ROTAVIRUS INFECTION
Aim: To know diagnostic criteria of rotavirus infection in children, how to examine the child with Rotavirus infection and prove the diagnosis, differentiate, give the individual treatment and prophylaxis.
Professional motivation: rotavirus infection is the main cause of viral gastroenteritis in infants. This infection is widely spread all over the world. Secretory diarrhea leads to moderate or severe dehydration that needs to perform differentiation of rotavirus infection between cholera, enterotoxigenic escherichiosis, and other secretory diarrheas. That's why, knowledge of Rotavirus infection diagnostic criteria, treatment and prophylaxis is very actual.
Basic Level:
1. To know how to ask complaints, disease history and life history in children (propedeutic
Pediatrics).
2. To perform clinical examination of the child (propedeutic Pediatrics).
3. To know microbiology, pathophysiology, and pathomorphology of Rotavirus infection (microbiology, pathophysiology, pathomorphology).
4. To diagnose Rotavirus infection after clinical and laboratory examination of the child (infectious diseases, Propedeutic Pediatrics, microbiology, pathophysiology).
5. To give etiologic, pathogenetic, and symptomatic treatment (pharmacology).
Students' Independent Study Program
Objectives for students' independent studies
You should prepare for practical class using existing text books and lectures, special attention should be paid to the following:
1. Etiology, epidemiology, pathogenesis, pathomorphology of Rotavirus infection.
2. Classification of Rotavirus infection.
3. Main diagnostic criteria of Rotavirus infection.
4. Differential diagnosis of Rotavirus infection.
5. Rotavirus infection treatment and prophylaxis.
Rotavirus infection is an acute contagious disease of people and animals that is caused by Rotavirus, is transmitted by a fecal-oral mechanism, and is characterized by the damage of gastro-intestinal tract (as gastroenteritis).
Etiology: an agent is Rotavirus from Rheoviridae.
Epidemiology:
• the source of infection is a patient or a yirus carrier;
• the mechanism of transmission is fecal-oral (through the infected water, food,
direct contact);
• receptivity is high in case of decreased immunity. Pathogenesis
1. Virus invasion to the thin intestine epithelial cells (enterocytes).
2. Replication of virus and destruction of enterocytes.
3. Increased growth of immature cells.
4. Enzyme deficiency.
5. Violation of digestion and absorbtion, accumulation of disaccharides.
6. Overabundance of liquid and electrolytes in the intestine.
7. Diarrhea. Diagnostic criteria
1. Latent period is 1-4 days.
2. DVF-syndrome (diarrhea, vomiting, fever):
• Diarrhea (gastroenteritis, enterocolitis) during 3-6 days stools are "sprinkling",
colorless, watery;
• Vomiting (precedes or appears together with diarrhea) during 1-3 days;
• Fever (moderate) - 2-4 days.
Features of Rotavirus infection in new-borns
• Often is hospital infection.
• Acute beginning with the refuse of breast feeding, vomiting, diarrhea, development of the severe dehydration.
• Possible gradual beginning with increase of dehydration severity.
Often is lethal.
Confirmation of diagnosis
• 
Complete blood analysis: normal.
• Biochemical blood test: increased, normal or decreased concentration of electrolytes.
• Virology by immune-electronic microscopy, 1EA, diffuse precipitation in a gel.
• Serology - NR, CBR, DHAR.
• In koprogram - lymphocytes, impaired enzyme intestinal function.
Diagnosis example:
Rotavirus infection typical form, severe degree. Hypotonic dehydration, 2nd degree. A differential diagnosis is performed with cholera, salmonellosis, enterotoxigenic escherichiosis; acute intestinal infections caused by relative pathogenic bacteria.
Treatment
Therapy of an acute intestinal infection for children has 4 constituents: diet, rehydration therapy, antibacterial therapy and auxiliary therapy (enterosorption, probiotics).
1. Rehydration therapy
Timely and adequate rehydration therapy is a near-term and most essential link in treatment of an acute intestinal infection, both secretory and invasive. Early application of adequate rehydration therapy is the main condition of rapid and successful treatment. Rehydration therapy is done according the severity of child's dehydration (Table 1).
