Infantile Diarrhea

Infantile Diarrhea
SUN Mei
Pediatric Dept. 2 nd Clinical College,
China Medical University

1. Definition:
Introduction
Infantile diarrhea is one of the most
common diseases in infants and toddlers. It
is not a definitely disease but a syndrome
caused by infectious and non-infectious
non infectious
factors. Clinical manifestations are mainly
diarrhea and vomiting, in severe cases it
usually associated with dehydration and
electrolyte and acid-base acid base disturbances.

Major causes of death among children under five in
developing countries, 2002
25%
23%
Deaths associated
with malnutrition
54%
4%
5%
18%
10%
15%
Acute respiratory infection Diarrhea
Malaria Measles
HIV/AIDS Perinatal
Other Sources: The world health report 2003, WHO,Geneva.

2.Nomenclature: 2. Nomenclature: Infectious
Noninfectious.
The infectious diarrhea dose not include
that having legal name such as bacillary
dysentery, cholera and so on. Diarrhea caused
by other infectious agents and unknown
pathogens may all be named “enteritis enteritis” and
should be defined with the name of the
specific pathogen. Such as enteropathogenic E.
Coli. enteritis, rotavirus enteritis.

3. Predisposing age
Peak incidence occurs in infants
under two to three years of age.
Especially under one year, which
account for about half of the
patients.

4. Prevalent seasons
Bacterial enteritis is most prevalent in
summer.
Viral enteritis in autumn and winter months
but they may be occur all year round.
Noninfectious diarrhea may occur at any
season.

Predisposing factors
1. Immature digestive function
Low gastric acidity: Normally in adults and
adolescents the majority of ingested bacterial
pathogens will be killed at the acid environment
of stomach (pH 1.5-2.0, 1.5 2.0,

2. The rapid growth. growth.
The body
weight of one year old children is 3
times of birth weight. The nutrient
requirements are relatively great,
the gastrointestinal tract is usually
overburdened and commonly
encounter stress.

3. Poor immune function (host
defenses)
Immunoglobulins especially the level
of IgM and secretory IgA from
gastrointestinal mucosa are very low.
The SlgA could resist the local
infection of mucosa and IgM could
resist infection of gram-negative
gram negative
bacilli.

4. Disturbed enteric bacterial flora:
Normal bacterial flora is highly effective
in resisting colonization by potentially
pathogenic invaders. The newborn infants
have not acquired a normal enteric flora.
In infants, the GI normal flora can easy
lose or shift in their balance by antibiotics
or other factors, which may increase the
infants’ infants susceptibility to enteric infections.

5. Formula feeding:
Bottle-fed Bottle fed infant has much more
opportunities of contamination;
Breast milk contains many factors such as
SIgA, SIgA,
complement C3, C4, lysozyme, lysozyme
lysosome, lysosome lectoferrin and some cells, these
factors are less in animal milk or have been
destroyed after boiling.

Etiology
Infectious factors
1. Intestinal infection
Viruses.
– Rotavirus is the most common cause of infantile
diarrhea especially in autumn and winter.
– Norwalk virus is more responsible for diarrhea
among older children and adults.
– Others such as calicivirus (杯状病毒 杯状病毒),enteric enteric
adenovirus, astrovirus, astrovirus,
corona-like corona like viruses,
small round viruses, ECHO, Coxsackie, CMV.

Bacteria
Etiology
Escherichia coli (E. coli)
Enteropathogenic E. coli EPEC
Enterotoxigenic E. coli ETEC
Enteroinvasive E. coli EIEC
Enterohemorrhagic E. coli EHEC
Enteroadherent-aggregative Enteroadherent aggregative E. coli EAEC

Campylobacter jejuni, jejuni
Yersinia enterocolitica.
enterocolitica.
Other bacteria: such as staphylococcus
aureus, aureus,
pseudomonas aeruginosa, aeruginosa proteus, proteus
Klebsiella, Klebsiella,
Salmonella typhymurium and
citrobacter. citrobacter.

