Diarrhoeal diseases

1. CONTROL OF
DIARRHOEAL
DISEASES
Namita Batra Guin
Associate Professor
Dept. of Community Health Nursing

2.  Diarrhoea is defined as passage of unusually loose or
watery stools, which are usually passed more than
three times in a 24 hour period.
 However it is the recent change in consistency of the
stools rather than the number that is more important.
 Passage of even one large watery stool in young child
is diarrhoea.

3. 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)

4.  6-12 months of age are affected severely & account
for high mortality.
 Dehydration occurs when water & salts are not
replaced adequately -may lead to shock & death.
 Diarrhoea also produces under nutrition and growth
failure.
 Diarrhoeal disease constitute one of the important
“nutritional leak” in young children.
 Even a brief episode of diarrhoea leads to the loss of
1-2 % of body weight in children.

5. Acute watery
diarrhoea
Acute bloody
diarrhoea
(dysentery)
Persistent
diarrhoea
Diarrhoea
with severe
malnutrition
(marasmus
and
kwashiorkor)

6. Acute watery diarrhoea
 Start suddenly
 Most episodes recover or self limiting within 3-7 days.
These may last up to 14 days
 >75% of all episodes are of acute watery diarrhoea.
Dysentery
 Diarrhoea with visible blood & mucus in the faeces.
 Also abdominal cramps, fever, anorexia and rapid
weight loss.

7. Persistent Diarrhoea
 Diarrhoea which lasts for > 14 days
 Incidence is around 5% i.e. 5% of acute diarrhoea
may persist beyond 2 weeks

8.  Diarrhoeal disease is the 2nd leading cause of death in
children under 5 yrs of age.
 Globally, there are about 2 Bn cases of diarrhoeal disease
every yr.
 Diarrhoeal disease kills 1.5 Mn children every yr.
 African and South-East Asian regions together account for
nearly 78% of them.
 India alone contributes about 20% of all global under-5
diarrhoeal deaths.
 It is both preventable and treatable.

9.  In developing countries, children under three years old
experience on an average three episodes of diarrhoea
every year
 Each episode deprives the child of the nutrition
necessary for growth
 As a result, diarrhoea is a major cause of malnutrition,
and malnourished children are more likely to fall ill
from diarrhoea. It makes a vicious cycle

10. ARIs*
19%
Diarrhoea*
19%
Malaria*
5%
Other
32%
Perinatal
18%
Malnutrition*
54%
Measles*
7%
* Based on data taken from The Global Burden of Disease 1996, edited by Murray CJL and
Lopez AD, and Epidemiologic evidence for a potentiating effect of malnutrition on child
mortality, Pelletier DL, Frongillo EA and Habicht JP, AmJ Public Health 1993;83:1130-1133
LEADING CAUSES OF DEATHS IN CHILDREN
UNDER 5 YRS

11.  NFHS-3 data projected morbidity profile of
children <3yr:-
Fever - 27%
Acute respiratory infections -17%
Diarrhoea -13%
Underweight - 43%

12.  Bacteria- Account 1/3rd of total causes
E. Coli
V. Cholera
V. Parahaemolyticus
Shigella- bloody diarrhoea or dysentery
E. coli
S. Typhi
Staph. Aureus
Clostridium perfringens

13.  Viruses- 1/3rd of total causes
Rotavirus
Astroviruses
Calciviruses
Coronaviruses
Norwalk group viruses
Enteroviruses
 Rotavirus causes 15-25% diarrhoea cases in developing
countries
Rotavirus

14.  Parasites-
E. histolytica- Dysentery
Giardia intestinalis
Trichuriasis
Cryptosporidium parvum
 1/3rd causes can’t be pin pointed

15.  Bottle fed babies have more chances to develop
diarrhoea because of unclean bottles
 Flies can also bring germs to uncovered food
 Drinking contaminated water
 Unclean food, milk, unclean hands & unclean utensils

16. Management of
Diarrhoea

17.  The 3 essential elements in management of all
children with diarrhoea are :
 Rehydration therapy
 Zinc supplementation
 Continued feeding

18.  During diarrhoea there is an increase loss of water
and electrolytes (sodium, potassium and
bicarbonate) in the liquid stool.
 Dehydration occurs when
• These losses are not adequately replaced and
• A deficit of water and electrolytes develops.
 The degree of dehydration is graded
• According to symptoms and signs
• This reflects the amount of fluid lost
 The rehydration regimen is selected according to
the degree of dehydration

19.  Zinc is an important micronutrient for a child’s overall health and
development.
 Zinc is lost in greater quantity during diarrhoea.
 Replacing the lost zinc is important to help the child recover and to
keep the child healthy in the coming months.
 It has been shown that the zinc supplements given during an
episode of diarrhoea
Reduce the duration and severity of the episode, and
Lower the incidence of diarrhoea in the following 2-3 months.
 For these reasons, all patients with diarrhoea should be given zinc
supplements as soon as possible after the diarrhoea has started.