Table 1
Clinical signs of dehydration severity (present 2 or more from the noted signs)
Sign | Mild (1st degree) | Moderate (2nd degree) | Severe (3rd degree) | |
Loss of body weight | Children aged before 3 yrs | 3-5 % | 6-9 % | 10 % and more |
Children aged 3-14 years | <3% | 3-6 % | 6-9 % | |
General condition | Disturbance | Disturbance or somnolence | Languor, somnolence | |
Thirst | Drinks voraciously | Drinks voraciously | Does not drink | |
Anterior fontanel | Not changed | Slightly sunken | Sunken | |
Eyeballs | Not changed | Soft | Sunken expressively | |
Mucus membranes of the mouth | Moist | Slightly dry | Dry | |
Skin fold | Disappears at once | Disappears slowly | It can disappear slowly (> 2 sec.) or does not disappear at all | |
Arterial pressure | Normal | Hypotonia | Severe hypotonia | |
Urination | Normal | Decreased | Considerably decreased to 10 ml/kg day |
Oral rehydration (by mouth)
Oral rehydration is most effective, when is performed from the first hours of the disease. Oral rehydration must be the first aid at home when the disease begins. It doesn't have any contraindications.
In accordance with recommendations of WHO optimum composition of solutions for oral rehydration is:
sodium - 60 mmol/1;
potassium - 20 mmol/1; bicarbonates - 10 mmol/1;
glucose -110 mmol/1;
osmolarity is - 250 mosmol/1.
Content of sodium and potassium in solutions for oral rehydration must correspond their average losses at an acute intestinal infection. The concentration of glucose in them must help water resorption not only in an intestine but also in kidneys. Because high osmolarity it is not recommended to give fruit juices, sweet drinks (Coca-cola, and others like that) during the oral rehydration.
The method of oral rehydration have to start immediately, because dehydration begins after the first liquid, watery emptying, yet long before appearance of clinical signs of dehydration. Valuable rehydration therapy is performed in 2 stages.
The 1" stage is rehydration therapy which is carried out during 4-6 hours for proceeding of the lost fluid. During the mild dehydration - 30-50 ml/kg, at moderate degree - 60-100 ml/kg.
Table 2
A calculation of oral rehydration solutions volume
Body weight in kg | An amount of solution for 4-6 hours (ml) | |
mild dehydration | moderate dehydration | |
1 200 | ||
1 000 | 1 600 | |
1 250 | 2 000 |
Speed of fluid introduction through a mouth is 5 ml/kg/hour.
Criteria of the 1st stage efficiency: (are estimated in 4-6 hours)
• disappearance of thirst,
• improvement of the tissues turgor,
• moistening of mucus membranes,
• increase of diuresis,
• disappearance of microcirculation violation signs.
Choice of subsequent tactic:
1. if signs of dehydration have disappeared - continue the 2nd stage of rehydration therapy;
2. the signs of dehydration have diminished, but still are present - it is needed to continue to give solution through a mouth during the following 4-6 hours in a previous volume;
3. the signs of dehydration have increased - parenteral rehydration should be start.
The 2nd stage is supporting therapy, which is done depend the losses of fluid, which
proceed, with vomit and emptying.
Method of the 2 nd stage:
Supporting oral rehydration means that to the child for every following 6 hours is entered so many rehydration solution, as he has lost during previous 6 hours.
Oriented volume of solution for supporting rehydration for children before 2 yrs is 50-100 ml, children elder than 2 yrs - 100-200 ml or 10 ml/kg of solution after every emptying. On this stage oral rehydration solution is possible to alternate with fruit or vegetable sugar free decoctions, or tea, especially green. At vomiting rehydration therapy is continued after 10-minute pauses. In the hospital in case the child refuse to drink or at presence of vomiting tube rehydration should be done. Nasogastric tube rehydration can be done continuously with a help of the system for intravenous infusion, with maximal speed 10 ml/min.
Parenteral rehydration
At acute intestinal infections, which are accompanied by the 3rd stage of dehydration, with multiple vomiting, anorexia, waiver of drink, oral rehydration is combined with the parenteral rehydration.
Solutions for parenteral rehydration:
• Ringer's lactate,
• Ringer's acetate,
• Isotonic glucose solution,
• Isotonic sodium chloride solution.
To the children aged before 3 months is better not to use 0.9 % NaCl, so as it has relatively plenty of chlorine (154 mmol/1) and relatively high osmolarity (308 mosmol/1). Monotherapy by glucose solution is not effective. Composition and correlation of solutions depends from the type of dehydration.
To the children of early age it is necessary to eliminate solutions, which contain plenty of sodium, chlorine, glucose (solutions of Disol, Trisol, Quartasol, Acesol, Laktasol, Chlosol and others like that) because of possible hypernatremia and intracellular edema development.
At presence of some ions deficit in blood plasma (sodium, potassium, magnesium, calcium) or acid-base balance changes it is need to correct them.
To perform parenterally rehydration it is necessary to define:
• Daily requirement of fluid and electrolytes.
• Type and degree of dehydration.
• Level of fluid deficit.
• Current losses of fluid.
