1. UNICEF and IAP guidelineson management of AcuteWatery Diarrhoea Dr Muzammil Koshish DCH, DNB Resident, JLN Hospital and Research Centre, Bhillai.
2. Definition of diarrhoea• Diarrhoea is the passage of loose or watery stools, usually at least three times in a 24 hour period• It is the consistency of the stools rather than the number, that is most important• Frequent passing of formed stools is not diarrhoea• Babies fed only breast milk often pass loose, "pasty" stools ; this also is not diarrhoea
3. Clinical types of diarrhoeal diseasesFour clinical types of diarrhoea can be recognized, each reflecting the basicunderlying pathology and altered physiology:· acute watery diarrhoea (including cholera), which lasts several hours or days:the main danger is dehydration; weight loss also occurs if feeding is not continued;· acute bloody diarrhoea, which is also called dysentery: the main dangers areintestinal damage, sepsis and malnutrition; other complications, includingdehydration, may also occur;· persistent diarrhoea, which lasts 14 days or longer: the main danger ismalnutrition and serious non-intestinal infection; dehydration may also occur;· diarrhoea with severe malnutrition (marasmus or kwashiorkor): the maindangers are severe systemic infection, dehydration, heart failure and vitamin andmineral deficiency.
4. Determine the degree of dehydration A B CLOOK AT:CONDITIONa Well, alert Restless, irritable Lethargic or unconsciousEYESb Normal Sunken SunkenTHIRST Drinks normally Thirsty, drinks Drinks poorly, or , not thirsty eagerly not able to drinkFEEL: SKIN PINCHc Goes back quickly Goes back slowly Goes back very slowlyDECIDE The patient has NO If the patient has If the patients has SIGNS OF two or more signs in two or more signs in DEHYDRATION B (or C), there is C, there is SEVERE SOME DEHYDRATION DEHYDRATION Weigh the patientTREAT Use Treatment Pan Weigh the patient and use Treatment A and use Treatment Plan C URGENTLY Plan B
5. Select a plan to prevent or treat dehydrationChoose the Treatment Plan that corresponds with the childs degree ofdehydration:No signs of dehydration - follow Treatment Plan A at home to preventdehydration and malnutritionSome dehydration - follow Treatment Plan B to treat dehydrationSevere dehydration - follow Treatment Plan C to treat severe dehydrationurgently
6. Estimate the fluid deficit Children with some dehydration or severe dehydration should be weighed without clothing, as an aid in estimating their fluid requirements. If weighing is not possible, a childs age may be used to estimate the weightA childs fluid deficit can be estimated as follows:Assessment Fluid deficit as % of body weight Fluid deficit in ml/kg bodyweightNo signs of dehydration <5% <50 ml/kgSome dehydration 5-10% 50-100 ml/kgSevere dehydration >10% >100 ml/kg
7. MANAGEMENT OF ACUTE DIARRHOEA (WITHOUTBLOOD)ObjectivesThe objectives of treatment are to:•prevent dehydration, if there are no signs of dehydration;•treat dehydration, when it is present;•prevent nutritional damage, by feeding during and afterdiarrhoea; and•reduce the duration and severity of diarrhoea, and the occurrenceof future episodes, by giving supplemental zinc.
8. Treatment Plan A: home therapy to prevent dehydration andmalnutritionRule 1: Give the child more fluids than usual, to preventdehydration Suitable fluidsFluids that normally contain salt, such as:ORS solutionsalted 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 waterwater in which a cereal has been cooked (e.g. unsalted rice water)unsalted soupyoghurt drinks without saltgreen coconut waterweak tea (unsweetened)unsweetened fresh fruit juice.
9. Unsuitable fluids drinks sweetened with sugar, which can cause osmotic diarrhoea andhypernatraemia. examples are:soft drinkssweetened fruit drinkssweetened tea.fluids with stimulant, diuretic or purgative effects, for example:coffeesome medicinal teas or infusions.How much fluid to giveThe general rule is: give as much fluid as the child or adult wants untildiarrhoea stops.As a guide, after each loose stool, give: .• children under 2 years of age: 50-100 ml (a quarter to half a large cup) offluid;• children aged 2 to 10 years: 100-200 ml (a half to one large cup);
10. Rule 2: Give supplemental zinc (10 - 20 mg) to the child,every morning for 14 daysRule 3: Continue to feed the child, to preventmalnutritionRule 4: Take the child to a health worker if there are signsof dehydration or other problemsThe mother should take her child to a health worker if the child: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
11. Treatment Plan B: oral rehydration therapy for children withsome dehydration Children with some dehydration should receive oral rehydration therapy (ORT) with ORS solution in a health facility following Treatment Plan B, as described below. Guidelines for treating children and adults with some dehydration APPROXIMATE AMOUNT OF ORS SOLUTION TO GIVE IN THE FIRST 4 HOURS Agea Less than 4 – 11 12 – 23 2 –4 years 5 – 14 years 15 years or 4 months months months older Weight Less than 5–7.9 kg 8-10.9 kg 11-15.9kg 6-29.9kg 30 kg or 5 kg more In ml 200-400 400-600 600-800 800-1200 1200-2200 2200-4000 in local measure
12. How to give ORS solutionoA family member should be taught to prepare and give ORSsolution.oThe solution should be given to infants and young childrenusing a clean spoon or cup. Feeding bottles should not be used.oFor babies, a dropper or syringe (without the needle) can be usedto put small amounts of solution into the mouth.o Children under 2 years of age should be offered a teaspoonfulevery 12 minutes; older children (and adults) may take frequentsips directly from the cup.
