persisitent diarrhea in children

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  • Comp- gf.mn. Gf not due malabs, poor cal intake, poor diet managemt.
  • Cn in mn.major are well hydrated. Most can be managd at home. Admit <4m, dehyd,system inf, severe mn wt <60%
  • 1 normal 5days
  • Palatable, acceptable
  • Less starch glucse.
  • Live microbial feed supplement, which beneficially affects host by improving the host intestinal microbial balance“ secrete iga, produce lactate

  • Low purge, recurrrent, abd dist, mn
  • Loose bulky celiac, pasty yellow pancreas, urinelike chloride, toddlers –freq hetero mucus foul alternate normal stool nn.
    3 celaic-post age- 1undiges nutrients break into short chain fatty acids.3=nec. 4=mn-dm
  • lactose is not absorbed in the small intestine and reaches the colon intact The colonic bacteria ferment the nonabsorbed lactose to short-chain organic acids, generating an osmotic load and causing water to be secreted into the lumen
  • activation of the intracellular mediators such as cAMP, cGMP, and intracellular calcium, which stimulate active chloride secretion from the crypt cells and inhibit the neutral coupled sodium chloride absorption
    Patients with chloride diarrhea have hypochloremic metabolic alkalosis with low serum chloride concentration, high stool chloride content coupled with chloride-free urine, low serum potassium, and high serum bicarbonate. Hydramnios is present in the mothers.
  • Jeju bx- villous atrophy
  • 1encopresis? Breath hydrogen tests can be used to determine a specific carbohydrate malabsorption. A breath hydrogen test for glucose or lactulose can be used to diagnose bacterial overgrowth. Sorbitol, which is a nonabsorbable sugar, is found in apple, pear, and prune juices, and can cause diarrhea in toddlers. Moreover, apple and pear juices contain higher amounts of fructose in excess of glucose concentration, a feature postulated to cause diarrhea in toddlers
  • Juice >150ml/kg/d? <90ml/kd
  • persisitent diarrhea in children

    1. 1. Persistent diarrhea Dr.P.soundararajan
    2. 2. Definitions • Diarrhea with passage of 3 or more loose stools of presumed infectious etiology starting acutely and lasting for more than 14 days. • Chronic diarrhea; noninfectious etiology • Protracted diarrhea – Persistent diarrhea with weight loss and malnutrition
    3. 3. Disease burden • 24 lakh child deaths in India each year • 5 children die every minute • 25% of the global burden is in India • More in infancy [31 episodes per 100 child years]
    4. 4. 25% of the global burden is in India
    5. 5. Causes • Persistent multiple infections • Parasitosis • Malabsorption • Protein allergy/ intolerance
    6. 6. Pathology • Delay in repair of damaged epithelium of gut • Damage of mucosal absorptive surface • Loss of brush border enzymes • Bacterial overgrowth  altered intestinal flora • Prolonged cell mediated immune form of damage of small intestinal mucosa
    7. 7. Presentation • Mild form – Several motions – No significant weight loss – No significant dehydration • Moderate form – Several motions – Marginal weight loss – Without dehydration – Non tolerance to milk • Severe form – Dehydration with several motions – Weight loss – Non tolerance to milk & cereals – Secondary infection
    8. 8. Diagnosis • Asses dehydration. • Asses malnutrition. • Stool - R/E, • Stool culture, • Reducing sugar, pH.
    9. 9. • Mild PD: low milk diet – 50ml milk+2tsp puffed rice powder+ 1tsp oil+ 1.5 tsp sugar +100ml boiled water – Rice with curd – Milk sooji gruel – 85kcal, 2g protein. – 6-7 feeds / day
    10. 10. • Moderate PD: no milk diet – Egg white 1.5 + 3tsp cooked rice+ glucose & oil 1.5tsp+ 120ml boiled water – 90cal, 2.4g protein. • Severe PD: no milk, no cereal diet. – Phase I: Resuscitation < 24 hours – Phase II: PPN(1-4 days), IV fluids, plasma, antimicrobials, electrolyte balance – Phase III: > 5 days Nutritional rehabilitation with calorie dense, lactose free formulae – Chicken puree 5tsp or 1.5 egg white + glucose & oil 1.5 tsp+150 ml water – 67cal , 3g protein
    11. 11. Micronutrients • Vitamin A: single dose 2L iu >1yr child • Twice RDA of zinc, copper, folate, vitamin D • Zinc: 20mg/day 2-4weeks • Mg sulphate i.m 0.2ml/kg/day bid 2-3days • Potassium 5-6meq/kg/day
    12. 12. Antibiotics • Blood in stool [quinolones] • Systemic sepsis [ampicillin & amikacin] • Severe malnutrition • Young infants • Discharge criteria • Regular diet: when?
    13. 13. Probiotics? • Lactobacillus GG • Saccharomyces boulardii • Bifidobacteria
    14. 14. Prevention • Prompt treatment of AWD • Judicious use of antibiotics • Diet management • Vaccines • Promotion of breast feeding
    15. 15. CHRONIC DIARRHEA
    16. 16. Definition • Diarrhea of more than 2 weeks duration or 3 attacks during last 3 months. • With specific congenital, biochemical or metabolic disorders. • Non infectious
    17. 17. • Osmotic • Secretory • Reduced anatomic surface • Altered intestinal motility • Inflammation
    18. 18. Causes • CMPA / soy protein allergy • PEM • Lactose intolerance • Post GE malabsorption • Parasites • Celiac disease • Excessive intake of carbonated drinks • Inflammatory bowel disease • Irritable bowel syndrome
    19. 19. Osmotic diarrhea • Lactase deficiency • Carbonated drinks • Antacids
    20. 20. Secretory diarrhea • Activation of cAMP • Activation of cGMP • Activation of intracellular calcium E.Coli Shigella Salmonella cholera
    21. 21. CMPA • Few weeks after introducing cow milk • Diarrhea, vomiting, colic, GI bleed, FTT. • Due to IgA deficiency?
    22. 22. Celiac disease • Intolerance to wheat gliadin • Features – Chronic diarrhea – Abd distension – FTT, anorexia, irritable – Foul, greasy,bulky stool. • Diagnosis: – anti endomysial antibody – Villous atrophy • Management
    23. 23. Work up • History of intake of fluids • Nutrition assessment • Stool pH / RS / WBC / ova ,cyst / cl.difficile culture • Stool fat estimate • Breath H2 estimate • Stool electrolytes • Sweat chloride • Small bowel biopsy / endoscopy • Barium studies • Hormones assay
    24. 24. Case scene 1. • 8 month old child presents with 18 days of loose stools, many episodes per day following milk feeds. initially treated with antibiotics for 1 week. • On exam, no dehydration, 3% weight loss+, perianal excoriation + • What stool exam you do? • Diagnosis & management?
    25. 25. Scene 2 • 7 month old child 2 weeks after introduction of cow’s milk, cries irritably frequently, loose stools many episodes, • O/E ; irritable, poor weight gain, • Stool occult blood positive. • One more stool exam to do? • Diagnosis?
    26. 26. Scene3 • 2year old child,3 weeks diarrhea, stools are bulky, oily, foul smelling, not responding to 2 weeks of antibiotics. • O/E poor weight gain, abd distension, • Stool test to do? • Diagnosis?
    27. 27. Thank you
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