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1. DIARRHEAL DISEASE IN CHILDREN
Dr. Amsalu

2. Introduction
• The term gastroenteritis denotes infections
of the GIT.
• The term diarrheal disorders is more
commonly used to denote infectious diarrhea
in public health settings.

3. Definition
The term diarrhea comes from Greek word
"diarrhoia", meaning to flow through.
Loose stool > 3x/24hrs. (WHO)
An increase in the fluidity, volume and
frequency of stools.
• A young infant normally has ~5g/kg of stool
output per day.

4. Definition
• Acute gastroenteritis: diarrhea lasting less
than 14 days
• Persistent diarrhea: lasting for > 14 days
• Chronic diarrhea > 1 month
• Dysentery : bloody diarrhea

5. Major causes of mortality among
children under 5
5
FACT
Burden usually severe in less developed
countries; in Ethiopia among the 5 common
killers of under 5 children.
Perinatal
22%
ARI
20%
Diarrhoea
12%
Malaria
8%
HIV
4%
Other
29%
Measles
5%

6. EPIDEMIOLOGY
• Episodes = 3.2 per child year
• Effects
– >700 million episodes of diarrhea annually in U5
yr of age in developing countries(WHO)
– Lead to18% of childhood deaths
– 1.8 million deaths per year globally.
– 30% of deaths in developing world.

7. Trends in global diarrhea incidence

8. • Rotavirus account for 35% of severe and fatal
watery diarrhea episodes, 500,000 deaths
per year worldwide.
• Early and repeated episodes of childhood
diarrhea during periods of critical
development, associated with malnutrition,
co-infections, and anemia may have long-
term effects on linear growth, as well as on
physical and cognitive functions.

9. Risks
Behavioral risk factors
– Inadequate breast feeding(first 4-6 months).
–Using feeding bottles
–Eating food hrs after cooking.
–contaminated food & water.
–Not washing hands.
9

10. Risks
Host factors
– Malnutrition,
– Measles,
– Immunosupression,
– young age
– vitamin A deficiency (increases the risk of dying
from diarrhea, measles, and malaria by 20–24%.)
– Zinc deficiency (increases mortality from diarrhea,
pneumonia, and malaria by 13–21%)

11. Transmission
• feco-oral route
• ingestion of contaminated food or water

12. Etiology
 Feco-oral transmission
 Shigella,
 Escherichia coli,
 noroviruses,
 rotavirus,
 Giardia lamblia,
 Cryptosporidium parvum,
 Entamoeba histolytica
 contamination of food or water supply
 cholera

13. ETIOLOGY OF DIARRHEA
• Common viral agents
– Rotavirus
– Norwalk-like virus and caliciviruses
• Less common viral agents
– adenoviruses
– astroviruses

14. Food borne
• Salmonella, Shigella, and, E. coli organisms
are the most common pathogens in
developing countries .

15. Antibiotic-associated diarrhea
• Clostridium difficile -pseudomembranous
colitis
• most cases of antibiotic-associated diarrhea
in children are not due to C. difficile.

16. Mechanism of absorption
• Water absorption in the intestines is 99% with
93% in the small intestine and the rest in the
large bowel.
– Pathologies in the small intestine will have large
volume loss than large bowel.

17. Mechanism of absorption
 Neutral sodium chloride (NaCl) absorption,
 cation exchanger, exchanges Na/H
 anion exchanger,exchanges Cl/HCO3
 Absorption through out small intestine but
predominant in the ileum
 controls intracellular pH
 Electrogenic sodium absorption(Na/K ATPase)
 Found in both small & large intestine but
predominant in the colon.

18. Mechanism ,
sodium co-transport.
Absorption coupled with organic substances like
glucose, amino acids, peptides
Functional only in the small intestine
Not affected during acute gastro enteritis
It is the basis for Oral Rehydration Salts.

19. PATHOPHYSIOLOGY
Diarrhea can be subdivided based upon
pathophysiology
1. Osmotic
2. Secretory
3. Motility
4. Inflammatory

20. Osmotic diarrhea
 occurs when an absorbable solute, such as
lactose, is not absorbed properly.
 Mechanism =Damage to intestinal epithelial cells
 Etiologies
 Rotavirus selectively invades mature enterocytes.
 Shigella produces a "shiga" toxin , which can cause
villous cell destruction leading to malabsorption.
 results :
 Increased solute in the gut lumen fluid retention in
the intestinal lumendiarrhea

21. Secretory diarrhea
• occurs when there is active secretion of water
into the gut lumen.
• infectious
– classic example is cholera
• viral enterotoxin
– rotavirus produces the non-structural glycoprotein
(NSP4). NSP4 causes calcium-dependent
transepithelial chloride secretion from the crypt
cells, with a resultant secretory diarrhea

22. Secretory diarrhea
• preformed toxins.
– Clostridia perfringens and Clostridia difficile
– shiga-like toxins of Escheria coli, Staphylococcus
aureus, and Shigella species
• non-infectious causes.
– vasoactive intestinal peptide and gastrin.
– bile acids, fatty acids, and laxatives
– congenital problems (eg, congenital chloride
diarrhea).

