Diarrhoea management


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WHO and UNICEF recommended management of Childhood Diarrhoea.
HLFPPT has been implementing Childhood Diarrhea management programmes with UNICEF and Micronutrient Initiative.

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  • Data from prevalence studies done in India shows that the majority of diarrheal episodes are due to ETEC or rotavirus. Rotavirus is responsible for at least a third of the dehydrated hospitalized patients with diarrhea. It is important to note that antimicrobials are required for only a small proportion of children with acute diarrhea. Diarrhea due to Entamoeba or Giardia is very uncommon and therefore the irrational widespread use of metronidazole is not justified. Also it is crucial to emphasize that most dehydrating diarrheas donot require antimicrobials.
  • The fluid chart was discussed in the last IAP National task force meeting, a consensus was reached and it had been approved. But just to recapitulate. Basically we need to emphasize that ringer lactate with 5% dextrose should be the first choice but if not possible to give that half normal saline with 5% dextrose should be given as the second choice. This needs to be given at slower infusion rates over 1 hour with continuous monitoring. If at the end of 1 st hour there is rapid improvement consider severe dehydration and repeat the rehydrating solution slowly over another hour and so on till child clinically better and able to accept orally. At end of 1 st hour if no improvement septic shock must be considered and treated as in the standard manner. There must be very frequent monitoring to see responses and to look for features of overhydration and cardiac decompensation.
  • PC-1\\D:Aniruddha-04\\Wallace Trotz_Medical Slides
  • PC-1\\D:Aniruddha-04\\Wallace Trotz_Medical Slides
  • PC-1\\D:Aniruddha-04\\Wallace Trotz_Medical Slides
  • PC-1\\D:Aniruddha-04\\Wallace Trotz_Medical Slides
  • This slide just emphasizes that although the basic format for assessing dehydration remains the same, there are certain signs which may be unreliable, such as Mental status Skin turgor & Moist tongue and tears Also edema and hypovolemia can coexist.
  • Although a history of diarrhea with large volume of stools &/ or vomiting, increased thirst, recent sunken eyes and other markers of decreased perfusion like prolonged CFT, weak radial pulse or decreased urine flow would point towards dehydration, at times it may become difficult to assess dehydration using clinical signs alone So it is best to assume that all with watery diarrhea have some dehydration
  • Which ORS should be used? The WHO recommends ReSoMal (oral rehydration solution for malnourished children). But neither is it available in India nor is there any evidence to recommend its use. The IAP National task force meeting in 1997 and again in 2003 decided that there was no need to confuse issues by using different ORS for different situations and the same standard WHO ORS could be used but over a prolonged period of time. Now of-course with the availability of reduced osmolarity ORS it should be used ideally in SMN children but with potassium supplements given additionally. Basically the message that needs to be given is that around the world for all causes of diarrhea in all ages, a single solution should be used for logistics and programmatic advantages.
  • Slide indicates the effectiveness, safety, and cost-benefit ratio of WHO-ORS.
  • Bihar, UP and Rajasthan have dismal ORS use rates.
  • The composition of ORS with different osmolarity that have been evaluated
  • This the summary of results of published meta-analysis of all randomized clinical trials comparing reduced osmolarity ORS with standard WHO ORS (311mosmol/l) in children with acute non-cholera diarrhea: There was a significant reduction by 39% in need for unscheduled IV fluids, 12% significant reduction in stool output and 29% significant reduction in vomiting in the group that received the reduced osmolarity ORS solution.
  • Zinc deficiency, like iron deficiency, is widely prevalent with the magnitude being highest in South Asia and Sub-Saharan Africa.
  • Reasons for zinc deficiency being so common in developing countries.
  • Zinc deficiency has detrimental effects on intestinal mucosal functions, which the zinc reverses.
  • After few years, large community based study from AIIMS, New Delhi documented the benefits of zinc supplementation in under-five children.
  • Zinc improves immune functions as has been demonstrated by increase in lymphocyte subtypes.
  • Most agencies including WHO, UNICEF, and IAP now recommend routine zinc supplementation during acute diarrhea.
