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Approach to ADD- Acute Diarrheal Disease in children.pptx
1. Approach to ADD- Acute
Diarrheal Disease in
children Dr Neminathan
CASE BASED DISCUSSIONS
2. Importance of diarrhea in Gen Practice
13% of our under five children die of diarrhea.
Rational approach to diarrhea is an interesting &
challenging exercise in day-to-day practice
Majority of ADD in children are benign and viral in
nature.
3. Diarrhea defn
Increase in the stool frequency &
liquidity that is considered abnormal
by the mother
Acute - < 14 days duration
Chronic - > 14 days duration
4. Practical EVENT 1
8yrs boy presents with severe abd pain, with
few loose stools & vomiting . No h/o
fever
Diagnosed as AGE , started with oral AB
Condition worsened , diagnosed as ACUTE
APPENDICITIS – operated as an EMERGENCY
5. EXPERIENCE GAINED 1
PATIENT HEARING A MUST
Respect chief complaints
Remember that mother can pick up even a minute
change in physiology of the child – GIVE DUE
RESPECT TO MOTHERS WORDS
6. Practical EVENT 2
These are three children presenting with following
complaints
1-Vomiting followed by diarrhea with fever
2-few loose stools ,persistant vomiting ,fever
3-sudden onset highgrade fever,diarrhea vomit
7. EXPERIENCE GAINED 2
Give importance to CHRONOLOGY OF EVENTS
1-Vomiting followed by diarrhea with fever =
AGE
2-few loose stools ,persistant vomiting ,fever =
UTI
3-sudden onset highgrade fever,diarrhea vomit =
VIRAL FEVER
8. Practical EVENT 3
1month old infant with loose stools of 20 days
Seen by multiple drs
Solely breast fed, well thriving, active & happy
child
Stool culture grew E Coli sensitive to all Abs
As he continued to have persistent loose stools in
spite of AB, he was referred to our institution
9. EXPERIENCE GAINED 3
Do not ignore clinical setting
Clinical setting of purely breast fed
well thriving , active child rules out infectious
etiology.
Does not need any investigations or treatment
10. Practical EVENT 4
6 months old presented with diarrhea of 3 days
duration – received symptomatic treatment –
DIARRHEA SETTLED ABRUPTLY – parents were
happy ,though the child was irritable.
Over the next few hours, vomiting,
abdominal distention , drowsy child symptoms
attributed to cry – aerophagy
Referred for inconsolable cry – o/e banana shaped
mass – Abd USG - INTUSSUSEPTION
11. EXPERIENCE GAINED 4
SUDDEN IMPROVEMENT may be OMINOUS
SUDDEN ABRUPT IMPROVEMENT is rare in clinical
practice
It must be considered as a sign of complication
Sequence of recovery is important ,if not so needs
close periodic observation in anticipation.
12. Practical EVENT 5
This is 2 month old with fresh blood in stools from
15th day of life
Happy play full well thriving solely breast fed
Diagnosing as bacterial dysentery , oral walamycin
was started, as there was no response IV amikacin
was started, as there was no clinical improvement a
trail of metronidazole was given , finally breast
feeding was stopped and started on soya milk
13. EXPERIENCE GAINED 5 ALL
BLOODY STOOLS are not DYSENTRY
Its irrational to start on empirical colistin
Avoid routine amikacin & metronidazole
Simple guidance to mother to stop cows milk
would have solved the issue
14. Practical EVENT 6
5 yrs old child with sudden onset watery diarrhea ,
skin rash and dry cough of 1day duration .