20.  During diarrhoea,
A decrease in food intake and nutrient absorption and
Increased nutrient requirements
 Often combine to cause weight loss and failure to
grow
 And malnutrition in turn can make the diarrhoea
More severe,
More prolonged and
More frequent
As compared with diarrhoea in non-malnourished
children
 This vicious circle can be broken by giving
nutrient-rich foods during the diarrhoea and when
the child is well.

21.  Antibiotics should not be used routinely.
They are reliably helpful only for
Children with bloody diarrhoea (probable shigellosis),
Suspected cholera with severe dehydration, and
Other serious non-intestinal infections such as pneumonia.
 Antiprotozoal drugs are rarely indicated.
 “Antidiarrhoeal”drugs and anti-emetics
Should not be given to young children with acute or persistent
diarrhoea or dysentry
They do not prevent dehydration or improve nutrient status and
Some have dangerous, sometimes fatal side-effects.

22.  In all children with diarrhoea, decide if dehydration is present and
give appropriate treatment
 Hydration status should be classified as severe dehydration, some
dehydration or no dehydration (as per the table below) and
appropriate treatment given.
Severe dehydration
(I/V rehydration)
Two or more of the following signs:
•Lethargy/unconciousness
•Sunken eyes
•Unable to drink or drinks poorly
•Skin pinch goes back very slowly (≥2 sec.)
Some dehydration
•Give fluid & food
•After rehydration
advice mother
Two or more of the following signs
•Restlessness, irritibality
•Sunken eyes
•Drinks eagerly, thirsty
•Skin pinch goes back slowly
No dehydration
•Give fluids and food
•Advice mother
Not enough signs to classify some or severe dehydration

24. Skin Pinch

25. sunken eyes

26.  Children with severe dehydration require rapid
IV rehydration with close monitoring.
 Followed by oral rehydration once the child
starts to improve sufficiently.
 In areas where there is a cholera outbreak,
give an antibiotic effective against cholera.

27. TREAT SEVERE DEHYDRATION QUICKLY :
DIARRHOEA TREATMENT PLAN C
 Start IV fluids immediately. While the drip is being set up, give ORS solution
if the child can drink.
 The recommended IV fluid is Ringer’s Lactate (also called Hartman’s
Solution)
 If Ringer’s lactate is not available, normal saline (0.9% NaCl) can be used.
 5% glucose (dextrose) solution on its own is not effective and should not be
used.
 Give 100 ml/kg of the chosen solution divided as shown in the table below:
Age First, give 30 ml/kg
in:
Then, give 70 ml/kg
in:
<12 months old 1 hour 5 hours
≥12 months old 30 minutes 2 ½ hours

28.  Reassess the child every 15-30 minutes.
 If hydration status is not improving, give the IV
drip more rapidly.
 Also give ORS (about 5 ml/kg/hour) as soon
as the child can drink.
 Note: If possible, observe the child for at least
6 hour after rehydration to be sure the mother
can maintain hydration giving the child ORS
solution by mouth.

29.  Reassess the child every 15-30 minutes until a
strong radial pulse is present.
If hydration is not improving, give the IV solution
more rapidly.
Thereafter, reassess every hour, to confirm if
hydration is improving.
 Skin pinch
 Level of conciousness, and
 Ability to drink
 Sunken eyes recover slower than other signs,
therefore less useful for monitoring

30.  When full amount of IV fluid has been given,
reassess the child’s hydration
If signs of severe dehydration are still present, repeat
the IV fluid infusion.
If the child is improving but still shows signs of some
dehydration, discontinue IV treatment and give ORS
solution for 4 hours
If the child is normally breastfed, encourage the
mother to continue breastfeeding frequently.
 If there are no signs of dehydration, Treatment
plan A.

31.  Observe the child for at least 6 hours before
discharge, to confirm that the mother is able to
maintain the child’s hydration by giving ORS
solution.
 All children should start to receive some ORS
solution (about 5 ml/kg/hour) by cup when they
can drink without difficulty (usually within 3-4
hours for infants, or 1-2 hours for older
children).
 When severe dehydration is corrected,
prescribe zinc.

