CHILD WITH DIARRHEA AND VOMITING

OUTLINES (1)
ACUTE GASTROENTERITIS ( AGE ) Definition of diarrhea and gastroenteritis Differential diagnosis if AGE Epidemiology of AGE Etiology Short-term consequences of AGE - Dehydration - Electrolyte imbalance - Metabolic acidosis

(1) Definition
Acute gastroenteritis is a clinical syndrome of diarrhoea and/or vomiting of acute onset, often accompanied by fever, caused by infectious agents or by bacterial toxins (either ingested preformed in food or produced in the gut); and is not secondary to some primary disease process outside the alimentary tract
Alternative name

Infectious diarrhoea; Acute diarrhoea

DIARRHEA
Passage of loose watery stools 3 or more loose or watery stools/day Alteration in normal bowel movement characterized by decreased in consistency and increased in frequency

Acute diarrhea < 14 days duration Persistent diarrhea > 14 days Chronic diarrhea > 30 days

TYPES OF GASTROENTERITIS
1. Bacterial gastroenteritis i. Bacterial infection ii. Food poisoning iii. Antimicrobial Associated (Pseudomembranous colitis -Clostridium difficile) 2. Viral gastroenteritis 3. Parasites gastroenteritis 4. Non-infectious

( 2 )DIFFERENTIAL DIAGNOSIS
Differential diagnosis Common Infant -Gastroenteritis -Systemic infection -Antibiotic associated -Overfeeding -Primary disaccharidase deficiency -Hirschprung toxic colitis -Adrenogenital syndrome Child Adolescent -Gastroenteritis -Gastroenteritis -Food poisoning -Food poisoning -Systemic infection -Antibiotic associated -Antibiotic associated -Toxic ingestion -Hyperthyroidism

Rare

 Although gastroenteritis consists of the triad of vomiting, diarrhoea and fever, other conditions can present with the above symptoms as well. These include:-Acute appendicitis -Strangulated hernia -Intussusception or other causes of bowel obstruction -Urinary tract infection -Meningitis and other types of sepsis -Any cause of raised intracranial pressure -Diabetic ketoacidosis -Inborn error of metabolism -Haemolytic uraemic syndrome -Inflammatory bowel disease

!!!Always consider another diagnosis in the presence of any of the following warning signs: #Abdominal distension #Bile-stained vomiting #Blood in vomitus or stool (in appropriate clinical setting) #Severe abdominal pain #Vomiting in the absence of diarrhoea #Headache

( 3 ) epidemiology
Diarrheal diseases continue to be a major cause of morbidity and mortality in children in developing nations. In developed nations , they are an important cause of hospital admission although mortality rates may be lower. About 9% of all hospitalisations of children younger than 5 years were reported to be a result of diarrhoea. In Malaysia, the mortality of severe diarrhea in children requiring hospital admission was low, with a case fatality rate of 2.1/1000 admissions. Rotavirus and nontyphoidal salmonellae were the most common viral and bacterial pathogens causing severe diarrhea in children requiring hospital admission.

( 4) ETIOLOGY
COMMON CAUSATIVE AGENTS OF GASTROENTERITIS

VIRUSES Rotavirus Enteric adenovurus Astrovirus Calicivirus

BACTERIA Aeromonas Bacillus cereus Campylobacter jejuni Clostridium perfringes E.coli Salmonella spp. Shigella spp. Vibrio Cholerae Yersinia enterocolitica

PARASITES Blas hominis Crypt. Parvum Ent. histolytica

WATERY DIARRHEA

CAUSATIVE AGENTS

2 years old

Rotavirus Astrovirus Calicivirus Enteric adenovirus Enteropathogenic Escherichia coli (EPEC), Enterotoxigenic Escherichia coli (ETEC), Vibrio cholerae
Enterotoxigenic Escherichia coli (ETEC) Rotavirus Shigella Vibrio cholerae

2-5 years old

MUCOUSY / BLODDY 2 years old

CAUSATIVE AGENTS Shigella shiga-toxin producing Escherichia coli (STEC) Campylobacter jejuni Shigella shiga-toxin producing Escherichia coli (STEC) non-typhoidal Salmonella E. histolytica

2-5 years old

!!! In Malaysia, major enteric viruses causing childhood AGE are rotavirus, norovirus, and enteric adenovirus. For bacterial gastroenteritis, the most important causative agent is the nontyphoidal Salmonella, followed by Campylobacter, Shigella and E.coli.

