DIARRHOEA IN CHILDREN

GUDIED BY :- PROFESSOR DULARI GANDHI HOD Department of pediatrics

Presented by :Dr. Sumit Kumar

INTRODUCTION

Leading cause of childhood morbidity & mortality in developing countries Important cause of malnutrition 80% of deaths due to diarrhoea occur in the first two years of life. Children <3 years of age in developing countries experience around three episodes of diarrhoea each

Definition

Diarrhoea is the passage of loose or watery stools at least three times in 24 hour .

Clinical Types

Acute watery diarrhoea (including cholera): Lasts several hours or days Main danger is dehydration Weight loss occurs if feeding is not continued; Acute bloody diarrhoea: Also called dysentery Main dangers - damage of the intestinal mucosa, sepsis and malnutrition Other complications : dehydration , HUS

Persistent diarrhoea : Lasts 14 days or longer a/w malnutrition Main danger - malnutrition & serious non-intestinal infection Other complications : dehydration Diarrhoea with severe malnutrition : Main dangers - severe systemic infection , dehydration, heart failure and vitamin and mineral deficiency.

ETIOLOGY OF ACUTE DIARRHOEA

Viral : Rota Virus Adenovirus Norwalk Agent Bacterial : V. Cholera

ETEC, EIEC
Salmonella

Shigella
Fungal : Candida Campylobacter

Parasitic Infection : Giardia Lamblia Cryptosporidium Entamoeba Histolytica Diet :

Drugs : Laxatives Sorbitol Antacids Lactulose Theophylline

Food Poisoning Antibiotics Food allergy

Quinidine

Pathophysiology of acute diarrhea

Increased secretion of fluid and electrolytes

Decreased digestion and absortion of nutrients

Abnormal transit due to aberrations of intestinal motility

Assessment of the child with diarrhoea

History Ask the mother or other caretaker about: Presence of blood in the stool; Duration of diarrhoea; Number of watery stools per day; Number of episodes of vomiting; Presence of fever, cough, or other important problems (e.g. convulsions, recent measles); Pre-illness feeding practices; Type and amount of fluids (including breastmilk) and food taken during the illness; Drugs or other remedies taken; Immunization history.

Dysentery: Mucous & blood in stool Persistent diarrhoea: Min 14 days Malnutrition with diarrhoea: Weight-for-length or weight-for-age indicate moderate or severe malnutrition Oedema with muscle wasting Obvious marasmus

Dehydration

During diarrhoea there is an increased loss of water and electrolytes (Na, Cl , K , and HCO3 ) in the liquid stool.

Dehydration occurs when these losses are not replaced adequately and a deficit of water and electrolytes develops.

NO DEHYDRATION

SOME DEHYDRATION SEVERE DEHYDRATION

WHO/IMNCI/IAP

Treatment Plan A: home therapy to prevent dehydration and malnutrition

Children with no signs of dehydration need extra fluids and salt to replace their losses of water and electrolytes due to diarrhoea. If these are not given, signs of dehydration may develop.

four rules of Treatment Plan A:

Rule 1: give the child more fluids than usual Suitable fluids : two groups: Fluids that contain salt : ORS solution Salted drinks (e.G. Salted rice water or a salted yoghurt drink) Vegetable or chicken soup with salt. Fluids that do not contain salt, such as: Plain water Water in which a cereal has been cooked Unsalted soup Yoghurt drinks without salt Green coconut water Weak tea (unsweetened) Unsweetened fresh fruit juice.

Unsuitable fluids Drinkssweetened with sugar, which can cause osmotic diarrhoea and hypernatraemia. Some examples are: Commercial carbonated beverages Commercial fruit juices Sweetened tea. With stimulant, diuretic or purgative effects, for example: Coffee Some medicinal teas or infusions.

How much fluid to give The general rule is: give as much fluid as the child or adult wants until diarrhoea stops.

Children under 2 years of age: 50-100 ml (a quarter to half a large cup) of fluid; Children aged 2 up to 10 years: 100-200 ml (a half to one large cup); Older children and adults: as much fluid as they want.

Rule 2: Give supplemental zinc (10 - 20 mg) to the child, every day for 10 to 14 days Dose : infant 0.5 mg/kg/day <6 mth 10 mg/day >6 mth 20 mg/day Preparations : zinconia 20mg/5ml zincovit 10mg/5ml

Rule 3: Continue to feed the child, to prevent malnutrition

Food should never be withheld Breastfeeding should always be continued.