Child was prescribed with ORS and sent home
15. Practical EVENT 6
Visited second dr , as the episodes of stools didn’t
improve , as the parents were very concerned and
insisting on medicine to stop diarrhea, dr
prescribed racecatodril – diarrhea stopped –
parents happy –
after 2 days went third dr for abdominal distension
& diagnosed PARALYTIC ILEUS – parents unhappy
with previous dr
16. EXPERINCE GAINED 6 AVOID
ANTIMOTILITY DRUGS
Anti motility drugs like Lomotil, lopremide may cause
dread full complications - PARALYTIC ILEUS &
TOXIC MEGACOLON
Be rational –follow WHO PROTOCOL– ORS & ZINC
17. Practical EVENT 7
5 years old child with sudden fever vomiting few
loose stools of 3 days
Wise GP Started with paracetamol & ORS as per
protocol , patient got neighbor advice & gave
ibuprofen , later gave self medication with
mefenamic acid as per advice from internet .
Fever disappeared on day 5 , abdominal pain
appeared
18. EXPERIENCE GAINED 7
DENGUE CAN PRESENT LIKE ADD
Keep dengue in the back of mind – now its
hyperendemic
All that BEGINS with DIAARHEA does not END with
ADD
20. EXPERIENCE GAINED 8
GUESSING BY EXPERIENCE
Infant with watery diarrhea vomiting mod fever-
Rota
Older pre school child same presentation –
norwalks agent
Child with large watery stools vomiting severe
dehydration – ET Ecoli , cholera
Blood & mucous, fever, abd cramps & tenesmus –
Shigella
21. Practical EVENT 9
12 yrs old boy from kolikode immunized for age,
presented with high grade fever , tachycardia ,
muffled heart sound – clinically diagnosed of
myocarditis – started on IVIG .On the next day
developed bloody stools, his sibling had similar
stools. Vitals stable ,altered sensorium ,CBC
leucocytosis, started on CIPRO. Stool culture grew
shigella sonnie sensitive to cipro, but clinically failed
to respond , started developing seizures and he
succumbed
22. EXPERIENCE GAINED 9 NEVER
UNDERESTIMATE SHIGELLA
Never start on cipro for dysentery – high resistance
Shigella can cause death due to lethal toxic
enchelopathy- ekiri syndrome
Never under estimate SHIGELLA
23. Practical EVENT 10
3 days old neonate taken to gynec for vomiting
Well looking baby ,anicteric, feeding well – thought
to have mucous gastritis – reassured – sent home
Returned back with persistent symptoms –
prescribed – domperidone drops
Shrewd grand mother showed the color of vomitus –
green – gyn referred to pediatrician
24. EXPERENCE GAINED 10 DIAGNOSIS
WRITTEN ON THE FACE
Bilious vomiting in neonate INTESTIONAL
OBSTRUCTION until proven otherwise
Rope in ped surgeon urgently
25. CARRY HOME MESSAGES
Switch back to NORMAL pre diarrheal diet as
early as possible – include PREBIOTIC foods –
breast milk, curd, banana
Counseling DANGER SIGNS is a very important
component of management – mother should be
thought when to report back .
26. CARRY HOME MESSAGES
Keep watch full eye & look for Electrolyte
imbalance – improperly diluted ORS is the
commonest cause hypernatremic dehydration –
take time & educate mothers
Vast majority are viral – avoid routine ABs
In bacterial ADD -cefixime 8mg/kg/day-BD
Parasitic diarrhea(giardia&amoebiasis) rare
27. CARRY HOME MESSAGES
Primery lactose intolerance rare - never
stop BREAST MILK Avoid
COMBO DRUGS – norflox+ metro , oflox+orni
Avoid ANTIMOTILITY AGENTS
For all ADD only WHO RED ORS & ZINC
No role for probiotics
28. FAQs – Cough
Avoid cough syrup in less than 2 years
Avoid polypharmacy in cough syrup
Common cold –1st gen AH diphenhydramine
5mg/kg/day – 6 hrly
Isolated dry cough –
dextromethorphan 1-2mg/kg/day-8hrly
Allergic rhinitis & post nasal drib cough school
going – 2nd gen AH
30. Honey
Good demulcent effect , antioxidant , increased
cytokine release , excellent safety profile
Recommended by WHO
Dose – 2.5 ml to 5 ml HS with warm water
Not for children bellow 1 year - botulism
Ideal to use pasteurized honey
