Contemporary gastroenteritis of infancy: clinical features and prehospital management.

In a prospective survey carried out over 12 months 447 children aged under 2 years were admitted to the Manchester Regional Infectious Diseases Unit for treatment of gastroenteritis. Comparison of the children with those in a survey 15 years previously in the same unit showed that the illness was milder than in the earlier series, with no deaths and with lower incidences of hypernatraemia (1%), uraemia (8%), and dehydration (14%). These improved findings occurred despite several deficiencies of care in the prehospital phase of the illness, particularly poor compliance with the widely recommended guidelines for fluid and dietary management in infantile gastroenteritis.     

A Survey of Infantile Gastroenteritis

In 1967 we admitted 339 cases of infantile gastroenteritis; one-third of these were dehydrated, and in this group the commonest biochemical abnormality found was hypernatraemia, sometimes with metabolic acidosis. A higher incidence of dehydration was found in the patients who had received oral glucose fluids before admission. Enteropathic Escherichia coli were isolated from the faeces of 16% of the cases. Associated infections, especially of the respiratory tract, were common. Treatment was aimed at the restoration of fluid and electrolyte balance. Usually this was achieved with oral fluids, though intravenous fluids were used in the most severely dehydrated cases. Recovery was complete in 320 cases and a further 14 cases were discharged as carriers of enteropathic E. coli. There were five deaths (1·5%) in the series; three occurred immediately after admission.     

Blood histamine levels (BHL) in infants and children with respiratory and non-respiratory diseases

BACKGROUND: Blood histamine levels are decreased after severe allergic reactions and in various chronic diseases. AIMS: To study blood histamine levels in infants and children with acute infectious and non-infectious, non-allergic, disease. METHODS: Blood histamine levels were investigated by a fluorometric method in infants and children admitted to hospital with bronchiolitis, non-wheezing bronchitis, acute infections of the urinary tract, skin and ear-nose-throat, gastroenteritis, or hyperthermia of unknown aetiology. Results of blood histamine levels and white blood cell counts were compared with those obtained for children recovering from benign non-infectious, non-allergic illnesses. RESULTS: As compared with control children, white blood cell numbers were significantly increased in children with acute infections of the urinary tract, skin and ear-nose-throat, and were significantly decreased in children with gastroenteritis. Blood histamine levels were significantly lower in children with gastroenteritis and hyperthermia than in children with other diseases and control children. It was not possible to correlate blood histamine levels and the number of blood basophils. CONCLUSIONS: BHL are significantly decreased in infants and children with acute gastroenteritis and hyperthermia of unknown aetiology. The mechanisms responsible for the decrease in blood histamine levels in children with gastroenteritis and hyperthermia are discussed.     

Electron microscopy in the diagnosis of viral gastroenteritis in hospitalised children in the Czech Republic

Our study has been aimed at demonstrating the main role of viruses in the aetiology of acute gastroenteritis in children less than 5 years old and at pointing out the diagnostic potential of electron microscopy in the diagnosis of viral gastroenteritis. A prospective study was conducted to analyse the aetiology of diarrhoeal diseases in children less than 5 years of age admitted to the Department of Infectious Diseases between September 2006 and December 2008. All children were tested by faecal culture, latex agglutination and electron microscopy. A total of 832 children were included in the study. An aetiological agent was detected in 788 children (94.6 %). A bacterial aetiology was found in 22 (2.6 %) children and bacterial–viral co-infection was found in 146 (17.6 %) patients. The most frequent causative agents of gastroenteritis in children were viruses, which were detected in 620 (74.5 %) patients. The main causes of viral gastroenteritis were rotaviruses (detected in 410 children), followed by caliciviruses (42), coronaviruses (28), adenoviruses (19) and astroviruses (14). Dual viral infections were detected in 107 children, with rotavirus–calicivirus co-infection being the most common. Electron microscopy proved to be a more sensitive method in comparison with the latex agglutination test for the diagnosis of rotaviruses and adenoviruses. The major role of viruses in diarrhoeal diseases among children under 5 years of age in the Czech Republic has been confirmed. The diagnostic potential of electron microscopy, particularly in small outbreaks of gastroenteritis, was clearly shown.     