Aim - give as much nutrient rich food as the child will accept.

Rule 4: take the child to a health worker if there are warningsigns of dehydration or other problems Starts to pass many watery stools; Has repeated vomiting; Becomes very thirsty; Is eating or drinking poorly; Develops a fever; Has blood in the stool; or The child does not get better in three days.

Treatment Plan B: oral rehydration therapy for children with some dehydration

Treatment Plan C: for patients with severe dehydration

LAB INVESTIGATIONS FOR DIARRHOEA

Investigations are not routinely done in case of no or some dehydration I) STOOL: MICROSCOPY : low sensitivity & specificity a) leucocyte (>10/hpf )- Invasive diarrhoea b) hanging drop V. cholera. c) culture & sensitive - persistant diarrhoea II) BLOOD TESTS a) CBC b) S. electrolyte

ROLE OF ANTIBIOTICS

Bacteria Salmonella typhi, Salmonella paratyphi Nontyphoidal Salmonella

Antibiotic Ampicillin, chloramphenicol, TMP-SMZ, cefotaxime, ciprofloxacin Usually none (if 3 months old); ampicillin, cefotaxime, ciprofloxacin Nalidixic acid Adults: fluoroquinolones

Shigella ( Dysentery ) Children: Third-generation cephalosporin, TMP-SMZ Escherichia coli

Enterotoxigenic Enteroinvasive Enteropathogenic Enterohemorrhagic Enteroaggregative Campylobacter jejuni

Usually none if endemic; TMP-SMZ or ciprofloxacin for traveler's diarrhea TMP-SMZ, ampicillin if susceptible TMP-SMZ or an aminoglycoside

Usually none TMP-SMZ or an aminoglycoside Mild disease needs no treatment; erythromycin or azithromycin for diarrhea; aminoglycoside, ciprofloxacin, meropenem, or imipenem for systemic illness

Bacteria Yersinia enterocolitica

Antibiotic None for uncomplicated diarrhea; TMP-SMZ; gentamicin or cefotaxime for extraintestinal disease Tetracycline, doxycycline, TMPSMZ Oral metronidazole, oral vancomycin Metronidazole followed by iodoquinol to treat luminal infection Metronidazole, quinacrine, furazolidone, others None; azithromycin or paromomycin and octreotide in persons with HIV/AIDS

Vibrio cholerae Clostridium difficile

Entamoeba histolytica

Giardia lamblia Cryptosporidium parvum

Anti secretory agents

Racecadotril also known as acetorphan acts as a peripherally acting enkephalinase inhibitor. antisecretory effectit reduces the secretion of excessive water and electrolytes into the intestine. Role is controvertial. Dose: 1.5mg/kg/dose up to 4 doses a day Duration : 5 days but not >7 days

Complications
1) 2) 3) 4) 5) 6) 7) 8)

DEHYDRATION DYSELECTROLYTAEMIA PPT. OF MALNUTRITION PERSISTENT DIARRHOEA TOXIC ILEUS HUS DIC CORTICAL VIEN THROMBOSIS.

ORAL REHYDRATON SOLUTION

ORS -special combination of dry salts that, when properly mixed with clean water, can help rehydrate the body when a lot of fluid has been lost due to diarrhoea. Basis of ORS Glucose linked absorption of sodium remains intact irrespective of etiology of diarrhoea.

TYPES OF ORS FORMULATIONS

Glucose based ORS Rice based ORS

Low osmolarity ORS

Home available ORS Mineral based ORS(zinc)

Who ors composition

NORMAL OS. gms
Sodium chloride Potassium chloride Trisodium citrate Glucose 3.5 1.5 2.9 20

LOW OS. gms

2.6 1.5 2.9 13.5 Sodium Potassium Chloride Trisodium Citrate Glucose Total

NORMAL OS. MMOL/L

90 20 80 10

LOW OS. MMMOL/L

75 20 65 10

Water

1 litre

1 litre

111 311

75 245

Composition of Resomal
Ingredient Resomal {mmol\l}

Glucose Sodium Potassium Chloride Citate Magnesium Zinc Copper Osmolarity

125 45 40 70 7 3 0.3 0.045 300

What is NOT oral rehydration fluid? (1) Glucose water without salt (2) Fluids without starch/sugar

(3) Fluids consumed in small quantity, e.g. tea