  • Combined estimate from the studies (completed till 2004) from India and neighboring countries suggested a faster recovery from diarrhea, lesser risk of prolonged diarrhea and lower stool output with the use of zinc during an acute episode.
  • Zinc is beneficial in all forms of diarrhea, including cholera and acute dysentery.
  • Following the tremendous research and recommendations related to the benefit of zinc in diarrhea, GOI has taken steps to ensure its production and delivery.
  • Diarrhoea management

    1. 1. Acute Diarrhea Management
    2. 2. Reduce Child mortality
    3. 3. What is Diarrhea ?It is defined as 3 or more watery stool in 24 hrsOther namesMore common when child is on cow’s milk/formula feed
    4. 4. 0-2 months 2months-5 yearsBF Infant Many times but notSemisolid /not watery wateryEvery time after feedingWhat is and what is not diarrhea?
    5. 5. Acute watery diarrhea- If <14 days ,sever dehydration Ecoli,cholera ,malnutrition Persistent diarrhea-If >14 days, 20-30 % death, under nourished and HIV exposedDysentery-(atisar)with blood ,with or without mucus 10%-15 % of deathsTypes of serious diarrhoea inchildren
    6. 6. Lets look at the important microbial causes of acute diarrhea in < 5 yearsRotavirus: 5-10% : community, 25-30% indehydrating diarrheaETEC : 20%Shigella: 5-10% of acute diarrhea; Most commoncause of dysenteryEPEC, LA-EC, Campylobacter, Salmonella: 5-7%G. lamblia, E-histolytica: < 2%Eh - uncommon cause of dysentery <5%V. cholerae (01 & 0139): 5-10% (endemic)
    7. 7. Proportion of water is more in children ,so dehydration occur early.Child can loose 5ml-200 ml liquid in 24 hrsMetabolic rate is high and use more water as compared to adultsKidney can conserve less water ,so loss is moreSodium loss can be 70-110 m mol/kgChloride and potassium loss is balanced &sameWhy are children more prone todiarrhoea
    8. 8. Did child vomit in past 6-8 hrs?Did child pass urine in past 6-8 hrs?What type of liquids did the child get ?Did the child get sufficient food before this episode ?During diarrhea is child getting food that is different and is less calorie dense?Look for cough ,fever ,otitis media ,sepsis ,h/o measlesWeight /nutritionAssessment of diarrhea
    9. 9. ASSESS: Degree of DehydrationDECIDE: Plan of treatment
    10. 10. Does the child have diarrhea?If yes, ask: ◦ For how long? How many? ◦ Has the child been vomiting ◦ Is there blood in stool?
    11. 11. LOOK LOOK AT THE CHILD’S GENERAL CONDITION IS THE CHILD ◦ Lethargic or Unconscious? ◦ Restless or Irritable? LOOK FOR SUNKEN EYES Look for skin pinch -goes back promptly/slowly/ very slowly OFFER THE CHILD FLUID TO DRINK – THIRSTY Not able to drink or drinking poorly? Drinking eagerly, appears thirsty? Drinking normally?
    12. 12. Look at Eyes for DehydrationShrunken Eyes Normal eyes
    13. 13. Degree of Dehydration
    14. 14. Degree of dehydration decided on: Two or more of the followingSome Dehydration Severe Dehydration•Restless, Irritable •Lethargic or unconscious•Sunken Eyes •Sunken Eyes•Drinks eagerly, Thirsty •Not able to drink or drinking poorly•Skin Pinch goes back“slowly” •Skin Pinch goes back “very slowly” OR NO DEHYDRATION
    15. 15. Film Clip: assessment of dehydration
    16. 16. No Dehydration: PLAN-ASome Dehydration: PLAN-BSevere Dehydration: PLAN-C
    17. 17. PLAN – ATreat Diarrhea at Home.4 Rules of Home Treatment: GIVE EXTRA FLUID CONTINUE FEEDING WHEN TO RETURN [ADVICE TO M OTHER] GIVE ORAL ZINC FOR 14 DAYS
    18. 18. Give extra fluid TELL THE MOTHER: Breastfeed frequently and for longer at each feed If exclusively breastfeed give ORS for replacement of stool losses If not exclusively breastfed, give one or more of the following: ORS, food-based fluid (such as soup, rice water, coconut water and yogurt drinks), or clean water. TEACH THE MOTHER HOW TO MIX AND GIVE O.R.S AMOUNT OF FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE: Up to 2 years: 50 to 100 ml after each loose stool. 2 years or more: 100 to 200 ml after each loose stool.