Childhood gastroenteritis: a population study.

A prospective study of gastroenteritis based on a population was carried out for 12 months on over 7000 children in general practice. The incidence of gastroenteritis was highest in the first year (127.7 children affected per 1000) and second year (90.8) of life, and gastroenteritis was rare after six years of age. Children from urban areas had gastroenteritis more commonly than children from semirural areas. A potential pathogen was isolated from half of the specimens: 78% were viruses, and rotavirus was identified most often.     

Rotavirus and adenovirus in Rondônia

Acute gastroenteritis is one of the most common diseases in humans worldwide. Viral gastroenteritis is a global problem in infants and young children. In this study the incidence of diarrhea was assessed in 877 hospitalized children under five years old, over a period of 24 months and distributed in 470 cases of diarrhea and 407 age-matched group with other pathologies, as control group. Two antigen detection techniques based on enzyme immunoassay (EIA) and latex particles were used for detection of rotavirus and adenovirus. Rotavirus A was a major cause of gastroenteritis with 23.6% of cases, being 90% of these cases in young children. Adenovirus infections was detected by EIA with frequency of 6.4%. Rotavirus and adenovirus were detected in 10.1 and 1.7% of stools from control group, respectively. Interestingly, the frequency of the youngest children in the control group excreting Rotavirus A was comparable to that detected in stools from diarrheic children. We cannot rule out the existence of other enteric viruses because the etiology of 171 cases of diarrhea was not determined and active search for astrovirus and calicivirus was not done. This is the first study that shows the presence of enteric viruses in the infantile population from Western Brazilian Amazonia and it was important to help physicians in the treatment of viral gastroenteritis.     

Detection and molecular characterization of adenoviruses in Korean children hospitalized with acute gastroenteritis

Human adenoviruses (HAdVs) are an important cause of acute gastroenteritis in children. However, few studies on the epidemiology or types of HAdVs associated with acute gastroenteritis have been conducted in Korea. Therefore, in the present study, the incidence of HAdV in 2064 stool samples from Korean children hospitalized with acute gastroenteritis (2004-2006) was assessed and the types of viruses present determined. Polymerase chain reaction, sequencing, and phylogenic analyses revealed that 113 samples (5.5%) were HAdV-positive. While HAdVs were mainly detected during July to October, no seasonal difference between the enteric and non-enteric viruses in the incidence of HAdV was observed. HAdV-41 and HAdV-40 were found in 54 (47.8%) and 3 (2.6%) HAdV-positive samples, respectively. HAdV-3, HAdV-7, HAdV-2, HAdV-31, HAdV-4, and HAdV-37 were detected in 11 (9.7%), 5 (4.4%), 2 (1.7%), 2 (1.7%), 1 (0.8%), and 1 (0.8%) of sample(s), respectively. Thus, not only enteric, but also non-enteric, HAdVs may play an important role in acute gastroenteritis in Korean children.     

The Changing Pattern of Rheumatic Fever in Childhood

The manifestations of acute rheumatic fever were compared in 231 children admitted to hospital from 1937 to 1940 with those in 252 children admitted from 1957 to 1960. Of the 178 in the early group seen during an initial attack, 82 had cardiac involvement; of these, 12 died early. Of the 218 patients in the later group with an initial attack, 96 had cardiac involvement; of these, two died early. Despite this decrease in early mortality, the incidence of isolated mitral value involvement (73% in the early group and 62% in the later group) and the incidence of congestive failure (20% and 13%) were similar. This reduction in the number of early deaths may be due to lowered virulence of the streptococcus, improved socioeconomic conditions, or therapy with penicillin and corticosteroids. The incidence of chorea and the frequency of recurrences were also less in the later group.     

Clostridium difficile and its cytotoxin in infants admitted to hospital with infectious gastroenteritis.

