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Pediatrics, Rotavirus: Treatment & Medication
Updated: Jun 1, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Prehospital care of affected infants should be directed toward ensuring a secure airway, breathing, identification of circulatory compromise, and maintenance of adequate circulation. Field personnel may not be able to achieve access in the child with a contracted circulatory volume.
- Infants who appear significantly dehydrated ideally should have 20 mL/kg isotonic sodium chloride solution or Ringer lactate solution administered en route to the hospital.
- Patients who are less severely affected need only monitored transport.
- The destination ED should be an ED approved for pediatrics (EDAP) or a pediatric critical care center (PCCC).
Emergency Department Care
- After ensuring proper airway and breathing and assessing circulation, identification and treatment of dehydrated infants is the main objective. In many cases, appropriate rehydration may be accomplished using established oral rehydration protocols. Lethargic children require a fingerstick glucose level immediately either by EMS or in the ED.
- For severely dehydrated children, vascular access (often via an IO line) is required.
- Administer 20 mL/kg boluses until volume is restored. A total requirement of 60-80 mL/kg is not uncommon.
- If more than 40 mL/kg is necessary, consider electrolytes, BUN, and creatinine levels.
- Maintenance of hydration is the key issue for children who are not dehydrated. Selection of an appropriate fluid is crucial.
- Infants who receive hyperosmolar fluids (eg, commercial soft drinks, sports drinks, gelatin) and those who are fed high salt-content solutions (eg, commercial soup, boiled milk) are at risk for significant hypernatremia.
- Ideal maintenance beverages for dehydrated infants with viral enteritis are commercial infant solutions such as Pedialyte and Rice-Lyte. These beverages contain a small amount (usually 2-3%) of glucose and the correct balance of sodium and potassium.
- Rehydrating infants with these beverages may be particularly difficult within the first 2 days of the illness because vomiting frequently occurs.
- If the infant is vomiting, administer small, frequent feedings.
- Once vomiting has resolved, the baby may be given a standard soy-based infant formula. This formula provides adequate energy intake for intestinal healing.
- Supplemental feedings of oral maintenance solutions may be administered if fluid losses are excessive.
- Avoid sports drinks and other hyperosmolar beverages for the reasons previously stated. Similarly, excessive free-water intake may predispose the infant to hyponatremia.
- Antiemetics may be considered for children older than 6 months to control emesis.
Medication
In most cases, no medication is required. Instead, attention should be directed to appropriate fluid intake. Antiemetic and antidiarrheal medications have some risks for children in the age group typically affected by rotavirus and should be avoided if possible. Some recent studies have used antidiarrheals in children with success, but this practice is not widely accepted.10,11 Antidiarrheals are generally only recommended in cases of excessive or significantly prolonged diarrhea in which no other etiology has been determined.12 Antiemetics have also been used with some success for vomiting in children with gastroenteritis.13 Antibiotics are not indicated if rotavirus gastroenteritis is suspected.14A rotavirus vaccine (RotaShield) was released for general use in 1998-1999. Despite promising initial results, RotaShield was withdrawn from the market in 1999 because of a causal relationship between the vaccine and several cases of intussusception. The risk was observed 3-14 days following administration of the first dose of the RotaShield vaccine in infants older than 3 months.
Clinical trials are currently ongoing for production of a new vaccine without significant adverse effects. Promising oral vaccines that have been shown to be efficacious in preventing rotavirus diarrhea and in reducing the severity of the disease are still being studied.
In February 2006, the United States Food and Drug Administration (FDA) approved one of the aforementioned oral vaccines known as RotaTeq. RotaTeq administration has been recommended for children as 3 separate oral doses at ages 2, 4, and 6 months.3,15 In April 2008, the FDA approved Rotarix, another oral vaccine, for prevention of rotavirus gastroenteritis. Rotarix administration is currently recommended as 2 separate doses to patients at ages 2 and 4 months.3,15 Rotarix was efficacious in a large study showing that it protected patients against severe rotavirus gastroenteritis as well as decreasing the rate of severe diarrhea or gastroenteritis of any cause.16
The minimum recommended age for the first dose of either RotaTeq or Rotarix vaccine is 6 weeks while the maximum age for the first dose of each is 14 weeks and 6 days.3,15 The minimum time recommended between each dose of either vaccine is 4 weeks, and the maximum age for the final vaccine dose is 8 months and 0 days.3,15 No maximum time between doses is specified by the Advisory Committee on Immunization Practices (ACIP).3
Either rotavirus vaccine can be given before, simultaneously, or after patient receipt of any blood product including those with antibodies.3 In addition, a study involving 484 infants between the ages of 6-12 weeks were randomized to receive either Rotarix concurrently with their 2-, 4-, and 6-month vaccines or Rotarix separately at ages 3 and 5 months.17 The 2-, 4-, and 6-month vaccines were Haemophilus influenzae type b conjugate vaccine, 7-valent pneumococcal conjugate vaccine, and combined diphtheria-tetanus-acellular pertussis-hepatitis B-poliovirus vaccine. Serum antibodies were drawn one month after the third dose of the above vaccines, and it was determined that the antibody response was similar to all of the antigens in both study groups.17
[#rotavirusvaccination]ACIP and the American Academy of Pediatrics (AAP) recommend that completion of the vaccination be completed by the same product.3,15 However, if it is unknown which product was initially administered, the patient's vaccination series should still be completed with whichever vaccine is available.3,15 ACIP and AAP do not directly state a preference for either RotaTeq or Rotarix.3,15 Due to the use of different clinical scales defining severe rotavirus gastroenteritis in the trials of RotaTeq and Rotarix, a direct comparison of effectiveness currently cannot be made between the two vaccines.15,18
Other vaccines may eventually be released in the United States, although a definitive date has not yet been set. In addition, side effects, such as intussusception, will be closely monitored for RotaTeq and any other future rotavirus vaccines. Between February 3, 2006, to January 31, 2007, 28 cases of intussusception after RotaTeq administration have been reported to the US Food and Drug Administration (FDA).19 However, this number does not exceed the basal expected number of cases of intussusception in the general population. The cases have developed after the first, second, or third dose of RotaTeq. Fortunately, no deaths were reported, but 16 of the 28 case patients required hospitalization and surgery, while the other 12 patients were treated with a contrast or air enema.