    19. 19. Continue feeding Continue usual feeding, which the child was taking before becoming sick 3-4 times (6 times) Upto 6 months of age: Exclusive Breast feeding6 months to 12 months of age : add Complementary Feeding 12 months and above : Family Food
    20. 20. When to Return [Advice to mother] Advise mother to return immediately if the child has any of these signs: Not able to drink or breastfeed or drinks poorly Becomes sicker Develops a fever Blood in stool[IF IT WAS NOT THERE EARLIER]
    21. 21. PLAN – B Plan-B is carried out at ORT Corner in OPD/clinic/ PHC Treat ‘some’ dehydration with ORS (50-100 ml/kg Give 75 ml/kg of ORS in first 4 hours If the child wants more, give more After 4 hours: Re-assess and classify degree of
    22. 22. Signs of sever dehydrationChild not improving after 4 hoursRefer to higher center –give ORS on way /keep warm /BFWhen child comes back follow up as other children PLAN -C
    23. 23. PLAN – CStartI. V. Fluid immediatelyGive 100 ml/kg of Ringer’s Lactate Age First give Then give 30ml/kg 70 ml/kg in in Under 12 1 hour 5 hours months 12 months and ½ hour 2½ hour older
    24. 24. Fluid therapy in severe dehydration Use intravenous or intraosseus route Ringers Lactate with 5% dextrose or ½ normal saline with 5% dextrose at 15 ml/kg/hour for the first hour * do not use 5% dextrose alone Continue monitoring every 5-10 min. Assess after 1 hourIf no improvement or worsening If improvement(pulse slows/faster capillary refill /increase in blood pressure) Consider septic shock Consider severe dehydration with shock Repeat Ringers Lactate 15 ml/kg over 1 h Switch to ORS 5-10ml/kg/hr orally or by nasogastric tube for up to 10 hrs
    25. 25. Classify and Treat DiarrheaDiarrhea •Persistent diarrhea •Give first dose ofLasting 14 COTRIM/CIPROFLIXdays or more •Sever Persistent • Treat to prevent low sugar diarrhea •Home foods •ORS/ZN /BF/Vit A •Do HIV RAPID TEST •Keep warm •Refer to Hospital if severBlood in Stool •Dysentery Give COTRIM/CIPROFLOX for •Sever Dysentery 3 days Change if no improvement after 2 days Prevent low blood sugar Keep warm Refer to Hospital if sever
    26. 26. Antimicrobials should be given during diarrhea only for:DysenteryCholeraSevere malnutritionAssociated systemic infection
    27. 27. Some key facts about feeding during diarrheaFeeding does not worsen diarrheaPrevents malabsorption & facilitates mucosal repair Isolauri et al. 1989. JPGNPrevents growth faltering and malnutrition Brown et al. 1988. J Pediatr
    28. 28. Some key facts about feeding during diarrhea• There is no basis for fasting in diarrhea• Continue to breastfeed• Encourage the child to drink & eat• Be patient while feeding• Feed small amounts frequently• Give foods that the child likes• Give a variety of nutrient-rich foods• Do not dilute milk Brown et al. 1988. J Pediatr• Routine lactose free feeding not required• Do not give sugary drinks
    29. 29. Increase amount of calories during convalescencewith energy dense foods (enrich foods with fats andsugar)•Feed an extra meal (for at least 2 weeks afterdiarrhea stops)•Give an extra amount•Use extra rich foods•Feed with extra patience•Give extra breastfeeds as often as child wants
    30. 30. Increase amount of calories during convalescencewith energy dense foods (enrich foods with fats andsugar)•Feed an extra meal (for at least 2 weeks afterdiarrhea stops)•Give an extra amount•Use extra rich foods•Feed with extra patience•Give extra breastfeeds as often as child wants
    31. 31. Assessment of dehydration inseverely malnourished children Basic format remains the same Some signs unreliable Mental state Skin turgor Edema and hypovolemia can coexist
