Childhood Diarrhoeal disease &

Management

Dr. Alok Acharya

MBBS, MD Community Medicine
Assistant Professor
Department of Community Medicine
 What is diarrhoea?
Passage of 3 or more loose, liquid or watery stools
in a day

What is not a diarrhoea?

1.Frequent formed stools

2.Pasty stools in breastfed child

3.Stools during or after feeding

4.PSEUDODIARRHOEA:Small volume of stool frequently

(IBS)
 Types

1. Acute watery diarrhoea : <2 weeks, 90% attacks are self limited
(resolved by ORS)
Lasts several hours to days ;Main danger is dehydration, weight loss
Pthogen V. cholera, E.coli, rotavirus.

2. Acute Bloody diarrhoea: Dysentry ;damage intestinal mucosa,-

sepsis and malnurtition, dehydration; pathogen common is Shigella

3. Persistent diarrhoea :2-4 weeks danger is malnutrition, serious non-

intestinal infection,dehydration, e.g person with AIDS

4. Diarrhoea with severe malnutrition (marasmus and kwashiorkar):

dangers are systemic infection, dehydration, heart failure and vitmin
and mineral deficiency.
 Problem statement

Worldwide-children deaths : 1.6 million every yr

World-wide 4% of all deaths

Worldwide 18% of under five deaths

In Southeast Asia -nearly 8% of all deaths

IN NEPAL “Incidence of diarrhoea per 1,000 under‐five

years' children has considerably decreased to 501/1,000
under 5 year children in FY 2071/72 from
528/1,000 in 2069/70 and 629/1,000 in 2070/71.”
 Agent factors

Virus
Rota,Astro,Adeno,Calci,Corona,Norwalk,Entero

Bacteria
Campylobacter Jejuni,E.Coli,Shigella,Salmonella,
V.cholerae,V.parahaemolyticus,Bacillus cereus

Others
E.Histolytica,Giardia,Trichuriasis
Cryptosporidium,Intestinal worms
 Important pathogens in children
Pathogen % of cases
Virus Rota virus 15-25
Bacteria ETEC (Entero toxigenic 10-20
Ecoli)
EPEC (Entero 1-5
pathogenic Ecoli)
Salmonella (Nontyphoid) 1-5
V.Cholerae 01 5-10
Shigella 5-15
Campylobacter jejuni 10-15
Protozoans Cryptosporidium 5-15
No - 20-30
pathogens
Viruses: cause for 50% cases of diarrhoea <2 yr
found
Cryptosporidium: diarrhoea in infants and immuno-defficients
 Reservoir of infection
• Humans
• Humans and animals: Campylobacter,salmonella,
yersinia enterocolitica

Host factors

• Most common age: 6 months- 2 yr

• Highest at the time of weaning
(contaminated food,
contact with feces as infant starts to crawl)
• Common in non-breast fed infants
• Malnutrition, Measles
• Incorrect feeding practices
• Lack of hygiene
 Environmental factors

In temperate climates
Bacterial diarrhoea: summer
Viral diarrhoea: winter

In tropical areas
Viral diarrhoea: whole year
Bacterial diarrhoea: summer,rainy season

Social factors

Poverty,ignorance,illiteracy

Mode of transmission
Faeco-oral
(water borne,food borne,fomites,fingers,dirt)
Poverty, water and diseases
 MANAGEMENT

ORAL REHYDRATION THERAPY

DRUGS
(ANTIBIOTICS,ANTIMOTILITY DRUGS)

NUTRITIONAL MANAGEMENT
 ASSESSMENT
OF
HYDRATION STATUS
Look, Feel and Decide Chart for assessment of Dehydartion in diarrhoea

Condition Well,Alert *Restless, *Lethargic or

Irritable* unconscious;Floppy*
Eyes Normal Sunken Very sunken
Look at
Tears +nt -nt -nt
(CETTT)
Tongue Moist Dry Very Dry
Thirst Not thirsty *Thirsty, *Drinks poorly or
drinks eagerly* unable to drink*

Feel Skin Goes back *Goes back slowly* *Goes back very
pinch instantly slowly*

Decide No 2 or more signs 2 or more signs

dehydration including atleast including atleast one
one * marked * marked
(SOME (SEVERE
DEHYDRATION) DEHYDRATION)
Treat Treat. A Weigh the Weigh the
Skin Pinch
sunken eyes
 TREATMENT PLAN A

4 Rules of home treatment

1.Give extra fluid-

 Breastfed frequently,

 Give one or more : ORS solution, food based fluids (such as

soup,rice water and yoghurt drinks), clean water

 Teach the mother how to mix and give ORS.Give the mother 2
packets of ORS to use at home.

 Show the mother how much fluid to give (After each loose stool
and between them) in addition to the usual fluid intake:

 Up to 2 years : 50-100 ml
 2 years or more:100-200 ml
 >10 years: as much as wanted
Tell the mother to:

 Give frequent small sips from cup

 In case of vomiting: Wait 10 min.then continue but slowly,
 Continue giving extra fluids until the diarrhoea stops

2.Give Zinc Supplements:

Tell the mother how much zinc to give:

< 6 months (dose 10 mg/day): ½ tab x 14 days
>6 months (dose 20 mg/day): 1 tab x 14 days

3. Continue feeding

4. Tell the mother when to return

 TREATMENT PLAN B

• Determine amount of ORS over 4 hour period:

75 ml/kg body
• If the child wants more ORS then give more
• For infants < 6 months (not breastfed):
give 100-200 ml clean water also

Age < 4 4-12 12-24 24-60

(months)
Weight (kg) <6 6-<10 10-<12 12-19

Amount (ml) 200-400 400- 700- 900-

700 900 1400
Tell the mother to:

 Give frequent small sips from cup

 In case of vomiting: Wait 10 min.then continue but slowly,
 Continue giving extra fluids until the diarrhoea stops

After 4 hours

 Reassess as per assessment chart and treat accordingly

(Plan A,B or C)

 If the mother must leave before completing treatment:

• Show her how to prepare ORS solution at home
• Show her how to prepare ORS to give to finish 4 hr treatment
• Also give 2 packets ORS

 Explain the 4 rules of home treatment:

1.Give extra fluid 2.Give zinc supplements

3.Continue feeding 4.When to return
 TREATMENT PLAN C

Can you give the IV fluid immediately? YES

If the child can drink, give ORS orally while the drip is set up.

