Several conditions arc often confused with gastroenteritis. Many doctors have failed to realize that a fully breast-fed baby has loose stools which arc often bright green, explosive, contain mucus and curds (soap plaques), and may be very frequent—up to 24 in 24 hours. Some confuse the loose, green, starvation stools of an underfed baby with gastroenteritis. Babies with Hirschsprung's disease may present with diarrhea and vomiting. Necrotizing enterocolitis occurs especially in low birth-weight babies who are bottle fed: they have fever, shock, diarrhea, vomiting and abdominal distension. Carbohydrate intolerance is commonly associated with diarrhea. Some children with acute appendicitis, peritonitis and intussusception have diarrhea. Toddlers, aged twelve months to two or three years, sometimes have very loose stools, though well and thriving: the condition is termed the irritable colon syndrome, or 'toddler diarrhea". It has to be distinguished from the various diseases associated with stea-torrhoca. One has seen many children treated by anti-diarrhea medicines for incontinence of faeces and liquid stools leaking out of the anus due to gross constipation. At any age ulcerative colitis may occur: blood and mucus may not appear in the stool for some months after the first attack of diarrhea. Many medicines, such as penicillin by mouth, cause diarrhea.
Diarrhea is not due to teething.
When a child with gastroenteritis is referred to the casualty doctor or family doctor, an important decision has to be made: namely whether he is to be allowed to go home, or whether hospital treatment is required. The first essential is to decide how ill the child is: if he is ill he should be admitted. The next essential is to assess the degree of dehydration, if any.
Dehydration can be very rapid in a baby or young child. It is assessed as follows:
Mild dehydration ( < 5%)—good general condition and some loss of skin turgor.
Moderate (5%)—looks ill with a dry mouth but no peripheral circulatory failure.
Severe (10%)—signs of peripheral circulatory failure and gross dehydration.
Over (10%)—the child is severely shocked and moribund.
When a baby is overweight it is difficult to assess the dehydration. An overweight baby may have severe acidosis and dehydration without apparent loss of tissue turgor, becuuse fatty tissue is largely water-free. Better signs of dehydration in a fat baby arc a dry mouth, a sunken fontanelle and sunken eyes. Ovcrvcntilation suggests hypernatraemic acidosis and one must look for an associated infection, such as otitis media, urinary tract infection or septicaemia.
If a baby's general condition is good and there is only slight loss of tissue turgor, a rectal swab is taken and he is taken off all food for 24 hours (not more) and given an oral electrolyte solution. This can be made with Elcctxosol tablets (eight in a litre of water) or by using Dioralytc sachets. Dioralytc contains dextrose in addition to sodium and potassium chloride and sodium bicarbonate, and a sachet is made up to 200 ml with water.
An infant is given 150-200 ml per kg per 24 hours and other feeds. This should not be given for more than 48 hours.
An older child is given 1-3 1 in the 24 hours. The water should be tepid, for iced water increases peristalsis. Antibiotics arc not given. Even if Sonne dysentery is diagnosed, they are not given, because they prolong the carrier state; the same applies to a salmonella infection. It is futile to prescribe kaolin. Diphenoxylate (Lomotil) should not be prescribed. Do not give mctoclopramide or prochlorperazine.
If the child is sent home, the family doctor is spoken to, and if necessary asked to sec the baby later in the day. The parents are told thai if there is any deterioration in his condition he must be brought to the hospital immediately. He must certainly be seen next day.
If the child is ill with loss of tissue turgor and a depressed fontanclle, he must be admitted. Blood is taken for culture, blood urea and electrolytes and an intravenous line is set up with 045% sodium chloride in 4-8% dextrose. Give 25 ml per kg as fast as the drip will run before admitting the child. If the baby is profoundly shocked give 10 ml per kg plasma by push before attempting replacement of the deficit.
For deficit replacement, 5% dehydration will need 50 ml per kg and 10% dehydration will need 100 ml per kg. Maintenance is worked out as 2 ml per kg of body weight. The procedure is summarized below:
0-1 h-----------------→ 4 h-----------------→ 12 h--------------------→ 24 h
⅓ replacement ⅓ replacement ⅓ replacemen+ + maintenance
maintenance maintenance +
+ on-going losses
on-going losses
The doctor should anticipate the development of convulsions if there is hypertonic dehydration.
Gastroenteritis in a baby or young child must be treated with caution because he can deteriorate with extretne rapidity, collapse and die
No comments:
Post a Comment