DIARRHEA

IN
CHILDREN
 Diarrhea
 Definition:
An increase in the fluidity, volume and
frequency of stools.

 Acute diarrhea:
Short in duration (less than 2 weeks).

 Chronic diarrhea:
2 weeks or more
 Etiology of Diarrhea(infant)
Acute Diarrhea Chronic Diarrhea
Gastroenteritis Post infections
Systemic infection Secondary disaccaridase
deficiency
Antibiotic association Irritable colon syndrome
Overfeeding Milk protein intolerance
 Types of Diarrhea
 Acute watery diarrhea: (80% of cases)
Dehydration
Malnutrition
 Dysentery: (10% of cases)
Anorexia/weight loss
Damage to the mucosa
 Persistent diarrhea: (10% of cases)
Dehydration
Malnutrition
 Types of Diarrhea
• 1. Watery diarrhea
• 2. Steatorrhea
• 3. Creatorrhea / azotorrhea
• 4. Mucus & blood
• 5. Undigested food particles
• 6. Overflow incontinence
 Etiology
• Viral: 70-80% of infectious diarrhea in
developed countries
• Bacterial: 10-20% of infectious diarrhea but
responsible for most cases of severe diarrhea
• Protozoan: less than 10%
 Viral Diarrhea
• Rotavirus
• Norovirus (Norwalk-like)
• Enteric Adenovirus
• Astrovirus
 Bacterial Diarrhea
• Campylobacter
• Salmonella
• Shigella
• Enterohemorrhagic Escherichia coli
 Protozoa

• Ent amoeba histolytica

• Giardia lamblia
• Trichuris trichura
• Strongyloides
• Balantidum coli
 Mechanisms of Diarrhea

Osmotic
Secretory
Exudative
Motility disorders
 Watery Diarrhea :

• Osmotic Diarrhea
• Secretoric Diarrhea
 Mechanisms of Diarrhea
 Osmotic
Defect present:
Digestive enzyme deficiencies
Ingestion of unabsorbable solute
Examples:
Viral infection
Lactase deficiency
Sorbitol/magnesium sulfate
Infections
Comments:
Stop with fasting
No stool WBCs
 Gamb.9 : Diare karena
virus
 Mechanisms of Diarrhea
 Secretory:

Defect:
Increased secretion
Decreased absorption

Examples:
Cholera
Toxinogenic E.coli

Comments:
Persists during fasting
No stool leukocytes
Gamb.4 : Diare karena enterotoksin
Gamb.5 : Diare karena enterotoksin
 Mechanisms of Diarrhea

 Exudative Diarrhea:

Defects:
Inflammation
Decreased colonic reabsorption
Increased motility

Examples:
Bacterial enteritis

Comments:
Blood, mucus and WBCs in stool
 Mechanisms of Diarrhea

 Increased motility:
Defect:
Decreased transit time

Example:
Irritable bowel syndrome
 Complications of Diarrhea

Dehydration  blood circulation↓

Metabolic Acidosis
Gastrointestinal complications
Nutritional complications
 Clasification of Dehydration (1)

1. Diare without dehydration

2. Diare with not severe dehydration
3. Diare with severe dehydration
 Clasification of Dehydration (2)

1. Without signs of dehydration.

2. Mild & moderate dehydration
3. Severe dehydration
 Types of Dehydration

1. Isotonic [ isonatremic ]
2. Hypotonic [ hyponatremic ]
3. Hypertonic [ hyponatremic ]
 Types of dehydration
Isotonic Hypertonic Hypotonic
(isonatremic) (hypernatremic) (hyponatremic)
Loses H2O = Na H2O > Na H2O < Na

