Posted: July 2nd, 2024

Acute Gastroenteritis in Infants: A Case Study Analysis

Acute Gastroenteritis in Infants: A Case Study Analysis

This paper examines a case study of a 4.5-month-old female infant presenting with acute gastroenteritis, dehydration, and metabolic acidosis. The analysis explores the clinical presentation, diagnostic considerations, and management strategies for this common pediatric condition.

Clinical Presentation and Diagnosis

The patient exhibited classic symptoms of acute gastroenteritis, including vomiting, diarrhea, fever, and irritability. These symptoms persisted for four days prior to hospital presentation, with a notable deterioration in the child’s condition despite home management attempts. The acute onset and duration of symptoms (less than 14 days) classify this case as acute rather than chronic diarrhea (Shane et al., 2017).

Physical examination revealed several signs indicative of significant dehydration:
– Lethargy and irritability
– Sunken eyes with dark circles
– Depressed anterior fontanelle
– Cool skin with poor elasticity
– Delayed capillary refill time
– Tachycardia and tachypnea
– Dry, cracked lips and rugged tongue
– Sunken abdominal wall

Laboratory findings further supported the diagnosis of dehydration and metabolic acidosis:
– Elevated BUN and creatinine levels
– Decreased serum bicarbonate (11 meq/L)
– Acidic blood pH (7.31)
– Elevated urine specific gravity (1.029)

The presence of watery, non-bloody stools and the absence of leukocytes or bacterial pathogens on stool examination suggest a non-inflammatory, likely viral etiology. The physician’s assessment of rotavirus as the probable cause aligns with epidemiological data showing rotavirus as a leading cause of acute gastroenteritis in young children (Troeger et al., 2018).

Pathophysiology and Clinical Implications

The pathophysiology of viral gastroenteritis primarily involves increased intestinal secretions and impaired absorption. This leads to fluid and electrolyte losses through diarrhea and vomiting, resulting in dehydration and potential acid-base disturbances (Dekate et al., 2021).

Infants are particularly vulnerable to rapid dehydration due to their high metabolic rate and proportionally greater body water content. The patient’s 10% weight loss over 10 days indicates severe dehydration, necessitating prompt intervention. The metabolic acidosis observed likely results from a combination of bicarbonate loss in diarrheal stools and lactic acidosis from decreased tissue perfusion.

Management Approach

The initial management focused on fluid resuscitation and electrolyte correction through intravenous administration of D5W with electrolytes. This approach aims to rapidly restore intravascular volume, improving tissue perfusion and correcting metabolic derangements. Oral rehydration was withheld initially to allow gastrointestinal rest and prevent exacerbation of vomiting.

Isolation precautions were implemented to prevent nosocomial spread, an important consideration given the high infectivity of viral gastroenteritis pathogens. The gradual reintroduction of oral fluids and progression to formula feedings aligns with current guidelines for managing acute gastroenteritis in infants (Guarino et al., 2018).

The patient’s clinical improvement, as evidenced by normalization of vital signs and improved hydration status, supports the effectiveness of the chosen management strategy. Follow-up care and parental education on oral rehydration and feeding practices are crucial components in preventing recurrence and ensuring optimal recovery.

Conclusion

This case highlights the importance of prompt recognition and management of acute gastroenteritis and dehydration in infants. While most cases are self-limiting, severe dehydration can lead to significant morbidity if not addressed appropriately. A systematic approach to assessment, diagnosis, and treatment, coupled with close monitoring and follow-up, is essential for optimal outcomes in pediatric gastroenteritis cases.

References

Dekate, P., Jayashree, M. and Singhi, S.C., 2021. Management of acute diarrhea in emergency room. Indian Journal of Pediatrics, 88(6), pp.603-613.

Guarino, A., Lo Vecchio, A., Dias, J.A., Berkley, J.A., Boey, C., Bruzzese, D., Cohen, M.B., Cruchet, S., Liguoro, I., Salazar-Lindo, E. and Sandhu, B., 2018. Universal recommendations for the management of acute diarrhea in nonmalnourished children. Journal of Pediatric Gastroenterology and Nutrition, 67(5), pp.586-593.

Shane, A.L., Mody, R.K., Crump, J.A., Tarr, P.I., Steiner, T.S., Kotloff, K., Langley, J.M., Wanke, C., Warren, C.A., Cheng, A.C. and Cantey, J., 2017. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clinical Infectious Diseases, 65(12), pp.e45-e80.

