This document discusses the management of common childhood respiratory diseases. It focuses on upper respiratory tract infections like rhinitis, pharyngitis, tonsillitis, croup, and epiglottitis. It describes the causes, signs, symptoms, diagnosis, and treatment of each condition. Pertussis is also reviewed as it is a contagious bacterial infection of the respiratory tract that is particularly dangerous for infants. Proper management of respiratory diseases in children requires identifying the infection and providing symptomatic relief or antibiotic treatment when necessary.

1. UNIT-IV
common childhood disease

2. UNIT-IV:
Management of common childhood disease
This unit focuses on :
• Respiratory system disorders and infection (ARI)
• Gastrointestinal infections and infestations (CDD)
• Febrile illness (malaria, meningitis, measles)
• Nutritional deficiencies
• Protein Energy Malnutrition (PEM)
• Micro-nutrients deficiency (Vit A, D, C)

3. common Respiratory system disorders
in pediatrics

4. OBJECTIVES:
• By the end of this session each student should :
• identify upper and lower acute respiratory infections
• Identify causes, the clinical manifestations and complications of common
respiratory tract infections in pediatrics
• Describe the management and prevention ways of common respiratory infections

5. • Introduction
• The respiratory system serves to supply sufficient oxygen to meet metabolic
demands and remove carbon dioxide.
• Abnormalities in any of the multiple processes including
• ventilation,
• perfusion,
• and diffusion that are involved in tissue oxygenation and carbon dioxide removal can
lead to respiratory failure.

6. diagnostic Approach to Respiratory Disease
• Diagnostic Approach to
• A careful history and
• physical examination are essential to the accurate diagnosis of a child presenting with
respiratory signs and/or symptoms.
• Sometimes, but not always, additional diagnostic tests .
• The history should include question about:
• respiratory symptoms (dyspnea, cough, pain, wheezing, apnea, cyanosis),
• chronicity,
• timing during day or night,
• and associations with activities including exercise or food intake.
• The respiratory system interacts with a number of other systems, and
questions related / to other may be relevant,
• The respiratory system interacts witha number of other systems, and questions related / to

7. The Pediatric Airway
2/10/2024 7

8. Review anatomy of respiratory tract.
1.1. The upper respiratory tract
-The nose
- oropharynx
- Pharynx
- -Tonsils
-The larynx
1.2 .The lower respiratory tract.
- trachea
- bronchi
- lungs (alveoli)
2/10/2024 8

9. Acute Respiratory infection (ARI)
• Acute Respiratory tract infections may be devided into:
• upper and lower tract
• It is one of the leading causes of morbidity & mortality in
developing countries.
• More than 90% death in ARI due to pneumonia.

10. What are the common sign of ARI?
1.Fast breathing
2. Chest in drawing - the lower chest goes in when the child
is breath in.
3. Nasal flaring
4. Noisy breathing: wheezing (soft musical noise sound
heard w/n the child breaths out )
5. Fever
6. Stridor harsh noise sound heard when the child breaths in
7. Cough.
2/10/2024 10

11. Risk factor (predisposing factor)
• Malnutrition
• LBW
• Inadequate BF
• Poor ventilation
• Immunodeficiency state (AIDS)
• Non immunized child
• Environmental pollution
2/10/2024 11

12. Upper respiratory tract infections
2/10/2024 12

13. Upper respiratory infections
• Includes
• Rhinitis - Sinusitis
• Tonsillitis - Croup
• Otitis media - Pharyngitis
• Lower Respiratory tract infection Includes:
• Bronchitis - Bronchiolitis
• Pneumonia
2/10/2024 13

14. 1. rhinitis
• It is an inflammation of the mucus membrane of nose by
viral infection or allergic reaction .
common cold : Commonest URTI
• is a viral infection caused by rhinovirus with prominent
symptoms of
• rhinorrhea and nasal obstruction,
• absent or mild fever, and no systemic manifestations.
• It is often referred to as rhinitis but usually involves the sinus
mucosa and is more correctly termed rhino sinusitis
2/10/2024 14

15. Cause:-
• Rhinovirus - Commonest
• Corona virus
• less commonly, influenza, para influenza, and
adenoviruses.
• Viral infection of nasal epithelium causes an acute
inflammatory response with mucosal infiltration by
2/10/2024 15

16. Common Cold….
• Clinical presentation
- Watery nasal discharge (runny nose)
- Sneezing , nasal congestion (stiffness)
- Irritation of throat & eye water
- Usually lasts for 1 week
2/10/2024 16

17. Cont...
• There is often a change in the color or consistency of
nasal secretions, which is not indicative of sinusitis or
bacterial super infection.
• Examination of the nasal mucosa may reveal swollen,
erythematous nasal turbinate
2/10/2024 17

18. Treatment
• Management consists of symptomatic therapies.
• Advice to :-
• to have bed rest.
• take much hot fluid diets -
• to take tea with honey
• to avoid predisposing factors
• Vitamins
• Analgesics (Paracetamol)
N.B
• - Avoid use of antibiotics
2/10/2024 18

19. Complications and prognosis
• Otitis media - is the most common complication and occurs in 5% to
20% of children with a cold.
• Bacterial sinusitis, which should be considered if rhinorrhea or daytime
cough persists without improvement for at least 10 to 14 days or
• if severe signs of sinus involvement develop such as fever, facial pain, or
facial swelling.
• RX for bacterial sinusitis amoxicillin (45 mg/kg/day) for 7 days after
resolution of symptoms.
2/10/2024 19

20. 2. Pharyngitis (sore throat)
• It is an inflammation of the mucus membrane of pharynx,
including erythema, edema, exudates, or ulcers.
Etiology : viral ( >90% ) is the major cause, but self
limiting
• Rhinovirus - Coronavirus
• Adenovirus - Parainfluenza virus
Bacteria - (group – A Beta- hemolytic streptococcus)
2/10/2024 20

21. Pharyngitis
2/10/2024 21

22. Pharngitis ….Cont…
Clinical manifestation
• cough
• fever
• Sore throat
• White exudates on the throat
• Headache
• Dysphagia & odynophagia
• Tender & enlarged cervical lymph nodes.
• Enlarged tonsils
2/10/2024 22

23. Diagnosis
D/x – clinical manifestation
_throat Culture
• HISTORY
• Classic symptoms → Fever, throat pain, dysphagia
• Viral → Most likely concurrent URI symptoms
of rhinorrhea, cough, hoarseness, conjunctivitis &
ulcerative lesions
• Bacterial → Look for associated headache,
2/10/2024 23

