8. 8
Diarrhea Key FactsDiarrhea Key Facts
Globally: 1.7 billion cases/y.Globally: 1.7 billion cases/y. 2 attacks/child/y2 attacks/child/y
2nd2nd largest U-5 killerlargest U-5 killer (0.76mn/y:2013)(0.76mn/y:2013);; waswas No.1No.1 (5mn)(5mn)
Most deaths from dehydrationMost deaths from dehydration
It is preventable and treatable.It is preventable and treatable. Safe water and sanitationSafe water and sanitation
can largely prevent itcan largely prevent it
BangladeshBangladesh:: 250k deaths/y250k deaths/y
A leading c/of malnutrition in U-5A leading c/of malnutrition in U-5
Mortality rate is falling fast (Mortality rate is falling fast (ORT)ORT)
9. 9
Diarrhea Death is FallingDiarrhea Death is Falling
Successful ORTSuccessful ORT
Breastfeeding, no bottle, no formulaBreastfeeding, no bottle, no formula
Safe water and food, health educationSafe water and food, health education
Hand washing, improved sanitationHand washing, improved sanitation
ImmunizationImmunization
HPVAC, ZnHPVAC, Zn
Fall in MnFall in Mn
AwarenessAwareness
HPVAC: high potency Vitamin A capsule. Zn: zincHPVAC: high potency Vitamin A capsule. Zn: zinc
10. 10
30 Years of ORS30 Years of ORS
Absorption of salt plus water is enhanced withAbsorption of salt plus water is enhanced with glucose,glucose,
amino a.amino a. ⇒⇒ discovery of ORS and later rice ORSdiscovery of ORS and later rice ORS
WHO:WHO:
““ORT is the most rewarding scientific achievementORT is the most rewarding scientific achievement
of 20th century”of 20th century”
11. 11
Definition of DiarrheaDefinition of Diarrhea
Passage of ≥3 loose stools/24h. Loose stool: one that
takes up the shape of the container
Exception!!Exception!!
EBFEBF babiesbabies passpass manymany loose/unformed motions/dloose/unformed motions/d
They doThey do notnot develop dehydration and thrive well!develop dehydration and thrive well!
We call theseWe call these BM stoolsBM stools!!
With itsWith its other unique qualities BMother unique qualities BM
also has ORS like actionalso has ORS like action
13. 13
Diarrhea Harms ..Diarrhea Harms ..
DehydrationDehydration
DyselectrolytemiasDyselectrolytemias
MalnutritionMalnutrition
VADXVADX
AnemiaAnemia
More infxMore infx
Growth failureGrowth failure
VADX: Vitamin A deficiency and xerophthalmia. Infx.: infectionVADX: Vitamin A deficiency and xerophthalmia. Infx.: infection
14. 14
Diarrhea CausesDiarrhea Causes MalnutritionMalnutrition
Food intakeFood intake ⇓⇓ by 1/3 (by 1/3 (appetite poor, NVD)appetite poor, NVD)
Starvation therapyStarvation therapy (‘rest to bowel’)(‘rest to bowel’)
Faulty feeds, food fadsFaulty feeds, food fads
MalabsorptionMalabsorption
VADXVADX ⇔⇔ InfxInfx
More nutrients to cope with diarrheaMore nutrients to cope with diarrhea
Mn. makes D. worse. Mn.Mn. makes D. worse. Mn. ⇔⇔ longer, severer D.longer, severer D.
The cycle can be broken by good nutritionThe cycle can be broken by good nutrition
Stress on feeding in D.!Stress on feeding in D.!
D: diarrheaD: diarrhea
15. 15
Diarrhea Kills ..Diarrhea Kills ..
ShockShock, ARF, ARF
DyselectrolytemiaDyselectrolytemia (hypokalemia)(hypokalemia)
Severe malnutritionSevere malnutrition
Associated infx. (pneumonia)Associated infx. (pneumonia)
HUS (E coli)HUS (E coli)
GBS (C jejunae)GBS (C jejunae)
How dehydration kills
HypovolemiaHypovolemia
For each 1% dehydration body function falls by 5%For each 1% dehydration body function falls by 5%
20% dehydration is lethal20% dehydration is lethal
19. 19
Types of Ac. DiarrheaTypes of Ac. Diarrhea
33 clinical typesclinical types
Ac.Ac. waterywatery DD (AWD) 75%(AWD) 75% lasts several hours to dayslasts several hours to days
Ac.Ac. invasiveinvasive DD (AID) 15% or(AID) 15% or ac. bloody D (dysentery)ac. bloody D (dysentery)
PersistentPersistent DD (PD) 10%(PD) 10% lasts 14d or morelasts 14d or more
20. 20
Ac. Watery DiarrheaAc. Watery Diarrhea
CommonestCommonest
Large motions: rapid dehydrationLarge motions: rapid dehydration
45% of diarrheal deaths45% of diarrheal deaths
No invasionNo invasion
Duration ~7 daysDuration ~7 days
21. 21
Cl. Features of AWDCl. Features of AWD
UsuallyUsually starts as astarts as a viral syndrome*viral syndrome*
Loose/watery stoolsLoose/watery stools
NVNV
++ FeverFever
+/-+/- Abdominal painAbdominal pain
*Viral syndrome: cold, cough, flushing, red eyes, malaise, bodyache, etc.
