Childhood Diarrhea


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Management of Childhood Diarrhea in Low-Resource Settings

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  • Analysis of prescription practices as part of UNICEF 10 districts survey revealed, of those who sought care, only 47 per cent of the children were prescribed ORS. Tonics, anti-diarrhoeal drugs, and injections continued to be prescribed for diarrhoea. Overall, 23 per cent of the children who had diarrhoea in the two weeks prior to the survey received an injectable drug, 18 per cent were given anti-diarrhoeal drugs, and 6 per cent
    were treated with antibiotics. We will see later in subsequent sessions that these antidiarrheal drugs, tonics and injections have no role.
  • present in the body in very small quantities.
    increases skin, and mucosal resistance to infection.
    increases skin, and mucosal resistance to infection.
    Zinc cannot be stored in the body, and nearly 50%of zinc excretion takes place through the gastrointestinal tract and is increased during episodes of diarrhea.
    Breast milk not sufficient source > 6 month
    Inadequate intake of complementary foods
  • Childhood Diarrhea

    1. 1. Diarrhea Management in the Community
    2. 2. CHILDHOOD DIARRHEA One in 5* children die of diarrhea or diarrhea related complications every year in India. Diarrheal illness is the second leading cause of child mortality; among children younger than 5 years, it causes 1.5 to 2 million deaths annually. In developing countries, children experience between three to six episodes of diarrhea annually. *Predicting the distribution of under-five deaths by cause in countries without adequate vital registration systems Saul S Morris,1 Robert E Black2 and Lana Tomaskovic3(International Journal of Epidemiology 2003;32:1041–1051)
    3. 3. Magnitude of problem • In India,~380,000 *children die from diarrhea and its complications every year. • 9.8 million child deaths each year, 2/3 of which are preventable with low-cost interventions • 2 million child deaths from diarrhea, 88% of Diarrhea diseases are preventable by easily available interventions. • Diarrheal diseases are responsible for 18%** of deaths among children under 5 years of age. • Despite easy and affordable treatment, most patients do not access the recommended treatment. • Timely use of ORS-Zinc can save over 133,000 lives by 2015*** • • • • *World Health Organization, Global Burden of Disease estimates, 2004 update. **Causes of Child Deaths - March 26, 2005 The Lancet ***Role of zinc administration in prevention of childhood diarrhea and pneumonia-a meta analysis,Agarwal I R,Sentz J,Miller M A,Paediatrics 2007,June 119(6)
    4. 4. Causes of Child Deaths in Low-Income Countries: Diarrhea 18% Source: WHO, World Health Statistics 2011
    5. 5. What is Diarrhea? • Any Change in number or consistency of stools in exclusively breast-fed children. • Passage of 3 or more than 3 loose or watery stools in 24 hours in children over 2 months of age. • Diarrheal illness may be of the following typesacute watery diarrhea and chronic or persistent diarrhea (lasting for ≥14 days). • Blood in stools-Dysentery. • Usually seen in children between 2 months and 5 years of age.
    6. 6. When is it NOT Diarrhea? • Frequent passage of soft, semisolid stools in an exclusively breast-fed child. • No change in consistency or number of stools.
    7. 7. Diarrhea and Dehydration Cause •Passage of 3 or more than 3 loose or watery stools in 24 hours. •Any Change in number or consistency of stools. •Often associated with vomiting. Effect •During diarrhea and/vomiting, there is loss of water and electrolytes. •Dehydration occurs when these losses are not replaced adequately and a deficit of water and electrolytes develops.
    8. 8. Consequences of Diarrhoea The two main dangers: malnutrition and death. Commonest cause of diarrhea related deaths: dehydration Equally important causes of death are dysentery and prolonged malnourishing diarrhea Malnutrition is associated with nearly two-thirds of diarrhea-related deaths.