Principle of volume calculation for the infusion therapy:
Daily volume of fluid in case of dehydration consists of:
a) deficit of fluid before the treatment (a loss of body weight during the disease),
b) physiologic fluid's requirement,
c) current pathological losses.
a) For the calculation of physiologic fluid's requirements it is possible to recommend the method of Holiday Segar that is used the most widely in the world (Table 3).
b) The calculation of fluid's deficit depends on the degree of dehydration. It is determined by the clinical signs or weight lost %:
1 % of dehydration = 10 ml/kg
1 kg of weight loss = 1 liter
Consequently, at a 1st degree of dehydration (5 % weight loss) daily deficit of fluid is 50 ml/kg/day; at 2nd degree (10 % weight loss) - 100 ml/kg/day.
The expected volume of fluid is entered during a day.
The fluid is entered in peripheral veins during 4-8 hours, with repeating infusion if necessary in 12 hours. According to it a patient gets intravenously 1/6 of daily volume during 4 hours, or 1/3 - during 8 hours et cetera). A remained volume is entered through a mouth! Fluid's requirement per hour of the infusion is more physiologic: New-born:
1st day of life - 2 ml/kg/hour;
2nd day of life - 3 ml/kg/hour;
3 rd day of life - 4 ml/kg/hour;
Elder children:
weight up to 10 kg - 4 ml/kg/hour;
weight from 10 to 20 kg - 40 ml/hour + 2 ml for every kg over 10 kg;
weight more than 20 kg - 60 ml/hour + 1 ml on every kg over 20 kg
A calculation of salts requirements:
Special attention should be paid to the correction of sodium and potassium deficit, losses of which can be considerable. It is necessary to remember, that sodium a child will get with crystalloid solutions which are entered in certain correlations with glucose depending type and severity of dehydration. If laboratory control is not done, potassium is entered according the physiologic necessity (1 -2 mmol/kg/day). Maximal daily amount must not exceed 3-4 mmol/ kg/day. Medicine, mainlypotassium chloride, is entered intravenously droplet on 5 % glucose solution. Nowadays insulin adding to these solutions is not recommended. A concentration of potassium chloride in prepared solution must not exceed 0.3-0.5 % (maximally 6 ml 7.5 % KC1 on 100 ml of glucose). 1 ml of 7.5 % KC1 solution contains 1 mmol of K+. Before entering potassium it is necessary to restore urination, as anuria or severe oliguria is a contraindication for intravenous potassium infusion. Blood potassium in plasma as 6.5 mmol/1 is threatened for the life, in concentration 7 mmol/1 hemodialysis is needed.
Determination of salts deficit is based on laboratory information.
Acute intestinal infections in children mainly are accompanied by isotonic type of dehydration, that's why determination of blood electrolytes to all children with diarrhea is not necessary. Determination of Na+ and K+ is necessary at 3rd degree of dehydration and for children with 2nd degree of dehydration, in which general condition severity does not correspond the diarhea severity, anamnesis is complicated, a rapid effect from the rehydration therapy is absent.
A calculation of sodium and potassium deficit is done by the following formula:
Ion deficit = (normal ION concentration - patient's ION concentration) x M x C, where M is weight of the patient
C is a coefficient of intracellular fluid volume.
C = 0.3 - before 1 year
C = 0.2 - after 1 year and for adults.
Than it is necessary to define the amount of sodium and potassium in solutions which are entered, volume and correlations of which are already expected. A content of these ions in solutions which are often used, are represented in a table.
After the urgent intravenous rehydration it is necessary to check up the level of sodium and potassium in plasma.
Table 4
Content of ions in crystalloid solutions
Content of the ion in mmol/1 Osmolarity | ||||||
SOLUTION | Na+ | K+ | Cl- | Ca-H- | Acetate (bicarbonate) | mosmol/1 |
Physiological solution | - | - | - | |||
Ringer's solution | - | |||||
Ringer's lactate | 1,5 | 28 (bicarbonate) | ||||
4 % NaHC03 | - | - | - | 500 (bicarbonate) | ||
5 % dextrose solution on 0,45 % solution of NaCl | - | - | - | - |
Taking into account importance of magnesium ions for the child's organism, and also that the magnesium losses go parallell with potassium losses on the first stage of rehydration therapy a 25 % solution of magnesium is rotined in the dose of 0,5-0,75 mmol/kg (1 ml of solution = 1 mmol of magnesium).
In children with a severe malnutrition daily necessity in potassium and magnesium is enlarged (up to 3-4 mmol potassium and 0.4-0.6 mmol magnesium).
c) Current pathological losses are determined by weighing of dry and wet diapers, determining the amount of the vomit or with a help of calculations:
10 ml/kg/day on every degree of temperature over 37.0 °C;
20 ml/kg/day in case of vomiting;
20-40 ml/kg/day in case of intestinal paresis;
25-75 ml/kg/day in case of diarhea;
30 ml/kg/day for perspiration.