Etiology
Fungi: especially Candida albicans
Protracted use of broad-spectrum broad spectrum antibiotics may
alter the normal enteric flora, that may allow the
emergence of resistant organisms such as
staphylococcus aureus or Candida albicans, albicans,
especially
in debilitated children and those with immunologic
deficiency.
Protozoa
Entamoeba histolytic, Giardia Lamblia
Balantidium coli.

Etiology
2. . Extraintestinal infections
Otitis media, upper respiratory infection,
meningitis, pneumonia, urinary infection, cutaneous
infection or other acute infectious diseases may
associate with diarrhea and vomiting.
Extragastrointestinal infections cause a temporary
upset of gastrointestinal function (toxin, fever).
Pathogens infect intestine directly.
Local irritation of the rectum (bladder infection).

Etiology
Antibiotic-associated Antibiotic associated diarrhea, AAD:
Some antibiotics decrease
carbohydrate transport and intestinal
lactase levels.
Eradication of normal gut flora and
overgrowth of other organisms may
cause diarrhea.

Etiology
Noninfectious factors
Dietary factor :
Excess or irregular feeding
Sudden alteration of diet. Feeding starch or fat
too early, changing food or weaning suddenly.
Allergy to cow's milk or disaccharidase
deficiency.
Weather factor
Cool �� increased bowel peristalsis
Hot �� secretion of digestive juice may decrease
thirsty �� excess drinking �� over burdened GI tract.

Pathogenesis
Each kind of diarrhea has different pathogenesis,
such as:
“secretary secretary”
“effusive effusive”
“osmotic osmotic”
“abnormal abnormal GI peristalsis”
peristalsis

Rotavirus invade the mucosa of small intestine
↓
Mucosa shows patchy inflammation,
microvilli are irregular, swollen and shortened
↓
Epithelial cells are swollen, microvilli are damaged
Glucose-coupled Glucose coupled Decreased activity of The total absorptive
sodium transport disaccharidase area decrease
decreased ↓
↓ Lactose can not be
watery stools digested and absorbed
↓
Organic acid increased
↓
Osmolarity is increased in IT
Figure 1. Pathogenesis of rotaviral enteritis

Ingested ETEC (ID=10 8 )
↓
adhere to and colonize in upper intestinal mucosa
via colonization factors (CF) and multiply
↓
Produce enterotoxins (ST and/or LT)
↓ ↓
heat-stable heat stable enterotoxin heat-labile heat labile enterotoxin
↓ bind to receptors and activate ↓
Guanyl cyclase Adenyl cyclase
↓ ↓
GTP → cGMP↑ cGMP
cAMP↑← cAMP↑←
ATP
↓ ↓
→→ Promote ←←
secretion of sodium, chloride, water
↓↓
watery diarrhea
Figure 2. Pathogenesis of ETEC enteritis

Invasive pathogens
↓
invade and multiply within intestinal mucosa
↓
inflammatory changes
(congestion, swollen, inflammatory cells
infiltration, effusion and ulcer)
↓
water and electrolyte are not absorbed entirely
↓
diarrhea
/ \
WBC,RBC increase severe general
in stools toxic symptoms
Figure 3. Pathogenesis of invasive enteritis

Feeding fault (overfeeding, unsuitable nutrients)
↓immature immature digestive function
↓ overburdened GI tract
Disturbances of digestive function
↓
Nutrients can not be digested and absorbed properly
↓
Accumulated in upper intestinal tract. Acidity of contents decrease decrease
↓
Bacteria resided in lower IT immigrate into and multiply in upper upper
IT
↓ (endogenous infection)
Nutrients are resolved by bacteria
↓ ↓
Fermentative process putrid process
↓ ↓
Organic acids are increased toxic products(amines etc.)
(Lactic and acetic acid) ↓
↓ ↓ liver
Hyperosmolarity irritate ↓
↓ ↓ Blood stream
hyperperistalsis of intestinal wall ↓
↓ General toxic symptoms
Diarrhea
Figure 4. Pathogenesis of dietary diarrhea