    32. 32. Diagnosis of dehydration in severely malnourished children• History of diarrhea (with large volume of stools)• Increased thirst• Recent sunken eyes• Prolonged CFT, weak/absent radial pulse,• Decreased or absent urine flow Difficult using clinical signs alone Best to assume that all with watery
    33. 33. Which ORS should be used in severemalnutrition?• Low osmolarity ORS with potassium supplements given in addition to ORS• ReSoMal :not available in India no evidence
    34. 34. What Is ORS
    35. 35. Safe & effective Can alone successfully rehydrate 95-97% patients with diarrhea, Reduces hospital case fatality rates by 40 - 50%Cost saving Reduces hospital admission rates by 50% and cost of treatment by 90% BUT
    36. 36. ORS use rates are dismally low in someregions> 50% Goa, Himachal, Meghalaya, Tripura, Manipur> 40% West Bengal, J&K, Mizo, Chhattisgarh> 20% Bihar, Orissa, Uttaranchal, Punjab, Gujarat, MP, Southern States< 20% Rajasthan, UP, Assam, Jharkhand, NagalandRecent NFHS 3 data
    37. 37. Improved GI physiology in low osmolarity ORS Increase in Gastric emptying Low OSM ORS Availability of ORS Prevents vomiting 210-260 mmol/L Small bowel 290mmol/LBlood Net flow of water into Blood Decrease in Stool Output
    38. 38. Composition of standard and low osmolarity ORS solutions Standard ORS Solution Low OsmolarityORS (mEq or mmol/L)Glucose 111 75Sodium 90 75Chloride 80 65Potassium 20 20Citrate 10 10Osmolarity 311 245
    39. 39. Summary of results of published meta-analysis of all randomized clinical trials (12) comparing low osmolarity ORS (245mosmol/l) with standard WHO ORS (311mosmol/l) in children with acute non- cholera diarrhea: 39% reduction in need for unscheduled IV fluids 19% reduction in stool output 29% reduction in vomitingHahn et al, 2001; WHO/FCH/CAH 0.1.22, 2001
    40. 40. Low osmolarity ORS is safe and effective for all agesShould be given to young infants (< 2m) including neonates if there is dehydrationIn exclusively breastfed young infants with no dehydration encourage exclusive breastfeeding more frequently and for longer
    41. 41. Film clip: ammaji kehti hain
    42. 42. Film clip: ammaji kehti hain
    43. 43. Making ORS PAGE -20
    44. 44. How much fluids (p 17)0-4 m 200-400 ml 2 glasses4-12 m 400-600ml 3 glasses12-24 m 600-1000ml 5 glasses2-5 yrs 1.0 -1.4 litres 7 glasses Small sips from glass If vomits wait for 10 min and give again Continue BF Revaluate after 4 hours
    45. 45. Caused by Vibero CholeraOccur in EpidemicRice water stool and sever dehydrationLoss of fluid may be 200-350 ml/kgUsually IV fluids required /IG fluidsDoxycycline 6 mg/kg single dosageCholera management
    46. 46.  Diarrhea with blood in stool (Shigellae ,E Histolytica ) Assess dehydration ,if sever refer Give ORS ,DIET AB–Ciprofloxacin -15 mg/kg orally 2 times a day/Cotrim (ped ) Reassess after 2 daysDysentery management
    47. 47. Diarrhea more than 14 daysMalnutrition /multiple deficienciesPrevent dehydrationHigh calorie foodZinc ,vitamins, minerals for 14 days No iron preparationAB –cotrimoxazole /ciprofloxacin 5 -7 daysHIV testingSevere Acute Malnutrition –IN HOSPITALManagement of persistentdiarrhoea
    48. 48. Antiemetic in acute diarrhea Vomitingcommonly associated symptom : Low osmolarity ORS reduces vomiting Mostly managed by frequent small sips (5-10 ml) of ORS.Antiemetic have no role in the management of acute gastroenteritis
    49. 49. With the current evidence availablepro or prebiotics are notrecommended for the treatment ofdiarrheaIAP consensus statement 2003,2007Ind Pediatr, 2004, 2006
    50. 50. IMNCI diet A, B, C
    51. 51. Fever, fast breathingConvulsions ◦ hypernaterima.,hyponatremia ◦ HypogiycemiaMeningitisVitamin A deficiencyOther problems with diarrhea
    52. 52. WHY ZINC?
