Module V: Diarrhoea and Malnutrition

1. Describe the clinical criteria for a diagnosis of diarrhoea.

The occurrence of three or more loose bowel motions within a period of 24 hours, with or
without any noticed or reported blood in stool.

2. Identify the clinical findings (history, physical examination, and screening laboratory tests)
that guide investigation into the aetiology of a diarrhoeal condition and describe when
such investigations are indicated)
History  Frequency of stools
 Number of days
 Blood in stools
 Local reports of cholera outbreak
 Recent antibiotic or other drug treatment
 Possible lactose intolerance
 Feeding practices (breastmilk, weaning,
mashed food, others)
Physical Examination  Signs of dehydration:
o Restlessness/irritability
o Lethargy/reduced consciousness
o Sunken eyes
o Skin pinch condition
o Thirsty/Poor drinking/Unable to
drink
 Blood in stool
 Signs of severe malnutrition:
o Bilateral pedal oedema
o Severe muscle wasting
 Abdominal mass and distension
Laboratory Tests  Stool examination
o Presence of mucus, blood,
leukocytes (colitis)
 Stool culture
o In those with suspected haemolytic-
uraemic syndrome (HUS)

3. Demonstrate the ability to examine for signs of dehydration.

Severe Dehydration Two or more of the following signs:
 Lethargy/unconsciousness
 Sunken eyes
 Unable to drink/drinks poorly
 Skin pinch returns very slowly (≥2 secs)
Some Dehydration Two or more of the following sings:
 Restlessness/irritability
 Sunken eyes
 Thirsty/eagerly drinks
  Skin pinch returns slowly
No Dehydration Not enough signs to classify as Some or Severe
Dehydration

4. Describe the management of acute diarrhoea using the IMCI charts.

Depending on the presence and severity of any associated dehydration, Plans A,B and C are
the recommended treatments for the classifications No Dehydration, Some Dehydration and
Severe Dehydration respectively.

Principles of Management:
 Assess presence of any dehydration
o No Dehydration: Plan A with ORS (green coconut juice is an ideal alternative for
ORS as well as rice water or starchy water from boiled cassava/dalo)
o Some Dehydration: Plan B with ORS (75mls/kg) and reassess within 4 hours for
signs of improvement
 Give replacement/deficit fluids (75mls/kg)
 Give maintenance dose for 24 hours
 Given on-going loses (depends on estimation of volume of stool)
o Severe Dehydration: Plan C with Normal Saline (100mls/kg) IV
 Assess level of nutrition
o Vitamin A and zinc for reepithelialisation of GIT mucosa
 Assess hygiene
o Sanitation
o Food preparation
o Water source
 Prevent constipation
o Cycogenic megacolon

5. Discuss strategies used to classify and treat chronic diarrhoeal conditions.

Chronic diarrhoea is also referred to as Persistent diarrhoea and it is classified as such when
the diarrhoea, that begins acutely, goes on for at least 14 days or more, with or without
blood. Presence of some to severe dehydration, the diarrhoeal condition is then called
Severe Persistent Diarrhoea.

Treatment:
 Assess the child for signs of dehydration and give fluids according the Treatment Plans B
or C, as appropriate
 Examine child for non-intestinal infections such as pneumonia, sepsis, UTI, oral thrush,
and otitis media and treat appropriately
 Give micronutrients and vitamins for 2 weeks that provides as broad a range of vitamins
and minerals as possible such as:
o Folate 50mcg o Iron 10mg
o Zinc 10mg o Copper 1mg
o Vitamin A 400mcg o Magnesium 80mg
  Treat those with blood in the stool with an oral antibiotic effective for Shigella
(ciprofloxacin, pivmecillinam, other fluoroquinolones)
 Give treatment for Amoebiasis (Oral metronidazole: 7.5mg/kg TDS for 5/6) only if:
o Faecal microscopic examination shows trophozoites of Entamoea histolytica
within RBCs
OR
o No clinical improvement with two different antibiotics known to be effective
against Shigella
 Give treatment for Giardiasis (metronidazole: 5mg/kg TDS for 5/7) if cysts or
trophozoites of Giardia lamblia are seen in faeces
 Feeding is essential for all children suffering persistent diarrhoea:
o Infants aged under 6 months, breastfeeding should continue for as often and as
long as the child demands it
o Other foods should be withheld for 4-6hrs for those treated with Plans B or C
o Inpatient care should aim to provide a daily intake of at least 110 calories/kg
o Children aged 6 months or older, foods should be given 6 times daily to achieve
a total intake of at least 110 calories/kg/day (referred to as 6 feeds)
 Monitor body weight, temperature, food taken and frequency of loose bowel motions

6. Be able to calculate the nutritional requirements for normal growth for children and put
those results in practice.
 Protein should account for 7-15% of caloric intake and should include a balance of the
11 essential amino acids. Protein requirements range from 0.7-2.5 gm/kg/day.
 Fats should provide 30-50% of caloric intake. Although most of these calories are
derived from long-chain triglycerides, sterols, medium-chain triglycerides, and fatty acids
may be important in certain diets. Linoleic acid and arachidonic acid are essential for
tissue membrane synthesis, and approximately 3% of intake must be composed of these
triglycerides.
 The remaining 50-60% of calories should come from carbohydrates. About half of these
are contributed by mono- and disaccharides (e.g., sucrose, lactose) and the remainder
by starches.

