Diarrhea & Dehydration

Prof. Dr. M. Juffrie, SpAK, Ph.D

 Quantum of Problem
Great public health problem in developing
countries
 II killer disease
 High Morbidity & Mortality.
 70% deaths due to dehydration.
 ORS brought revolution : Greatest invention of
century.
 5 Millions - 1.5 millions deaths/ annum now.
 Main focus on Prolonged/ Persistent diarrhea/CD.
Physiological Definition of Diarrhea
 Loss of fluid and electrolytes via stools is net
result of imbalance between secretory and
absorptive processes in small & large
intestine. Electrolytes have a critical role in the
regulation of water absorption and secretion
across the intestine.
Watery stools, more than 3 time a day (24
hours) (WHO, 2007)

Walker Smith 2004

Normal Villi
 What is not Diarrhea ?

• Stools of an infant
– Breast fed
– Artificially fed
• Exaggerated gastrocolic reflex
• Irritable bowel syndrome (IBS)
• Spurious / factitious diarrhea
Age specific incidence for diarrhoea episode per Child per year from 2
reviews of prospective studies in developing areas,1980 - 2000

Number of episodes/person/year

3
1980-1990
2 1990-2000

0
0-5m 6-11m 1 year 2 years 3 years 4 years

2-5 episodes/year
Kosek et al. Bulletin of the WHO 2003; 81:197-204.
 Types of Diarrhea
(a) Depending upon duration.
 Acute diarrhea 3 - 7 days
 Prolonged or Indeterminate 8 - 14 days
 Persistent diarrhea > 14 days
(b) Depending upon characteristics of stools.
 Watery diarrhea --- Secretory & Osmotic
 Bloody diarrhea --- Blood & Mucus (Dysentery)
(c) Severity of diarrhea
 Diarrhea with severe malnutrition
 Diarrhea with HIV infection
 Diarrhea with the other immune deficient states.
 Pathogenesis
• Absorption disorder
• Secretory disorder
• Osmotic disorder
 Treatment of Acute Diarrhea

• Oral Rehydration Therapy

• Dietary therapy
• Zinc therapy
• Antimicrobials
• Education
Oral Rehydration Therapy (ORT)

 Oral Rehydration Solution (ORS)

WHO - ORS = Physiological Basis

 Other Fluids & Liquid Diets

 Home Available Fluids
Recommended Not recommended
• Salt sugar solution • Simple sugar
• Lemon water(Sikanjabi) solution
• Rice water / Kanjee • Glucose solution
• Soups • Carbonated soft
• Dal water drinks
• Lassi • Fruit juices-tinned or
• Coconut water fresh
• Plain water • Fluids for athletes
• Gelatin desserts
• Tea/Coffee
Composition of WHO High & Low Osmolality
ORS

------------------------------------------------------------------------------------------------------------------------------------
Ingredients / L High Osmolality Low Osmolality Components / Litre_________
Sodium Chloride 3.5 2.6 Na 90 75
Sodium Citrate 2.9 2.9 Citrate 10 10
or
Sodium Carbonate 2.5 2.5 H CO3 30 30
Potassium Chloride 1.5 1.5 K 2020
Glucose 20 13.5 Glucose 111 75
Osmolality 311 245
-------------------------------------------------------------------------------------------------------------------------------------
 Limitations of WHO High Osm-ORS
 Does not lower volume, frequency and duration of
diarrhea
 Induces vomiting due to taste, acceptability poor
 Enhances volume, purge rate & duration of
diarrhea due to high osmolality
 More chances of dehydration – Dehydrating fluid
 So more oftenly IV fluids required
 Hypernatremia
 Good to correct deficit fluids but not good for
maintenance therapy
 Need of Low Osm-ORS

• Does lower volume, frequency & duration

• Equally effective in cholera, toxin related & RV
diarrhea : Deficit & maintenance therapy
• No need of IV fluids
• Good for all ages infancy to adulthood
• Asymptomatic hyponatremia.
 Role of Diet in Acute Diarrhea
Dietary therapy
• Key role in treatment of diarrhea
• Gained great importance in recent years.
• Early refeeding during or after rehydration
mandatory
• Delayed feeding even by one day-slow recovery
• Fasting deterimental for outcome
 Advantages of Dietary Therapy

• Maintains nutrition, helps in absorption

• Faster recovery
• Take care of infection and avoids malnutrition
• Prevents prolongation of diarrhea
• Corrects malnutrition in mal-nourished
children.
• Extra diet in convalescence / on recovery
What are the Diets to be Continued or Given ?