22. 22
Causes of AWDCauses of AWD
RotavirusRotavirus
ETECETEC
EPECEPEC
V. choleraeV. cholerae
No pathogen detectable in 5%No pathogen detectable in 5%
GiardiaGiardia
Nontyph. salmonellaNontyph. salmonella
CryptosporidiumCryptosporidium
A. hydrophilaA. hydrophila
23. 23
Rota VirusRota Virus
33% of all D.33% of all D.
60% of all D. <2yoa60% of all D. <2yoa
20k deaths in Bangladesh20k deaths in Bangladesh
Starts as upper respiratory catarrhStarts as upper respiratory catarrh
Yellowish/greenish watery stools with flakes of fecesYellowish/greenish watery stools with flakes of feces
Rapid dehydrationRapid dehydration
Vaccine preventable: v. effectiveVaccine preventable: v. effective
28. 28
Remember AWD..Remember AWD..
CommonestCommonest
Rapid severe dehydrationRapid severe dehydration
Rx only by ORTRx only by ORT
No ABT (antibiotic therapy)* Self- limitingNo ABT (antibiotic therapy)* Self- limiting
Wrong Rx may lead to PDWrong Rx may lead to PD
Increased fluid and continued feeding is v. imp.Increased fluid and continued feeding is v. imp.
*ABT recommended in cholera*ABT recommended in cholera
29. 29
Ac. Inv. Diarrhea (Dysentery)Ac. Inv. Diarrhea (Dysentery)
FeaturesFeatures
InvasionInvasion
InflammationInflammation
System upsetSystem upset
Characteristic stoolsCharacteristic stools
Dysentery:Dysentery: loose stools mixed with mucus and blood; AP andloose stools mixed with mucus and blood; AP and
tenesmus (urge to purge with little output: irritation of internal analtenesmus (urge to purge with little output: irritation of internal anal
sphincter)sphincter)
39. 39
Remember AID may cause:Remember AID may cause:
Complications: HUS (E. coli), GBS (Campylobacter)Complications: HUS (E. coli), GBS (Campylobacter)
MalnutritionMalnutrition
AnemiaAnemia
Persistent diarrheaPersistent diarrhea
DeathDeath
40. 40
Persistent DiarrheaPersistent Diarrhea
30-50% of deaths in diarrhea!30-50% of deaths in diarrhea!
Almost unknown in EBFBAlmost unknown in EBFB
Starts as AWD/AID; but predisposingStarts as AWD/AID; but predisposing
factors prolong itfactors prolong it >> 1414dd
Child is malnourished, develops VADXChild is malnourished, develops VADX
Often with serious non-GIT infx.Often with serious non-GIT infx.
EBFB: exclusively breastfed babies
41. 41
Predisposing Factors for PDPredisposing Factors for PD
Not breastfeedingNot breastfeeding
Bottle feedingBottle feeding
Unjustified ABTUnjustified ABT
MalnutritionMalnutrition
VADXVADX
ImmunodeficiencyImmunodeficiency
Starvation therapyStarvation therapy
Food intoleranceFood intolerance
Preventing these can avert PDPreventing these can avert PD
43. 43
Effects of PDEffects of PD
AA seriousserious conditioncondition!!
DehydrationDehydration
Rapid wt. loss, malnutritionRapid wt. loss, malnutrition
Malabsorption: Nutrient deficiencies,Malabsorption: Nutrient deficiencies, VADXVADX
44. 44
Causes of PDCauses of PD
No single microbial causeNo single microbial cause
SomeSome maymay play a role:play a role:
CryptosporidiumCryptosporidium
EnteroaggregativeEnteroaggregative E. coliE. coli
ShigellaShigella
45. 45
Chronic vs. PDChronic vs. PD
Don’t confuse chr. D with PDDon’t confuse chr. D with PD
Chr. diarrhea is:Chr. diarrhea is:
insidiousinsidious
long lasting/recurrentlong lasting/recurrent
usuallyusually non-infx. causes (eg thyrotoxicosis)non-infx. causes (eg thyrotoxicosis)
46. 46
History.History. Volume ofVolume of urineurine (never forget)(never forget)
Looking at the stoolLooking at the stool
Physical ExamPhysical Exam
S/S/of dehydrationof dehydration and malnutritionand malnutrition
Assessing DiarrheaAssessing Diarrhea
49. 49
History takingHistory taking
1. General Danger Signs1. General Danger Signs
2. Main Symptoms2. Main Symptoms
a. Cougha. Cough
b.b. DiarrheaDiarrhea √√
c. Feverc. Fever
d. Ear Problemsd. Ear Problems
3. Nutritional Status3. Nutritional Status
4. Immunization Status4. Immunization Status
5. Other Problems5. Other Problems IMCI record form
56. 56
Thirst: 3 stagesThirst: 3 stages
Not able to drink or drinks poorlyNot able to drink or drinks poorly
weak, drinks with help, swallows only if fluid isweak, drinks with help, swallows only if fluid is
put in mouthput in mouth
Drinking eagerly, thirstyDrinking eagerly, thirsty
wants to drink morewants to drink more
Drinks normallyDrinks normally
58. 58
Skin PinchSkin Pinch
Middle of umbilicus and flankMiddle of umbilicus and flank
Pinch all layers with thumb + index in long axis forPinch all layers with thumb + index in long axis for
1 sec and release suddenly:1 sec and release suddenly:
– goes backgoes back very slowlyvery slowly (>2 sec)(>2 sec)
– sslowlylowly
– oror immediatelyimmediately
61. 61
Exception!Exception!