Age Energy (kcal/kg/day) Protein (g/kg/day)

0-6 months 115 2.2
6-12 months 95 2.0
1-3 years 95 1.8
4-6 years 90 1.5
7-10 years 75 1.2
Adolescence (male/female)
11-14 years 65/55 1.0
15-18 years 60/40 0.8

Calculation of daily caloric intake is similar to that for fluid maintenance:

 First 10kg multiply by 100mls (kcal in this case)
 Second 10kg multiply by 50mls (kcal)
 Rest of the weight multiply by 20mls (kcal)
 Example: Tom is 5 years old = (age + 4) x 2 = 18kg
10kg x 100kcal = 1000kcal
8kg x 50kcal = 400kcal
1000kcal + 400kcal = 1400kcal

How do you know a 2 year old is getting enough?

In general, 2 year olds (1100kcal/day) have to eat more than half as much as the average
adult (1800-2000kcal/day) but their stomach and intestine are less than half that of adults.
They therefore require their foods to be spaced out (5-6times/day) so it takes a longer time
for digestion and absorption –thus the 6 feeds.

7. Be able to plot and interpret a growth chart (wt/age, wt/ht, etc) and recognise the early
signs of failure to thrive.
Failure to thrive is used to describe suboptimal weight gain in infants and toddlers. It is also
called weight or growth faltering in case parents consider the term pejorative. Recognition
of the entity depends upon demonstration of inadequate weight gain when plotted on a
weight-for-age centile chart;
 Mild failure to thrive being a fall across 2 centile lines,
 Severe failure to thrive being a fall across 3 centile lines.

Between 6 weeks and 1 year of age, only 5% of children will cross two lines, and only 1% will
cross three. The weight of a child with ‘failure to thrive’ may fall within the normal range but
most are below the 2nd centile when identified.

8. List common factors leading to malnutrition in children.

Worldwide, malnutrition is common and is responsible directly and indirectly for about half
of all deaths of children under 5 years of age. It is far from rare in hospitals, affecting 20-40%
of patients in a children’s hospital.
Among its numerous risk factors, here are some:
 Socioeconomic status  Congenital heart diseases
(poverty)  Chronic illnesses (HIV/AIDS)
 Parental neglect  Feeding disorders (improper
 Poor education weaning)
 Restrictive diets  Anorexia nervosa
 Micronutrient deficiencies  Overcrowding
 Preterm infants

9. Describe the common micronutrient deficiencies seen in malnourished children.

WHO classifies malnutrition based upon the degree of wasting or stunting and the presence
of oedema. Common micronutrient deficiencies associated with malnutrition in children are;
 Essential fatty acids (linoleic acid and linolenic acid)
 Fat-soluble vitamins (A, D, E and K)
 Water-soluble vitamins (thiamine, riboflavin, niacin, pyridoxine, vitamin B 12, ascorbic
acid and folate)
  Mineral and trace elements (calcium, phosphate, copper, selenium, zinc,
magnesium, iron, and iodine)

