Acute diarrhea is defined as sudden onset of loose or watery stools lasting less than 14 days. It is a major cause of death in children worldwide. Rotavirus is a leading cause of acute diarrhea in infants and young children. Management involves oral rehydration therapy based on the degree of dehydration. For mild dehydration, oral rehydration solution is given at home. Moderate dehydration is treated with oral and/or intravenous fluids in a healthcare setting. Severe dehydration requires intravenous fluids in a hospital. Early feeding and zinc supplementation are also recommended. Antibiotics may be used in certain infections but are not routinely recommended.

1. Acute Diarrhea
GMC

2. Definition
 DIARRHEA- Change in consistency and frequency of
stools i.e. liquid or watery stools, that occurs >3 times /
day.
 ACUTE DIARRHEA- Sudden onset of excessively loose
stools of >10ml/kg/day in infants and >200g/24 hr in
older children
Lasting for <14 days

3. Epidemiology
 Diarrheal disorders in childhood account for a large
proportion(18%) of childhood deaths, with an estimated 1.5
million deaths/year globally, making it the second most
common cause of child deaths worldwide
 The World Health Organization (WHO)and UNICEF estimate
that almost 2.5 billion episodes of diarrhea occur annually in
children < 5 yr of age in developing countries, with more than
80% of the episodes occurring in Africa and South Asia (46%
and 38%, respectively)
 Global mortality may be declining, but the overall incidence of
diarrhea remains unchanged.

4. Etiology of acute diarrhea
INFANT CHILD ADOLESCENT
AGE, Dysnerty AGE, Dysentry AGE, Dysentry
Systemic infections Systemic infections Systemic infections
Antibiotic associated Antibiotic associated Antibiotic associated
Overfeeding Food poisoning
Toxin ingestion
Hyperthyroidism

5. Etiology of AGE
• Bacterial
 E. coli ( ETEC, EPEC, EIEC, EHEC, EAEC)
 Shigella
 Vibrio cholerae
 Salmonella
 Campylobacter spp.
 Others : Bacillus cereus,
Clostridium difficile,
Staph. Aureus, etc

6. Continued…
 Viral :
 Rotavirus- one of the leading cause
 Norovirus spp.
 Enteric Adenoviruses serotype 40 and 41
 Others : Astrovirus, coronavirus, cytomegalovirus,
picorna virus
 Parasitic:
 Giardia lamblia
 Cryptosporidium parvum
 Entamoeba histolytica
 Isospora belli
 Others : Blastocystis hominis, Balantidium coli , etc

7. Risk Factors-
 Age – common in <2 yrs of age
 Poor sanitation
 Poor personal hygiene
 Nonavailability of safe drinking water
 Malnutrition
 Malabsorption
 Low rates of breastfeeding and immunization
 Concomitant infections like HIV
 Use of antibiotics

8. Pathogenesis
1. Bacterial diarrhea
NON-INFLAMMATORY
Bacteria produces enterotoxins
Stimulates production of cAMP
Inhibition of absorption of Na+
and Cl- from villi cells
Stimulation of secretion of Cl-
from crypt cells
INFLAMMATORY
Direct invasion or produce
cytotoxins
Disrupts mucosal
integrity
Consequent fluid, proteins
and cells(erythrocytes and
leucocytes) enter the
intestinal lumen

9. 2.Rota viral diarrhea
Rota virus invades the enterocytes of villi but spares crypt cells
Destruction of enterocytes in villi
Migration of immature crypt like cells over the destructed villi
Act as crypts like cells (no brush border enzymes)
Non absorptive and only secretory in function

10. 3.Protozoal diarrhea:
a. Mucosal adhesion(G. Lamblia, non virulent E.
histolytica and cryptosporidium):
shortening of villi + mechanical irritation+
superimposed colonization
b. Mucosal invasion (virulent E. Histolytica) invades
epithelial cells= microabscess and ulcer formation

11. Pathophysiology
ICF- 40%
TBW(60%)
ECF- 20% (diarrheal losses come from ECF Na+ K+)
decrease ECF volume
Isonatremic
(50%)
Hyponatremic (45%) Hypernatremic (5%)
Na+ conc. remains
same (140mEq/L)
Excess Na loss in stools
Dec serum Na
(<14OmEq/L)
Inc. S. Na+ (>150
mEq/L )
Same osmolality Decreased osmolality Increased osmolality
water moves from ECF to
ICF
Water moves from ICF
to ECF
Loss of skin turgor and elasticity Soggy, doughy or
leathery skin