24. • Physical Exam
VIRAL - vesicles/ulcerative lesions present on pharynx or
posterior soft palate
• Also look for conjunctivitis
Bacterial - look for whitish exudate covering pharynx and tonsils
• tender anterior cervical adenopathy
• palatal/uvular petechial
• rash covering torso and upper arms
2/10/2024 24

25. Diagnosis
• Streptococcal :
Throat culture(Gold standard)
Rapid Strep. Antigen kits
• Infectious Mononucleosis:
• CBC(Atypical lymphocytes)
2/10/2024 25

26. Differential diagnosis
• pharyngeal abscesses
• Peritonsilar abscesses
• Epiglotitis
• Thrush
• Autoimmune ulceration
2/10/2024 26

27. Pharngitis ….Cont….
Management
In case of viral
- bed rest
- Increased fluid intake (Home care)
- Paracetamole for fever & pain
In case of bacteria.
-Antibiotic (Benzathine pencilline)
2/10/2024 27

28. Dose of Benzathine pencilline)
Age dose
• < 12 month 300,000 IU
• 2-6 yrs 600,000IU
• 7-10yrs 1.2 million IU
• > 10 yrs Adult dose(2.4mIU)
• Other antibiotic (amoxicillin, Ampcilline, P.P.F e.t.c) for
10 days.
Complication of group- A Beta hemolytic
streptococcus
I suppurative - peritonsillar abscess
2/10/2024 28

29. 3. Tonsillitis
3.1 AcuteTonsillitis
- Is an inflammation and formation of edema of the tonsils.
• Also it is an Infection of throat which involves (tonsils,
adenoids,& Pharynx).
2/10/2024 29

30. Cause
viral (Adenovirus, Herpes simplex virus, Epstein-Barr virus
(EBV), Cytomegalovirus…)
• Bacterial (group A beta hemolytic Streptococcus
pyogenes (GABHS)), s. aureus, H influenza
2/10/2024 30

31. Clinical features
• Viral: has insidious onset and other signs of URTI like runny
nose, sneezing, coryza etc., low grade fever or no fever
• Streptococcal: is more common in children older than 2 years
and peaks in children between 4 and 7 years of age.
2/10/2024 31

32. Cont...
• May present with:
• abdominal pain, Vomiting
• pain upon swallowing,
• Headache, malaise
• High grade fever,
• Sore throat
• Diffuse redness and
exudates, petechiae over
the palates,
• and, tender cervical
lymphadenopathy.
2/10/2024 32

33. SIGNS
Bacterial tonsilopharyngitis VS Viral tonsilopharyngitis
Bacterial
• Erythematous throat with
exudation
• Enlarged tonsils
• Petechiae on soft palate
• Anterior cervical
Lymphadenitis
• + Fever
Viral
• Erythematous throat
• ulcers on tonsils
• + rhinitis
• +Conjuctivitis
2/10/2024 33

34. 2/10/2024 34
Clinical Evaluation

35. Acute bacterial tonsillitis.
The tonsils are enlarged and inflamed with exudates.
2/10/2024 35

36. Cont...
2/10/2024 36
Exudative
tonsillitis is a
common sign
of GABHS or
Epstein bar
virus
infection.

37. Complications
1. Suppurative (early) Complications
-Pharyngeal abscess
Peritonsilar abscess
• Fever, refusal to swallow
Stridor, trismus (spasm of the jaw muscles)
- Acute ottitis media , sinusitis, meningitis.
II. Immunologic (late) Complications
-Acute Rheumatic Fever
- Post streptococcal glomerulonephritis.
2/10/2024 37

38. 3.2 Chronic Tonsillitis.
• Usually follows repeated attacks of acute tonsillitis.
Clinical manifestation
• Persistent sore throat
• Tonsils may be hypertrophied
• Offensive breath(bad mouth odor)
• Cough
• Persistent enlargement of anterior cervical lympnodes
Rx
• Tonsillectomy is the Rx of choice
2/10/2024 38

39. Cont...
Indications of Surgery (Tonsillectomy)
• Obstructive sleep apnea
• Seven infections per year
• Five infections per year for two years
• Three episodes per year for three years
• Peritonsilar abscess
2/10/2024 39

40. 4 . Croup (Laryngo trachio bronchitis )
• Is acute inflammation of the larynx, Trachea and bronchi.
• Infants and young children develop more severe
disease because of their narrow upper airway.
• It affects children of age 3 month to 5 year
Causes:
• Viral (most common-para-influenza viruses) accounts
75%
• Bacterial (rare)
• Haemophilus influenzae type B,
• Streptococcus pyogenes,
• Streptococcus pneumoniae, and S. aureus
2/10/2024 40

41. Clinical manifestation
• Sudden onset of barky cough
• Hoarse voice
• Fever
• Dyspnea & cough
• Inspiratory strider
• cyanotic ( sign of air hunger )
• Respiratory distress
• May be abrupt in onset or be preceded by mild URI
symptoms
2/10/2024 41

42. Cont...
Natural course
• Symptoms are usually worse at night
• Usually resolve within 48 hours
• Often followed by upper respiratory infection
type symptoms
Danger signs
• Severe stridor on inspiration and expiration
2/10/2024 42

43. Diagnosis
• clinical manifestation
• Neck X-ray: Sub-glottic narrowing of the trachea
(“pencil end”) appearance.
• Chest X-ray: If complications or comorbid chest
infections are suspected.
2/10/2024 43

44. Croup…con’t…
Treatment
• High humidity
• Humidified oxygen life saving
• Prednisolone 2 mg /kg /day
• Tracheostomy or intubation can be life saving
• Observe v/s
• Antibiotic if bacterial
• Reassure parents & child
2/10/2024 44

45. 5. Epiglottitis
• Is an acute inflammatory (infectious) process involving
the epiglottis and surrounding structures.
causes
• H.influenzae type b causes almost all cases of
epiglottitis.
• Rarely streptococcus pnuermoniae and
• Streptococcus pyogeanes can lead to epiglotitis.
2/10/2024 45

46. Clinical manifestations
• Classically epiglottitis starts suddenly with rapid
progression to complete obstruction.
• Patients are toxic with high grade fever,
• sore throat,
• dysphagia, tachycardia,
• restlessness,
• drooling of saliva and stridor.
2/10/2024 46

47. Cont...
• Big children hyperextend their neck and sit leaning
forward.
• Throat examination, without adequate respiratory support
preparation, should be avoided since it causes sudden
reflex laryngeal spasm.
2/10/2024 47

48. Child with classic presentation of acute epiglottitis
2/10/2024 48
This child's "tripod" positioning (trunk leaning forward, neck
hyperextended, chin thrust forward) is indicative of
epiglottitis. Note the child's toxic appearance.
"sniffing" posture "tripod"

49. Diagnosis
•Mainly clinical.
•Laryngoscope shows cherry red epiglottis if it is done
with proper preparation for respiratory support or
intubation.
2/10/2024 49

50. Normal epiglottis and acute epiglottitis
2/10/2024 50
A) Normal epiglottis. B) Characteristic erythematous,
edematous epiglottis of acute epiglottitis.

