Diarrhea in Children

Two million children die each year in

Developing Countries from Diarrhoea
Source : WHO
 Definitions
A change in Stool Consistency, Volume and
increased frequency of Defecation
Classification
 Acute if < 2 weeks
 Persistent if acute in onset but persists >2
weeks
 Recurrent if the episodes are distinctly
separated by a completely normal intervening
period ( 48-72 hrs)
 What is not diarrhea

 Passage of frequent formed stools

 Passage of frequent watery motions in a well
looking neonate from Day 4-7
 Passage of loose golden-brown pasty stools in a
breastfed child
 Defecation (formed stools) immediately after
meals in older children.
 Etiology of Diarrhea
 Viruses
– Rotavirus, Norwalk virus, Adenoviruses
 Bacteria
– E. coli (ETEC, EPEC, EAEC, EHEC)
– Vibrio cholerae
– Salmonella spp., Shigella, Campylobacter
 Protozoa
– Entamoeba histolytica
– Giardia spp., Cryptosporidium
 Systemic Infection (Parenteral Diarrhea)
– Pneumonia, UTI, Septicemia, Otitis media
 Predisposing Factors

 More in Summers and rainy season

 Poor hygiene
 Unhygienic feeding
 Malnutrition
– More chances of persistent diarrhea
– More chances of mortality (15-20 times)
– More chances of systemic infection
 Diarrhea & malnutrition
Vicious cycle

Diarrhea
 Losses
 Immunity  Catabolism
 Mucosal integrity  Absorption
Common  Appetite
predisposing factors Voluntary restriction

Malnutrition
 Assessment
History
 Diarrhea or not?
 Acute or persistent or recurrent?
 Watery/Rice watery/ bloody/mucoid
 Associated features (vomiting, fever, tenesmus)
 Clues of systemic infection
 Mode of feeding/ type of treatment given
 Examination
 State of Dehydration (No, Some, Severe)
 State of Nutrition (Weight, Anthropometry)
 Signs of systemic infection
– Fever preceding (>24 hours) onset of diarrhea
– Fever persisting for > 72 hours
– General condition poorer than state of dehydration
– Specific clues (crepitations, bulging fontanelle etc.)
 Investigations
 Not Much role
 Stool microscopy (history of mucus in stools ,
non response to therapy in dysentery)
 Stool culture (Only of pragmatic interest)
 Serum electrolytes/ Blood gas (in altered
sensorium, marked irritability, seizures,
abdominal distension)
 Screening for systemic infection if some clue
 Look and feel Signs Dehy. Plan

1. General Condition 2 of the following: SEVERE Plan

-Lethargic or unconscious -Lethargic or unconscious C
-Restless and irritable -Sunken eyes

2. Look for sunken -Not able to drink

eyes -Skin pinch goes back very

slowly
3. Offer the child fluid
2 of the following: SOME Plan
-Not able to drink or
drinking poorly -Restless, irritable B
-Drinking eagerly (thirsty) -Sunken eyes
-Drinks eagerly, thirsty
4. Skin pinch
-Skin pinch goes back slowly
-goes back slowly
Not enough signs to classify NO Plan
-goes back very slowly
as some or severe A
dehydration
Wrong method of skin pintch
What to Give in Diarrhea?
Oral Rehydration
Therapy

The Mainstay Of
Treatment

However

Does not offer rapid

relief of diarrheal
symptoms
 What is ORT

 WHO ORS Solution

 Home made sugar-salt solution
 Food based fluids (Rice water + salt, Lassi +
Salt)
 Culturally acceptable home fluids (Coconut
water, lemon water, plain water, dal water,
soups)
 Advantages of new formula
 Sodium and glucose in same molar
concentration facilitates Na absorption
 Significant reduction of stool output
 Reduction of duration of diarrhea
 Reduction of vomiting
 Significant reduction of use of unscheduled IV
fluid
Home made ORS
 What is NOT ORT

 Glucose water without salt

 Aerated beverages
 Fruit juices
 Tea/Coffee
How to mix and give ORS
How to mix and give ORS
How much to give?
 Plan A : for No Dehydration

 Continue feeding
 ORT
– Home available fluids
– Sugar salt solution/food based solutions
– ORS
< 2 yrs: 50-100 mL/loose stool
2-10 yrs: 100-200 mL/loose stool
>10 yrs: As much as child wants
 Plan B : for Some Dehydration

 Rehydration Therapy
- ORS 75 mL/Kg over 4 hours
- Preferably manage in health facility
- If child wants more, give more
- If eyelids turn puffy, stop & give other fluids
Continue giving ORS when eyes turn normal
 Continue Feeding
 ORS and instructions as in Plan A
 Plan C : for Severe Dehydration

Yes 1. Give IV fluids.

