gish abay

1. Diarrheal Diseases in Children
Dr .Tazebew T.(MD)

2. Brainstorming questions
1)How do you define diarrhea in children?
2)How to differentiate small bowel diarrhea from
large bowel diarrhea?
3)What are the commonest causes of diarrhea in
children ?(bacteria,viruses,protozoa…)
4)What are the management principle of diarrhea
in children?
5)Mention some of complications of diarrhea in
children?

3. Outline
o Definition and Classification
o Epidemiology
o Etiology
o Pathophysiology and manifestations
o Complications
o Management
o Prevention

4. Definition and classification
• Diarrhea
 Passage of > 3 loose stools/day or watery stool of any frequency or
>10ml/kg/day in infants ,in older children >200gm/day
o Classification:
Acute watery - acute onset, no mucus or blood and lasts less than 14days
Persistent - starts acutely , watery and lasts > 14days
Severe persistent –persistent diarrhea with any form of dehydration

5. Cont…
Dysentery – blood in the stool ( historical, witnessed,
microscopy)
• It is often associated with fever ,frequent small stool
,urgency, abdominal pain and tenesmus.
• Common clinical features of dysentery include
anorexia, rapid weight loss
• Complications like renal failure and encephalopathy

6. Epidemiology
• One of the leading causes of morbidity & mortality in
children
• Causes about 2 million deaths annually in children of
under five ˷80% of these deaths occur in children in the
first 2 years
• Common in children of age below 5yrs
• Peak incidence is during the age of 6-11months?
o Age of complementary feeding
o Related with developmental age
o Declining levels of antibodies acquired from the mother
• Major route of transmission is feco-oral or ingestion of
contaminated food or water

7. Risk factors
A. Host factors
 Inappropriate breast feeding practice
– no EBF for the 1st 6months
– early interruption , bottle feeding
 Unsanitary food preparations
 Lack of immunization
 Young age
 Measles infection
 Malnutrition
 Immunocompromization
 Vit A and Zinc deficiency

8. Risk factors cont…
B. Environmental factors
• Seasonality
• Inadequate food intake due to different reasons
• Poverty and poor living conditions
• Poor domestic and environmental sanitation
especially unsafe water

9. Etiology
I. Non-Infectious
 Anatomic defects - short bowel syndrome, villus atrophy
 Malabsorption- disaccharidase deficiency, Celiac disease
 Food allergy/intolerance
II. Infectious
1. Inflammatory
 Usually caused by bacteria that invade intestine directly or
produce cytotoxins
2. Non-inflammatory
 through enterotoxin production by some bacteria, villus
destruction by viruses or adherence by parasites

10. Infectious etiology
A. Bacteria
Shigella
Salmonella
Vibrio cholerae
E.coli
Campylobacter jejuni
Clostridium difficile
B. Viruses
 Rota virus
 Astro agent
 Calici virus
 Enteric Adeno virus
 CMV(in
immunocompromized)

11. Etiology cont…
C. Parasites
Gardia lamblia
Entamoba histiolytica
Strongyloidiasis
Isospora belli
Cryptosporidium prvum
D. Fungi
 Candida albicans

12. Etiologies of dysentery
• Shigela spp.
• Invasive Eschericha coli
• Campylobacteriosis (Campylobacter jejuni)
• Amebic dysentery (Entamoeba histolytica)
• Bilharzial dysentery (Schistosoma japonicum,
Schistosoma mansoni)
• Salmonellosis (Salmonella typhimurium)
• Typhoid fever (Salmonella typhi)
• Enteric fever (Salmonella choleraesuis, Salmonella
paratyphi)

13. Pathophysiology
• The basis of all forms of Diahhrea is disturbed
intestinal solute transport
• Movement of water across intestinal membranes is
passive and determined by both active & passive
fluxes of solutes particularly Na, Cl, and Glucose

14. Mechanisms of diarrheal diseases
I. Secretary
 Through increase in cAMP, CGMP or Calcium
 Decreased absorption and increased secretion
 Doesn't stop with fasting
E.g. cholera, toxigenic E.coli, VIP
II. Osmotic
 maldigestion, ingestion of unabsorbable solutes
 It stops with fasting
e.g. Lactase deficiency, glucose malabsorption, lactulose