Control of correct rehydration therapy is frequency of pulse, frequency of breathing, dynamics of body weight and diuresis.
Rehydration therapy depending the type of dehydration
It is necessary to take into account the type of dehydration to choice solutions and their correlations for the rehydration therapy. There are 3 types of dehydration: isotonic, hypertonic (water deficient) and hypotonic (salt deficient) (Table 5).
An isotonic rehydration (Na 130-150 mmol/1) develops as a result of equal losses of salts and water; it is the most often type of dehydration in children with an acute intestinal infection. In the first days (in case of microcirculation maintenance) rehydration is performed / 5 % glucose solution in combination with 0.9 % sodium chloride or Ringer's lactate olution in correlation (2:1) with parallel correction of electrolytes.
Table 5
Signs of different forms of dehydration
Index | Isotonic type of dehydration | Hypotonic type of dehydration | Hypertonic type of dehydration |
Breathing | No peculiarities | Hypoventilation | Hyperventilation |
Blood pressure | Decreased or increased | Low | Remains normal for a long time |
Temperature of the body | Subfebrile | Normal, tendency to the hypothermia | Febrile |
Skin | Cold, dry, elasticity is decreased | Cold with a cyanotic tint, elasticity is decreased | Elasticity is stored, warm |
Nervous system | Malaise | Excitation, possible cramps | Disturbance, sleeplessness |
Diuresis | Diminished | Diminished | For long time it remains normal |
Specific gravity of urine | Norm or insignificantly encreased | Decreased to 1010 or low | Increased to 1035 and more |
Osmolality of plasma | Norm | Decreased | Increased |
A level of electrolytes in the blood | Normal | Low | Increased |
Next days of rehydration therapy glucose-saline solutions in a volume which provides the physiologic fluid's requirement of organism, remnant volume for the compensation of dehydration, current pathological losses, correction of plasma electrolytes are performed.
Hypertonic dehydration (Na > 150 mmol/1) develops as a result of fluid losses predominance above salts loses, inadequate rapid infusion of salts with small amount of water.
Rehydration therapy should be done by a 5 % glucose solution in combination with 0.9 % sodium chloride solution in correlation (3:1).
During the rehydration therapy for patients with hypertonic dehydration it is need to take into account daily sodium requirements (2-3 mmol/kg). Thus should be taken into account sodium in solutions for infusion.
If the level of sodium is 140-150 mmol/1, then amount of sodium should be decreased 2 times from physiology necessities, and at the increase of it more than 150 mmol/1 solutions which contain sodium are eliminated, except colloid ones.
It is necessary to investigate a potassium level and correct it if it is needed.
To prevent cerebral edema control of plasma osmolarity and body weight is needed. On this stage a speed of infusion is 15-20 drops per hour.
Hypotonic dehydration (Na < 130 mmol/1) develops as a result of salts losses predominance above fluid loses, excessive infusion of water with small amount of salts. It developes in case of intestinal infections which are accompanied by frequent vomiting, or during oral rehydration by solutions with small amount of salts.
Rehydration therapy is done by 5 % glucose solution in combination with 0.9 % sodium chloride in correlation (1:1).
If the level of sodium is less than 129 mmol/1 it is needed to correct it (calculate it by formula described before). During the correction of sodium hypertonic solutions are avoided. Their infusion can result in acute intracellular dehydration, first of all cerebral. Except this, anaphylactic reactions can develop. The correction of sodium is done by 0.9 % NaCl, Ringer's lactate.
If it is impossible to investigate blood electrolytes, glucose-saline solutions are infused in correlation 1:1.
By the WHO recommendations (if the fast rehydration is necessary in case of laboratory control absence) the volume and speed of 0.9 % NaCl, Ringer's lactate infusion on the first rehydration stage should be the following (Table 6):
Table 6
Speed of infusion during the rehydration therapy
Age of the child | Speed of infusion | Speed of infusion |
B efore 12 months | 30 ml/kg for the first 1 hour | 70 ml/kg for the next 5 hours |
Elder than 12 months | 30 ml/kg for the first 30 minutes | 70 ml/kg for the next 2.5 hours |
The condition of the child is checked up each 15-30 minutes to normal pulse filling on a radial artery. If the condition of child does not get better, speed of infusion should be increased. After that the condition of the child is estimated every hour (abdominal skin fold, consciousness, possibility to drink).