During a prospective study of infectious gastroenteritis in children under 2 years, 19 out of 390 patients (4.9%) were found to have Clostridium difficile cytotoxin in the faeces. In several there was no history of use of antibiotics. The symptoms of many infants with toxin settled spontaneously, but one child became acutely and severely ill and developed a toxic megacolon and five others required, and responded to, vancomycin. Cl difficile was cultured from the stools in 191 (49%) of the children. The highly significant increased prevalence of past use of antibiotics in 118 control patients was not associated with an increased incidence of either isolation of Cl difficile or presence of faecal cytotoxin. Cl difficile should not be overlooked as a cause of acute diarrhoea and vomiting in children under 2 years.     

Pediatric in-Hospital Death from Infectious Disease in Uganda: Derivation of Clinical Prediction Models

Background

Pediatric hospital mortality from infectious diseases in resource constrained countries remains unacceptably high. Improved methods of risk-stratification can assist in referral decision making and resource allocation. The purpose of this study was to create prediction models for in-hospital mortality among children admitted with suspected infectious diseases.

Methods

This two-site prospective observational study enrolled children between 6 months and 5 years admitted with a proven or suspected infection. Baseline clinical and laboratory variables were collected on enrolled children. The primary outcome was death during admission. Stepwise logistic regression minimizing Akaike’s information criterion was used to identify the most promising multivariate models. The final model was chosen based on parsimony.

Results

1307 children were enrolled consecutively, and 65 (5%) of whom died during their admission. Malaria, pneumonia and gastroenteritis were diagnosed in 50%, 31% and 8% of children, respectively. The primary model included an abnormal Blantyre coma scale, HIV and weight-for-age z-score. This model had an area under the curve (AUC) of 0.85 (95% CI, 0.80–0.89) with a sensitivity and specificity of 83% and 76%, respectively. The positive and negative predictive values were 15% and 99%, respectively. Two alternate models with similar performance characteristics were developed withholding HIV and weight-for-age z-score, for use when these variables are not available.

Conclusions

Risk stratification of children admitted with infectious diseases can be calculated based on several easily measured variables. Risk stratification at admission can be used for allocation of scarce human and physical resources and to guide referral among children admitted to lower level health facilities.     

Apparent disapperance of hypernatraemic dehydration from infant deaths in Sheffield.

The death certificates and necropsy reports of the 1115 Sheffield infants who died under 2 years of age in 1969-78 were examined. This study showed the apparent disappearance of deaths with hypernatraemia and in particular deaths presenting as cot deaths. The fall in incidence may be as much the result of an intensive local campaign on child care and infant feeding as of the change in the composition of dried milk for baby feeding.     

Reducing accident death rates in children and young adults: the contribution of hospital care. Steering Committee of the Major Trauma Outcome Study Group.

OBJECTIVE: To assess the contribution of trauma care to the recent decline in accident death rates among children and young people. DESIGN: Logistic regression modelling of temporal trends in the probability of death in patients admitted to hospital for the treatment of severe injury. SETTING: Hospitals participating the United Kingdom major trauma outcome study. SUBJECTS: 3230 patients with an injury severity score of 16 or more, who were admitted for more than three days, transferred or admitted to intensive care, or died from their injuries. MAIN OUTCOME MEASURES: Death or survival in hospital within three months of injury. RESULTS: Over the seven year period 1989-95 there was a substantial decline in the probability of death among children and young adults admitted to hospital after severe injury. The overall estimate of the reduction in the odds of death was 16% per year (odds ratio for the yearly trend 0.84; 95% confidence interval 0.79 to 0.89). This decline did not differ significantly between age groups. (0-4 years 0.79; 5-14 years 0.87; 15-24 years 0.83). CONCLUSIONS: Reductions in hospital case fatality have made an important contribution to reaching the Health of the Nation targets. The contribution of hospital care in the reduction of accident mortality should be taken into account in decisions about the allocation of resources to preventive and curative services.     