15. Cont…
III. Decreased absorptive surface
e.g. Rota virus, short bowel syndrome,Celiac disease
IV. Motility disorders
e.g. increased motility with decreased transit time (
thyrotoxicosis, irritable bowel syndrome---) or stasis
with proliferation of pathogens

16. Clinical manifestations
GI– nausea, vomiting, diarrhea, abdominal cramp
Systemic– loss of appetite, myalgia, UTI, endocarditis,
meningitis
Symptoms and signs of dehydration
Immune-mediated—extra intestinal manifestations
e.g.
 Reactive arthritis - Salmonella, Shigella, C.jejuni
 Guillain Barre Syndrome - C.jejuni
 HUS - E.coli, Shigella

17. Complications
• Dehydration & Shock
• Acute renal failure
• Malnutrition
• Sepsis, DIC
• Metabolic acidosis
• Paralytic ileus
• Convulsions and coma (electrolyte disturbance, cerebral
thrombosis)
• Persistent diarrhea

18. Dysentery
• Diarrhoea presenting with loose frequent stools
containing blood.
• Most are due to Shigella and nearly all require
antibiotic treatment.
• Diagnosis
 It mainly through its clinical picture.
• Other findings on examination may include:
■ abdominal pain
■ fever
■ convulsions
■ lethargy
■ dehydration
■ rectal prolapse.

19. Complications of dysentery
• Electrolyte imbalances
• Convulsions
• Hemolytic uremic syndrome (HUS)
• Leukemoid reaction
• Toxic megacolon
• Protein losing enteropathy
• Arthritis
• Perforation

20. A) Isotonic dehydration
 This is the most type of dehydration
Losses of water and Na are in the same
proportion
There is a balanced deficit of water and Na
• Serum Na concentration is normal (130-150 m
mol / l )
• Serum osmolality is normal (275-295)
• Hypovolemia occurs as a result of loss of extra
cellular fluid

21. B) Hypernatremic dehydration
 There is loss of water excess of Na
It is usually results from ;
ingestion of hypertonic fluid that not efficiently
absorbed
 Insufficient intake of water or low –solute drink
• Serum Na concentration is elevated (>150
mmol/l)
• Serum osmolality is elevated (>295m osmol/l )
• Thirst is severe and the child is very irritable
• Sezures may occur (Na >165 mmol /l)

22. C) Hyponatremic dehydration
 There is loss of Na excess of water
• It is usually from drinking large amounts of
water or hypotonic fluid with low Na or
• IV infusion 5%glucose without Na
• There is deficit of water and Na but the deficit of
Na is greater
• Serum Na concentration is low (<130 mmol /l)
• Serum osmolality is low (<275 mosmol /l)
• The child is lethargic , infrequently seizures

23. Hypokalemia
 Patients with diarrhea often develop K
depletion
• The signs of hypokalemia may include ;
– General muscular weakness
– Cardiac arrhythmias
– Paralytic ileus

24. Evaluation
 Hx
 type of diarrhea
Vomiting (character)
Fever
Associated illness e.g.
cough, rash, UTI
Urine out put
Abd.pain/distension
Hx of seizure
Previous Hx of similar
ilnes
Feeding Hx
Developmental Hx
Immunization
Social & family Hx
Antibiotics exposure
Any similar illnes in the
vicinty

25. Physical exam
• General examination and V/S
• Look for signs of:
A. water loss
Loss of skin turgor
Weak/absent pulse
Tachycardia
Sunken eyes
Sunken fontanel
Delayed capillary refilling
Cold skin
Anuria, oliguria
mental changes

26. Cont…
B. Loss of nutrients
Hypoglycemia
Convulsions, mental changes
C. Loss of bicarbonate
Vomiting & retching
Deep respiration
Decreased myocardial contractility
D. Potassium loss
Abdominal distension
Paralytic ileus

27. Cont…
• Stool microscopy/culture
– Dysentry, Epidemic (?cholera)
– Persistent diarrhea
– Suspected septicemia
– Immunosupressed child
Assess for Dehydration:
 The 4 important signs in well -nourished child are:
1. Mental status 2. Eye ball
3. Drinking 4. Skin turgor