10. Describe the normal role of these micronutrients and the possible dietary sources.
Micronutrient Normal Role Dietary Source
Linoleic acid Production of eicosanoids Vegetable oils
(an omega-6 fatty acid) (prostaglandins & leukotrienes)  Safflower oil (78%)
thus, modify responses to  Grape seed oil (73%)
hormones, blood clotting,  Sunflower oil (68%)
inflammation, immunity,  Corn oil (59%)
stomach acid secretion, airway  Soybean oil (51%)
diameter, lipid breakdown and  Sesame oil (45%)
smooth muscle contraction  Canola oil (21%)
Linolenic acid [α-linolenic acid] As above Seed oils
(an omega-3 fatty acid)  Canola, soybeans, walnuts,
kiwifruit seeds
Vitamin A Maintains general health and Sources of carotene:
vigour of epithelial cells. β-  Orange, yellow and green
carotene acts as an vegetables
antioxidant. Formation of light-
sensitive pigments in Sources of Vitamin A:
photoreceptors of retina. Aids  Liver and milk
in growth of bones and teeth
by helping regulate
osteoblactic/osteocalstic
activity
Vitamin D Essential for absorption of Ca2+ Fish-liver oils, egg yolk and
and phosphorus from GIT. fortified milk
Works with parathyroid
hormone (PTH) to maintain
Ca2+ homeostatsis
Vitamin E (tocopherols) Inhibits catabolism of certain Fresh nuts and whate germ,
phospholipids. Involved in seed oils and green leafy
DNA, RNA and RBC formation. vegetables
May promote wound healing,
contribute to structure and
function of nervous system,
and prevent scarring. Offer
protection from liver toxicity
and acts as an antioxidant.
Vitamin K Coenzyme essential for Spinach, cauliflower, cabbage
synthesis of several clotting and liver
factors by liver, including
prothrombin
Thiamine (Vitamin B1) Acts as coenzyme for various Whole-grain products, eggs,
enzymatic reactions that pork, nuts, liver and yeast
breakdown carbon-carbon
bonds. Involved in
carbohydrate metabolism of
pyruvic acid to CO2 and H2O.
 Essential for acetycholine (ACh)
synthesis.
Riblovin (Vitamin B2) Component of certain Yeast, liver, beef, veal, lamb,
coenzymes in carbohydrate eggs, whole-grain products,
and protein metabolism, asparagus, peas, beets and
especially in cells of eye, peanuts
integument, intestinal mucosa
and blood.
Niacin (Vitamin B3) Essential component of NAD Yeast, meats, liver, fish, whole-
and NADP, coenzymes in grain products, peas, beans,
oxidation-reduction reactions. and nuts
Inhibits production of
cholesterol and assists in
triglyceride metabolism.
Pyridoxine (Vitamin B6) Essential coenzyme for amino Salmon, yeast, tomatoes,
acid metabolism. Assists yellow corn, spinach, whole-
production of circulating grain products, liver and
antibodies. May function as yogurt
coenzyme in triglyceride
metabolism
Cyanocobalamin (Vitamin B12) Coenzyme necessary for RBC Liver, kidney, milk, eggs,
formation, formation of cheese and meat
methionine amino acid,
entrance of some amino acids
into Krebs cycle and
manufacture of choline (for
ACh)
Ascorbic acid (Vitamin C) Promotes protein synthesis Citrus fruits, tomatoes and
including laying down of green vegetables
collagen for connective tissue
formation. As coenzyme, may
combine with poisons until
their excretion. Promotes
wound healing, works with
antibodies and functions as an
antioxidant
Folic acid (folate, folacin) Component of enzyme systems Green leafy vegetables,
synthesizing nitrogenous bases broccoli, asparagus, breads,
of DNA and RNA. Essential for dried beans and citrus fruits
normal RBC and WBC
production
Zinc Necessary for normal growth Widespread in many foods,
and wound healing, normal especially meat
taste sensations and appetite.
Important in CO2 metabolism
and protein digestion
Magnesium Required for normal Widespread in various foods,
functioning of muscle and such as green leafy vegetables,
nervous tissue. Participates in seafood and whole-grain
bone formation. Constituent of cereals
many coenzymes
Iron As component of haemoglobin,
reversibly binds O2. Component
of cytochromes involved in
electron transport
Iodine Required by thyroid gland to
synthesize thyroid hormones,
which regulate metabolic rates
Meat, liver, shellfish, egg yolk,
beans, legumes, dried fruits,
nuts, and cereals
Seafood, iodized salt, and
vegetables grown in iodine-
rich soils

11. Be able to counsel a mother on breastfeeding, weaning with dietary advice for toddlers
and older children.
In developing countries, breastfeeding dramatically improves survival during infancy as a
result of reduced gastrointestinal infection. Consequently, breastfeeding is one of the 4 most
important WHO strategies for improving infant and child survival. Many mothers find that
breastfeeding helps them establish an intimate, loving relationship with their baby. It may
confer an advantage in cognitive development in children and it is associated with a reduced
incidence of obesity and hypertension in later life as well as reduced inflammatory bowel
disease and diabetes mellitus. For the mother, there is reduction in breast cancer incidence
as well as ovarian and osteoporosis.

12. Discuss the clinical manifestations of a child with failure to thrive and be able to
distinguish between aetiologies.
Kwashiorkor: After fluid therapy, start with a high caloric, low protein diet (half-strength
milk) and wait until it is tolerated. Brush-border enzymes are required for absorption, which
are at the moment absent due to long-term deficiency of protein supply and would
therefore result in an osmotic diarrhoea if a high protein diet was rushed and given
prematurely.

13. Outline the management strategies of an infant who is failing to grow normally.
 Take a history
 Find the cause
o 1 month old child is likely to be due to breastfeeding malpractice or a congenital
defect (cleft palate, heart disease)
o 5-6month old is likely to be due to improper weaning practice
o
 Treat according to cause

14. Outline strategies to prevent or decrease the incidence of malnutrition in your community.