23. Motility
• uncommon causes of acute diarrhea..
• Hypomotility,
– Stasisinflammationbacterial
overgrowthsecondary bile acid
deconjugationmalabsorption.
• hypermotility
– irritable colon of infancy  decreased transit time
 malabsoption

24. Inflammation
 The most common cause of inflammatory
diarrhea is infection
 ingestion of the offending organism 
colonization of epitelium & adherence to the
enterocytemucosal invasion or production of
an enterotoxin .
 Intestinal inflammation can also be caused by
chronic diseases, such as inflammatory bowel
disease and celiac disease
 Present with bloody diarrhea

25. Pathogenesis of infectious diarrhea

26. Associated Clinical manifestations
– Fever: may be suggestive of an
inflammatory process & also occurs as a
result of dehydration,
– Vomiting suggests organisms that infect
the upper intestine (enteric viruses,
enterotoxin- producing bacteria, Giardia, &
cryptosporidium),
– Severe abdominal pain & tenesmus
26

27. Assessment of Diarrhea
—For how long?
—Is there blood in the stool?
—Assess for sign of DHN
—Look at the child’s general condition.
—Is the child: Lethargic or unconscious?
Restless and irritable?
— Look for sunken eyes.
—Offer the child fluid. Is the child: Not
able to drink or drinking poorly?
Drinking eagerly, thirsty?
—Pinch the skin of the abdomen. Does it
go back: Very slowly (longer than 2 27

28. Assessment Cont…
• Mistakes in taking a skin pinch:
– Pinching either too close to the midline or too
far laterally
– Pinching the skin in an horizontal direction
– Not pinching the skin long enough
– Releasing the skin so that the finger and thumb
remain in a closed position
• Classification of skin pinches:
– Normal — it goes back immediately
– Slowly — the fold is visible for less than 2
second
28

29. Assessment Cont…
Severe dehydration will have two of these signs:
 sensorium abnormally sleepy or lethargic
 sunken eyes
 drinking poorly or not at all
 very slow skin pinch
Some dehydration will have two of these signs:
 restlessness or irritability
 sunken eyes
 drinking eagerly
 slow skin pinch
No dehydration
 None of the above signs
29

30. Assessment Cont…
30

31. Degree of Dehydration
Factors Mild < 5% Moderate
5-10%
Severe >10%
General Condition Well, alert Restless, thirsty,
irritable
Drowsy, cold
extremities, lethargic
Eyes Normal Sunken Very sunken, dry
Anterior
fontanelle
Normal depressed Very depressed
Tears Present Absent Absent
Mouth + tongue Moist Sticky Dry
Skin turgor Slightly decrease Decreased Very decreased
**Pulse (N=110-
120 beat/min)
Slightly increase Rapid, weak Rapid, sometime
impalpable
**BP (N=90/60
mm Hg)
Normal Deceased Deceased, may be
unrecordable
Respiratory rate Slightly increased Increased Deep, rapid
Urine output Normal Reduced Markedly reduced
31

32. Types of dehydration
Isotonic 70-
80%(isonatremic)
Hypertonic
(hypernatremic)
Hypotonic
(hyponatremic)
Loses H2O = Na H2O > Na H2O < Na
Plasma
osmolality
Normal Increase
(> 295)
Decrease
(<275)
Serum Na Normal Increase
(>150)
Decrease
(<130)
Causes Boiled skimmed
milk, fever,
hyperventlation
Bacillary dysentry,
cholera, oral intake of
low electolite fluids
Thirst ++ +++ +/-
Skin turgor ++ Not lost +++
Mental state Irritable/lethargic Very irritable Lethargy/coma
Shock In severe cases Uncommon Common
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33. Laboratory Investigation
CBC
Stool specimen(mucus, blood,
WBC)
Rectal swab
Culture blood
 Stool culture: in bloody diarrhea,
WBC, immunocompromized
Sereum electrolites 33

34. Treatment of diarrhea
Main principle in management of acute
diarrhea is
1. Replace lost water and salts.
2. Continue to feed to prevent malnutrition.
3. Antibiotics & antiprotozoals when
needed.
4. Prevention of diarrhea
34

35. Treatment Cont…
• No sign of DHN  Plan A
–Fluid deficit < 5 %
–Can be treated at home
–More fluid than usual to prevent DHN
–Appropriate supply of foods to prevent
malnutrition
–Bring back the baby to the health
inistitution, if diarrhea doesn’t get better
or gets worse.
35

36. Home Fluids for Diarrhoea Must Be:
• Ideal home fluids contain:
–salts and nutrients (sodium, potassium,
chloride, and bicarbonate)
–calories to replenish diet
• Examples of home fluids:
–ORS solution
–salted soup
–salted drinks
36

37. Unsuitable fluids
• Fluids which are sweetened with sugar,
which can cause osmotic diarrhoea and
hypernatraemia.
Examples:
• soft drinks
• sweetened fruit drinks
• sweetened tea.
• Fluids which are stimulant, diuretic or
purgative effects eg,coffee
37