    9. 9. Diarrhea & Malnutrition Vicious cycle ↓ Immunity ↓ Mucosal integrity Common predisposing factors ↓ Absorption ↓ Appetite Voluntary restriction ↑ Losses ↑ Catabolism
    10. 10. What are our challenges in the treatment of diarrhea? • Low ORS use rates • Use of zinc as an adjunct to ORS • Inappropriate management of dehydration • Inadequate emphasis on feeding • Irrational use of antimicrobials & other drugs • Hand washing
    12. 12. Prescription Practices10 district survey in India ORS 47% Zinc 1.3% Antibiotics 5.6% Injections 23.0% Antidiarrheals 18.2% Tonic 31.5% Management Practices for Childhood Diarrhea in India , UNICEF 2009
    13. 13. Two simple rules for effective management of Diarrhea •ORS •ZINC
    15. 15. ORS-Benefits • Replaces water and salts lost during diarrhea. • Reduces dehydration and need for hospitalization. • Decrease in severity of diarrhea and vomiting. • Decrease in duration of illness.
    16. 16. Low osmolarity ORS Composition Ingredient g/L Dissociates into mmol/L Glucose, anhydrous (C6H12O6) 13.5 Glucose 75 Trisodium Citrate,dihydrate Na3C6H5O7·2H2O 2.9 Sodium 75 Sodium Chloride (NaCl) 2.6 Chloride 65 Potassium Chloride (KCl) 1.5 Potassium 20 20.5 Citrate 10 TOTAL 245 TOTAL
    17. 17. Preparation of ORS Three Important Rules CLEAN HANDS CLEAN WATER CLEAN UTENSILS
    18. 18. Preparation of ORS
    19. 19. WHAT IS ZINC? What are it’s benefits?
    20. 20. What is Zinc? • • • • • • Zinc is a micro-nutrient and promotes immunity. It is an important antioxidant and preserves cellular membrane integrity. Promotes the growth and development of the nervous system. Rich sources of Zinc are foods of animal origin, such as meat and fish. Zinc is also present in nuts, seeds, legumes, and whole grain cereal, but the high phytate content of these foods interferes with its absorption. Zinc cannot be stored in the body, and zinc excretion through the gastrointestinal tract is increased during episodes of diarrhea. • Young children who have frequent episodes of diarrhea and have diets low in animal products and high in phytate-rich foods are most at risk of Zinc deficiency.
    21. 21. ZINC- Benefits • Zinc reduces the fluid and salt loss in stools by improving mucosal permeability. • Accelerated regeneration of mucosa • Increased levels of brush-border enzymes • Enhanced cellular immunity • Higher levels of secretory antibodies • Zinc improves absorption of ORS. • Reduces the severity and duration of illness. • Reduces need for antibiotics. • Reduces the chances of complications. • Full dose for 14 days protects against diarrhea and pneumonia for next 3 months. • Acts as a general tonic-improves appetite and promotes growth.
    22. 22. Research Studies on efficacy of Zinc • A study conducted by an international team of scientists working in Bangladesh and led by researchers from the Johns Hopkins Bloomberg School of Public Health. • The researchers treated 8,070 children with diarrhea living in areas of Bangladesh. • Groups of children were randomized by region to receive zinc in addition to standard treatments and compared to children who did not receive zinc. • The children in the zinc areas received 20 mg elemental zinc daily for 14 days during each episode of diarrhea in addition to ORS therapy.
    23. 23. Research StudiesContd. • The researchers found the incidence of diarrhea was significantly less and non-injury deaths were 50 percent less in children who received zinc compared to those who did not. • In addition, it was found that oral rehydration solution therapy (ORS) use, which is one of the standard treatments for diarrheal disease, increased by 20 percent among the children who received zinc. Antibiotic use decreased by 60 percent among the same group. These findings are published in the November 9, 2002, of the British Medical Journal.