After all volume is entered the child's condition should be estimated again:
• if the signs of severe dehydration still present - repeat infusion again according the
table 6;
• if the child's condition gets better, but there are signs of moderate dehydration -
continue oral rehydration according the table 2. If a child is breast fed, it is recommended to continue feeding; numbers of feeding should be increased;
• if signs of dehydration are absent, then the duration of feeding should be increased. At the same time at presence of diarrhea for supporting rehydration 50-100 ml of oral rehydration solution is given to the children aged before 2 yrs, 100-200 ml to the children elder than 2 yrs or 10 ml/kg additionally after every emptying (up to 1/3 expected volume for oral rehydration). Children on the artificial feeding are fed by the same chart, by lactose free formulas.
Monitoring of children with a severe malnutrition and dehydration during the rehydration therapy should be done each 30 minutes during the first 2 hours, and then every hour next 4-10 hours. At signs of hyperhydratation (increase of pulse frequency on 15 per minute, breathing frequency on 5 per minute) rehydration should be stopped. Than estimate the child's condition through an hour.
During parenteral rehydration for such children, and also for children with pneumonia. toxic encephalopathy, speed of fluid infusion must not exceed 15 ml/kg/hour. At these states daily body weight gain in the first 3 days must not exceed 1-3 %.
In case if dehydration is absent and infectious toxic shock is developed reanimation measures according the protocol should be done.
2. Antibacterial therapy
Antibacterial therapy at invasive diarrhea is given to:
1. Children with severe and moderate forms of disease.
2. Children aged before 3 months independent of the disease severity.
3. Children with the immune deficiency, HIV-infected children, children, that receive immune suppressive therapy (chemical, irradiation), long corticosteroid therapy, children with hemolytic anemia, hemoglobinopathies independent of age and the disease severity.
4. Children with hemocolitis independent of age and the disease severity.
5. Children with the secondary bacterial complications in all age groups.
Antibacterial therapy at secretory diarrhea is given to:
1. Children with severe and moderate forms aged before 6 months.
2. Children with the immune deficiency, HIV-infected children, children, that receive immune suppressive therapy (chemical, irradiation), long corticosteroid therapy, children with hemolytic anemia, hemoglobinopathies.
3. Cholera, parasitogenic diarrhea independent of age and the disease severity.
4. Children with the secondary bacterial complications in all age groups.
Antibacterial therapy is not indicated to:
1. Children with mild, effaced and moderate forms of infections, except for those which are listed above.
2. Children bacillus carriers of any etiology (transitory, postinfectional).
3. Children with alimentary dysfunction, as a result of an acute intestinal infection (intestine dysbiosis, lactase insufficiency, celiac syndrome, secondary enzymopathy etc.).
Antibacterial therapy if the etiology of an acute intestinal infection is known:
Azithromycin (through a mouth) | 6-20 mg/kg Course of treatment 1-5 days | once a day 1-1,5 hours before the meal |
Erythromycin (through a mouth) | children aged 1 -3 years daily dose 0,4 g children aged 4-6 years - 0,5-0,75 g children aged 6-8 years - 0,75 g children aged 6-8 years - 1 g Course of treatment 7-10 days | 4 times per day 1-1,5 hours before the meal |
Amoxicillin/clavulanat | Through a mouth (suspension) children aged 1-2 years 78 mg children aged 2-7 years 156 mg children aged 7-12 years 312 mg IV-30 mg/kg Course of treatment 5-10 days | 3 times per day 3-4 times per day |
Aminoglycosides (IM, IV) | Gentamycin 2-3 mg/kg/day Amikacin 15 mg/kg/day Netylmycin: children before 1 year - 7,5-9 mg/kg children elder 1 year - 6-7,5 mg/kg Course of treatment 5-7 days | 2 times per day 2-3 times per day 3 times per day 3 times per day |
Furazolidonum (through a mouth) | 8-10 mg/kg daily dose Course of treatment 10 days | 4 times per day |
Doxycyclin (through a mouth) to children elder than 8yrs | children aged 9-12 years daily dose - the first day 4 mg/kg, then 2 mg/kg Course of treatment 7-10 days | 2 times per day |
Vancomycinum (through a mouth) | 40 mg/kg daily dose Course of treatment 7-10 days | 3-4 times per day |
Chloramphenicol | Through a mouth children before 3 yrs - 10-15 mg/kg children aged 4-8 years - 0,15-0,2 g children elder than 8 yrs - 0,2-0,3 g IM children before 1 year daily dose - 25-30 mg/kg children elder 1 year daily dose - 50 mg/kg Course of treatment 5-10 days | 3-4 times per day 30 min before the meal 2-3 injections |
Metronidazole (through a mouth) | Amebiasis: children aged 2-5 years - 0,25 g children aged 6-10 years - 0,375g children aged 11-15 years - 0,5g Course of treatment 10 days Giardiasis: children aged 2-5 years - 0,2 g children aged 6-10 years - 0,3 g children aged 11-15 years - 0,4g Course of treatment 5-7 days | once a day during a meal |
