Pediatric Infective Diarrhoea in Developing countries
DIARRHOEA IINN IINNFFAANNTTSS AANNDD
Dr. Taher Y. Kagalwala
Saifee Hospital, Masina Hospital, Habib Hospital
Saboo Siddik Mat. And Gen. Nsg. Home
October 15, 2014 Dr.Kagalwala/Diarr 1
WWhhaatt iiss ddiiaarrrrhhooeeaa??
• It is the passage of liquid or watery stools
• Usually, this is more than three times a day.
• More important than this is: when there is a
recent change in the consistency, frequency or
character of the stools.
• Frequent stools in an exclusively breastfed baby
is NOT diarrhoea.
• Teething can cause a few loose stools;
diarrhoea lasting more than 24 hours is NOT
due to teething.
October 15, 2014 Dr.Kagalwala/Diarr 3
CCoommmmoonn EEttiioollooggiiccaall CCaauusseess
1. Infectious causes:
• Viral – esp. rotavirus, respiratory and
• Bacterial – esp. E. coli (ETEC, EPEC)
• Others – fungal, protozoal, helminthic and
2. Non-infectious causes:
• Endocrine – hyperthyroidism
• Secondary to a remote cause – e.g.
October 15, 2014 Dr.Kagalwala/Diarr 4
CClliinniiccaall FFeeaattuurreess -- 11
1. Symptoms and signs of the primary
2. Symptoms and signs of dehydration.
3. Symptoms and signs of
complications and side-effects of
October 15, 2014 Dr.Kagalwala/Diarr 5
CClliinniiccaall FFeeaattuurreess -- 22
1. Primary Illness:
• Bacterial – dysentery and not diarrhoea –
marked by high fever, toxicity, tenesmus and
sometimes rectal prolapse while defecating;
stool will show mucus, visible or occult blood
and at times, frank blood.
• Viral – watery stools with absence of most of
the above findings, though there may be
mucusy stools. Slight to moderate fever and
presence of cough/cold, conjunctivitis and
recurrent vomiting are all compatible.
October 15, 2014 Dr.Kagalwala/Diarr 6
CClliinniiccaall FFeeaattuurreess –– 33aa
2. Dehydration (1 of 2):
5 – 7% wt loss
7 – 9 % wt loss
10% or more wt.
Normal to mildly
Pulses Normal but fast Faster, slight low
Moist but sticky Slightly dry Dry
Skin turgor Normal Recoil 1-3
Recoil > 3
October 15, 2014 Dr.Kagalwala/Diarr 7
CClliinniiccaall FFeeaattuurreess –– 33bb
2. Dehydration (2 of 2)
Mild Moderate Severe
Normal (< 3
Normal (< 3
Delayed 3 or >
Urine Output Normal Slightly less
(anuria < 4
(anuria > 4
Mental status Normal but
Irritable Irritable to
October 15, 2014 Dr.Kagalwala/Diarr 8
CClliinniiccaall FFeeaattuurreess -- 44
3. Symptoms and signs of complications:
• Hypovolemic shock
• Acute renal failure (pre-renal)
• Venous thrombosis
October 15, 2014 Dr.Kagalwala/Diarr 9
CCaassee SSttuuddyy -- 11
18 – month old female child from a middle-class
family presents with:
• Fever , mild – 4 days
• Red eyes, running nose and a mild to mod.
cough – 3 days
• Vomiting – 2 days ( frequent, whitish yellow)
• Loose motions – yellow, 13 – 15 since the last
24 hours, curdy smell, with mucus
• Not passed urine since the last four hours, with
h/o passing concentrated urine earlier too.
October 15, 2014 Dr.Kagalwala/Diarr 10
CCaassee SSttuuddyy –– 22aa
On examination (1 of 2):
• Average child, 9.5 kg, fever 99.2* F
• Crying continuously, eagerly drinks water if
offered by the mother
• P 120/min, RR 34/min, nonacidotic, BP not
• AF closed, eyes look okay but reduced tears
• Oral mucosa is moist
October 15, 2014 Dr.Kagalwala/Diarr 11
CCaassee SSttuuddyy –– 22bb
On examination (2 of 2):
• CRT 3 seconds
• Skin turgor – slightly prolonged (3
• Per abdomen – normal to increased
peristalsis. No other findings of note.
