mgt of AGE

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Acute gastroenteritis : 

Acute gastroenteritis Capt jyoti p shewale

Global Problem : 

Global Problem 4.6 million children less than 5 years of age die of diarrheal diseases. Diarrhea accounts for 19% of all deaths among children ages 0-4. 85% percent of diarrheal deaths occur in the first year of life. World Health Organization. 1997. WHO Fact Sheet: Reducing Mortality from Major Childhood Killer Diseases. Fact Sheet Number 180. http://www.who.int/chd/pub/imci/fs_180.html Centers for Disease Control and Prevention. 1992. Diarrhea: The Management of Acute Diarrhea in Children: Oral Rehydratioin, Maintenance, and Nutritional Therapy. http://www.rehydrate.org/html Graph. http://www.who.int/chd/images/deaths.gif

Diarrhea : 

Diarrhea The passing of 3 or more watery or loose stools in a 24-hour period. Three types: acute watery persistent dysentery World Health Organization. 1998. The Epidemiology and Etiology of Diarrhea. http://www.who.int/chd/pub/cdd/meded/1med.html World Health Organization. 1997. WHO Fact Sheet: Reducing Mortality from Major Childhood Killer Diseases. Fact Sheet Number 180. http://www.who.int/chd/pub/imci/fs_180.htm

ECF and ICF : 

ECF and ICF Body has two fluid compartments Extracellular fluid (ECF) space makes up 1/3 of our body fluids Intracellular fluid (ICF) space makes up 2/3 of our body fluids Extracellular space refers to fluids outside our cells which may be interstitial fluid or plasma Total body water = 0.6 X weight (kg) for children and adults and 0.78 X weight (kg) for neonates and infants

Slide 7: 

ICF (mEq/L) ECF (mEq/L) Sodium 20 135-145 Potassium 150 3-5 Chloride --- 98-110 Bicarbonate 10 20-25 Phosphate 110-115 5 Protein 75 10 ECF and ICF Composition

Etiological Agents : 

Etiological Agents Bacterial, Viral, and Parasitic Agents Rotavirus Enterotoxigenic E. Coli Shigellae Salmonellae Vibrio Cholerae Campylobacter jejuni Cryptosporidium Protozoans Giardia Entamoeba Rotavirus E.Coli Giardia World Health Organization. 1997. http://www.who.int/chd/pub/imci/fs_180.html

Causes : 

Causes Viruses (about 70%) Rotaviruses Noroviruses (Norwalk-like viruses) Enteric adenoviruses Caliciviruses Astroviruses Enteroviruses Protozoa (<10%) Giardia lamblia Entamoeba histolytica Cryptosporidium Bacteria (10-20%) Shiga toxin producing E. coli Vibrio cholerae Non-typhoid Salmonella spp Salmonella typhi and S paratyphi Shigella spp Enteropathogenic E. coli Enteroinvasive E. coli Campylobacter jejuni Yersinia enterocolitica Clostridium difficile Helminths Strongyloides stercoralis

Transmission : 

Transmission Diarrheal agents are mostly spread via the fecal-oral route. physical contact with infected feces eating or drinking contaminated food or water person to person relay World Health Organization. 1998. The Epidemiology and Etiology of Diarrhea. http://www.who.int/chd/pub/cdd/meded/1med.html

Socioeconomic factors : 

Socioeconomic factors Poverty Overcrowding Poor sanitation Contamination of water Inadequate food hygiene UNICEF. 1998. The State of the World’s Children, 1998. Oxford and New York: Oxford University Press.

Behavioral Factors : 

Behavioral Factors Failure to breast-feed exclusively for the first 4-6 months of life Failure to continue breast-feeding until one year of age Using infant bottles Storing food at room temperature Contaminated drinking water Failure to wash hands Failure to dispose of feces hygienically Claeson, M., & Merson, M. 1990. Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9: 345-355.

Host Factors : 

Host Factors Immunosuppression Measles Malnutrition

Risk Factors : 

Risk Factors Household crowding Low maternal education Low birth weight Claeson, M., & Merson, M. 1990. Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9: 345-355.

