Acute Diarrhoea


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Acute Diarrhoea

  1. 1. Dr. Rajkumar Patil Asstt.Prof., Dept. of Community Medicine, AVMC, Pondicherry Acute diarrhoeal disorders
  2. 2. What is diarrhoea? Passage of 3 or more loose, liquid or watery stools in a day What is not a diarrhoea? 1.Frequent formed stools 2.Pasty stools in breastfed child 3.Stools during or after feeding 4.PSEUDODIARRHOEA:Small volume of stool frequently (IBS)
  3. 3. Types Acute diarrhoea : <2 weeks, 90% attacks are self limited (resolved by ORS) Persistent diarrhoea :2-4 weeks Chronic diarrhoea : >4 weeks Dysentery: Bloody diarrhoea
  4. 4. <ul><li>Problem statement </li></ul><ul><li>Worldwide-children deaths : 1.6 million every yr </li></ul><ul><li>World-wide 4% of all deaths </li></ul><ul><li>Worldwide 18% of under five deaths </li></ul><ul><li>In Southeast Asia -nearly 8% of all deaths </li></ul><ul><li>In India 33% of total paediatric admissions </li></ul><ul><li>In India 17% of all deaths in </li></ul><ul><li>indoor paediatric patients </li></ul>
  5. 5. Agent factors Virus Rota,Astro,Adeno,Calci,Corona,Norwalk,Entero Bacteria Campylobacter Jejuni,E.Coli,Shigella,Salmonella, V.cholerae,V.parahaemolyticus,Bacillus cereus Others E.Histolytica,Giardia,Trichuriasis Cryptosporidium,Intestinal worms
  6. 6. Important pathogens in children Viruses: cause for 50% cases of diarrhoea <2 yr Cryptosporidium: diarrhoea in infants and immuno-defficients Pathogen % of cases Virus Rota virus 15-25 Bacteria ETEC 10-20 EPEC 1-5 Salmonella (Nontyphoid) 1-5 V.Cholerae 01 5-10 Shigella 5-15 Campylobacter jejuni 10-15 Protozoans Cryptosporidium 5-15 No pathogens found - 20-30
  7. 7. <ul><li>Reservoir of infection </li></ul><ul><li>Humans </li></ul><ul><li>Humans and animals: Campylobacter,salmonella, </li></ul><ul><li>yersinia enterocolitica </li></ul><ul><li>Host factors </li></ul><ul><li>Most common age: 6 months- 2 yr </li></ul><ul><li>Highest at the time of weaning </li></ul><ul><li>(contaminated food, </li></ul><ul><li>contact with feces as infant starts to crawl) </li></ul><ul><li>Common in non-breast fed infants </li></ul><ul><li>Malnutrition, Measles </li></ul><ul><li>Incorrect feeding practices </li></ul><ul><li>Lack of hygiene </li></ul>
  8. 8. Environmental factors In temperate climates Bacterial diarrhoea: summer Viral diarrhoea: winter In tropical areas Viral diarrhoea: whole year Bacterial diarrhoea: summer,rainy season Social factors Poverty,ignorance,illiteracy Mode of transmission Faeco-oral (water borne,food borne,fomites,fingers,dirt)
  9. 9. Poverty, water and diseases
  10. 10. <ul><li>MANAGEMENT </li></ul><ul><li>ORAL REHYDRATION THERAPY </li></ul><ul><li>DRUGS </li></ul><ul><li>(ANTIBIOTICS,ANTIMOTILITY DRUGS) </li></ul><ul><li>NUTRITIONAL MANAGEMENT </li></ul>
  12. 12. Look, Feel and Decide Chart for assessment of Dehydartion in diarrhoea Look at (CETTT) Condition Well,Alert *Restless, Irritable* *Lethargic or unconscious;Floppy* Eyes Normal Sunken Very sunken Tears +nt -nt -nt Tongue Moist Dry Very Dry Thirst Not thirsty *Thirsty, drinks eagerly* *Drinks poorly or unable to drink* Feel Skin pinch Goes back instantly *Goes back slowly* *Goes back very slowly* Decide No dehydration 2 or more signs including atleast one * marked (SOME DEHYDRATION) 2 or more signs including atleast one * marked (SEVERE DEHYDRATION) Treat Treat. A Weigh the child,Treat.B Weigh the child,Treat C
  13. 14. Skin Pinch
  14. 15. sunken eyes
  15. 16. <ul><li>TREATMENT PLAN A </li></ul><ul><li>4 Rules of home treatment </li></ul><ul><li>1.Give extra fluid- </li></ul><ul><li>Breastfed frequently, </li></ul><ul><li>Give one or more : ORS solution, food based fluids (such as soup,rice water and yoghurt drinks), clean water </li></ul><ul><li>Teach the mother how to mix and give ORS.Give the mother 2 packets of ORS to use at home. </li></ul><ul><li>Show the mother how much fluid to give (After each loose stool and between them) in addition to the usual fluid intake: </li></ul><ul><li>Up to 2 years : 50-100 ml </li></ul><ul><li>2 years or more:100-200 ml </li></ul><ul><li>> 10 years: as much as wanted </li></ul>
