Advocacy Morning Report 10.15

Clinic Case- L. Rz-Mz.

CC: 9 month old male, diarrhea X3 days (7-8 episodes per day), non-bloody, no mucus HPI/ROS: Afebrile, decreased PO solids X2 days, taking liquids moderately well, fewer diapers today, + tears, slightly decreased activity, one episode of emesis. No rash PMH/PSH: Term infant, NSVD, born in Utah, previously healthy, no hospitalizations, no surgeries, no regular medications

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Case- L.Rz-Mz. Cont.

FH: (NIDDM, HTN) no immuno-deficiecies, no IBD, celiac or malabsorption syndromes – Cousin in Guatemala died from a diarrheal illness at 6m of age

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SH: Lives w/ parents, maternal aunt and paternal GM, 3 sibs (2, 5, 9: born in Guatemala) – – – – – – – –

In basement apt. in West Valley, UT. Extended family lives upstairs. Family immigrated from Guatemala 1 year ago. 2 and 5y w/diarrhea. No travel or street food. Family drinks bottled water. Family income ~$200/wk. Medicaid insurance coverage only for patient, none of other siblings covered

Physical Exam     

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V/S: T 37.0 HR 140 RR 48 BP 110/55 >98% RA General: Alert, quiet in mother’s arms, cries with exam HEENT: +Tears, dry mucus membranes CV/Chest: Mild tachycardia+ intermittent tachypnea, Capillary refill ~3 sec Abdomen: +Hyperactive BS, Diffuse mild tenderness to deep palpation, no guarding or peritoneal signs Skin: No rashes, no mottling, no skin tenting

Diagnosis? Degree of Dehydration?

La madre’s preoccupationes/preguntas  “Va

mi bebé a morir ?”  If he needs treatment, how can I get my uninsured children treatment?  Is it possible for me to treat them all at home?

L. Rz-Mz.’s diagnosis  1.

Acute Gastro-enteritis  2. Moderate dehydration  3. Management: How would you manage L. Rz-Mz’s case? – Further work-up? – Approach to mother’s concerns  4.

Treatment Options

Expanded Work-up ?? 

Estimate fluid deficit based on hydration status – Weight (kg) X (% dehydration) = __x1000 = __ mL for resuscitation

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Electrolytes (markers of deyhdration: HCO3 (low/N), hypernatremia (high/N), BUN (high/N), Potassium (low/N) Stool studies (based on clinical history) – – – –

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Viruses: Rota, adenovirus Stool for culture Stool for C. Difficle A/B toxins Ova and Parasites (only accepted by lab if +travel history) – Stool electrolytes Other (KUB, UA/Urine Cx, Celiac disease, endocrine studies, toxicology screen, CA wk-up)

Advocacy Morning Report A Culturally Sensitive Approach to Diarrhea Associated Mild-Moderate Dehydration

Lindsay Hatzenbuehler MD MPH October 16, 2009

Presentation Outline  Introduction

(*Recognition of disease burden)  Parent perceptions of illness (*Parent advocacy)  Evidence Based Medicine: Indications for current management (*RCT)  Management Recommendations

Introduction: Diarrheal Disease Burden 

U.S. – Each child <5 y has 1.2-2.7 episodes of diarrhea/yr – 3 million outpatient visits  $1 billion in healthcare costs

– 1.4% are hospitalized  Accounts for 10.6% of hospitalizations  Resulting in >200,000 hospitalizations/yr – 300 <5yr die from diarrhea associated illness  Averages to <0.0001% of deaths in this age group  Risk factors: prematurity, infancy, African-American race, living in the Southern USA, living in metropolitan areas

Disease Burden cont. 

Internationally: – 99 million DALYs lost due to diarrhea associated morbidity & premature deaths in <5y – <5y diarrhea associated mortality  1975 4.5 million deaths/yr  2002 1.6 million deaths/yr* – Accounts for 16-18% of deaths from all causes – 80% die <2yrs of life – 42,000/wk, 6,000/d, 4/minute, 1/14sec

– Risk factors: Poor sanitation*, malnutrition*, lack of access to health care/resuscitative measures*

Intl’ Disease Burden cont. 

Guatemala – <5 MR 45/1000 live births – <5y diarrhea associated mortality 13% of deaths from all causes – 6th cause of death in all ages

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Mexico – <5 MR 28/1000 live births – <5y diarrhea associated mortality 5% of deaths from all causes – Not included in top ten all cause deaths

Back to L. Rz-Mz.’s Case  1.

Acute Gastro-enteritis  2. Moderate dehydration  3. Expanded Work-up?  4. Approach to mother’s concern  5. Treatment options

Approach to Mother’s Concerns  Try to understand the source of her questions – Immigrant population   

Western Medicine is viewed as foreign Medical care usually NOT as accessible Home remedies (herbal/home preparations) are often used first

– International MR from diarrhea associated causes are much higher than in the U.S. ~18% Intl’, 13% Guatemala 

Are her questions legitimate concerns? – “Va mi bebé a morir ?” – If he needs treatment, how can I get my uninsured children treatment? – Is it possible for me to treat them all at home?

