persistent diarrhea, causes pathogenesis management

1. Persistent Diarrhea
in Children
Definition, Epidemiology, Etiology
Clinical Features, Complications, Management
Prognosis and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
Whatever is in the heavens and whatever is on the earth,
belongs to our creator (Allah)
The Holy Quran surah Al-Baqara 2:284
Al- Quran

3. Persistent Diarrhea

4. Case scenario
• A 10 month old baby presents with diarrhea for the last 20 days.
• He passes 3 to 8 loose or watery stools per day. He has received
multiple treatments.
• He is taking animal milk from bazar with little semisolids
• On examination, his weight is 6 kg
• He is irritable, has sunken eyes and skin pinch goes back
immediately
• What is your diagnosis ?
• How much dehydration is present ?
• Is malnutrition present ?

5. Case scenario
• A 10 month old baby presents with diarrhea for the last 20 days.
• He passes 3 to 8 loose or watery stools per day. He has received
multiple treatments.
• He is taking animal milk from bazar with little semisolids
• On examination, his weight is 6 kg
• He is irritable, has sunken eyes and skin pinch goes back
immediately
• What is your diagnosis ? Persistent Diarrhea
• How much dehydration is present ? Some dehydration
• Is malnutrition present ? Moderate Malnutrition

6. Persistent Diarrhea
• An episode of Acute diarrhea which lasts for more than two
weeks (14 days or more) is called Persistent diarrhea
• About 5 - 15 % episodes of Acute diarrhea develop
Persistent diarrhea
• Persistent diarrhea is a major cause of SAM (severe acute
malnutrition) in children
• Risk of death in children with persistent diarrhea is
increased many times (Case fatality – 5 %)
• Half of the total deaths in children with diarrhea are due to
Persistent diarrhea

7. Risk Factors for Persistent Diarrhea
• Low birth weight
• Young age
• Malnutrition (PEM)
• Micronutrient deficiencies
• Absence of breast-feeding
• Recent introduction of animal milk

8. Pathogenesis of Persistent Diarrhea
• Post-infection mucosal damage
• Failure of repair mechanisms
• Malnutrition (previous or developing now)
• Micronutrient deficiencies (Vitamin A, Zinc)
• Food (lactose) intolerance – Osmotic diarrhea

9. Diarrhea leads to Malnutrition
DIARRHOEA MALNUTRITION

10. Pathology of Persistent Diarrhea
• Mucosal injury
• Flattening of villi
• Destruction of brush border
• Reduced of brush border enzymes
• Malabsorption
• Lactose
• Malnutrition
• Moderate (MAM)
• Severe (SAM)
Normal and Atrophic
Intestinal Villi

11. Management of
Persistent Diarrhea

12. Principles of Management in
Persistent Diarrhea
• Persistent Diarrhea results from mucosal damage and
malabsorption
• Adequate calories need to be provided to prevent or
treat malnutrition
• Foods intake should consist of nutrients which are
tolerated (easily digested and absorbed), and avoid
foods to which intolerance is present
• Micronutrients help in repair the mucosal damage
• Ensure cleanliness to avoid infections

13. Persistent Diarrhea - Nutritional History
Type of milk (fresh animal milk, packed milk,
powdered formula
Dilution of milk feeds
Frequency of feeds & Volume per feed
Total volume in 24 hours
Semisolid foods (name, frequency, quantity)
• Calculate Total calories taken in 24 hours

14. Nutritional Examination
- Hair – PCM, Kwashiorkor
- Face – Marasmus, Kwashiorkor
- Eyes – Vit A deficiency (Bitot spot)
- Lips - Riboflavin deficiency
- Tongue - Iron deficiency
- Gums - Ascorbic acid deficiency

15. Skin Examination For Nutritional Problems
o Xerosis – Vit A deficiency
o Petechiae – Vit C deficiency, Vitamin K deficiency
o Dermatitis – Zinc deficiency, kwashiorkor
o Edema – kwashiorkor
oLoss of subcutaneous fat – marasmus
o Nails - koilonychia – iron deficiency

16. Anthropometry (measurements for growth)
• Weight
• Length / Height
• Mid-arm circumference (MUAC)
• Nutritional Diagnosis
• No Acute Malnutrition
• Moderate Acute Malnutrition
• Severe Acute Malnutrition

17. Nutritional Therapy
• Low Osmolality ORS for rehydration
• Continue Mother’s milk feeds
• Manage lactose intolerance –
-- Galactosidase enzyme given to Breastfed babies
-- lactose-free milk in place of animal milk
-- replace milk feeds with semi-solid cereal feeds
• Adequate energy (calories)
• Micronutrients (Vitamin A, Zinc, Folic acid)

18. Nutritional Therapy – Milk and Semi-solids
• Mother’s milk (add Galactosidase oral enzyme if needed)
• Lactose free milk feeds if needed (avoid animal milk)
• Small frequent semisolid feeds (early weaning)
• Cooked soft rice, noodles, banana, egg white, potato, oil
• Other solid foods introduced slowly guided by age,
choice and tolerance

19. Nutritional Therapy – Adequate Calories
• Gradually increase intake of the child
• Do not reduce intake even if it increases number of
stools
• Provide 100 calories / kg / day
• Provide 150 calories / kg / day in malnourished
children

20. Micronutrients
• Vitamin A 50000 – 200000 IU once
• Zinc 1-2 mg / kg / day
• Folic Acid 5 mg / day
• Vitamin D 400 – 800 IU / day
• Iron 1-2 mg / kg / day (start after 14 days / after recovery
from diarrhea)

21. Persistent Diarrhea - recovery
• Post-infection mucosal damage in small intestine
• Failure of repair mechanisms
• Malabsorption and food intolerance
• Micronutrient deficiencies (Vitamin A, Zinc)
• MANAGEMENT
• Micronutrients (Vitamin A, Zinc, Folic acid)
• Adequate energy (calories)
• Soft, easily digestible foods (rice, noodles, banana, egg
white, potato, oil)
• Recovery occurs quickly in 1-2 weeks

22. Prevention of Persistent Diarrhea
• Vaccination –
Rota virus
Measles
• Breastfeeding, avoid animal milk
• Adequate nutrition (semisolid foods from 4-6 months)
• Micronutrients (Vitamins and Minerals)
• Safe drinking water, unpolluted milk, clean food
• Hand washing
• Control of insects and flies in the house

23. Textbook of Paediatrics - 6th edition 2021
Pakistan Pediatric Association
• Written by senior teachers of
Pediatrics in Pakistan
• Provides up-to-date essential
information on Pediatric diseases
and Child Health
• Published by Paramount Books,
Pakistan
• www.paramountbooks.com.pk