Clinical manifestations
Classification by the course of diarrhea
Acute diarrhea: continuous course < two weeks
Prolonged diarrhea: continuous course varies
Chronic diarrhea: > 2 months.
between 2 weeks ~ 2 months

According to severity of diarrhea it may be
divided into 2 types:
Mild diarrhea: diarrhea caused by dietary factors or extra-
gastrointestinal infections.
Gastrointestinal symptoms: The stools become
frequent but usually no more than ten times a day,
gruel-like gruel like or watery, yellow or greenish yellow in
color, smell sour, Vomiting is less common and
abdominal pain is mild.
Systemic symptoms: There is no obvious systemic
symptoms. Infants may be restless or irritable,
temperature is normal or slight high.
There is no dehydration, electrolyte and acid-
base disturbances.

Severe diarrhea: caused by intestinal infections.
Gastrointestinal symptoms: The stools become
more frequent, >10 times daily, watery in consistency,
yellow or greenish yellow, sometimes with mucus, pus
and blood. Vomiting is severe even blood in vomitus. vomitus.
Other symptoms include: anorexia, nausea,
abdominal pain and abdominal distention.
Systemic symptoms: Obvious bvious systemic toxic
symptoms. Infants may be very irritable, lethargy
even coma. The temperature may be high or low.
Water and electrolyte disturbances: usually
present moderate even severe dehydration, acidosis
and electrolyte disturbances.

Dehydration: Excessive Loss of Water
and Electrolytes Due to Diarrhea and Vomiting.
Some signs are usually used as criteria.
Dryness of lips, skin and mucous membranes.
Poor skin turgor (elasticity).
Depressed anterior fontanel.
Lack of tears.
Sunken eyes socket.
Signs of shock: poor peripheral circulation. They may
show tachycardia, thin and thready pulse, a low or
falling blood pressure, pallor, cool extremities, delayed
capillary refilling, hypothermia, oliguria

Severity of dehydration: classified into 3
degrees: mild, moderate and severe degree.
Table 1. Severity of dehydration
water loss mild moderate severe
10%
(% of BW)

(go go on)
mild moderate severe
mucosa slightly dry dry very dry
eye socket slightly sunken sunken deep sunken
fontanel slight depression depression deep depression
tears present decreased absent
urine present oliguria anuria
peripheral fair slight poor collapse
circulation cool extremities
thin pulse
low and dull H.S

The types of dehydration
According to the osmolarity of remainder of body
fluid followed dehydration, the dehydration can be
divided into three types:
–Isotonic, Isotonic,
–hypotonic hypotonic
–hypertonic hypertonic dehydration.
During diarrhea, both water and electrolyte are
lost but may not be proportional. The three types of
dehydration may be classified by the serum sodium
concentration, because sodium is the main component
of ECF.

Table 2. The types of dehydration
Isotonic hypotonic hypertonic
causes vomiting, diarrhea wrong rehydration excessive intake
and poor intake diarrhea associated sodium sodium
or
with malnutrition malnutrition
excessive sweat
proportional sodium loss= loss of sodium > water loss >
loss of water loss of water water loss sodium loss
and sodium ECF↓, ECF , no ECF→ ECF ICF ICF→ECF ICF ECF
change in ICF ECF↓ ECF ICF↑ ICF circulation is
better maintained
Serum Na (mmol mmol/L) /L)
130-150 130 150 < 130 >150
ECF=extracellular
ECF= extracellular fluid ICF= intracellular fluid

Isotonic hypotonic hypertonic
volume of ECF decreased severely decreased less severely
decreased
volume of ICF not changed increased decreased
symptoms more severe less severe
and signs shock occurs easily shock is rare
skin color gray gray
temperature cold cold cold or warm
turgor poor very poor fair
feel dry clammy thickened doughy
mucosa dry slight moist parched
psyche lethargy coma irritability
pulse rapid rapid slightly rapid
Bp low very low slightly low
thirsty yes yes or no polydipsia

