Paeditric Diarrhea

1. Acute Diarrhea in Children
Classification, Epidemiology, Etiology
Clinical Features, Complications, Management
Prognosis and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
Surely this Quran guides to the correct and the best path
The Holy Quran surah Bani-Israeel 17:9

3. Case scenario
• A 8 months old child presents to the hospital in emergency.
He started vomiting in the morning and vomited four times.
After six hours, he started passing watery stools.
• On examination, he is drowsy, has sunken eyes and skin
pinch takes 2 seconds to go back.
• His weight is 7 kg
• What is your diagnosis ?
• How much dehydration is present ?
• How will you manage this child ?

4. Acute Diarrhea
• Diarrhea is an increase in the:
• Fluidity of stools
• Volume of stools
• Number of stools
relative to the usual habits of child
• Diarrhea is 3 or more loose, liquid or watery
stools / day

5. Epidemiology of Diarrhea

6. Causes of death among children under 5 years – 2016
• Neonatal deaths
• Prematurity 18 %
• Asphyxia 12 %
• Cong anomalies 9 %
• Neonatal sepsis 7 %
• Infant & child deaths
• Pneumonia 16 %
• Other infection 10 %
• Diarrhea
• Injuries
• NCD
• Measles
9 %
6 %
5 %
1 %

7. Diarrhea in Children
• Diarrhea is a major cause of death in children under five
years of age
• Diarrhea is most common in children under 2 years of age
when it may occur every month
• Diarrhea kills because of the dehydration and malnutrition it
produces
• Lack of Breastfeeding, polluted water, unclean animal milk
feeds and contaminated food are important predisposing
factors of diarrhea

8. Etiology and Pathogenesis
of Diarrhea

9. Etiology of Diarrhea
• Virus
• Rotavirus (6 mo to 2 yrs) – 40 %
• Bacteria
• Escherichia coli (EPEC, ETEC, EIEC) – 25 %
• Vibrio cholera (rice-water stools) – 5 %
• Shigella (mucus and blood in stool) – 10 %
• Salmonella (fever and watery stools) – 10 %
• Protozoa
• Entameoba histolytica (loose stools) – 10 %

10. Transmission of Diarrhea Pathogens : Fecal-Oral

11. Transmission of Diarrhea : Fecal-Oral

12. Pathogenesis and Pathology

13. Morphology of Small Intestine
•Villi:
Covered mainly (90%) by tall
columnar absorptive cells
(enterocytes) having a
microvillus brush border
•Crypts of Lieberkuhn:
Covered mainly by short
columnar secretory cells
without brush border

14. Pathogenesis of Diarrhea
• OSMOTIC DIARRHOEA – Rota virus
• SECRETORY DIARRHOEA – E. Coli, Vibrio
• INVASIVE DIARRHOEA – Shigella, Compylobacter

15. Osmotic Diarrhea
Rota virus

16. Rota virus invades absorptive cells

17. Pathogenesis of Rotavirus Diarrhea
Absorptive cells replaced by Secretary cells
• Rota virus destroys
absorptive cells
• Secretary cells from
the crypts replace
absorptive cells
• Nutrient
Malabsorption and
diarrhea results

18. Rotavirus decreases absorption and
produces Osmotic Diarrhea

19. Secretory Diarrhea
Vibrio cholera

20. Pathogenesis of Secretory Diarrhea
Enterotoxigenic Bacteria
secrete an Enterotoxin
that stimulates the
production of cyclic AMP
Increased C-AMP leads
to:
Inhibition of absorption
of Na+ & Cl- from the
cells of villi
Stimulation of secretion
of Cl- from crypt cells

21. Secretary Diarrhea by secretion of Electrolytes
(Vibrio cholera and E. Coli)
• Vibrio cholera and E. Coli
Bacteria produce
Exotoxins
• Exotoxins stimulate
Secretion of Chloride,
Sodium and water from
crypt cells
• Profuse watery diarrhea

22. Invasive Diarrhea
Shigella

23. Invasive diarrhea by destruction of mucosa
(Shigella and EIEC)
• Toxins cause
destruction of mucosa
in colon and distal part
of ileum.
• Mucosal ulcers develop
• Visible (or microscopic)
blood and mucus in
stools

24. Clinical Features
and
Complications
of
Diarrheal Illness

25. Clinical Types of Diarrhea
• Acute watery diarrhea
(watery stools)
• Dysentery
(blood in stool)
• Persistent diarrhea
(diarrhea more than 14 days)
80
10
10
Acute Watery
Dysentery
Persistent

