TREATMENT

Objectives
• Prevent dehydration, if no signs of dehydration
• Treat dehydration, when present
• Prevent nutritional damage
• Reduce the duration & severity and the occurrence of future
episodes
 No Dehydration:
1
Treatment Plan A

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Tx a
• ors

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Reduced Osmolarity ORS
• As safe and effective as old ORS, but reduces stool output or
have other important clinical benefits
• Reduce osmolarity to avoid hypertonicity by reducing glucose
and salt concentration
• Studies showed reduced output of 20% and vomiting by 30%

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Reduced Osmolarity ORS

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

• ors

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 Some Dehydration:
2
Treatment Plan B

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Tx a
• ors

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

After 4 Hours…
• With signs of severe dehydration  IV therapy following Treat
Plan C
• With some signs of dehydration  repeat Plan B + other
food/fluids
• No signs of dehydration  fully
rehydrated

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Failure of Rehydration
• Continuing rapid stool loss (>15-20 ml/kg/hr)
• Insufficient ORS intake due to lethargy or fatigue
• Frequent, severe vomiting

Give ORS via NGT or Ringer’s Lactate Solution IV (75 mk/kg in

4 hours)

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• ors

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 Severe Dehydration:
3
Treatment Plan C

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WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.
WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.
IV INFUSION

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

4 Suspected Cholera

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Suspected Cholera
• Child >5 years develops severe dehydration from acute watery
diarrhea
• Patient older than 2 years has acute watery diarrhea when
cholera is known to be occuring in the area

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Management of Cholera
• IV rehydration following guidelines for patients with some or
severe dehydration
• Reassess every 1-2 hours
• ORS solution
• 200-350 ml/kg for first 24 hours
• Rice-based ORS superior to standard ORS

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

RICE-BASED ORS

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Management of Cholera
• First dose: when vomiting stops, usually 4-6 hours after start of
rehydration therapy
Antibiotic of Choice Alternative

Doxycycline Erythromycin
Adult 300mg once Children 12.5 mg/kg
or 4x a day x 3 days
Tetracycline Adults 250mg
Children 12.5 mg/kg 4x a day x 3 days
4x a day x 3 days
Adult 500mg
4x a day x 3 days
WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.
5 Dysentery

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Management of Dysentery
• Appropriate fluids to prevent or treat dehydration

Antibiotic of Choice Alternative

Ciprofloxacin Pivmecillinam
Children 15 mg/kg Children 20 mg/kg
2x a day x 3 days 4x a day x 5 days
Adult 500mg Adults 400mg
2x a day x 3 days 4x a day x 3 days

Ceftriaxone
Childn 50-100 mg/kg
OD IM x 2-5 days
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MANAGEMENT OF DIARRHEA.
6 Persistent Diarrhea

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Management of Persistent Diarrhea

• Treatment goal: restore weight and normal intestinal function

1) Appropriate fluids
2) Nutritious diet
3) Supplementary vitamins & minerals
4) Antimicrobial for diagnosed infections

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Successful Treatment
• Adequate food intake
• Weight gain
• Fewer diarrheal stools
• Lack of fever

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

7 With Severe Malnutrition

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

With Severe Malnutrition
With Severe Malnutrition
• Assess hydration: eagerness to drink, lethargy, cool and moist
extremities, weak or absent radial pulse, reduced or absent
urine flow
• Distinguish from septic shock

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Management
• Should take place at hospital
• Rehydration should be by mouth
• NG tube if drinking poorly
• IV causes over0hydration and heart failure (use only in shock)
• SLOW rehydration: 70-100 ml/kg over 12 hours
• 10 ml/kg/hour during first two hours
• Continue at this rate or lower based on ongoing stool loss
• Increasing edema is evidence of over-hydration

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

ORS in Management
• Full strength ORS solution should not be used for oral or NG
rehydration
• Too much sodium and too little potassium
• When using the new ORS solution containing 75 mEq/l of
sodium
• Dissolve one packet into two liters of clean water
• Add 45 ml of potassium chloride solution
• Add and dissolve 50g sucrose

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Feeding
• Mothers should remain with their children to breastfeed and
other feeding
• To begin as soon as possible
• Usually within 2-3 hours of starting rehydration
• Food to be given every 2-3 hours, day and night

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Initial Diet
• Should be given from admission until appetite is back to normal
• 75 Kcal/100 ml composed of
• Skimmed milk powder: 25g
• Vegetable oil: 20g
• Sugar: 60g
• Rice powder: 60g
• Water to make: 1000ml
• Combine all ingredients and boil gently for five minutes to cook rice
powder
• Should receive 130ml/kg/day of the diet
• If cannot tolerate, NG tube divided into 6 feedings

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Subsequent Diet
• After appetite returns, 100 Kcal/100ml
• Skimmed milk powder: 80g
• Vegetable oil: 60g
• Sugar: 50g
• Water: 1000ml
• Fresh skimmed milk briefly boiled may replace skim milk
powder and water
• Should be given as much as can tolerate aiming for minimum
daily intake of 120 ml/kg/day and reaching 200 ml/kg/day or
more as appetite improves

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Vitamins, Minerals, and Salts
• Mixture of following to be added to every two liters of both liquid diets
previously stated
• KCl: 3.6g
• K3 citrate: 1.3g
• MgCl2 6H2O: 1.2g
• Zn acetate 2H2O
• CuSO4 7H2O: 22mg
• NaSeO4 10H2O: 0.44mg
• KI: 0.20mg
• Vitamin A should be added if any corneal clouding and conjunctival spots
• Multivitamin mixtures that procide at least two RDAs of all vitamins should
be added to diet or given separate
• Supplementary iron should be given when weight gain established

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Antimicrobials
• All severely malnourished children should receive broad
spectrum antimicrobial treatment for several days when
admitted
• Should also be given in any signs of septic shock
• Should be checked daily for other infections and treated as
identified

WORLD HEALTH ORGANIZATION. MANAGEMENT OF DIARRHEA.

Mechanisms of Diarrhea

PREVENTION
PREVENTION
• Breastfeeding
• Safe water
• Handwashing
• Food safety
• Use of latrines and safe disposal of stools
• Measles immunization