Can you give intravenous (IV)
         2. After 4-6 hours, reassess the child
fluids?
       and choose the suitable treatment plan.

No     
Yes 1. Start treatment with ORS solution,
Can the child drink?          as in Plan B
       2. Send the child for IV treatment

No   

1. Start rehydration using the tube

Are you trained to use a Yes
2. If IV treatment is available nearby,
nasogastric tube for         
send the child for immediate IV
rehydration?       
treatment.

No   
 
URGENT:
Send the child for IV t/t
I/V correction of Severe dehydration
 Ringer Lactate or Normal saline or N/2 saline in
dextrose (100 mL/Kg)
– < 1 yr: 30 mL/Kg in first hour and 70 mL/Kg in next 5
hrs
– > 1 Yr: 30 mL/Kg in first 30 min. and 70 mL/Kg in
next 2.5 hrs
 Start ORS and feeding when able to drink
 Frequent monitoring for signs of dehydration/
complications
 Indications of I/V fluids

 Severe Dehydration
 Persistent vomiting (Not retaining anything)
 Abdominal distension/Paralytic ileus
 Unconscious child
 Increased purge rate (>5ml/kg/hr)
 Oral ulcer
 Glucose malabsorption (Very rare)
 Diarrhea - Treatment
Antibiotics not indicated in most cases
Indications
 Dysentery – Nalidixic acid / Cotrimoxazole /
Quinolones
 Cholera - Tetracycline / ciprofloxacin
 Systemic infections (Parenteral diarrhea)
 Routinely in severely malnourished
 Diarrhoea - Treatment
Zinc
 16% faster recovery
 Reduction in duration of diarrhea
 Reduction in stool output by 30%
 Reduction in antibiotic prescriptions
Recommendation:
20 mg elemental zinc/day for up to 10 days .
 Symptomatic Therapy -
Loperamide & Diphenoxylate
Drawbacks
 Leads to Post Treatment Constipation
 May worsen certain forms of Invasive Bacterial
Diarrhoea
 Severe adverse effect of Paralytic Ileus

Contraindicated in most childhood diarrheas

 Diarrhoea - Treatment
Racecadotril
 Represents a new class of drugs – Oral Enkephalinase
Inhibitors
 has a specific antisecretory action & does not prolong
intestinal transit time
 Well tolerated in children; no significant adverse effects
documented till date
 Limited data in artificial settings demonstrate reduction in
stool output in secretory diarrhea
 Overall evidence insufficient to recommend routine use
 Diarrhoea - Treatment
Probiotics
 Lactobacillus, Bifidobacterium, Saccharomyces
 Enteroprotective by competing for attachment
with pathogenic bacteria
 Strengthen junction between enterocytes
 Enhance immune response to pathogens
Overall a trend towards benefit in diarrhea
 Diarrhoea - Treatment
Probiotics
 Most data from developed countries
 Can not be replicated in Indian setting
– High breastfeeding rates
– Different and higher intestinal flora
– Benefit shown mainly in rotavirus; relative
contribution of which is less in India
 Good quality studies required in setting of
developing countries
 Nutritional Management
Very Important Aspect
Feeding does not worsen diarrhea
Prevents malabsorption & facilitates
mucosal repair
– Continue feeding during diarrhea
– Do not dilute milk during diarrhea
– Routine lactose free feeding not required
– Increase amount of calories during convalescence
with energy dense foods (enrich foods with fats and
sugar)
 Prevention of Diarrhea
 Exclusive breastfeeding for six months
 Timely and safe complementary feeding after 6 months
 Hand washing
– Before cooking and serving food
– Before feeding the child
– After toilet
 Safe drinking water
 Food hygiene
 Safe waste/ excreta disposal
 Immunization
Thank

You