60-100 ml/kg. 
Table 2
A calculation of oral rehydration solutions volume
Body weight in kg

An amount of solution for 4-6 hours (ml)

mild dehydration
 moderate dehydration
5
250
400
10
500
800
15
750
1 200
20
1 000
1 600
25
1 250
2 000
Speed of liquid introduction through a mouth is 5 ml/kg/hour.
Criteria of the 1st stage efficiency: (are estimated in 4-6 hours)
·        disappearance of thirst,
·        improvement of the tissues turgor,
·        moistening of mucus membranes,
·        increase of diuresis,
·        disappearance of microcirculation violation signs.
Choice of subsequent tactic:
1.     if signs of dehydration have disappeared - continue the 2nd stage of rehydration therapy.
2.     the signs of dehydration have diminished, but still are present - it is needed to continue to give solution through a mouth during the following 4-6 hours in a previous volume.
3.     the signs of dehydration have increased – parenteral rehydration should be start.
The 2nd stage is supporting therapy, which is done depend the losses of liquid, which proceed, with vomit and emptying.
Method of the 2nd stage:
Supporting oral rehydration means that to the child for every following 6 hours is entered so many rehydration solution, as he has lost during previous 6 hours.
Oriented volume of solution for supporting rehydration for children before 2 yrs is 50-100 ml, children elder than 2 yrs – 100-200 ml or 10 ml/kg of solution after every emptying. On this stage oral rehydration solution is possible to alternate with fruit or vegetable sugar free decoctions,  or tea, especially green. At vomit rehydration therapy is continued after 10-minute pauses. In the hospital in case the child refuse to drink or at presence of vomit tube rehydration should be done. Nasogastric tube rehydration can be done continuously with a help of the system for intravenous infusion, with maximal speed 10 ml/min.