28. Classification of dehydration: Two signs needed
Parameter No dehydration Some
dehydration
Severe
dehydration
Mental
status
Alert Restless,
irritable
Lethargic or
unconscious
Eye ball No sunken eyes sunken eyes sunken eyes
Drinking Drinking
normally
Eager to drink Unable to drink
Skin
turgor
Normal skin
turgor
Skin pinch
returns slowly
Skin pinch returns
very slowly

29. Skin pinch/skin turgor
Pinching the child’s abdomen to
test for decreased skin turgor

30. Work up
• The following investigations directed to diarrhea can be
done in hospitals
 Stool examination (microscopy)
 Stool Culture &Sensitivity test
 Serum electrolytes
 Random blood sugar
 CBC (Hct, WBC with differential, platelet count)
 Peripheral RBC morphology
 RVI screening
 BUN, creatinine

31. Management of dehydration
1. No DHN– Mx plan A
 Treat diarrhea at home:
 Rules of 3 ‘Fs’, 4 Rules
1. Give extra FLUID
2. Continue FEEDING
3. When to come for FOLLOW UP
4. Supplemental Zinc

32. Cont…
• Fluid – in addition to the usual fluid intake
give ORS: 10ml/kg
OR
50-100ml for those below 2yrs per bowel
100-200ml for children > 2yrs motion
 Other fluids; breast milk, food-based fluids(soup, rice
water , yogurt) or clean water
• Unsuitable fluids: commercial carbonated
beverages, commercial fruit juices ,sweetened
tea, coffee and some medicinal teas or infusions.

33. Cont…
• Feeding- frequent breast feeding
-cow’s milk or formula
- continue other foods if he started
• Return/follow up-see him in 2days
 come back immediately if the child becomes
sick(unable to drink, repeated vomiting, sicker
,fever, dysentery)

34. Cont…
B. Some DHN– plan B, loss is estimated to be
5%-10% of body weight
Treat with ORS:
Volume is 75ml/kg
Give over 4hrs
Continue breast feeding
If vomiting, wait for 10minutes
After 4hrs, reassess and classify DHN

35. ORS inappropriate for
• Paralytic ileus
• Frequent emesis
• Abdominal distension
• Patients who are in shock
• Initial treatment of Severe dehydration
because fluid must be replaced very rapidly
• Patients who are unable to drink

36. Cont…
C. Severe DHN-
• Treatment plan C-loss estimated to be ≥10% of
body weight
• Start IV immediately
• Ringer’s lactate or NS
• Volume is 100ml/kg

37. Mx of severe dehydration
Infants (below
12months of age)
1st give
30ml/kg over 1hour
(repeat if no response *)
Then give
70ml/kg over 5hrs
Children>12mont
hs of age
Over 30minutes
(repeat if no response *)
Over two and half
hours

38. Case presentation
• The following example describes how to treat a
child with SEVERE DEHYDRATION according to
Plan C.
• A six-month old (9 kg) girl, Eleni, had diarrhoea
with SEVERE DEHYDRATION.
• She was not in shock and did not have severe
malnutrition.
• She was not able to drink. The health worker
decided to treat the infant with IV fluid according
to Plan C

39. • The health worker gave Eleni 270 ml (30 ml x 9
kg) of Ringer’s lactate by IV during the first hour.
• Over the following five hours, he gave her 630 ml
of IV fluid (70 ml x 9 kg), approximately 125 ml
per hour.
• The health worker assessed the infant’s hydration
status every 1-2 hours (that is, he assessed for
dehydration).
• Her hydration status was improving, so the
health worker continued giving Eleni the fluid at a
steady rate

40. • After 4 hours of IV treatment, Eleni was able
to drink.
• The health worker continued giving her IV
fluid and began giving her approximately 45
ml of ORS solution to drink per hour.

41. • After Eleni had been on IV fluid for 6 hours,
the health worker reassessed her dehydration.
She had improved and was reclassified as
SOME DEHYDRATION.
• The health worker chose Plan B to continue
treatment. The health worker stopped the IV
fluid.
• He began giving Eleni ORS solution as
indicated in Plan B.

