Diarrheal Diseases in Children is a common problem globally. It is defined as having 3 or more loose stools in 24 hours. It accounts for approximately 20% of under 5 deaths annually. Risk factors include failing to exclusively breastfeed for the first 6 months, poor hygiene and malnutrition. Treatment depends on the degree of dehydration and includes oral rehydration solution. Prevention strategies focus on exclusive breastfeeding, hygiene and immunization.

1. Diarrheal Diseases(DD) in Children
Hansa H.(MD)
June 13/6/2016
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2. Definition
• defined as the passage of three or more loose or watery stools
in a 24-hour period,
• A loose stool being one that would take the shape of a
container.
 For infants and children, this would result in stool output >10
g/kg/24 hr,
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3. Epidemiology
3-4 episodes/child /year.
Globally, there are about two billion cases of diarrheal disease
every year.
accounts for approximately 20% of under five child deaths
• Diarrheal disease kills 1.5 million children every year.
• Main cause of death is DHN
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4. • Diarrhea is a leading cause of malnutrition in children under
five years old
Diarrheal disease mainly affects children under two years old.
Very peak 6-12months of age  weaning + the time when
maternal immunity is used up
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5. Risk factors
1. Maternal behavior
Failing to breast-feed exclusively for the first 4-6 months of
life.
Using infant feeding bottles
Storing cooked food at room temperature for a long time
Failing to wash hands after defecation, after disposing of
faeces or before handling food.
Failing to dispose of faeces hygienically.
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6. 2 . Host factors
 Failing to breast-feed until at least 2 years of age
 Malnutrition
 Measles
 immunodeficiency
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7. Transmission
Fecal- oral
Direct & Indirect contact
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8. pathogenesis
In the small intestine, water is absorbed by three basic
mechanisms:
A) "Neutral" NaCl absorption : is mediated by two coupled
systems;
Na/H (cation exchanger)
Cl/HCO3 (anion exchanger)
B) "Electrogenic" sodium absorption or Na/K ATPase active
transport)
- occurs in both the large and small intestine, but
predominates in the colon.
- Sodium enters the cell via an electrochemical gradient.
- mechanism that is commonly damaged during acute enteric
infection, resulting in diarrhea
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9. C .Sodium co-transport (Na, A.A & glucose)
 operates throughout the small intestine but is not present in the colon.
 Sodium absorption is coupled to the absorption of organic solutes such
as glucose, many amino acids, and peptides.
 This co-transport mechanism remains intact during most acute
diarrheal disorders.
 It is for this reason that oral rehydration(ORS) is possible during acute diarrheal
illness
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10. • Small intestine absorbs large amount of ingested & secreted fluid, compared to large
intestine
• Thus, disorders of small bowel produce voluminous diarrhea, whereas disorders of
colonic absorption produce lower volume.
e.g. dysentery
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11. Under normal circumstances the absorptive process for water and electrolytes >
secretion.
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12. • Diarrhea results when there is an alteration of these mechanisms.
Absorption= =>Villous
Na, Amino acid, Glucose
Glucose facilitates the absorption of Na 25x ↑
Secretion ==> Crypts
Chloride
e.g. V.cholera toxin mediated conversion of ATP CAMP
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13. Etiology
1) Non infectious cause
Dietetic ;
- formula feeding :overfeeding
-Weaning foods: excess CHO
Malabsorption
- lactase enzyme defect
Endocrinopathies :thyrotoxicosis
DEFECTS OF ELECTROLYTE AND METABOLITE TRANSPORT
Congenital chloride diarrhea
Congenital sodium diarrhea
Acrodermatitis enteropathica
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14. 2) Infectious
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15. Types of diarrhea
 Acute diarrhea
-Short duration(less than 14 days)
 Persistent diarrhea
-Lasting 14 days or longer & is infectious in origin.
 Dysentery
-Blood in stool (seen or reported)
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16. • Based on mechanisms
-Secretory
-Osmotic
-Exudative
-Motility disorder(inc. or dec.)