51. Management
Maintenance of the airway
• Routine tracheostomy/nasotracheal intubation
• Oxygenation
Administer empiric antimicrobial therapy:
• Cefotaxime / ceftriaxone
PLUS
• Clindamycin OR vancomycin
Monitor
2/10/2024 51

52. 6. Pertusis (Whooping Cough)
• Pertusis is an acute bacterial infection of the respiratory
tract, which is contagious.
• Etiology: Bordetella Pertussis and Bordetella
Parapertussis
• Only B. pertussis produce pertussis toxin (PT), the major
virulence protein.
• pertussis toxin has cause histamine sensitivity, insulin
secretion, leukocyte dysfunction- causes inflammation.
• Common cause of mortality and morbidity in infants <2 yr.
2/10/2024 52

53. Clinical Manifestations:
• The disease has insidious onset and 3 phases.
1. Catarrhal phase(runny nose): Lasts 1-2 wks
• Cough, congestion and rhinorrhea.
• Variably accompanied by low-grade fever, sneezing,
lacrimation, and conjunctival suffusion.
• As initial symptoms wane, coughing marks the onset of the
paroxysmal stage.
2. Paroxysmal phase (outburst): Lasts for 1-2 wk.
• Characterized by repeated violent coughs lasting for several
minute followed by loud whoop.
• Cyanosis and sub conjunctival hemorrhage occurs due to
violent cough.
• vomiting and turning red with cough
2/10/2024 53

54. 3. Convalescent phase (recovering): ≥2 wk
• During this phase the cough may diminish slowly.
• Paradoxically, in infants, cough and whooping may
become louder and more classic in convalescence
• Highly communicable in the early catarrhal stage and
before the paroxysmal cough stage.
• Dx: Clinical findings especially in paroxysmal phase
2/10/2024 54

55. • Treatment:
• Antibiotics for super infections like pneumonia.
• Erythromycin
• Azithromycin is the preferred agent for neonates
Nursing Care:
• Proper feeding of the child, rest
• Proper ventilation
• Reassurance the mother (care giver)
• Prevention and Control: Immunization of children.
2/10/2024 55

56. 2/10/2024 56

57. 7. Ear infection
• Otitis media : it is an inflammation of the middle ear.
Cause Bacterial (Streptococcus pneumonia ,S. aureus H.
influenzae and Moraxella catarrhalis )
Viral: rare
I. Acute otitis media
• It is an inflammation and pus draining from the ear < 2 wks.
Clinical manifestation
II Chronic otitis media (COM)
• Chronic pus draining from the ear for about 2 wks or more.
2/10/2024 57

58. Pathogenesis
• The two important factors are Eustachian tube
dysfunction and URTI.
• Both lead to obstruction of the tubes and serous fluid
collection in the middle ear.
• If there is an associated entry of pathogenic organisms,
suppurative otitis media may follow.
2/10/2024 58

59. Clinical manifestations
Acute
manifestatio
2/10/2024 59

60. Cont...
Clinical diagnostic
signs
2/10/2024 60

61. Treatment
1. Medical Management
• Initiate high does antibiotics for 7-10 days
• Amoxicillin 60-80mg/kg/day in three divided doses
• Amoxicillin with clavulanic acid 50-90mg/kg/day TID
• Cotrimoazol ( 8mg/kg trimethoprime / 40 mg/kg
sulphamethoxazol) BID
• Clarithromycin, cefuroxime, clindamycin and ceftriaxone are
alternatives in case of resistance
• Ear wicking frequently to clear pussy discharge
• Analgesic- acetaminophen 15mg/kg PO or 20mg/kg PR every 4hrs.
PRN
2/10/2024 61

62. • Complications of OM
• Mastoiditis
• Hearing loss
• Intracranial (meningitis ,brain abscess)
Chronic otitis media
C/m
• Purulent discharge c offensive odour.
• Perforation of ear
Mgt
• Dry the ear by wicking:
Steps
1. Roll clean absorbent cloth.
2. Place the wick in the ear
3. Remove the wick when wet
• Treat fever & pain if present
2/10/2024 62

63. Chronic otitis media (COM)…con’t…
Antibiotic usually not effective, but a single antibiotic
course is tried.
Precaution
• Do not put oil or other fluid in to the ear
• Do not let the child go swimming
Mastoidits:-
• inflammation of the mastoid bone & cells.
Cause: - TB
- As complication of acute & chronic
otitis media.
2/10/2024
63

64. Mastoidits…con’t…
Clinical manifestation (c/m)
• Tender swelling behind the ear mastoid process or
tender on palpation.
• Fever and Pain.
Dx
- x-ray - C/M
Management
• Give paracetamol for pain & fever
• Antibiotics (vancomicine ceftriaxone )
• Steroid to decrease swelling and inflammation
(Hydrocortisone, dexamethasone)
• Surgical miringotomy tympanostomy tube placement,
2/10/2024 64

65. PNEUMONIA
• Definition:
• Pneumonia is an inflammation of the parenchymal structure of the lungs,
such as the alveoli and the bronchioles.
• Pneumonia is caused by
• bacteria,
• viruses,
• fungi,
• parasites and other non infectious agents.
• The etiologic agents are dependent basically on the age and the immunity
status of the child.
2/10/2024 Esayas Aydiko(MSc in pediatrics nursing) 65

66. Aetiology
2/10/2024 66

67. Cont.
2/10/2024 67

68. Clinical manifestation
• Severe pneumonia:
• Cough or difficult breathing
• Lower chest indrawing,
• Nasal flaring,
• Grunting in young infants.
• Fast breathing or abnormal breath sounds may also be
present.
2/10/2024 68

69. Cont...
• Pneumonia:
• Cough
• Fast breathing
• But no signs for severe pneumonia
• No pneumonia
• Cough or cold, if no sign for pneumonia or
severe pneumonia.
2/10/2024 69