Troeger, C., Khalil, I.A., Rao, P.C., Cao, S., Blacker, B.F., Ahmed, T., Armah, G., Bines, J.E., Brewer, T.G., Colombara, D.V. and Kang, G., 2018. Rotavirus vaccination and the global burden of rotavirus diarrhea among children younger than 5 years. JAMA Pediatrics, 172(10), pp.958-965.

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Patient Case
Mother’s Chief Complaints
“Our daughter has been vomiting and has had diarrhea for three days. She also has had a fever, but I’ve been giving her acetaminophen every six hours. The clear liquids and Pedialyte that she has been drinking don’t seem to be helping much and she looks so sickly.”
HPI
J.L. is a 41 ⁄2-month-old Asian American female infant who was taken to the emergency room of a local hospital because her parents were concerned about vomiting, diarrhea, fever, and irritability. The patient was in good health until four days prior to presentation when she felt
warm to her mother. The patient attends daycare, and other children at the daycare center have had similar symptoms recently.
During the first day of her illness, she continued to take normal feedings of Similac with iron formula (approximately 6 ounces every six hours) and an occasional feeding of rice cereal. However, by the second day, her appetite had decreased significantly and she began to have frequent, loose, and watery stools (i.e., 6–8/day). During the 12 hours prior to presentation, J.L. had eight watery stools. The stools did not appear to contain blood. Early on the morning of the second day of illness, the patient vomited shortly after feeding. The vomitus was non-bloody. She continued to vomit after each feeding for the next two meals and
became increasingly more irritable. The mother called her pediatrician, who recommended 12 hours of clear liquids, including weak tea with sugar, Pedialyte, and warm 7-Up. Except for one episode in the past 48 hours, vomiting improved but diarrhea continued despite these measures. Over the following two days, fever was intermittent and the child became more lethargic. The parents continued the clear liquids that the doctor had ordered.
On the day of presentation at the hospital, the mother stated that her daughter had a temperature of 101.5°F, was sleepy but very irritable when awake, and had fewer wet diapers than normal. She also noted that her daughter’s skin was cool to the touch, her lips were dry and cracked, and her eyes appeared sunken with dark circles around them. At a doctor’s appointment 10 days prior to presentation, the patient’s weight was 14.5 lbs.
Patient Case Question 1. Is this patient’s diarrhea considered acute or chronic?

CASE STUDY DIARRHEA
For the Disease Summary for this case study,

PMH
• Born at 37 weeks’ gestation following uncomplicated labor and spontaneous vaginal delivery to a 23 yo Asian American female
• Apgar scores were normal at 9 and 9 at one and five minutes after birth
• Weighed 7.7 lbs at birth
• Benign heart murmur observed at birth; no other complications
Maternal History
• Uncomplicated delivery
• During her pregnancy, she experienced one episode of bacterial vaginosis that responded to metronidazole
• Prenatal medications: prenatal vitamins and iron supplement
• Denies use of alcohol, tobacco, and illicit drugs
Immunizations
Shots are up-to-date, including hepatitis B vaccine
All
NKDA
FH
• Asian American mother (23 yo) and father (35 yo), both in good health
• No siblings
SH
• Both parents work outside of the home and patient attends daycare regularly
• Family has one cat, and their home is supplied with city water
PE and Lab Tests
Gen
Patient is ill-appearing and lethargic but is arousable with stimulation. There is no muscle twitching. The anterior fontanelle is depressed and the eyes are sunken and dark. The skin is cool. Abdominal skin shows poor elasticity (skin remained in folds when pinched).
VS
See Patient Case Table 22.1
Patient Case Table 22.1 Vital Signs
BP 85/55 RR 51 WT 13.0 lbs (10% weight
loss in past 10 days)
P 156 T (rectal) 101.1°F SaO2 98%

GASTROINTESTINAL DISORDERS
Skin
• No rashes or lesions
• Skin turgor subnormal
• Capillary refill time delayed to 5 seconds
HEENT
• Pupils equal, round, and responsive to light
• TMs gray and translucent
• Nose clear
• Tongue dry and rugged
Neck/LN
Supple and otherwise normal with no enlarged nodes
Lungs/Thorax
• Tachypneic
• No crackles or wheezes
Heart
• Tachycardic
• No murmurs noted
Abd
• Anterior abdominal wall is sunken and presents a concave (rather than normal convex)
contour
• (
) BS
• Soft, NT/ND
• No masses or HSM
Genit/Rect
• Normal female external genitalia
• Greenish, watery stool in diaper
MS/Ext
• Weak peripheral pulses
• Muscle tone normal at 5/5 throughout
Neuro
• Lethargic and sleepy but arousable
• Irritable and crying when awake but no tears noted
• No focal defects noted
Laboratory Blood Test Results
See Patient Case Table 22.2

