CHILDREN DIARRHEA IN CHILDREN, .pptx

1. ACUTE DIARRHEA IN
CHILDREN
Dr Noorul Qamar

2. DEFINATION
 Depending upon duration- <7 days but can persist
up to 14 days
 Passage of watery/ liquid stools at least 3 times in
24 hrs period.
 Recent:-- change in consistency is more important
than in frequency.
 In diarrhoea- stool output > 10gm/kg/24hrs (normal-
5mg/kg/24hrs)

3.  Most common cause of death among under 5
children worldwide
 In india 13% of 1.8 million U5 deaths are because
of diarrhea
 Represent 1/5 th of global child mortality due to
diarrhea
 1.1 – 6 episodes in children 0-4 yrs

4. FOLLOWING CONDITION ARE NOT A
DIARRHEA
 Frequently formed stools
 pasty stools in breast fed infant
 During /immediately after feeds (Gastrocolic reflex)
 Loose greenish yellow stools on day 3 or 4–
transitional diarrhea ; needs no treatment

5. CLINICAL TYPES
 Acute watery diarrhea –
starts suddenly
lasts several hrs/days
cause dehydration
 Acute bloody diarrhea ( dysentery)-
Acute diarrhea associated with blood
intestinal,sepsis,malnutrition,dehydration

6. DYSENTERY --- Bloody diarrhea with fever,
abdominal cramps, tenesmus, mucoid stools

7. CONSEQUENCES
 Malnutrition
 Dehydration
 Death

8. DIARRHEA CAUSES UNDERNUTRITION
 Impaired intestinal absorption causes loss of macro
& micro nutrients(zinc)
 Urinary loss of specific nutrients (vit A)
 Child with diarrhea often not hungry
 Mother often make mistake of not feeding the child
 Doctors don’t emphasize on the need of continued
feeding during diarrhea episodes

9. CAUSES

Common organisms causing diarrhea are:
Viruses : Rotavirus
Enterovirus
Norwalk,Calcivirus,coronavirus
Bacteria : E. coli
Shigella
Campylobacter jejuni
V. Cholerae, S.aureus
Salmonella (non typhoidal),
Aeromonas hydrophilia
Protozoal : Giardia duodenalis
Entamoeba Histolytica
Cryptosporidium

10.  Drugs- Antibiotics associated dia( C.difficle toxin)
 Fungus- Candida albicans
 Infection- UTIand Septicaemia
 Most common----Rotavirus and enterotoxigenic
E.coli

11.  Usually affect small bowel
 Large bowel affected by --- shigella , C jejuni, E
histolytica

12. SMALL BOWEL DIARRHEA LARGE BOWEL DIARRHEA
FREQUENT
Offensive
LESS FREQUENT
Odourless
LARGE QUANTITY SMALL QUANTITY
WATERY SEMI LOOSE /ASSOCIATED
WITH BLOOD
CAUSES DEHYDRATION NO DEHYDRATION UNLESS E
coli ,SHEGILLA
FLUID REPLACEMENT NOT MUCH
NO ANTIMICROBIALS ANTIMICROBIALS

13. ROTAVIRUS
 commonest cause of diarrhea in children between 6-24
months of age. (20-25%)
 It affects the small intestines
 spreads through faeco-oral route mainly in winter
seasons.
 It causes acute onset of fever followed by watery
diarrhea,canpersist up to 1 week
 Patchy blunting of intestinal villi with reduction of
mucosal disaccharides which returns to normal with in
2-3 weeks

14. E. COLI
 commonest cause of diarrhea in developing countries.
 spreads through contaminated food and water.
 Five types of E. coli have been identified:
a) Enterotoxigenic E. coli (ETEC): It produces
enterotoxins that cause secretion of fluid and
electrolytes and is commonest cause of traveler's
diarrhea. This diarrhea is self limited.
 b) Localized adherent E. coli (LA-EC):
Enteroadherance and production of a potent cytotoxin
are important mechanisms for causing diarrhea. This
disease is usually self limited

