pediatric diarrhoea

1. DIARRHOEA
Dr Owani Denis
19.02.08

2. INTRODUCTION
 DEFINITION:
 Passage of >3 loose or watery motions in 24hrs.
 Diarrhoea episode: At least 2 consecutive days of
normal stool is considered a new episode
 Classification:
 Acute diarrhoea: Diarhoea lasting <14 days
 Persistent diarrhoea: Lasting >14 days
 Dysentery: Diarrhoea with visible blood in stool.

3. ACUTE DIARRHOEA
 Defn: Diarrhoea lasting <14 days
 Aetiology:
 Acute diarrhoea in children is predominantly
viral in etiology
 Rotavirus-most common
 Other viral causes-adenovirus, enterovirus
 Other causes: bacterial, toxins, food
poisoning, systemic infections, antibiotic
associated.

4. …
 Pathogenesis:
 3 main mechanisms:
 Secretory diarrhoea:
 Often caused by toxins (e.g cholera toxin,
ETEC), binding to a receptor on the surface
epithelium of bowel stimulating
accumulation of intracellular cAMP or cGMP.
 Tends to be watery & of large volume

5. …
 Osmotic diarrhoea:
 Occurs after ingestion of a poorly absorbed
solute.
 The solute may be one that is normally not
well absorbed (e.g, lactulose) or one that is
not well absorbed b’se of a disorder of the
small bowel (e.g, lactose with lactase def).
 Usually of lesser volume than secretory
diarrhoea & stops with fasting.

6. …
 Motility disorders:
 May be associated with rapid or delayed
transit
 Generally not associated with large
volume diarrhoea
 Slowed motility may be associated with
bacterial overgrowth.

7. …
 Risk factors:
 Bottle feeding
 Early weaning before the child can handle
the added diet
 Stopping B/feeding before 2 years
 Poor toilet habits
 Failure to wash hands before feeding
 Drinking unboiled water
 HIV
 Failure to immunize against measles
 Malnutrition.

8. Management:
 Diagnosis: clinical
 Stool analysis not usually indicated in acute
diarrhoea except for diarrhoea with
pus/mucus in stool, blood in stool, suspected
infectious diarrhoea (e.g, cholera)
 Assessment:
 The most important complications of acute
diarrhoea is fluid and electrolytes loss
 Hence assess for fluid loss (dehydration) and
electrolyte imbalance.

9. …
 Assessment of dehydration:
 Cardinal signs used to assess & classify
dehydration:
 Mental state
 Sunken eyes
 Skin tugor
 Ability to drink

10. …
 Severe dehydration:
o A child is classified as having severe
dehydration if he/she has >2 of the
following cardinal signs:
 Lethargic or unconscious
 Sunken eyes
 Skin pinch goes back very slowly (i.e > 2
seconds)
 Drinks poorly or doesn’t drink at all

11. …
 Some dehydration:
o >2 of the following:
 Irritable or restless
 Sunken eyes
 Skin pinch goes back slowly (i.e <2
seconds)
 Thirsty/drinks eagerly

12. …
 No dehydration:
o No enough signs to classify as severe or
some dehydration.
 Conscious and alert
 Eyes not sunken
 Skin pinch goes back immediately
 Drinks normally.

13. …
 Other signs of dehydration include:
 Dry mucous membranes
 Lack of tears on crying
 Sunken anterior fontanel
 Reduced urine output (oliguria, anuria)
 Rapid small volume pulses

14. …
 Treatment of acute diarrhoea:
 The mainstay in the Rx of acute diarrhoea
is correction/prevention of fluid and
electrolyte deficits.
 Antibiotics not generally indicated

15. …
 Types of Rehydration fluids:
• Oral rehydration salts (ORS)-low
osmolarity ORS
• Ringer’s lactate
• ½ strength darrow’s solution
• Normal saline

16. …
 Fluid loss in dehydration:-
• Severe dehydration: >10% of body weight
• Some dehydration: 6-9% of body wt
• No dehydration: 0-5% of body wt

17. …
 No dehydration:
o Aim: to prevent development of
dehydration.
 Use Plan A rehydration:
 3Fs (3 rules of home Rx):
 Fluids
 Feeding
 Follow up

18. …
o Fluid (Plan A):
 Give extra fluid, as much as the child will
take
 B/feed frequently & for longer at each feed
 If the child is not exclusively b/fed, give
one or more of the following: ORS, food-
based fluids, or clean water
 Teach the mother how to mix & give ORS at
home. Give the mother 2 pks of ORS to use
at home

19. …
 Show the mother how much fluid to give in
addition to the usual fluid intake:
• Up to 2yrs of age: 50-100mls ORS after each
loose stool
• >2yrs of age: 100-200mls ORS after each
loose stool
 Tell the mother to:-
• Give frequent small sips from a cup
• If the child vomits, wait 10mins. Then
continue slowly

20. …
• Continue giving extra fluids until diarrhoea
stops
o Feeding: Continue feeding
o Follow up: When to return.