Marasmic and elderly: pinchMarasmic and elderly: pinch goes back slowlygoes back slowly
Obesity/edema:Obesity/edema: goes back immediatelygoes back immediately thoughthough
dehydrated!dehydrated!
ThoughThough lessless reliable it is usefulreliable it is useful
63. 63
Any 2 signs:Any 2 signs:
• Lethargic or unconsciousLethargic or unconscious
• Sunken eyesSunken eyes
• Unable to drink/drink poorlyUnable to drink/drink poorly
• Skin pinch returns v. slowlySkin pinch returns v. slowly
SevereSevere
dehydrationdehydration
(Rx plan A)(Rx plan A)
Any 2 signs:Any 2 signs:
• Restless, irritableRestless, irritable
• Sunken eyesSunken eyes
• Drinks eagerly, thirstyDrinks eagerly, thirsty
• Skin pinch returns slowlySkin pinch returns slowly
SomeSome
dehydrationdehydration
(Rx plan B)(Rx plan B)
Not enough signs to classify asNot enough signs to classify as
aboveabove
NoNo
dehydrationdehydration
(Rx plan C)(Rx plan C)
64. 64
NoNo
dehydrationdehydration
Plan APlan A
SomeSome
dehydrationdehydration
Plan BPlan B
SevereSevere
dehydrationdehydration
Plan CPlan C
Look:Look:
Gen. Con.Gen. Con.
EyesEyes
ThirstThirst
Well, alertWell, alert
Not sunkenNot sunken
Drinks wellDrinks well
Restless, irritableRestless, irritable
SunkenSunken
Thirsty, drinksThirsty, drinks
eagerlyeagerly
Lethargic/comaLethargic/coma
SunkenSunken
Drinks poorly orDrinks poorly or
not able tonot able to
Feel:Feel:
Skin pinchSkin pinch Goes backGoes back
quicklyquickly
Goes backGoes back
slowlyslowly
Very slowlyVery slowly
Classifying DehydrationClassifying Dehydration
65. 65
Principles of RxPrinciples of Rx
Only rehydration in most casesOnly rehydration in most cases
Correct existing deficitCorrect existing deficit
Replace further lossReplace further loss
IVF in severe dehydrationIVF in severe dehydration
FeedingFeeding, specially BM continued, specially BM continued
AntimicrobialsAntimicrobials if warrantedif warranted
66. 66
SSevere ....:evere ....: immediate replacement with IVF, NGTimmediate replacement with IVF, NGT
or ORTor ORT (Plan C)(Plan C)
Some ......:Some ......: ORTC/at homeORTC/at home (Plan B)(Plan B)
No .....:No .....: at homeat home (Plan A)(Plan A)
Rehydration PlanRehydration Plan
67. 67
Rx PlanRx Plan
AA
Rx atRx at
homehome
TeachTeach
IF/CFIF/CF **
BB
ORS in 4h: 70 ml/kgORS in 4h: 70 ml/kg
<4 mo 200- 400ml<4 mo 200- 400ml
4-12 mo 400- 600ml4-12 mo 400- 600ml
1-2y 600- 800ml1-2y 600- 800ml
2-4y 800-1200ml2-4y 800-1200ml
5-14y 1200-2200ml5-14y 1200-2200ml
Reassess after 4 h: selectReassess after 4 h: select
plan A, B, or Cplan A, B, or C
CC
Start IVF @ 100ml/kgStart IVF @ 100ml/kg
50% in first 2h50% in first 2h
50% next 3-4h50% next 3-4h
Replace further loss;Replace further loss;
ORT if can drinkORT if can drink
Assess pulse, BP, UOPAssess pulse, BP, UOP
frequently and review Rxfrequently and review Rx
planplan**
IF/CF: increased fluid and continued feedingIF/CF: increased fluid and continued feeding
69. 69
Feeding in DiarrheaFeeding in Diarrhea
Growth slows during diarrhea but children catch upGrowth slows during diarrhea but children catch up laterlater
Give an extra meal for 2wGive an extra meal for 2w
ContinueContinue BM+ORTBM+ORT, family foods, family foods
Severe malnutrition: feed during ORT, rehydrate slowlySevere malnutrition: feed during ORT, rehydrate slowly
70. 70
Any dehydrationAny dehydration SevereSevere PDPD
No dehydrationNo dehydration Persistent diarrheaPersistent diarrhea
Classification of PDClassification of PD
71. 71
Severe PD:Severe PD: hospitalisehospitalise
FeedingFeeding is most important:is most important:
– tempo.tempo. ⇓⇓ animal milkanimal milk
– energy, protein, vitamins, mineralsenergy, protein, vitamins, minerals
– avoidavoid aggravatingaggravating foodsfoods
– enoughenough food during convalescencefood during convalescence
No routine ABTNo routine ABT
Treatment of PDTreatment of PD
73. 73
Dysentery SyndromeDysentery Syndrome
Basically IDBasically ID
Bloody mucoid stools, F, cramps, tenesmus. High MMBloody mucoid stools, F, cramps, tenesmus. High MM
