Paediatrics Indonesians' 18' 83 _.::'9o. March - April 1978.

83·

ORIGINAL ARTICLE

Treatment of Acute Infantile Gastroenteritis

. Dehydration Acidosis with Ringer's Lactate
and Glucose-Electrolyte Solution

by

HERNAWAN, SUNOTO, TITUT S. P.USPONEGORO and SUHAR/ONO

(Department of Child Health, Medical School, University

of Indoneszia, Jakarta).

Abstract

Fifty patients hospitalized with severe gastroenteritis - dehydration with

acidosis were investigated. The age average was 8 months with the range of
1 - f 8 months. The amount of the Ringer's lactate solurtvon given was as follows:
1st hour : 30 ml/kg b.w.
the following 7 hours: 70 ml/kg b.w. or 10 ml/kg b.w./hour.
After 8 hours on fi,'litmteTt:d .treatment, the child was given orial solution,
either glucose-electrolyte solution or milk formula in 1;4 dilution.
The mortality rate was 6% (3 out of 50 patients) i.e. one due to seizures
suspected encephal'i!tis, one due rto potasium deficiency (K = 2.1 mEq/1) and
the thi~d due to dehydmtion itself because the child was admirtted already in a
morzbund stage (subvinum vitae}.

Presented at the Second Asian Congress of Pediatrics, Jakarta, 3 • 6 August; 1976.

Received 20th. Dec. 1976.
84 HERNAWAN ET ALi

Introduction The cause of this high mor·tality in

developing countries may be due to:
Aou,te infantile gastroenteritis in Indo-
nesia •amd other develop1ng countries is 1. The severity of the disease caused
still one of the major causes of morb1dLty by delayed admission to 1he hospital.
and mor·taHty in children. The 5 leading
2. The Lnappropr;:,:::~-te treatment due to
diseases in children in .the Department
lack of facilities in <the peripheral
of Child· Heaith, Medical School, Uni-
hospi·tal and health centres.
versity of Indonesia . are (Sutejo et al.,
1968): 3. The igno11ance of the pa,rents, for
example they wiJthdraw food or fluid
1. Upper res·p1r;a,tory tract infection.
which they th1nk could increase the
2. Gastroerute,riti,s. di.an11hoea.
3. Protein Calorie Malnutrition (PCM).
4. Vittamin A deficiency,and The primary and most important s'tep
5. Tuberculosis. in the treatment of ·acute gastroen,~·eritis
is restore the fluid loss (Ironside, 1970;
The incidence of gas•troenteritis in
Rohde, 1974; Santhana Krishnan et al.,
developing countries is estimated as 50 -
1974), rats the majority of cases of acute
70% per 100 population per yeatr and
gastmem~:emitis is considered as a self-
70 - 80% out of them are children
limiting disease (Tumbelak,a, 1965; Bro-
UJnder 5 years of age, particularly below
towasis·to, 1974; Rohde, 1974).
2 years (Brotowasi-sto, 1974). The num-
ber of hospitalized patiemtts wi·th gas- At the beginni111g Riinger's lactate so-
troenteritis- dehyd11ation with acidosis lu,tioiTh was used 1n the treatment of
in the Department of Child Health, cholera, but according 1t:o Mahalanabis
Medical School, Universitty of Indonesia, et al. (1972), Ringer's lactate can be
Jakarta, in 1975 was 1.127 (22.8%) out used also m the treatment of acute non
of 4.938 ttotal admissions (Sunoto et al., cholera diarrhoea. The purpose of this
1976). study is to prove the efficacy of Ringer's
lactate soLution (the cheapest 18J1'1d the only
This f1gure is more or less similar to
available solution m the peripheral hos-
other developing countries like Malay-
pital . arud rural health centres) in the
sia (Abraham and Tan, 1974), India
treatment of acute gastroenteritis witth
(Naruka et al., 1974), Puerto Rico (Or-
severe dehydration and acidosis as a
tiz, 1974), etc.
parenteral solution.
The mortaHty rate in hospitals is still
very high, and varies from 10 - 20% Materials and Methods
(Sutoto et al., 1974; Naruka et al.,
1974), whereas in developed countries Fifty patiemt.s with acute iillfantile
the mortality is 1% (Walker Smith, gastroenteritis with severe dehydt\~lltion
1972; Biddulph, 1972). and acidosis were hospitalized in the
 RINGER'S LACTATE FOR. GASTRO ENTERITIS 85