38. Some DHN  Plan B
• Fluid deficit 5-10%
• ORS 75ml/kg over 4-6 hrs.
• Reassess the degree of DHN
–If no sign of DHN home Rx with
replacement of on going losses(50-
100ml/bowel motion).
–If sign of some DHN repeat plan B
–If worse  IV RX
38

39. Plan B
 Oral Rehydration Solution (ORS):
• Effective in all types diarrhea
• Can prevent dehydration if given early in the
disease.
• Cheap, easy to administer; can be given by
mother at home.
• No chance of overhydration or electrolyte
overdose.
 Methods of administration: spoon, cup, dropper,
syringe, naso-gastric tube.
39

40. ORS Composition
 Sodium Chloride
 Tri-Sodium Citrate (bicarbonate)
 Potassium Chloride
 Glucose
40

41. Types of ORS
Solution Glu
g/dl
Na
mEq/L
K
meq/L
Cl
meq/
L
WHO 2.0 90 20 80
Rehydralyte 2.5 75 20 65
Pedialyte 2.5 45 20 35
Infalyte 2.0 50 20 40
41

42. Severe DHN  Plan C
• Fluid deficit 10-15%.
• IV fluid RL 
– 30ml/kg in the 1st hr(over 1/2hr if >1 yr) to
combat circulatory collapse.
– 70ml/kg in the 5hrs(2and half hr if >1yr)
• Reassess after the 1st hr  strong pulse &
↑BP , if not repeat 30ml/kg.
• Reassess an infant after 6 hours and a child
after 3 hours.
• Reclassify dehydration choose plan (A, B, 42

43. Indication for IV rehydration
1.Severe dehydration.
2.Severe and repeated vomiting.
3.Paralytic ileus and abdominal
distension.
4.Glucose malbsorption.
The preferred IV solution is R/L lactate
which will be changed to bicarbonate.
Also give ORS (about 5 ml/kg/hour) as
soon as the child can drink: usually after
3-4 hours (infants) or 1-2 hours
43

44. Treatment Cont…
Antimicrobial therapy is administered to
selected patients –
- to shorten the clinical course
- to decrease excretion of pathogens
and
- to prevent complications
Give antiprotozoal for patients with
proven ameabiasis and no response to
treatment for shigella
44

45. Treatment of diarrhea Cont...
Treatment of DHN in malnourished
pts
Whenever possible rehydration should be
PO.
IV infusions are very dangerous and not
recommended unless there is severe shock
or loss of consciousness from confirmed
dehydration.
Malnourished patients tend to develop
electrolyte imbalance with a great excess 45

46. Treatment of diarrhea Cont...
We use a special ORS for severely
malnourished ,called ResoMal.
A total b/n 50-100 ml of Resomal per kg of
body wt. is usually more than enough to
restore normal hydration.
Give this amount over 12 hrs starting with
5ml/kg every 30 minutes for the 2 hours
orally or by NGT and then 5-10 ml/kg per
hour .
For each watery stool give 30 ml of
resomal soln. 46

47. Treatment of diarrhea Cont...
• If the child is in shock and if the child is
unconscious ,then use IV fluids R/L with
5 % D/W or ½ N/S with 5 % D/W.
• Give 15 ml/kg over the 1st hour and
reassess the child if there is improvement
repeat the 15 ml/kg IV over the next hour .
• If there is no improvement then assume
that the child has septic shock.
• As soon as the child regains consciousness
stop the drip and treat the child orally or by
NGT with 10 ml/kg /hr of resomal. 47

48. Persistent Diarrhea
• Diarrhoea that occurs for 14 or more days
• Less than 10 percent of all diarrhoea but
associated with 30 to 50 percent of diarrhoea
deaths.
• Malnutrition greatly increases the risk of
death.
48

49. Causes
• Proximate Causes
–Secondary disaccharidase deficiency
–Salmonella sp.
–Shigella sp.
–Enteroadherent E. coli
–Cryptosporidium
49

50. Persistent Diarrhea
• Contributing Factors
– Protein energy malnutrition
– Micronutrient deficiencies
– Immunodeficiency
• Refer those who have persistent
diarrhoea AND who are also dehydrated
to hospital
– mortality is 8 to 10 times higher than that
with acute diarrhoea
– may need nutritional rehabilitation
50

51. Risk factors for Persistent
Diarrhea
• Age of baby < 1 yr.
• Malnutrition
• Recent introduction of animal milk
• Recent acute diarrhea
• Previous persistent diarrhea
N.B Important cause of mortality
51

52. Treatment of persistent diarrhea
• Correct Dehydration
• Correct Nutritional Problems
– Reduce disaccharides
– Increase energy intake
– Supplement micronutrients (possibly)
• Give Antibiotics for Dysentery
• Avoid These Therapies
– Antibiotics for watery diarrhoea
– Anti-motility agents
– Diluted feeds
52

53. Prevention of diarrhea
Wash your hands frequently,
especially after using the toilet,
changing diapers.
Wash your hands before and
after preparing food.
Breast feeding,
Nutrition,
Hygienic food preparation,
Vaccination for rotavirus,
measles……… 53