Metabolic acidosis
The more severe the acidosis will be. causes:
excessive loss of bicarbonate in intestinal
juice.
starvation ketosis due to poor intake and
malabsorption
hypoperfusion and hypotension lead to tissue
hypoxia and accumulation of lactic acid
decreased excretion of fixed acid due to
oliguria.
oliguria

According to the severity of acidosis it could be
divided into three degrees.
CO 2 CP
normal 18-27 18 27 mEq/L mEq/L
40-60 40 60 vol% vol
mild acidosis 13-18 13 18 30-40 30 40
moderate 9-13 9 13 20-30 20 30
severe

Clinical manifestations:
lassitude, lethargy, coma or irritability.
Deep, rapid respiration (Kussmauls
( Kussmauls
breathing) and cool expiratory air.
The expiratory air smells like 'acetone.‘ 'acetone.
Cherry lips.
Nausea, vomiting.

Hypokalemia
Normal serum potassium is 4-4.5 4 4.5 mmol/L. mmol/L.
When
serum potassium is less than 3.5mmol/L
hypokalemia can be diagnosed.
Causes:
excessive loss of potassium
poor intake
The capacity of the kidney to retain K is not as
good as that for sodium. During K deficiency, the
kidney still excrete certain amounts of potassium.

Prior to rehydration,
rehydration,
serum K usually
remains normal,
because:
① Hemoconcentration.
Hemoconcentration
② During acidosis K
moves from ICF into
ECF.
③ Oliguria reduce the
excretion of K.
Along with rehydration
serum K will gradually fall,
because:
① Hemodilution.
Hemodilution
②Acidosis Acidosis is being corrected, K
returns from ECF to ICF.
③ K excretion is increased
along with urine discharge.
④ Synthesis of glycogen with
infused glucose needs K.
⑤Ongoing Ongoing loss of potassium
due to diarrhea.

Clinical manifestations of hypokalemia
Central nervous system: lassitude
Skeletal muscle: weakness, hypotonia , diminished
reflexes and even paralysis.
Smooth muscle: Abdominal distention with diminished
or absent peristalsis. Bowel sound is decreased.
Heart: Increased myocardial irritability, presenting as
tachycardia, arrhythmia, dull heart sounds. ECG shows
prolonged Q-T Q T interval, flat or inverted T waves,
prominent u wave and depressed S-T S T segments.
2Na+1H
Alkalosis: ICF �� ECF
3K

Hypocalcemia and hypomagnesemia
Normal value:
Serum calcium is 9-11 9 11 mg/dl or 2.2-2.7 2.2 2.7 mmol/L. mmol/L.
When the value is < 7 mg/dl (1.75 mmol/L) mmol/L)
hypocalcemia is diagnosed.
Serum magnesium: 2.0-3.0 2.0 3.0 mg/dl or 0.8-1.2 0.8 1.2 mmol/L. mmol/L.
If the concentration is < 1.5mg/dl (0.6 mmol/L) mmol/L)
hypomagnesemia is defined.
Causes:
poor intake.
malabsorption.
malabsorption
excessive loss of Ca, Mg via diarrhea.
prolonged diarrhea or active rickets.

Hypocalcemia and
hypomagnesemia
Prior to rehydration there may be no any
hypocalcemic symptoms and sighs due to:
① hemoconcentration.
hemoconcentration
② increased ionic calcium during acidosis.
After rehydration and acidosis being corrected
symptoms occur, because:
① hemodilution.
hemodilution
② Ionic calcium decreased after acidosis is corrected

Hypocalcemia and
hypomagnesemia
Manifestations:
Tetany and convulsion.
If the patient has been given calcium the
tetany or convulsion arenot relieved,
hypomagnesemia should be considered.

Some enteritis caused by
specific pathogens.
1. Rotavirus enteritis or autumn diarrhea.
Pathogen: Human rotavirus (HRV).
Predisposing age: 6 - 24 months.
Predisposing seasons: autumn and winter.
Suddenly onset with low-grade low grade fever and
symptoms of common cold, no obvious toxic
symptoms.