Stool CS is rarely possibleStool CS is rarely possible
More severe in malnourished, not breast-fed, or bottle fedMore severe in malnourished, not breast-fed, or bottle fed
babies.babies. ⇑⇑ frequent and severe in measlesfrequent and severe in measles
⇑⇑ likely to become PDlikely to become PD
MM: morbidity and mortalityMM: morbidity and mortality
74. 74
Classification of DysenteryClassification of Dysentery
ClassifyClassify dysenterydysentery if blood is in stoolif blood is in stool
15% diarrheas in U-5y are dysentery15% diarrheas in U-5y are dysentery
15% of diarrheal deaths15% of diarrheal deaths
Blood in the stool Dysentery
75. Other Causes of Bloody StoolsOther Causes of Bloody Stools
Rectal polyp, anal fissureRectal polyp, anal fissure
Meckel diverticulumMeckel diverticulum
Diverticulosis/diverticulitisDiverticulosis/diverticulitis
Cow’s milk protein intoleranceCow’s milk protein intolerance
AV malformationAV malformation
Hemorrhagic diseaseHemorrhagic disease
75
76. 76
3 Types of Dehydration3 Types of Dehydration
Serum Na
Isotonic 130-150mmol/l
Hypertonic >160 mmol/l
(hypernatremic)
Hypotonic <130 mmol/l
(hyponatremic)
77. 77
Isotonic:Isotonic: commonestcommonest
Fluid lost in DV is isotonicFluid lost in DV is isotonic
Plasma osmolality 275-295mOsmol/lPlasma osmolality 275-295mOsmol/l
Serum Na isSerum Na is 130-150 mmol/ l130-150 mmol/ l
The patientThe patient
Proportionately dehydratedProportionately dehydrated
78. 78
HypertonicHypertonic
Rehydration by hypertonic fluidRehydration by hypertonic fluid
Serum Na isSerum Na is >160 mmol/l>160 mmol/l
Osmolality is >295mOsmol/lOsmolality is >295mOsmol/l
The patient isThe patient is
sseverely dry, thirsty, irritable, bounding pulseeverely dry, thirsty, irritable, bounding pulse
fits at Na >165mmol/lfits at Na >165mmol/l
79. 79
HypotonicHypotonic
Rehydrated with hypotonic fluidRehydrated with hypotonic fluid
Serum NaSerum Na <130 mmol/l<130 mmol/l
OsmolalityOsmolality <275mOsmol/l<275mOsmol/l
The patient isThe patient is
Lethargic, feeble pulseLethargic, feeble pulse
May have fitsMay have fits
81. New ORS (WHO):
All ingredients except K +
and alkali are
reduced: 27.9 ⇒ 20.5 g
It is hypo-osmolar: 311 ⇒ 245mmol/L
82. NewNew OldOld
NaClNaCl 2.6 g/l2.6 g/l 3.5 g/l3.5 g/l
GlucoseGlucose 13.513.5 2020
KClKCl 1.51.5 1.51.5
Trisodium citrateTrisodium citrate 2.92.9 2.92.9
TotalTotal 20.520.5 27.927.9
OsmolarityOsmolarity mmol/Lmmol/L mmol/Lmmol/L
NaNa 7575 9090
ClCl 6565 8080
GlucoseGlucose 7575 111111
KK 2020 2020
BaseBase 1010 1010
TotalTotal 245245 311311
Old and New ORSOld and New ORS (1L)(1L)
83. 83
Old vs. New ORSOld vs. New ORS
OldOld
HypertonicHypertonic
More vomitingMore vomiting
More stoolsMore stools
IVFIVF
NewNew
IsotonicIsotonic
-20%-20%
-30%-30%
-33%-33%
84. 84
Rice based ORSRice based ORS
WaterWater 500ml500ml
Rice powderRice powder 30-40g30-40g
NaClNaCl 2.5g2.5g
Boil for 5-7 minBoil for 5-7 min
Rice ORS is equally effectiveRice ORS is equally effective
85. 85
Home Made SSSHome Made SSS (salt sugar solution)(salt sugar solution)
Water 500 ml
Table salt 3 finger pinch
Sugar/molasses 4 finger grip
3 finger pinch
4 finger grip
86. 86
Use of ORSUse of ORS
Only for diarrhea or V+D
Not for vomiting alone
Never as soft drink nor tonic or water
Do not use in excess
Rice ORS is not a food
87. 87
ORS may be IneffectiveORS may be Ineffective
Severe dehydration, vomitingSevere dehydration, vomiting
Lethargic, unconsciousLethargic, unconscious
Rapid loss of waterRapid loss of water
Sugar malabsorption (large stools, reducing substance)Sugar malabsorption (large stools, reducing substance)
89. 89
WHO:WHO: increased fluidsincreased fluids (ORS or home-made SSS plus(ORS or home-made SSS plus
continued feedingcontinued feeding (IF/CF)(IF/CF)
It is the key program to control diarrhea dehydrationIt is the key program to control diarrhea dehydration
Sugar-salt soln. (SSS)Sugar-salt soln. (SSS)
Oral Rehydration Therapy (ORT)?Oral Rehydration Therapy (ORT)?