A study involving more than 63,000 patients who received Rotarix versus placebo at ages 2 and 4 months showed a decreased risk of intussusception for those patients receiving Rotarix.16 The intussusception data were determined over a 31-day observation period (inpatient or outpatient) after each dose of the Rotarix vaccine, and this also included a 100-day surveillance period for all serious adverse events.16 Although more patients who received Rotarix were observed to have seizures or pneumonia-related deaths, this link has not been directly established to Rotarix.16,4 In addition, the FDA is requiring the Rotarix manufacturer to report data on postmarketing safety that involves more than 40,000 patients.4
In June 2007, the FDA also revised the RotaTeq Adverse Reactions and Post-Marketing sections of the label to include Kawasaki disease, as 6 cases of Kawasaki disease were reported in the phase 3 clinical trial of RotaTeq.20 Five of the cases occurred in patients who received RotaTeq, while the other case was reported in a patient who received the placebo. Kawasaki disease has also been reported with Rotarix administration. In clinical trials, 17 cases of Kawasaki disease have been reported in those who received Rotarix, while 9 cases were reported in patients who received a placebo.3
Although more research is necessary, nitazoxanide was shown to reduce rotavirus diarrhea and gastroenteritis in a small study of 38 patients between the ages of 5 months to 7 years.21 Time to resolution of illness was 31 hours for the group who received nitazoxanide compared with 75 hours for the placebo group. Nitazoxanide is currently approved by the FDA for treatment of diarrhea in children and adults with diarrhea from Giardia or Cryptosporidium.
Vaccines
Elicit active immunization to increase resistance to infection. Vaccines consist of microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.
Rotavirus vaccine (RotaTeq, Rotarix)
Currently, 2 orally administered live-virus vaccines are marketed in the United States. Each is indicated to prevent rotavirus gastroenteritis, a major cause of severe diarrhea in infants.
RotaTeq is a pentavalent vaccine that contains 5 live reassortant rotaviruses and is administered as a 3-dose regimen against G1, G2, G3, and G4 serotypes, the 4 most common rotavirus group A serotypes. Also contains attachment protein P1A (genotype P[8]).
Rotarix protects against rotavirus gastroenteritis caused by G1, G3, G4, and G9 strains and is administered as a 2-dose series in infants between ages 6 and 24 wk.
Clinical trials found that each vaccine prevented 74-78% of all rotavirus gastroenteritis cases, nearly all severe rotavirus gastroenteritis cases, and nearly all hospitalizations due to rotavirus.
Adult
Not indicated
Pediatric
<6 weeks: Not established
RotaTeq
2 mL PO as a single dose at age 2 months, followed by 2 additional doses at ages 4 and 6 months; do not administer after age 8 months
Rotarix
1 mL PO as a single dose at age 2 months, administer a second dose at age 4 months; do not administer after age 8 months
Immunosuppressive therapies (eg, irradiation, antimetabolites, alkylating agents, cytotoxic drugs, high-dose corticosteroids) may decrease immune response; immunodeficiency states including HIV must be weighed clinically to determine risk versus benefit of vaccination; patients with significant acute gastroenteritis or moderate-to-severe acute illnesses should not receive the vaccine until their symptoms have improved
Documented hypersensitivity or severe allergy to prior rotavirus vaccine or to a vaccine component; patients with anaphylactic or severe allergy to latex should not receive Rotarix since the oral applicator contains latex (RotaTeq is latex-free); patients at risk of developing latex allergy (eg, those with spina bifida or bladder exstrophy) may receive either vaccine, although RotaTeq is preferred
Pregnancy
Precautions
Common adverse effects include diarrhea, vomiting, otitis media, inflamed nasal passages, and bronchospasm; refrigerate and protect from light; handle and discard empty tube according to biological waste procedures; previously marketed rotavirus vaccine (RotaShield) was associated with intussusception, but RotaTeq did not show an increased risk compared with placebo in clinical trials (monitor for signs of intestinal blockage) and Rotarix did not show an increase in intussusception in 31,673 infants compared with 31,552 infants who received placebo; risk versus benefit of patients who have had prior intussusception must be clinically determined as current vaccines do not show direct correlation with increased intussusception; do not mix in same syringe with other vaccines or solutions
More on Pediatrics, Rotavirus |
| Overview: Pediatrics, Rotavirus |
| Differential Diagnoses & Workup: Pediatrics, Rotavirus |
 Treatment & Medication: Pediatrics, Rotavirus |
| Follow-up: Pediatrics, Rotavirus |
| Multimedia: Pediatrics, Rotavirus |
| References |
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References
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Further Reading
Keywords
rotavirus, rotavirus infection, rotavirus symptoms, rotavirus treatment, rotavirus vaccine, gastroenteritis, contagious virus, infection in children, enteritis, viral infection, diarrheal illness, childhood dehydrating gastroenteritis, severe dehydration, dehydration, fluid loss, diarrhea, Reoviridae, hypovolemia, viral enteritis, rotavirus outbreak, rotavirus genome