  16. 18. <ul><li>Tell the mother to: </li></ul><ul><li>Give frequent small sips from cup </li></ul><ul><li>In case of vomiting: Wait 10 min.then continue but slowly, </li></ul><ul><li>Continue giving extra fluids until the diarrhoea stops </li></ul><ul><li>2.Give Zinc Supplements: </li></ul><ul><li>Tell the mother how much zinc to give: </li></ul><ul><li>< 6 months (dose 10 mg/day): ½ tab x 14 days </li></ul><ul><li>> 6 months (dose 20 mg/day): 1 tab x 14 days </li></ul><ul><li>3. Continue feeding </li></ul><ul><li>4. Tell the mother when to return </li></ul>
  17. 19. <ul><li>TREATMENT PLAN B </li></ul><ul><li>Determine amount of ORS over 4 hour period: </li></ul><ul><li>75 ml/kg body </li></ul><ul><li>If the child wants more ORS then give more </li></ul><ul><li>For infants < 6 months (not breastfed): </li></ul><ul><li>give 100-200 ml clean water also </li></ul>Age (months) < 4 4-12 12-24 24-60 Weight (kg) <6 6-<10 10-<12 12-19 Amount (ml) 200-400 400-700 700-900 900-1400
  18. 20. <ul><li>Tell the mother to: </li></ul><ul><li>Give frequent small sips from cup </li></ul><ul><li>In case of vomiting: Wait 10 min.then continue but slowly, </li></ul><ul><li>Continue giving extra fluids until the diarrhoea stops </li></ul><ul><li>After 4 hours </li></ul><ul><li>Reassess as per assessment chart and treat accordingly </li></ul><ul><li>(Plan A,B or C) </li></ul><ul><li>If the mother must leave before completing treatment: </li></ul><ul><li>Show her how to prepare ORS solution at home </li></ul><ul><li>Show her how to prepare ORS to give to finish 4 hr treatment </li></ul><ul><li>Also give 2 packets ORS </li></ul><ul><li>Explain the 4 rules of home treatment: </li></ul><ul><li>1.Give extra fluid 2.Give zinc supplements </li></ul><ul><li>3.Continue feeding 4.When to return </li></ul>
  19. 21. TREATMENT PLAN C Can you give the IV fluid immediately? YES If the child can drink, give ORS orally while the drip is set up. <ul><li>* Repeat once if radial pulse is still very weak or not detectable </li></ul><ul><li>Reassess the child every 1-2 hours. </li></ul><ul><li>If hydration status is not improving give the IV drip more rapidly </li></ul><ul><li>Also give ORS (5 ml/kg/hour) as soon as the child can drink. </li></ul><ul><li>Reassess an infant after 6 hours and child after 3 hours: </li></ul><ul><li>Decide the treatment </li></ul>Age First give 30ml/kg in Then give 70 ml/kg in < 12 months 1 hour* 5 hour* 12 months - 5 years 30 min.* 2 ½ hours*
  20. 22. <ul><li>Can you give the IV fluid immediately? NO </li></ul><ul><li>Is IV treatment available nearby (within 30 min.) YES </li></ul><ul><li>Refer urgently to hospital for IV treatment </li></ul><ul><li>(If the child can drink. Provide the mother with ORS solution and show her how to give frequent sips during the trip) </li></ul><ul><li>Is IV treatment available nearby (within 30 min.) NO </li></ul><ul><li>Are you trained to use a nasogastric tube for rehydration? YES </li></ul><ul><li>Start rehydration (ORS solution) by tube/mouth : 20 ml/kg/hour for 6 hours. </li></ul><ul><li>Reassess the child every 1-2 hours </li></ul><ul><li>If vomiting or increasing abdominal distension, give the fluid more slowly </li></ul><ul><li>If hydration status is not improving after 3 hours, send the child for IV therapy </li></ul><ul><li>After 6 hours, reassess the child and treat (A,B or C) </li></ul>
  21. 23. Are you trained to use a nasogastric tube for rehydration? NO Can the child drink YES Give ORS orally NO Refer urgently to hospital for IV/NG treatment If the child is > 2 years and there is cholera epidemic in the area Give antibiotic for cholera