Pathophysiology : 

Pathophysiology Intestinal wall becomes damaged Impaired absorption Body expels large amounts of fluids Shock, blood pressure drops, kidneys shut down Death

Diarrhea Classification : 

Diarrhea Classification Pathophysiology Osmotic Secretory Exudation Abnormal motility Duration Acute (< 6 weeks) Chronic (> 6 weeks)

Clinical assessment : 

Clinical assessment History Diarrhea Vomiting Urine output Abdominal pain Signs of infection Appearance and behavior Travel

Slide 21: 

Clinical features

Slide 22: 

Clinical features

DD – AGE and complications : 

DD – AGE and complications Infective AGE – Commonest Acute watery diarrhoea (viral) >3 stools/day No blood in stools Cholera Diarrhoea with severe dehydration during cholera outbreak Stool culture +ve for Vibrio cholera O1 or O139 Dysentery – blood in the stool Persistent diarrhoea – lasting > 14 days Diarrhoea with severe malnutrition

DD – less common : 

DD – less common Other DD: Other infections Systemic: septicaemia, meningitis, DF Local: UTI, URTI, hepatitis A Surgical: intestinal obstruction vomiting, abd pain / crying attacks > diarrhoea pyloric stenosis, intussusception, acute appendicitis, necrotizing enterocolitis, Hirschprung disease Metabolic Diabetes mellitus/DKA and Inborn errors of metabolism Other coeliac dis, cows milk protein intolerance, adrenal insuf., Reyes synd Chronic constipation with overflow incont. – spurious diarrhoea

Physical assessment : 

Physical assessment General HEENT Cardiovascular Respiratory Abdomen/Back Urine output Rectal Extremities Skin

Slide 26: 

Physical The following table highlights the physical findings seen with different levels of pediatric dehydration.

Clinical Signs and Symptoms : 

Clinical Signs and Symptoms

Slide 29: 

Skin pinch test showing laxity with dehydration *Pitfall: Skin pinch may not be elicitable in hypernatremic dehydr.

Slide 30: 

Child with severe dehydration Poor GC Drowsy Sunken eyes Chest risen due to deep breathing in response to acidosis

Laboratory Tests that can Help : 

Laboratory Tests that can Help Urine specific gravity Urine electrolytes Fractional excretion of Na+ (UNa/PNa)/(UCr/PCr) Serum electrolytes Serum osmolality 2(Na) + BUN/2.8 + glucose/18 Renal function

Management : 

Management Rehydration + replace ongoing losses ORT Iv fluids Antiemetics Probiotics Nutritional management Zinc supplementation Antibiotics - role Antidiarrhoeals – role

WHO MANAGEMENT GUIDELINES : 

WHO MANAGEMENT GUIDELINES PLAN “ A ” PLAN “ B ” PLAN “ C ”

WHO MANAGEMENT GUIDELINES : 

WHO MANAGEMENT GUIDELINES Plan A for “ No Dehydration ” Objective: Prevention of dehydration It is carried at home ORS administration, in amounts exceeding normal requirements

WHO MANAGEMENT GUIDELINES : 

WHO MANAGEMENT GUIDELINES Plan A for “No dehydration” Continuing normal feeding Ask the parents to bring back the child after 2 days

WHO MANAGEMENT GUIDELINES : 

WHO MANAGEMENT GUIDELINES Plan A for “No dehydration”

WHO MANAGEMENT GUIDELINES : 

WHO MANAGEMENT GUIDELINES Plan B for “Some dehydration” Objective : Correction of dehydration Prevention of malnutrition ORS – 75 ml (50 – 100 ml)/kg over 4hrs Continuing breastfeeding/other feeding Reassessment after 4 hrs - if adequately rehydrated – Plan A - if poor response to ORS – Plan C

WHO MANAGEMENT GUIDELINES : 

WHO MANAGEMENT GUIDELINES Plan “B”

WHO MANAGEMENT GUIDELINES : 

WHO MANAGEMENT GUIDELINES Plan C for “Severe dehydration” Objective: Quick correction of severe dehydration with I V fluids in the hospital

WHO MANAGEMENT GUIDELINES : 

WHO MANAGEMENT GUIDELINES Plan C for “Severe dehydration” < 1 year 30 ml/kg within first hour 70 ml/kg over next 5 hours > 1 year 30 ml/kg within ½ hour 70 ml/kg over next 2-1/2hr

WHO MANAGEMENT GUIDELINES : 

WHO MANAGEMENT GUIDELINES Plan C for “Severe dehydration” Assess every 1- 2 hr -no improvement, IV fluid rapidly -improvement, ORS -after 6 hrs in infants and 3 hrs in older children, opt for the suitable plan A, B or C depending upon the hydration.

