Overview, Assessment and Management of Diarrhoea in children

1. CHILDHOOD DIARRHOEA
By Samuel Omobude

2. OUTLINE
Introduction
Classification
Epidemiology
Aetiology
Pathophysiology
Assessing the Diarrhoea Patient
Complications
Management
Prevention and Control
Conclusion

3. Diarrhoea is a leading
cause of childhood
morbidity and mortality
especially in developing
countries.
Normal stool pattern of
children has a wide range.
However, passage of 3 or more
loose stools per day is
generally considered abnormal
after 1year of age (infancy).
Diarrhoea is defined as a
change in the consistency
of the stool to being
abnormally loose or
watery and increase in the
frequency of stools more
than is normal for a child.
INTRODUCTION

4. According to Cause
Infective
Non-Infective
According to Duration
Acute Diarrhoea
Persistent Diarrhoea
Intractable/Protracted Diarrhoea
Chronic Diarrhoea
According to Mechanism of Diarrhoea
Osmotic Diarrhoea
Secretory Diarrhoea
CLASSIFICATION
OF DIARRHOEA

5. Classification of Childhood Diarrhoea…
According to Causes
Viral: Commonly Rotavirus
Bacterial: e.g. Enterotoxogenic
Escherichia coli (ETEC), Shigella,
Campylobacter jejuni etc.
Protozoa: e.g. Cryptosporidium
Infective Causes
Intake of osmotic active
substances
Antibiotic side effects
Inherited metabolic
disorders
Gluten sensitivity
Non-Infective Causes

6. Classification of Childhood Diarrhoea…
• Begins acutely
• Lasting less than 14 days
• Include Acute Watery Diarrhoea (no blood
in stool) and Acute Bloody Diarrhoea i.e.
Dysentery (Stool contains blood)
Acute Watery Diarrhoea
• Describes episodes of diarrhea which are
chronic (lasting more than 4 weeks) for
which no known cause can be found and
which do not respond to specific and non-
specific forms of treatment.
Intractable (Protracted) Diarrhoea
• Long lasting (usually recurring) diarrhoea
• Usually of non-infective causes such Inherited
metabolic disorder and Gluten sensitivity
Chronic Diarrhoea
• Begins acutely
• Lasts up to 14 days
• About one-fifth of acute watery diarrhea in
children progresses to becoming persistent
diarrhea.
Persistent Diarrhoea
Classification according to Duration

7. Epidemiology
An estimated 1.3 billion episodes and 4 million
deaths occur each year in under-fives due to
diarrhoea.
Where episodes are frequent, young children may
spend more than 15% of their days with diarrhea.
Worldwide, these children experience more than 3
episodes each year, and in some areas the average
exceeds nine episodes yearly.
In our facility, within the last 6 months, we have had a total of 118 admissions out of a
total 360 admissions recorded due to diarrhoea and dysentery.
Diarrhoeal disease also represents an
economic burden for the developing
countries.
In many of these countries, more than
a third of the hospital beds for children
are occupied by patients with
diarrhoea.
Diarrhoea is a leading cause
of illness and death among
children in developing
countries.

8. Epidemiology…
Route of Transmission: Faeco-oral
Failure at exclusive breastfeeding
Using infant feeding bottles
Storing cooked food at room
temperature
Unhygienic source of drinking
water
Poor handwashing practice
Behavioural Risk Factors
Undernutrition
Current or recent
measles infection
Immunosuppression
Host Factors
Risk Factors
Age
Seasonality
Asymptomatic infection
Epidemics
Other Risk Factors

9. Pathophysiology of Diarrhoea
Normally, absorption and secretion of water and
electrolytes occur throughout the intestine.
The major site of absorption being the small intestine
(80%), while the large intestine also play a significant 10%
absorption of daily fluid entry into the gut.
Absorption of water and electrolytes into the
extracellular fluid compartment occur at the villi of
the small intestine, while secretion of water from
the ECF into the gut occurs at the crypts.