  22. 24. Naso-gastric tube ORT
  23. 25. <ul><li>FOLLOW UP </li></ul><ul><li>Follow up after 2 days in dysentery, after 5 days in </li></ul><ul><li>acute diarrhoea </li></ul><ul><li>Return immediately if the child develops: </li></ul><ul><li>Many watery stools, </li></ul><ul><li>Repeated vomiting, </li></ul><ul><li>Fever, </li></ul><ul><li>Poor or unable to drink and eat/ breastfeed, </li></ul><ul><li>Blood in stool </li></ul>
  24. 26. Composition of WHO -ORS SGPT:2.6,13.5,1.5,2.9 Ingredients Normal (gm) Low osmolarity (gm) S odium chloride 3.5 2.6 G lucose 20.0 13.5 P otassium Chloride 1.5 1.5 T risodium citrate dehydrate 2.9 2.9 27.9 gm (310 mOsm/l) 20.5 gm (245 mOsm/l)
  25. 27. Hypo-osmolar ORS SGPTC:7575,201065 Ingredients Low osmolarity (mmol/l) Sodium 75 Glucose 75 Potassium 20 Citrate 10 Chloride 65 245 mOsm/l
  26. 28. Benefits of citrate ORS over bicarbonate ORS 1.Trisodium citrate made the ORS stable 2. Resulted in less stool output Benefits of low-osmolarity ORS over normal ORS 1.Osmolarity reduced to avoid the adverse effects of hyper-tonicity 2.Need for unscheduled IV management reduced 33% in children with hypo-osmolar ORS 2.Stool output and vomiting decreased 3.India-first country in the world to launch new ORS since June 2004
  27. 29. <ul><li>Home made ORS </li></ul><ul><li>1 tsp table salt + 4 heaped tsp sugar </li></ul><ul><li>in 1 litre of water </li></ul><ul><li>SUPER ORS </li></ul><ul><li>Amino acid based ORS </li></ul><ul><li>Amino acids (Alanine, Glycine co-transport the Na + ) are used </li></ul><ul><li>in place of glucose </li></ul><ul><li>Powder of boiled rice (50 mg/L) can be used in place of amino acids </li></ul><ul><li>Decrease purging rates and improve absorption </li></ul>
  28. 31. ORS
  29. 34. DRUGS IN DIARRHOEA Antibiotics in Dysentery and Cholera In Dysentery: Cotrimoxazole Better in 2 days No Yes Look for trophozites of E.Histolytica in stool Complete the 5 days treatment Absent Present Refer to hospital Treat with Metronidazole /Give Ciprofloxacin I st line antibiotic: Cotrimoxazole, II nd line antibiotic:Nalidixic acid
  30. 35. DOSAGE OF COTRIMOXAZOLE AND NALIDIXIC ACID IN DYSENTERY Age/Wt. Cotrimoxazole (2 times/day for 5 days) Nalidixic acid (4 times/day for 5 days) Paediatric tablet 20 mg TMP+ 100 mg SMX Syrup 40 mg+ 200 mg (per 5 ml) Tablet 500 mg 2 - < 12 months (4- <10kg) 2 tab 1 tsp 1/4 1 - 5 years (10-19 kg) 3 tab 1.5 tsp 1/2
  31. 36. Anti-diarrhoeals Loperamide Useful in: Mild to moderate diarrhoea C/I: Bloody dirrhoea, high fever, worsening of diarrhoea inspite of antidiarrhoeals, children Dose : 4 mg (2 tabs. Stat) , then 1 tab after each loose stool (max. 16 mg/day)
  32. 37. DRUGS WHICH SHOULD NOT BE USED IN DIARRHOEA 1.Neomycin(Damages the intestinal mucosa) 2.Purgatives 3.Atropine(Dangerous for children and dysentery patients) 4.Steroids(Useless) 5.Oxygen(Unnecessary) 6.Charcoal(No value)
  33. 38. NUTRITIONAL MANAGEMENT OF DIARRHOEA 1.Continue feeding 2.Energy dense foods should be given: Khichri , rice with milk, curd and sugar, mashed banana with milk, mashed potatoes and lentils 3.Foods with high fibre content should be avoided 4.During recovery, an intake of at least 125% of normal requirement should be attempted
  34. 39. National diarrhoea diseases control programme 1.Short term: Appropriate clinical management -ORT -Appropriate feeding -Chemotherapy 2.Long term a. Better MCH practices -Maternal nutrition -Child nutrition: breast feeding, proper weaning, supplementary feeding
  35. 40. b. Preventive strategies -Sanitation -Health education -Immunization -Fly control -Food Hygiene:Boil it,cook it,peel it or forget it c. Prevention and control of diarrhoeal epidemics -Strengthening of epidemiological surveillance
  36. 41. Thank you Thank you