Ornidazole (through a mouth) | Giardiasis - 40 mg/kg Course of treatment 1-3 days Amebiasis - 25-30 mg/kg Course of treatment 1-3 days | once a day |
Albendazole (through a mouth) | Giardiasis children elder 2 yrs 400 mg Course of treatment 5 days | once a day |
Tinidazole (through a mouth) | Amebiasis - 30 mg/kg Course of treatment 3 days | once a day |
lntetrix (through a mouth) | children after 12 years - 1 capsule Course of treatment 10 days | 4 times per day |
Carbapenems | lmipenem/cilastatin (IM, IV) children with body weight less than 40 kg - 15 mg/kg (maximal daily dose is 2 g) children with body weight more than 40 kg - 500- 1000 mg maximal daily dose is 2 g) Meropenem (IV) 10-12 mg/kg children with body weight more than 50 kg - 500 mg Course of treatment according the evidences | 4 times per day 2-4 times per day 3 times per day |
It is recommended to prescribe for empiric therapy of an acute intestinal infection (in case of the unknown etiology): Nifuroxazide, Trimetoprim/sulfamethoxazolum, Cefotaxime, Ceftriaxone, Ciprofloxacin.
At a necessity of empiric antibacterial therapy of secretory diarrhea cefalosporins of 3rd-4th generations are used.
Diet
An important moment in organization of sick children feeding is a waiver of water-tea pauses, as it is well-proven that even at the severe forms of diarrhea the digestive function of greater part of intestine is saved, and pauses will decelerate reparation processes, reduce intestine tolerance to the meal, and considerably weaken immunity of organism. A volume and composition of meal depends from child's age, weight and severity of diarrhea, character of previous diseases. Rational feeding is important for rapid renewal of the intestinal function.
In the acute period of gastroenteritis it is recommended to diminish daily volume of meal on 1/2-1/3, in the acute period of colitis - on 1/2-1/4. Possibly increase of feedings up to 8-10 times per day for infants, especially at urges to vomit. In this time most physiologic is early, but gradual renewal of feed. Proceeding in high-quality and quantitative composition of meal is characteristic for this age of child, carried out in short period after the rehydration and disappearance of dehydration (4-5 days). In this period it is recommended diet for every day. The fat, fried, smoked food and others like that are eliminated from a ration in elder children.
If a child is breast fed, it is recommended to continue feeding.
Products with high amount of lactose should be eliminated (milk formulas, milk, fruit juices). This will decrease secretory diarrhea duration. Children on the artificial feeding are fed by the same chart, by lactose free formulas. Lactose free diet should last individually from 1-4 weeks to 1.5-2 months. Porridges prepared on water are recommended, meet puree should be given earlier. Diary milk formulas after 8 month are recommended.
Soya containing formulas are not recommended because intestine excessive sensitivity to soy proteins in diarrhea. It is risky for protein entheropathy development. Apple prepared in the oven, bananas, apple and carrot puree contain large amount of pectins are recommended in case of colitis.
Auxiliary therapy of an acute intestinal infection
Probiotics can be applied as independent etiotropic treatment (in cases when antibacterial therapy is not indicated) or as additional medicine during antibacterial therapy. Probiotics, which contain lacto-, bifidobacteria and propinebacteria. Self eliminate probiotics (contain saccharomycets) or probiotics which contain lactobacteria are used in invasive diarrhea on a background of antibacterial therapy. The last ones are stable to antibiotics.
To the children with the immunodeficiency, those which are treated in the intensive care units probiotics aren't appointed.
The course of therapy lasts for 5-10 days.
Enterosorbents
Enterosorbents are able to fix on their surface hundreds of millions bacteria. Fixed microbes are ruined and eliminated from a sick organism. Together with the bacteria enerosorbents fix on their surface rotaviruses from the intestine. Except for the infectants enerosorption destroy the toxins of microbes and products of their metabolism. They transform toxic matters in less toxic.
The most perspective at treatment of an acute intestinal infection in children are "white", alumsilicate enerosorbents. Unlike coal sorbents they do not require introduction of high dose of preparation for achievement of therapeutic effect. Also coal sorbents get to the submucous layer of the intestine and can damage it.
In obedience to WHO recommendations (2006) in auxiliary therapy of an acute intestinal infection are recommended preparations of zinc (to the children before 6 months - 10 mg per day, children elder than 6 months - 20 mg per day during 10-14 days).