15.  c) Diffuse adherent E. coli (DA-EC):
Similar to LA-EC.
 d) Enteroinvasive E. coli (EIEC): They are
uncommon and occur in sporadic food borne
outbreaks and resemble shigellosis. It affects colon
and treatment with antimicrobials is essential.
 e) Enterohemorrhagic E. coli (EHEC): It seen in
Europe and parts of North & South America where
outbreaks can be caused by undercooked meat.
EHEC produces Shiga like toxin that affects colon.
It leads to acute onset of cramps, bloody diarrhea.
Type O157:47 can lead to hemolytic uremic
syndrome

16. SHIGELLA
 commonest cause of dysentery in children.
 Spread occurs from person to person contact
 commonly seen in hot, humid climates.
 Infectious dose is low (10 to 100 organisms).
 It affects the colon by invasion and also releases
Shiga toxin which is cytotoxic and neurotoxic that
causes watery diarrhea.
 S. flexneri is commonest in developing countries S.
sonnei is commonest in developed countries.
S. boydii is less common
S. dysenteriae causes epidemics. (resistent to
antimicrobials)
Patients present with dysentery.
Treatment with antimicrobials is essential

17. CAMPYLOBACTER JEJUNI
 diarrhea by invasion of the ileum and large
intestine.
 Produces cytotoxin & heat labile enterotoxin
 Diarrhea is watery
 few cases of dysentery may occur

18. V. CHOLERA
 seen in Africa, Asia and Latin America
 Caused by V cholera 01 & o139
 spreads through contaminated food and water.
 adheres to small intestine and produces an
enterotoxin similar to E. coli (ETEC)--- secretory
diarrhea
 Rice water stools,rapid dehydration & shock
 Fluid replacement and treatment with antimicrobials
is essential.

19. SALMONELLA
 1-5% of gastroenteritis
 from ingestion of contaminated animal products.
 affects the ileum
 releases enterotoxin that causes watery /exudative
diarrhea.
 Antimicrobials are not needed and can even
prolong shedding of the pathogen in the stool.

20. GIARDIA DUODENALIS
 Children between 1-5 years are most commonly
affected
 spread through faeco-oral route.
 affects the small bowel
 leads to acute or persistent diarrhea with
malabsorption and bloating.
 Treatment with metronidazole (5 mg/kg/dose tds for
5 days) or tinidazole (50 mg/kg single dose; max 2
doses)

21. ENTAMOEBA HISTOLYTICA
 invades the large intestines
 causes bloody diarrhea.
 Presence of trophozoites in stools is suggestive of
invasive disease
 treatment with metronidazole (10 mg/kg/dose tds
for 5 days)
 90% of infections are asymptomatic and are caused
by non-pathogenic strains of E. histolytica that need
no treatment.

22. CRYPTOSPORIDIUM
 persistent diarrhea in 5-15% of children in
developing countries.
 spreads through faecal-oral route
 affects small intestines causing mucosal damage
and malabsorption.
 Treatment with Nitazoxanide is effective.

23.  Diarrhea may be associated with systemic
infections ---
Acute otitis media
Pneumonia
UTI
Septicemia
Necrotizing enterocolitis

24. CLINICAL FEATURES
 History :
Stool frequency
Quantity and type of stool
Blood in the stool
Fever
Decreased passage of urine
Vomiting - pronounced in rotaviral
Abdominal distension
Altered Sensorium
Feeding history

25. EXAMINATION
Severe dehydration ---
two of following signs
lethargic/unconcious
sunken eyes
skin pinch goes back very slowly

26.  Some dehydration --two of the following signs
Restless , irritable
Sunken eyes
Skin pinch goes back slowly

27.  Evaluation of dehydration difficult in obese & malnourished
baby
 Useful & reliable signs for assessing dehydration
excessive fluid loss through vomiting /diarrhea
recent onset of sunken eyes mod.
eagerness to drink
prolonged capillary refill (>2sec)
weak / absent radial pulse severe
decreased /absent urine flow

