Rotavirus infection: Optimal treatment and prevention
Which fluids should you avoid when treating patients’ gastroenteritis? Should nursing mothers continue to breastfeed? And what about the timing of the 2 vaccines and their administration with other vaccines? Read on.
Although oral rehydration solutions are contraindicated for infants and young children with depressed consciousness, vomiting is not a contraindication to oral intake. About half of the oral intake stays in the stomach, even after vomiting. A single dose of ondansetron may safely reduce vomiting.15
Patients with mainly diarrhea can take fluids or feed at will. With children who refuse to drink, oral rehydration solutions can be administered via nasogastric tube at approximately 5 mL/min to limit vomiting and maintain hydration.14 In dehydrated infants and toddlers with collapsed veins, nasogastric intubation has been shown to be less traumatic than repetitive attempts at placing IV catheters.
DO encourage nursing mothers to con tinue breastfeeding during rehydration treatments. If a mother is bottle feeding, keep this in mind: Rotavirus can cause temporary lactase deficiency for some non-breastfeeding infants; lactose-free formulas may help.
DON’T assume that parents know how to provide proper supplementation. Tell them to avoid fluids containing mostly sugar that lack significant electrolyte supplementation (eg, cola) unless no other fluid alternative is available. Advise caregivers to avoid juices and other liquids high in complex or simple sugars because the osmotic load may worsen diarrhea.14
DON’T give antidiarrheal agents for acute treatment in infants and young children. Such treatment has resulted in death.14
TABLE 1
Prevent or correct dehydration using the WHO-recommended oral rehydration salts solution13
| With this formulation… | …rehydrate per these specifications… | …at this rate | ||
|---|---|---|---|---|
| Component (mmol/L) | Age | Weight (kg) | mL solution/4 h | |
| Sodium (75); chloride (65); glucose (75); potassium (20); citrate (10) | ≤4 mo 4-12 mo 12 mo-2 y 2-5 y | <6 6 to <10 10 to <12 12 to 19 | 200-400 400-700 700-900 900-1400 | |
| WHO, World Health Organization. | ||||
KEEP IN MIND
Hospitalization may be needed to replace fluids via IV or interosseous supplementation. For the severely dehydrated child, 20 mL/kg isotonic fluid can be administered as a rapid bolus.14 It may be necessary to repeat a rapid fluid infusion of 10 to 20 mL/kg every 20 to 30 minutes. For less severely ill infants who require IV rehydration, standard references such as the Harriet Lane Handbook16 provide excellent guidance.
Probiotics may help. Consider probiotics with Lactobacillus or Bifida bacterium to reduce the severity of diarrhea in infants and children who are mildly to moderately ill.17,18 Their usefulness in the severely ill patient has not been demonstrated.
Available vaccines and clinical recommendations
In February 2006, the US Food and Drug Administration (FDA) licensed a 3-dose, oral pentavalent rotavirus vaccine (RV5, RotaTeq) for use among infants. The vaccine contains live reassortant rotaviruses19—4 human rotavirus G outer-surface proteins and 1 human P attachment protein reassorted into a bovine rotavirus not infectious to humans.
In February 2008, the FDA approved a 2-dose, oral monovalent rotavirus vaccine (RV1, Rotarix), an attenuated live human rotavirus containing 1 G protein and 1 P protein. Both vaccines have proven to be clinically effective in rotavirus prevention trials, but effectiveness may depend on which rotavirus serotypes circulate each season.
ACIP, AAP, and AAFP recommend that all infants be routinely vaccinated with either RV5 or RV1.6,20–22 Vaccination should be complete by the time infants reach the age of 8 months (TABLE 2). Guidelines for vaccination emphasize the following points:
Timing. According to the ACIP, the first dose of either vaccine must be administered between the ages of 6 weeks and 14 weeks 6 days (the RV5 manufacturer [Merck] states a maximum age of 12 weeks). Give subsequent doses at 4- to 10-week intervals, as long as all doses are administered by 8 months of age. The RV1 manufacturer (GlaxoSmithKline) suggests completing the second (final) dose of its vaccine by age 24 weeks.
If an infant 15 weeks of age or older accidentally receives a first dose of RV vaccine, the series should be continued, as long as the last dose can be given by 8 months of age. Either vaccine can be administered concurrently with all other vaccines.
Contraindications. The only absolute contraindications to RV5 administration are a demonstrated hypersensitivity to any component of the vaccine and severe combined immunodeficiency disease (SCID). Contraindications to RV1 vaccine are vaccine component hypersensitivity, SCID, latex-induced allergy (anaphylaxis), and uncorrected malformation of the gastrointestinal (GI) tract that might predispose to intussusception.
Precautions. Precautions for vaccines include other forms of primary or secondary immunocompromised or immunodeficiency states, including cancer and acute or chronic GI disorders such as ongoing gastroenteritis or intussusception. Infants with transient mild illness with or without low-grade fever and infants who are breastfeeding can receive either vaccine. RV5 is shed in 9% of recipients and RV1 in 26% of recipients after Dose 1, but transmission of vaccine virus is not known to occur. Likewise, reversion of vaccine virus to more virulent pathogens is not known to occur. A household member with an immuno-compromised condition does not preclude giving either RV vaccine to an infant. The risk of transmitting vaccine virus is much smaller than the risk of acquiring infectious wild-type rotavirus.