Oral Rehydration Therapy : 

Oral Rehydration Therapy

Physiology of Rehydration : 

Physiology of Rehydration Enterotoxins inhibit GTPase activity  cAMP  Cl- secretion  Na+ and fluid loss Preserved reabsorption by Na+ -glucose co-transporter Amino acid stimulated Na+ co-transporter

ORS : 

ORS *clinical trials  Less hyponatremia with Na+ ORS in cholera, but not others

ORS (contd.) : 

ORS (contd.) Other formulations Rice-based ORS Provides more glucose for utilizing glucose coupled Na co-transport Provides amino acids for amino acid coupled NA co-transport Taste – not palatable, difficult to administer Home prepared ORT solution Pinch of salt + 2 teaspoons sugar to 1 litre of boiled cooled water Important to prepare ORS following instructions strictly

Nutritional Management : 

Nutritional Management Appropriate feeding during diarrhea is encouraged Decrease in stool output Shortened duration of illness Significant weight gain Improved nutritional status Duggan, C., & Nurko, S. “Feeding the gut”: Scientific basis for continued enteral nutrition during acute diarrhea. Journal of Pediatrics, 131(6): 801-808.

Nutritional Management : 

Recommendations for nutritional therapy depend on the age and diet of the child. Breast-fed infants Weaned Children Nutritional Management

Nutritional Management : 

Nutritional Management Breast-fed infants Continue nursing on demand ORS http://www.rehydrate.org/html/dia020.html Duggan, C., & Nurko, S. “Feeding the gut”: Scientific basis for continued enteral nutrition during acute diarrhea. Journal of Pediatrics, 131(6): 801-808. http://www.rehydrate.org/html/dia020.html

Nutritional Management : 

Nutritional Management Weaned Children Continuation of regular diet Easily digested diet Complex carbohydrates (rice, potatoes, bread) Lean meats (e.g. chicken) Yogurts, fruits, and vegetables Duggan, C., & Nurko, S. “Feeding the gut”: Scientific basis for continued enteral nutrition during acute diarrhea. Journal of Pediatrics, 131(6): 801-808.

Nutritional Management : 

Nutritional Management Micronutrient supplementation Zinc Vitamin A Folic Acid Duggan, C., & Nurko, S. “Feeding the gut”: Scientific basis for continued enteral nutrition during acute diarrhea. Journal of Pediatrics, 131(6): 801-808.

Nutritional Management - Dos : 

Nutritional Management - Dos Feed as early as possible Milk Continue breastfeeding -  freq Other fluids - coconut water, rice cunjee, soup, yogurt drinks Resume normal (solid) diet when appetite returns Yogurt  lactobacillus Rice / cereal - complex carbohydrates  more glucose and amino acids  fluid reabsorption and stool volume Banana, fruit  K+, high energy, fibre stool bulk - solid Vegetables  fibre Fish / lean meat (proteins)  amino acids help fluid reabsorption Mix with 1-2 teaspoons of vegetable oil

Nutritional Management – Dont’s : 

Nutritional Management – Dont’s Avoid foods high in fat and sugars Commercial fruit juices, cola and sports drinks are inappropriate - sugar content, Na Don’t add sugar or glucose to coconut water Fruit juices should be prepared without adding sugar as far as possible All these can worsen diarrhoea

Drug Therapy : 

Drug Therapy Avoid Adverse reactions Antibiotic resistance Unnecessary costs Claeson, M., & Merson, M. 1990. Global progress in the control of diarrheal diseases. Pediatric Infectious Disease Journal, 9: 345-355.

