Clinic Case- L. Rz-Mz.

CC: 9 month old male, diarrhea X3 days

(7-8 episodes per day), non-bloody, no
mucus
HPI/ROS: Afebrile, decreased PO solids
X2 days, taking liquids moderately
well, fewer diapers today, + tears,
slightly decreased activity, one
episode of emesis. No rash
PMH/PSH: Term infant, NSVD, born in
Utah, previously healthy, no
hospitalizations, no surgeries, no
regular medications
 Case- L.Rz-Mz. Cont.
 FH: (NIDDM, HTN) no immuno-deficiecies, no IBD,
celiac or malabsorption syndromes
– Cousin in Guatemala died from a diarrheal
illness at 6m of age
 SH: Lives w/ parents, maternal aunt and paternal
GM, 3 sibs (2, 5, 9: born in Guatemala)
– In basement apt. in West Valley, UT.
– Extended family lives upstairs.
– Family immigrated from Guatemala 1 year ago.
– 2 and 5y w/diarrhea.
– No travel or street food.
– Family drinks bottled water.
– Family income ~$200/wk.
– Medicaid insurance coverage only for patient,
none of other siblings covered
 Physical Exam
 V/S: T 37.0 HR 140 RR 48 BP 110/55 >98% RA
 General: Alert, quiet in mother’s arms, cries
with exam
 HEENT: +Tears, dry mucus membranes
 CV/Chest: Mild tachycardia+ intermittent
tachypnea, Capillary refill ~3 sec
 Abdomen: +Hyperactive BS, Diffuse mild
tenderness to deep palpation, no guarding or
peritoneal signs
 Skin: No rashes, no mottling, no skin tenting
 Diagnosis?

Degree of Dehydration?
 La madre’s
preoccupationes/preguntas
 “Va mi bebé a morir ?”
 If he needs treatment, how can I
get my uninsured children
treatment?
 Is it possible for me to treat them
all at home?
 L. Rz-Mz.’s diagnosis
 1. Acute Gastro-enteritis
 2. Moderate dehydration
 3. Management: How would you
manage L. Rz-Mz’s case?
– Further work-up?
– Approach to mother’s concerns
 4. Treatment Options
 Expanded Work-up ??
 Estimate fluid deficit based on hydration status
– Weight (kg) X (% dehydration) = __x1000 = __ mL for
resuscitation
 Electrolytes (markers of deyhdration: HCO3
(low/N), hypernatremia (high/N), BUN (high/N),
Potassium (low/N)
 Stool studies (based on clinical history)
– Viruses: Rota, adenovirus
– Stool for culture
– Stool for C. Difficle A/B toxins
– Ova and Parasites (only accepted by lab if +travel
history)
– Stool electrolytes
 Other (KUB, UA/Urine Cx, Celiac disease, endocrine studies,
toxicology screen, CA wk-up)
 Advocacy Morning Report

A Culturally Sensitive Approach to Diarrhea

Associated Mild-Moderate Dehydration

Lindsay Hatzenbuehler MD
MPH
October 16, 2009
 Presentation Outline
 Introduction (*Recognition of
disease burden)
 Parent perceptions of illness
(*Parent advocacy)
 Evidence Based Medicine:
Indications for current
management (*RCT)
 Management Recommendations
 Introduction: Diarrheal Disease
Burden
 U.S.
– Each child <5 y has 1.2-2.7 episodes of diarrhea/yr
– 3 million outpatient visits
 $1 billion in healthcare costs
– 1.4% are hospitalized
 Accounts for 10.6% of hospitalizations
 Resulting in >200,000 hospitalizations/yr
– 300 <5yr die from diarrhea associated illness
 Averages to <0.0001% of deaths in this age group
 Risk factors: prematurity, infancy, African-American
race, living in the Southern USA, living in metropolitan
areas
 Disease Burden cont.
 Internationally:
– 99 million DALYs lost due to diarrhea associated
morbidity & premature deaths in <5y
– <5y diarrhea associated mortality
 1975 4.5 million deaths/yr
 2002 1.6 million deaths/yr*
– Accounts for 16-18% of deaths from all causes
– 80% die <2yrs of life
– 42,000/wk, 6,000/d, 4/minute, 1/14sec

– Risk factors: Poor sanitation*, malnutrition*, lack

of access to health care/resuscitative measures*
 Intl’ Disease Burden cont.
 Guatemala
– <5 MR 45/1000 live births
– <5y diarrhea associated mortality 13% of deaths from
all causes
– 6th cause of death in all ages
 Mexico
– <5 MR 28/1000 live births
– <5y diarrhea associated mortality 5% of deaths from all
causes
– Not included in top ten all cause deaths
 Back to L. Rz-Mz.’s Case
 1. Acute Gastro-enteritis
 2. Moderate dehydration
 3. Expanded Work-up?
 4. Approach to mother’s concern
 5. Treatment options
 Approach to Mother’s
Concerns
 Try to understand the source of her questions
– Immigrant population
 Western Medicine is viewed as foreign
 Medical care usually NOT as accessible
 Home remedies (herbal/home preparations) are often used first
– International MR from diarrhea associated causes are much
higher than in the U.S. ~18% Intl’, 13% Guatemala
 Are her questions legitimate concerns?
– “Va mi bebé a morir ?”
– If he needs treatment, how can I get my uninsured
children treatment?
– Is it possible for me to treat them all at home?
Diarrheal Associated Dehydration:
Parent Perceptions
 “Theimpact of rotavirus
gastroenteritis on the family.”
– Mast TC, DeMuro-Mercon C,Lelly CM,
Floyd LE, Walter EB. BMC Pediatrics. Feb
2009, 9:11