• Age appropriate diets

• Breast feeding : Aseptic paint.
• Artificially fed – milk
• Whatever child taking earlier
• Rice, khichri, pulses/ curd/yogurt
• Small frequent aliquots – Spoon & Katori
 Foods to be Avoided

• Fat rich
• Fruits and fruit juices
• Junk foods
• Spicy foods
• Carbonated fluids
• Sugar & glucose rich foods
 Diarrhea

ORS
Continue breast
feeding
PD

Mucosal injury Malnutrition

(Malabsorption) (Marasmus)
Cereal supplements

“TREAT THE DIARRHEA WITH REGULAR DIET”

 Role of Zinc in Acute Diarrhea

Acute as well as persistent diarrhea

 Tremendous loss in stools.
 Absorption of Zinc intact
Deficiency during diarrhea results into lowering of
 Cell division & maturation.
 Tissue growth & repair.
 Maturation of enterocytes.
 Brush border enzymes.
 Water & electrolyte absorption.
 Immune functions.
 Zinc Supplementation in AD
 Responsible for > 200 enzymes in body.
 Improves the immune function & absorption.
 Supplementation in AD and PD helpful in 20-30%
reduction in diarrhea.
 42% lower rate of treatment failure or death.
Dosages
o Infants 10mg daily x 2 weeks.
o Older children 20mg daily x 2 weeks.
o Persistent diarrhea x 4 weeks
Acta Pediatr 2001
Am J Clin Nutr 2000
ASCODD 2001
 Antimicrobial Therapy in AD

 No proof that antibiotics effective in

reducing the duration of diarrhea
 Cochrane review of 12 trials – no
advantage rather adverse effects more in
acute watery diarrhea.
 Why Antibiotics are not Required in AD?

 Lack of knowledge of sensitivity of drug

against causative agent
 Risk of development of resistant bacteria
 Risk of adverse reactions (AAD)
 Cost of treatment
 Indications for Antimicrobials
----------------------------------------------------------------------------------------------------Micro
- organisms Drugs
----------------------------------------------------------------------------------------------------
 Bacteria
- Shigella Nalidixic acid, Norfloxaclin Ciprofloxacin
Ofloxacin, Cefotaxime, Ceftriaxone
- Salmonella typhi Ciprofloxacin, Ofloxacin
- Vibrio cholera Cotrimoxazole, Tetracycline,Ciprofloxacin,
- Compylobacter jejuni Nalidixic acid, Norfloxacin, Furazolidine
- EPEC (PD) Furazolidine, Norfloxacin, Cotrimoxazole
 Protozoa
- Giardia lamblia } Mitronidazole,
- Entameba histolytica } Tinidazole, Nitazoxanide, Furazolidine
-Cryptosporidium parvum Pramomycin, Nitazoxanide
----------------------------------------------------------------------------------------------------
 Other Special Indications of Antibiotics.
Severity of symptoms Host related risk factors

* Severely sick child * Neonatal age

* Septicemia * Malnutrition
* Neurological involvement * HIV Infection
* Septic shock State * Other immune deficiency
* Invasive diarrhea
Socio- environmental indications
* Cholera
* Nosocomial infection
* At risk contacts.
* Epidemics
 Probiotics

• Duration of acute diarrhea decreases by one day

in meta-analysis

• Saccharomyces boulardii : Strong benefit in AAD

• Shown in meta-analysis of seven studies

Aliment Pharmacol Ther 2002

 Diet in Indeterminate Diarrhea
(8-14 days)
• Breast feeds continue
• Diet A : Low lactose diet
• Diet B : Lactose free diet, if no response to
Diet A.
• Diet C : Monosaccharide based diet if no
response to Diet B.
 Dietary Algorithm for Treatment Of PD
Stabilize

Success Start Diet A

Treatment failure (Screen for infections)

Start Diet B

 
Discharge Success Failure (Screen for infection)
  
Appropriate Discharge Diet C
diet 7-14 days   
Diet A after 10 days Success Failure
  

After 7-14 days Gradually Parenteral

normal diet Diet B then nutrition
Diet A & normal
Bull WHO 1996
 Traditional Practices to be Avoided

