This document provides information on the management of acute diarrhea in children. It defines acute diarrhea and dysentery. The most common causes are viral, bacterial, and parasitic infections acquired through the fecal-oral route. Rotavirus is the leading cause and can cause dehydration. Signs and symptoms include diarrhea, vomiting, fever and abdominal pain. Complications include dehydration, electrolyte disturbances, and malnutrition. Management involves fluid resuscitation, continued feeding, zinc and vitamin A supplementation, and antibiotics for bacterial infections. Close monitoring of hydration and electrolytes is important.

1. Dr Maila K.G
School of Paediatrics and Child Health
University of Limpopo

2.  Introduction and Epidemiology
 Aetiology
 Pathophysiology
 Signs and symptoms
 Complications
 Work-up including Classification
 Management
 Fluid and Electrolytes
 Feeding and Nutrition
 Prevention

3.  Define Acute diarrhea and Dysentery
 What causes diarrhea and how?
 Complications of Diarrhea
 Differential Diagnosis
 Develop an approach to management of acute diarrhea
 Complications

4. Definitions and Terms:
Acute Gastroenteritis (AGE): diarrheal disease of
rapid onset, with or without accompanying
symptoms, signs, such as nausea, vomiting,
fever, or abdominal pain
Diarrhea: the frequent passage of unformed
liquid stools (3 or more loose, watery stool per
day)
Dysentery: blood or mucus in stools

5.  Acute: short in duration of < 7 days
 Persistent diarrhea: starts acutely and lasts longer than 1 week

6.  One of the most common illness of infancy
 Second to respiratory illness as a cause of childhood deaths WW
 It represents a major cause of morbidity and mortality
 3-10 episodes of diarrhea/year/subject in children <5 yrs and
decreases to < 1 for children >5
 Deaths are usually a result of dehydration but malnutrition
plays an important role as it increases the incidence and severity
of diarrhea
 By 3 years, virtually all children become infected by the most
common agent

7.  AGE is a clinical syndrome produced by a variety of Viral,
Bacterial and Parasitic enteropathogens.
 AGE is almost entirely caused by infections acquired through
fecal-oral route, but ingestion of contaminated food or water also
plays a role
 We have: Non-enteric, Non-infectious and Infectious causes of
the Gastro-intestinal tract
 Episodes usually last 5-10 days

8.  Non-enteric causes:
 otitis media. Meningitis, sepsis generally
 Non-infectious causes:
 milk/food allergies, drug side effects, malabsorption
 Infections of the gastrointestinal tract
 Viral
 Bacterial
 Protozoal

9. Viral
Rotavirus
Enterovirus, Calicivirus
Adenovirus, Astrovirus
Bacterial
E.Coli, Shigella
Salmonella, Campylobacter
C.difficile, V. Cholera

10.  Entamoeba Hystolitica
 Giardia lamblia
 Cryptosporidium

11.  Rotavirus is known to be the most common pathogen in children
 It is more severe than other causes and more often results in
dehydration, Hospitalization, Shock, Metabolic disturbances and
Death
 Bacterial pathogens are more common where poor sanitation,
hygiene and water supply play a role causing dysenterey

12. Pathophysiology
The 2 primary mechanisms
(1) Damage to the villous brush border of the
intestinemalabsorption of intestinal contents an
osmotic diarrhea
(2) Release of toxins that bind to specific enterocyte
receptorsrelease of chloride ions into the intestinal
lumensecretory diarrhea

13.  Rotavirus attach and enter mature enterocytes at the tip of the small
intestinal villi
 Cause structural changes to the bowel mucosa, including villous
shortening and mononuclear inflammatory infiltrates in the lamina
propria
 This virus induce maldigestion of carbohydrates and their
accumulation in the intestinal lumen (in the absence of lactase)
 Malabsorption of nutrients and concomitant inhibition of water
reabsorption can lead to a malabsorption component of diarrhea
 Rotavirus secretes an enterotoxin, NSP4 which leads to a calcium-
dependent chloride secretory mechanism

14. Sign & Symptoms
 Nausea & Vomiting
 Diarrhea
 Loss of appetite
 Fever
 Headaches
 Abdominal pain
 Abdominal cramps
 Bloody stools
 Dehydration
 Lethargic

15.  Vomiting is largely attributed to local factors and poor gastric
emptying, and should not be treated with antiemetic drugs
 Abdominal pains are usually spasmodic due to disordered
motility or is associated with colitis in dysentery
 Diarrhea is the manifestation of secretion or absorption
disturbance and disordered motility, a symptom of damage
already done in the infected gut.