Depavtroent of Child Health Medical companyimg diseases can be seen in tables

School, Oniversity of I.ndones•i,a/Dr. Cipto 3 and 4. Sometimes in. one patient there
Mangunl<usumo Gene val Hosp~tal, Jakar- are 2 or more accompanying diseases.
ta. They consisted of 32 boys and 18
gids (Table 1) .. The age average was 8 To estimate the degree of dehydrati-
mon<ths with the range of 1 - 18 months on, the scoring system. by Maurice King
(Table 2). The nutritional state and ac- ( 1974) was ~sed as follows :

Score for signs and symptoms observed

Part of the body
examined

General condition
0

Healthy
I 1

restless, apath~tic,
I 2

delirium, stupor
sleeping or malaise or coma
Elasticity of the skin Normal decreased very decreased'·
E y e Normal sunken very sunk.en
Fontanelle Normal sunken very sunken
M o u t h ~ormal d r y very dry or
\.I·- .
,
cyanotic
Pulse rate per minute strong; 12Q- 140 more than 140
less than
120

The rsum of the scores of the above to Mangunkusumo General Hospital.

s•ilgns .and symptoms could be categorized Blood gas analysis .rund electrolyte exa-
as foltows: mination W1ere dcine <twice, Le. before and
after treatment.
0- 2: mild dehydration (5% deficit).
3- 6: moderate dehydration (8% defi- Method of the treatment.
cit).
The amoul11t of the Ringer's lactate
7- 12: severe dehydration (10% deficit). (RL) giv~n was as follows :
Laboratory examinations 1st hour: 30 ml/kg bw
the following 7 hours: 70 ml/kg b.w
Routine stool examination and screen-
or 10 ml/kg b.w./hour.
ing test for fat and su~ar dntolerimce
were done i:n the Department of Child After 8 hours on parenteral treatment,
Health. Blood gas analysis and <electrolyte ·the child was given oral solution, eHher
examination were donein ithe Depart- .glucose-eleCJ:.rolyte solution or milk for-
ment of Clinical Pathology, Medical mul'a in % dilution. If oral solution
School, University of Indonesi.a/Dr. Cip- . couLd not be given, parenteral. treatment
 HERNAWAN ET. AL.

TABLE 2: Age Incidence

TABLE 1 : Sex Incidence
Age (months) Total
S e x
I Total
0- 3 5

32
3- 6 9
Male
6- 9 20
Female 18
9 - 12 7
12 - 15 4

I
I
15- 18
18 - 21
5

I 21 - 24

TABLE 3: Nutritional state

Total

-Normal 38

- Under weight 12
-Marasmus

- Marasmic kwashiorkor

- Kwashiorkor
 RINGER'S LACTATE FOR 'GASTROENTERITIS
87

was co1n.tinued with Rlinger's lactate i!ll averaging 136 meq/1. potassium 4.7 and
5% Dex·trose. Clinical evaluation was chloride ion 100.5 mEq/l (table 7).
done including the general condiltion of
the child, the rehydration, blood gas The results of •the RL administration
analysis and electrolyte examination.
Complication were also noted if prese1111t. The result of the RL administration
was excellent in 44 (88%), good in 2
(4 %.) ·md poor in 4 (8% }, as can be seen
Result. in table 5.