    24. 24. • • • • Recommendations for Use of Zinc in Acute Diarrhea WHO/UNICEF Joint Statement (2001) Endorsed by Indian Academy of Pediatrics (2003) Endorsed by Government of India (2006) Zinc has been included in the WHO and India Essential Medicines List for the treatment of diarrhoea
    25. 25. Evidence of Efficacy of ZINC • 15% faster recovery during the episode of diarrhea*. • 16 % decrease in duration of diarrhea*. • 24% decrease in frequency of episodes lasting more than 7 days*. • 9-23% decrease in frequency of stools*. • Up to 31% reduction in stool output during the episode of diarrhea**. • 42% reduction in treatment failure or death in persistent diarrhea *ACUTE CHILDHOOD DIARRHEA: A REVIEW OF RECENT ADVANCES IN THE STANDARD MANAGEMENT Seema Alam, Rajeev Khanna, Uzma Firdaus Pediatric Gastroenterology Section, Department of Pediatrics, JNMC, AMU, Aligarh **Zinc with ORT reduces the stool output and duration of diarrhea in hospitalized children -a randomized controlled trial;S Bhatnagar et al, Dept of Paediatrics at AIIMS and Kasturba Hospital ,New Delhi ***Zinc Investigators’ Collaborative Group. AJCN 2000.
    26. 26. Long Term Effects of Zinc • Zinc supplementation for 10-14 has longer term effects on childhood illnesses in the 2-3 months after treatment • 34% reduction in prevalence of diarrhoea • 26% reduction in incidence of pneumonia Zinc Investigators’ Collaborative Group. Pediatrics. 1999.
    27. 27. Cost Effectiveness of ORS and Zinc Supplementation • Decreases the duration and severity of the episode • Decreases the need for expensive hospitalization • Decreases the use of unnecessary antibiotics and other drugs • Further cost-benefit analyses are underway Robberstad, Strand, Sommerfelt, and Black. Bull WHO 2004. Baqui, Black, Arifeen. J Health Pop Nutr. 2004.
    28. 28. Current total costs of treating a case of diarrhea higher than the cost of Zinc treatment Reported total costs of treating a case of diarrhea, Location for differing levels of perceived severity of treatmen Mild Moderate Severe t At home <Rs. 50 Rs. 50-100 ORS sachets are sold for Rs 5-7 in the private sector ($0.10-$0.14). Zinc treatment for 10-14 day regimen costs ~Rs.28-33 in the private sector ($0.56-$0.66) Source: Formative research in preparation for promotion of zinc treatment for childhood diarrhea: Cross-country comparison of diarrhea treatment practices and implications for programs; June 2004 Private Rs.100-200 Rs. 300-500 Rs.500-1500
    29. 29. Dosage of Zinc • Available as ZINC Tablets. • Given for 14 days for full benefits. • 20 milligrams per day for children older than six months. • 10 mg per day in those younger than six months.
    30. 30. Administration of ZINC Age Tablet Preparation Duration Less than 2 months Not required 2 months – 6 months ½ tablet (10 mg) Dissolved in 1 tsp of breast milk 14 days 6 months- 5 years 1 tablet (20 mg) Dissolved in 1 tsp of breast milk/ORS/clean drinking water 14 days
    31. 31. Objective of Treatment • Prevent dehydration, if no signs of dehydration are present. • Treat dehydration, if present. • Reduce duration and severity of illness. • Prevent nutritional damage. • Reduce the occurrence of future episodes.
    32. 32. WHO-UNICEF recommended policies • Caregivers/ mothers should start treatment with new low osmolarity ORS solution immediately upon onset of diarrhea in a child. • Zinc supplementation with 20 mg per day of zinc supplementation for 14 days (10 mg per day for infants under six months old). • Emphasize continued feeding or increased breastfeeding during, and increased feeding after, the diarrheal episode. • Emphasize handwashing.
