43: PEDIATRIC GASTROENTERITIS: ONE THING YOU SHOULD TRY AT HOME LEVEL II
A 3-day history of vomiting, diarrhea, and other symptoms causes a young mother to seek medical attention at the emergency department for her 9-month-old daughter. The patient has signs of moderate dehydration on physical and laboratory examination. The presumed diagnosis is viral gastroenteritis. Students should understand that replacement of fluid and electrolyte losses is critical to the effective treatment of acute diarrhea. Oral rehydration therapy (ORT) with carbohydrate-based solutions is the primary treatment for diarrhea in children with mild-to-moderate dehydration. When caregivers are properly instructed, therapy can begin at home which may potentially prevent an ED visit or hospital stay. IV fluids are often needed for cases of severe dehydration. Fluid losses should be replenished, and early refeeding with age-appropriate diets is essential to reduce stool volume after completion of rehydration therapy. Although antidiarrheal and antiemetic products are available, they have limited effectiveness, can cause adverse effects, and, most important, may divert attention from appropriate fluid and electrolyte replacement. Ondansetron can be used in patients with intractable vomiting who present to the ED after failed attempts at ORT. Families should have a commercially available oral rehydration solution (ORS) at home to start treatment as soon as vomiting and diarrhea begins. The availability of two oral rotavirus vaccines has dramatically reduced morbidity and mortality of rotavirus-induced diarrhea in countries where universal immunization has been adopted. Its use and effectiveness will continue to grow as support increases from public health agencies.
1.a. Create a list of the patient’s drug therapy problems.
This patient has typical viral gastroenteritis and diarrhea, a common pediatric problem. The peak incidence occurs between 6 and 24 months of age and is characterized by the acute onset of emesis, progressing to watery diarrhea as the vomiting resolves. A number of viruses cause viral gastroenteritis, but rotavirus and norovirus are the most common. Prior to the introduction of rotavirus vaccines in 2006 and 2008, rotavirus was the most common cause of pediatric gastroenteritis in the United States causing approximately 55,000–70,000 hospitalizations per year, 200,000 emergency room (ER) visits, and 400,000 outpatient physician visits among children younger than 5 years of age.1 Mortality due to rotavirus gastroenteritis in the United States is uncommon with an estimated 20–60 deaths per year. Worldwide, the incidence of rotavirus diarrhea has increased over the past 30 years and is responsible for approximately 450,000 deaths in 2008 in children younger than 5 years of age, accounting for 37% of all diarrhea-related mortality and 5% of all deaths in children ≤5 years of age.2
Currently, norovirus is the leading cause of gastroenteritis in the United States. Norovirus results in 19–21 million cases of gastroenteritis per year, 10–15% of severe gastroenteritis cases in children under 5 years of age, ...