Parenteral rehydration

At acute intestinal infections, which are accompanied by the 3rd stage of dehydration, with multiple vomits, anorexia, waiver of drink, oral rehydration is combined with the parenteral rehydration.
Solutions for parenteral rehydration:
·        Ringer’s lactat,
·        Ringer’s acetate,
·        Isotonic glucose solution,
·        Isotonic sodium chloride solution.
To the children aged before 3 months is better not to use 0.9% NaCl, so as it has relatively plenty of chlorine (154 mmol/l) and relatively high osmolarity (308 mosmol/l). Monotherapy by glucose solution is not effective. Composition and correlation of solutions depends from the type of dehydration.
To the children of early age it is necessary to eliminate solutions, which contain plenty of sodium, chlorine, glucose (solutions of Disol, Trisol, Quartasol, Acesol, Laktasol, Chlosol and others like that) because of possible hypernatremia and intracellular edema development.
At presence of some ions deficit in blood plasma (sodium, potassium, magnesium, calcium) or acid-base balance changes it is need to correct them.
 To perform parenterally rehydration it is necessary to define:
·        Day's requirement of liquid and electrolytes.
·        Type and degree of dehydration.
·        Level of liquid deficit.
·        Current losses of liquid.
Principle of volume calculation for the infusion therapy:
Day's volume of liquid in case of dehydration consists of:
a)     deficit of liquid before the treatment (a loss of body weight during the disease),
b)    physiologic liquid’s requirement,
c)     current pathological losses.
a) For the calculation of physiologic liquid’s requirement it is possible to recommend the method of Holiday Segar that is used the most widely in the world (Table 3).
Table 3
Determination of physiology requirements is in a liquid on the method of Holiday Segar
Weight
Day's necessity
1-10 kg
100 ml/kg
10,1-20 kg
1000 ml + 50 ml/kg on every kilogram over 10 kg
more than 20 kg
1500 ml + 20 ml/kg on every kilogram over 20 kg
b) The calculation of liquid’s deficit depends on the degree of dehydration is determined by the clinical signs or weight lost %:
1% of dehydration = 10 ml/kg
1 kg of weight loss = 1 liter
Consequently, at a 1st degree of dehydration (5% weight loss) day's deficit of liquid is 50 ml/kg/day; at 2nd degree (10% weight loss) - 100 ml/kg/day.
The expected volume of liquid is entered during a day.
A liquid is entered in peripheral veins during 4-8 hours, repeating infusion if necessary in 12 hours. According to it a patient gets intravenously 1/6 of day's volume during 4 hours, or 1/3 - during 8 hours et cetera). A remained volume is entered through a mouth!
Liquid’s requirement per hour of the infusion is more physiologic:
New-born:
1-st day of life – 2 ml/kg/hour;
2-nd day of life – 3 ml/kg/hour;
3-rd day of life – 4 ml/kg/hour;
Elder children:
weight up to 10 kg - 4 ml/kg/hour;
weight from 10 to 20 kg - 40 ml/hour + 2 ml for every kg over 10 kg;
weight more than 20 kg - 60 ml/hour + 1 ml on every kg of weight of body over 20 kg
A calculation of salts requirements:
Special attention should be paid to the correction of sodium and potassium deficit, losses of which can be considerable. It is necessary to remember, that sodium a child will get with crystalloid solutions which are entered in certain correlations with glucose depending type and severity of dehydration. If laboratory control is not done, potassium is entered according the physiologic necessity (1-2 mmol/kg/day). Maximal daily amount must not exceed 3-4 mmol/kg/day. Medicine, mainly potassium chloride, is entered intravenously droplet on 5% glucose solution. Nowadays insulin adding to these solutions is not recommended. A concentration of potassium chloride in prepared solution must not exceed 0.3-0.5% (maximally 6 ml 7.5% KCl on 100 ml of glucose). 1 ml of 7.5% KCl solution contains 1 mmol of K+. Before entering potassium it is necessary to restore urination, as anuria or severe oliguria is contra-indication for intravenous potassium infusion. Blood potassium in plasma as 6.5 mmol/l is threatened for the life, in concentration 7 mmol/l hemodialysis is needed.
Determination of salts deficit is based on laboratory information.
Acute intestinal infections in children mainly are accompanied by isotonic type of dehydration, that’s why determination of blood electrolytes to all children with diarrhea is not necessary. Determination of Na+ and K+ is necessary at 3rd degree of dehydration and for children with 2nd degree of dehydration, in which general condition severity does not correspond the diarhea severity, anamnes is complicated, a rapid effect from the rehydration therapy is absent.
A calculation of sodium and potassium deficit is done by the following formula:
Ion deficit = (normal ION concentration – patient’s ION concentration) х  M х К, where
M is weight of the patient
K is a coefficient of intracellular liquid volume.
K = 0.3 - before 1 year
K = 0.2 - after 1 year and for adults.
Than it is necessary to define the amount of sodium and potassium in solutions which are entered, volume and correlations of which are already expected. A content of these ions in solutions which are often used, are represented in a table. After the urgent intravenous rehydration it is necessary to check up the level of sodium and potassium in plasma.
Table 4
Content of ions in crystalloid solutions
Content of the ion in mmol/l Osmolarity
SOLUTION

Na+

K+

Cl-

Ca++

Acetate (bicarbonate)
mosmol/l
Physiological solution
154
-
154
-
-
308
Ringer's solution
147
4
155
2
-
308
Ringer's lactat
130
4
109
1,5
28 (bicarbonate)
273
4% NaHCO3
500
-
-
-
500 (bicarbonate)
1000
5% dextrose solution on 0,45% solution of NaCl
77
-
-
-
-
252
Taking into account importance of magnesium ions for the child’s organism, and also that the magnesium losses go parallell with potassium losses on the first stage of rehydration therapy a 25% solution of magnesium is rotined in the dose of 0,5-0,75 mmol/kg (1 ml of solution = 1 mmol of magnesium).
In children with a severe malnutrition daily necessity in potassium and magnesium is enlarged (up to 3-4 mmol potassium and 0.4-0.6 mmol magnesium).
c) Current pathological losses are determined by weighing of dry and wet diapers, determining the amount of the vomit or with a help of calculations:
10 ml/kg/day on every degree of temperature over 37.0 oC;
20 ml/kg/day  in case of vomit;
20-40 ml/kg/day in case of intestinal paresis;
25-75 ml/kg/day in case of diarhea;
30 ml/kg/day for perspiration.
Control of correct rehydration therapy is frequency of pulse, frequency of breathing, body weight and diuresis dynamics.
Rehydration therapy depending the type of dehydration
It is necessary to take into account the type of dehydration to choice solutions and their correlations for the rehydration therapy. There are 3 types of dehydration: isotonic, hypertonic (water deficient) and hypotonic  (salt deficient) (Table 5).
Table 5
Signs of different forms of dehydration
Index