Vomiting usually precedes diarrhea. The
diarrhea is typically acute in onset and
generally watery in character, frequent and
in large amount, odorless.
It is usually associated with dehydration
which is usually isotonic and associated with
electrolyte, acid-base acid base disturbance.
It is a self-limited self limited disease, the clinical
illness generally lasts for 3-8 3 8 days,

Some enteritis caused by
specific pathogens.
2. ETEC enteritis
Sudden onset without significant fever or
other systemic symptoms.
Main symptoms are diarrhea and vomiting.
Frequent diarrhea in large amount. The
stool is watery.
Dehydration, electrolyte disturbances and
acidosis may develop.
Self-limited Self limited disease with nature course of
3-7 7 days.
days

3. Invasive bacterial enteritis.
a dysentery-like dysentery like syndrome that is the
same as that caused by shigellar. shigellar
It is usually abrupt in onset and is characterized
by high fever.
Frequent diarrhea with mucus, pus and blood.
Microscopic findings of stools are leukocytes and
erythrocytes in varying amount.
Other gastrointestinal symptom includes nausea,
vomiting, crampy abdominal pain, tenesmus, tenesmus,
fecal
urgency.
There are sometimes severe systemic toxemia, such
as chills, malaise, hyperpyrexia even convulsion or
infectious shock.
Stool bacterial culture may find the pathogen.

Some enteritis caused by
specific pathogens.
4. Candid albicans enteritis
Patients who have chronic debilitating illness,
malnutrition or prolonged treated with
antibiotics may catch this disease.
It occurs predominately in infants under two
years of age.
The patient may be associated with thrush.
Diarrhea, stool with mucus and many frothes. frothes.
Chlamydospore,
Chlamydospore,
blastospore,
blastospore,
candidal filament
may be seen under microscope.

Differential diagnosis
1.Physiologic 1. Physiologic diarrhea
It occurs in infants apparently fatty,
younger than six months, usually breast
feeding.
Accompanied by eczema.
Beside diarrhea the infants have no other
symptom and have good appetite and
normal weight gain.
After solid foods (supplemental food )
are added the stools turn to normal.

Differential diagnosis
2. Bacillary dysentery
Epidemic data (contact history).
Stool bacteria culture.

Differential diagnosis
3. Acute necrotizing enterocolitis:
enterocolitis:
which must be treated with surgical
therapy in time.
Severe systemic toxic symptoms.
Obvious bloody diarrhea.

Treatment
Principle:
Regulating and continue feeding.
Correcting water and electrolyte
disturbances.
Reasonable medicine administration.
Good care and symptomatic treatment.

Dietary therapy
Oral fluids may be given unless there is severe
vomiting or in advanced condition.
For breast-fed breast fed infants reduce the frequency of
feeding or shorten the feeding time.
For bottle-fed bottle fed infants may start with rice porridge,
gruel, diluted milk or skimmed milk.
In viral enteritis because of lactase deficiency and
defected sodium-coupled
sodium coupled-glucose glucose transport. it is
necessary to use lactose-free lactose free diet. (replace milk
with soybean milk or lactose-free lactose free formula ).

Reasonable medicine administration
Antibiotics: is not effective for viral and
non-invasive non invasive bacterial enteritis. But in
cases with severe systemic symptoms
such as high fever, antibiotics should be
given early, specifically and in full dose.
Microcological therapy: restore normal
enteric bacteria flora.

Reasonable medicine administration
Intestinal mucosa protector: which can
absorb pathogen and toxin, improve the
barrier function of GI wall.
WHO/UNICN recent recommendation
Provide children with 20mg/d of zinc
supplementation for 10-14 10 14 days (10mg/d
for infants under 6 months old).

Reasonable medicine administration
Antidiarrheal medicines are ineffective
or even dangerous. Such as loperamide,
loperamide,
tincture of opium, which may inhibit GI
motility, increase the multiplication of
bacteria and absorption of toxin.

Good care and symptomatic treatment
Monitoring water intake and loss.
Control infusion rate in different
period.
Vomiting manage.
Abdominal distension manage.