90. 90
ORT CornerORT Corner
OPD room for ORTOPD room for ORT
Trained person, ORS and toolsTrained person, ORS and tools
ForFor ‘No- and Some- dehydration’‘No- and Some- dehydration’
4 - hr stay4 - hr stay ⇒⇒ reassessedreassessed
Training and counseling mothersTraining and counseling mothers
92. 92
Antimicrobials in DiarrheasAntimicrobials in Diarrheas
Not used routinely, mostlyNot used routinely, mostly NONENONE
Kills commensalsKills commensals
Secondary/superinfectionSecondary/superinfection
Expensive, toxic, allergicExpensive, toxic, allergic
93. 93
Indications of ABTIndications of ABT
ShigellosisShigellosis
Inv.Inv. ssalmonellosisalmonellosis
CholeraCholera
GiardiasisGiardiasis
E. histolyticaE. histolytica
C jejuniC jejuni
Y enterocoliticaY enterocolitica
94. 94
Do not use:
Loperamide, diphenoxylate:Loperamide, diphenoxylate: not effective: SoB andnot effective: SoB and
severe distensionsevere distension
Antispasmodics:Antispasmodics: inhibit peristalsisinhibit peristalsis
Kaolin, pectin, charcoal, attapulgite:Kaolin, pectin, charcoal, attapulgite: ⇑⇑ consistency, butconsistency, but
nono ⇓⇓ fluid loss. They canfluid loss. They can ⇓⇓ action of other drugsaction of other drugs
95. 95
ZINC IN DIARRHEAZINC IN DIARRHEA (ICCDR’B)(ICCDR’B)
Significant role in the MDG #4Significant role in the MDG #4
Globally, 400k lives could be saved:Globally, 400k lives could be saved:
⇓⇓ severity, duration, recurrence, admissionseverity, duration, recurrence, admission
positive impact on pneumoniapositive impact on pneumonia
Entire U-5 of Bangladesh is targeted:Entire U-5 of Bangladesh is targeted:
It could save 75k lives/yIt could save 75k lives/y
96. 96
Why Zinc Rx. In Bangladesh?Why Zinc Rx. In Bangladesh?
It is rich in protein foods: poor haveIt is rich in protein foods: poor have ↓↓ ZnZn
Soil is poor in ZnSoil is poor in Zn
U-5 are the most vulnerableU-5 are the most vulnerable
Evidence of benefit existsEvidence of benefit exists
Essential for growth, immunityEssential for growth, immunity
Supplement till ideal foods for all attainedSupplement till ideal foods for all attained
97. 97
Prevention of DiarrheaPrevention of Diarrhea
EBF, no bottle nor formulaEBF, no bottle nor formula
Hand washingHand washing
Safe food, waterSafe food, water
Safe eatingSafe eating
Disposal of excretaDisposal of excreta
ImmunizationImmunization
HPVACHPVAC
Safe complementary feedsSafe complementary feeds
No overcrowdingNo overcrowding
All are virtually low-cost interventionsAll are virtually low-cost interventions
100. 100
MESSAGEMESSAGE
ORTORT ⇓⇓ diarrheal MR by 70%diarrheal MR by 70%
No ABT in most diarrheasNo ABT in most diarrheas
Feeding is v. importantFeeding is v. important
Prevention is low-costPrevention is low-cost
Zn has a roleZn has a role
Vitamin A in prolonged diarrheaVitamin A in prolonged diarrhea
101. HUSHUS
destroys RBCs. It is the commonest c/of ARF in children.destroys RBCs. It is the commonest c/of ARF in children.
Although it can cause serious complications, mostAlthough it can cause serious complications, most
children recoverchildren recover
Healthy RBC are smooth and round. In HUS, toxinsHealthy RBC are smooth and round. In HUS, toxins
destroy RBC and render them misshapen (schistocyte):destroy RBC and render them misshapen (schistocyte):
may clog the tiny BV in the kidneysmay clog the tiny BV in the kidneys
101
102. 102
Healthy RBCs (left) are smooth and round. In HUS, toxins
destroy them (right). These misshapen cells may clog the
103. Causes of HUSCauses of HUS
E. coliE. coli toxinstoxins destroy RBCsdestroy RBCs
It is found in contaminated meat, dairies, and juice.It is found in contaminated meat, dairies, and juice.