29. DEGREE OF DEHYDRATION
FACTORS No Dehydration <3% Some dehydration
3-9%
SEVERE >9%
GENERAL
CONDITION
WELL ALERT Restless, thirsty,
irritable
Drowsy, cold
extremities, lethargic
Ant FONTANELLE N DEPRESSED Very DEPRESSED
TEARS N ABSENT ABSENT
EYES N SUNKEN VERY SUNKEN
MOUTH +TOUNGE MOIST Sticky Dry
SKIN TURGOR SLIGHTLY DEC Decreased Very decreased
PULSE SLIGHTLY INC Rapid, weak Rapid, sometime
impalpable
BP N Deceased Deceased, may be
unrecordable
RESP RATE MILDLY INCREASED Increased Deep, rapid
URINARY OUTPUT N
PLAN-A
Reduced
PLAN-B
Markedly reduced
PLAN-C

30. TYPES OF DEHYDRATION
ISOTONIC HYPERTONIC HYPOTONIC
Loses H2O = Na H2O > Na H2O < Na
Plasma
osmolality
Normal Increase Decrease
Serum Na Normal Increase Decrease
ECV
ICV
Decrease
maintained
Decrease
Decrease +++
Decrease +++
Increase
Thirst ++ +++ +/-
Skin turgor ++ Not lost +++
Mental state Irritable/lethargic Very irritable Lethargy/coma
shock In severe cases Uncommon Common

31.  No investigations are routinely required in acute
diarrhea. Majority of the cases need no
investigations.
 In a small proportion the following situations may
require investigations.
Stool culture should be done in cases of bloody diarrhea
and cholera only.
When diarrhea is prolonged beyond 5 days than stool
examination for giardiasis and amebiasis is justified.
Confirmation is with a fresh stool sample showing
trophozoites
To confirm a case of secondary lactose intolerance stool
pH and reducing sugar can be done.

32.  Diarrhea associated with clinical signs of
electrolyte imbalance or metabolic acidosis may
need serum sodium, serum potassium or blood gas
analysis
 Complete blood count, peripheral blood smear,
chest radiography, urine culture should be done
wherever needed in case of sepsis or if extra-
intestinal infection is clinically evident

33. INVESTIGATIONS
 Stool routine ----not of much value as more than 10
leukocytes per HPF are also seen in rotaviral
diarrhoea.
 There is no role of stool pH and reducing
substances in acute diarrhoea as the lactose
intolerance in this condition is self-limiting.
 Trophozoites of giardia and E Histolytica may be
sometimes demonstrated
 Stool culture usually grows E coli which may be a
commensal.
 Serum electrolytes may be needed in very
dehydrated patients.

34. MANAGEMENT
 ORAL REHYDRATION THERAPY ----
Home made fluids with salt & sugar
food based solutions
lassi
lemon water
coconut water
soups
thin rice kanji
dal water without salt

35. PATIENTS WITHOUT PHYSICAL SIGNS OF
DEHYDRATION
 Plan A ---
<24 mths : 50-100 ml after each stool
500ml/day
2-10yrs : 100-200 ml after each stool
1000ml/day
>10 yrs : as much as want after each stool
2000ml/day

36. WARNING SIGN-
 High purge rate
 Persistent vomiting
 Marked thirst
 Refusal to eat/drink
 Fever
 Blood in stool
 Rice watery stool-cholera
 Not better in3 days
 Anuria/failure of urine >12 hrs
 Altered sensorium/drowsiness/covulsion

37. PATIENT WITH PHYSICAL SIGNS OF
DEHYDRATION
 Plan B ------
75 ml per kg body weight ORS in 1st 4 hrs and then
reasess.
In children less than 6 months, give 100-200 ml
water if not breast-fed
On going losses 10-20 ml/kg/stool should be replaced
with ORS

38. SEVERE DEHYDRATION
 Comatose, lethargic, persistent vomiting,
abdominal distention : iv fluids
 Severe dehydration / shock : rapid iv infusion of
RL with 5% D
NS in 5%D