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17.  Osmotic
1) Defect present:
-Digestive enzyme deficiencies
2) Transport defects
- Ingestion of unabsorbable solute
Examples:
Lactase deficiency
Sorbitol/magnesium sulfate
Infections
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18. Characteristics:
-Stop with fasting
-Watery, acidic
-Reducing substances
-osmolality; osmoles >2 × (Na+ + K+)
-No stool WBCs
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19. Secretory:
Defect:
Increased secretion(Cl)
Decreased absorption(Na)
Examples:
Cholera
Toxinogenic E.coli
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20. characterizes:
Persists during fasting
Watery
Normal osmolality; osmoles = 2 × (Na+ + K+)
No stool leukocytes
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21.  Exudative Diarrhea:
Defects:
-Inflammation
-Decreased colonic reabsorption
-Increased motility
Examples:
Bacterial enteritis
stool containes:
Blood, mucus and WBCs in stool
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22.  Increased motility:
Defect:
-Decreased transit time
Example:
-Irritable bowel syndrome
-Thyrotoxicosis
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23.  Decreased motility:
Defect:
-Neuromuscular d/o( Stasis =bacterial
overgrowth)
-Loose to normal appearing stool
Example:
Pseudo obstruction
Blind loop
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24. Clinical feature
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25. Three types of dehydration
lsotonic dehydration
The principal features of isotonic dehydration are:
i. there is a balanced deficit of water and sodium;
ii. serum sodium concentration is normal (130-150 mmolll);
iii. serum osmolality is normal (275-295 m0smolIl);
iv. hypovolaemia occurs as a result of a substantial loss of extracellular fluid
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26. Hypertonic (hypernatraemic) dehydration
The principal features of dehydration are:
i. Loss of water > loss of Na;
ii. serum sodium concentration is elevated (>l50 mmolll);
iii. serum osmolality is elevated (>295 mOsmol/l);
iv. Thirsty, irritability, seizure and brain damage .
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27. Hypotonic (hyponatraemic) dehydration
The principal features of dehydration are:
i. The deficit of sodium is greater than water.
ii. serum sodium concentration is low (<l30 mmolll);
iii. serum osmolality is low (<275 mOsmolIl);
iv. the child is lethargic; infrequently, there are seizures.
NB.these types of DHN are not differntiated clinically
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28. Dehydration( clinical)
Evaluate (WHO criteria)
• Level of consciousness
• Conscious and alert
• Restless or irritable
• Lethargic or unconscious
• Eyeballs
• Normal or sunken (recent )
• Thirst
• Drinks normally
• Drinks eagerly /thirst
• Unable to drink/breast feed
•
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29. • Skin Pinch
• Goes back quickly/slowly/very slowly
• Additionally:-
• Urine out put/pulse volume/weight/tear production
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30. Classification for degree of Dehydration (WHO)
I – Severe Dehydration ( 2 of the following signs)
• Lethargic or unconscious
• Unable to drink (breast feed)
• Sunken eyeballs
• Skin pinch goes back very slowly (> 2 second)
• Additional (weight loss >10%, weak /feeble pulse
II-Some Dehydration ( 2 of the following signs)
• Irritable or restless
• Sunken eyes
• Drinks eagerly /thirsty
• Skin pinch goes back slowely
• Additional (weight loss 5 –10%, dry tangue and buccal mucosa
III-No Dehydration – No enough signs of the above
Weight loss of <5%
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31. Treatment of child with acute diarrhea
I-No dehydration
Treatment plan A (Rx at home)
• give the child more fluids than usual
• Continue feeding
• Zinc supplement
• See again any time if no improvement
Fluids: ORS, food based fluids (Eg. Soup, rice water and yoghurt)
Amount: Age < 2years 100ml after each loose stool
Age 2 –10  100-200 ml after each loose stool
Older children – as much as they tolerate
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32. II-Some dehydration
-Treatment plan B ( ORS by mouth or NGT, 75ml/kg over 4 hrs
• Determine amount of ORS solution to give in the 1st 4 hrs
• Tell the mother to continue breast feeding
• Teach how to give the ORS and follow frequently
• Given sufficient ORS packets and correct advice
• Reassess and classify at the end
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33. III. Severe dehydration
Treatment plan C
Calculate 100ml/kg of RL or NS
Age < 12 months (give 30ml/kg, IV, in the first 1hr and the rest 70ml/kg in
the next 5hrs
Age  12 months(give the first 30ml/kg in the 1st 30 min and the rest
70ml/kg in the next 2.5 hrs
- Give sips of ORS by mouth in addition to the IV-fluids
• NB where IV Rx is not possible give ORS 20ml/kg /hr for 6hrs (total of