A Survey of Intestinal Protozoan Infections among Gastroenteritis Patients during a 3-Year Period (2004-2006) in Gyeonggi-do (Province), South Korea

The incidence and etiology of parasite-associated gastroenteritis during 2004-2006 in Gyeonggi-do (province), South Korea was determined by means of antigen detection ELISA on 6,071 stool specimens collected from 6 general hospitals. At least 1 parasitic agent was detected in 3.4% (208/6,071) of the stool samples. Among these, Giardia lamblia was the most numerous (152 cases; 2.5%), followed by Entamoeba histolytica (25 cases; 0.4%), Cryptosporidium parvum (23 cases; 0.4%), and mixed infections (8 cases; 0.1%). Patients aged 1-5 years had the largest proportion (69.2%; 144/208) of parasite-positive stool specimens. Parasite-mediated gastroenteritis was most common from June to September. The detection rate gradually increased from 2004 to 2006. This study shows that parasite-mediated gastroenteritis may be significant among children in Korea and that parasite infection surveillance should be constantly performed.     

Scaling properties and symmetrical patterns in the epidemiology of rotavirus infection

The rich epidemiological database of the incidence of rotavirus, as a cause of severe diarrhoea in young children, coupled with knowledge of the natural history of the infection, can make this virus a paradigm for studies of epidemic dynamics. The cyclic recurrence of childhood rotavirus epidemics in unvaccinated populations provides one of the best documented phenomena in population dynamics. This paper makes use of epidemiological data on rotavirus infection in young children admitted to hospital in Melbourne, Australia from 1977 to 2000. Several mathematical methods were used to characterize the overall dynamics of rotavirus infections as a whole and individually as serotypes G1, G2, G3, G4 and G9. These mathematical methods are as follows: seasonal autoregressive integrated moving-average (SARIMA) models, power spectral density (PSD), higher-order spectral analysis (HOSA) (bispectrum estimation and quadratic phase coupling (QPC)), detrended fluctuation analysis (DFA), wavelet analysis (WA) and a surrogate data analysis technique. Each of these techniques revealed different dynamic aspects of rotavirus epidemiology. In particular, we confirm the existence of an annual, biannual and a quinquennial period but additionally we found other embedded cycles (e.g. ca. 3 years). There seems to be an overall unique geometric and dynamic structure of the data despite the apparent changes in the dynamics of the last years. The inherent dynamics seems to be conserved regardless of the emergence of new serotypes, the re-emergence of old serotypes or the transient disappearance of a particular serotype. More importantly, the dynamics of all serotypes is multiple synchronized so that they behave as a single entity at the epidemic level. Overall, the whole dynamics follow a scale-free power-law fractal scaling behaviour. We found that there are three different scaling regions in the time-series, suggesting that processes influencing the epidemic dynamics of rotavirus over less than 12 months differ from those that operate between 1 and ca. 3 years, as well as those between 3 and ca. 5 years. To discard the possibility that the observed patterns could be due to artefacts, we applied a surrogate data analysis technique which enabled us to discern if only random components or linear features of the incidence of rotavirus contribute to its dynamics. The global dynamics of the epidemic is portrayed by wavelet-based incidence analysis. The resulting wavelet transform of the incidence of rotavirus crisply reveals a repeating pattern over time that looks similar on many scales (a property called self-similarity). Both the self-similar behaviour and the absence of a single characteristic scale of the power-law fractal-like scaling of the incidence of rotavirus infection imply that there is not a universal inherently more virulent serotype to which severe gastroenteritis can uniquely be ascribed.     

Physiological and hormonal control of thermal depression in the tiger snake, Notechis scutatus