13. Monitoring the progress of oral rehydration therapyCheck the child from time to time during rehydration to ensure that ORSsolution is being taken satisfactorily and that signs of dehydration are notworsening.If at any time the child develops signs of severe dehydration, shift toTreatment Plan C.If there are no signs of dehydration, the child should be considered fullyrehydrated.When rehydration is complete: - the skin pinch is normal;- thirst has subsided;- urine is passed;-the child becomes quiet, is no longer irritable and often falls asleep.
14. When oral rehydration fails or is not appropriateThe usual causes for these “failures” are: continuing rapid stool loss (more than 15-20 ml/kg/hour), asoccurs in some children with cholera; insufficient intake of ORS solution owing to fatigue or lethargy; frequent, severe vomiting.
15. Giving ZincBegin to give supplemental zinc, as in Treatment Plan A, as soon thechild is able to eat following the initial four-hour rehydrationperiod.Giving foodExcept for breastmilk, food should not be given during the initialfour-hour rehydration period.All children older than 6 months should be given some food beforebeing sent home.
16. Treatment Plan C: for patients with severe dehydrationGuidelines for intravenous rehydrationThe preferred treatment for children with severe dehydration israpid intravenous rehydration, following Treatment Plan C.Children who can drink, even poorly, should be given ORS solutionby mouth until the IV drip is running.In addition, all children should start to receive some ORS solution(about 5 ml/kg/h) when they can drink without difficulty, which isusually within 34 hours (for infants) or 12 hours (for older patients).
17. Guidelines for intravenous treatment of children and adultswith severe dehydrationGive 100 ml/kg Ringers Lactate Solutiona divided as follows:Age First give Then give 30 ml/kg in: 70 ml/kg in:Infants(under 12 months) 1 hourb 5 hoursOlder 30 minutesb 21/2 hoursa IfRingers Lactate Solution is not available, normal saline may be used (SeeAnnex 2).b Repeat once if radial pulse is still very weak or not detectable.
18. Monitoring the progress of intravenous rehydrationPatients should be reassessed every 15-30 minutes until a strongradial pulse is present.If signs of severe dehydration are still present, repeat the IV fluidinfusion as outlined in Treatment Plan C.If the child is improving but still shows signs of some dehydration,discontinue the IV infusion and give ORS solution for four hours, asspecified in Treatment Plan B.If there are no signs of dehydration, follow Treatment Plan A.
19. Giving ZincBegin to give supplemental zinc, as in Treatment Plan A, as soon thechild is able to eat.Giving foodExcept for breastmilk, food should not be given during the initialrehydration period.All children older than 6 months should be given some food beforebeing sent home.
20. What to do if intravenous therapy is not availableIf IV therapy is not available at the facility, but can be given nearby(i.e. within 30 minutes), send the child immediately for IVtreatment.If the child can drink, give the mother some ORS solution and showher how to give it to her child during the journey.If IV therapy is not available nearby, give ORS solution by NG tube,at a rate of 20 ml/kg body weight per hour for six hours (total of 120ml/kg body weight).If NG treatment is not possible but the child can drink, ORSsolution should be given by mouth at a rate of 20 ml/kg body weightper hour for six hours (total of 120 ml/kg body weight).
21. Vitamin A deficiencyDiarrhoea reduces the absorption of, and increases the need for,vitamin A..especially a problem when diarrhoea occurs during or shortly aftermeasles, or in children who are already malnourished.children with diarrhoea should be examined routinely for cornealclouding and conjunctival lesions (Bitots spots).oral vitamin A should be given at once and again the next day: 200000 units/dose for age 12 months to 5 years, 100 000 units for age 6months to 12 months, and 50 000 units for age less than 6 months.