12. Acute bloody diarrhea(dysentery)
 Refers to presence of grossly visible blood in stools
 Consequence of colonic infection by bacteria/amoeba
 Bacillary dysentery more common in children
 Etiology: Shigella spp, EIEC, EHEC, Salmonella and
campylobacter jejuni
 Grows in SI spreads to colon inflames the
mucosal cells of epithelium releases toxins breaks
through colonic wall causes necrosis
hemorrhage and inc. mucus production

13. Assessment of child with acute diarrhea
 Goals:
1. Determine type of acute diarrhea i.e. bloody or watery
2. Look for dehydration and other complications
3. Assess for malnutrition
4. r/o systemic infections
5. Assess feeding (pre and post illness)
 History
 Examination
 Laboratory investigations

14.  History:
 Age
 Breastfeeding +/-
 Loose stools- duration, episodes/day, volume, blood
mixed+/-, colour & consistency, tenesmus, foul smell+/-
 h/o vomiting, abdominal pain, fever, cough or any other
symptoms
 Feeding history- pre and post illness
 Drug history- opoids, anticholinergics, antimotility drugs
 Immunization history
 Socioeconomic history

15. Examination
 General appearance-
lethargic/alert/irritable/restless/unconscious
 Anthropometry-Height, weight, muscle wasting, edema
 Vitals:
 Pulse- weak and thready, inc. HR(dec in severe cases)
 BP- decreases
 RR- kussmaul breathing
 Temperature- febrile+/-
 General & systemic examination
 Look for depressed fontanelle, sunken eyes, absence of
tears, dry mouth ,distended abdomen, skin pinch, chest
indrawing, splenomegaly

16. Look at
Condition Well alert Restless Lethargic/unconscious
;floppy
Eyes Normal Sunken Very sunken & dry
Tears Present Absent Absent
Mouth & tongue Moist Dry Very dry
Thirst Drinks
normally; not
thirsty
Thirsty, drinks
eagerly
Drinks poorly/ isn’t
able to drink
Feel
Skin pinch Goes back
quickly
Goes back slowly Goes back very slowly
Decide No signs Some signs Severe dehydration
Treat Plan A Plan B Plan C

17. Lab Investigations
 Can be managed effectively even in absence of lab
investigations
 Complete blood count
 S. electrolytes
 Renal function test
 Stool microscopy & culture
 Arterial blood gas
 Urine R/E

18. Management Principles
 Rehydration and maintaining hydration
 Ensuring adequate feeding (nutritional)
 Oral supplementation of zinc
 Early recognition of danger signs and treatment of
complications

19. Treatment of dehydration
 Oral rehydration therapy

20. Biological basis of ORT:
Water and sodium is lost during diarrhea
however glucose dependent sodium pump
remains intact and functioning
Transports one molecule of glucose along with
a molecule of sodium and water across
intestinal mucosa
Results in repletion of Na and water losses

22.  Home available fluids

23. Plan A :
 Treated at home after explanation of feeding and danger
signs
Age Amount of ORS
or other ORT
fluids to give
after each stool
Amount of ORS to
provide for use at
home
<24
months
50-100ml 500ml/day
2-10 years 100-200ml 1000ml/day
10 years As much as wants 2000ml/day

24.  Mother must be explained about the use of ORS
 Show the mother how to use and mix ORS
 Give a teaspoonful every 1-2 min under 2 yr
 Give frequent sips from a cup for older children
 If the child vomits , wait for 10 mins and then give the
solution more slowly
 If diarrhea continues after the ORS packets are used
up, tell the mother to give other fluids as described
earlier or return for more ORS

25. Danger signs:
 Increased episodes of watery stool
 Continuing diarrhea for more than 3 days
 Persistent severe vomiting
 Marked thirst
 Eating or drinking poorly
 Fever
 Blood in stool
 Rice water stool
 Failure to pass urine for >12 hrs or anuria
 Altered sensorium, convulsion, drowsiness

26. Plan B:
 Treated in health centre or hospital
 Contains 3 components:
1. Daily fluid requirement:
Up to 10kg = 100ml/kg
10-20kg = 50ml/kg
>20kg = 20ml/kg
2. Rehydration therapy:
 Give 75 ml/kg of ORS within 4hrs orally
 If ORS not tolerated then NG tube can be used

27. 3. Maintenance fluid to replace losses:
 Started when sign of dehydration disappears (usually
within 4 hrs)
 ORS should be administered in volumes equal to
diarrheal losses
 Maximum to 10ml/kg per stool
 Breastfeeding and semi solid foods are continued
 Plain water can be offered in between

