SeminarOn“APPROACH TO DIARRHEOA INCHILDREN”Presented byVijay kr. SinghDNB PGT (Pediatrics)Under guidance ofDr T K MAITYMD(PEDIATRICS)Consultant pediatrician M R Bangur HospitalDate 18 june 2013VenueDNB Seminar hall M R Bangur hospital Kolkata-33
DIARRHEOADiarrhea is best defined asexcessive stool loss of fluid andelectrolyte more than threewithin 24hrs period. Recentchange of consistency is moreimportant than frequency
Types of diarrheaAcute watery diarrhoea-start suddenlyand last for hours or days.Dysentery- it is similar to acutediarrhea but associated blood loss instool.Persistent diarrhea- if diarrhea persistmore than 14days
WHO and UNICEF estimate thatalmost 2.5billion episode ofdiarrhea in children less than 5years of age in developingcountries. More than 80%occringin Africa and south Asia. Globallymortality dicrease significantly butincidence remain unchanged.
Epidemiology of diarrheaDiarrhoeal disorder in childhoodaccount for a large proportion 18%of childhood death about 1.5 milliondeaths per year globally and makingsecond most common cause ofchildhood mortality
Diarrhea can cause undernutritionand worsen the milder form ofmalnutrition becauseImpaired intestinal absorption of macroand micronutrient.Urinary loss of specific nutrient Vit A.Increase catabolism due to infection.A child with diarrhea is often not hungry.Mother often make the mistake of not tofeed during diarrhea.
Etiology of diarrheaOrganism causes noninflammatory(enterotoxin or adherence /superficial invasion) Location- Proximal small intestine Causes watery diarrheaThese are E.coli(ETEC,LT,ST) Clostiridum perfringens Bacillus cereus Staph. Aureus, giadia lambia, Rota virus, Norwaklikevirus,Crytosporidium,Microsporidia,
Enteropathogens elicit noninflamatorydiarrheoa through entrotoxineproduction by some bacteria,destruction of villous surface byviruses, adherence by parasite andadherence and translocation bybacteria. Bacterial enterotoxin canselectively activate enterocyteintracellular signal transduction andcause alteration in the water andelectrolyte fluxes across enterocyte.
Location- colon DysenteryOrganisms Shigella E.coli(EIEC,EHEC) Salmonella enteridis Vibrio parahemolyticus Clostiridum difficilue, campylobacter jejuni,Entaemaeba hitolytica. Inflammatory diarrhea is usually caused by bacteria anddirectly invade the intestine or produce cytotoxin withconsequent fluid, protein, and cells. That inter theintestineInflammtory(invasive, cytotoxin)
PenetratingLocation- Distal small intestineSalmonella typhiYersinia enteropathicaCampylobacter fetus
Risk factors of gastroenteritisEnvinmental contamination andincreased exposure to pathogensMalnutritionLack of exclusive breast feeding orprolong and predominantbreastfeedingMeaslesImmunodeficiency
Clinical evaluation of diarrheaChild dehydration can be classifiedaccording to WHO criteriaNo dehydration Treatment planASome dehydration Treatment Plan BSevere dehydration Treatment Plan C
Signs of dehydration: Decreased urination (fewer than 4 wet diapers in24 h), Increased thirst, No tears, Dry skin, mouth and tongue, Faster heart beat, Sunken eyes, Grayish skin, Sunken soft spot (Anteriar fontanelle) on baby’shead
Treatment PLAN A•Age less than 24 months•50-100ml per each loose stool•Age between 2yrs to 10yrs•100 to 200 ml after each stool•Age more than 10 yrs•As much as wants
Treatment Plan BThe fluid therapy has three component.Correction of the existing water andelectrolyte deficient.Replacement of ongoing loss due tocontinuing diarrhea Deficient replacement
75 ml/ kg of ORS In first 4 yrsMaintenance therapy This begins when dehydration corrected over4hrs ORS 10-20 ml/kg after each stool . Offer plan water in between
High stool purge- 5ml/ kg/hr Persistent vomiting > 3episode per hr Incorrect preparation Abdominal distention Glucose malabsorptionWhen ORT therapy is ineffective
Treatment Plan CStart IV fluid immdiatelyAge <12months30ml/kg in 60 minutesThen 70ml/ kg in 5hrsAge between 12months to 5 years30ml/kg in 30 minutesThen 70 ml/kg in2.5 hrs
MonitoringReassess the child every 15-30 minutesuntil a strong radial pulse is present.Repeat IV fluid is severe dehydrationstill present.If child is improving but still showssign of dehydration.Discontinue IV fluid and give ORS for4hrs
Secretory diarrhea Secretory diarrhea is often caused by asecretagogue, such as cholera toxin, bindingto a receptor on the surface epithelium ofthe bowel and thereby stimulatingintracellular accumulation of cyclicadenosine monophosphate or cyclicguanosine monophosphate. Someintraluminal fatty acids and bile salts causethe colonic mucosa to secrete through thismechanism.
Secretory diarrhoea occurs afteringestion of a poorly absorbed solute. The solutemay be one that is normally not well absorbed(magnesium, phosphate, lactulose, or sorbitol) orone that is not well absorbed because of adisorder of the small bowel (lactose with lactasedeficiency or glucose with rotavirus diarrhea).Malabsorbed carbohydrate is fermented in thecolon, and short-chain fatty acids (SCFAs) areproduced.
ROLE OF DRUGS IN DIARRHOEA ORS Antibiotics Zinc supplement Antimotility drugs Probiotics Enkephaline inhibitor
ORSAn oral rehydration solution (ORS)lowosmolility is an exact mixture ofwater, salts and sugar. These solutions canbe absorbed even when your child isvomiting. The key is to give small amountsof ORS often (for example, 1 teaspoonevery 5 minutes), gradually increasing theamount until your child can drinknormally.
AntibioticsAntibiotics have very minorroll in diarrhoea.It is only in bacterial infectivediarrhoea and dysentry.
ZincIt increase recovery rateDecrese stool out putMaintain mucusal layerIncrese immunityDose 20mg/ day in case of age lessthan 6month 10mg once a day
Antimotility agentsIt is contra indicated indysentry.No role in management ofacute watery diarrhoea.
ProbioticsIt restore the beneficial bacterialintestinal flora and enhance hostprotective immunity such as downregulation of pro- inflammatorycytokines and up- regulate anti –inflammatory cytokines.
ENKEPHALINSE INHIBITORIt consistently has beenshown to reduce stool output.But experience with this drugis limited.
Foods to avoidDo not give your child sugary drinkssuch as: fruit juice or sweetened fruitdrinks, carbonated drinks (pop/soda),sweetened tea, broth or rice water.These have the wrong amounts ofwater, salts and sugar and can makeyour child’s diarrhea worse.
Preventive measure fordiarrhoeal diseaseImprove domestic & food hygiene.Improve water supply.Improve excreta disposalMaintain good nutrition. Health education.Immunization