• Other systems – normal.
October 15, 2014 Dr.Kagalwala/Diarr 12
CCaassee SSttuuddyy –– 33
• What is the likely diagnosis?
• Is the girl dehydrated? How much? Why are
there inconsistencies (mucosae are moist, for
• What investigations are needed?
- Stool routine?
- Serum electrolytes?
- Any other?
• Will she need hospitalisation?
October 15, 2014 Dr.Kagalwala/Diarr 13
CCaassee SSttuuddyy -- 44
Management (1 of 4):
ORS: Sip by sip, at least 40-50 ml/kg as
deficit plus about ¼ to ½ of a 200-ml glass
for every medium to large stool passed
plus 3 - 5 ml/kg/vomit to replace losses in
October 15, 2014 Dr.Kagalwala/Diarr 14
CCaassee SSttuuddyy -- 55
Management (2 of 4):
• The child’s mother should be asked to continue
breastfeeding her (if she is doing so); continue
nourishing her with khichdi, rice-dal, soft bananas,
grated apples, vegetables etc. There is no need to ban
any food except food that is too spicy.
• She can be taught how to check the hydration status
from time to time (urine output, AF tension, eyeball
tension, skin turgor, etc. )
• ORS substitutes may be used only to give “variety” to the
child’s intake of liquids. (Buttermilk, rice water, dal soup,
October 15, 2014 Dr.Kagalwala/Diarr 15
CCaassee SSttuuddyy -- 66
Management (3 of 4):
What is the role of :
• Anti-diarrhoeals – norflox +metro, for example
• Anti-motility agents – atropine derivatives
• Anti-secretory agents - racecadotril
• Stool binding mixtures – pectin + kaolin
• Probiotics – lactobacilli, saccharomyces
• Antibiotics – cefixime, gentamicin
October 15, 2014 Dr.Kagalwala/Diarr 16
CCaassee SSttuuddyy -- 77
Management (4 of 4):
• When will you refer for hospitalisation?
• What home-based fluids are NOT useful?
(coffee, tea, arrowroot kanji)
• How often will you see the child?
• What supportive medications will be needed?
• Perianal excoriation and rashes will need topical
antifungal and protective creams.
October 15, 2014 Dr.Kagalwala/Diarr 17
SSoommee rreecceenntt iinnffoo oonn OORRSS
• Presence of salt and sugar together facilitate the
reabsorption of water from the gut-lumen along with the
salt and sugar.
• We have moved from a sweetish, high osmolar liquid to
a salty, high Na+ ORS to ORS’s having probiotics,
prebiotics, amino-acids, etc. to the most recent “LOW
OSMOLAR ORS” that is approved by the WHO for use
all over the world in all age groups for all types of
diarrhoeal illness including cholera.
• This new ORS has only 245 mOsm/L as compared to
the higher osmolarity of the previous WHO-approved
October 15, 2014 Dr.Kagalwala/Diarr 18
• Monsoon diarrhoeas may be bacterial in origin,
but winter diarrhoeas are almost always viral.
• Most children with watery diarrhoea do not need
• Most children with typical diarrhoea do not need
• ORS is the mainstay of therapy.
• IV therapy is only recommended for kids with
uncontrolled vomiting, very frequent diarrhoea,
grade II dehydration or more and those with
altered sensorium or any other complications.
October 15, 2014 Dr.Kagalwala/Diarr 19
JJuusstt oonnee mmoorree sslliiddee::
October 15, 2014 Dr.Kagalwala/Diarr 20
TThhiiss bbooookk iiss oonn ssaallee!!
• This comprehensive book
on parenting is written for
• It is priced at Rs. 395/=,
but is available to doctors
at a special price of Rs.
• It carries detailed
information for the care of
children from 0 – 18
• Thank you – Dr. Taher
October 15, 2014 Dr.Kagalwala/Diarr 21