70. Cont...
• Respiratory distress ;is manifested with
• Rapid and difficult of breathing,
• Nasal flaring,
• Intercostal retraction,
• Chest indrawing and cyanosis.
Other possible findings ;
• Crepitation ,
• Diminished breath sounds,
• Bronchial breathing and dullness on percussion
2/10/2024 70

71. Diagnosis
• Mainly reached on the basis of clinical features.
• A chest X-ray in case of failure to respond to
treatment & complications such as;
 pleural effusion,
 Atelectasis, or
 Abscess formation.
2/10/2024 71

72. RX of sever pneumonia in hospital.
1. I.V Antibiotics Crystalline pencilline 100,000 Iu /Kg/24 hrs.
2. Supplementation of 02.
3. Maintenance of adequate fluid intake.
Prevention & control of ARI.
• B/F , Early diagnosis & Rx (case mgt).,, Weaning
• Vit- A supplementation
• Health Education.
• Avoid over crowding.
• Minimize exposure to smoking
• Prevention of malnutrition .
• Immunization against measles, streptococcus pneumonia & Hemophilus influenza type b e.t.c
2/10/2024 72

73. Referral Criteria
- Refer only if expected that the pt will receive better care.
- If this is not possible needless referral avoided, instead treat with
available antibiotic.
- If you think the mother will not take the child to hospital or delay, or
what ever the reason; you should take the following steps.
• If timely referral is likely, give first dose of antibiotic.
• If there is long referral time, give additional doses.
• If referral is un certain, give full course.
2/10/2024 73

74. Standard case mgt of ARI (Pneumonia) in IMNCI
• Selecting antibiotic based on the efficacy, cost, easy
administration, side effect and sensitivity of
antimicrobial.
• 1
st
line: - Antibiotic - Cotrimoxazole
• 2
nd
line: - Antibiotic -Amoxicillin.
2/10/2024 74

75. Cotrimoxazole BID for 5 days
syrup 240 mg/5ml
Amoxicillin TID
for 5 days syrup
125mg/5ml
Adult tablet 480 mg 120mg syrup tablet 250
mg
syrup
1-2 month
< 4kg
1/4 1/2 2.5 1/4 2.5 ml
2-12
month/4-
10 kg /
1/2 2 5 ml 1/2 5 ml
1-5yrs /10-
19 kg/
1 3 10ml 1 10 ml
2/10/2024 75

76. THANK YOU

77. Diarrheal Diseases
2/10/2024 77

78. 2. Diarrheal diseases
Definition :
• Diarrhea is a passage of three or more loose or watery
stools per 24 hrs.
• In children < 6month, diarrhea is defined as daily stools
with a volume greater than 10 g/kg/
• In children >6month, diarrhea is defined as daily stools
with a weight greater than 20 g/kg.
• In practice, this typically means loose or watery stools passed 3
or more times per day
2/10/2024 78

79. Epidemiology
2.1 Morbidity:
• Second cause of under five mortality (after pneumonia)
• Complicated by malnutrition and poor hygiene
• Common in poor society due to lack of clean water, waste
disposal and unclean environment
• Diarrhea incidence is high in the bottle fed than in
exclusively breast fed infants.
2/10/2024 79

80. Cont…
• Diarrhea is most common in children b/n 6 month to 2
years.
• It is also common in babies less than 6 month who are
drinking cow’s milk ( formula feeding).
2.2 Mortality: -
• Death is mainly due to severe dehydration
• Globally Diarrheal diseases accounts 19% death.
• 50% watery diarrhea < 2years of age are caused by Rota virus.
2/10/2024 80

81. Etiology
• Viral: - Rotavirus, Measles virus, corona and adenoviruses
• Bacterial: - E.coli, shigella, campylobacter, salmonella
• S. aures ,Vibro cholera
• Protozoa Gardia lamblia Entamoeba .H
• Drug - ( Antibiotic & laxative)
• Allergy - to certain foods (Milk, wheat…)
• Malabsorption: Autoimmunity, enzyme deficiency
• Toxin (food poisoning):Toxins of s,aureus, E.coli etc
2/10/2024 81

82. Types of diarrhea
Types Greatest Danger
1. Acute watery diarrhea (80%
of cases)
Dehydration
K +loss
2. Bloody diarrhea (Dysentery)
10% of cases
Tissue damage
Toxemia(sepsis)
3. Persistent diarrhea(> 2 wks)
10% of cases
Malnutrition
4. Chronic diarrhea (>4wks ) Malnutrition
2/10/2024 82

83. Definitions of classifications
1. Acute watery diarrhea  is an abrupt onset of
watery diarrhea occurred due to poisoning and
infection of virus and bacteria.
• An episode of diarrhea lasting <14days usually , DHN and
serum electrolytes disturbance contributes for malnutrition.
2. Dysentery Diarrhea with visible blood in it.
3. Persistent  lasting more than 14days
4. Chronic  lasting more than 1month
2/10/2024 83

84. • There are two classifications for persistent diarrhea:
• Severe persistent diarrhea
• Persistent diarrhea
• Severe persistent diarrhea: If a child has had diarrhea for 14 days and
has some or severe dehydration.
• Persistent diarrhea: A child who has had diarrhea for 14 days or more
and has no signs of dehydration.
• The leading cause of diarrhoea in infants is the rotavirus followed by
enteric adenoviruses.
• Shigella is most frequently a pathogen in children between 1 to 5
years with bloody diarrhea.
• Amoebic dysentery is rare in young infant.
2/10/2024 84

85. Cont...
Common causes of chronic diarrhea
• HIV infection (Cryptosporidiosis , Isosporiasis)
(TMP-SMZ drug of choice))
• Malnutrition (Repeated infection)
• Celiac disease (Gluten sensitivity)
• Gardiasis
2/10/2024 85

86. Cont...
Pathogenesis
• Feco-oral transmission
• Proliferation of pathogens in the intestine
• Mucosal damage and microvillus atrophy
• Fluid exudation and secretion in to the intestine
• Malabsorption and further fluid loss
2/10/2024 86

87. Mechanism of diarrhea
1. Secretory diarrhea (enterotoxins like cholera toxin, E.coli toxin,
S.aureus toxin) - decrease in the digestive and absorptive function of
the villus epithelium & Excessive secretion by crypt epithelia (secretory
cells )
2. Inflammatory diarrhea (bacteria, viruses, parasites, autoimmunity)
3. Osmotic diarrhea (malabsorption, enzyme deficiency)
4. Hypermobility ( irritable bowel syndrome )
5. Hypo motility (bacterial over growth)