( 5 ) short-term

consequences of AGE

A) Dehydration
1) Secretory diarrhea - when secretion>absorption due to inflammation - recognized clinically by 4 features: i) stools are large-volume, watery and often >1L/day ii) diarrhea persists during fasting iii) measured stool osmolar gap ( 290-((Na + K)) of <50m0sm/L iv) dont have excessive fat, blood or pus in their stool, but often develop depletion in fluid, Na and K

2) Osmotic diarrhea
- due to invasion of the enterocytes by bacteria or viral will result in reduced in absorption area # eg: rotavirus infection - can be due to after malabsorption of an ingested substances which pulls water into bowel lumen # eg: laxatives, pancreatic insufficiency or lactose intolerance - osmotic gap >50 m0sm/L >>>By using these two mechanisms, both will cause rapid loss of fluid through stools which later result in DEHYDRATION<<< >>>most serious complication is when dehydration leading to shock<<<

Increased risk of dehydration

Infants, particularly those under 6 months of age or those born with low birthweight. If they have passed 6 diarrheal stools in the previous 24hr. If they have vomited three or more times in previous 24hr. If they have been unable to tolerate ( or not been offered ) extra fluids. If they are malnutrition.

Types of dehydration
Isotonic (isonatremic) Hypertonic (hypernatremic) Hypotonic (hyponatremic)

Loses
Plasma osmolality

H2O = Na
Normal

H2O > Na
Increase

H2O < Na
Decrease

Serum Na
ECV ICV Thirst Skin turgor Mental state shock

Normal
Decrease maintained ++ ++ Irritable/lethargic In severe cases

Increase
Decrease Decrease +++ +++ Not lost Very irritable Uncommon

Decrease
Decrease +++ Increase +/+++ Lethargy/coma Common

B) Electrolytes imbalance

Sodium Imbalance Most important electrolyte affected by dehydration Hypernatremia When body loses more water than electrolytes concentrating the amount of sodium Sign of hyponatremia include thirst,confusion and seizure Hyponatremia Result when body loses more sodium than water especially in cases of severe vomiting and diarrhea Signs of hyponatremia include headache, confusion and lethargy Potassium Imbalance Potassium is mostly found inside the bodys cells so small changes in the potassium level in the bloodstream can have a significant impact on person with gastroenteritis Hyperkalaemia High potassium can cause dangerous arrhythmia or abnormal heart rhythm Low potassium usually causes milder symptoms like muscle cramps, fatigue and constipation

 Metabolic Acidosis

Metabolic acidosis occurs when an acid other than carbonic acid accumulate in the body resulting in a fall in the plasma bicarbonate
Gastrointestinal base loss Loss of bicarbonate in diarrhea, small bowel fistula, urinary diversion procedure.

Outlines ( 2 )
MANAGEMENT Assessment i) History ii) Clinical Rehydration therapy i) Oral rehydration therapy ii) Intravenous- overview Nutritional therapy Others- antibiotics, anti-diarrheal, antiemetics, probiotics, diosmectitie, zinc

1) assessment
AIM - Identify the presence of, the degree of, and type of dehydration - Identify the aetiological agent, if indicated and possible - Identify co-morbidity and complications - To assess nutritional status - To ascertain the most appropriate mode of treatment

a) History
The following aspects should be covered: Assess the onset, frequency, quantity and character of both vomiting (presence of bile, blood) and diarrhoea (presence of blood or mucous) Recent oral intake (including breast milk and other fluids and food) Urine output Weight before illness (if available) Associated symptoms (fever, change in mental status, infectious disease contact) Past medical history (underlying medical problems, history of other recent infections, medications, immune compromised states) Relevant social history

b) Physical examination
The following aspects should be covered: Accurate body weight/any changes, anthropometric measurements Vital signs (temperature, heart rate, respiratory rate, blood pressure) General conditions Eyes: sunken eyes, presence / absence of tears Mucous membrane moist or dry Respiratory pattern Bowel sounds Extremities (perfusion, capillary filling time) Skin turgor (anterior abdominal wall) Inspection of stool (presence of blood or mucous

c) Laboratory tests
Blood: full blood count, blood urea and serum electrolytes ( BUSE )-if > 5% dehydration Septic workout: blood culture, dengue serology, BFMP, thyphidot Arterial blood gas Stool: viral studies, bacteriology (culture if stool is profuse and watery, or contains blood and mucuos), microscopy (if stool is bloody/mucousy), reducing substances (if watery) Urine: specific gravity Blood glucose level in infants

d) Clinical assessment of dehydration Goal of assessment

- to provide a starting point for treatment - to conservatively determine which: > patient can safely be sent home for therapy > patient should remain for observation > patient needs immediate intensive therapy Can be based on reliable previous weight-> The best measure of dehydration is by the percentage loss of body weight. But, if not available, the degree of dehydration can be assessed clinically. Most useful signs for significant dehydration are: Prolonged capillary refill time (normal < 2 seconds) Reduced skin turgor Abnormal respiratory pattern