– Duke Clinical Research Institute

– Protocol by Merck Research Laboratories
 Design: Observational study (qualitative)
case-control frequency statistics
comparison, in 2006 pre-RotaTeq
 Study subjects: English literate parents
and children (n=62) 2-36 months with
acute GE < 3 days prior, Feb-March, ED +
outpt. Clinics
 Methods: GE severity scored* (mild,
moderate, severe), Stool samples tested
for Rota, parent interviews
 Results: Stool collected n=43/62
– 27/43 = 63% were R+
 ED visit 100% > Outpt 53% p =0.03
 No difference in age in R+ vs. R-
 At enrollment, R+ GE scores 10.64 > 7.25 p
=0.0016
– R+ 92% vs. R- 38% moderate/severe illness
 Parent interviews only of R+ pt n = 17
– On illness severity, transmission, emotions,
schedule disruption, seeking medical care,
economic impact and Rota vaccine
development
 Parent responses
 Illness severity:
– …we were…concerned…he had only one wet diaper in
that whole 24 hr period and couldn’t keep ice chips
down
– …After church… I fed him lunch, and he threw up from
then until Wednesday. …He got so dehydrated we had
to bring him to the ER.
 Emotions:
– I was horrified…I know when the kidneys shut down.
That was my main concern; he wasn’t drinking
anything, eating anything.
– My husband was scared. He said you got to take her to
the doctor now.
– Very very anxious because he was so lethargic…it was
very scary as a parent
 Major Study
 Diarrheal
Conclusions
illness substantially impacts
family life
 Parents sought health care due to
concerns for severe disease/dehydration
 Rotavirus vaccination supported
 Recommendations:
– health care providers should provide
support and education of parents
– “Families should be encouraged to have a
supply of ORS at all times…and to start
therapy as soon as the diarrhea begins”
 Back to L. Rz-Mz.’s Case
 1. Acute Gastro-enteritis
 2. Moderate dehydration
 3. Expanded Work-up?
 4. Approach to mother’s concern
 5. Treatment options
– If he needs treatment, how can I get my
uninsured children treatment?
– Is it possible for me to treat them all at home?
 Management of Mild/Moderate
Diarrhea Associated Dehydration
 AAP Practice Parameter: The Management
of Acute Gastroenteritis in Young Children
(Ages 1m-5y) (Pediatrics March 1996).
– Children w/o dehydration can be fed normally
– ORT is preferred in children with mild to
moderate dehydration
 Most dehydrated children will not refuse ORT
 Start slowly + Check hydration status q2 hrs
– Children should be fed as soon as hydrated
– Pharmacologic agents should not be used to
treat acute gastroenteritis
 CDC Recommendations
 “The management of acute diarrhea
in children: oral rehydration,
maitenence, and nutritional
therapy.” MMWR. 1992;41 1-20.
 “…families with…small children…
should be encouraged to keep a
supply or ORS…all times
[to]use...when diarrhea first occurs.”
 ORAL
Treatment
Options:
 C-ORS vs. WHO-ORS
 “TheWorld Health Organization Oral
Rehydration in US Pediatric Practice:
A Randomized Trial to Evaluate
Parent Satisfaction.”
– Ladinsky M, Duggan A, Santosham S,
Wilson M. Arch Ped Adolesc Med. Vol
154. Jul 2000.
C-ORS Vs. WHO-ORS
 Background: US practitioners rarely use WHO-ORS as an
inexpensive alternative to C-ORS due to concerns about
parent satisfaction.
– C-ORS ($6/L Pedialyte), WHO-ORS packets ($0.55/L)
 Equal Osmolality, WHO >NaCl, <glucose, <less citrate
 WHO-ORS group allowed to add crystal light/unsweetened
Kool-Aid
– Few Medicaid and commercial insurance plans cover C-ORS
Objective: Compare caretaker satisfaction of prepared C-ORS
with WHO-ORS packet based solution
Design: RCT, 3-47m outpt management of diarrhea (<7d)
randomized to 2 groups, phone interview f/u 48 hrs
Results: 97 families randomized* (primarily
low-middle income in govt. assistance
program) -(94%) participated in f/u
interviews
 Study Conclusions
 Caregivers who prepared WHO-ORS were
more satisfied than C-ORS group
– Absolute difference 36%*
 Fear of parental dissatisfaction need not be a
barrier to use of WHO-ORS in the U.S.
 Lower cost products can be purchased by
outpatient providers and dispensed to families
at time of treatment
– “They could also be provided at health
maintenance visits to be kept at home for use in
time of need.”
 Homemade C-BORS vs.
Packet C-BORS vs. C-ORS
 “Safetyand Effectiveness of
Homemade and Reconstituted
Packet Cereal-based ORS: A
Randomized Clinical Trial.” Meyers
et al.
– Pediatrics. Vol 100;5. Nov 1997
 Studypopulation: 232 children