Swimming pools or lakes can be contaminatedSwimming pools or lakes can be contaminated
Most E coli AGE recover fully and do not develop HUSMost E coli AGE recover fully and do not develop HUS
103
104. CF of HUSCF of HUS
The child is pale, tired, irritable. May have small bruises,The child is pale, tired, irritable. May have small bruises,
epistaxis, haematuria. SS may not develop till a weekepistaxis, haematuria. SS may not develop till a week
ARF (>50%). Damaged RBCs, acid hematin clog the tiny BVARF (>50%). Damaged RBCs, acid hematin clog the tiny BV
in the kidneys. CF of AGN may appear. UOP falls. HTNin the kidneys. CF of AGN may appear. UOP falls. HTN
Anuria for 12h should attend EDAnuria for 12h should attend ED
DiagnosisDiagnosis
H/o and PE. Dx is confirmed by PBF study to see if the RBCH/o and PE. Dx is confirmed by PBF study to see if the RBC
are misshapenare misshapen
CF: cl. features. ED: emergency dept.CF: cl. features. ED: emergency dept.
104
105. RxRx
Maintaining FEB to ease SS and prevent further problemsMaintaining FEB to ease SS and prevent further problems
BT may be neededBT may be needed
In severe cases: dialysisIn severe cases: dialysis
Some children may develop CKDSome children may develop CKD
Limiting protein in diet and treating HTN with ACEI helpsLimiting protein in diet and treating HTN with ACEI helps
delay/prevent the onset of CKDdelay/prevent the onset of CKD
Most children recover completelyMost children recover completely
105
106. PreventionPrevention
Food hygiene especially for meats; avoiding uncleanFood hygiene especially for meats; avoiding unclean
swimming areas are the best waysswimming areas are the best ways
Points to PonderPoints to Ponder
HUS is the commonest c/of short-term-ARF in children.HUS is the commonest c/of short-term-ARF in children.
Most children recoverMost children recover
Most cases of HUS follow an AGE byMost cases of HUS follow an AGE by E. coliE. coli
Maintaining FEB eases SS and prevents further problemsMaintaining FEB eases SS and prevents further problems
A child may need BTA child may need BT
Only the most severe cases require dialysisOnly the most severe cases require dialysis
106
107. 107
MCQMCQ
Diarrhea is the biggest child killerDiarrhea is the biggest child killer
Ac. ID causes more dehydration than AWDAc. ID causes more dehydration than AWD
Shigella is the commonest c/of Ac. IDShigella is the commonest c/of Ac. ID
Diarrhea can cause ARFDiarrhea can cause ARF
Glucose in ORS is meant for providing nutritionGlucose in ORS is meant for providing nutrition
C jejuni can cause GBSC jejuni can cause GBS
108. 108
MCQMCQ
Most diarrheas do not need ABTMost diarrheas do not need ABT
Cholera is an example of ac. invasive DCholera is an example of ac. invasive D
In EBF babies diarrhea is virtually nilIn EBF babies diarrhea is virtually nil
Persistent D is synonymous with chr. DPersistent D is synonymous with chr. D
Giardia causes ac. invasive DGiardia causes ac. invasive D
Breast milk stools can cause dehydrationBreast milk stools can cause dehydration
109. 109
MCQMCQ
Persistent D with mild dehydr. is classified as severe PDPersistent D with mild dehydr. is classified as severe PD
Zinc Rx reduces diarrheal mortalityZinc Rx reduces diarrheal mortality
Breast milk is discontinued if there is lactose intoleranceBreast milk is discontinued if there is lactose intolerance
Vitamin A is supplemented in prolonged diarrheaVitamin A is supplemented in prolonged diarrhea
Diarrhea prevention interventions are expensiveDiarrhea prevention interventions are expensive
110. 110
OSPEOSPE
A 3 mo old formula fed child had mild runny nose andA 3 mo old formula fed child had mild runny nose and
cough for 1 d. It was f/by passage of frequent loosecough for 1 d. It was f/by passage of frequent loose
watery motions containing flakes of feces.watery motions containing flakes of feces.
– What is the most probable Dx?What is the most probable Dx?
He was lethargic and could not drink. He had sunkenHe was lethargic and could not drink. He had sunken
eyes and skin pinch went back v. slowlyeyes and skin pinch went back v. slowly
– Classify his dehydration according to IMCIClassify his dehydration according to IMCI
– How do you treat this child?How do you treat this child?
111. 111
A 2y old child had ac. HGF with V and AP immediatelyA 2y old child had ac. HGF with V and AP immediately
f/by frequent loose mucoid and bloody stools. He hadf/by frequent loose mucoid and bloody stools. He had
tenesmus.tenesmus.
– What is the most probable Dx?What is the most probable Dx?
– How can you confirm it?How can you confirm it?
He was restless with sunken eyes but drank eagerly; skinHe was restless with sunken eyes but drank eagerly; skin
pinch went back slowly.pinch went back slowly.