    53. 53. Zinc deficiency is widespread in lowand middle income countries like India IZiNCG advocacy statement (http://www.izincg.org/pdf/IZiNCG_Advocacy- PrintingFormat.pdf)
    54. 54. Why zinc deficiency is common in children fromdeveloping countries? • Breast milk not sufficient source >6 mo • Intake of complementary foods low, particularly animal foods • Limited bioavailability;↑ phytates from cereals • High fecal losses during diarrheal illness • Low content of soil, of foods
    55. 55. Zinc deficiency has direct effects on mucosal functions Disrupts intestinal mucosa Reduces brush border enzymes Increases mucosal permeability Increases intestinal secretionRoy 1992, Hoque 2005
    56. 56. 937 children, 6-35 mo, diarrhea < 7 d20 mg zinc daily % reduction (95%CI)Risk of continued diarrhea 23 (12 to 32)*Mean no of watery stools/d 39 (6 to 70)*Sazawal et al, N Eng J Med 1995
    57. 57. Zinc critical for immune and non immune functions that resist or clear infection & its consequencesThe percentage of anergic children decreased from67% to 47% (p=0.05) in the zinc supplementedgroup as compared to the controlsZinc supplemented group had:↑ 25% CD3+ (p=0.02)↑ 64% CD4+ (p=0.001)↑ 73% CD4/CD8 (p=0.004)Sazawal et al, Ind Pediatr 1997
    58. 58. Recommendations for Use of Zinc in Acute DiarrheaWHO/UNICEF Joint statement (2001), IAP2003, GOI 200720 mg/day (10 mg/day for infants 2-6 mo) ofzinc supplementation for 14 days startingas early as possible after onset of diarrhea
    59. 59. Zinc reduces diarrheal duration and severity when given during a diarrheal episodeRCT: 1995-2004 No. of subjectsStudies from Nepal, Bangladesh 4362Sazawal, New Delhi 931Bahl, New Delhi 805Bhatnagar, New Delhi 266Combined estimate (meta-analysis):Recovery from diarrhea was faster: Relative Hazards 0.84, 95%CI0.78 to 0.89Episodes lasting > 7 days were less: OR 0.66, 95%CI 0.52 to 0.83Total stool output was less; Ratio of GM 0.76 , 95%CI 0.59 to 0.98Bahl, 2004
    60. 60. Role of Zinc in Cholera and DysenteryIn children with cholera, zinc supplemented patientshad 12% shorter duration of diarrhea and 11% lessstool output than control patientsRoy et al, BMJ,2008Zinc supplementation shortens duration ofacute shigellosis & reduces diarrhealmorbidity during the subsequent 6 monthsSazawal et al 1998; Rahman et al 2001; Roy et al, BMJ,2008
    61. 61. Zinc experience in India (2007-• 2008) Policy decision taken for including zinc in RCH/NRHM• Several pharmaceutical companies manufactured syrup & dispersible zinc tablets• State PIPs included zinc• GOI sanctioned funds for procurement of zinc tablets as part of RCH kit
    62. 62. Dose of Zinc 2- 6 months 10 mg for 14 days6 mo-5 yrs 20 mg for 14 days
    63. 63. Exclusive BreastfeedingImproved dietary HabitsSafeand clean waterPrevention of Diarrhea
    64. 64. Zinc Preparation
    65. 65. Compliance card
    66. 66. Hand Washing
    67. 67. Key messagesZinc along with ORS is more effectiveZinc acts like tonic and not medicine6mo and more children should get 20 mg/d for 14 days2-6 mo children to get 10 mg for 14 daysHome cooked foods like rice water, lemon water,dal soup, fresh fruit juice without sugar should be given .
    68. 68. National Policy for treatment of Diarrhea in children 20072.8.2011 NHRM office Lucknow UP order for implementation of ORS+Zinc Jodi by health workers up to ASHA &Anganwari workersRevised diarrhea managementpolicy and guidelines (2007)
    69. 69. Questions?