42. DHN management follow up sheet
d
a
t
e
Time B
p
P
R
RR T0 CNS WT UOP Skin
pinch
Capillary
refill
- - - _ _ _
Wt and mental status are the most
important sign of improvement in
the absence of fluid overload
where as improvement from
sunken eyeball takes time .

43. ORS
The formula for ORS recommended by WHO/ UNICEF contains
Reduced
osmolarity ORS
Grams /
litre
Reduced
Osmolarity ORS
mmols/litre
Sodium chloride 2.6 Sodium 75
Glucose,
anhydrous
13.5 Chloride 65
Potassium
chloride
1.5 Glucose,
anhydrous
75
Trisodium citrate,
dihydrate
1.9 Potassium 20
Citrate 10
Total osmolarity 245

44. Zinc supplementation
• Zinc deficiency is common in developing countries
and zinc is lost during diarrhoea and associated
with:
– impaired electrolyte and water absorption
– decreased brush border enzyme activity
– impaired cellular and humoral immunity
• Zinc supplementation
– reduce duration and severity of diarrhea
– increased use of ORS and reduction in the
inappropriate use of antimicrobials
– Reduce recurrence with in 2-3 months
– It helps for epithilization
– 10 mg/day for infants <6 mo of age and 20 mg/day for
those >6 mo for 10 days

45. Vitamin A
Usually given for patients with diarrhea who
had
a)measles infection
b) malnutrition
Vitamin A(dosing)
 50,000 IU for children less than 6 months
 100,000 IU for 6 – 12 months and
 200,000 IU for those older than 12 months

46. • Anti diarrhoeal drugs and anti-emetics should
not be given to young children with acute or
persistent diarrhoea or dysentery
• They do not prevent dehydration or improve
nutritional status
• Some have dangerous, sometimes fatal, side-
effects.

47. • ondansetron is an effective and less-toxic
antiemetic agent .
• Because persistent vomiting can limit oral
rehydration therapy, a single sublingual dose
ondansetron (4 mg 4-11 yr and
• 8mg for children older than 11 yr [generally 0.2
mg/kg]) may be given.
• However, most children do not require specific
antiemetic therapy;
• careful oral rehydration therapy is usually
sufficient

48. Antibiotics should not be used for children with
acute bloody diarrhea unless a specific pathogen
has been isolated.
 Antibiotic therapy may be a risk factor for the
development of hemolytic uremic syndrome in
patients with bloody diarrhea due to E. Coli
O157:H7, which may be indistinguishable from
bloody diarrhea seen with other non E Coli
bacterial etiologies

49. Antibiotics?
• Dysentery
• Suspected cholera
• Suspected or proven sepsis
• Associated non-gastrointestinal infections like
pneumonia, meningitis, UTI
• Associated malnutrition

50. Antimicrobial agents
Type of diarrhea Antimicrobial agents
Shigellosis Cotrimoxazole
Ciprofloxacin
Ceftriaxone
Cholera Tetracycline or Doxycycline
(adults and older children)
Erythromycine
Ciprofloxaciline
Amebiasis Metronidazole /tinidazole

51. Prevention
This involves intervention at two levels:
• Primary prevention (to reduce disease transmission)
– Rotavirus and measles vaccines
– Hand washing with soap
– Providing adequate and safe drinking water
– Environmental sanitation
• Secondary prevention (to reduce disease severity)
– Promote breastfeeding
– Vitamin A supplementation
– Treatment of episodes of AD with zinc
 summarized by the “ 5F” diagram (as it involve: Feces,
Food/Fluid , Flies, fomites (utensils) and Finger)

52. Take home message
• Diarrhea is one of leading cause of under 5
mortality
• Classification of DHN as NO, SOME and
SEVERE is important for management
• Antibiotics ,antiemetics and antimotilty agents
shouldn't not be given routinely.

53. Home assignment
1)A one-year old girl has a two-day history of
diarrhea and vomiting. Her weight is 6.5 kg.
She is restless and irritable. Her airway and
breathing are OK. AVPU=voice. Skin pinch lasts
4 seconds. Her eyes are sunken and the
mother confirms this fact. How do you
manage her?

54. AMESEGNALEHU!!!