Remember!!!!!
Young infants are at risk for dehydration: -increased surface area: body volume ratio leading to increased insensible fluid losses - milk as main source of nutrition: # large osmotic load promote osmotic diarrhea # large protein load and high renal solute load - tendency to more severe vomiting and diarrhea - unable to obtain fluids for themselves when thirsty others risk factors for severe dehydration following AGE: -failure to give ORS - discontinuation of breast feeding - frequent stool (>8/day) or vomiting (>2/day) - malnutrition - Vibrio cholerae

Notes: 1) In hypernatremic dehydration, signs of dehydration may not be prominent because dehydration is mainly intracellular. Skin is doughy in consistency and there is abnormal behaviour. 2) Repeated assessment is necessary, especially in infants and young children. 3) Watery stools maybe mistaken as urine output.

REHYDRATION THERAPY

ORAL REHYDRATION THERAPY

Na (mmol/L) Child < 5 years K (mmol/L) Cl (mmol/L) Base (mmol/L)

Cholera
Non- cholera WHO ORS Fluid not suitable for oral rehydration Cola Apple juice

101
56 75

27
25 20

92
55 65

32
14 10

1.6 0.4

44

45

13.4 -

Principles of ORT treatment

1. Adequate rehydration therapy using an appropriate ORS 2. Replacement of ongoing fluid losses from vomiting and diarrhea with ORS 3. Frequent feeding of appropriate foods as soon as dehydration is corrected.

 ORT is recommended as first-line therapy for both mildly and moderately dehydrated children. ORT seems to be a preferred treatment option for patients with moderate dehydration from gastroenteritis Preparation : 1 sachet in 250 ml / 8 oz water

Treatment for dehydration

PLAN A PLAN B PLAN C

PLAN A
Mild dehydration (5%)
Treat diarrhea at home 1. Give extra fluid Breastfeed frequently & longer Add on ORS / cooled boiled water / food-based fluids ORS given for each loose stool
Age < 2 years 2 years
*If weight is available, give 10 ml/kg of ORS

ORS (ml) 50 100 100 - 200

Give frequently small sips If child vomits, wait 10 minutes then continue but more slowly Continue until diarrhea stops Give 8 sachets ORS to use at home

2. Continue feeding - Breastfed / formula fed / semi-solid / solid food should continue - Food high in simple sugar should be avoided as osmotic load may worsen the diarrhea
3. When to return (clinic / hospital) - Not able to drink / breastfeed / drinking poorly - Become sicker - Develops fever - Has blood in stool

PLAN B
Moderate dehydration (7.5%)
Give recommended amount ORS over 4-hour period

Age
Weight (kg) ORS (ml)

< 4 mo
<6 200 - 400

4 12 mo
6-9 400 - 700

1 2 yr
10 - 11 700 - 900

2 5 yr
12 19 900 - 1400

*Childs weight (kg) x 75 If patient want more ORS than shown, give more

Give frequently small sips If child vomits, wait 10 minutes then continue but more slowly Continue breastfeeding whenever the child wants After 4 hours - reassess & classify the dehydration - select the appropriate plan to continue treatment (plan A, B / C) - begin feeding the child If child refuse ORS, consider nasogastric tube Give IV fluid therapy if failed oral / nasogastric therapy, vomiting persist / impending shock

PLAN C
Severe dehydration (10%)
Start IV / IO immediately. If patient can drink, give ORS while drip is being set up. Check acid-base electrolytes. 1. Resuscitate

Give bolus NS / Ringers lactate as fast as posible: - neonate 10 ml/kg - pediatric 20 ml/kg Reassess capillary filling after every bolus If not respond to rapid bolus rehydration give inotropic agents (dobutamine / dopamineto) to maintain perfusion. Consider other underlying problems. Stop the boluses once perfusion improve / fluid overload is suspected / max. amount of ORS - neonate 40 - 60 ml/kg - pediatric 60 - 80 ml/kg