Prophylaxis:
• timely exposure and treatment of patients;
• stage-by-stage placing of patients in semiboxings;
• final and current disinfection;
• sanitary-epidemic regime in child's collectives, hospitals;
• observation of contacts;
• for the specific prophylaxis of rotavirus infection there are two vaccines. Both
accepted oral and contain a weak living virus of lst-4th types.
Test and assignments for self assessment Multiple choice. Choose the correct answer:
1. Indicate the source of illness at Rotavirus infection:
A. Sick people; virus carrier
B. Virus carrier
C. Sick animal; virus carrier
D. Sick birds
E. Sick animal; sick people
2. Indicate the basic mechanism of Rotaviral infection transmission:
A. Air-droplet
B. Fecal-oral
C. Transmissive
D. Contact
E. Alimentary
3. In what age children have Rotaviral infection most often?
A. 0-12 mo
B. 3-12 mo
C. 12 mo-3 years
D. 4 mo-2 years
E. 4 mo-5 years
4. The peak of morbidity on Rotaviral infection is:
A. January-April
B. March-June
C. May-August
D. July-November
E. November-February
5. Rotaviral infection is characterized by such syndromes:
A. Cardio-vascular; toxic; respiratory
B. Dyspepsia; dehydration
C. Cardio-vascular; dyspepsia; dehydration
D. Toxic; dyspepsia; dehydration
E. Cardio-vascular; respiratory; dehydration
6. Which laboratory methods are used in early diagnostics of Rotaviral infection?
A. Bacteriological
B. Koprogram
C. Complement binding reaction
D. Method of immune-enzyme analysis
E. Reaction of neutralization
7. What features of respiratory syndrome at Rotaviral infection?
A. Expressed cough, rhinitis
B. Mild rhinitis
C. Long lasting cough
D. Moderate throat hyperemia
E. Expressed throat hyperemia
8. Character of feces at Rotaviral infection:
A. "Sprinkling", colorless, watery
B. In a small amount with mucus, blood
C. Watery bright-yellow with the small amount of mucus
D. Muddy with large amount of mucus
E. Pasty with undigested food admixtures
9. What artificial mild formula is given to the children with Rotaviral infection?
A. With probiotics
B. For preterm infants
C. Sour-milk
D. Containing soya
E. Lactose-free
10. What from the indicated preparations diminish the secretion of water and electrolytes in the
intestine?
A. Rehydron
B. Smecta
C. Loperamide
D. Bifidum bacterin
E. Enterosgel
Algorithm of practical students' work
Complaints and anamnesis taking in newborns and infants
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Tactful and calm conversation with the parents of sick child.
5. Explanation of future steps concerning the child (hospitalization, some methods of examination, etc.).
Complaints and anamnesis taking in toddlers and preschoolers (children aged from 1 to 6 years)
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. By means of game playing find a contact with a child.
5. Tactful and calm conversation with the parents of sick child.
6. Explanation of future steps concerning the child (hospitalization, some methods of examination, etc.).
Complaints and anamnesis taking in school age children
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Tactful and calm conversation with sick child his/her parents.
5. Explanation of further steps to child and his/her parents (hospitalization, some methods of examination, etc.).
1. To collect complaints:
• fever, poor appetite, anxiety, sickliness;
• nausea, vomiting, «sprinkling», colorless, watery diarrhea without pathological admixtures;
• weight loss.
2. To collect anamnesis of the disease, epidemiological anamnesis
• Acute beginning of the disease from the fever, toxic syndrome, vomiting, diarrhea, joining
and progress of dehydration.
• Eating of the infected products, contact with a patient who had diarrhea 2-7 days prior to
the disease beginning.
• There are alike signs in surrounders, which ate same products.
• Conversation accomplishment.
3. To inspect a patient:
Physical methods of examination of newborns and infants
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the parents what examination should be performed and obtain there informed consent.
5. Prepare for examination(clean and warm hands, warm phonendoscope, etc.).
Physical methods of examination of toddlers and preschoolers
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the parents what examination should be performed and obtain there informed consent.
5. Find a contact with a child; try to gain his/her confidence.
6. Prepare for examination(clean and warm hands, warm phonendoscope, etc.).
Physical methods of examination of school age children
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to the parents what examination should be performed and obtain there informed consent.
5. Find a contact with a child; try to gain his/her confidence.
6. Prepare for examination (clean and warm hands, warm phonendoscope, use the screen if necessary etc.).
A. Examination:
• a skin is dry, pale, sunken eyes, acute lines of the face;
• dry and bright mucus membranes, coated tongue;
B. Palpation:
• lowering of skin elasticity, soft tissues turgor, sunken big fontanel, weight deficit;
• tender abdomen, grumbling of thin intestine. C.Auscultation:
• increased intestinal murmurs;
• tachycardia, strengthening, or deafness of cardiac tones;
• tachypnea, harsh breathing. Conversation accomplishment.