FLUID THERAPY
Common used fluids and tonicity
Non-electrolyte Non electrolyte solutions:
5%, 10% Glucose (GS). Because the glucose is
discomposed for energy supply after enter the
body, the solutions are known as no tonic
solution only used in providing water and
calorie.

Electrolyte solutions
0.9% Natri chloride (Normal saline, NS). It is
isotonic. But its chlorine component is more than
that in plasma, large amount infusion of NS may
lead to hyperchloremia and acidosis.
Natri bicarbonate (NB). It is a basic solution
with two concentrations that are commonly used:
5% NB is 3.6 tonic solution and 5% NB 1 ml/kg
could elevate 1 mEq/L mEq/L
CO2 CP. The isotonic
concentration for NB is 1.4%.
10% Kalii chloride. It is 8.9 tonic solution.

Oral rehydration salt (ORS)
It was advocated by the WHO.
Formula of oral rehydration salt:
Component amount (grams)
NaCl 3.5
NaHCO 3
KCl
2.5
1.5
KCl 1.5
Glucose 20
Water 1000ml
It is 2/3 tonic and potassium concentration is 0.15%.

Mixed solution
Table 3. Components and ingredient of mixed solution
Solution component ratio ingredient(ml)
NS 10%GS 1.4%NB 10%GS 10%NaCl 10% NaCl 5%NB 10%KCl 10% KCl
2:1 isotonic sol. 2 1 500 30 47
1:1 sol (1/2tonic) 1 1 500 500
20
2:3:1 sol (1/2) 2 3 1 500 15 24
4:3:2 sol (2/3) 4 3 2 500 20 33
1:2 sol (1/3) 1 2 500 15
1:4 sol (1/5) 1 4 500 9
normal maintenance
solution (1/3) 1 4 500 9 7.5

Indications:
Oral fluid therapy
Mild or moderate dehydration.
No severe vomiting nor abdominal distention.
Replacement volume of deficit requirements is
50ml/kg in mild dehydration, 50-100ml/kg 50 100ml/kg in
moderate dehydration, is given within 4-6 4 6 hrs.
Replacement of abnormal maintenance
requirements which is ongoing abnormal loss here
is about 30ml/kg, is given within 18 hrs.

ORS may be used with unlimited water intake. The
fluid is best given in small amount frequently.
Potassium concentration in ORS is 20
mEq/L(0.15%), mEq/L(0.15%),
a general dosage for diarrhea. For
patients with hypokalemia, hypokalemia,
additional potassium
should be added.
Patients with obvious acidosis should be corrected
with additional Nat bicarb. bicarb
For viral enteritis ORS is effective. In viral enteritis
stool sodium is about 50 mEq/L, mEq/L,
while in the ORS
the sodium is 90mEq/L. When administering,
additional water should be given.

Indications:
Intravenous fluid therapy
Moderate or severe dehydration.
The illness is not relieved by Oral fluid therapy or
complicated with severe vomiting.

The therapy for the first day.
When fluid therapy is talked, the amounts
of fluid, the kind of fluid and the infusion
rate are three key points in this topic.
The total amount of fluid needed for
replacement of:
preexisting losses
ongoing abnormal losses
normal losses.

Preexisting losses means the body water deficits due
to diarrhea and vomiting, by the deficits we
evaluated the severity of dehydration.
Ongoing abnormal losses due to ongoing diarrhea.
The amount of the stools is not readily measurable,
it is about 10-30 10 30 ml/kg/day,
Normal losses means normal maintenance
requirements that include urine, feces, sweat and
insensible water losses through skin and lungs. This
requirement is about 60-80 60 80 ml/kg.

In summary the total volume of fluid:
for mild dehydration 90-120 90 120 ml/kg
moderate dehydration 120-159 120 159 ml/kg
severe dehydration 150-180 150 180 ml/kg

Kind of fluids
For preexisting losses:
Isotonic dehydration: 1/2 tonics
Hypotonic dehydration: 2/3 tonics
Hypertonic dehydration: 1/3 tonic
For ongoing abnormal losses 1/2 tonic solution is
used,
For ongoing normal loss 1/3 tonic solution is used.
These two ongoing losses go together replenished
with 1/2 -1/3 1/3 tonic solution.