10. CHILDHOOD DIARRHOEA 10

11. Pathophysiology of Diarrhoea…
Absorption of water from the small intestine is caused by
osmotic gradients that are created when solutes (particularly
sodium) are actively absorbed from the bowel lumen by the
villous epithelial cells.
There are several mechanisms whereby sodium is absorbed in
the small intestine

12. • To enter the epithelial cells;
• sodium is linked to the absorption of chloride,
or
• absorbed directly as sodium ion, or
• exchanged for hydrogen ion, or
• linked to the absorption of organic materials
such as glucose or certain amino acids.
• After being absorbed, sodium is transported out of
the epithelial cells by an ion pump referred to as
Na+K+ ATPase.
• This transfers sodium into the extracellular fluid
(ECF), which elevates its osmolality and causes
water and other electrolytes to flow passively from
the bowel lumen through intercellular channels and
into the ECF.
• This process maintains an osmotic balance between
fluid in the bowel and ECF in the intestinal tissue.

13. Pathophysiology of Diarrhoea…
Secretion occurs by Chloride channels in the crypts cells which
become more permeable to chloride ions.
Secretory stimuli increase the ability of chloride to pass through
the luminal membrane of the crypt cells, allowing that ion to
enter the bowel lumen.
This movement of chloride ion creates an osmotic gradient that
causes water and other electrolytes to flow passively from the
ECF into the bowel lumen through the intercellular channels.

14. Pathophysiology of Diarrhoea…
Across the lumen of normal small intestine, absorption
predominates secretion so the net effect is absorption.
Diarrhoea results from a distortion of this physiologic balance
between absorption and secretion in favour of secretion.

15. Pathogenic Mechanism in Diarrhoea
Viruses
Viruses, such as rotavirus, replicate within
the villous epithelium of the small bowel,
causing patchy epithelial cell destruction and
villous shortening.

16. Pathogenic Mechanism in Diarrhoea…
Bacteria
Mucosa Adherence
Bacteria that multiply within the small intestine must first
adhere to the mucosa to avoid being swept away.
Mucosal adherence causes changes in the gut epithelium that
may reduce its absorptive capacity or cause fluid secretion.
Mucosa Invasion
Some bacteria cause bloody diarrhoea by invading and destroying mucosal epithelial
cells. This occurs mostly in the colon and the distal part of the ileum. Invasion is
followed by the formation of microabscesses and superficial ulcers, and hence the
presence of red and white blood cells, or frank blood, in the stool.
Toxin-mediated
Some bacteria cause intestinal secretion by producing toxins that alter
epithelial cell function; these toxins reduce the absorption of sodium
by the villi and may increase the secretion of chloride in the crypts,
resulting in net secretion of water and electrolytes

17. Pathogenic Mechanism in Diarrhoea…
Protoz
oa
02
Mucosal adhesion
G. lamblia and Cryptosporidium adhere to the small
bowel epithelium and cause shortening of the villi,
which may be how they cause diarrhoea.
Mucosa Invasion
E. histolytica causes diarrhoea by invading epithelial cells in the
colon (or ileum) and causing microabscesses and ulcers.

18. Assessing a child with Diarrhoea
• History:
• The clinical assessment consists of taking a brief history and examining the child. Its
objectives are to:
• detect dehydration, if present, and determine the degree of severity;
• diagnose dysentery, if present;
• diagnose persistent diarrhoea, if present;
• evaluate feeding practices and determine the child's nutritional status, especially to detect severe
undernutrition;
• diagnose any concurrent illness; and
• determine the child's immunization history, especially as regards immunization for measles.
• In critical cases e.g. in shock, RESUSCITATION precedes HISTORY
CHILDHOOD DIARRHOEA 18

19. Assessing a child with Diarrhoea
• History:
• Duration of illness
• Onset
• Stool frequency and consistency
volume: - large = small bowel
- small = large bowel
add constituents - blood, mucus
• Associated vomiting - frequency, volume, duration
• Associated oliguria or anuria
CHILDHOOD DIARRHOEA 19

