Acute diarrhea in children MBBS Lecture

1. Acute Diarrhoea
Dr Muhammad Sajjad Sabir
MBBS, MCPS ,FCPS(Pediatrics(

2. Acute Diarrhoea
Definitions
Increased frequency and water
content of stools than is normal for
the individual
Usually: ≥ 3 stools per day
(consistency softer than normal --or–
one watery stool)
stool weight >10g /kg
stool weight >200g/day

3. Diarrhea
 Acute diarrhea:
Short in duration (less than 2 weeks).
 Persistent diarrhea:
Starts acutely & lasts more than 2
weeks
Severe Persistent diarrhea: dehydration +ve
 Dysentery:
Loose stool containing blood

4. Chronic Diarrhea
Definition
“Chronic diarrhea is defined
as a diarrheal episode that
lasts for ≥14 days’’

5. Common CausesCommon Causes
ofof
Acute DiarrhoeaAcute Diarrhoea

6. Viral gastroenteritis
 Infection – highly contagious
 Viral gastroenteritis (“stomach flu”)
Rotavirus
 Usually cause
explosive, watery
diarrhoea
 Typically last only
48-72hrs
 Usually no blood
and pus in stool

7.  Bacterial enterocolitis
 Sign of inflammation – blood or pus in stool,
fever
E. Coli bacteria
•Contaminated food or water
•Usually affect small kids

8. Bacterial enterocolitis
 Sign of inflammation – blood or pus in
stool, fever
Salmonella enteritidis
bact
•In contaminated raw or
undercooked chicken and
eggs

9. Bacterial enterocolitis
 Sign of inflammation – blood or pus in
stool, fever
Shigella bacteria
Campylobacter
bacteria

10. Cryptosporidium
• in contaminated
water – can survive
chlorination
 Parasites
Giardia lamblia
• in contaminated
water
•Usually not
associated with
inflammation

11. • Food Poisoning
Staphylococcus aureus
• Produces toxins in food before it is eaten
•Usually food contaminated left
unrefrigerated overnight

12. • Food Poisoning
Clostridium perfringens
• Multiplies in food
•Produces toxins in SI after contaminated food
is eaten

13. Common Causes of AcuteCommon Causes of Acute
Diarrhoea – cont.Diarrhoea – cont.
• Traveller’s Diarrhoea
• Drugs / medications

14. History
 Duration
 Frequency
 Consistency
 Presence of blood / mucus
 Fever
 Feeding
 Vomiting
 Abdominal pain

15. Physical
Examination

16. WHO Classification
of Dehydration
 No dehydration
 Some dehydration
 Severe dehydration

19. Severe Dehydration
If any two of the following signs are
present, severe dehydration should be
diagnosed:
 lethargy or unconsciousness
 sunken eyes
 skin pinch goes back very
slowly(2 seconds or more)
 not able to drink or drinks poorly

20. Skin pinch goes back very slowly
(2 seconds or more)

21. Some Dehydration
If the child has two or more of the
following signs, the child has some
dehydration:

restlessness/irritability
 thirsty and drinks eagerly
 sunken eyes
 skin pinch goes back slowly

22. No Dehydration
 Drinks well
 Eyes -- not sunken
 Skin pinch goes back rapidly
 Passing urine normally

23. Degree of Dehydration

24. Factors No
Dehydration
< 3% loss of
body weight
Some
Dehydration
3-9% loss of
body weight
Severe
Dehydration
>9% loss of
body weight
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
Resp Rate Slightly increased Increased Deep, rapid
Urine output Normal Reduced Markedly reduced

25. Management

26.  Severe or prolonged episode
of diarrhoea
 Fever
 Repeated vomiting,
 Refusal to drink fluids
 Severe abdominal pain
 Diarrhoea with blood or mucus
 Signs of dehydration
When Treatment is Needed?When Treatment is Needed?

27. Laboratory Investigation
 Blood CP
 Serum Electrolytes
 Urea & Creatinine
 Stool R/E
mucus, blood, and leukocytes
G. lamblia and E. histolytica
 Culture
 blood
 stool: cholera, shigella, campylobacter

28. Management
of
Severe Dehydration

29. Severe Dehydration
 Start IV fluid immediately
 If the child can drink, give ORS by
mouth
 Give 100 ml/kg Ringer’s lactate
(or, if not available, Normal Saline)
 If in shock 20ml N/Saline Bolus*
* Repeat once if radial pulse still very weak/undetectable

30. AGE First give
30 ml/kg in:
Then give
70 ml/kg in:
Infants
(< 12 months)
1 hour* 5 hours
Children
(12 mo to 5 yrs)
30 minutes* 2 ½ hours
Diarrhoea Treatment Plan C:
* Repeat once if radial pulse still very weak/undetectable
Administration of IV fluid (100 ml) to a
severely dehydrated child

31. Monitoring
 Reassess the child every 15–30 minutes
until a strong radial pulse is present.
 If hydration is not improving, give the IV
solution more rapidly
 Sunken eyes recover more slowly than
other signs and are less useful for
monitoring
 When the full amount of IV fluid has been
given, reassess the child’s hydration status

32. Management
of
Some Dehydration

33. Diarrhoea Treatment Plan
B:
Treat some dehydration with ORS
DETERMINE AMOUNT OF ORS TO GIVE
DURING FIRST 4 HOURS
ORS required (in
ml)=
weight (in kg) X 75