88. Risk factors
Behavioral & practice that increase risk of diarrhea
Lack of exclusively BF for the first “6” month of age
Using infant bottle feeding.
Keeping cooked food at room temperature.
Poor sanitation (personal, environmental)
Poor weaning practice
Improper waste disposal method (falling to use latrine)
2/10/2024 88

89. Host factor increase susceptibility to diarrhea
• Under nutrition - Measles
• Immuno deficiency - age
• Not vaccinated against measles or Rota virus
The danger of diarrhea
• DHN & Intestinal perforation
• Death – About 70% death is due to DHN.
• Malnutrition: Mechanism by
1. anorexia
2. Loss of nutrient
3. Increased expenditure of energy due to
infection
2/10/2024 89

90. Assessment parameters
 Does the child have diarrhea? How long?
 Is there blood in the stool?
 Look at the child’s general condition( unconscious,
lethargic, irritable or restless, alert)
 Look for sunken eyes( Severely wasted)
 Offer the child fluid( not able to drink, drinks poorly,
drinks eagerly)

91. Cont...
• Pinch the skin of the abdomen( half way b/n the umbilicus and the side of the
abdomen, for 1 second and release avoid fingertips,
• when you release the skin, look if the skin pinch goes back :
- very slowly >3”,
• slowly>2”
• and immediately
• Note: pinching the skin may give misleading in formation in maramic or
obese children.
• In marasmic children the skin will go back slowly even if the pt. not dehydrated.
• In kwashiorkor children the skin will go back immediately even if the pt. dehydrated.
2/10/2024 91

92. Signs and symptoms of diarrhea
• Acute onset of fever, vomiting and watery diarrhea
• abdominal cramp and irritability
• Watery diarrhea is mainly due to viral infection
• Bloody stool, frequent passage of mucoid stool with
tensmus suggest bacterial or amoebic colitis
• Bulky, greasy and foul smelling stools are often due to
malabsorption syndromes
2/10/2024 92

93. Cont...
 Dehydration: Lethargy, depressed consciousness, sunken
anterior fontanel, dry mucous membranes, sunken eyes, lack
of tears, poor skin turgor, delayed capillary refill
 Failure to thrive and malnutrition: Reduced muscle/fat mass or
peripheral edema
 Perianal erythema---Frequent stools can cause perianal skin
breakdown, particularly in young children.
2/10/2024 93

94. Dehydration:
94

95. Dehydration status in diarrhea
2/10/2024 95

96. Cont...
1. Severe dehydration: If two or more of the
following signs are present,
- Lethargic or unconscious
- Sunken eyes
- Not able to drink or drinking poorly
- Skin pinch goes back very slowly
2/10/2024 96

97. Cont...
2. Some dehydration: if two or more of the following
signs are present,
• Restless, irritable,
• Sunken eyes,
• Drinks eagerly, thirsty
• Skin pinch goes back slowly
3. No dehydration: if there are no enough signs
to classify as “some” or “severe” dehydration.
2/10/2024 97

98. Cont...
Diagnosis
• Clinical manifestation
• Excessive mucus or blood in the stool is suggestive of
bacterial or parasitic infection
• Watery diarrhea signal viral enteritis in infants
• Excess RBC and Leucocytes in stool suggests bacterial
or parasitic mucosal invasion.
• Stool culture for suspected bacteria
2/10/2024 98

99. Laboratory Investigation
CBC
Stool specimen
Rectal swab
Blood Culture
 Stool culture: in bloody diarrhea, WBC,
immunocompromized
Serum electrolytes
99

100. Acute watery diarrhea
2/10/2024 100

101. Complications
 Dehydration or shock
 Malnutrition
 Anaemia
 Paralytic ileus ( serum electrolytes)
 Rectal prolapse
 Acid base disturbance etc

102. MANAGEMENT
• The broad principles of management of acute
gastroenteritis in children include:
• oral rehydration therapy,
• entral feeding and
• Diet selection,
• zinc supplementation
• Recognition of DHN and correction is the first priority in
the treatment of diarrhea
2/10/2024 102

103. ORT( Oral Rehyderation therapy)
• is the administration of fluid by mouth to prevent or
correct DHN.
• -ORT is the corner stone of diarrhea disease control
programs because
• Simple
• Highly effective
• Un expensive
2/10/2024 103

104. ORS (oral rehydration solution )
-DHN treated with ORS solution
Ingredients of ORS
• Nacl _______________________3.5 gram
• Glucose ____________________20 gram
• Trisodium citrate dehydrate ____2.9 gram
• NaHC03 ( sodium bicarbonate) ___2.5gram
• Kcl (potassium chloride________ 1. 5 gram
2/10/2024 104

105.  ORS in mixing with one liter of clean water
• Solution can be kept & used for 24 hours.
• Throw any solution remaining from the day before.
How to prepare ORS.
1. Wash hands.
2. Measure one liter ( 3 beer bottle ) clean water in a clean
container
3. Pour all powder from the sack in to the water & mix well until
it dissolved.
4. Over 90% of DHN in children can be managed by ORT. How
ever in rare instance. IV may be necessary.
2/10/2024 105

106. Indication for I.V
• Persistent & intractable vomiting
• Sever DHN with shock & disturbance of consciousness.
• Paralytic ileus and abdominal distension.
• Glucose malbsorption
Where to locate ORT corner
• Staff frequently pass by
• Near the toilet & washing facility.
• In a pleasant & well ventilated area.
• Near a water source
2/10/2024 106

107. Furniture & supply in the ORT corner
• A table for mixing ORS solution & holding supplies
• Shelves to hold the supplies
• Chair for the mother to sit
• Small table for cup of ORS solution to Rest
• ORS packet
• Bottle that will hold the correct amount of water for mixing ORS solution
• Cups
• Spoons ( 3) or
• Dropper ( for small infant)
• Waste basket
2/10/2024 107

108. Plan A: Treat diarrhea at home
• Counsel the mother “4” Rules of Home Rx.
1. Give Extra fluid
• Tell the mother
• To continue B/F frequently
• If the child is exclusive breast feeding, give ORS in addition to breast
milk.
2/10/2024 108

