This document discusses the management of persistent diarrhea in severely acutely malnourished (SAM) children. It outlines 3 dietary approaches - Diet A which limits lactose, Diet B which further reduces starch, and Diet C which uses only glucose and protein. Diet C is for children who do not tolerate Diets A or B. The diets gradually advance based on tolerance. Supplementation with vitamins, minerals, and occasionally antibiotics is also recommended. The goal is to rehydrate, refeed, and correct nutritional deficiencies to support recovery from persistent diarrhea and malnutrition.

1. DEHYDRATION IN SAM CHILD
PERSISTANT DIARRHEA
By: Dr. Kuldeep Temani

2. MANAGEMENT OF DEHYDRATION IN
SAM CHILD

3. Assessment of dehydration in SAM
child
• Dehydration tend to be over diagnosed and its
severity often overestimated in SAM child.
• usual sign of dehydration like skin pinch,
sunken eye ball ,appearance of child is no use
in SAM child. because
• Loss of elasticity of skin, and sunken eye may
be either due to loss of subcutaneous fat in
sam child.
• Irritability, lethargic, unconscious child may be
due to hypoglycemia, infection and other
complication of SAM.

4. • Oral mucosa feel dry
• Presence of thirst, hypothermia, week pulse
and oliguria, absent tear
• Its safe to assume that all SAM child with
watery diarrhea have some dehydration
Sign dehydration in SAM child

5. MANAGEMENT OF SOME DEHYDRATION
IN SAM CHILD

6. •Recommended solution
by WHO is Resomal
•Recommended solution
by IAP IS RO-ORS with
potassium supplement.

7. Ingredients of Resomal
Ingredients Mmol/l
Glucose 125 mmol/l
Sodium 45 mmol/l
Potassium 40 mmol/l
Chloride 70 mmol/l
Magnesium 3 mmol/l
Zinc .3 mmol/l
Copper .045mmol/l
citrate 7 mmol/l
Total osmolarity 290.345 mmol/l

8. Ingredients of ors solution
(mmol/l)
Low osmolarity ors Who-ors(old)
sodium 75 90
potassium 20 20
chloride 60 80
citrate 10 10
glucose 75 111
Total
osmolarity
245 311

9. • Basis of solution
• SAM children are deficient in potassium
and have very high level of sodium, normal
ores solution is dangerous for them.
• They need solution which contain less
sodium and more potassium.
• These pt. are also deficient in in other
minerals like magnesium, copper, zinc, and
these minerals are added
ReSoMal

10. ReSoMal
• ReSoMal contains a mixture of salts and minerals to
correct deficiencies of potassium, magnesium, zinc
and copper and to address high levels of sodium in
children with SAM.
• It is supplied as powder in sachets. Previously, one
sachet needed to be reconstituted by adding 2 liters
of boiled water to the content of each sachet,
producing thereafter 2 liters of rehydration solution.
• The reconstituted solution has to be consumed
immediately or used within 24 hours if stored in a
refrigerator.
• a quantity of reconstituted ReSoMal was being
wasted.

11. • In order to resolve this problem, discussion was
initiated in 2010 between UNICEF Programmed
Division, Supply Division, Regional Offices,
nutritionists working in in-patient centers and
suppliers - and concluded that the sachet sizes
should be reduced.
• It was agreed that the optimal volume of the
solution should be 1 liter. Hence, it was decided
to reduce the sachet sizes by 50 per cent.
• New sachets must be reconstituted by adding
1 liter of boiled, cooled water, which will result
in 1 liter of liquid ReSoMal.
ReSoMal

13. Some dehydration
• Dehydration should be corrected slowly over
period of 12 hour.
• ReSoMal should be given orally or by nasogastric
tube at 5 ml/kg every 30 minutes for first 2 hours
• Then 5-10 ml/kg every hour for next 4-10 hour.
• Exact amount depend on how much child want,
volume of stool loss and whether child is
vomiting
• Ongoing stool losses should be replaced with
approximately 5-10 ml/kg ors after each watery
stool

14. • BF should be continued during the rehydration
phase.
• Refeeding must be started with starter f-75
formula within 2-3 hr. of starting rehydration.
• The feed must be given on alternate
hours(eg.hours 2, 4, 6) with ors (hr. 1, 3, 5).
• Once rehydration complete feeding must be
continued and ongoing losses replaced with
ors.
Some dehydration

15. • Monitor every ½ hourly for first 2 hour and
then every hours for next 4-10 hours.
• Monitor pulse rate, respiratory rate ,oral
mucosa, urine frequency or volume, and
frequency of stool and vomiting.
• Decrease in heart rate and respiratory rate( if
initially increased ) and increased in urine
output indicate rehydration is proceeding.
• Return of tear, a moist oral mucosa, less
shunken eye and fontanelle improved skin
turgor also indicate rehydration.
Some dehydration

16. Some dehydration
Sam child Non sam child
recommended fluid ReSoMal Ro-ors
Rout of
administration
Oral/NG Oral/NG
Time for correction 12 hours 4 hours
Amount of fluid Very less 5ml/kg
every 30 minute
75 ml/kg
For ongoing losses 5-10 ml/kg for each
watery stool
10-20 ml/kg for
each watery stool

18. Scenario A
Clinical assessment of dehydration
This 2 year old male child was brought to the
emergency room with diarrhoea for 6 days.
He had angular stomatitis, peri-anal
ulceration, weighed 7.0 kg and the MUAC was
10.2 cm.
His hands were cold, pulse weak and fast and
skin pinch went back very slowly.
The resident doctor gave 140ml of normal
saline by rapid IV infusion but his condition
deteriorated.