Isotonic type of dehydration
Hypotonic type of dehydration
Hypertonic type of dehydration
Breathing
No peculiarities
Hypoventilation 
Hyperventilation
Blood pressure

Decreased or increased
Low
Remains normal for a long time
Temperature of the body
Subfebrile
Normal, tendency to the hypothermia
Febrile
Skin
Cold, dry, elasticity is decreased
Cold with a cyanotic tint, elasticity is decreased
Elasticity is stored, warm
Nervous system

 Malaise

Excitation, possible cramps
Disturbance, sleeplessness
Diuresis

Diminished

Diminished
For long time it remains normal
Specific gravity of urine
Norm or insignificantly encreased
Decreased to 1010 or low

Encreased to 1035 and more

Osmolality of plasma
Norm

Decreased

Encreased
A level of electrolytes in the blood
Normal

Low

Encreased

Main Differential Signs of the Dehydration Types


 Symptom, sign
Hypertonic dehydration
Isotonic dehydration
Hypotonic dehydration
Body temperature

Highly increased

Normal, subfebril
subnormal
Thirst
Severe
Moderate
Refuse to drink
CNS reaction
Exiting 
Some exiting or depression
Adynamia 
Concentration of the sodium in blood
Increased
Normal
Decreased
Loss of body weight
5-10 %
Less than 5 %

More than 10 %


At isotonic rehydration (Na 130-150 mmol/l) develops as a result of equal losses of salts and water; it is the most often type of dehydration in children with an acute intestinal infection. In the first days (in case of microcirculation maintenance) rehydration is performed by 5% glucose solution in combination with 0.9% sodium chloride or Ringer’s lactate solution in correlation (2:1) with parallel correction of electrolytes.
Next days of rehydration therapy glucose-saline solutions in a volume which provides the physiology liquid’s requirement of organism, remnant volume for the compensation of dehydration, current pathological losses, correction of plasma electrolytes are performed.
Hypertonic dehydration (Na > 150 mmol/l) develops as a result of liquid losses predominance above salts loses, inadequate rapid injection of salts with small amount of water.
Rehydration therapy should be done by a 5% glucose solution in combination with 0.9% sodium chloride solution in correlation (3:1).
During the rehydration therapy for patients with hypertonic dehydration it is need to take into account daily sodium requirements (2-3 mmol/kg). Thus should be taken into account sodium in solutions for infusion.
If the level of sodium is 140-150 mmol/l, then amount of sodium should be  decreased 2 times from physiology necessities, and at the increase of it more than 150 mmol/l solutions which contain sodium are eliminated, except  colloid ones.
It is necessary to investigate a potassium level and correct it if it is needed.
To prevent cerebral edema control of plasma osmolarity and body weight is needed. On this stage a speed of infusion is 15-20 drops per hour.
Hypotonic dehydration (Na < 130 mmol/l) develops as a result of salts losses predominance above liquid loses, excessive injection of water with small amount of salts. It developes in case of intestinal infections which are accompanied by frequent vomit, or during oral rehydration by solutions with small amount of salts.
Rehydration therapy is done by 5% glucose solution in combination with 0.9% sodium chloride in correlation (1:1).
If the level of sodium is less than 129 mmol/l it is needed to correct it (calculate it by formula described before). During the correction of sodium hypertyonic solutions are avoided. Their infusion can result in acute intracellular dehydration, first of all cerebral. Except this, anaphylactic reactions can develop. The correction of sodium is done by 0.9% NaCl, Ringer’s lactat.
If it is impossible to investigate blood electrolytes, glucose-saline solutions are infused in correlation 1:1.
By the WHO recommendations (if the fast rehydration is necessary in case of laboratory control absence) the volume and speed of 0.9% NaCl, Ringer’s lactat infusion on the first rehydration stage should be the following (Table 6):
Table 6
Speed of infusion during the rehydration therapy
Age of the child
Speed of infusion
Speed of infusion
Before 12 months