109. Plan- A …Cont…
• If the child is not B/F give ORS, Food based fluids (such
as soup, gruel (Atmit), rice water Or clean boiled water
• Give enough ORS
• Teach the mother how to mix & give ORS.
• Show the mother how much fluid to give her
-Up to 2 years 50 to 100 ml after each losses stool
-2 years or more100 to 200 ml after each loses stool
2/10/2024 109

110. Plan- A …Cont…
2 continue feeding with home made cereal based food like
“Atmit “Genfo “Juice?
3 Advise when to return immediately:
i. bloody stool iii. Develop fever
ii. Drinking poorly iv. Becomes sicker.
4.Give Zink supplement.
Plan-B Treat some DHN with ORS
• Give recommended amount of ORS over 4 hrs, period at
health facility.
2/10/2024 110

111. Amount of ORS to give during 1st
4 hours.
Amount of
ORS to
give during
1st 4 hours.
Up to
4Month
4-12
month
12
months
up to 2
Yrs
2 to 5 Yrs
Wt < 6kg 6-10kg 10-12kg 12-19kg
In ml 200-400 400-700 700-800 900-1400
2/10/2024 111

112. Plan-B Treat some DHN con’t...
Amount of ORS to give during 1
st
4 hours. Can also
be calculated 75 ml/KG
For infant < 6 month who are not breast fed give 100-
200 ml clean water.
Show the mother how to give ORS solution
Over 4 hours.
Reassesses & classify the child for DHN.
select the appropriate plan to continue Rx
2/10/2024 112

113. If the mother must leave before completing Rx.
Show how to prepare ORS solution at home.
Give enough ORS packet to complete DHN.
Explain the “4’ rule of home Rx
Show how much ORS to give in 4 hours
Plan -C treat of severe DHN
• Dehydration therapy using I.V fluids or NG tube
recommended
• Give 100 ml /kg Ringer lactate solution or if not available,
normal saline) as divided as follows.
2/10/2024 113

114. Plan-c …Cont…
Age First give
30ml /kg
Then give
70 m1/kg
Total
100ml/kg
Infant < 12
month
1 hours 5 hours 6 hours.
12 month
up to 5
years
30 minutes 2 &1/2hrs 3 hours
2/10/2024 114

115. Plan –C Cont…
• Reassess the child every 1-2 hrs, if the hydration status is
not improving give I.v drip more rapidly
• Reassess an infant every 6 hours & a child after 3 hours
then choose the appropriate plan (A, B , C) to continue Rx
• If no I.V therapy rehydration by mouth
• (NG – tube) offer ORS Solution, giving 20/ ml/Kg/ hours for 6
hrs ( total 120 ml /kg /6hrs.
2/10/2024 115

116. Control and Prevention of diarrhea
-Breast feeding
-Improved weaning practice.
-Use of plenty of clean water.
-Hand washing.
- Use of latrine
-Measles and rota V. immunization
-proper disposal of the stool of young children
2/10/2024 116

117. Common GIT disorder
• Pyloric stenosis : is hypertrophy of the muscle of the
pylorus, causing partial obstruction of the stomach
(narrowing of the pyloric sphincter).
• It is common in male (m:F= 6:1)
• On set 2- 6 wks.
Etiology: The exact cause is unknown.
2/10/2024 117

118. Pyloric stenosis: Cont…
Clinical manifestation
Vomiting starts between 2-6 wks of age.
• It is gradually increases it’s frequency and force becoming
projectile vomiting.
• Excessive hunger
• Loss of Wt. or failure to gain wt.
2/10/2024 118

119. Pyloric stenosis: Cont…
DX
• X-ray examination with barium meal.
-Narrowing of pyloric canal.
-Enlarged stomach.
• Usually based on clinical manifestation.
-Persistent projectile vomiting.
-Palpation of pyloric mass can be felt.
2/10/2024 119

120. RX pyloric stenosis
RX may be surgical or medical.
1. Surgical is the best management.
2. Medical Rx like Gastric lavage
Intussusceptions
• It is invagination or telescoping of one portion of the
intestine into one another
• The most common site is the ileocecal valve, in which the
ileum invaginates in to the cecum and further in to the
colon.
2/10/2024 120

121. Intussusceptions…Cont…
Etiology - Usually unknown
The possible contributing cause
-Polyps or cyst.
-Abdominal surgery.
Clinical manifestation
• Sudden on set
• Vomiting
• Abdominal pain
• Passage of non fecal stool
• Bloody and mucous on finger on rectal examination.
• The abdomen becomes tender and distended.
• DHN and Fever.
• The sign of shock.
2/10/2024 121

122. Diagnosis evaluation
C/m
• Rectal examination
• Abdominal examination by palpation.
• Barium enema clearly demonstrates obstruction.
Rx
1. Non surgical reduction the initial Rx(rectal tube)
2. Surgical intervention involves manual reducing the
invagination & resection.
2/10/2024 122

123. Appendicitis
Defn It is an inflammation of appendix.
Etiology
-exact cause is un known.
-bacteria
- virus
C/M
• Nausea & vomiting
• Leucocytosis (12,000-15,000 cells)
• Fever
• Pain and tenderness in the right RLQ in old child
• Constipation.
• Abdominal pain
• rigidity of the overlying rectus muscle
2/10/2024 123

124. Appendicitis con’t…
-Laxative and enema are contradiction for appendicitis
Diagnosis
• P/E- Localized abdominal tenderness is the single
most reliable finding .
• referred rebound tenderness Rovsing sign
• Psoas and obturator signs
• WBC count.
• History
• US and CT scan
• N.B Dx of appendicitis in childhood is difficult
Rx
• Appendectomy (surgical removal of the appendix).
2/10/2024 124

125. Malnutrition
2/10/2024 125

126. HUMAN NUTRITION
• Nutrients are substances that are crucial for human life, growth
& well-being.
• Macronutrients (carbohydrates, lipids, proteins & water) are
needed for energy and cell multiplication & repair.
• Micronutrients are trace elements & vitamins, which are
essential for metabolic processes.
2/10/2024 126

127. Types of Malnutrition
• Undernutrition: too little
• Protein Energy Malnutriton(PEM)
• Micronutrient deficiencies
• Overnutrition: too much
• Obesity
• Chronic diseases (diabetes, hypertension,..
2/10/2024 127

128. Cont...
• Micronutrient malnutrition -- arises from inadequate vitamin and
mineral supply to cells in body to satisfy physiological
requirements
– Vitamin A, Iron & Iodine
– Others: Zinc, vitamin D
2/10/2024 128