19. Questions
• Q1: What important condition needs to
be recognised in this child?
• Q2: Was the doctor’s management
correct?
• Q3: List 2 pathophysiological
mechanisms in this condition that affect
fluid management.

20. Answer 1
• The child has severe acute malnutrition:
SAM with shock

21. ANSWER 2
• The doctor’s choice of IV normal saline,
amount of fluid and rapidity of given IV fluid
were all incorrect and may have caused the
child’s deterioration.
• The IV fluid of choice (in order of
preference) according to availability are:
–Ringers lactate with 5% dextrose
–Half-nomal saline with 5% dextrose
–Half-strength Darows solution with 5%
dextrose
–Ringers lactate

22. • Amount of fluid
–Give IV fluid 15ml/kg over 1 hour
• Monitor pulse and breathing rate at the
start and every 5-10 minutes
• If there is improvement (pulse and
respiratory rate fall), repeat IV fluid
15ml/kg over 1 hour
• Then switch to oral or nasogastric
rehydration with Resomal 5-10 ml/kg/hr
ANSWER 2

23. ANSWER 3
• The pathophysiological mechanisms that affect fluid
management are:
1. Although plasma sodium may be very low, total body
sodium is often increased due to
– increased sodium inside cells
– additional sodium in extracellular fluid if there is
nutritional oedema
– reduced excretion of sodium by the kidneys
2. Cardiac function is impaired in SAM
This explains why treatment with IV fluids can result
in death from sodium overload and heart failure.

24. CONCLUSION
• The correct management is reduced
sodium oral rehydration fluid (ORF; e.g.
ReSoMal) given by mouth or naso-gastric
tube if necessary.
• The volume and rate of ORF are much
less for malnourished than well
nourished children (see next slide)
• IV fluids should be used only to treat
shock in children with SAM who are
lethargic or have lost consciousness!

25. How can we prevent diarrhoeal
disease?
This involves intervention at two levels:
• Primary prevention (to reduce disease transmission)
– Rotavirus and measles vaccines
– Handwashing 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
Next

27. Definition
•Diarrhea that starts as
an acute episode and
last at least 14 days is
sad to be persistant

28. Etiology
• Persistent infection
• PEM
• Malabsorption of carbohydrate and
fat due to combination of
malnutrition and enteric infection
• Infrequently, dietary protein
intolerance

29. Complication
•Malnutrition and
worsening of malnutrition
•dehydration

30. INVESTIGATION
• Following ix recommended in each pt of PD
1. Examination of stool
macroscopic, , consistency, presence of
mucus and blood
2. microscopic-pus cell, RBC, parasites, ova,
cyst, trophozoites of E.histolytica,
G.lamblia
3. Stool culture for salmonella shigella
4. Stool for reducing sugar carbohydrate
intolerance
5. Stool ph. carbohydrate intolerance

31. Management
• Indication of hospitalization
1. Presences of dehydration
2. Severe malnutrition
3. Suspicion systemic infection
4. Age less than 6 month and not
breastfeed

32. • Assessment and correction of
dehydration
• Dietary management
• Additional drug
• Antimicrobial therapy
Management #

33. Dietary management
• Diet A (reduced lactose diet)
• Diet B (lactose free diet with
reduced starch)
• Diet C (monosaccharide based
diet)

34. Diet A
• Basis of diet A
1. In PD due to persistent infection or reinfection of
same and different microorganism
2. And due to malnutrition there is damaged to small
bowel epithelium. Brush border of small bowel
epithelium contain disaccharides.
3. In the absence of these enzyme disaccharide are not
hydrolyzed in simple sugar and reach unchanged in
to the lower gut where these draw water from gut
wall throw osmosis.
4. Unabsorbed sugar fermented by gut bacteria
leading to production H2, methane, co2,these gas
cause abdominal distention and frothy character of
stool.