– Classify his dehydration according to IMCIClassify his dehydration according to IMCI
– How do treat it?How do treat it?
– What ABT do you suggest?What ABT do you suggest?
OSPEOSPE
D can last several days, and can cause dehyd. and salt loss. Children with Mn or impaired immunity (HIV) are most at risk. D. is usually a symptom of an inf in GIT, which can be c/by a variety of bacterial, viral and parasitic MO. Inf is spread through food/drink, or P2P (poor hygiene).
Worldwide, 780 million lack access to improved drinking-water and 2.5 billion lack improved sanitation. Diarrhoea due to infection is widespread throughout LICs.: children under 3yoa experience on average 3 episodes/y. Each episode deprives the child of the nutrition necessary for growth. As a result, D is a major c/of Mn, and malnourished children are more likely to fall ill from D.
The most severe threat posed by diarrhoea is dehydration. During a diarrhoeal episode, water and electrolytes (sodium, chloride, potassium and bicarbonate) are lost through liquid stools, vomit, sweat, urine and breathing. Dehydration occurs when these losses are not replaced.
The degree of dehydration is rated on a scale of three.
Early dehydration – no signs or symptoms.
Moderate dehydration:
thirst
restless or irritable behaviour
decreased skin elasticity
sunken eyes
Severe dehydration:
symptoms become more severe
shock, with diminished consciousness, lack of urine output, cool, moist extremities, a rapid and feeble pulse, low or undetectable blood pressure, and pale skin.
Death can follow severe dehydration if body fluids and electrolytes are not replenished, either through the use of oral rehydration salts (ORS) solution, or through an intravenous drip.
Infection: Diarrhoea is a symptom of infections caused by a host of bacterial, viral and parasitic organisms, most of which are spread by faeces-contaminated water. Infection is more common when there is a shortage of adequate sanitation and hygiene and safe water for drinking, cooking and cleaning. Rotavirus andEscherichia coli are the two most common etiological agents of diarrhoea in developing countries.
Malnutrition: Children who die from diarrhoea often suffer from underlying malnutrition, which makes them more vulnerable to diarrhoea. Each diarrhoeal episode, in turn, makes their malnutrition even worse. Diarrhoea is a leading cause of malnutrition in children under five years old.
Source: Water contaminated with human faeces, for example, from sewage, septic tanks and latrines, is of particular concern. Animal faeces also contain microorganisms that can cause diarrhoea.
Other causes: Diarrhoeal disease can also spread from person-to-person, aggravated by poor personal hygiene. Food is another major cause of diarrhoea when it is prepared or stored in unhygienic conditions. Water can contaminate food during irrigation. Fish and seafood from polluted water may also contribute to the disease.
Prevention and Rx.:
safe drinking-water; improved sanitation; hand washing with soap; EBF; good hygiene; health education; rota. vax.
Rehydration: ORS. ORS is absorbed in small gut and replaces the water and electrolytes lost in D. Zinc reduces the duration of D by 25% and are associated with a 30% reduction in stool volume. IVF in severe dehydration or shock.
Nutritious foods: the vicious circle of Mn and D can be broken by nutrient-rich foods and BM. Consulting a HCP, in particular for management of persistent D or when there is blood in stool or if there are s/of dehydration.
WHO works to: promote national policies and investments that support case management of D and its complications as well as increasing access to safe water and sanitation in LICs; conduct research to develop and test new D prevention and control strategies in this area; build capacity in implementing preventive interventions, including sanitation, source water improvements, and household water treatment and safe storage; develop new health interventions, such as the rota vax; and help to train HW, especially at community level
Schistocyte/schizocyte (schistos for &quot;divided&quot;) is a broken part of a RBC; typically irregularly shaped, jagged, and have 2 pointed ends. A true schistocyte does not have central pallor. It is sometimes referred to as &quot;helmet cells&quot;. Several microangiopathic d, (DIC, HUS, thrombotic microangiopathies), generate fibrin strands that sever RBCs as they try to move past a thrombus. It is often seen in hemolytic a. and is frequently a consequence of mechanical artificial heart valves and HUS, thrombotic thrombocytopenic purpura. Excessive schistocytes present in blood can be a s/of microangiopathic hemolytic a (MAHA) where the most common cause is aortic stenosis
Rotavirus is contagious; causes AGE: severe watery D, often with V, F, AP, anorexia. Infants and young children are most affected: severely dehydrated and need to be hospitalized and can even die. R. vax. are v effective. Older children and adults also can get it. IP: 2d. V and watery D can last 3-8d. Dehydration: low UOP, dry mouth and throat, feeling dizzy, few or no tears, unusually sleepy or fussy. Adults have mild d. Children, even those that are vaccinated, may get it more than once. Neither natural inf nor R. vax. provides full protection. Usually 1st attack causes the most severe SS. Vaccinated children if get sick, SS are usually mild
Cholera is an ac. D c/by Vibrio cholerae. 3-5 million cases and &gt;100k deaths/y globally. Often mild/asymptomatic, but can be severe. 1/10 (5-10%) inf. are severe: profuse watery D, V, and leg cramps, dehydration and shock. Death may occur within hours.