Age First give Then give

30ml/kg in 70 ml/kg in
< 12 months 1 hour* 5 hour*
12 months - 5 years 30 min.* 2 ½ hours*
* Repeat once if radial pulse is still very weak or not detectable

• Reassess the child every 1-2 hours.

If hydration status is not improving give the IV drip more rapidly

• Also give ORS (5 ml/kg/hour) as soon as the child can drink.

• Reassess an infant after 6 hours and child after 3 hours:

Decide the treatment
Can you give the IV fluid immediately? NO

Is IV treatment available nearby (within 30 min.) YES

Refer urgently to hospital for IV treatment

(If the child can drink. Provide the mother with ORS solution and show her how
to give frequent sips during the trip)
Is IV treatment available nearby (within 30 min.) NO

Are you trained to use a nasogastric tube for rehydration? YES

Start rehydration (ORS solution) by tube/mouth : 20 ml/kg/hour for 6

hours.
Reassess the child every 1-2 hours
• If vomiting or increasing abdominal distension, give the fluid more slowly
• If hydration status is not improving after 3 hours, send the child for IV therapy
• After 6 hours, reassess the child and treat (A,B or C)
Are you trained to use a nasogastric tube for rehydration?

NO

Can the child drink YES Give ORS orally

NO

Refer urgently to hospital for IV/NG treatment

If the child is >2 years and there is cholera epidemic in the area
Give antibiotic for cholera
ORT

Naso-gastric tube
 FOLLOW UP

• Follow up after 2 days in dysentery, after 5 days in

acute diarrhoea

• Return immediately if the child develops:

 Many watery stools,

 Repeated vomiting,
 Fever,
 Poor or unable to drink and eat/ breastfeed,
 Blood in stool
 Composition of WHO -ORS

Ingredients Normal Low osmolarity

(gm) (gm)
Sodium chloride 3.5 2.6

Glucose 20.0 13.5

Potassium Chloride 1.5 1.5

Trisodium citrate 2.9 2.9

dehydrate
27.9 gm 20.5 gm
(310 mOsm/l) (245 mOsm/l)
SGPT:2.6,13.5,1.5,2.9
Home made ORS

1 tsp table salt + 4 heaped tsp sugar

in 1 litre of water

SUPER ORS

 Amino acid based ORS

 Amino acids (Alanine, Glycine co-transport the Na+) are used

in place of glucose

 Powder of boiled rice (50 mg/L) can be used in place of amino acids

 Decrease purging rates and improve absorption

ORS
 DRUGS IN DIARRHOEA

Antibiotics in Dysentery and Cholera

In Dysentery:
Cotrimoxazole

Better in 2 days

No Yes

Look for trophozites of E.Histolytica in stool Complete the 5 days treatment

Absent Present

Refer to hospital Treat with Metronidazole

/Give Ciprofloxacin
 DOSAGE OF COTRIMOXAZOLE AND NALIDIXIC ACID IN DYSENTERY

Age/Wt. Cotrimoxazole Nalidixic acid

(2 times/day (4 times/day
for 5 days) for 5 days)
Paediatric tablet Syrup Tablet
20 mg TMP+ 40 mg+ 500 mg
100 mg SMX 200 mg
(per 5 ml)
2 - < 12 2 tab 1 tsp 1/4
months
(4- <10kg)
1 - 5 years 3 tab 1.5 tsp 1/2
(10-19 kg)
 Anti-diarrhoeals

Loperamide

Useful in: Mild to moderate diarrhoea

C/I: Bloody dirrhoea, high fever,

worsening of diarrhoea inspite of
antidiarrhoeals, children

Dose :4 mg (2 tabs. Stat) ,

then 1 tab after each loose stool (max. 16 mg/day)
DRUGS WHICH SHOULD NOT BE USED IN DIARRHOEA

1.Neomycin(Damages the intestinal mucosa)

2.Purgatives
3.Atropine(Dangerous for children and dysentery patients)
4.Steroids(Useless)
5.Oxygen(Unnecessary)
6.Charcoal(No value)
 NUTRITIONAL MANAGEMENT OF DIARRHOEA

1.Continue feeding

2.Energy dense foods should be given:

Khichri , rice with milk, curd and sugar,
mashed banana with milk, mashed potatoes and lentils

3.Foods with high fibre content should be avoided

4.During recovery, an intake of at least 125% of

normal requirement should be attempted
 National diarrhoea diseases control programme

1.Short term: Appropriate clinical management

-ORT
-Appropriate feeding
-Chemotherapy

2.Long term

a. Better MCH practices

-Maternal nutrition
-Child nutrition: breast feeding, proper weaning,
supplementary feeding
b. Preventive strategies

-Sanitation
-Health education
-Immunization
-Fly control
-Food Hygiene

c. Prevention and control of diarrhoeal epidemics

-Strengthening of epidemiological surveillance

THANKS !!!   