Understanding

Poor Growth and Gastroenteritis

Tuesday, 12 September 2017 5:09 pm

Poor growth = replacing previous term 'failure to thrive'

Influences on growth
Nutrition
Absorption of food
Metab of food - Fat, Protein, and CHO
Energy utilization & chronic disease
E.g. sepsis or malignant disease = greater energy need + caloridic
content but loss of appetite = rapid, significant weight loss
Hormones - GH, steroids, thyroid hormones, insulin (promotes weight gain)
Outputs - e.g. diarrhoea
Genetics

Carbs and diet

Simple vs complex carbs, and role of Amylase/Glycaemic index
Simple carbs - rapid absorption = rapid inc. in glucose whereas
complex carbs take several hours to digest
Lactose v glucose absorption
Energy value of 4Cals/gm
A 'portion' of carbohydrate, i.e. 15gms:
= a slice of bread, one WeetBix
A normal diet will have approx. 12-15 portions of carbs/day (3-4 per
meal and 2 for a snack)
Normal diet consists of 40-50% carbs

Fats and diet

Most fats are long chain TAGs
Digestion:
Lipase from tongue and pancreas: turn triglyceride --> monoglyceride
Bile salts from GB and liver turn monoglycerides into micelles
Micelles are transported via betalipoprotein in small intestinal mucosa
and turned into VLDLs --> then absorbed via lymphatics
Therefore: fat malabsorption can be due to pancreatic, hepatic and small
intestinal mucosal reasons
DDx: for steatorrhea: pancreatic (e.g. chronic pancreatitis), hepatic or small
intestinal mucosal dysfunction or betalipoprotein deficiency

Fats
- Energy dense and contain 8Kcal/g
 intestinal mucosal reasons
DDx: for steatorrhea: pancreatic (e.g. chronic pancreatitis), hepatic or small
intestinal mucosal dysfunction or betalipoprotein deficiency

Fats
- Energy dense and contain 8Kcal/g
- Most balanced diets have approx. 30-40% calories from fat, or about
50-80gm fat/fay
- Full cream milk - ~65Cals/100mls, Light milk ~57 Cals/100mls and Skim milk
is 44Cals/100mls
21 Cal deficit; need to replace 500mls of full cream milk with skim milk
to save the calories in one slice bread

Protein
- ~4Cal/g
- Many amino acids are essential
- Normal diet should be 15-20% protein = 80gms protein/day
- 1 egg =~7gms protein

Breast feeding benefits:

More fat and CHO than formula - hence about 10% more calorie dense &
why breast-fed infants grow more quickly
Lower protein & may lower/defer incidence allergies in childhood
Larger protein in cow's milk which is difficult to digest before 12 mo
Contain:
Omega-3 fats help with CNS development --> may enhance IQ
IgA antibiotics that help infants recover from gastroenteritis and respiratory
infections
Stimulates bonding (via oxytocin release) and helps mothers return to pre-
pregnancy weight
Free, & hygienic --> important in communities without safe water supply
Formula without clean water = inc likelihood of gastro

Infant feeding:
- Introduction of solids by 6mo, should ideally start by 4mo
- Food family eats from 12 mo, inc no cow's milk until 12 mo
- Maximum 500ml/day cow's milk at any age

Poor growth = Failure to thrive

Poor weight gain
D: <3rd centile, or crossing two percentile chart lines
Causes:
Organic causes Non organic causes
Malabsorption: celiac disease, CMPI, Not provided with
chronic gastroenteritis sufficient food -->
 D: <3rd centile, or crossing two percentile chart lines
Causes:
Organic causes Non organic causes
Malabsorption: celiac disease, CMPI, Not provided with
chronic gastroenteritis sufficient food -->
Increased energy use: chronic malnourished
infection, cardiac failure, chronic lung
disease
Reduced hormones: GH, thyroid
hormone
Genetic causes
Cerebral palsy/neurological: unable to
swallow --> poor feeding

Detection of poor growth

Weight centile low relative to length and HC centile
Crossing centiles, e.g. previously between 25th and 50th to below 10th
Appear physically malnourished: poor fat and muscle stores, loose skin folds
in groin and axilla
Low/high centiles not necessarily abnormal - school photo position analogy

Inadequate calorie intake

Aetiology of poor growth
Organic
Non-organic
Mixed - e.g. a neurologically compromised child; feeds for long
periods of time but does not take in enough calories due to poor
suckling. Absorbs food normally, but doesn't get enough
Parents usually give up feeding 8-10mins without positive
feedback it's working
Early socialization revolves around feeding --> later
developmental effects
Parental ability - neglect

Gastrointestinal disease
Acute v chronic diarrhoea (chronic = more than 4 loose motions /day
for >2wks)
Infectious diarrhoea
Commonest worldwide cause of morbidity and mortality <5years age
Villous atrophy/partial villous atrophy:
Celiac disease
CMPI (cow's milk protein intolerance)
Giardia
Rare causes
 Villous atrophy/partial villous atrophy:
Celiac disease
CMPI (cow's milk protein intolerance)
Giardia
Rare causes

Celiac disease:
- Wheat/gluten intolerance
- Cause subtotal villous atrophy
- Normal growth pattern whilst child is still breast fed; but at 6 mo when
breads and cereals introduced to diet - may suddenly present with FTT
- Iron deficiency unresponsive to supplemental iron, celiac serology and
abnormal small intestinal mucosa
- A lifelong condition

Prevalence of gastroenteritis
Worldwide: 5-8mill deaths in children <5y
Aus: approx. 8% (20 000 children) of admissions of children <5yo due to
gastroenteritis; triple (60 000) present to ED and 10x to GP
1/5 present to GP for assessment of dehydration
Rotavirus vaccinations have changed paediatric landscape; prior to their
introduction 50% hospital admissions were mod/severe gastroenteritis due
to Rotavirus
Handful children die from GE every year; minimal numbers compared to
developing countries due to rarity of malnutrition in Aus

