Acute Diarrhoeal Disease

2. What is diarrhoea?
Passage of 3 or more loose, liquid or watery stools
in a day

3. Types
Acute diarrhoea : <2 weeks, 90% attacks are self limited
(resolved by ORS)
Persistent diarrhoea :2-4 weeks
Chronic diarrhoea : >4 weeks
Dysentery: Bloody diarrhoea

4. Problem statement
• Worldwide-children deaths : 1.6 million every
yr
• World-wide 4% of all deaths
• Worldwide 18% of under five deaths
• In Southeast Asia -nearly 8% of all deaths
• In India 33% of total paediatric admissions
• In India 17% of all
deaths in
indoor paediatric patients

5. Agent factors
Virus
Rota,Astro,Adeno,Calci,Corona,Norwalk,Entero
Bacteria
Campylobacter Jejuni,E.Coli,Shigella,Salmonella,
V.cholerae,V.parahaemolyticus,Bacillus cereus
Others
E.Histolytica,Giardia,Trichuriasis
Cryptosporidium,Intestinal worms

6. Reservoir of infection
• Humans and animals:
Campylobacter,salmonella,
yersinia enterocolitica
Host factors
• Most common age: 6 months- 2 yr
• Highest at the time of
weaning (contaminated food,
contact with feces as infant starts to crawl)
• Common in non-breast fed infants
• Malnutrition, Measles
• Incorrect feeding practices
• Lack of hygiene

7. Environmental factors
In temperate climates
Bacterial diarrhoea: summer
Viral diarrhoea: winter
In tropical areas
Viral diarrhoea: whole year
Bacterial diarrhoea: summer,rainy season
Social factors
Poverty,ignorance,illiteracy
Mode of transmission
Faeco-oral
(water borne,food borne,fomites,fingers,dirt)

8. MANAGEMENT
ORAL REHYDRATION THERAPY
DRUGS
(ANTIBIOTICS,ANTIMOTILITY DRUGS)
NUTRITIONAL MANAGEMENT

9. ASSESSMENT
OF
HYDRATION STATUS

10. Look, Feel and Decide Chart for assessment of Dehydartion in diarrhoea
Look at
(CETTT)
Condition Well,Alert *Restless,
Irritable*
*Lethargic or
unconscious;Floppy*
Eyes Normal Sunken Very sunken
Tears +nt -nt -nt
Tongue Moist Dry Very Dry
Thirst Not thirsty *Thirsty,
drinks eagerly*
*Drinks poorly or
unable to drink*
Feel Skin
pinch
Goes back
instantly
*Goes back slowly* *Goes back very
slowly*
Decide No
dehydration
2 or more signs
including atleast
one * marked
(SOME
DEHYDRATION)
2 or more signs
including atleast one
* marked
(SEVERE
DEHYDRATION)
Treat Treat. A Weigh the
child,Treat.B
Weigh the
child,Treat C

12. Skin Pinch

13. sunken eyes

14. TREATMENT PLAN A
4 Rules of home
treatment 1.Give
extra fluid-
Breastfed frequently,
Give one or more : ORS solution, food based
fluids (such as soup,rice water and yoghurt
drinks), clean water
Teach the mother how to mix and give ORS.Give
the mother 2 packets of ORS to use at home.

15. Show the mother how much fluid
to give (After each loose stool and
between them) in addition to the
usual fluid intake:
Up to 2 years : 50-100 ml
2 years or more:100-200 ml
>10 years: as much as wanted

17. Tell the mother to:
Give frequent small sips from cup
In case of vomiting: Wait 10 min.then continue
but slowly,
Continue giving extra fluids until the diarrhoea
stops
2.Give Zinc Supplements:
Tell the mother how much zinc to give:
< 6 months (dose 10 mg/day): ½ tab x 14 days
>6 months (dose 20 mg/day): 1 tab x 14 days
3. Continue feeding
4. Tell the mother when to return

18. TREATMENT PLAN B
• Determine amount of ORS over 4 hour period:
75 ml/kg body
• If the child wants more ORS then give more
• For infants < 6 months (not breastfed):
give 100-200 ml clean water also
Age
(months)
< 4 4-12 12-24 24-60
Weight (kg) <6 6-<10 10-<12 12-19
Amount (ml) 200-400 400-70
0
700-90
0
900-14
00

19. Tell the mother to:
 Give frequent small sips from cup
 In case of vomiting: Wait 10 min.then continue but slowly,
 Continue giving extra fluids until the diarrhoea stops
After 4 hours
 Reassess as per assessment chart and treat accordingly
(Plan A,B or C)
 If the mother must leave before completing treatment:
•
•
•
Show her how to prepare ORS solution at home
Show her how to prepare ORS to give to finish 4 hr treatment
Also give 2 packets ORS
 Explain the 4 rules of home treatment:
1.Give extra fluid
3.Continue feeding
2.Give zinc supplements
4.When to return

20. TREATMENT PLAN C
Can you give the IV fluid immediately? YES
If the child can drink, give ORS orally while the drip is set up.
Age First give
30ml/kg in
Then give
70 ml/kg in
< 12 months 1 hour* 5 hour*
12 months - 5 years 30 min.* 2 ½ hours*
* Repeat once if radial pulse is still very weak or not detectable
•Reassess the child every 1-2 hours.
If hydration status is not improving give the IV drip more rapidly
•Also give ORS (5 ml/kg/hour) as soon as the child can drink.
•Reassess an infant after 6 hours and child after 3 hours:
Decide the treatment