28. Guidelines for treating patients with
some dehydration
Age <4
months
4-11
months
12-23
months
2-4 yrs 5-14yrs >15 yrs
Weight <5 kg 5-8 kg 8-11 kg 11-16 kg 16- 20
kg
>30kg
ORS
(ml)
200-400 400-600 600-800 800-
1200
1200-
2200
>2200
No. of
glasses
1-2 2-3 3-4 4-6 6-11 12-20

29. Plan C:
 Treated in hospital
 Start i.v. fluids immediately
 Ringer lactate with 5% dextrose
 NS or plain ringer solution may be used as
alternatives
 Total of 100ml/kg of fluid is given
Age 30ml/kg 70ml/kg
<12 months 1 hr 5 hrs
>12 months 30 mins 2 and half
hours

30.  ORS solution should be started simultaneously
(5ml/kg/hr) if the child can take orally
 If iv fluids can not be given, then give ORS via NG
feeding at 20 ml/kg/hr for 6 hrs (total of 120 ml/kg)
 Child should be reassessed every 1-2 hr
 If there is repeated vomiting or abdominal distention,
give fluids more slowly
 If no improvement in hydration after 3hrs, iv fluids
should be started as early as possible

31.  The child must be reassessed every 15-30 mins for
pulses and hydration status after the bolus of 100ml/kg
of iv fluids
 Persistence of severe dehydration: iv infusion must be
repeated
 Hydration improved but some signs of dehydration
present: IVF stopped and treated as plan B
 No dehydration: IVF stopped and treated as plan A

32. Nutritional management:
 Early feeding during diarrhea:
 Decrease the stool volume by facilitating sodium and
water absorption
 Facilitates early gut epithelial recovery
 Prevents malnutrition
 Infants with exclusive breastfeeding must be continued
 Energy dense foods with less bulk are recommended in
small quantities but frequently (every 2-3 hrs)

33.  Avoids food with high fiber content like coarse fruits
and vegetables
 Enrich staple food with fat, oil and sugar; mashed
banana with milk or curd
 In non breastfed infants, undiluted cow or buffalo milk
after correction or dehydration with semi solid foods can
be given
 During recovery, give at least 125% RDA with nutrient
dense foods until child reaches pre-illness weight or
ideally normal nutritional status

34. Zinc Supplementation
 >6 months = 20 mg of elemental zinc/day
 <6 months = 10mg of elemental zinc/day
 Decreases severity and duration of diarrhea
 Reduces risk if persistent diarrhea

35. Symptomatic Treatment
 Vomiting :
 single dose of ondansetron (0.1-0.2 mg/kg/dose)
 Abdominal distention:
If bowel sounds are absent and distension is gross then
paralytic ileus must be suspected due to:
 Hypokalemia
 NEC
 Intake of antimotility drugs
 Septicaemia

36. Hypokalemia with paralytic ileus: give iv fluids
and NG aspiration
KCL : 30-40 mEq/L iv with parenteral fluids
provided the child is passing urine
 Convulsion: Due to
 Hypo or hypernatremia
 Hypoglycemia
 Hypokalaemia following bicarbonate therapy for acidosis
 Encephalitis
 Meningitis
 Febrile seizure

37. Drug therapy:
 Use of probiotics nonpathogenic bacteria
(lactobacillus, bifidobaterium):
 To prevent diarrhea
 Enhance the host protective immunity
• Antimotility drugs: Loperamide
 Not used in children with dysentery and probably
have no role on management of acute watery
diarrhea

38. Antibiotic therapy:
Not recommended for routine treatment
Indications:
 Infective agents : Shigella, V. cholerae, Etamoeba
histolytica
 Malnourished or prematurely born young (presumed to
have sepsis)
 Well nourished infants with diarrhea after the correction
of dehydration, antibiotic is considered:
 Sucking is poor
 Abdominal distension
 Fever or hypothermia
 Significant lethargy or inactivity

39. Antisecretary drugs: Racecadotril that exerts
antidiarrheal effects
Dysentery:
 ORS
 Zinc supplemantation
 Continue oral diet
 Antibiotis : shigellosis- ciprofloxacin 15mg/kg/dayXBDX 3
days
 Iv ceftriaxone: 50-100mg/kg/dayX3-5days
 Amoebic dysentery: tinidazole/metronidazole

40. Complications
Dehydration
Electrolytes imbalance
Renal failure
Convulsions
Micronutrients deficiencies (zinc, iron )
Severe systemic infections
Hemolytic Uremic Syndrome

41. Prevention
 Promotion of exclusive
breastfeeding
 Improved complementary
feeding practices
 Rotavirus immunizations
 Improved water and sanitary
facilities

42. References
Essentials Pediatrics, OP Ghai 8th Edition
Textbook of Pediatrics, Nelson 20th Edition