UA
Normal except for SG 1.029
Stool Examination
() leukocytes and bacterial pathogens
Patient Case Question 2. The emergency room physician’s assessment of the patient’s
condition was that of viral gastroenteritis, probably due to rotavirus, with dehydration and metabolic acidosis. Provide a minimum of eight clinical signs and symptoms that support an assessment of viral gastroenteritis.
Patient Case Question 3. Provide a minimum of fifteen clinical signs and symptoms that support an assessment of dehydration.
Patient Case Question 4. Provide a minimum of five clinical signs and symptoms that support an assessment of metabolic acidosis.
Patient Case Question 5. Is this patient’s diarrhea considered mild or severe?
Patient Case Question 6. Is this patient’s diarrhea technically considered inflammatory or non-inflammatory?
Clinical Course
J.L. was hospitalized and an intravenous catheter was inserted. Fluid loss from emesis and bowel movements was replaced with intravenous D5W and electrolytes. No oral fluids were given during the first 24 hours. The infant was also placed in isolation to prevent transmission of possible infectious microbes to other patients or to hospital personnel. J.L. became more active and alert. Her heart rate improved to 120, respirations to 40, blood pressure to 90/58, and urine specific gravity to 1.020. On the second hospital day, oral feedings of Pedialyte and one-fourth strength infant formula were introduced. Intravenous fluids were discontinued after determination that oral intake was sufficient to sustain an adequate fluid
volume.
J.L. was discharged from the hospital on the fourth day and her parents were instructed to continue oral feedings. The infant was seen in the pediatric outpatient clinic on the fifth day after her discharge. She was taking infant formula without diarrhea (approximately
25 ounces/24 hours) and had gained a half pound since her discharge. Physical examination findings were within normal limits.
Patient Case Question 7. Which of the following factors contributes most prominently
to an infant’s vulnerability to dehydration?
Patient Case Table 22.2 Laboratory Blood Test Results
Na 137 meq/L Hb 13.1 g/dL WBC 12,800/mm3
K 4.4 meq/L Hct 40% • Neutros 33%
Cl 112 meq/L Plt 220,000/mm3 • Bands 3%
HCO3 11 meq/L ESR 18 mm/hr • Lymphs 55%
BUN 23 mg/dL pH 7.31 • Monos 7%
Cr 1.3 mg/dL PaO2 96 mm Hg • Basos 1%
Glu, fasting 95 mg/dL PaCO2 22 mm Hg • Eos 1%
GASTROINTESTINAL DISORDERS
a. a significantly lower percentage of an infant’s total body weight is water when compared with older children and adults
b. an infant’s basal metabolic rate is lower than an adult’s basal metabolic rate
c. infants normally have a very high rate of water turnover when compared with older
children and adults
d. an infant’s body weight is composed of a greater proportion of fat than is an adult’s body weight
Patient Case Question 8. Which of the following pathophysiologic mechanisms best
explains this patient’s diarrhea?
a. increased intestinal motility is the result of a neuroendocrine condition
b. an infectious agent in the gastrointestinal tract has probably promoted gastrointestinal secretions while, at the same time, impaired absorption capability
c. both a and b
d. none of the above
Patient Case Question 9. The immediate goal of rapid infusion of intravenous fluids during treatment of dehydration is to replace fluid in which of the following fluid compartments of the body?
a. intracellular
b. intravascular
c. interstitial
d. joint spaces
e. abdominal, pleural, and pericardial cavities
Patient Case Question 10. Vomiting and diarrhea result in hydrogen ion disturbances
by causing . . .
a. decreased blood flow and shifting of cells from aerobic metabolism to anaerobic
metabolism, which results in the production of lactic acid
b. decreased renal function and decreased excretion of hydrogen ions in the urine
c. a significant bicarbonate loss in diarrheal stools
d. two of the above
e. three of the above
f. none of the above
Patient Case Question 11. Based on the patient’s electrolyte levels, which of the following types of dehydration did she have?
a. isonatremic
b. hyponatremic
c. hypernatremic
d. hypokalemic
e. hyperkalemic
Patient Case Question 12. If the patient has a serum osmolality of 280 mmol/kg H2O, a serum sodium concentration of 140 mmol/L, and a serum potassium concentration
of 4.0 mmol/L . . .
a. what is the osmotic gap?
b. can the patient have chronic osmotic diarrhea?

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Tags: Acute Gastroenteritis in Infants: A Case Study Analysis, Diarrhea case study, J.L. is a 41 ⁄2-month-old Asian American female infant who was taken to the emergency room of a local hospital, Our daughter has been vomiting and has had diarrhea for three days