21. Can you give the IV fluid immediately? NO
Is IV treatment available nearby (within 30 min.) YES
Refer urgently to hospital for IV treatment
(If the child can drink. Provide the mother with ORS solution and show her how
to give frequent sips during the trip)
Is IV treatment available nearby (within 30 min.) NO
Are you trained to use a nasogastric tube for rehydration? YES
Start rehydration (ORS solution) by tube/mouth : 20 ml/kg/hour for 6
hours.
Reassess the child every 1-2 hours
•If vomiting or increasing abdominal distension, give the fluid more slowly
•If hydration status is not improving after 3 hours, send the child for IV therapy
•After 6 hours, reassess the child and treat (A,B or C)

22. Are you trained to use a nasogastric tube for rehydration?
NO
Can the child drink YES Give ORS orally
NO
Refer urgently to hospital for IV/NG treatment
If the child is >2 years and there is cholera epidemic in the area
Give antibiotic for cholera

23. Naso-gastric tube
ORT

24. FOLLOW UP
• Follow up after 2 days in dysentery, after 5 days in
acute diarrhoea
• Return immediately if the child develops:
 Many watery stools,
 Repeated vomiting,
 Fever,
 Poor or unable to drink and eat/ breastfeed,
 Blood in stool

25. Composition of WHO -ORS
Ingredients Normal
(gm)
Low osmolarity
(gm)
Sodium chloride 3.5 2.6
Glucose 20.0 13.5
Potassium Chloride 1.5 1.5
Trisodium citrate
dehydrate
2.9 2.9
27.9 gm
(310 mOsm/l)
20.5 gm
(245 mOsm/l)
SGPT:2.6,13.5,1.5,2.9

26. Ingredients Low osmolarity
(mmol/l)
Sodium 75
Glucose 75
Potassium 20
Citrate 10
Chloride 65
245 mOsm/l
Hypo-osmolar ORS
SGPTC:7575,201065

27. Benefits of citrate ORS over bicarbonate ORS
1.Trisodium citrate made the ORS stable
2. Resulted in less stool output
Benefits of low-osmolarity ORS over normal ORS
1.Osmolarity reduced to avoid the adverse effects of hyper-tonicity
2.Need for unscheduled IV management reduced 33% in children
with hypo-osmolar ORS
2.Stool output and vomiting decreased
3.India-first country in the world to launch new ORS since June 2004

28. Home made ORS
1 tsp table salt + 4 heaped tsp sugar
in 1 litre of water
SUPER ORS
 Amino acid based ORS
 Amino acids (Alanine, Glycine co-transport the Na+) are
used in place of glucose
 Powder of boiled rice (50 mg/L) can be used in place of amino
acids
 Decrease purging rates and improve absorption

30. ORS

33. DRUGS IN DIARRHOEA
Antibiotics in Dysentery and Cholera
In Dysentery:
Cotrimoxazole
Better in 2 days
No Yes
Look for trophozites of E.Histolytica in stool Complete the 5 days treatment
Absent Present
Treat with Metronidazole
Refer to hospital
/Give Ciprofloxacin

34. Age/Wt. Cotrimoxazole
(2 times/day
for 5 days)
Nalidixic acid
(4 times/day
for 5 days)
Paediatric tablet
20 mg TMP+
100 mg SMX
Syrup
40 mg+
200 mg
(per 5 ml)
Tablet
500 mg
2 - < 12
months
(4- <10kg)
2 tab 1 tsp 1/4
1 - 5 years
(10-19 kg)
3 tab 1.5 tsp 1/2
DOSAGE OF COTRIMOXAZOLE AND NALIDIXIC ACID IN DYSENTERY

35. Anti-diarrhoeals
Loperamide
Useful in: Mild to moderate diarrhoea
C/I: Bloody dirrhoea, high fever,
worsening of diarrhoea inspite of
antidiarrhoeals, children
Dose :4 mg (2 tabs. Stat) ,
then 1 tab after each loose stool (max. 16 mg/day)

36. DRUGS WHICH SHOULD NOT BE USED IN DIARRHOEA
1.Neomycin(Damages the intestinal mucosa)
2.Purgatives
3.Atropine(Dangerous for children and dysentery patients)
4.Steroids(Useless)
5.Oxygen(Unnecessary)
6.Charcoal(No value)

37. NUTRITIONAL MANAGEMENT OF DIARRHOEA
1.Continue feeding
2.Energy dense foods should be given:
Khichri , rice with milk, curd and sugar,
mashed banana with milk, mashed potatoes and lentils
3.Foods with high fibre content should be avoided
4.During recovery, an intake of at least 125% of
normal requirement should be attempted

38. National diarrhoea diseases control programme
1.Short term: Appropriate clinical management
-ORT
-Appropriate feeding
-Chemotherapy
2.Long term
a. Better MCH practices
-Maternal nutrition
-Child nutrition: breast feeding, proper weaning,
supplementary feeding

39. b. Preventive strategies
-Sanitation
-Health education
-Immunization
-Fly control
-Food Hygiene:Boil it,cook it,peel it or forget it
c. Prevention and control of diarrhoeal epidemics
-Strengthening of epidemiological surveillance