3. Types of serious diarrhoea in
children
Acute watery diarrhea- If <14 days ,sever
dehydration Ecoli,cholera ,malnutrition
Persistent diarrhea-If >14 days, 20-30 %
death, under nourished and HIV exposed
Dysentery-(atisar) with blood ,with or without
mucus 10%-15 % of deaths
4. Why are children more prone to
diarrhoea
Proportion of water is more in children ,so
dehydration occur early.
Metabolic rate is high and use more water as
compared to adults
Kidney can conserve less water ,so loss is more
Sodium loss can be 70-110 m mol/kg
Chloride and potassium loss is balanced &same
5. Assessment of diarrhea
Did child vomit?
Did child pass urine?
What type of liquids did the child get ?
Did the child get sufficient food before this episode ?
During diarrhea is child getting food that is different
and is less calorie dense?
Look for cough ,fever ,otitis media ,sepsis ,h/o
measles
Weight /nutrition
7. Does the child have diarrhea?
If yes, ask:
For how long? How many?
Has the child been vomiting
Is there blood in stool?
8. LOOK AT THE CHILD’S GENERAL
CONDITION
IS THE CHILD
◦ Lethargic or Unconscious?
◦ Restless or Irritable?
LOOK FOR SUNKEN EYES
Look for skin pinch -goes back
promptly/slowly/ very slowly
OFFER THE CHILD FLUID TO DRINK –
THIRSTY
Not able to drink or drinking
poorly?
Drinking eagerly, appears thirsty?
Drinking normally?
LOOK
9. Look at Eyes for Dehydration
Shrunken Eyes
Normal eyes
10.
11.
12.
13. Two or more of the following
Degree of dehydration decided
on:
•Restless, Irritable
•Sunken Eyes
•Drinks eagerly, Thirsty
•Skin Pinch goes back
“slowly”
Some Dehydration Severe Dehydration
•Lethargic or unconscious
•Sunken Eyes
•Not able to drink or drinking
poorly
•Skin Pinch goes back “very
slowly”
OR NO DEHYDRATION
15. Treat Diarrhea at Home.
4 Rules of Home Treatment:
GIVE EXTRA FLUID
CONTINUE FEEDING
WHEN TO RETURN [ADVICE TO
MOTHER]
GIVE ORAL ZINC FOR 14 DAYS
PLAN – A
16. Plan-B is carried out at ORT Corner in
OPD/clinic/ PHC
Treat ‘some’ dehydration with ORS (50-100
ml/kg
If the child wants more, give more
After 4 hours:
Re-assess and classify degree of
dehydration.
PLAN – B
17. PLAN -C
Signs of sever dehydration
Child not improving after 4 hours
Refer to higher center –give ORS on way /keep
warm /BF
When child comes back follow up as other children
20. Increase amount of calories during convalescence
with energy dense foods (enrich foods with fats
and sugar)
•Feed an extra meal (for at least 2 weeks after
diarrhea stops)
•Give an extra amount
•Use extra rich foods
•Feed with extra patience
•Give extra breastfeeds as often as child wants
21. Increase amount of calories during convalescence
with energy dense foods (enrich foods with fats
and sugar)
•Feed an extra meal (for at least 2 weeks after
diarrhea stops)
•Give an extra amount
•Use extra rich foods
•Feed with extra patience
•Give extra breastfeeds as often as child wants
23. PRINICIPLE OF ORS
The sodium-coupled co-transport with glucose and
other carrier organic solutes remains intact, even with
viral enteritis associated with epithelial damage .
24. Ingredient Standard WHO
ORS mmol/l
Reduced
osmolarity ORS
mmol/l (2002)
Glucose 111 75
Na 90 75
K 20 20
Cl 80 65
Citrate 10 10
Osmolarity
mOsm/kg
311 245
25. Limitation of high osmolarity ORS
Does not lower volume, frequency and duration of
diarrhoea.
Induces vomiting due to taste, so acceptability poor.
More chances of dehydration, more chances of
requiring iv fluid.
Hypernatremia.
Good to correct fluid deficit, not good for
maintenance fluid.