Plasma sodium concentrations in field-caught Western tiger snakes, Notechis scutatus, from semi-arid Carnac Island (CI) varied seasonally, with snakes exhibiting significant hypernatraemia during summer and normal concentrations following autumn rain. In contrast, field-caught tiger snakes from a perennial fresh-water swamp (Herdsman Lake, HL) exhibited no significant increase in plasma sodium concentrations during summer. Laboratory-induced hypernatraemia caused thermal depression in both populations; there was a weak negative relationship between plasma sodium concentration and temperature selection that was significant for CI snakes. Hypernatraemia significantly elevated circulating concentrations of the neuropeptide arginine vasotocin (AVT) in both CI and HL snakes. CI snakes injected with a physiological dosage of AVT also evidenced thermal depression. Despite the positive correlation between AVT and both plasma sodium concentration and osmolality for laboratory snakes, field samples from CI snakes indicate that circulating levels of AVT may be influenced more by plasma osmolality than sodium levels. The data suggest that, in CI snakes, chronic dehydration in the field leads to hypernatraemia which may lead to elevated levels of AVT if plasma osmolality also increases. This will in turn invoke a depression in thermal behaviour that may improve the water economy and survival of snakes on semi-arid CI. Although HL snakes do not experience seasonal dehydration, physiological changes away from the stable homeostatic state appear to prompt the same behavioural shifts, illustrating the intrinsic nature of the thermal behaviour in different populations of the same species of snake.     

Has treatment for childhood gastroenteritis changed?

Because so many children with gastroenteritis in our area were being treated with drugs, which are potentially harmful, we assessed the extent of treatment before admission to hospital of 288 children. Sixty four had been treated: 45 with antibiotic, antidiarrhoeal, or antiemetic drugs and 34 had been given glucose-electrolyte solution, 15 of those had also been given drugs; 119 had had no treatment. Since 1979 there has been a decrease in the use of drugs for gastroenteritis, but glucose-electrolyte mixtures are still underused.     

Effect of nutrition improvement project on morbidity from infectious diseases in preschool children in Vietnam: comparison with control commune.

OBJECTIVE: To evaluate the effect of a nutrition improvement project based on home garden production and nutrition education on morbidity from acute respiratory infection and diarrhoeal disease in preschool children. DESIGN: The morbidity survey comprised five data collections undertaken by trained interviewers to ascertain the incidence and severity of respiratory infections and the incidence of diarrhoeal disease in children in two communes. SETTING: A project commune and a control commune in Vietnam. SUBJECTS: Preschool children to 6 years of age living in the project commune Khai Xuan (average 469 children) and the control commune Ching Cong (average 251 children). MAIN OUTCOME MEASURES: Differences between the two communes over time in the incidence and severity of respiratory infections and the incidence of diarrhoeal disease. RESULTS: In Khai Xuan there was a significant reduction (P < 0.0001) in the incidence of respiratory infections (from 49.5% to 11.2%) and diarrhoeal infections (18.3% to 5.1%); the incidence of pneumonia and severe pneumonia was also significantly reduced (P < 0.0001). In Ching Cong there was no significant change in the incidence and severity of respiratory disease nor in the incidence of diarrhoeal disease. CONCLUSIONS: These findings emphasise the successful health outcome of a nutrition project based on household food production and nutrition education and the value of evaluating nutrition projects by reference to measurable health outcomes.     

Reduction in morbidity and mortality from childhood diarrhoeal disease after species A rotavirus vaccine introduction in Latin America - a review

Countries in Latin America were among the first to implement routine vaccination against species A rotavirus (RVA). We evaluate data from Latin America on reductions in gastroenteritis and RVA disease burden following the introduction of RVA vaccine. Published literature was reviewed to identify case-control studies of vaccine effectiveness and population-based studies examining longitudinal trends of diarrhoeal disease reduction after RVA vaccine introduction in Latin American countries. RVA vaccine effectiveness and impact on gastroenteritis mortality and hospitalization rates and RVA hospitalization rates are described. Among middle-income Latin American countries with published data (Mexico, Brazil, El Salvador and Panama), RVA vaccine contributed to a gastroenteritis-associated mortality reduction of 22-41%, a gastroenteritis-associated hospitalization reduction of 17-51% and a RVA hospitalization reduction of 59-81% among children younger than five years of age. In Brazil and El Salvador, case-control studies demonstrated that a full RVA vaccination schedule was 76-85% effective against RVA hospitalization; a lower effectiveness of 46% was seen in Nicaragua, the only low-income country with available data. A growing body of literature offers convincing evidence of "real world" vaccine program successes in Latin American settings, which may be expanded as more countries in the region include RVA vaccine in their immunization programs.