34. Diarrhoea Treatment Plan
B:
— If the child wants more ORS
give more
— Infants under 6 months who are
not breastfed, also give 100–200
ml clean water during this
period

35.  TEACH THE MOTHER
 HOW TO MIX ORS
 HOW TO GIVE ORS
 GIVE THE MOTHER 2
PACKETS OF ORS TO USE
AT HOME
Diarrhoea Treatment Plan
B:

36.  SHOW THE MOTHER HOW MUCH FLUID
TO GIVE IN ADDITION TO THE USUAL
FLUID INTAKE:
 Up to 2 years 50 to 100 ml after
each loose stool
 2 years or more 100 to 200 ml after
each loose stool
Diarrhoea Treatment Plan
B:

37. Diarrhoea Treatment Plan
B:
SHOW THE MOTHER HOW TO GIVE ORS
— Give frequent small sips from a
CUP
— If the child vomits:

Wait 10 minutes

Then continue ORS , but more slowly
— Continue breastfeeding whenever the

38. Diarrhoea Treatment Plan
B:
Explain
3 Rules of Home Treatment
1. GIVE EXTRA FLUID
2. CONTINUE FEEDING
3. WHEN TO RETURN

39. WHEN TO RETURN
If child develops any of the following signs:
 — drinking poorly or unable to
drink or breastfeed
 — becomes more sick
 — develops a fever
 — has blood in the stool

40. Management
of
Child with
No Dehydration

41. If there is no dehydration, teach the mother the
three rules of home treatment:
 (i) give extra fluid
 (ii) continue feeding
 (iii) return if the child develops any of
following signs:
— drinking poorly or unable to drink or breastfeed
— becomes more sick
— develops a fever
— has blood in the stool.
Diarrhoea Treatment Plan A
:

42. TELL THE MOTHER:
 — Breastfeed frequently and for longer at
each feed
 — If exclusively breastfed, give ORS or
clean water in addition to breast milk
 — If not exclusively breastfed, give one or
more of the following:
 ORS solution
 Food-based fluids (such as soup, rice water,
yoghurt drinks)
 Clean water
Diarrhoea Treatment Plan A
:

43. Role of Antibiotics
Indicated when
 Fever
 Blood/mucus in stool
 Severe or prolonged episode of diarrhoea
 Severe abdominal pain
 Amoebiasis
 Giardiasis

44.  Oral
 Co-trimoxazol
 Naladixic acid
 Cefixime
 Injectable
 Ampiciline
 Cirofloxacine
 Ceftriaxone
 Metronidazol
only when
 Amoebiasis
 Giardiasis
Role of Antibiotics

45. Role of Zinc
 25% reduction in duration of
diarrhoea episode
 30% reduction in stool volume
 Decreases morbidity & mortality
 Prevents recurrent diarrhoea

46.  Zinc supplementation is efficacious in
reducing severity and duration of
diarrhoea
 dose of Zn 2 RDAs per day for 10-14
days
 10 mg per day < 6 months age
 20 mg per day > six months age
Role of Zinc

47. Role of Probiotics
Probiotic – Live microorganisms
(bacteria or yeasts) which, when
administered in adequate amounts,
confer a health benefit on the host
Examples
 Saccharomyces boulardii (Enflore)
 Lactobacilli
 Enterococci
 Bifidobacteria

48. Mechanism of action of Probiotics
 competition for nutrition
 destruction of receptor site for toxin
 producing protease
 aid host with both the digestion and absorption of
nutrients
 Produce abundant lactate--lowering pH of intestine ,
limiting the growth of certain enteropathogens (eg
Salmonella
 colonise intestinal epithelia---depriving pathogens of
attachment sites
 increasing macrophage activity
 enhancing the production of immunoglobulins (eg
IgA)

49. Potential Advantages of Probiotics
 Multiple Mechanisms of Action
 Resistance is Infrequent
 Use May Reduce Exposure to Antibiotics
 Delivery of Microbial Enzymes
 Well Tolerated
 Benefit to Risk Ratio is Favorable

50. How to prepare ORS at home

51. Thanks….
But it’s not the end !!!

52. 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
 Proper hygiene

53.  access to clean water
 safe sanitation
 hygiene education
 exclusive breast-feeding
 improved weaning practices
 immunizing all children; especially measles
 keeping food and water clean
 washing hands with soap (the baby's as well)
before touching food
 sanitary disposal of stools
Prevention

54. Points to 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 mainstay of management
 Breast feeding should be continued,
but formula feeding should cease
until recovery.

55.  Antibiotics usually not required
 Antidiarrhoeal and antiemetics
agents are contraindicated
 zinc supplementation should be
given as an adjunct
 Use Probiotics
Points to Remember

57. Thank You for
Being Patient Till
the End

58. SOLUTIO
N
glucose
(g/L)
Na
(mmol/L)
K
(mmol/L)
Cl
(mmol/L)
BASE
(mmol/L)
OSMOLA
RITY
(mOsm/L)
Low
osmolality
ORS
13.5 75 20 65 10 245
WHO
(2002)
13.5 75 20 65 30 245
WHO
(1975)
20 90 20 80 10 311
Pedialyte 25 45 20 35 30 250
COMPOSITION OF COMMERCIAL ORS AND
COMMONLY CONSUMED BEVERAGES