120ml/kg)through NGT
• Do not give antibiotics except for suspected cholera or dysentery
• Reassess frequently and classify at the end
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34. COMPOSITION OF STANDARD ORS
• Sodium=90mmol/l
• Potassium=20mmol/l
• Citrate=10mmol/l
• Chloride=80mmol/l
• Glucose=111mol/l
Dilute 1 pack of ORS in one liter of water
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35. Children with severe Malnutrition
• ReSoMal (Rehydration solution for the malnutrition)
• Contents:
Glucose = 125mmol/l Citrate = 7 mmol/l
Na = 45mmol/l Mg = 3mmol/l
K=40mmol/l Zn 0.3mmol/l
Cl= 70mmol/l Cu= 0.045mmol/l
• ORS-too high Na &too low K
• Dilute 1 packet of ORS with 2 liters of water and add 50 gm of sugar and 40ml
of mineral mix.(K, CU, Zn, Mg)
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36. • Reliable clues for dehydration in malnourished children
• Hx of recent watery diarrhea
• Thirst
• Sunken eyes (Recent )
• Weak or absent radial pulse
• Cold hands and feet
• Urine flow decreased
• Not Reliable
• Mental status
• Mouth, tongue and buccal mucosa
• Skin pinch
• Rehydration
• Rehydrate orally whenever possible
• IV only when there are definite signs of shock
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37. Dehydration
• Resomal schedule 5ml/kg every 30 min for the first 2 hrs and then 5-10ml/kg/hr for
10 hrs
• Reassess every hour
• Stop if:
• The RR, PR increases
• Juglar veins become engorged
• Increasing edema
• Rehydration is completed when:
- the child is no more thirsty
- Urine is passed
- No sing of dehyration
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38. Intravenous Rehydration
• Indicated only if the child is in shock
• Fluids
• Half- strength Darrows solution 5% glucose
• Ringers lactate 5% glucose
• 0.45 saline with 5% glucose
Schedule
• Give 15ml/kg over 1hr, and monitor carefully for signs of over hydration
• Replacement Rx = 30ml/each loose stole once the patient is hydrated
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39. Dysentery
Definition
• Dysentery is defined as diarrhoea with visible blood in the stools.
Etiology
• Shigella, (most common cause)
• Campylobacterjejuni,
• Salmonella
• Enteroinvasive Escherichia coli
• Entamoeba histolytica
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40. Epidemiology
- Is an important cause of morbidity and mortality
-10% of all diarrhoeal episodes in children under 5 years are dysenteric,
-About 15% of all diarrhoeal deaths is due to dysentry
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41. Clinical features and diagnosis
• visible blood in the diarrhoeal stool.
• dehydration ,fever,
• Cramping abdominal pain and
• pain in the rectum during defecation (tenesmus),
Diagnosis
• stool exam= numerous pus cells (Leukocytes), cyst or trophozoites of E.hystolytica
or Gardia
=Stool culture
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42. Complication –due to Desentry
-dehydration
- intestinal perforation,
- Toxic megacolon,
-rectal prolapse,
-convulsions (with or without a high fever),
-septicaemia,
-haemolytic-uraemic syndrome,
-prolonged hyponatraemia
-severe malnutrition
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43. Management of Dysentery
• Antibotics for 5 days (Choice depends on local sensitivity
• Treat dehydration
• Feeding
• Continue breast feeding
• Give small nutrient rich meals at least 6x/day
• Give extra meal each day for 2 weeks
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44. Laboratory investigation
Stool examination
Stool microscopy
Stool cultures
Stool ph
Reducing substances
Stool osmolality
Immunoassay for viral identification from stool
Stool AFS
Blood (serology , culture, CBC ,electroltes…)
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45. Complications
Electrolyte
imbalance
 Reactive arthritis
 GBS
 GN
 HUS
Dehydration
Malnutrition
 Anemia
 Hypoglycemia
 Sepsis
 Metabolic acidosis
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46. Prevention of diarrhea
Measures that interrupt the transmission of pathogens include:
• giving only breast milk for the first 4-6 months of life;
• avoiding the use of infant feeding bottles;
• improving practices related to the preparation and storage of weaning foods
• using clean water for drinking;
• washing hands (after defecation or disposing of faeces, and before preparing food or
eating);
• safely disposing of faeces, including those of infants.
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47. Measures that strengthen host defences include:
• continuing to breast-feed for at least the first 2 years of life;
• improving nutritional status (by improving the nutritional value of weaning foods
and giving children more food);
• immunizing against measles, Rota virus vaccine
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48. THANK YOU!
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