Diarrheal Associated Dehydration: Parent Perceptions  “The

impact of rotavirus gastroenteritis on the family.” – Mast TC, DeMuro-Mercon C,Lelly CM, Floyd LE, Walter EB. BMC Pediatrics. Feb 2009, 9:11 – Duke Clinical Research Institute – Protocol by Merck Research Laboratories

 Design:

Observational study (qualitative) case-control frequency statistics comparison, in 2006 pre-RotaTeq  Study subjects: English literate parents and children (n=62) 2-36 months with acute GE < 3 days prior, Feb-March, ED + outpt. Clinics  Methods: GE severity scored* (mild, moderate, severe), Stool samples tested for Rota, parent interviews

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Results: Stool collected n=43/62 – 27/43 = 63% were R+  ED visit 100% > Outpt 53% p =0.03  No difference in age in R+ vs. R At enrollment, R+ GE scores 10.64 > 7.25 p =0.0016 – R+ 92% vs. R- 38% moderate/severe illness

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Parent interviews only of R+ pt n = 17 – On illness severity, transmission, emotions, schedule disruption, seeking medical care, economic impact and Rota vaccine development

Parent responses 

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Illness severity: – …we were…concerned…he had only one wet diaper in that whole 24 hr period and couldn’t keep ice chips down – …After church… I fed him lunch, and he threw up from then until Wednesday. …He got so dehydrated we had to bring him to the ER. Emotions: – I was horrified…I know when the kidneys shut down. That was my main concern; he wasn’t drinking anything, eating anything. – My husband was scared. He said you got to take her to the doctor now. – Very very anxious because he was so lethargic…it was very scary as a parent

 Diarrheal

Major Study Conclusions

illness substantially impacts family life  Parents sought health care due to concerns for severe disease/dehydration  Rotavirus vaccination supported  Recommendations: – health care providers should provide support and education of parents – “Families should be encouraged to have a supply of ORS at all times…and to start therapy as soon as the diarrhea begins”

Back to L. Rz-Mz.’s Case     

1. Acute Gastro-enteritis 2. Moderate dehydration 3. Expanded Work-up? 4. Approach to mother’s concern 5. Treatment options – If he needs treatment, how can I get my uninsured children treatment? – Is it possible for me to treat them all at home?

Management of Mild/Moderate Diarrhea Associated Dehydration 

AAP Practice Parameter: The Management of Acute Gastroenteritis in Young Children (Ages 1m-5y) (Pediatrics March 1996). – Children w/o dehydration can be fed normally – ORT is preferred in children with mild to moderate dehydration  Most dehydrated children will not refuse ORT  Start slowly + Check hydration status q2 hrs

– Children should be fed as soon as hydrated – Pharmacologic agents should not be used to treat acute gastroenteritis

CDC Recommendations  “The

management of acute diarrhea in children: oral rehydration, maitenence, and nutritional therapy.” MMWR. 1992;41 1-20.  “…families with…small children… should be encouraged to keep a supply or ORS…all times [to]use...when diarrhea first occurs.”

ORAL Treatment Options:

C-ORS vs. WHO-ORS  “The

World Health Organization Oral Rehydration in US Pediatric Practice: A Randomized Trial to Evaluate Parent Satisfaction.” – Ladinsky M, Duggan A, Santosham S, Wilson M. Arch Ped Adolesc Med. Vol 154. Jul 2000.

C-ORS

Vs.

WHO-ORS

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Background: US practitioners rarely use WHO-ORS as an inexpensive alternative to C-ORS due to concerns about parent satisfaction. – C-ORS ($6/L Pedialyte), WHO-ORS packets ($0.55/L)  Equal Osmolality, WHO >NaCl,
– Few Medicaid and commercial insurance plans cover C-ORS

Objective: Compare caretaker satisfaction of prepared C-ORS with WHO-ORS packet based solution Design: RCT, 3-47m outpt management of diarrhea (<7d) randomized to 2 groups, phone interview f/u 48 hrs

Results: 97 families randomized* (primarily low-middle income in govt. assistance program) -(94%) participated in f/u interviews

Study Conclusions 

Caregivers who prepared WHO-ORS were more satisfied than C-ORS group – Absolute difference 36%*

Fear of parental dissatisfaction need not be a barrier to use of WHO-ORS in the U.S.  Lower cost products can be purchased by outpatient providers and dispensed to families at time of treatment 

– “They could also be provided at health maintenance visits to be kept at home for use in time of need.”