 Assess every 1-2 hr during rehydration Give ORS (5 ml/kg/hr) as soon as child can drink (infant : after 3-4h, older child : 1-2h) Once child can take orally the rest of the fluid requirement can be given by ORS. Check hydration status & choose appropriate treatment (plan A/B)
If fail to set IV / IO line, sent to nearest centre immediately
Try to give ORS (20 ml/kg/hr) over 6 hr Reassess every 1-2 hr If repeated vomiting / increasing abdominal distension, give the fluid more slowly Reassess after 6 hr, select the appropriate plan to continue treatment (plan A,B/C)

2. Intravenous therapy
Indication :
- severe dehydration

- unconscious child - continuous rapid looses stool (>15-20 ml/kg/hr) - frequent, severe vomiting, drinking poorly - abdominal distension with paralytic ileus - glucose malabsorption (increase in stool output && large amount of glucose in the stool when ORS sol. given)

I.

Fluid deficit
Fluid deficit (ml) = % dehydration x body weight (g)
- mild dehydration 5% - moderate dehydration 7.5% - severe dehydration 10%

II. Maintenance fluid therapy

Age
D1 D2 D3 D4 D5 - D30 D31 - 6 month 6 month - 1 year > 1 year 1st 10kg = 100 ml/kg 10 20kg = + 50 ml/kg for next 10 subsequent kg

Amount (ml/kg/day)
60 80 100 120 150 150 120

Fluid
Dextrose 10% 1/5 NS + Dextrose 10% 1/5 NS + Dextrose 10% 1/5 NS + Dextrose 10% 1/5 NS + Dextrose 10% 1/5 NS + Dextrose 5% 1/5 NS + Dextrose 5% 1/2 NS + Dextrose 5% @ 1/5 NS + Dextrose 5%

20 kg = + 20 ml/kg for any subsequent kg

Amount (ml/kg/day) x weight (kg) Total fluid require

= Maintenance + Deficit Resuscitation 24 hours

III. Treating metabolic acidosis

Acidosis usually self corrects with rehydration ; correct only if pH < 7.1 Sodium bicarbonate correction : IV 8.4% NaHCO3 (mEq or ml) = 1/3 x base deficit x weight usually only half this volume (1/2 correction) is given Review with repeat blood gas

IV. Electrolyte requirement & replacement formulae

Daily requirement of K+ = 2-3 mmol/kg/day x body weight (kg) Daily requirement of Na+ = 2-3 mmol/kg/day x body weight (kg)

Na+ deficit (mmol) = (140 mmol/L patients serum Na level) x 0.6 x wt (kg)
* 140 mmol/L : desired Na+ level. 0.6 : proportion of body weight for distribution of Na+

Type of dehydration
1. Hyponatraemic 2. Isonatraemic 3. Hypernatraemic (< 130 mmol/L) (130 -150 mmol/L) (> 150 mmol/L)

Electrolyte disorder

I.

Hypernatraemia (serum Na > 150 mmol/l)

This can result from ingestion of hypertonic liquids, such as over-concentrated milk feeds or homemade solutions to which salt is added, or loss of hypotonic fluids in the stool or urine. It is more common in hot weather. Resuscitation - If in shock, give NS / RL 20 ml/kg intravenously over to 1 hour and repeat as necessary Rehydration - if oral rehydration failed, start IV - reduce serum Na slowly (not exceed 10 mmol/L/day) dramatic fall result in cerebral edema, seizures. - give total fluid in 48 72 hrs. - use NS 5% dextrose : for fluid replacement , continue until serum NA < 145 mmol/l. - then, use NA 5% dextrose @ 1/5 NA 5% dextrose - add KCl when child passes urine and review BUSE - monitor BUSE 6 hourly

a.

a.

Example: 10 month old child weighing 9kg is 5% dehydrated and not tolerating oral fluids. Serum sodium is above 150 mmol/l Fluid deficit = 5% of 9000g = 450 ml Maintenance at 120 ml/kg/24 h = 1080 ml/24 h To rehydrate over 48 hours, the rate of infusion should be 1/48 x (450 + 1080 + 1080) ml/hr = 54 ml/hour

II.