Slide 55: 

IAP - Chemotherapy

Slide 56: 

IAP - Chemotherapy

Pharmacological measures : 

Pharmacological measures Antiemetics Probiotics Zinc Antibiotics – limited role Antidiarrhoeals – no role

Antiemetics : 

Antiemetics Ondansetron - useful in reducing vomiting over 8 hrs vomiting, oral intake, need for iv fluids, hospital admission A/E: diarrhoeal episodes and representation after discharge. Some other antiemetics suggested:1 Dopamine antagonists – domperidone metoclopramide - not recommended for use in neonates (in any form). A/E: may increase gut motility Promethazine (not recommended for children <2 years in any form) A/E: drowsiness and complicates assessment When to give: during oral replacement / iv replacement Marc Bevan, et al. Proposal for the inclusion of anti-emetic medications (for children) in the who model list of essential medicines. Report - Second Meeting of the Subcommittee of EC on the Selection and Use of Essential Medicines, Geneva, 29 September to 3 October 2008. Elliott EJ, et al. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev 2006;(3):CD005506. Evidence-Based Child Health 2006 (in press). Cited in Elizabeth Jane Elliott. Acute gastroenteritis in children. BMJ 2007;334;35-40.

Probiotics : 

Probiotics Found to  duration of diarrhoea and daily frequency of stools1 Lactobacillus rhamnosus and a mix of L. delbrueckii var bulgaricus, Streptococcus thermophilus, L. acidophilus, and Bifidobacterium bifidum2 Saccharomyces boulardii not shown significant difference 2 1. Allen SJ, Okoko B, Martinez E, Gregorio G, Dans LF. Probiotics for treating infectious diarrhoea. Cochrane Database Syst Rev 2003;(4):CD003048. 2.Canani BC et al. Probiotics for treatment of acute diarrhoea in children: randomised clinical trial of five different preparations. BMJ 2007;335;340;online

Zinc supplementation : 

Zinc supplementation WHO recommends: > 6 months: 20 mg /day for infants < 6 months: 10 mg /day 1 of zinc suppl. for 10–14 days Reduce severity and duration of diarrhoea2 Prevents re-infection3 1.WHO/UNICEF Joint statement – Clinical Management of Acute Diarrhoea 2.Bahl, R., et al., ‘Effect of zinc supplementation on clinical course of acute diarrhoea‘ – Report of a Meeting, New Delhi, 7-8 May 2001. Journal of Health, Population and Nutrition, vol. 19, no. 4, December 2001, pp. 338-346. 3.Bhutta Z.A., Black, R.E., Brown K. H., et al., ‘Prevention of diarrhoea and pneumonia by zinc supplementation in children in developing countries: Pooled analysis of randomized controlled trials’, Zinc Investigators’ Collaborative Group, Journal of Paediatrics, vol. 135, no. 6, December 1999, pp. 689-697.

Role of antibiotics : 

Role of antibiotics Most AGE do not require nor benefit from AB A/E: AB diarrhoea, prolonged Salmonella excretion Indicated for AGE complicated by septicaemia with some bacterial infections Protozoal infections – Giardia, Amoebic desentery Evidence of other systemic or severe local bacterial infection, eg. UTI, pharyngitis, otitis media, septicaemia, meningitis WHO 2005. Management of Common illnesses with Limited Resources (Paediatric) - WHO 2005 Elizabeth Jane Elliott. Acute gastroenteritis in children. BMJ 2007;334;35-40. M S Murphy. Guidelines for managing acute gastroenteritis based on a systematic review of published research. Arch. Dis. Child. 1998;79;279-284

Role of antibiotics - Indications : 

Role of antibiotics - Indications WHO 2005. Management of Common illnesses with Limited Resources (Paediatric) - WHO 2005

Role of antibiotics - Indications : 

Role of antibiotics - Indications WHO 2005. Management of Common illnesses with Limited Resources (Paediatric) - WHO 2005

Role of antidiarrheals : 

Role of antidiarrheals Not recommended Can mask dehydration and ongoing losses Inadequate evidence on safety

NURSING MANAGEMENT : 

NURSING MANAGEMENT

ASSESSMENT : 

ASSESSMENT Record vital parameters Perform physical examination Monitor the intake and output strictly 1/31/2010 ThepowerpointTemplates.com 66

NURSING DIAGNOSIS : 

NURSING DIAGNOSIS Fluid volume deficit related to active loss from gastro intestinal tract Altered family process related to child with a serious illness 1/31/2010 ThepowerpointTemplates.com 67