Informing about the results of examination
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a child and his/her parents what examinations should be performed and obtain their informed consent.
5. Involve adolescent and his/her relatives in to the conversation (compare present examination results with previous ones, clarify whether your expectations are clear for them or not).
6. Conversation accomplishment.
4. To estimate the results of additional researches
• Complete blood analysis: normal.
• Biochemical blood test: increased, normal or decreased concentration of electrolytes.
• Koprogram: intestinal enzymopathy.
• Fecal culture: negative.
• Virology: IEA (feces investigation) with specific test system, positive.
• Explaining the results of examination to child's parents.
• Conversation accomplishment.
5. To substantiate the diagnosis.
Planning and prediction of conservative treatment results
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to child's parents the necessity of further treatment directions correctly and accessibly.
5. Discuss with parents and their child the peculiarities of drug intake, duration of usage, side effects and find out whether they understand your explanations.
6. Conversation accomplishment
6. To prescribe the treatment: regime, diet, rehydration therapy, correction of electrolytes;
probiotics, enzymes, detoxication, symptomatic medicine.
Informing about treatment prognosis
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Correct and clear explanation of expected results of treatment.
5. Discuss with the parents and their child the importance of continuous treatment, following the
treatment scheme; make sure that your explanations are properly understood.
6. Conversation accomplishment.
Step
1.A boy, 1 year old, is ill for 3 days. Main syndromes are: toxic with hyperthermia; dyspeptic with vomiting, diarrhea (like rice-water), «sprinkling»; back pharyngeal wall is bright red; moderate signs of dehydration are present. Put preliminary diagnosis.
A. Enterotoxigenic Escherichiosis
B. Enteropatogenic Escherichiosis
C. Cholera
D. Rotaviral infection
E. Enterovirus infection
2. A boy, 6 months old, has repeated vomiting, appetite is absent; is ill for 2 days. During
examination: malaise, a skin is pale, mucus membranes of oral cavity are dry. Moderate thirst is
present. Large fontanel is lower than skull bones. Weight loss is 4 %. Body temperature 38 °C.
Abdomen is soft, intestinal grumbling. Feces are watery, colorless 12 times per day. Urination was 8
times per day. What type of dehydration has developed?
A. Isotonic
B. Hypertonic
C. Hypotonic
D. Moderate
E. Severe
3. A boy, 8 months old, entered the infectious department. The disease had acute beginning.
Now: doesn't want to drink anything; vomiting repeats, body temperature is 35.5 °C. Objectively:
skin and mucus membranes are dry; large fontanel is lower than skull bones; cool extremities; tachycardia. In entrance room he became unconscious, tonic-clonic seizures has appeared. What fluids does he need for the rehydration, in what correlation?
A. 5 % glucose, 0.9 % NaCl, 1:2
B. 5 % glucose, 0.9 % NaCl, 1:1
C. 10%glucose, 0.45%NaCl,2:l
D. 5 % glucose, 0.9 % NaCl, Albumen 1:1:1
E. 10%glucose,0.45%NaCl,3:l
A real life situation to be solved
1. A boy, 3 years old, is ill for 2 days. Main syndromes are: toxic with hyperthermia; dyspeptic with vomiting, diarrhea (like rice-water); catarrhal signs in upper respiratory tract; moderatedehydration.
1. What infection can cause this signs?
2. How to prove the diagnosis?
2. A girl, 1.5 years old, has rotavirus infection.
1. What diseases it must be differentiated from?
2. What type of diarrhea is typical for it?
Answers for the self-control:
Tests: l.A;2.B;3.D; 4.E; 5. D; 6.D;7.E; 8.A; 9.E; 10. C. Step: LP: 2.A; 3.B; Real-life situation 1:
1. Rotavirus
2. Virological investigation of feces, serologic reactions.
Real-life situation 2:
1. Cholera; enterotoxigenic escherichiosis.
2. Secretory.
Result Level
Students must know:
• Etiology, epidemiology, pathogenesis, pathomorphology of Rotavirus infection.
• Classification of Rotavirus infection.
• Main diagnostic criteria of Rotavirus infection.
• Differential diagnosis of Rotavirus infection.
• Rotavirus infection treatment and prevention. Students should be able to do*.
• To diagnose Rotavirus infection.
• Interpret results of laboratory and instrumental examination of the child in case of Rotavirus infection.
• Perform differential diagnosis of Rotavirus infection.
Prescribe treatment to children with this pathology and its prophylaxis.
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