16.  Infectious outside the GIT e.g UTI or Meningitis
 Surgical problems: Intussusception
 Underlying immunodeficiency: HIV
 Primary gastrointestinal tract pathology
 Inflammatory bowel disease, cystic fibrosis

17.  Recognize poor perfusion and other signs of shock
 Cold peripheries
 Depressed LOC
 Increase capillary refill time (>3sec)
 Poor/weak peripheral pulses
 Reduced urine-output
 signs of dehydration.docx

18.  Altered LOC
 Intractable vomiting or ORS failure
 Severe dehydration with/without shock
 Young age <6 months with dehydration
 Dysentery <1 year
 Tender abdomen; suspected surgical diagnoses
 Persistent diarrhoea

19.  After resuscitation, in children with severe dehydration, shock or
other signs of metabolic, nutritional or other co-morbidities
 Electrolytes and serum acid base determination
 All severely dehydrated patients, mod dehydration with an atypical
presentation, malnourished children
 Blood glucose disturbances occur in severely ill patients as a result of
glycogen depletion with lack of intake, or associated with the stress
response of dehydration

20. Acute Long Term
Dehydration: neurological sequelae Susceptibility to reinfection
Electrolyte disturbance Malnutrition
Iatrogenic: complications relating to fluid
administration
Development of food intolerance
Metabolic acidosis Death
Hemolytic Uremic Syndrome
Death

21.  Large amounts of Sodium are lost in diarrheal stools
 In acidosis, a shift of intracellular potassium to EC compartment
results in a spurious elevation of the serum level despite
intracellular potassium loss
 Give K+ to all patients with severe diarrhea until dehydration
and acidosis are corrected
 Sodium disturbances occur frequently
 Sodium content of the stool water varies from plasma-like in
secretory diarrhea , to very low in pure Osmotic diarrhea

23.  Always SHOUT for HELP
 A…….B…..
 Circulation
 Establish vascular access or IO if failed venous access after 2 good attempts
 Give 20ml/kg of R/L or Normal Saline rapid infusion or 5ml/kg in aliquots X4
is much safer
 Watch for signs of circulatory overload i.e hepatomegaly, gallop rhythm or
basal crackles, puffiness of the eyelids, tachy-pnoea and –cardia.
 Repeat R/L 20ml/kg if patient is still shocked. Re-assess and give more if still
shocked
 Don’t-Ever-Forget-Glucose
 Re-assess ABC and response so far
 Give 1st dose Ceftriaxone 80mg/kg stat to cover sepsis

24.  ABC still as essential as the normally nourished patients
 Give 15ml/kg infusion over 30 minutes
 Re-assess and repeat if still shocked
 Give up to 4 boluses and thereafter, T/F to HC or ICU
 Patient response should guide further fluid therapy
 When shock has been treated successfully, proceed to the
management of dehydration.
 But remember your patient can go back into shocked if
improperly rehydrated

25.  Its NB to use solutions with sufficient Na conc. To prevent Hyponatremia
 ½ DD is appropriate if IV route is used, or ORS for enteral replacements
 Where vomiting is the main source of fluid loss, rehydration fluid
(0.45%NaCl and 5% Dextrose) with added K is appropriate
 Dose of ½ DD or ORS for rapid rehydration over 4 hours
 Some Dehydration: 50ml/kg over 4 hrs (12.5ml/kg/hour)
 Severe Dehydration: 100mls/kg/4hours (25mls/kg./hour)
 Rapid rehydration over 4hrs should not be used in severe malnutrition,
cardiac failure, severe pneumonia, encephalopathy etc.
 However, rehydrate over 24hours or even 48 hours
 APPROPRIATE RESPONSE AT 4.docx
 Severely malnourished have a deficient K and elevated Na levels, thus
require a special ORS: ReSolMal