30 ml/kg for the first 1 hour
70 ml/kg for the next 5 hours

Elder than 12 months

30 ml/kg for the first 30 minutes
70 ml/kg for the next 2.5 hours


The condition of the child is checked up each 15-30 minutes to normal pulse filling on a radial artery. If the condition of child does not get better, speed of infusion should be increased. After that the condition of the child is estimated every hour (abdominal skin fold, consciousness, possibility to drink).
After all volume is entered the child’s condition should be estimated again:
·        if the signs of severe dehydration still present – repeat infusion again according the table 6.
·        if the child’s condition gets better, but there are signs of moderate dehydration – continue oral rtehyderation according the table 2. If a child is breast fed, it is recommended to continue feeding; numbers of feeding should be increased.
·        if signs of dehydration are absent, then the duration of feeding should be increased. At the same time at presence of diarrhea for supporting rehydration 50-100 ml of oral rehydration solution is given to the children aged before 2 yrs, 100-200 ml to the children elder than 2 yrs or 10 ml/kg  additionally after every emptying (up to 1/3 expected volume for oral rehydration). Children on the artificial feeding are fed by the same chart, by lactose free formulas.
Supervision after children with a severe malnutrition and dehydration during the rehydration therapy should be done each 30 minutes during the first 2 hours, and then every hour next 4-10 hours. At signs of hyperhydratation (increase of pulse frequency on 15 per minute, breathing frequency on 5 per minute) rehydration should be stopped. Than estimate the child’s condition through an hour.
During parenteral rehydration for such children, and also for children with pneumonia, toxic encephalopathy, speed of liquid infusion must not exceed 15 ml/kg/hour. At these states daily body weight gain in the first 3 days must not exceed 1-3%.
In case if dehydration is absent and infectious toxic shock is developed reanimation measures according the protocol should be done.

1.     Antibacterial therapy

   

Antibacterial therapy at invasive diarrhea is given to:
1.     Children with severe and moderate forms of disease.
2.     Children aged before 3 months independent of the disease severity.
3.     Children with the immune deficiency, HIV-infected children,  children, that receive immune suppressive therapy (chemical, ray), long corticosteroid therapy, children with hemolytic anemia,  hemoglobinopathies independent of age and the disease severity.
4.     Children with hemocolitis independent of age and the disease severity.
5.     Children with the secondary bacterial complications in all age groups.
Antibacterial therapy at secretory diarrhea is given to:
1.     Children with severe and moderate forms aged before 6 months.
2.     Children with the immune deficiency, HIV-infected children, children, that receive immune suppressive therapy (chemical, ray), long corticosteroid therapy, children with hemolytic anemia, hemoglobinopathies.
3.     Cholera, parasitogenic diarrhea independent of age and the disease severity.
4.     Children with the secondary bacterial complications in all age groups.
Antibacterial therapy is not indicated to:
1.      Children with mild, effaced and moderate forms of infections, except for those which are listed above.
2.      Children with bacterial transmitting of any etiology (transitory, postinfectional).
3.      Children with alimentary dysfunction, as a result of an acute intestinal infection (intestine dysbiosis, lactase insufficiency, celiac syndrome, secondary enzymopathy etc.).

Antibacterial therapy if the etiology of an acute intestinal infection is known
Table 8
Antibacterial preparations which are recommended for treatment of an acute intestinal infections for children at the known exciter of illness
Acute intestinal infection etiology
Starting preparation

Preparation of reserve

Shigella

Ciprofloxacin*
Nifuroxazid

Ceftriaxon
Trimetoprim/sulfamethoxazolum  Azythromycin
Salmonella

Ceftriaxon
Cefotaxim
Nifuroxazid

Trimetoprim/sulfamethoxazolum  Ciprofloxacin
Ampycillin**
Chlorampheniсol**
Azythromycin
Entherotoxigenic
E.coli
Trimetoprim/sulfamethoxazolum Doxycyclin (to the children elder than 8 years)
Aminoglycosides**
Nifuroxazid 