20. Assessing a child with Diarrhoea
• History:
• Associated features e.g. Fever, convulsion, coma
• Other family members with diarrhoea
• Socio-economic class
• Past medical history
• Immunization status
• Nutritional history
CHILDHOOD DIARRHOEA 20

21. Assessing a child with Diarrhoea…
General Examination
Abdominal
Examination
Respiratory System
Cardiovascular
System
Weakness May be Distended Tachypnoea Thready pulse
Febrile May be tender Acidotic Breath Tachycardia / Bradycardia
Dehydrated Hyperactive bowel sounds Hypotension
Systemic Examination

22. Assessing a Child with Diarrhoea
Assessing a child with Dehydration
Oliguria or Anuria
Dry buccal mucosa
Eager to drink or too weak to
drink
Cold, Clammy
extremities in SHOCK
Reduced Skin tugor
Depressed Anterior Fontanelle
Sucken Eye ball
Crying with little or no tears
Delayed capillary refill

23. Assessing a Child with Diarrhoea
Features of Shock
25%
25 –
40 %
>
40%
Phase 1
Mild agitation
Tachycardia
Tachypnoea
Cool, clammy
/sweaty extremities
Normal or Increased
systolic BP
If not
managed
Marked tachycardia
Acidotic breathing
Thready pulse
cold mottled skin
oliguria or anuria
Very restless or
lethargic.
Phase 2
Phase 3
Tachycardia or
Bradycardia,
Hypotension
Very feeble pulse
Cyanosis,
Coma/Unresponsive
Features of multiple
organ dysfunction
(bleeding, pulmonary
and cerebral oedema)

24. Acute
Consequences of
Diarrhoea
Dehydration
(Isotonic/Hypertonic/Hypotonic)
01
Metabolic Acidosis
02
Hypokalaemia
03

25. MANAGEMENT
Look, Feel, Decide and Treat
1. Look at: No dehydration A Moderate dehydration
B
Severe dehydration C
General
appearance
Well and alert *Restless and irritable *Lethargic or unconscious;
Floppy
Eyes Normal Sunken Very sunken and dry
Tears Present Absent Absent
Mouth and
Tongue
Moist Dry Very dry
Thirst Drinks normally, not
thirsty
*Thirsty, drinks eagerly *Drinks poorly or unable to
drink
2. Skin Pinch Returns quickly *Returns slowly Goes back very slowly
3. Decide No detectable signs of
dehydration
1 or more signs plus at
least one *sign=Some
dehydration
2 or more signs plus at least one
*sign=Severe dehydration
4. Treat Use treatment plan A Weigh patient and use
treatment plan B
Weigh patient and use treatment
plan C urgently!
CHILDHOOD DIARRHOEA 25

26. Investigations
01
02
03
04
Electrolyte/Urea/Creatinine
Stool MCS (in dysentery)
Watery stool – secretory diarrhoea.
blood ± mucus – dysentery.
Pale bulky malodorous – malabsorption.
Direct Inspection of Stool
MP, Full Blood Count
Ancillary

27. Management
Summarily
Rehydration (Correct
Dehydration)
Assess Electrolyte Derangements
Give Zinc and Probiotic
Adequate Nutrition
Give Antibiotic, if indicated

28. Management…
Correcting Dehydration
Main aim of treatment is rehydration and to prevent worsening
dehydration
ORS: 1 satchet in 1L of water
For home-based treatment, Sugar-salt solution can be made
Salted drinks like Yoghurt; Vegetable or chicken soup with salt
is also safe.
Avoid carbonated drinks, free juice and sweetened tea.
For Mild Dehydration

29. COMPOSITION OF ORS Preparing SSS
• 5 cubes of sugar or 10 level (3ml
teaspoon) teaspoon of granulated
sugar – 40gm
• One level teaspoon (3ml
teaspoon) of salt – 3.5gm of NaCl.
• One beer bottle of water or 2
(35cl) Coca cola bottle.- 650ml of
water.
CHILDHOOD DIARRHOEA 29