NURSING DIAGNOSIS : 

NURSING DIAGNOSIS Anxiety related to persistent vomiting and diarrhea Altered nutrition less than body requirement related to poor assimilation of nutritients 1/31/2010 ThepowerpointTemplates.com 68

NURSING DIAGNOSIS : 

NURSING DIAGNOSIS Potential for injury related to increased gastric secretion Potential for fluid volume excess related to over hydration Potential for infections related to the presence of infectious organisms 1/31/2010 ThepowerpointTemplates.com 69

Slide 70: 

Cues Inference Nursing Diagnosis Goal/Plan Intervention/Plan Rationale Evaluation Subjective data:   “6 na beses siyang dumumi sa ngayon tapos matubig, sa ihi naman kakaunti lang 2-3x” as verbalized by the mother.   Objective data:   Increased bowel sounds/peristalsis Frequent, and often severe, mushy stools Changes in stool color   intestinal fluid output overwhelms the absorptive capacity of the GI tract   damage to the villous brush border of the intestine, malabsorption of intestinal contents leading to an osmotic diarrhea, release of toxins that bind to specific enterocyte receptors release of chloride ions into the intestinal lumen, leading to secretory diarrhea. Diarrhea related to presence of toxins as manifested by frequent elimination of mushy stools. After 3 days of Nursing Intervention the patient’s parent/ watcher will:   >Report reduction in frequency of stools,   >return to more normal stool consistency. > Observe and record stool frequency, characteristics, amount, and precipitating factors.   > Identify foods and fluids that precipitate diarrhea, e.g., raw vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products   >Monitor Intake and Output. Note number, character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. Measure urine specific gravity; observe for oliguria.   >Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill. COLLABORATIVE   > Administer parenteral fluids, blood transfusions as indicated.           > Monitor laboratory studies, e.g., electrolytes (especially potassium, magnesium) and ABGs (acid-base balance).   > Administer medications as indicated: Antidiarrheal e.g., dipphenoxylate (Lomotil), loperamide (Imodium), anodyne suppositories   > Electrolytes, e.g., potassium supplement (KCl-IV;K-Lyte, Slow-K);   > Helps differentiate individual disease and assesses severity of episode.   >Avoiding intestinal irritants promotes intestinal rest.             > Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.     > Indicates excessive fluid loss/resultant dehydration             > Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia. Note: fluids containing sodium may be restricted in presence of regional enteritis.   > Determines replacement needs and effectiveness of therapy.         > Reduces fluid losses from intestines.               > Electrolytes are lost in large amounts, especially in bowel with denuded, ulcerated areas, and diarrhea can also lead to metabolic acidosis through loss of bicarbonate (HCO3).   After 3 days of nursing intervention the goal was partially met. The patient’s watcher verbalized a mushy stool and less frequent of defecation.

NURSING MANAGEMENT : 

NURSING MANAGEMENT Out patient care Feeding and nutrition Maintenance 1/31/2010 ThepowerpointTemplates.com 71

Nursing Orders : 

Nursing Orders Write the type of basic fluid D51/2 NS most commonly used on pediatric wards (premixed bags are present) Can create any fluid you desire but may take longer to get if not premixed available Add other electrolytes as desired to the basic fluid Most commonly KCL added at 20 mEq/L but may need more to replace deficit Often only added after first void in dehydrated patients Write how fast you want it to run in ml/hr For example for 15 kg non-dehydrated child write D51/2NS + 20 mEq/L of KCL to run at 50 ml/hr

Patient Rounds : 

Patient Rounds Report total 24 hr intake Report what part of total intake was oral v.s. intravenous v.s. G-tube Subsequently report intake as ml/kg/day for children with weight < 10 kg Intake for children with weight > 10 kg should be reported as % of maintenance For example a 25 kg afebrile child had a total intake of 2000 ml for the past 24 hr, 1600 ml was from iv fluids and 400 ml was po, this represents 125 % of maintenance need for this child

Patient Rounds cont. : 

Patient Rounds cont. Report total 24 hr output Report where this output came from (urine, vomit, diarrhea, chest tube, stoma etc) For the urinary output report this in ml/kg/hr as well

On discharge advice : 