35. Diet A
1. Infant age less than 6 month
• Encourage exclusive breast feeding
• Reestablish lactation
• If only animal milk must be given,
replace it with curd and lactose free
milk formula(give with a cup and
spoon)
• If required, cooked rice can be mixed
with milk/curd/lactose free formula

36. Diet A #
• Limit daily intake of milk 50-60 ml/kg
• Lactose not more than 2 gm/kg day
• To reduced lactose concentration in
animal milk do not dilute it reduced
energy density critically.
• Milk can be mixed with cereals
• Start feeding as soon as the child can eat
• Offer 6-7 feed per day

37. • Total energy intake of 110 kcal/kg to
begin with increase energy intake
steadily up to
150 kcal/kg over next two week
Diet A #

38. Advantage of diet A
• Well tolerated
• Highly palatable
• Consumed in large quantity
• Provide adequate calories, good
quality proteins and micronutrient
• Results in faster weight gain

39. Diet A #
Ingredients measures Weight/volume
Milk 1/3katori 50 ml
Sugar 1 ½ tsp 7 gm
Oil 1 tsp 4.5 gm
Powder puff
rice*
2 tsp 6.0 gm
Water 2/3 katori 100 ml
Calories/100gm 85 kcal
Proteins/100gm 2.0gm

40. • Puffed rice can be substitute by
cooked rice and sooji
• Preparation
• Mix milk, sugar, rice together. add
boil water and mix well. add oil,
the feed can now be given to the
child
Diet A #

41. Diet B
Lactose free diet with reduced starch

42. Diet B
• Basis for diet B
• some children do not respond well to initial
low lactose diet. they have impaired
digestion of starch and other disaccharides
other than lactose.
• therefor not only milk is eliminated but
starch is reduced and partially substitute by
glucose.
• Substituting only part of the cereal with
glucose increase the digestibility but at the
same time does not cause very high
osmolarity

43. Diet B #
• Milk free diet (Lactose free)
• Carbohydrates provided as a
mixtures cereals and glucose
• Milk protein is replaced by chicken,
egg, and protein hydrolysate

44. Diet B #
ingredients measures Weight/volume
Egg white 10 tsp ½ egg white
gulcose 1 ½ tsp 7 gm
Oil 1 ½ tsp 7 gm
Powder puff
rice*
3 tsp 9.0 gm
Water ¾ katori 120 ml
Calories/100gm 90 kcal
Proteins/100gm 2.4 gm

45. Diet C
Monosaccharide
based diet

46. Diet c
• Basis for diet C
• Over all 80-85% pt. with severe persistent
diarrhea will recover with sustained wt. gain
on the initial diet A or the second diet B.
• Some pt. may not tolerate moderate intake of
cereal in diet B
• These children are given the third diet C.
• Diet C contain only glucose and a protein
source as egg white or chicken or protein
hydrolysates.
• Energy density is increased by adding oil to
the diet

47. Diet C #
ingredients measures Weight/volume
Egg white or
chicken puree
10 tsp ½ egg white or
15 gm
glucose 1 ½ tsp 7 gm
Oil 1 ½ tsp 7 gm
Water 1 katori 150 ml
Calories/100gm 67 kcal
Proteins/100gm 3 gm

48. preparation
• Boil chicken, remove bones and
make chicken puree.
• Mix chicken puree with glucose and
oil.
• Add boiled water to make a smooth
flowing feed

49. Supplemental vitamins and minerals
• About twice the RDA should be given to
all children for at least 2-4 week.
• Iron supplements should be given only
after diarrhea ceased.
• Provide Vitamin A(as a single large
dose) and zinc ,these have been show
effect recovery from persistent
diarrhea.
• is
• and minerals

50. Vitamin A
• >12 months 2,00,000 iu orally
• 6-12 months 1,00,000 iu orally
• Children less than 8 kg irrespective of
there age should be given 1,00,000
iu orally

51. zinc
• <6 months 10 mg/day
• > 6 months 20 mg/day

52. Other recommendation
• Magnesium sulphate 50% :
0.2ml/kg/dose twice a day for 2-3
days
• Potassium 5-6 meq/kg/day orally or
i.v. as a part of initial stabilization
period.

53. Indication for change from the initial diet A
to diet B or diet B to diet C
• In the absence of initial or hospital acquired
infection, the diet should be changed when
treatment failure, defined as
1. A marked increased in stool frequency usually
more than 10 watery stool/day any time after
initiating treatment.
2. Return of sign of dehydration any time after
initiating treatment.
3. Failure to established weight gain by day 7.
4. Unless sign of treatment failure occur earlier
each diet should be given for minimum period of
7 days

54. Resumption of regular diet after
discharge
• Children discharge on diet B should be given
small quantities of milk as apart of mixed diet
after 10 days.
• If they have no sign suggestive of lactose
intolerance (diarrhea, vomiting, abdominal
pain, abdominal distention, excessive
flatulence)
• milk can be gradually increased over next few
days
• A normal diet appropriate for age can be
resumed over next week.

55. Recommendation for antimicrobial
therapy
• High fever
• Presence of blood and mucus in stool
• Associated systemic infection
• Severe malnutrition
• Severe abdominal pain
• Recent use of antibiotics or hospitalized
patients
• Immunocompromised patients, including
(HIV)