26. Clinical features
and
Clinical Assessment in Diarrhea
• History
• Vomiting – frequency, amount,
• Diarrhea – duration, frequency, consistency, amount
• Pain abdomen – relation to stools
• Fever – intensity, duration
• Blood in stools (dysentery) – frequency
• Examination
• Dehydration (occurs rapidly in children) – assess for signs of
dehydration and classify severity of dehydration
• Assess for Complications

27. Complications of Diarrhea
• Dehydration – develops rapidly
• Hypovolemic Shock – needs IV fluids in emergency
• Acute Renal Failure – due to prolonged hypovolemia
• Convulsions – fever, electrolyte changes
• Electrolyte Imbalance – hypo or hypernatremia
• Hypokalemia – leads to muscular hypotonia
• Post diarrheal ileus – hypokalemia, sepsis, anti-motility drugs
• Metabolic acidosis – due to loss of bicarbonate
• Perianal Nappy Rash – painful for child
• Persistent diarrhea – diarrhea prolonged to more than 14 days
• Malnutrition – develops with prolonged / repeated diarrhea

28. Frequent Diarrhea results in Malnutrition

29. Diarrhea leads to Malnutrition
DIARRHOEA MALNUTRITION

30. Assessment
and
Management

31. Assess Dehydration in all Children
History
• Frequency of Diarrhea
• Severity of Vomiting
• Thirst
• Urine output
Examination
• General condition
• Anterior Fontenal
• Eyes
• Mucus membranes
• Skin turgor
• Pulse rate and volume
• Peripheral skin temperature

32. Four Important signs for Dehydration
• Sensorium (lethargic OR restless OR normal)
• Sunken Eyes (very sunken OR sunken)
• Drinking (poorly OR eagerly OR normally)
• Skin Pinch (very slowly OR slowly OR immediately)

33. Sensorium (lethargic OR restless OR normal)

34. Sunken Eyes (very sunken OR sunken)

35. Drinking (poorly OR eagerly OR normally)

36. Skin Pinch (very slowly OR slowly OR immediately)

37. Assessment of Dehydration
SIGNS No signs of
dehydration
Some (mod.)
dehydration
Severe
dehydration
G General
condition
well,
alert
restless,
irritable
lethargic,
unconscious
E Eyes normal sunken sunken
M Mouth &
Drinking
normal thirsty, drink
eagerly
poor or una-
ble to drink
S Skin pinch returns rapidly returns slowly very slowly
2 or more signs in 1 column indicate that the
child classification falls in that column
Always start from Red Column

38. Fluid loss in Dehydration
• No signs of dehydration –
 Fluid loss from body =< 50 ml / kg
 Weight loss < 5 % of body weight
• Some dehydration –
 Fluid loss from body = 50 - 100 ml / kg
 Weight loss - 5 - 10 % of body weight
• Severe dehydration –
 Fluid loss from body > 100 ml / kg
 Weight loss > 10 % of body weight

39. Management of Dehydration
No signs of
dehydration
Some (mod.)
dehydration
Severe
dehydration
G General
condition
well,
alert
restless,
irritable
lethargic,
unconscious
E Eyes normal sunken sunken
M Mouth &
Drinking
normal thirsty, drink
eagerly
poor or una-ble
to drink
S Skin pinch returns rapidly returns slowly very slowly
Management
of dehydration
Plan A
at Home
Plan B
At OR Center
Plan C
At Hospital

40. Plan A – No signs of Dehydration
(Prevent Dehydration)
• Low osmolar ORS - 50 - 100 ml (1/2 to 1 cup) after each
loose stool
• Continue Feeding – Milk / Semisolids
• Continue Mother milk or other milk feeds as before
• Give small frequent semisolid feeds (if more than 4 -
6 mo)
• Rice, banana, potato are useful in diarrhea
• Follow-up – Child needs to be seen again if diarrhea or
vomiting are increasing or he is lethargic or has blood in
stool

41. Oral Rehydration Solution (ORS)
• Sodium Chloride - 3.5 gm
• Sodium Citrate - 2.9 gm
• Potassium Chloride - 1.5 gm
• Glucose - 20 gm
•Sodium
•Chloride
•Citrate
90 mmol/l
80 mmol/l
10 mmol/l
•Potassium 20 mmol/l
•Glucose 111 mmol/l
•Osmolarity 311 mmol