Entheroinvasive
E.coli***

Nifuroxazid
Ciprofloxacin

Trimetoprim/sulfamethoxazolum Ceftriaxon
Azythromycin
Kampylobacter

Erythromycin
Ciprofloxacin

Aminoglycosides** Amoxacyllin/сlavulanat Carbapenems (imipenem, carbapenem)
Yersinia enterocolitica

Ceftriaxon
Cefotaksim
Ciprofloxacin

Trimetoprim/sulfamethoxazolum Doxycyclin (to the children elder than 8 years) Aminoglycosides** Chloramphenicol**

Vibrio сholerae 

Trimetoprim/sulfamethoxazolum Doxycyclin (to the children elder than 8 years)
Nifuroxazid
Furazolidonum
Ciprofloxacin

Clostridium deficile

Methronidazol

Ornidazol
Vancomycinum (through a mouth)

Giardia Lamblia 

Methronidazol
Furazolidonum

Ornidazol

Amoeba hystolitica

Methronidazol
Intetrix

Thynidazol

---------------
* - other fluorquinolons, except Cyprofloxacin, are not recommended to the children.
** - only in case of sensitivity to the antibiotic.
*** - in case of Entherohemorrhagic E.coli antibiotics can provoke hemolytic-uremic syndrome.
Table 9
A dosage of antibacterial preparations for children in case of an acute intestinal infections
Preparation

Dose

Number of receptions per day
Nifuroxazid  (through a mouth)

Suspension:
children aged 2-6 months 2,5-5 ml (110-220 mg)
6 month to 6 years - 5 ml (220 mg)
elder than 6 years – 5 ml (220 mg)
Pills:
children aged before 6 yrs - 0,2 g
elder than 6 years - 0,2 g
Course of treatment 5-7 days

2 times per day
3 times per day
4 times per day

3 times per day
4 times per day

Trimetoprim/sulfamethoxazolum (through a mouth)

children aged 2-5 years - 200 mg of sulfamethoxazolum/ 40 mg of trimetoprim
children aged 5-12 years - 400 mg of sulfamethoxazolum/ 80 mg of trimetoprim
children elder than 12 years - 800 mg of sulfamethoxazolum/ 160 mg of trimetoprim
Course of treatment 3-5 days
2 times per day

Ciprofloxacin (through a mouth)

15 mg/kg (maximal dose is 500 mg)
Course of treatment 3 days
2 times per day

Ceftriaxon (IM, IV)

50-100 mg/kg daily dose (a maximal dose is 1-2 g)
Course of treatment 2-5 days
onse a day

Cefotaxim (IM, IV)

50-100 mg/kg daily dose (a maximal dose is 1-2 g)
Course of treatment 3-5 days
2 times per day

Azythromycin (through a mouth)

6-20 mg/kg
Course of treatment 1-5 days
once a day
1-1,5 hours before the meal
Erythromycin (through a mouth)

children aged 1-3 years daily dose 0,4 g
children aged 4-6 years - 0,5-0,75 g
children aged 6-8 years - 0,75 g
children aged 6-8 years - 1 g
Course of treatment 7-10 days
4 times per day
1-1,5 hours before the meal

Amoxacyllin/сlavulanat

Through a mouth (suspension)
children aged 1-2 years 78 mg
children aged 2-7 years 156 mg children aged 7-12 years 312 mg IV - 30 mg/kg
Course of treatment 5-10 days
3 times per day
3-4 times per day

Aminoglycosides (IM, IV)

Gentamycin 2-3 mg/kg/day Amikacin 15 mg/kg/day
Netylmycin:
children before 1 year 7,5-9 mg/kg
children elder 1 year – 6-7,5 mg/kg
Course of treatment 5-7 days
2 times per day
2-3 times per day

3 times per day

3 times per day

Furazolidonum (through a mouth)
8-10 mg/kg daily dose
Course of treatment 10 days
4 times per day

Doxycyclin (through a mouth) to children elder than 8 yrs

children aged 9-12 years daily dose - the first day 4 mg/kg, then 2 mg/kg
Course of treatment 7-10 days
2 times per day