26.  Should be given enterally wherever possible but intravenously
where nil per Os is absolute
 Fluid restriction to approximately 50-60% of maintenance should
be adhered to, where there is a risk of inadequate secretion e.g in
Renal failure
 NORMAL MAINTENANCE FLUID REQUIREMENTS.docx

27.  Losses need to be replaced by equal volumes of fluids of similar
composition
 For moderate losses, add 30mls/kg to maintenance requirements. But
give more if there’s a need
 For those taking enterally:
 <2years: 50-100mls AELS
 >2years: 100-200mls AELS
 Small frequent volumes of home based sugar salt solution as little as
5mls every minute, can be effective in preventing dehydration even in
vomiting cases
 Continue Breast feeding and oral feeding once perfusion is restored

28.  Zinc: reduces the duration and severity of diarrhea
 Antimotility agents like loperamide are C/I due to potentially
serious side effects (malignant hyperpyrexia, lethargy and
dystonia)
 Vit A: reduces the severity of diarrhea, but do not give if a dose
was given in the previous month
 All children with diarrhea get vit A and Zinc according to age
 Other drugs, Any use?

29.  Hypokalemia (<3): even when the serum K conc. Is normal, these
patients have a depletion of the total body potassium
 Plasma k level doesn’t always provide an accurate est of total
body deficit. There may be K shift from intracellular space to the
plasma.
 <3mmol/l: stat dose oral K <5kg= 250mg. 5-10kg=500mg and
>10kg=1g stat
 Ongoing losses: < 5kg: 125mg, 5-10kg:250mg and >10kg: 500mg tds
 Re-assess after 4 hours
 Stop when abnormal losses stop

30. K<2>1.5
K<1.5: PARALYSIS, MUSCLE
WEAKNESS,APNOEA
 Attach ECG: prolonged QT and
Flat T waves
 Give stat doses as previous slide
 Oral KCl: 100mg/kg 6hrly with
max dose 3g/day
 Plus IV correction
 Add to iv fluids (200mls): ½ DD=2ms
15%KCl, Saline=4mls 15%KCl
 Recheck in 4hrs and manage
accordingly
 Admit to HC/ICU
 Give stat dose accordingly
 Oral K: 100mg/kg 6hrly
 Plus IV correction
 If ICU: 0.3mml/kg in 50mls N
saline via C.Vein over 1hour
 Recheck in 2hours
 Manage ongoing losses and
replacement

31. MILD SYMPTOMATIC (120-130) SEVERE SYMPTOMATIC (<120)
 Evaluate pt: if euvolemic, manage
underlying illness
 Dehydrated: rehydrate over 24-48
hours
 Recheck electrolytes 4hourly,
manage ongoing losses
 ABC
 Stop seizures (iv phenobarb
10mg/kg)
 Single dose Hypertonic saline
infusion over 1 hour (formula)
 4ml/kg 3% saline
 Re-check electrolytes in 1 hour
 Manage on-going losses

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33.  Passage of mucus and blood in stools
 Shigella is the most common cause in children SA
 Clinical
 Sudden onset
 Abdominal cramps, peritonitis associated with fever
 Meningismus and convulsions may occur
 Exclude intussusception (abdominal pain, bile stained vomitus, red
current jelly like mucus in stools)
 Investigation: Stool culture confirms the diagnosis of Shigellosis
 Treatment…….

34.  Diarrheal disease causes a significant burden of disease:
increased morbidity and mortality
 Diarrhea is defined as having 3/more watery or loose stools per
day
 Acute diarrhea last less than 2 weeks
 Primary prevention: water sanitation and hygiene
 Rotavirus vaccination

35.  Handbook of Paediatrics 7th edition pg 121-129, 461-481
 Std Rx guidelines and Essential Medicines List 2013 (Dept
ofHealth) pg 2.9-2.17
 Gastroenteritis presentation by Prof T Rogers Dept of Clinical
Microbiology
 South African medical journal, vol 102,no.2 2012 (Management
guidelines for Acute infective diarrhea in infants) prof F
Wittenburg
 Acute gastroenteritis in children by Dr Alta Terblanche,
Professional Nursing Today 2010

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