42. Low Osmolar Oral Rehydration solution (LoORS)
•Sodium Chloride - 2.6 gm
•Sodium Citrate - 2.9 gm
•Potassium Chloride - 1.5 gm
•Glucose - 13.5 gm
•Sodium
•Chloride
•Citrate
75 mmol/l
65 mmol/l
10 mmol/l
•Potassium 20 mmol/l
•Glucose 75 mmol/l
•Osmolarity 245 mmol

43. Plan B – Some Dehydration
(Correct Dehydration with ORS in 4 hours)
• Low Osmolar ORS - 75 ml / kg of body weight in 4 hours
• Continue Feeding – Mother milk
• How to give ORS – one spoon / minute slowly
• Where to give ORS – OPD or ORT area or Home
• Re-assess for dehydration after 4 hours and continue to
manage dehydration accordingly in Plan A, Plan B or Plan C

44. Plan C – Severe Dehydration
(Correct Dehydration with IV Fluids in 3 – 6 hours)
• Type of Fluid :for ALL types of dehydration
First Choice: Ringer’s lactate
Second Choice: O.9 % Normal Saline
• Amount:
100 ml / kg of body weight
• How given: (slow in infants)
• First 1/3 (30 ml/kg): rapidly in 1/2 - 1 hour
• Next 2/3 (70 ml/kg): slowly in 2.5 - 5 hours

45. Management of Diarrhea
• Increase Fluids – Oral fluids / ORS / IV fluids
• Manage Dehydration
• Continue Feeding – Milk / Semisolids
• Micronutrients
• Medications – rarely needed
• Manage Complications of Diarrhea

46. Drugs used in Acute Diarrhea
• Zinc (10 – 20 mg / day) is recommended in all children with
diarrhea for 14 days to help in recovery
• Antibiotics not effective for most cases of Acute Watery
Diarrhea (Rota virus, E coli, Salmonella)
• Antibiotics (ciprofloxacin) indicated for Blood in stool
(Shigella)
• Anti-emetics may be helpful to reduce vomiting
• Micronutrients (Vitamin A, Zinc help in recovery)

48. Drugs NOT recommended in Diarrhea
• Anti-motility drugs should never be used - can lead to
paralytic ileus and sepsis
• Adsorbents (kaolin) are not effective
• Anti-secretary drugs (racecadotril) do not have a significant
effect
• Probiotics do not give any significant advantage

49. Dysentery
• Dysentery is presence of mucus and blood in stool
• Dysentery is caused by Shigella, Compylobacter, and other
invasive organisms
• There may be fever, pain abdomen and tenesmus
• Management – Antibiotics
-- Ciprofloxacin oral or IV
-- Ceftriaxone injections in severe cases

50. Prognosis of Diarrhea in Children
• Acute diarrhea takes its time to resolve and usually recovers
in 5 – 7 days
• Antibiotics and other medicines do not reduce the severity
or shorten the duration of diarrhea
• Diarrhea may be prolonged to more than 14 days in 10 % of
cases
• Deaths in diarrhea are due to dehydration, associated viral
and bacterial infections, pneumonia, and malnutrition

51. Prevention

52. Prevention of Diarrhea in Children
• Vaccination –
Rota virus
Measles
• Breastfeeding, avoid animal milk
• Adequate nutrition (semisolid foods from 4-6 months)
• Micronutrients (Vitamins and Minerals)
• Safe drinking water, unpolluted milk, clean food
• Hand washing
• Control of insects and flies in the house

54. Case scenario
• A 8 months old child presents to the hospital in emergency.
He started vomiting in the morning and vomited four times.
After six hours, he started passing watery stools.
• On examination, he is drowsy, has sunken eyes and skin
pinch takes 2 seconds to go back.
• His weight is 7 kg
• What is your diagnosis ?
• How much dehydration is present ?
• How will you manage this child ?

55. Case scenario - Answers
• A 8 months old child presents to the hospital in emergency.
He started vomiting in the morning and vomited four times.
After six hours, he started passing watery stools.
• On examination, he is drowsy, has sunken eyes and skin
pinch takes 2 seconds to go back.
• His weight is 7 kg
• What is your diagnosis ? Acute Diarrhea
• How much dehydration is present ? Severe dehydration
• How will you manage this child ? IV Ringer lactate 100 ml/kg

56. Textbook of Paediatrics - 6th edition 2021
Pakistan Pediatric Association
• Written by senior teachers of
Pediatrics in Pakistan
• Provides up-to-date essential
information on Pediatric diseases
and Child Health
• Published by Paramount Books,
Pakistan
• www.paramountbooks.com.pk