Vancomycinum (through a mouth)
40 mg/kg daily dose
Course of treatment 7-10 days
3-4 times per day
Chloramfenicolum

Through a mouth
children before 3 yrs - 10-15 mg/kg
children aged 4-8 years - 0,15-0,2 g
children elder than 8 yrs - 0,2-0,3 g
IM
children before 1 year daily dose 25-30 mg/kg
children elder 1 year daily dose - 50 mg/kg
Course of treatment 5-10 days

3-4 times per day 30 min before the meal




2-3 injections


Methronidazolum (through a mouth)

Amebiasis:
children aged 2-5 years - 0,25 g
children aged 6-10 years - 0,375g
children aged 11-15 years - 0,5g
Course of treatment 10 days Giardiasis:
children aged 2-5 years - 0,2 g children aged 6-10 years - 0,3 g children aged 11-15 years - 0,4g
Course of treatment 5-7 days
once a day
during a meal

Ornidazolum (through a mouth)

Giardiasis - 40 mg/kg
Course of treatment 1-3 days Amebiasis – 25-30 mg/kg
Course of treatment 1-3 days
once a day

Albendazolum (through a mouth)

Giardiasis
children elder 2 yrs 400 mg
Course of treatment 5 days
once a day

Tinidazolum (through a mouth)

Amebiasis – 30 mg/kg
Course of treatment 3 days
once a day

Intetrix (through a mouth)

children after 12 years – 1 capsule
Course of treatment 10 days
4 times per day

Carbapenems

Imipenem/cilastatin (IM, IV) children with body weight less than 40 kg - 15 mg/kg (maximal daily dose is 2 g)
children with body weight more than 40 kg - 500-1000 mg maximal daily dose is 2 g)
Meropenem (IV) 10-12 mg/kg
children with body weight more than 50 kg - 500 mg
Course of treatment according the evidences
4 times per day

2-4 times per day


3 times per day


It is recommended to prescribe for empiric therapy of an acute intestinal infection (in case of the unknown etiology): Nifuroxazid, Trimetoprim/sulfamethoxazolum, Cefotaxim, Ceftriaxon, Ciprofloxacin.
At a necessity of empiric antibacterial therapy of secretory diarrhea cefalosporins of 3-4 generations are used.
Diet
An important moment in organization of sick children feeding is a waiver of water-tea pauses, as it is well-proven that even at the severe forms of diarrhea the digestive function of greater part of intestine is saved, and pauses will decelerate reparation processes, reduce intestine tolerance to the meal, and considerably weaken immunity of organism. A volume and composition of meal depends from child’s age, weight and severity of diarrhea, character of previous diseases. Rational feeding is important for rapid renewal of the intestinal function.
In the acute period of gastroenteritis it is recommended to diminish daily volume of meal on 1/2-1/3, in the acute period of colitis - on 1/2-1/4. Possibly increase of feedings up to 8-10 times per day for infants, especially at urges on vomit. In this time most physiology is consider early, but gradual renewal of feed. Proceeding in high-quality and quantitative composition of meal is characteristic for this age of child, carried out in short period after the rehydration and disappearance of dehydration (4-5 days). In this period it is recommended diet for every day. The fat, fried, smoked food and others like that are eliminated from a ration in elder children.
If a child is breast fed, it is recommended to continue feeding. Children on the artificial feeding are fed by the same chart, by lactose free formulas.
Products with high amount of lactose should be eliminated (milk formulas, milk, fruit juices). This will decrease secretory diarrhea duration Children on the artificial feeding are fed by the same chart, by lactose free formulas. Lactose free diet should last individually from 1-4 weeks to 1.5-2 months. Porridges prepared on water are recommended, meet puree should be given earlier. Diary milk formulas after 8 month are recommended.

   
 Soya containing formulas are not recommended because intestine excessive sensitivity to soy proteins in diarrhea. It is risky for protein entheropathy development. Apple prepared in the oven, bananas, apple and carrot puree contain large amount of pectins are recommended in case of colitis.