26. LOW OSMOLARITY ORS
Compared to WHO standard ORS , hypo-osmolar
ORS is associated with
a) fewer unscheduled intravenous fluid infusions(33%)
b)lower stool volumes (20%), and
c) less vomiting(30%)
27. Clinical relevance - low osmolarity ORS
Reduction in need of IV therapy results in reduced
hospitalization and in turn results:
Reduced risk of hospital acquired infections.
Reduced disruption of breastfeeding.
Reduced use of needles and interventions
Reduced therapy cost.
Reduced risk of diarrheal deaths in areas where
IV therapy is not readily available.
28. Rice-based ORS, Maltodextrin-containing and
Amino acid-containing ORS—SUPER ORS
They are not superior to glucose-based ORS for
acute non-cholera diarrhea, provided that feeding
was promptly resumed after initial rehydration of the
child.
29. Flavored/Colored ORS
Studies showed neither an advantage nor
disadvantage for the flavoured and coloured ORS
when compared to the standard ORS with regard to
safety, acceptability and correct use.
Concerns about the type of sweetners ,coloring and
flavouring agents used.
More expensive
30. Limitations for ORS
Altered mental status with concern for aspiration
Abdominal ileus
Underlying disorder that limits intestinal
absorption of ORT (e.g, short gut, carbohydrate
malabsorption)
31. PRACTICAL PROBLEMS
Vomiting: Give less amount more frequently,wait for
10 minutes and try again.Give food in the form of
Kanji,Amylase rich food.
Taste: It is a MEDICINE and the most important
medicine in diarrhea. Convince the parents. First drug
in your prescription.
If affording, flavoured ORS may help.
32. ORS IV fluids
Once ORT has been initiated, intervention with
intravenous hydration is indicated:
If stool output continues to be excessive, and ORT is
unable to adequately rehydrate the child
If there is severe and persistent vomiting, and
inadequate intake of ORS
33. WHO Statement
2006: The World Health Organization states that,
“there is no evidence to support the ongoing use
of IV therapy for the first-line management of
most cases of childhood gastroenteritis.”
34. Safe & effective
Can alone successfully rehydrate 95-97% patients
with diarrhea,
Reduces hospital case fatality rates by 40 - 50%
Cost saving
Reduces hospital admission rates by 50% and
cost of treatment by 90%
35. 39% reduction in need for unscheduled IV fluids
19% reduction in stool output
29% reduction in vomiting
Hahn et al, 2001; WHO/FCH/CAH 0.1.22, 2001
36. Should be given to young infants (< 2m)
including neonates if there is dehydration
In exclusively breastfed young infants with
no dehydration encourage exclusive
breastfeeding more frequently and for longer
Low osmolarity ORS is safe and effective
for all ages
39. IZiNCG advocacy statement (http://www.izincg.org/pdf/IZiNCG_Advocacy-
PrintingFormat.pdf)
Zinc deficiency is widespread in low
and middle income countries like India
40. Disrupts intestinal mucosa
Reduces brush border enzymes
Increases mucosal permeability
Increases intestinal secretion
Roy 1992, Hoque 2005
Zinc deficiency has direct effects on mucosal
functions
41. 20 mg/day (10 mg/day for infants 2-6 mo) of
zinc supplementation for 14 days starting
as early as possible after onset of diarrhea
WHO/UNICEF Joint statement (2001), IAP
2003, GOI 2007
Recommendations for Use of Zinc in
Acute Diarrhea
Slide indicates the effectiveness, safety, and cost-benefit ratio of WHO-ORS.
This the summary of results of published meta-analysis of all randomized clinical trials comparing reduced osmolarity ORS with standard WHO ORS (311mosmol/l) in children with acute non-cholera diarrhea:
There was a significant reduction by 39% in need for unscheduled IV fluids, 12% significant reduction in stool output and 29% significant reduction in vomiting in the group that received the reduced osmolarity ORS solution.
Zinc deficiency, like iron deficiency, is widely prevalent with the magnitude being highest in South Asia and Sub-Saharan Africa.
Zinc deficiency has detrimental effects on intestinal mucosal functions, which the zinc reverses.
Most agencies including WHO, UNICEF, and IAP now recommend routine zinc supplementation during acute diarrhea.