All children with D should be checked for duration of D, blood in stool and dehydration. General condition a child may be lethargic or unconscious (also a GDS) or look restless/irritable. Only children who cannot be consoled and calmed should be considered restless or irritable. Sunken eyes. The eyes of a dehydrated child may look sunken. In a severely malnourished child who is visibly wasted, the eyes may always look sunken, even if the child is not dehydrated. Even though less reliable in a visibly wasted child, it can still be used to classify the child&apos;s dehydration. Child’s reaction when offered to drink. A child is not able to drink if s/he is not able to take fluid in his/her mouth and swallow it. For example, a child may not be able to drink because s/he is lethargic or unconscious. A child is drinking poorly if the child is weak and cannot drink without help. S/he may be able to swallow only if fluid is put in his/her mouth. A child has the sign drinking eagerly, thirsty if it is clear that the child wants to drink. Notice if the child reaches out for the cup or spoon when you offer him/her water. When the water is taken away, see if the child is unhappy because s/he wants to drink more. If the child takes a drink only with encouragement and does not want to drink more, s/he does not have the sign “drinking eagerly, thirsty.”Standard Procedures for Skin Pinch Test
Locate the area on the child&apos;s abdomen halfway between the umbilicus and the side of the abdomen; then pinch the skin using the thumb and first finger.
The hand should be placed so that when the skin is pinched, the fold of skin will be in a line up and down the child&apos;s body and not across the child&apos;s body.
It is important to firmly pick up all of the layers of skin and the tissue under them for one second and then release it.
Elasticity of skin. Check elasticity of skin using the skin pinch test. When released, the skin pinch goes back either very slowly (longer than 2 seconds), or slowly (skin stays up even for a brief instant), or immediately. In a child with marasmus (severe malnutrition), the skin may go back slowly even if the child is not dehydrated. In an overweight child, or a child with oedema, the skin may go back immediately even if the child is dehydrated.
After the child is assessed for dehydration, the caretaker of a child with diarrhoea should be asked how long the child has had diarrhoea and if there is blood in the stool. This will allow identification of children with persistent diarrhoea and dysentery.
Classification of Dehydration
Based on a combination of the above clinical signs, children presenting with diarrhoea are classified into three categories:
Those who have severe dehydration and who require immediate IV infusion, nasogastric or oral fluid replacement according to the WHO treatment guidelines described in Plan C (see figure 4 under treatment procedures).
Consoled child
Superinfection is generally a 2nd inf superimposed on an earlier 1, esp. by a different MO, exogenous/endo-, that is resistant to Rx being used against the 1st inf
Campylobacter jejuni (formerly C fetus subsp. jejuni) is a G-ve slender, curved, and motile rod. It is microaerophilic (needs reduced O2, 3-5%, 2-10% CO2). It is relatively fragile, sensitive to stresses (21% O2, drying, heating, disinfectants, acid). It is an imp. enteric pathogen. It is the leading c/of bacterial D in USA, more than Shigella. and Salmonella combined. Although it is not carried by healthy individuals in US/Europe, it is often isolated from healthy cattle, chickens, birds and even flies. It is sometimes present in water.
Campylobacteriosis is the name of the illness. It causes D, which may be watery or sticky and can contain blood (usually occult) and PC, F, AP, N, HA and muscle pain. IP: 2-5d. Duration: 7-10d, but relapses are not uncommon (25%). Most inf are self-limiting and need not AB. Erythromycin reduces duration and carriage. Innoculum: is 400-500 bacteria. MoA is still not clear, but it does produce a heat-labile toxin. C. jejuni may also be invasive.
It is usually present in high numbers in D stools, but isolation requires special AB-containing media and a special microaerophilic atmosphere.
It frequently contaminates raw chicken. 20-100% of retail chickens are contaminated. Many healthy chickens carry it in gut. Raw milk is also a source. The bacteria are often carried by healthy cattle and by flies on farms. Cooking chicken, pasteurizing milk, and chlorinating water kill.
It is associated with reactive arthritis, HUS, and following septicemia, infections of nearly any organ. CFR is 0.1. Fatalities usually occur in cancer patients or in the otherwise debilitated. Only 20 reported cases of septic abortion induced by C. jejuni have been recorded in the literature. Meningitis, rec. colitis, ac. cholecystitis and GBS are v rare.
Although anyone can have it, U-5 and 15-29y are more afflicted. RA, is strongly associated with HLA-B27.
Isolation of C. jejuni from food is difficult because the bacteria are usually present in very low numbers (unlike the case of diarrheal stools in which 10/6 bacteria/gram is not unusual). The methods require an enrichment broth containing antibiotics, special antibiotic-containing plates and a microaerophilic atmosphere generally a microaerophilic atmosphere with 5% oxygen and an elevated concentration of carbon dioxide (10%). Isolation can take several days to a week
Yersinia enterocolitica is in the family Enterobacteriaceae that most often causes enterocolitis, a. D, terminal ileitis, mesenteric LAP and pseudoappendicitis but, if it spreads systemically, can also result in fatal sepsis