30. Management…
Correcting Dehydration
• Children with abdominal distension from paralytic
ileus.
• Glucose malabsorption
• Indicated by a marked increase in stool output
when ORS solution is given, failure of the signs
of dehydration to improve and a large amount
of glucose in the stool when ORS solution is
given.
When NOT to give ORS

31. Management…
Give 50 – 100 ml per loose
stool if child < 2yrs
Give 100 – 200 ml per loose
stool if child > 2yrs
Give the child more fluid
than usual to prevent
dehydration
Continue to feed the
child with usual diet
during diarrhoea and
increase afterwards
The child is fed with
small quantities of
food at an increased
frequency: 3-4hrly.
Give the child plenty food
to prevent malnutrition
3 Rules of Home Treatment
Passing more stools
Repeated vomiting
Becomes more thirsty
Eats or drinks water poorly
Develops fever
Passes blood in the stools
Doesn’t get better after 3days
Mother should bring the child
to hospital if there are signs
of dehydration or other
problems develops

32. Management…
Correcting Dehydration
IV Infusion @ 60-90mL/kg deficit + 100% Maintenance
First half given over 6-8hrs, then second half over 16-18hrs
Fluids of choice include:
5% Dextrose in Ringers Lactate
Ringers Lactate
Half strength Darrow solution (baseline E/U/Cr should be done)
However, if IV line cannot be secured;
Give 75mls/kg of ORS over 4hours, if patient cannot drink, NG tube can be passed.
For Moderate Dehydration

33. Management…
Correcting Dehydration
IV Infusion @ 100-150mL/kg deficit + 100% Maintenance
First half given over 6-8hrs, then second half over 16-18hrs
Fluids of choice include:
0.9% Normal Saline
Ringers Lactate
However, if IV line cannot be secured;
Give 75mls/kg of ORS over 4hours or 20mL/kg/hour over 6hours, if patient cannot dr
ink, NG tube can be passed.
For Severe Dehydration

34. Management…
Correcting Dehydration
IV Infusion @ 100-150mL/kg deficit + 100% Maintenance is calculated
The anti-shock is given at 20mL/kg over 30mins to 1hour
Reassess to know if patient is still in shock
If not Anti-shock may be given up to 3 times;
When out of shock;
Treat as severe dehydration.
Fluid of choice: 0.9% Normal Saline or Ringers Lactate
Treating Shock

35. Management…
Giving Zinc and Probiotics
Zinc
Given 10mg daily in children less than 6 months
OR 20mg daily in children above 6 months
Probiotics
Bioflor: contains Saccharomyces boulardii
Given as 100mg twice daily for 3 days
Aim: Reduce diarrhoea severity and duration

36. Management…
Ensure Adequate Nutrition
• Parent should be counselled to continue feeding in the period with diarrhoea
• Extra meal should be given in the recovery period for catch-up growth
Use of Antibiotics
Not an important form of therapy, since most diarrheas are self limiting
Only indicated when:
Organism responsible is identified e.g Cholera
If the diarrhea is persistent.
In Malnutrition
Dysentry
Parenteral diarrhea
Aim: To Prevent Malnutrition in the diarrhoea period

37. Prevention and Control
Most Cases of Diarrhoea are Preventable
Promoting breastfeeding
Improve complementary feeding practi
ces
Proper storage of cooked and uncook
ed food.
Feeding
Ensure good hand washing practices.
Proper disposal of faeces.
Ensure availability of safe portable wat
er
Personal Hygiene
Prevent overcrowding
Good environmental hygiene
Environmental Hyiene
Essentially,
Rota virus and Measles vaccine
Immunization

38. Conclusion
Diarrhoea is a common cause of
morbidity and mortality in children
especially in developing countries
Life-threatening complications are
most often preventable
Early commencement of treatment at
home using ORS is effective
Feeding during and after
diarrhoea episodes is
advocated
Antimicrobial agents are
used only when indicated
Complicated cases should be
referred to the hospital.