Infusing rates
Phase Ⅰ: : rapid expansion of plasma volume, which
is used in patient with poor peripheral circulation.
This phase of treatment is aimed at rapid
expansion of extracellular fluid volume, to relieve or
prevent shock and to restore renal function.
2:1 solution or 1.4% NB should be used in this
phase. This isotonic sodium-containing sodium containing solution must
be given immediately after admission to the hospital.
The amount given is 20 ml/kg and injected
intravenously within 0.5-1 0.5 1 hr.

Infusing rates
Phase Ⅱ: : For replacement of remaining fluid deficit.
It is aimed at correction of dehydration over the next
8-12 12 hours.
The amount and formulation of this phase are
dependent upon the severity and type of dehydration. The
amount = preexisting losses-the losses the amount of expansion .
This amount is about half of total amount.
This stage should be completed during the first 8-12 8 12
hrs or at an infusing rate of 8-10 8 10 ml/kg/hr.

Infusing rates
Phase Ⅲ: For replenish of ongoing normal and
abnormal losses.
The infusing rate is decreased to 5 ml/kg/hr in this
stage and the remaining fluid would then be given
during the following 12-16 12 16 hours.
The amount = total amount-preexisting amount preexisting losses.
(about half of total amount).
The kind of fluids: 1/3 tonic solution.

Correcting acidosis
There are two formulas for calculating the amount
of alkaline solution needed:
(40-CO (40 CO2 CP)×0.5 CP) 0.5×BW(kg)=ml BW(kg)=ml (of 5% N.B)
ABE×0.5 ABE 0.5×BW(kg)= BW(kg)= ml (of 5% N.B)
We usually give half of the amount calculated and
further regulate base on further CO 2 CP or blood gas
analysis.

Replacement of potassium
For mild hypokalemia: hypokalemia:
200-300 200 300 mg/kg. day or
3-4 mEq/kg,d mEq/kg,d
(KCl ( KCl)
severe hypokalemia: hypokalemia:
300-450 300 450 mg/kg.day or 4-8 4
mEq/Kg.d mEq/Kg.d
Generally the concentration of potassium in the
infusion is 27 mEq/L mEq/L
(=KCl (= KCl 0.2%) and should not
exceed 0.3%. For mild cases it may be given orally.

Some key points should be paid
attention to:
K + should not be administered until the kidneys are
functioning (there are urine in bladder or passed urine
during 6 hours before admission)
The concentration of KCl should be 0.15 -0.3%, 0.3%, < 0.3%.
The solution containing K + can not be injected
intravenously.
The duration of intravenous infusion of K + containing
solution should > 6-8 6 8 hrs.
In order to balance K + between ECF and ICF, K + losses
are usually replaced > 4-6 4 6 day's period.

Supplement of Calcium and magnesium
If patient shows the symptoms of hypocalcemia
(tetany tetany or convulsion) calcium should be
administered:
10% Cal gluconate 10ml + 10% or 25% glucose
10ml intravenous injection slowly.
If the symptom is not improved, magnesium
should be given.

For the second day:
The fluid therapy on the second day is mainly
composed of replacement of ongoing normal and
abnormal losses with 1/2 or 1/3 tonic Sodium-
containing solutions.
The volumes of ongoing abnormal maintenance
requirements are dependent on the amount of
diarrhea stools.
Correcting acidosis and hypokalemia if necessary.

CHECKPOINTS
Predisposing factors for infants suffering diarrhea.
Classification of infantile diarrhea by course and by
severity.
Mild, moderate and severe dehydration.
Characters haracters of rotavirus rotavirus
enteritis.
Physiologic diarrhea.
Principle for treatment of infantile diarrhea.
Formula of oral rehydration salt.
Some key points of replacement of potassium.