Accompanying Diseases Complication

Twenty seven (54%) out of 50 patients No c1ear complication such as over-

simultaneously suffered from other di- hydration and oedema occurred.
seases. They were upper .respiratmy tract
infection (5), Bronchitis (1), Otitis media Discussion
acuta (9), Infection of the gut (5), Fat
malabsorption (4), Sugar intolerance Among our patients, there were more
(2), Seizure (3) and V.S.D. (1). Some- boys than girls (table 1).
times in one patient 'there were 1, 2 or This ~an be explained by the fact that
more accompanymg diseases (table 4). usually boys are more active than girls,
so that the possibility of boys to get in-
Blood gas analysis fection is greater.
Before treatme:nt (IVFD), blood gas The age average was 8 months, with
f:lnalysis showed severe acidosis. The the ,rooge of 1 - 18 months. ThiiS can be
average of the pH was 7.30 with the unders1tood, because at this age, usually
range of 7.04 to 7 .48, whereas the average the infant gets additional food, so that
base excess was - 17 with the range the poss,ibiHty of contamination with
of- 8 to - 26 mEq/1. After treatment microocgamJsms is greater.
pH was 7.40 with the range of 7.27 to
Thirty patients (76%) were considered
7.57 and the average base excess was
normal and 12 (24%) unde,rweight. In
- 4 with the range of - 11 to + 5
this ·trial patient with P .C.M. were ex-
(table 6).
cluded due to the 'reason thEt:: in P.C.M.
there are so many factors (lactose and
Eleotrolyte findings
fat intolerance, overgrowth of bacteria,
Before IVFD, the average blood infestation of parasites, etc) which can
sodium concentration was 133 meq/1, ploay a.n impor(:a:nt and decisive role in
potassium 3.1 meq/1 and chloride ion ' causing diarrhoea.
83 meq/1. After IVFD, improvement After 8 hours on IVFD with RL as a
was obta~ned with the blood sodium parenteral solution, 44 patien$s (88%)
 •· HERNAWAN ET AL.
88

TABLE 4:
·. ,···:! '

-Upper Respiratory tract infection

I ·Total

5
- Bronchitis 1
.··:
- 0 . M. A. 9
- Infection of the: gut 5
-Fat malabsorption 4
-Sugar intolerance 2
-Fungal infection 2
- S .e i ·z u r e 3
'
-V. s. D. 1

* Sometimes there are more than 2 accompanying

diseases in one patient.

TABLE 5 : The results of the treatment

·!.

Excellent
''
I Total

44 (88%)
Good 2 ( 4%)
P o o r 4 ( 8%)

TABLE 6 : Blood gas analysis before and after treatment

pH
I Before treatment

7.30 ( 7.04 to 7.48)

I After treatment

7.40 ( 7.27 to 7.57)

BE -17 (-8 to -26) --4 (-11 to +5 )

TABLE 7: Electrolyte findings before and after treatment

Before treatment After treatment

Na 133 (117 160 136 (130 148

K 3.1 .( ;1,7 6.8) . 4.7 (. 2.1 6.5)

Cl 83 ( .70 115 .) 100.5 ( 82 115)

 RINGER'S LACTATE FOR GASTROENTERITIS
89

have ohtJaihed ·complete rehydration or tion inself because this chitd was admit·
have :CoOle irito a strute of only' niild cLe- ted · already in a moribund stage, The
hydratiaO. IVFD was stbpped and con- above findings were more or less simi-
tiJnued ~ith glucose-electro'lyt~ solution lar to the results of Mahalanabis et al.
or milk formula in % dilution. (1972).
Two patients (4%) still remained in F.rom this tdaf, it c.an be. concluded
severe ,d-ehydration af(:er 8 hours, but that RL solu1bion cruru be used in the treat-
after 24 hours of IVFD,, rehydration ment of acute gastroenteritis with severe
finally occurred. This can be understood, dehydmtion and acidosis as 1a pa.rertteral
because these 2 were in an u!!llderweight solution particularly in areas where
condition. Four patients (8%) still re- faci1lities and choice of parenteral fluids
mained in dehydration after 24 hours of rure limi1t:ed.
IVFD. One of :them improved only after
5 days .of IVFD. This can be explained .Acknowl~d~ements
that this case suffered from tprolonged
d1wrrhoea md vomitimg due to cholem The authors would like to thank
Eltor. . very much the Directorate General of
Three died, one due to encephalitis, Communicable Disease Control,, Ministry
one due to potasium deficiency (K = 2.1 of Health, for the supply of Ringer's
mEq/1) and the third due to dehydra- lactate and glucose electrolyte solutions.