129. Assessment of Nutritional status
• Direct method
• Clinical
• Anthropometric
• Dietary
• Laboratory
• Indirect method
• Health statistics
• Ecological variables
2/10/2024 129

130. Clinical Assessment
• Useful in severe forms of PEM
• Based on thorough physical examination for features of PEM &
vitamin deficiencies.
• Focuses on skin, eye, hair, mouth & bones.
• Deficiency signs such as hair changes, anemia, xerosis, cheilosis,
angular stomatitis, bleeding spongy gums, dental caries, etc. should
be actively looked for.
• ADVANTAGES - Fast & Easy to perform
- Inexpensive, - Non-invasive
LIMITATIONS - Did not detect early cases
- Trained staff needed
2/10/2024 130

131. ANTHROPOMETRY
• Anthropometry is a very valuable index for evaluation of
nutritional status.
• Objective with high specificity & sensitivity
• Measuring Ht, Wt, MUAC, HC, skin fold thickness & BMI
• Reading are numerical & gradable on standard growth charts
• Non-expensive & need minimal training
2/10/2024 131

132. ANTHROPOMETRY/2
• LIMITATIONS
• Inter-observers’ errors in measurement
• Limited nutritional diagnosis
• Problems with reference standards
• Arbitrary statistical cut-off levels for abnormality
2/10/2024 132

133. LAB ASSESSMENT
• Biochemical
• Serum proteins, creatinine /hydroxyproline
• Hematological
• CBC, iron, vitamin levels
• Microbiology
• Parasites/infection
DIETARY ASSESSMENT
• Breast & complementary feeding details
• 24 hr dietary recall
• Home visits
• Calculation of protein & Calorie content of children foods.
2/10/2024 133

134. SEVER MALNUTRITION
• “Malnutrition” means badly malnourished or shortage of
many nutrients.
They are two types
-Acute malnutrition
-Chronic malnutrition
• Sever acute malnutrition (SAM) ;-is syndrome a multi-
deficiency state involving PEM & other micronutrients
deficiency (anemia , vit,- A & D deficiency ).
2/10/2024 134

135. Sever Malnutrition….
• Most deaths in children have some form of malnutrition as the background
• Stunting is due to chronic malnutrition
• Wasting and edema are due to acute malnutrition .
• Is both medical and social disorder so management includes both medical
and social problems identified and managed—this prevents relapse of the
problem.
2/10/2024 135

136. 1. PROTEIN-ENERGY MALNUTRITION(PEM)
• PEM is a clinical conditions that result from lack of
protein and energy (calorie) inadequacy.
• Either because less dietary intakes of protein and calorie
than required or
• Because the needs for growth are greater than can be
supplied by what otherwise would be adequate intakes.
• However, PEM is almost always accompanied by
deficiencies of other nutrients
2/10/2024 136

137. Protein energy malnutrition (PEM)
Cause
• Lack of knowledge
• Poverty (low-income) or starvation
• Infection e,g diarrhea, I/P
• Emotions deprivation
• Cultural factors e,g -age bias
-Sex bias
• Season
• Improper weaning practice
• Lack of breast milk
2/10/2024 137

138. CLASSIFICATION OF PEM
1.1. Kwashiorkor
Defn : It is quantitative deficiency
of protein but energy intake
may be adequate.
• Common <2 years
Cause: the same as PEM
Clinical manifestation
• Growth failure
• Wasting of muscle but not
fat (fat present)
• Edema
• Hepatomegally
• Moon face (Puffy)
• Anorexia
• Decreased albumin
• Apathy &miserable
• Skin &hair change
- lightness (reddish to white)
- pulls out easily & painless
2/10/2024 138

139. 1.2 Marasmus
Definition ; It is semi starvation w/h includes deficiency of
energy, protein and other nutrients.
• Affects all age but common < 1 year
Cause ; The same as PEM.
Clinical manifestation
• Growth retardation or growth failure (wt. For age <60% or
wt. for Ht< 70%)
• Sunken eye balls
• Mood change (irritable)
• Good appetite
• Diarrhea
2/10/2024 139

140. Marasmus…Cont…
• “Old man face” appearance
• Mild skin & hair change (less common sign )
• Abdomen may be large or distended
• Wasting of subcutaneous tissue
Steps – Remove the child’s cloths.
• Look for sever wasting of the muscle of buttocks & legs.
• The child has no fat & look like skin & bone.
• When the wasting is extreme there are many fold of skin
on the buttocks & thigh.
• It look as if the child is wearing baggy pants
2/10/2024 140

141. Marasmus…con’t…
Comparison with kwashiorkor:
• in contrast to kwashiorkor, children with marasmus:
I. are often <1 year old
II. are bone & skin
III. have no edema
Vi. are not misery
V . have good appetite
2/10/2024 141

142. Malnutrition con’t…
Diagnosis
1.Detailed history –A child feeding practice
_ poor weaning practice.
_ Hx on the socio cultural
& other risk factors.
2. Meticulous clinical examination based on sign &
symptom.
3.Anthropometric measurement / assessment/.
2/10/2024 142

143. Anthropometric assessment
I. Gomez classification weight for age
• Comparing their Wt. With the reference child of the same age.
% of NCHS Reference Level of malnutrition
90-109 Normal
75-89 Mild (Grade-I)
60-74 Moderate (Grade-II)
<60 Sever (Grade-III)
Disadvantage:- edema is ignored
- The cut of point 90% may be too high many well nourished
children are below this point
2/10/2024 143

144. II. Well come classification (weight for age)
2/10/2024 144
Index
% of
NCHS
Reference
Level of malnutrition
___________________________
Edema No edema
Weight
for age
60-79% - Kwashiorkor - under weight
<60% -Marasmic- - Marasmus
kwashiorkor
Short coming:
Does not differentiate acute from chronic
malnutrition

145. III. Water low classification (Ht. For age & Wt. for Ht)
2/10/2024 145
I
Index %NCHS reference Level of malnutrition
Ht. For age - 90-94% Mild
stunted - 85-89% Moderate
(chronic mal.) - <85% Severe
Wt for Ht. - 80-89% - Mild
Wasted - 70-79% - Moderate
(SAM) - <70% - Sever

146. IV. BMI (Body mass index = Kg/m2
Usually Used for adult
• BMI =18.5-25.5 is normal
• BMI<16 is sever malnutrition
• BMI = 26 - 40 is obesity
• BMI >40 this is disease
4. Laboratory finding ; - ↓ Albumin & Hg.
- ↓ Micronutrient (Fe)
- Shown the sign of
infection
• What is the complication of malnutrition?
2/10/2024 146