Plasma Normal Increase Decrease

osmolality
Serum Na Normal Increase Decrease

ECV Decrease Decrease Decrease +++

ICV maintained Decrease +++ Increase
Thirst ++ +++ +/-

Skin turgor ++ Not lost +++

Mental state Irritable/lethargic Very irritable Lethargy/coma

shock In severe cases Uncommon Common

 Clinical Finding of Dehydration

Symptom/ Sign Mild Dehydration Moderate Dehydrat Severe Dehydration

Level of consiousness Well, Alert Restless,thirsty,irrita Drowsy,cold extrem,
ble lethargy
Capillary refill * 2 sec 2 – 4 sec > 4 sec, cool limb
Mucous membran Moist Stiky, Dry Dry, Parched, cracked
Tears Present Decreased, absent Absent
Heart rate Slightly increased Increased Very increased
Respiratory rate/ pat Slightly increased Increased Deep, rapid
Blood pressure Normal Decreased Very Decreased
Pulse Slightly increase Rapid, weak Faint or impalpable
Skin turgor * Normal Slow,decreased Very decreased
Fontanel Normal Depressssed Sunken
Eyes Normal Sunken Very sunken
Urine out put Normal Decreased, Oliguria Oliguria/anuria
Sign of dehydration
 Complications of Diarrhea

Metabolic Acidosis
 Reduced serum bicarbonate
 Reduced arterial PH
 Compensating respiratory alkalosis
 Complications of Diarrhea

Gastrointestinal complications
Secondary carbohydrate
malabsorption
Protein intolerance
Persistent diarrhea
 Laboratory Investigation

 Blood

 Stool specimen

 Rectal swab

 Culture blood no evidence of salmonella

 stool: no shigellae, yersinia or campylobacter
 Management
• Fluid replacement
– Fluids or Oral Rehydration Solutions (ORS)
– Parenteral rehydration
• Early refeeding
- breast feeding as soon as possible
- food
• Zinc
• Antibiotics not routine
• PROBIOTIC ?
 Management ( con’t)

 Oral Rehydration Solution (ORS):

• Effective in all types & all degrees of dehydration.
• Can prevent dehydration if given early in the disease.
• Cheap, easy to administer; can be given by mother at
home.
• No chance of overhydration or electrolyte overdose.

 Methods of administration: spoon, cup, dropper, syringe,

naso-gastric tube or iv.
Management Severe Dehydration
Rapid ORS → = intravenous fluid therapy in
restoring intravascular volume & correcting
acidosis.
Fluid deficit should be replaced over 4 hours.
Severe dehydration :
Required - laboratory evaluation
- Intravenous rehydration
-Severe dehydration : fluid deficit
-10 – 15 % of BW in infant
-6 – 9 % BW in older children
 MANAGEMENT SEVERE DEHYDRATION
Phase 1 : emergency treatment
characterized hypovolemic shock
required rapid treatment :
- intravenous or intraoseous line
- Fluid bolluses depending on severity of
dehydration.
Phase 2 : + deficit replacement :
- daily requirement
- replace on going loss ( vomit, stool, urine)
- insensible loss ( fever, sweat )
 ORS Composition

 Sodium Chloride

 Tri-Sodium Citrate (bicarbonate)

 Potassium Chloride

 Glucose
 Diet for post dehydration diarrhea
- Started as soon as patient is able tolerate
oral intake
- Diluting milk or formula is not indicate
Breast feeding as soon as possible
- Food that contain complex carbohydrates
( eg. Rice, wheat, potatoes, bread, cereals), lean
meats, fruits, and vegetables are encouraged.
Fatty foods and simple carbohydrates should be
avoided.
 Prevention
 Wash your hands frequently,
especially after using the toilet,
changing diapers.
 Wash your hands before and after
preparing food.
 Wash diarrhea-soiled clothing in
detergent and chlorine bleach.
 Never drink unpasteurized milk or
untreated water.
 Drink only bottled water.
 Proper hygiene.
 Points to Remember

 Diarrhea acute self-limited illness.

 Diarrhea and vomiting in infancy and childhood is
usually due to viral gastroenteritis.
 Fluid replacement with ORS is the mainstay of
management.
 Breast feeding should be continued, but formula
feeding should cease until recovery.
 Antibiotics and antiemetics agents are
contraindicated.