21. …
 Some dehydration:
 Managed in the health unit.
 Use rehydration Plan B:
 Fluid=ORS, Duration=4hrs
• Amt. of ORS req’d =75ml/kg over 4hrs.
 If the child wants more ORS than shown,
give more.
 Show mother how to give ORS solution

22. …
 If the mother must leave before completing
Rx:
 Show her how to prepare ORS soln at home
 Show her how much ORS to give to finish
the 4hr Rx at home
 Give her enough ORS pkts to complete
rehydration. Also give her 2pkts as
recommended in plan A.
 Explain the 3 rules of home Rx.

23. …
 Severe dehydration:
 Use rehydration Plan C:
 Start IV fluid immediately. If the child can drink,
give ORS by mouth while the drip is set up
 Amt. fluids given:
 100ml/kg of IV RL or NS divided as follows:
 Infants <12months (rehydrated over 6hrs):
 30ml/kg in first 1hr, then
 70ml/kg in the next 5hrs

24. …
 Children 1-5yrs (rehydrated over 3 hrs):
 30ml/kg in first 30min, then
 70ml/kg in the next 21/2 hrs
 Repeat once if radial pulse is still very
weak or undetectable.
 Reassess the child every 1-2hrs. If
hydration status is not improving, give IV
drip more rapidly.

25. …
 Reassess an infant after 6hrs & a child after
3hrs
 Classify dehydration then chose the
appropriate plan (A, B, or C) to continue Rx
 NB. If no IV access, start rehydration by NGT
or mouth with ORS soln:
 Give 20ml/kg/hr for 6hrs (total 120ml/kg).

26. …
 Reassess the child every 1-2hrs. If there
is repeated vomiting or increasing abd
distension, give the fluid more slowly.
 If hydration status not improving after
3hrs, send/refer the child for IV therapy.
…………………

27. Comparison of ORS solutions:
Mmol/L std ORS Low osm ORS
Na+ 90 75
Cl- 80 65
Glucose 111 75
K + 20 20
Citrate 10 10
Osmolarity 311 245

28. ///
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29. PERSISTENT DIARRHOEA
 Defn: Diarrhoea episode that begins acutely
and lasts for >14 days.
 On average, about 10% of acute diarrhoea
episodes become persistent (WHO), and
 Persistent diarrhoea accounts for about 30%
of hospital admissions in developing
countries.
 While only 10–20% of children with acute
diarrhea develop PD, approx. half of the
estimated deaths are attributed to PD

30. PD cont’d…
 Persistent diarrhoea is a syndrome of
 Malnutrition,
 Nutrient malabsorption,
 Various digestive disorders infection, and
 Diarrhoea
 Persistent diarrhoea and malnutrition are
closely related
 PD is largely a nutritional disease.

31. …
 It occurs more frequently in children who are
already malnourished and is itself an
important cause of malnutrition.
 Persistent diarrhea-malnutrition syndrome is
a complex of infection and immune failure
that involves protein, calorie & micronutrient
depletion, and metabolic disturbances.

32. …
 A single episode of PD can last 3-4 weeks
or longer and cause dramatic weight loss,
sometimes leading rapidly to severe
malnutrition, especially, marasmus.

33. Common causes of persistent diarrhoea
 Non-infectious causes:
 Malnutrition
 Lactose intolerance
 Cow’s milk protein intolerance
 Infectious causes:
 Cryptosporidium
 Microsporidium
 Shigella

34. …
 Giardia lamblia
 Rotavirus
 EAEC(entero adherent E.coli)
 HIV
 Small bowel bacterial overgrowth.

35. Management:
 Assessment:
 State of hydration (2 classifications):-
 Persistent diarrhoea (PD with no dehydration)
 Severe persistent diarrhoea (PD with some or
severe dehydration)
 Nutritional status
 Perianal excoriation
 Look for any possible infection

36. …
 Investigations:
o Stool:
 Bacterial culture
 Microscopy for RBCs & WBCs-suggest an
invasive bacterial infection.
 pH & reducing substance:- pH<5.5 & large
amt of reducing substance in stool indicate
CHO (lactose intolerance).

37. …
 Stool fat (qualitative by Sudan III test)
 Modified ZN-for cryptosporidium
 Treatment:
 Fluid and electrolyte management
 Nutritional therapy:
 Reduce temporarily the amt of animal milk
(lactose)
 Dietary modification:-lactose-free diet (e.g,
yogurt)

38. …
 Provide sufficient intake of energy
 50% of child’s energy should come from food
other than milk pdts
 Drugs:
 No blind therapy
 Give antibiotics appropriately/treat infections
 Give antiprotozoal if necessary
 Vitamins A, C, E, & folic acid (antioxidants)
 Zinc, selenium
…………