Hyponatraaemia (serum Na < 130 mmol/l) - give ORS - treat by isotonic fluid (NS / RL) but avoid overcorrection (> 135 mmol/L) or rapid correction (> 0.5 mmol/L/h) high risk of central pontine myelinolysis (CPM) - in symptomatic hyponatraemia dehydration : use hypertonic saline (eg. NaCl 3%) to increase the Na+ conc. rapidly - severe dehydration : NS + 5% Dextrose - mild dehydration : 1/5 NS + 5% Dextrose
* in 24 hrs

III. Hypokalaemia (serum K < 3 mmol/l) - give ORS @ food rich in K during diarrhoea and after it has stop

When to prescribe antibiotics

Most causes of the gastroenteritis are due to viral infections; antibiotic is not necessary Antibiotics are helpful only in children with bloody diarrhea, probable shigellosis and suspected cholera with severe dehydration

Example of antibiotic with respective organism

Organism Treatment

Salmonella typhi

Ampicillin, cefotaxime,trimethoprim

Other Salmonella

None; amoxicillin, ampicillin,cefotaxime,trimethoprim Trimethoprim,ampicillin

Shigella

Escherichia coli Toxigenic

None if endemic; trimethoprim, ciprofloxacin for Travelers diarrhea Trimethoprim, neomycin

Invasive / pathogenic

Campylobacter

No treatment for mild disease, erythromycin & azithromycin for diarrhea Tetracycline, trimethoprim

Vibrio cholera

Clostridium difficile

Oral vancomycin

Giardia lamblia

Quinacrine, furazolidone

Anti-diarrheal
Should not be given to young children with diarrhea or dysentry. Most of the time, diarrhea doesnt require treatment. It most often lasts only a couple of days whether treat it or not. However, medicine can help to feel better, especially if patient also have cramping. When diarrhea is a symptom of an infection caused by bacteria or parasites, antidiarrheal medicines can actually make the condition worse. This is because the medicine keeps body from getting rid of the bacteria or parasite that is causing the diarrhea.

Common anti diarrhea

Loperamide works by slowing down the speed of fluids moving through your intestines (bowels). Dont give loperamide to children 6 years of age Bismuth subsalicylate works by balancing the way fluid moves through intestines. It also reduces inflammation and keeps certain bacteria and viruses that cause diarrhea from growing in the stomach and intestines. People who are allergic to aspirin or other salicylate medicines should not take bismuth subsalicylate. Dont give bismuth subsalicylate to children 12 years of age or younger.

Anti-emetics
Prochlorperazine, promethazine, and metoclopramide have a high incidence of side effects and should be avoided in patients less than 2 years old and used with extreme caution in children older than 2 years.In limited studies, ondansetron when used as a single dose has shown to be safe in children with acute gastroenteritis. Oral ondansetron could be a consideration for children with AGE who fail ORT to prevent the need for intravenous fluid (IVF), or as an adjunct to IVF to help facilitate ORT and prevent admission.

are live microorganisms that may confer a health benefit on the host. The rationale for using probiotics is based on the assumption that they modify the composition of colonic microflora and counteract enteric pathogens. However, there are two main views as to how probiotics counteract diarrhea. According to one theory, probiotics act locally (at intestinal level). According to the other theory, probiotics act by modulating the immune response. At local level, probiotics: compete with pathogens for nutrients and receptors induce hydrolysis of toxins and receptors induce production of antimicrobial substances (including peptides of the innate immune system)

Probiotics

Probiotics
Lactobacillus containing compounds are not recommended in the treatment of acute diarrhoea in children. Based on limited scientific evidence, efficacy has not been shown, although toxic effects are not a concern.

Diosmectite
Diosmectite (Brand names Smecta, Smecdral): natural silicate of aluminium and magnesium us ed as an intestinal adsorbent in the treatment of several gastrointestinal diseases. It is insoluble in water. Diosmectite is able to absorbing excess water from intestinal tract.

 However anti-diarrhoeal drugs and antiemetics should not be given to young children because it does not prevent dehydration and some have dangerous, sometimes fatal side effects.

Zinc supplements
It has been shown that zinc supplements during an episode of diarrhoea reduce the duration and severity of the episode and lower the incidence of diarrhoea in the following 2-3months. WHO recommends zinc supplements as soon as possible after diarrhoea has started. Dose up to 6 months of age is 10 mg/day, and age 6 months and above 20mg/day, for 10-14 days.

PRINCIPLES OF FLUID REPLACEMENT

VOLUME REQUIRED = MAINTENANCE + DEFICIT + ONGOING LOSSES

? Calculate 24-Hour Maintenance Fluid

Body Weight (Kg) Volume Per Day

0-10 11-20

100 mL/kg 1000 mL + 50 mL/kg for each 1 kg > 10kg

20

1500 mL + 20 mL/kg for each 1 kg > 20 kg

? Calculate Fluid Deficit % Dehydration X Patients Weight X 1000 mL ? Correction Of Ongoing Losses

Usually not a problem and correction is often not necessary. Correction is mandatory in patients with profuse watery stools, ( i.e cholera) ; or in the following situations : continuous nasogastric drainage, ileostomy, etc.