randomized to 3 treatment arms
– homemade CBORS (n=66)
– packet CBORS (n=68)
– Pedialyte (n=69)
 Instructions given in specific
language, F/U visits by home nurses,
serum sodium values measured,
rates of illness compared
 Study Results
 203/232 (88%) completed the study
– 76% Latino American
– 84% participated in WIC
 Two parents in homemade 2/66 (0.03%),
and one parent in packet group 1/68
(0.014%) made mixing errors
– Resulted in high sodium >100meq/L cereal
– Children REFUSED the cereal
– All the children had normal serum sodium values
 No difference in diarrhea, vomiting, or rate
of hospitalization between groups
 Study Conclusions
 The lack of difference in outcomes may be due to
mild illness in overall study group
 “homemade CBORS is not the safest alternative
[due to potential]…mixing errors…[but] packet
CBORS was diluted correctly…which can also occur
with a commercial solution”
 A pre-packaged solution may represent the best
way to ensure that families have ORS at home
– could be distributed readily at primary care facilities
– cost may need to be subsidized
 International Studies
 Use of homemade ORS solutions/WHO packets have shown success
– “A Randomized Community Trial of Prepackaged and Homemade Oral
Rehydration Solutions.” Kassaye et al. Arch Ped Adol Med. Vol 148.
1288-1292. Dec 1994. (ETHIOPIA)
– “A Quantitative assessment of the Nigerian mother’s ability to prepare
salt-sugar solution for home management of diarrhea.” J Royal Soc
Health. 1994; 108: 55-59.
– “Safety of rapid intravenous rehydration and comparative efficacy of 3
oral rehydration solutions in the treatment of severely malnourished
children with dehydrating cholera.” Alam et al. J Pediatr Gastroenterol
Nutr. 2009 Mar;48(3):318-27 (BANGLADESH)
– “Oral zinc for treating diarrhoea in children” Cochrane Database of
Systematic Reviews. 16 July 2008
 Treatment for Mild-Moderate
Dehydration Secondary to
Diarrhea
 Continue breastfeeding
 Encourage PO fluid intake with a
recommended “Rehydration solution” in
small quantities
 Commercially available-ORS
– Pre-made: Pedialyte
– Packets: Ceralyte, WHO packets
 Consider buying for practice distribution
 If you trust the family: teach preparation of
a homemade ORS solution
 Advise parents to watch for further
dehydration symptoms
Home Recipes
rehydrate.org
 Take Home Points: Clinical
application
 Diarrhea is VERY common in infants and
children (especially Internationally)
 Dehydration is often associated with
diarrhea and can lead to death
 Children should be watched carefully
 Severe diarrhea causes parents great stress
– PCPs should sympathize with parents, especially
immigrants
 Take Home Points
Continued
 PCPs should recommend that parents with
infants and children should have ORS available
at home
 Pedialyte is NOT the only option
– Expensive and is often not covered by Medicaid
 Other options:
– WHO-ORS packet promotion (cheap option for
pediatric practices to distribute)
 Call Jianas Brothers (Kansas City, MO) 816-421-2880
– 1 carton (125 packets) $68.75
– Recipe hand outs (for trustworthy parents)
 References
 “A Randomized Community Trial of Prepackaged and Homemade Oral
Rehydration Solutions.” Kassaye et al. Arch Ped Adol Med. Vol 148. 1288-
1292. Dec 1994. (ETHIOPIA)
 “ Safety of rapid intravenous rehydration and comparative efficacy of 3 oral
rehydration solutions in the treatment of severely malnourished children
with dehydrating cholera.” Alam et al. J Pediatr Gastroenterol Nutr. 2009
Mar;48(3):318-27 (BANGLADESH)
 “Oral zinc for treating diarrhoea in children” Cochrane Database of
Systematic Reviews. 16 July 2008
 “The impact of rotavirus gastroenteritis on the family” Mast TC, DeMuro-
Mercon C,Lelly CM, Floyd LE, Walter E BMC Pediatrics. 2009, 9:11
 AAP Practice Parameter: The Management of Acute Gastroenteritis in Young Children
(Ages 1m-5y) (Pediatrics March 1996).
 “The World Health Organization Oral Rehydration in US Pediatric Practice: A
Randomized Trial to Evaluate Parent Satisfaction.”
 “Saftey and Effectiveness of Homemade and Reconstituted Packet Cereal-
based ORS: A Randomized Clinical Trial. Meyers et al. Pediatrics. Vol 100;5.
Nov 1997
 Ladinsky M, Duggan A, Santosham S, Wilson M. Arch Ped Adolesc Med. Vol
154. Jul 2000.
 http://rehydrate.org/solutions/homemade.htm
 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm
 http://search.ebscohost.com/login.aspx?
direct=true&db=chh&AN=CD005436&site=ehost-live