REFERENCES

1. ABRAHAM, S.C.E. and TAN, G.S.G. : 6. LUDAN, A.C. and J. DELMUNDO :

Gastroenteritis of infancy. Editorial Me- The Efficacy of Oral Electrolyte fluid in
dical Progress, July, 1974. the therapy of diarrhoea. J. Philipp. Med.
2. BIDDULPH, J, : Standardized Manage- Ass. 49 : 243 (1973).
ment of diarrhoea in young children. Pae-
7. MAHALANABIS, D., BRAYTON, J.B.,
diatr. Indones. 11 : 37 (1972).
MONDAL, A. and PIERCE, N.F.: The
3. BROTOWASISTO : - Surveillance in use of Ringer's lactate in the treatment of
Gastroenteritis. - Programme of Rehyd-
children with cholera and acute non cho-
ration in Indonesia. Seminar on Rehydra-
tion, Jakarta, August 26-29, 1974. lera diarrhoea. Bull. Wid. Hlth. Org. 46 :
311.319 (1972).
4. HARRIS, F. : In Paediatric Fluid The-
rapy. p. 39 (Blackwell Sci. Pub!., Oxford/ 8. NARUKA, O.S., USHA SHARMA and
London/Edinburg/Melbourne, 1972). S. SAXENA : A Clinical Profile of
5. IRONSIDE, A.G., TUXFORD, A.F. and Diarrhoea in Infancy and Childhood. A
HEYWORTH, B. : A survey of Infanti- study of 200 cases. Indian J. Pediatr. 41 :
le gastroenteritis. Br. med. J. 3:20 (1970). 374 (1974).

.
90
9. ORTIZ, 'A. : Acute infantile d~arrhoeal .14. SUNOTO, TITUT S. PUSPONEGORO,
,Disease. Arch.. pis. Chlliih. 16 : :121 SUSILO SURACHMAD and W.R. SAN-
(1974). BORN : Treatment of Acute Infantile
10. ROHDE, J.E. : · :Rehydration in the Fi- ./Gastroenteritis.· Presented at· the· Vth AsL
eld. Seminar on Rehydration, Jakarta, an PaCific Congress of Gastroeiuerology,
August 26-29, 1974. Singapore 23 • 27 May 1976.

11. SANTHANA KRISHNAN, s:R., .G. KU. 15. SUTOTO, DACHLAN, A.M, TB. BAG-
MARESAN and V. BALA(}OPALA DADIJI dan HENTY ANTO HENDAR-
RAJU : Fluid therapy. in infants .and DJ.l : Angka kcmatian penderita gas-
children with acute gastroenteritis and tr.oenteritis dehidrasi pada bayi dan anak
dehydration. Indian Pediatr. 11 : 345 selama 3 tahun (1971 - 1973) di Bagian
(1974). Ilmu Kesehatan Anak FKUI!RSCM Ja
karta. Seminar Rehidrasi, ·Jakarta 26 _ 29
12. SANTHANA KRISHNAN, K. DEENA
Agustus 1974.
DA YULU and V.B. RAJU : The role of
Oral Electrolyte iri the management of 16. TUMBELAKA, W.A.F.J. : Enteritis de-
Acute Gastroenteritis in Non-Hospitalized hidrasi pada anak. Proceeding naskah
children. Indian Pediatr. 11 : 351 (1974).
lengkap KPPIK - FKUI ke-Y hal. 505
13. SUNOTO : - Pathogenesis and pato- (1965).
fisiologi daripada diare. - Aspek bakte-
riologik dartpada diare. Seminar Rehid- 17. WALKER - SMITH, J. : Gastroente-
rasi, Jakarta 26-29 Agustus, 1974. ritis. Austr. med. J. 1 : 329-332 (1972).