Need for accurate history! --> no specific physical signs for GE

When did Sx start?
Vomiting? Projectile, bile stained, blood stained?
Pain with vomiting? Able to sleep? Abdo pain present?
How many vomits?
Diarrhoea? Color, frequency, consistency?
Intake? Volume - quantify it + time
Urine output - how many wet nappies?
Systemic review: inc. fever, photophobia, irritability, tachycardia, alertness
n/b: Need to rule out red flags via Hx and Ix, e.g. surgical causes like
appendicitis

Dehydration:
Mild Moderate Severe
<5% dehydrated 5-10% 10% +
Increased thirst dehydrated Moderate signs + hypotension
Few clinical signs Sunken eyes Poor peripheral perfusion
+/- loss of skin turgor, loss Definite loss (capillary refill >2sec)
of tears when crying, dry of skin turgor No urine output
mucous membranes Tachycardia
 <5% dehydrated 5-10% 10% +
Increased thirst dehydrated Moderate signs + hypotension
Few clinical signs Sunken eyes Poor peripheral perfusion
+/- loss of skin turgor, loss Definite loss (capillary refill >2sec)
of tears when crying, dry of skin turgor No urine output
mucous membranes Tachycardia
Reduced
urine output

DDx:
Causes of SBI:
UTI
Bacteremia
Pneumonia
Meningitis
Acute surgical causes:
Appendicitis
Intussception
Acute obstruction
Torsion of testis
Inguinal hernia
Reflux
Pyloric stenosis

Vomiting and Diarrhoea:

Very non-specific factors on history
GE is diagnosis of exclusion
Exclude other DDx of basis of history and physical examination
An acute GE will present with normal physical examination, apart from the
presence of dehydration
Ix:
Stool:
PCR
Detect common viral pathogens:
Rotavirus, Norovirus, Adenovirus
Direct immunoflourescence can be used to see the virus
MCS
Detect bacterial pathogens:
Salmonella, Shigella, Campylobacter, Giardia (protozoa)
Other tests:
Urine culture
FBC, blood culture
 MCS
Detect bacterial pathogens:
Salmonella, Shigella, Campylobacter, Giardia (protozoa)
Other tests:
Urine culture
FBC, blood culture
U/E/Cr
LP - if suspecting meningitis
Stool PCR + MCS
Abdo Xray and USS

Rotavirus:
Responsible for 50% of admissions for GE
pre-vaccination (2007 in Aus) --> now <10%
admissions
33% of patients have very high fevers of
39o C
dsRNA virus
Have differing G serotypes
Illness lasts 3-7d
Can be infected several times in your life
40% after initial infection have full
immunity
88% of subsequent infections have only
mild diarrhoea
Clinically significant Rotavirus occurs mainly
in 3-36month age group
Peak incidence is mid-late winter

Norovirus (Norwalk)
A RNA virus
Responsible for more than 50% of non-
bacterial GE
Usually milder illness than Rotavirus
Lasts 1-2d
Spread by fecal-oral route
Adenovirus:
DNA virus
Causes both resp and gastro symptoms
More than 50 different serotypes of adenovirus,
making development of vaccine difficult

Fluid rehydration: IV vs Oral

Oral works faster than IV
In mild-mod, @2hrs, better rehydrated on oral
25% of IV resited as opposed to 5%NG tubes
Cochrane review (2006): For every 25 children treated with NG fluids, one
would fail and need IV fluids

Home oral rehydration solutions:

Gastrolyte contents:
60 mmol/litre of Sodium(Osmolarity is 220)
2.1% dextrose or if it is gastrolyte R the carbohydrate is rice based
ORS that WHO used has 90 mmol and Osmolarity is 311, thought to
be better for malnourished populations but this is debatable
Flat (homemade) lemonade:
Lemonade is 15% dextrose(55 grams in 375mls!)
Flat lemonade is 1 part lemonade+4 parts water
Same for apple juice-need to dilute it and make it up like cordial,
High dextrose concentration, if undiluted, will cause an osmotic
diarrhoea and may worsen dehydration in gastroenteritis

Prevention of GE:
1. Clean drinking water
2. Hand hygiene
3. Breast feeding

Rotavirus immunization:
Prevention of GE:
1. Clean drinking water
2. Hand hygiene
3. Breast feeding

Rotavirus immunization:
Rotarix -live vaccine given orally, can be given as a 2 dose(1 ml) schedule at
2 and 4 months
Rotateq - live vaccine given orally, is 3 x 2mls given at 2,4 & 6 months
Will prevent about 70% of infections and about 85-100% of admissions to
hospital
Saves 10,000 paediatric admissions per year in Australia-approx 300
admissions to Gold Coast Hospital
The vaccine costs the community $12.5 million per year
An average public hospital admission costs $ 4,500 (2009/2010 data)-
Probably $6,000 in 2017
Minimum savings of $30 million to community in hospital costs alone- add
child care, work days lost-way in front immunising!
80% reduction in Rotavirus admissions between 2005 and 2009
90% reduction in Rotavirus nosocomial infections between 2005 and 2009

Precautions' to using vaccine:

Acute Gastroenteritis
Moderate-severe Illness
Immune-compromised host or household member
Recent administration of blood or antibody products

? Associations of vaccine use:

RotaShield vaccine was used in the USA in 1998/1999
Estimated risk was an extra 6 intussusceptions a year for Australian
population( Estimated 200 cases per year might increase to 206)
Research on Rotarix or Rotateq vaccines indicated that there has been no
association with intussusception incidence since vaccine introduction