Homemade C-BORS vs. Packet C-BORS vs. C-ORS  “Safety

and Effectiveness of Homemade and Reconstituted Packet Cereal-based ORS: A Randomized Clinical Trial.” Meyers et al. – Pediatrics. Vol 100;5. Nov 1997

 Study

population: 232 children randomized to 3 treatment arms – – –

homemade CBORS (n=66) packet CBORS (n=68) Pedialyte (n=69)

 Instructions

given in specific language, F/U visits by home nurses, serum sodium values measured, rates of illness compared

Study Results 

203/232 (88%) completed the study – 76% Latino American – 84% participated in WIC

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Two parents in homemade 2/66 (0.03%), and one parent in packet group 1/68 (0.014%) made mixing errors – – –

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Resulted in high sodium >100meq/L cereal Children REFUSED the cereal All the children had normal serum sodium values

No difference in diarrhea, vomiting, or rate of hospitalization between groups

Study Conclusions  

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The lack of difference in outcomes may be due to mild illness in overall study group “homemade CBORS is not the safest alternative [due to potential]…mixing errors…[but] packet CBORS was diluted correctly…which can also occur with a commercial solution” A pre-packaged solution may represent the best way to ensure that families have ORS at home – could be distributed readily at primary care facilities – cost may need to be subsidized

International Studies 

Use of homemade ORS solutions/WHO packets have shown success – “A Randomized Community Trial of Prepackaged and Homemade Oral Rehydration Solutions.” Kassaye et al. Arch Ped Adol Med. Vol 148. 1288-1292. Dec 1994. (ETHIOPIA) – “A Quantitative assessment of the Nigerian mother’s ability to prepare salt-sugar solution for home management of diarrhea.” J Royal Soc Health. 1994; 108: 55-59. – “Safety of rapid intravenous rehydration and comparative efficacy of 3 oral rehydration solutions in the treatment of severely malnourished children with dehydrating cholera.” Alam et al. J Pediatr Gastroenterol Nutr. 2009 Mar;48(3):318-27 (BANGLADESH) – “Oral zinc for treating diarrhoea in children” Cochrane Database of Systematic Reviews. 16 July 2008

Treatment for Mild-Moderate Dehydration Secondary to Diarrhea  

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Continue breastfeeding Encourage PO fluid intake with a recommended “Rehydration solution” in small quantities Commercially available-ORS – –

Pre-made: Pedialyte Packets: Ceralyte, WHO packets  Consider buying for practice distribution

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If you trust the family: teach preparation of a homemade ORS solution Advise parents to watch for further dehydration symptoms

Home Recipes rehydrate.org

Take Home Points: Clinical application  Diarrhea

is VERY common in infants and children (especially Internationally)  Dehydration is often associated with diarrhea and can lead to death  Children should be watched carefully  Severe diarrhea causes parents great stress – PCPs should sympathize with parents, especially immigrants

Take Home Points Continued  PCPs should recommend that parents with 

infants and children should have ORS available at home Pedialyte is NOT the only option – Expensive and is often not covered by Medicaid

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Other options: – WHO-ORS packet promotion (cheap option for pediatric practices to distribute)  Call Jianas Brothers (Kansas City, MO) 816-421-2880 – 1 carton (125 packets) $68.75

– Recipe hand outs (for trustworthy parents)

References 

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“A Randomized Community Trial of Prepackaged and Homemade Oral Rehydration Solutions.” Kassaye et al. Arch Ped Adol Med. Vol 148. 12881292. Dec 1994. (ETHIOPIA) “ Safety of rapid intravenous rehydration and comparative efficacy of 3 oral rehydration solutions in the treatment of severely malnourished children with dehydrating cholera.” Alam et al. J Pediatr Gastroenterol Nutr. 2009 Mar;48(3):318-27 (BANGLADESH) “Oral zinc for treating diarrhoea in children” Cochrane Database of Systematic Reviews. 16 July 2008 “The impact of rotavirus gastroenteritis on the family” Mast TC, DeMuroMercon C,Lelly CM, Floyd LE, Walter E BMC Pediatrics. 2009, 9:11

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AAP Practice Parameter: The Management of Acute Gastroenteritis in Young Children (Ages 1m-5y) (Pediatrics March 1996).

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“The World Health Organization Oral Rehydration in US Pediatric Practice: A Randomized Trial to Evaluate Parent Satisfaction.” “Saftey and Effectiveness of Homemade and Reconstituted Packet Cerealbased ORS: A Randomized Clinical Trial. Meyers et al. Pediatrics. Vol 100;5. Nov 1997 Ladinsky M, Duggan A, Santosham S, Wilson M. Arch Ped Adolesc Med. Vol 154. Jul 2000. http://rehydrate.org/solutions/homemade.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm http://search.ebscohost.com/login.aspx? direct=true&db=chh&AN=CD005436&site=ehost-live

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