39. ///
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40. DYSENTERY
 Defn: Diarrhoea with visible blood
 Bacillary dysentery is a localized ulcerative
infection of the colon characterized by:
 Abdominal pain
 Frequent passage of loose stools containing blood
& mucus
 It can be caused by a number of organisms:
• Shigella. Most common cause of bloody
diarrhoea (Classic dysentery)-10%.
o 4 strains:-s. dysenteriae type 1, s. flexineri, s. boydii, s.
sonnie

41. …
• E.coli (ETEC)
• Campylobacter jejuni
 Others causes of dysentery:
 Salmonella
 Aeromonas hydrophilia
 Pseudomonas
 Entamoeba histolytica

42. …
 High risk patients:
 Young
 Malnourished
 Children with measles now or in the
previous 3 months
 Non-breastfed
 Elderly

43. …
 Transmission (shigella):
 Person to person
 Contaminated food or water
 Infectious dose: 10-100 organisms
 Survival:
 Soiled linen-up to 7months
 Fresh water-5 months
 Sour milk- 4 months
 NB: freezing doesn’t eliminate

44. Pathogenesis:
 All four species of Shigella (s. dysenteriae 1,
s. flexneri, s. sonnei, & s. boydii) cause disease in
humans.
 The disease process involves invasion of colonic
mucosal cells and induction of an intense
inflammatory response, leading to the death of
epithelial and immune cells and the formation of
colonic mucosal ulcerations and abscesses.
 Site:-colon; rectal + distal colon > proximal colon
 50% of patients may have watery diarrhoea.

45. Clinical features and diagnosis
 Clinical manifestations:
 Shigella primarily infects the lower intestinal
tract.
 The incubation period ranges from 1-7days,
with an average of 3 days.
 The disease typically begins with
constitutional symptoms such as fever,
anorexia, and malaise;
 diarrhea initially is watery, but subsequently
contains blood and mucus. Tenesmus is a
common complaint.

46. …
 Patients with Shigella gastroenteritis typically
present with high fever, abdominal cramps,
and bloody, mucoid diarrhea.
• Fever — 30-40%
• Abdominal pain — 70-93%
• Mucoid diarrhea — 70-85%
• Bloody diarrhea — 35-55%
• Watery diarrhea — 30-40%
• Vomiting — 35%.

47. …
 The spectrum of severity of disease varies
according to the serogroup of the infecting
organism:-
 Shigella sonnei commonly causes mild disease,
which may be limited to watery diarrhea, while
 Shigella dysenteriae 1 or Shigella flexneri
commonly causes dysenteric symptoms (bloody
diarrhea).
 The course of disease in a normal healthy
host generally is self-limited, lasting no more
than seven days when left untreated.

48. Laboratory invest:
 Stool analysis:-
 Visible blood, pus & mucus
 Pus + mucus in stool =bacterial infection.
 Stool culture
 Initial inoculation should be on >1 low selectivity
medium, such as MacConkey or eosin methylene
blue (EMB).
 Colonies that appear suspicious on low selectivity
media are usually subcultured onto highly
selective media such as SS (Salmonella-Shigella),
XLD (xylose-lysine-deoxycholate), HE (hektoen
enteric), or deoxycholate citrate agar.

49. Management:
 Assess & admit if:-
 Dehydration
 Severely ill
 Malnourished
 Young infant (<2/12)
 If none of the above;
 Give antibiotics for 5/7
 Follow up in 2 days & if better in 2/7,
continue the antibiotic to complete 5 days.

50. …
 If no change in 2 days, change to 2nd line
drug +/- flagyl and admit.
 Flagyl is given for E. histolytica if
trophozoites engulfing RBCs are seen in
fresh stool or rectal mucus.
 Antimicrobials-
 Start immediately
 No role in prevention
 Lessen complications
 Shortens duration of illness
 Speeds recovery

51. …
 1st line: cotrimoxazole
 2nd line: nalidixic acid
 In epidemic, start straight away on nalidixic acid
 Avoid antimotility drugs
 Management of dehydration:
 Prevent dehydration by increasing appropriate fluids
 Treat dehydration according to degree of
dehydration
 Patients with dehydration are at increased risk of
complications.

52. Complications:
 Intestinal complications:
 Rectal prolapse
 Colonic perforation.
• Infants or severely malnourished.
• s. dysenteriae 1
 Toxic megacolon
• s. dysenteriae 1 or s .flexneri.
 Intestinal obstruction
• s. dysenteriae 1

53. …
 Systemic complications:-
 Bacteraemia
 Metabolic disturbances-
 Electrolyte imbalance
 Protein-losing enteropathy
 Malnutrition-Increased catabolism secondary
to fever, Stool protein loss, Decreased intake
caused by anorexia, & Malabsorption.

54. …
 Neurologic complications:
 Lethargy
 Confusion
 Convulsions- due to hypoglycemia, shigatoxin,
hyponatraemia
 Anaemia
 Reactive arthritis or Reiter’s syndrome
• s. flexneri
 Haemolytic uraemic syndrome

55. …
 Prevention of diarrhoea (Read…..)