32.  In general, the child should be given ORS
solution for the first 4 hours at a clinic while
 The child is monitored and
 The mother is taught how to prepare and give
ORS solution
 The amount of ORS to be given in the first 4
hours, is calculated according to the child’s
weight (or age if weight is not known), as
shown in the table below:

33.  Use the child’s age only when you do not know the
weight.
 The approximate amount of ORS required(in ml) can
also be calculated by multiplying the child’s weight (in
kg) by 75.
 If the child wants more ORS than shown, give more.
Age Up to 4
months
4 -12
months
12 months
up to 2
years
2 - 5 years
Weight <6kg 6-10 kg 10-12 kg 12-19 kg
Amount 200-400 ml 400-700 ml 700-900 ml 900-1400 ml

34.  Demonstrate to the mother, how to give the child
ORS solution, a teaspoonful every 1-2 minutes if
the child is under 2 years; frequent sips from a
cup for an older child.
 Check regularly to see if there are problems.
If the child vomits, wait 10 minutes; then, resume
giving ORS solution more slowly (e.g. a spoonful
every 2-3 minutes)
If the child’s eyelids become puffy, stop ORS solution
and give plain water or breast milk.
 Advise breastfeeding mothers to continue to
breastfeed whenever the child wants.

35.  Reassess the child after 4 hours, checking for signs of
dehydration.
 If the mother cannot stay for 4 hours,
Show her how to prepare ORS solution and
Give her enough ORS packets to complete the rehydration
at home plus for 2 more days.
 If there is no dehydration, teach the mother the four
rules of home treatment:
Give extra fluid
Give zinc supplements
Continue feeding
When to return

36.  Children with diarrhoea but no dehydration
should receive extra fluids at home to prevent
dehydration.
 They should continue to receive an
appropriate diet for their age, including
continued breastfeeding
 Treat the child as an outpatient
 Counsel the mother on the 4 rules of home
treatment.

37.  Give extra fluid, as follows :
If the child is being breastfed, advise the mother to breastfeed frequently
and for longer at each feed.
If the child is exclusively breastfed, give ORS solution or clean water in
addition to breast milk.
After the diarrhoea stops, exclusive breastfeeding should be resumed, if
appropriate to the child’s age.
 In non-exclusively breastfed children, give one or more of the
following:
ORS solution
Food based fluids (such as soup, rice water and yoghurt drinks)
Clean water
 To prevent dehydration from developing, advise the mother to give
extra fluids-as much as the child will take:
For children < 2 years, about 50-100 ml after each loose stool
For children 2 years and above, about 100-200 ml after each loose stool.

38.  Tell the mother to give small sips from a cup. If the child
vomits, wait 10 minutes and then give more slowly.
 She should continue giving extra fluid until the diarrhoea
stops.
 Teach the mother how to mix and give ORS solution and give
her two packets of ORS to take home.
 Advise the mother to return immediately to the clinic if the
child
Becomes more sick, or
Is unable to drink or breastfeed, or drinks poorly, or
Develops a fever, or shows blood in the stool.
 If the child shows none of these signs but is still not
improving, advise the mother to return for the follow-up at 5
days.

39.  Tell the mother how much zinc to give:
Up to 6 months ½ tablet (10 mg) per day for 14 days
6 months and more 1 tablet (20 mg) per day for 14 days
 Show the mother how to give the zinc supplements:
Infants, dissolve the tablet in a small amount of clean
water, expressed milk or ORS in a small cup or spoon.
Older children, tablet can be chewed or dissolved in a
small amount of clean in a cup or spoon.
 Remind the mother to give the zinc supplements for
the full 10-14 days.

40.  Continuation of nutritious feeding is an important
element in diarrhoea management
 In the initial 4 hour rehydration period, do not give any
food except breast milk.
 Breastfed children should continue to breastfeed
frequently throughout the episode of diarrhoea.
 After 4 hrs, if the child still has some dehydration and
ORS continues to be given, give food every 3-4 hrs.
 All children over 4-6 months old should be given some
food before being sent home.
 If the child is not normally breastfed, explore the
feasibility of relactation (i.e restarting breastfeeding after
it was stopped or give the ususal breastmilk substitute)

41.  If the child is 6 months or older or already taking solid
food, give freshly prepared food – cooked, mashed or
ground.
 The following are recommended:
Cereal or other starchy food mixed with pulses, vegetables
and meat/fish, if possible, with 1-2 tsps of vegetable oil
added to each serving.
Local complementary foods recommended by IMNCI in the
area
Fresh fruit juice or mashed banana to provide potassium
 Encourage the child to eat by offering food at least 6
times a day. Give the same food after the diarrhoea
stops and give an extra meal a day for 2 weeks.