• Antimotility & antispasmodic drugs

• Stool binding agents
• Enzyme preparations & steroids
• Antimicrobial agents in combination
• Bottle feeding
• IV fluids to every case
• Starvation-Nothing like bowel rest
• These will hamper natural clearance, lower
immunity, promote growth of unusual organisms &
PEM
 Practices to be Adopted

• Breast feeding: Aseptic paint for GIT

• Cereal supplementation
• Spoon & katori/ directly from pot
• Judicious use of antimicrobials
• Proper hygiene & sanitation
• Rotavirus vaccine
 When to refer to higher center

• Duration of diarrhea more than 7 days

• Fast deteriorating condition
• No response to usual therapy
• Associated complications
• Severely malnourished child
• HIV positive
 … to conclude

 Low Osm-ORS.. quite effective

 Zinc therapy ..important component
 Treat diarrhea with regular diet
 Limited use of antibiotics : Dysentery
DEHYDRATION
 OBJECTIVES
At the end of this lecture you will able to know
the followings:

*What is dehydration?
*What are the causes of dehydration?
*The clinical manifestaions of dehydration.
*The investigations required.
*Management of dehydration.
 DEHYDRATION
Fluid and electrolytes requirements
Water: : Constitutes about 70% of infant's body weight as
compared to 60% in adults.
Most of the water is found within the cells of
the body (intracellular space). The rest is found in
the extracellular space, which consists of the
blood vessels (intravascular space) and the spaces
between cells (interstitial space).
Total body water = intracellular space +
intravascular space + interstitial space
Average daily requirement of water (ml/kg):
-First year: 130 – 150.
-2 to 4 years: 100 – 130.
-4 to 10 years: 70 – 100.
-10 to 18 years: 50- 70.
Dietary Reference Intakes (DRI) of electrolytes:
Sodium (mg/day): 120 in the 1st 6months,
200 in the age 7-12 months,
225 in the age 1-3 years, and 300 from 4-8 years of age.
Potassium (mg/day): 500 in the 1st 6 months,
700 from7-12 months,
1000 from1-3 years, and 1400 from 4-8 years of age.
What is dehydration?
Dehydration occurs when the amount of water leaving the body is
greater than the amount being taken in.
We lose water routinely when:
• We breathe and humidified air leaves the body;
• We sweat to cool the body; and,
• We urinate or have a bowel movement to get rid the body waste
products.
Hyponatremia ;
Is a condition in which the body's stores of sodium are too low, and
this condition can result from drinking extreme amounts of water.
Hyponatremia can lead to confusion, lethargy, agitation, seizures,
and in extreme cases, even death.
Early symptoms are nonspecific may include disorientation, nausea,
or muscle cramps. The symptoms of hyponatremia may also mimic
those of dehydration, so athletes experiencing these symptoms
drinking more water that result in further worsening the condition.
CONSERVATION OF BODY WATER
• In a normal day, a person has to drink a significant amount of water to
replace the routine losses.
• If intravascular water is lost, the body can compensate by shifting
water from cells into the blood vessels, but this is a very short-term
solution. Signs and symptoms of dehydration will occur quickly if the
water is not replenished.

• The thirst mechanism signals the body to drink water when the body
is dry. As well, hormones like anti-diuretic hormone (ADH) work
within the kidney to limit the amount of water lost in the urine.

• The electrolytes in our body include sodium, potassium, chloride,

calcium and phosphate, but sodium is the substance of most concern
when replacing fluids lost through exercising.
Hypernatremic dehydration
• Dehydration,characterized by increased concentrations of sodium and
chloride in the extracellular fluid, it results from diarrhea in infants.
• The occurance of the hypernatremia and hyperchloremia lies in the
relatively greater expenditure of water than electrolyte via skin, lungs,
stool and urine. The water deficit in these infants is primarily
intracellular.

• The majority of infants with this type of dehydration show varying

degrees of depression of central nervous system varying from
lethargy to coma. Convulsions are frequently observed.