TYPES OF DEHYDRATION Can be classified according to serum sodium concentration

HYPONATRAEMIC < 130 mmol/L ISONATRAEMIC = 130 150 mmol/ L HYPERNATRAEMIC > 150 mmol/L

? Correct Isonatraemic Dehydration

18 months old girl Weight on admission = 10kg Dehydration estimated on admission = 10 % Initial serum Na+ = 142 mmol/L Rapid Phase (Resuscitation) 20ml/kg bolus NS over 1 hour 20ml X 10 kg = 200 ml over 1 hour

Replacement Volume required = maintenance + deficit + ongoing losses = 1000 ml + 1000ml = 2000ml Maintenance = 10 kg X 100 ml/kg = 1000ml Deficit = 10/100 X 10kg X 1000ml = 1000ml On going losses not included
2000ml 200ml(resuscitation) = 1800 ml 78 ml/hour X 23 hours

? Correct Hyponatraemic Dehydration

Sodium deficit (mmol) = (140mmol/L - patients serum Na level x 0.6 x body weight kg) 140 mmol/L = desired Na+ level 0.6 = proportion of body weight for distribution of sodium EX : Child 15 kg, Na+ level = 120 mmol/L Sodium deficit = (140-120)mmol/L X 0.6 X 15kg = 180 mmol/L Correction = Deficit above (180 mmol/L) + daily maintenance Asymptomatic Hyponatraemic dehydration = treatment is similar to isonatraemic dehydration. In symptomatic hyponatraemia, use hypertonic saline ( e.g NACL 3%) to increase serum sodium by 0.5 mmol/L per hour (RAPID CORRECTION POTENTIALLY DANGEROUS. RECOMMENDED RATE OF CORRECTION APP 1-2 mmol/L )

Hypernatremic dehydration
1yr old (10kg) female child presented with fever since 4 days ago. It is associated with vomiting and diarrhea more than 7 times per day On examination, patient appear Lethargic, cold, weak rapid pulse, low BP, sunken eyes, dry eyes, parched mucous membranes, capillary refill 5 sec, marked tenting of skin Na = 175, K+ = 3.2, HC03 = 20

 Feature of patient with hypernatremic dehydration: Skin has a characteristic doughy feel Anterior fontanelle may not be sunken Late sign of shock #Difficult to recognize clinically ( sign of dehydration less obvious water shift
from ICF to ECF

Management
The hypovolemic child requires fluid replacement and a slow correction of her fluid deficit over 48 to 72 hours. Any patient who has hypernatremia needs to be monitored for seizure activity. Generally, the serum sodium level should decrease at a rate no faster than 10 mmol/L/h, because rapid correction of hypernatremia can lead to fluid shifts from the ECF to the ICF and the development of cerebral edema and seizure Patients must be monitored for the signs and symptoms of cerebral edema throughout the course of their treatment

 Severe dehydration 1. Rapid phase (resuscitate) 20ml/kg bolus NS over 30-60 min 20x 10=200ml over 30-60 min 2. Replacement Total fluid needed= deficit+maintenance+loss deficit 15%x10x1000= 1500ml Maintenance 10kgx 1000ml/kg=1000ml # thus fluid needed in =maintenance+ deficit+loss =1000+ [1500-200] =2300ml of NS 5% Dextrose over 48-72 hour

ORS (Oral Rehydration Solution)

- First line therapy for mild to moderate diarrheal dehydration - less expensive than IV therapy with lower complication rate ( IV therapy may still be required for patient with severe dehydration ; patients with uncontrollable vomiting; patients unable to drink because of extreme fatigue, stupor, or coma; or patients with gastric or intestinal distention. )

ORS
Repletion phase Administer 50 mL/kg of ORS over 4 hours to patients with mild dehydration. Administer 100ml/kg of ORS over 4 hours to patient with moderate dehydration. Additional 10ml/kg ORS to replace ongoing loss from diarrhea / emesis. Reassess patient's hydration status Maintenance phase when rehydration is complete, maintenance therapy : 100 ml/kg in 24 hours until diarrhea stops. Feeding and fluids should be started.