42. Give extra fluid
Give zinc supplements
Continue feeding
• Advise the mother to return
immediately to the clinic if
• The child becomes more sick, or
• Is unable to drink or breastfeed, or
drinks poorly, or
• Develops a fever, or shows blood in
the stool.
• If the child shows none of these signs
but is still not improving, advise the
mother to return follow up at 5 days.
When to return

43. • Follow up after 2 days in dysentery, after 5 days in
 acute diarrhoea
Return immediately if the child develops:

 Many watery stools,
 Repeated vomiting,
 Fever,
 Poor or unable to drink and eat/ breastfeed,
 Blood in stool

44. FOLLOW UP
• Follow up after 2 days in dysentery, after 5 days in
acute diarrhoea
• Return immediately if the child develops:
 Many watery stools,
 Repeated vomiting,
 Fever,
 Poor or unable to drink and eat/ breastfeed,
 Blood in stool

45.  It is a balanced mixture of glucose and electrolytes
 Almost all deaths from diarrhoea can be prevented by
ORS
MECHANISM OF ACTION
 Sodium promotes absorption of water from the
intestine
 Glucose promotes the absorption of sodium and
water from the intestine

46. COMPOSITION OF WHO -
ORS
Ingredients Normal
(gm)
Low osmolarity
(gm)
Sodium chloride 3.5 2.6
Glucose 20.0 13.5
Potassium Chloride 1.5 1.5
Trisodium citrate
dehydrate
2.9 2.9
27.9 gm
(310 mOsm/l)
20.5 gm
(245 mOsm/l)
SGPT:2.6,13.5,1.5,2.9

47. Ingredients Low osmolarity
(mmol/l)
Sodium 75
Glucose 75
Potassium 20
Citrate 10
Chloride 65
245 mOsm/l
HYPO-OSMOLAR
ORS
SGPTC:7575,201065

48. 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

49. HOME MADE ORS
1 tsp table salt + 6 heaped tsp sugar
in 1 litre of water
SUPER ORS
Amino acid based ORS
 Amino acids (Alanine, Glycine co-transport the Na+) are used
in place of glucose
Powder of boiled rice (50 mg/L) can be used in place of amino acids
Decrease purging rates and improve absorption

51. ORS

54. 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

55. DIARRHOEA CAN BE
PREVENTED

 Promote exclusive breastfeeding
 Immunization against measles
 Using sanitary latrines
 Keeping food and water clean
 Washing hands before eating & after defecation.

56. 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

57.  Rotashield vaccine -1999
 Withdrawn because of its association with
intussuscption
 Two new oral, live attenuated rotavirus vaccines were
licensed in 2006 with very good safety and efficacy
 The first dose administered between ages 6-10 weeks
.
 subsequent doses at intervals 4-10 weeks.
 Vaccination should not be initiated before 6weeks and
after 12 weeks of age.
 All doses should be administered before 32 weeks.

58. Rota Rix vaccine
ROTA TEQ
VACCI
NE
Oral, live attenuated
 2 dose schedule
1st dose - 2 month of
age
2nd dose- 4 month
………………………
….
Oral, live attenuated,
pentavalent vaccine. Contains
5 live reassortant rotaviruses
3 dose schedule
at 2 month of age
4 month of age
6 month of age

59.  -

60.  Geneva and Seattle, June 5, 2009 — WHO has
recommended that rotavirus vaccination be included in
all national immunization programmes
 The new recommendation by the WHO's Strategic
Advisory Group of Experts (SAGE),extends an earlier
recommendation made in 2005 on vaccination in the
America and Europe, where clinical trials had
demonstrated safety and efficacy in low and
intermediate mortality populations.

61. ORS is best drink.
A child with diarrhoea needs
more food and frequent breast
feeding.
A child who is recovering from
diarrhoea needs an extra meal
every day for at least 2 weeks.
Medicine other than ORS
should not be used except on
medical advice.

62.  MODULES of IMNCI 2003
 K.PARK , TEXTBOOK OF COMMUNITY
MEDICINE
 SUNDER LAL, TEXTBOOK OF COMMUNITY
MADICINE.
 HARRISONS PRINCIPLES OF INTERNAL
MEDICINE 17th edition
 IAP GUIDELINES FOR MANAGEMENT OF
DIARRHEA
 WORLD HEALTH ORGANIZATION (WHO)
GUIDELINES ON TREATMENT OF
DIARRHEA (2005