39. First 30ml/kg Then 70ml/kg
<12 months 1hr 5 hrs
older ½ hr 2 ½ hrs

40.  Reassess the child every 1-2 hrs
 Also give ORS as soon as 5ml/kg child can drinks
Monitoring-
Urine output
Electrolyte
Blood urea and creatinine
Blood glucose
Vitals monitoring and mental status

41. HYPONATRAEMIA
 Sod defficit= (135-observed sod) *wt (kg) *0.6
 Using 3% NaCl -------until 125meq/l then defficit
slowly over24 hrs

42. HYPOKALEMIA
 Serum potassium level <2 meq/l or <3.5 meq/l with
ecg changes or evidence of paralytic ileus
 0.3 meq/kg/hr : potassium chloride
 Metabolic acidosis- given- 1meq/kg iv over 1-2 min
followed by 0.5meq/kg iv every 10 min

43. ZINC SUPPLEMENTATION
 10mg/day elemental zinc for infants <6 months
 20mg/day : >6 months
 Total duration 10-14 days
 Iron containing zinc formulation should not be used
as it may interfere with zinc absorption

44. ANTIMICROBIAL THERAPY
 Indications:
1) suspected cholera with severe
dehydration
2)bloody diarrhea
3) associated systemic infections
4) severely malnourished or immune compromised
5)infection with giardia ,amebiasis,
cryptosporidium, salmonella

45. FOR CHOLERA
 Tetracyclines (not in infants) : 12.5 mh/kg/dose 4
times /day X 3 days
 Cotrimoxazole : TMP 5mh/kg/dose + SMX
25mg/kg/dose 2 times /day X 3 days
 Eruthromycin : 12.5 mh/kg/dose 4 times /day X 3
days
 Furazolidone : 12.5 mh/kg/dose 4 times /day X 3
days

46. ANTIMOTILITY AGENTS
 Diphenoxylate
 Loperamide
 Does not abort acute attack
 Give more time for harmful bacteria to multiply in
gut
 Causes abdominal distension, bacterial
overgrowth, sepsis

47. ANTISECRETORY AGENTS
 Racecadrotil
 Inhibit intestinal enkephalinase
 Dosage:- 1.5 mg/kg/dose upto 3doses per day for
children above 3 months and above.
 not to be used in children with renal, hepatic impairment
 contraindicated in patients with fructose intolerance,
glucose malabsorption syndrome saccharase -
isomaltase deficiency as it contains saccharose.
 Treatment should be continued till two normal stools are
recorded and treatment should not exceed 7 days
 Adverse effects:- Vomiting, fever, hypokalemia, ileus,
bronchospasm, skin rashes

48. PROBIOTICS
 Lactobacillus rhamnosus
 L plantarum
 Bifidobactria
 Enterococcus faecium SF 68
 Saccharomyces boulardii
 Colonise the bowel and exert beneficial effects on
human heath

49. PREBIOTICS
 non-digestible food ingredients that beneficially
affect the host by stimulating the growth and/or
activity of one or a limited number of bacterial
species already established in the colon, and thus
in effect improve host health.

50. SYMBIOTICS
 Symbiotics are mixtures of probiotics and prebiotics
that beneficially affect the host by improving the
survival and implantation of live microbial dietary
supplements in the GI tract of the host

51. PREVENTION
 Wash your hands frequently,
especially after using the toilet,
changing diapers.
 Wash your hands before and after
preparing food.
 Wash diarrhea-soiled clothing in
detergent and chlorine bleach.
 Never drink unpasteurized milk or
untreated water.
 Drink only bottled water.
 Proper hygiene.

52. REMEMBER
 Gastroenteritis is acute self-limited
illness.
 Diarrhea and vomiting in infancy and
childhood is usually due to viral
gastroenteritis.
 Fluid replacement with ORS is the
mainstay of management.
 Breast feeding should be continued, but
formula feeding should cease until
recovery.
 Antibiotics and antiemetics agents are
contraindicated.

53.  THANKS….@@@@@@@@