22. ANTIMICROBIALS AND DRUGSAntimicrobials Antimicrobial therapy should not be given routinely to childrenwith diarrhoea.Such treatment is ineffective and may be dangerous.The diseases for which antimicrobials should be given are listedbelowCases of bloody diarrhoea (dysentery)Suspected cases of cholera with severe dehydration.Laboratory proven, symptomatic infection with Giardia duodenalis.diarrhoea associated with another acute infection (e.g.pneumonia, urinary tract infection)
23. "Antidiarrhoeal" drugsAdsorbents (e.g. kaolin, attapulgite, smectite, activated charcoal, cholestyramine)Antimotility drugs (e.g. loperamide hydrochloride, diphenoxylate with atropine, tinctureof opium, camphorated tincture of opium, paregoric, codeine).Bismuth subsalicylate. Bismuth subsalicylate decreases the number of diarrhoeastools.Antiemetics. These include drugs such as prochlorperazine and chlorpromazine,Cardiac stimulants. Shock in acute diarrhoeal disease is caused by dehydration andhypovolaemia.Blood or plasma. Blood, plasma or synthetic plasma expanders are never indicated forchildren with dehydration due to diarrhoea.Steroids. Steroids have no benefit and are never indicated.Purgatives. These can make diarrhoea and dehydration worse; they should never beused.
24. Probiotics and Prebiotics No proven role in Indian scenario
25. Prevention of Diarrhoea Breastfeeding Improved feeding practices Use of safe water Handwashing Food safety Use of latrines and safe disposal of stools Measles immunization
26. References:-1. Department of Child and Adolescent Health and Development, World Health Organization, ‘Reduced osmolarity oralrehydration salts (ORS) formulation – Report from a meeting of experts jointly organized by UNICEF and WHO’(WHO/FCH/CAH/01.22), New York, 18 July 2001 <http://www.who.int/child-adolescent-health/New_Publications/NEWS/Expert_consultation.htm>.2. Bahl, R., et al., ‘Effect of zinc supplementation on clinical course of acute diarrhoea‘ – Report of a Meeting, New Delhi, 7-8 May 2001. Journal of Health, Population and Nutrition,vol. 19, no. 4, December 2001, pp. 338-346.3. Bhutta Z.A., Black, R.E., Brown K. H., et al., ‘Prevention of diarrhoea and pneumonia by zinc supplementation in childrenin developing countries: Pooled analysis of randomized controlled trials’, Zinc Investigators’ Collaborative Group, Journalof Paediatrics,vol. 135, no. 6, December 1999, pp. 689-697. 2. Reduced osmolarity oral rehydration salts (ORS) formulation.A report from a meeting of experts jointly organized by UNICEF and WHO. UNICEF HOUSE, New York, USA, 18 July, 2001.WHO/FCH/CAH/0.1.223. Hahn SK, Kim YJ, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration due todiarrhoea in children: systematic review. British Medical Journal, 2001; 323: 81-85.4. Zinc Investigators’ Collaborative Group. Bhutta ZA,Bird SM, Black RE, Brown KH, Gardner JM, HidayatA et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries:pooled analysis of randomized controlled trials. AmJ Clin Nutr 2000; 72: 1516-1522.5. Bhatnagar S, Bahl R, Sharma PK, Kumar GK, Saxena SK, Bhan MK. Zinc treatment with oral rehydrationtherapy reduces stool output and duration of diarrhea in hospitalized children; a randomized controlledtrial. J Pediatr Gastroenterol Nutr 2004; 38:34-40.6. Strand TA, Chandyo RK, Bahl R, Sharma PR, Adhikari RK, Bhandari N, et al. Effectiveness and efficacyof zinc for the treatment of acute diarrhea in young children. Pediatrics. 2002 May;109: 898- 903.7. Bahl R, Bhandari N, Saksena M, Strand T, Kumar G.T, Bhan MK et al. Efficacy of zinc fortified oralrehydration solution in 6-35 month old children with acute diarrhea. J Pediatr 2002;141:677-682.8. Roy SK, Tomkins AM, Akramuzzaman SM, Behrens RH, Haider R, Mahalanabis D et al. Randomizedcontrolled trial of zinc supplementation in malnourished Bangladeshi children with acutediarrhoea. Arch Dis Child 1997;77: 196-200.9. Dutta P, Mitra U, Datta A, Niyogi SK, Dutta S, MannaB et al. Impact of zinc supplementation in malnourished children with acute diarrhoea. J TropPediatr 2000; 46: 259-263.10. Baqui AH, Black RE, El Arifeen S, Yunus M, Chakraborty J, Ahmed S et al. Effect of zinc supplementation started duringdiarrhoea on morbidity and mortality in Bangladeshi children: Community randomized trial. BMJ 2002;325(7372):1059. 11.Effect of zinc supplementation on clinical course of acute diarrhoea. Report of a Meeting, New Delhi, 7-8 May 2001. J HealthPopul Nutr 2001;19: 338-346.