Auxiliary therapy of an acute intestinal infection 
Probiotics can be applied as independent etiotropic treatment (in cases when antibacterial therapy is not indicated) or as additional medicine during antibacterial therapy. Probiotics, which contain lacto-, bifid bacteria and propineb bacteria. Self eliminate probiotics (contain saccharomycets) or probiotics which contain lacto bacteria are used in invasive diarrhea on a background of antibacterial therapy. The last ones are stable to antibiotics.

 

To the children with the immunodeficiency, those which are treated  in the intensive care units probiotics aren’t appointed.
The course of therapy lasts for 5-10 days.

Enterosorbents
Enterosorbents are able to fix on their surface hundreds of millions bacteria. Fixed microbes are ruined and hatch from a sick organism. Together with the bacteria enerosorbents fix on their surface rotaviruses from the intestine cavity. Except for the infectants enerosorption destroy the toxins of microbes and products of their metabolism. They transform toxic matters in less toxic.
The most perspective at treatment of an acute intestinal infection in children are "white", alumsilicate enerosorbents. Unlike coal sorbents they do not require introduction of high dose of preparation for achievement of therapeutic effect. Also coal sorbents get to the submucous layer of the intestine and can damage it.
 

In obedience to WHO recommendations (2006) in auxiliary therapy of an acute intestinal infection are recommended preparations of zinc (to the children before 6 months – 10 mg per day, children elder than 6 months - 20 mg per day during 10-14 days. 

Primary Prophylaxis:
         Sanitary disposal of human feces
         Protection, purification and boiling of water
         Correct preparing and saving of foodstuffs 
         Person hygiene

Secondary Prophylaxis
Ill Person
         Isolation period –until  the stool culture taken 3 days after stopping etiologic treatment is negative
         Current and terminal disinfection
         Medical supervision for 1-3 mo
Contact children   
Stool culture

Prophylaxis of acute bowel diseases:
 - Epidemiological control.
 - Isolation and sanation of ill person and carriers.
 - Reconvalescent may be discharged from hospital after one negative feces culture (taken 2 days after stop of antibiotic therapy).
 - Dispensarisation of reconvalescents for 3 months.
 - Feces culture in contacts, carriers.
 - Looking after contacts for 7 days without quarantine.
 - Disinfection in epidemic focus.


References:
Main:      
1.      Ambulatory pediatric care/ edited by Robert A. Derchewitz; - 2nd ed. – Lippincot – Raven, 1992. – p. 404-411, P.425-429.
2.      Current therapy in pediatric infections disease – 2/ edited by John D. Nelson, M.D. – B.C. Decker Inc. Toronto, Philadelphia, 1988. – p.74-77, 80-81.
3.      Principles and Practice of Pediatric Infectious Diseases. / Edited by Saran S. Long, Larry K. Pickering, Charles G. Prober, PhiladelphiaPa: Churchill Livingstone; 1997. – 1921 p.

Additional:
1.                         Cleary TG: Yersinia. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia: WB Saunders; 2000: 857-859.
2.                         Pickering L, ed: Yersinia enterocolitica and Yersinia pseudotuberculosis infections. In: Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove VillageIllAmerican Academy of Pediatrics; 2000: 642-643.
3.                         Textbook of Pediatric Nursing.  Dorothy R. Marlow; R. N., Ed. D. –London, 1989.-661p.
4.                         Pediatrics ( 2nd edition, editor – Paul H.Dworkin, M.D.) – 1992. – 550 pp.
5.                         Behrman R.E., Kliegman R.M., Jenson H.B. Nelson nextbook of Pediatrics. - Saunders. - 2004. - 2618 p.
6.                         Castaneda C. Effects of Saccharomyces boulardii in children with Chronic Diarrhoea, Especially Due to Giardiasis // Revista Mexicana de Puericultura y Pediatria. - 1995. - V. 12. - P. 1462-1464.
7.                         Guidelines for control of shigellosis, icluding epidemics due to Shigella type 1/-World Health Organisation, 2005.
8.                         Implementing the New Recommendation on the Clinical Management of Diarrhoea. - World Health Organisation, 2006.
9.                         Klein J.D., Zaoutis T.E. Pediatric Infectious Disease Secrets. - Philedelphia: Hanley & Belfus Inc, 2003. - P. 142.

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