PRACTICE RECOMMENDATIONS
• Patients with rotavirus infection require oral, enteral, or intravenous fluids to treat dehydration. A
• Give the first dose of rotavirus (RV) vaccine between the ages of 6 weeks and 14 weeks 6 days; give subsequent doses at 4- to 10-week intervals, completing by 8 months. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Rotavirus is the most common cause of severe gastroenteritis in infants and children younger than 5 years of age, and it accounts for approximately 5% of childhood deaths worldwide.1 In the United States, rotavirus causes numerous cases of dehydrating diarrhea and vomiting, and is responsible for direct and indirect healthcare costs of approximately $1 billion per year. Infection during childhood is almost universal.2
Improved personal hygiene and community sanitation have steadily reduced the prevalence of bacterial and parasitic disease. But these measures have had little effect on the spread of rotavirus and its potential complications of severe dehydration, hospitalization, and even death.1 Importantly, we now have the means to vaccinate against rotavirus infection and dramatically reduce the incidence of disease. In this article, I describe the available vaccines and the vaccination recommendations endorsed by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). I also review supportive treatment for rotavirus infection, which entails both do’s and don’ts.
Who is at risk of rotavirus disease?
For most term neonates, rotavirus disease is mild, perhaps because of partial protection from maternal antibodies.3 However, premature infants lacking full maternal antibody protection often suffer from more serious gastroenteritis. The most severe infections usually strike children between the ages of 4 months, when maternally derived antibody protection wanes, and 23 months, when dehydration risk lessens.4-6
The virus spreads from person to person via the fecal–oral route.6,7 Thirty percent to 50% of family members of an infected child may also become infected, but disease in older children and adults is usually subclinical or mild.6 Outbreaks of rotavirus are common in childcare centers and in children’s hospitals.7,8
How the disease presents
Rotavirus gastroenteritis peaks during the winter. With mild cases, a watery diarrhea will last a few days. In severe cases, onset is usually abrupt with fever, abdominal pain, and vomiting, which can precede diarrhea. A third of patients have a temperature higher than 102°F (38.9°C).6 There is a risk of dehydration, shock, and even, occasionally, infant death.9
Typically, the incubation period is 1 to 4 days, and the infection lasts 3 to 7 days. However, damage to the brush border of the intestinal villi can produce persistent disaccharide malabsorption, resulting in prolonged diarrhea even after resolution of infection.10,11 Stools generally do not contain blood or leukocytes. Ultrasound examination during rotavirus infections has shown thickening of the distal ileum and lymphadenopathy, which may predispose to intussusception.12 Other problems possibly linked to wild-type rotavirus infection are Kawasaki disease and sudden infant death syndrome. Recurrent rotavirus infection with one of the many different serotypes is common during childhood.
More than 25 different assays can detect rotavirus in stool, but the most reliable method is direct electron microscopy. A suitable clinically available alternative is enzyme immunoassay testing of stool samples. In mild cases, testing to detect rotavirus is not necessary. But for bloody, severe, or persistent diarrhea, stool testing for rotavirus and other entities is warranted.
Supportive treatment: Do’s and don’ts
No specific antiviral treatment is available for rotavirus infection. That said, the do’s and don’ts that follow will help guide your care.
DO administer oral, enteral, or intravenous (IV) fluids to prevent or correct dehydration. Oral rehydration therapy is the standard treatment for dehydration in anyone with acute gastroenteritis, including that caused by rotavirus. The recommended World Health Organization (WHO) oral rehydration solution contains sodium, chloride, and electrolytes (TABLE 1).13 Rice-based oral rehydration solution is an easily metabolized carbohydrate formulation that helps repair damaged tissues and enhances electrolyte absorption.9 WHO has endorsed guidelines that base fluid replacement on the patient’s age and weight, and that recommend oral zinc intake (10 mg/d for 10-14 days up to age 6 months; 20 mg/d for 10-14 days for older children) for all episodes of diarrhea (http://hetv.org/pdf/diarrhoea-guidelines.pdf). Oral glucose electrolyte solutions containing less sodium and chloride are also effective treatments.
DO recommend frequent small doses of oral rehydration solution, even if the patient is vomiting.14 Rehydration volumes are suggested in TABLE 1. Alternatively, give 10 to 20 mL/kg for each diarrheal episode, and 2 mL/kg for each bout of emesis. Feeding frequent small volumes (30 mL every 5-10 minutes) reduces the risk of emesis.