On discharge advice Prescribe ORS Zinc supplements Probiotics How to prepare and give ORS Continue to feed – breastfeeds, fluids and dietary advice Hygeine – handwashing, avoiding bottle feeds, boiled water for drinking How to recognize danger signs of dehydration WHO– lethargy/ irritability, thirst, sunken eyes, skin pinch When to follow-up

Follow-up after discharge : 

Follow-up after discharge Bring child immediately if: Sick Lethargic, LOC Unable to drink or breast-feed Poor drinking UOP Develops fever Blood in stool Not improving for 5 days May need hospital admission

Prevention : 

Prevention

Prevention Strategies : 

Prevention Strategies Breast Feeding Improved weaning practices Proper use of water Hand washing Disposing feces properly Effectiveness of measles vaccination

Prevention : 

Prevention WHO 2006. Ref: Fewtrell L et al. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and metaanalysis. The Lancet Infectious Diseases, 2005, 5(1):42–52.

Medicines under research : 

Medicines under research Racecadotril – antisecretory agent an enkephalinase inhibitor preserves the antisecretory activity of enkephalins does not slow intestinal transit or promote bacterial overgrowth Promising as an adjunctive in stool output in clinical trials Current guidelines do not emphasize use not required in most cases, may be used only as an adjunct as mainstay of treatment is rehydration

New Developments : 

New Developments “Super-ORS” Rotavirus vaccine

Complications : 

Dehydration Metabolic disturbances: Hypernatraemic dehydration lethargy and irritability (particularly marked in hypernatremic dehydration) rapid correction with i.v. fluids  fluid shifts across BBB  cerebral edema  convulsions or even death Hyponatraemia Loss of HCO3- and K+ in stool, poor tissue perfusion,  Metabolic acidosis hypokalaemia hypoglycemia ketosis renal failure Complications may have severe metabolic derangement

Complications : 

Complications Carbohydrate (lactose, glucose) intolerance  milk intolerance Bloody diarrhea (in Shigella, Salmonella, Campylobacter and E. coli O157) HUS (E. coli O157) Iatrogenic complications from inappropriate iv fluid Susceptibility to re-infection Death

Summary : 

Summary Mainstay of treatment is rehydration – saves lives Antiemetics – useful in reducing vomiting, but may diarrhoea Probiotics – useful in diarrhoea duration and freq Nutrition – early feeding improves outcome and re-infection Zinc supplementation - severity and duration of diarrhoea and re-infection Antibiotics – not required and does not benefit in most cases Indicated for Shigella dysentery and septicaemia complicating other bacterial AGE Antidiarrhoeals – should not be used

Case 2 : 

Case 2

Literature : 

Literature Pocket Book of Hospital Care for Children – Guidelines for the Management of Common Illnesses with Limited Resources - WHO 2005 Review of Medical Physiology – WF Ganong Nelsons Paediatrics - Forfar & Arneil’s Textbook of Paediatrics – 6th ed Elizabeth Jane Elliott. Acute gastroenteritis in children. BMJ 2007;334;35-40. M S Murphy. Guidelines for managing acute gastroenteritis based on a systematic review of published research. Arch. Dis. Child. 1998;79;279-284 Practice Parameter: The management of Acute gastroenteritis in young children. Pediatrics1996.97(3);424-435. Managing Acute Gastroenteritis Among Children - Oral Rehydration, Maintenance, and Nutritional Therapy. CDC MMWR. November 21, 2003 / Vol. 52 / No. RR-16 WHO/UNICEF Joint statement. Clinical Management of Acute Diarrhoea. May 2004 Allen SJ, Okoko B, Martinez E, Gregorio G, Dans LF. Probiotics for treating infectious diarrhoea. Cochrane Database Syst Rev 2003;(4):CD003048. Canani BC et al. Probiotics for treatment of acute diarrhoea in children: randomised clinical trial of five different preparations. BMJ 2007;335;340;online Marc Bevan, Elizabeth Seil, Robin Bell and Jane Robertson. Proposal for the inclusion of anti-emetic medications (for children) in the WHO model list of essential medicines. Report - Second Meeting of the Subcommittee of the Expert Committee on the Selection and Use of Essential Medicines, Geneva, 29 September to 3 October 2008

Acute Gastroenteritis : 

Acute Gastroenteritis