    33. 33. Diarrhea Water + Electrolytes Loss Dehydration ORS Rehydration Zinc Loss Lessen absorption capacity Decreases Immunity Zinc Tablets Faster Recovery of Intestine Mucosa Increase in absorption capacity Increase in immunity
    34. 34. Management of Diarrhea and Dehydration ASK 7-14 days Yes, freely Yes, but in decreased quantity Some Dehydration Severe Dehydration Condition Well , Alert Restless , Irritable Lethargic, unconscious Eyes Normal Sunken Sunken Thirst Drinks normally, Not thirsty Thirsty, drinks eagerly Drinks poorly or not able to drink Skin pinch Goes back quickly Goes back slowly bit in less than 2 seconds Goes back very slowly, in more than 2 seconds Fluid deficit DO 3-7 days No Dehydration SEE How long? How many? Is the child passing urine? More than 14 days Blood in stool Greatly reduced urine output <5 % of body wt or 50 ml./ kg body wt 5-10% of body wt or 50-100 ml / kg body wt >10% of body wt or 100 ml / kg body wt PLAN A PLAN B PLAN C
    35. 35. Assessment of a child with Diarrhea
    36. 36. PLAN A Home therapy to prevent dehydration and malnutrition Children with no signs of dehydration need extra fluid and salt to replace their losses of water and electrolytes due to diarrhea. Fluids to be given ORS Salted drinks e.g. salted rice water, salted yoghurt drink ,green coconut water. Home based ORS. Plain water should also be given. Commercial fizzy drinks, fruit juices, sweetened tea, coffee, medicinal tea should be avoided. How much to give? Give as much fluid as the child wants until diarrhea stops. Children < 2 years of age : 50-100 ml of fluid. Children 2 years - 10 years : 100-200 ml. Older children and adults : As much as they want. Zinc supplement Give 10 / 20 mg (depending on age of the child) every day for 14 days. What feeds to give? Breastfeeding should always be continued. The infant's usual diet should be continued during diarrhea and increased afterwards. .Emphasize washing of Hands
    37. 37. PLAN B For children with some dehydration • • • • • • • Approximate amount of ORS required (in ml) can be calculated by multiplying the patient's weight in kg by 75. More can be given, if required. Breast feeding should be continued. No other foods are to be given during the initial period. After 4 hours, the child should be given some food every 3-4 hours. After 4 hours, reassess the child and decide what treatment to be given next as per level of dehydration. Referred for IV rehydration if dehydration persists. AGE <4 months 4-11 months 12-23 months 2-4 years 5-15 years WEIGH T <5 kg 5-7.9 kg 8-10.9 kg ML 200-400 ml 400-600 ml 600-800 ml 800-1200 ml 1200-2400 ml 2400-4000 ml CUPS (200 ml) 2 3 5 7 12 20 11-15.9 kg 16-29.9 kg >15 years 30 kg or more
    38. 38. Signs of Dehydration
    39. 39. PLAN C For children with severe dehydration • Refer the patient. • Preferred treatment is rapid intravenous rehydration.
    40. 40. Skin pinch test for dehydration
    41. 41. Why are drugs prescribed in Diarrhea? • Lack of Knowledge • Lack of confidence in ORS and Zinc • Families demand drugs and Injections • Consultation/ Dispensing fees
    42. 42. Irrational use of drugs • Increases the cost of therapy • Diverts attention from main therapy- ORS, feeding and Zinc • Side-effects - antibiotic induced diarrhea • Complications- Simple infection converted into a lifethreatening infection due to - Abdominal distension, - Paralytic ileus - Respiratory depression - Septicemia - Pseudomembranous entero-colitis • Drug resistance Antibiotics, Adsorbents and Anti-motility drugs are NOT indicated in the routine treatment of acute childhood diarrhea.
    43. 43. Danger Signs Refer immediately if• • • • • • • Does not improve within 3 days. Increase in the number of stools. Develops very watery or bloody stools. Severe vomiting. Marked reduction in urine output. Develops high grade fever. Decrease in alertness or consciousness.
    44. 44. Prevention of diarrhea • Exclusive breast feeding for 6 months • Complementary feeding at 6 months • Hand washing • Safe drinking water • Environmental sanitation and safe disposal of excreta • Measles vaccination
    45. 45. CONCLUSION • • • • • A substantial reduction in the diarrhea burden will require greater emphasis on the following actions: Reinstate diarrhea prevention and treatment as a cornerstone of community-based primary health care. Reach every child with effective interventions. Ensure wide availability of low-osmolarity ORS. Ensure wide availability and use of zinc. THERE IS NO BETTER TIME THAN NOW
    46. 46. THANK YOU