• Dilute solutions of electrolyte are indicated in rehydration. Rapid

adjustment, however, appears to accentuate the CNS disturbance.
Rehydration is best carried out slowly over a 2- to 3-day period.
What causes dehydration?
• Diarrhea: is the most common reason for loss of excess water. Worldwide,
more than four million children die each year because of dehydration
from diarrhea. -Vomiting: can also be a cause of fluid loss .
• Sweat: The body can lose significant amounts of water when it tries to
cool itself by sweating whatever the cause of hotness of the body such as
intense exercising in a hot environment, or presence of fever .
• Diabetes: In people with diabetes, elevated blood sugar levels cause
sugar to spill into the urine and water then follows. For this reason,
frequent urination and excessive thirst are among the symptoms of
diabetes.
• Chronic renal failure: dehydration occurs due to polyuria.
• Burns: dehydration occur because water moves into the damaged skin.
Other inflammatory diseases of the skin are also associated with fluid
loss.
• Inability to drink fluids: The inability to drink adequately is the other
potential cause of dehydration.
Clinical picture:
Examination.
- Body weight. - Temperature.- Signs of
dehydration. - Systemic examination.
General manifestations:
- Dry skin and mucous membrane.
- Decrease all body secretions (urine, sweats,
tears, saliva)
- Depressed fontanel, sunken eyes, thirst,
irritability, lately hypotension, acidosis and
coma.
 DEGREES OF DEHYDRATION:
Degree of dehydration Plan A: Plan B: Some Plan C: Severe
No dehydration dehydration dehydration

General condition Calm, alert Restless Lethargic,

irritable unconscious

Eye manifestation Normal Sunken Sunken

Ability to drink Normal Thirsty, eager Poor

to drink

Skin pinch Goes back Slowly Very slowly

quickly
IMCI MANAGEMENT: Integrated
management of childhood illness ( WHO)
* Plan A: Give fluid and food to treat diarrhea at home
• If child is 2 years or older and there is Cholera in your area, give
antibiotic for cholera.
• Advise mother when to return immediately
• Follow-up in 5 days if not improving.
* Plan B: Give fluid and food for some dehydration.
• If child has also a severe classification:
• Refer URGENTLY to hospital with mother giving frequent sips of
ORS on the way
• Advise the mother to continue breast-feeding
• If child is 2 years or older and there is Cholera in your area, give
antibiotic for cholera.
• Advise mother when to return immediately
• Follow-up in 5 days if not improving.
 IMCI MANAGEMENT: Integrated management
of childhood illness ( WHO)
* Plan C: - Give fluids for severe dehydration or If child has also
another severe classification:
• Refer URGENTLY to hospital with mother giving frequent
sips of ORS on the way
• Advise the mother to continue breast-feeding
• If child is 2 years or older and there is Cholera in your area,
give antibiotic for cholera.
• 100 cc/kg/bw: 30 cc/kg in first ½ hour, 70 cc/kg in second
21/2 hour for child > 1 year; and in first 1 hour and 5 hours
further for child < 1 year (WHO 2007)
MANAGEMENT OF DEHYDRATION
-Replace Phase 1: Acute Resuscitation :
– Give Lactated Ringer OR Normal Saline at 10-20 ml/kg IV over 30-60
minutes.
– May repeat bolus until circulation stable
-Calculate 24 hour maintenance requirements
– Formula:
• First 10 kg: (100 cc/kg/24 hours)
• Second 10 kg: (50 cc/kg/24 hours)
• Remainder: (20 cc/kg/24 hours)
Example: 35 Kilogram Child
• Daily: 1000 cc + 500 cc + 300 cc = 1800 cc/day
-Calculate Deficit:
– Mild Dehydration: (40 ml/kg)
– Moderate Dehydration: (80 ml/kg)
– Severe Dehydration: (120 ml/kg)
MANAGEMENT Continue ---------
-Calculate remaining deficit:
– Substract fluid resuscitation given in Phase 1
-Calculate Replacement over 24 hours:
– First 8 hours: 50% Deficit + Maintenance
– Next 16 hours: 50% Deficit + Maintenance
• Determine Serum Sodium Concentration
– Hypertonic Dehydration (Serum Sodium > 150)
– Isotonic Dehydration
– Hypotonic Dehydration (Serum Sodium < 130)
• Add Potassium to Intravenous Fluids after patient voids urine
– Potassium source
• Potassium Chloride
• Potassium Acetate for Metabolic Acidosis
– Potassium dosing
• Weight <10 kilograms: 10 meq KCl /liter glucose
• Weight >10 Kilograms: 20 meq KCl /liter glucose