147. Mgt. of Sever Acute Malnutrition
Management of SAM focuses
• Dietary management
• Treatment of complication & infection
Treatment approach is classified in to “3” phases.
1. Phase –1
• The main focus of Phase –1 is Rx of infection & complication
like (DHN, hypoglycemia, hypothermia & electrolyte
imbalance.
1.1. Management of complication of malnutrition
• Infection,
• DHN ,
• sever anemia are the main danger
• In S.A.M, cardiac &renal functions are impaired.
2/10/2024 147

148. Management of complication of mal… Cont….
Complication Treatment
Hypoglycemia - 5 to 10 ml/kg of sugar water po for
conscious pt.
- 5 to 10 ml/kg of sugar water by NG-tube
or
- 5 ml/ k.g a single of injection 10% glucose
solution for unconscious pt.
- Antibiotic
2/10/2024 148

149. Mgt of Compln of mal…Cont…
Complication Management
• Hypothermia -use kangaroo care
Rectal Temp. < 37c0 technique with care taker
Axillary Temp. < 36.5c0 - put a hat on child
- Wrap the mother & child together.
- Keep the room warm.
- Treat hypoglycemia
- Treat by antibiotic
2/10/2024 149

150. Mgt of complication mal…Cont…
• Dehydration (DHN) - Taker over load of
&septic shock fluid solutes
- use resomal solution
to rehydrate SAM.
N.B the rehydration solution used in malnutrition is Resomal.
1.2 Dietary management
• F-75(130 ml)=100 kcal/ should be given
Preparation:
• Add 1 packet of F75 to 2L of water then given small & frequency
feeding 8 times / day.
• Vitamin - A
2/10/2024 150

151. 2. Transitional phase
AIM : This phase focuses on the restoration of the loss tissue &
promotion of catch up growth.
• A sign that a child is ready to progress to the next phase
(transitional phase)
• Return a good appetite.
• If edema is disappeared (reduced )
• No sever medical problem.
• N.B F-75 & F-100 consists of vegetable flour, minerals,
cereal oil, sugar, dried skimmed milk…..
2/10/2024 151

152. Transitional phase …Cont….
The only change that is made compared to phase- 1 is
changing diet from F75 to F 100.
2.1The criteria to move back from transitional phase to phase-1
• Excessive weight gain (Wt. Gain 10g/ k.g/day).
• Re- feeding edema.
• If any sign of fluid over load develop e.g C.H.F
• Rapid increase the size of the liver.
2/10/2024 152

153. 2.2 .The criteria to progress from transitional phase to
phase-2
Marasmic pt. spends a minimum of 2 days and if
tolerating the new diet with out complication.
When they are completing the diet with good appetite.
Complete loss of the edema (in kwashiorkor).
2/10/2024 153

154. 3. Phase- two (phase of recovery)
- Aim : restoration of the loss tissue & promotion of catch
up growth.
Criteria to asses recovery
• Have no edema
• Gain Wt. Rapidly
Management of phase- two
• Diet- F 100
• Five feeds of F100 or one porridge may be given.
• Treat Fe deficiency.
2/10/2024 154

155. Assessing the progress
-Wt. & ht. Measurement at least 3 times a week & plotted in
a chart.
- MUAC measures each week. Plotted in a chart.
• N.B failure to improve anthropometric assessment may
signal undiagnosed infection or in adequate intake of diet.
2/10/2024 155

156. Sign of failure to respond to Rx
• Failure to gain appetite by the day 4.
• Failure to start to lose edema by the day –4.
• Failure to regain Wt.
Causes of failure to respond Rx
• In accurate weighting machine.
• Insufficient food intake.
• Poorly trained staff.
• Infection & malabsorption.
• Micronutrient deficiencies ( vit. & mineral deficiency).
2/10/2024 156

157. Appetite Test
This is the minimum amount that malnourished patients should take to pass the
appetite test.
Bodywt. (K.g)
Plumpy’nut
Sachets
<4 K.g
4-6.9 K.g
7 -9.9 K.g
10-14.9 k.g
15-29 k.g
Over 30 k.g
1/8 to ¼
¼ to 1/3
1/3 to1/2
½ to3/4
¾ to1
>1
2/10/2024 157

158. Admission and discharge criteria for severely
malnourished
Age Admission criteria Discharge criteria
<6 month
old
Infants too weak to
suck effectively
Wt. For ht. < 70%.
No wt. Gain at home.
Mother does not have
enough milk to feed
her child.
Presence of bilateral
edema.
 Gaining wt.
If no medical
problem
2/10/2024 158

159. Age Admission criteria Discharge criteria
6 month
up to
18
Month
old.
 Wt. /Ht. <70% or
 Presence of bilateral
edema or.
 MUAC < 11c.m
 Wt/ ht.> 85% for two
consecutive wts.
 No edema for 10 days.
 MUAC>12 c.m
> 18
month
old
 BMI< 16 k.g / m2 or
 The presence of
bilateral edema or
 Wt. /Ht. <70%
 Wt/ ht> 85% for two
consecutive wts.
 No edema for 10 days
2/10/2024 159

160. What is role of Nurse in managing SAM.?
-Record intake, out put & daily wt.
-Turning position in abed frequently.
- Prevention of infection.
-Maintains temperature at normal range.
- A administer Fe & folic acid to prevent anemia.
2/10/2024 160

161. Prevention of malnutrition
• exclusive B/F for the first 6 month
• Proper weaning practice.
• Screening by anthropometric measurement ( wt/Ht.
,Wt/age…)
• Treatment of infection timely e.t.c
• Nutritional advice (  protein,  CHO &Vit ,& mineral
intake)
• Providing nutrition rehabilitation.
2/10/2024 161

162. 2. Micro –Nutrient/Vitamin/deficiencies
Vitamin –A deficiency
• Common among preschool age children.
• It is the leading case of blindness.
Cause:
• Inadequate intake (Retinol & B-Carotene)
• Infection
• PEM
Who has the greatest risk?
• Children 6-59 month
• Women during pregnancy and lactation
2/10/2024 162

163. Vitamin A (Retinol) deficiency
Function: development of healthy skin and nerve tissue.
• Aids in building up resistance to infection.
• Functions in eyesight and bone formation.
• All animals require a source of Vitamin A.
- It controls the general state of the epithelial cells and
reduces the risk of infection.
Deficiency signs: retarded growth in the young, the
development of a peculiar condition around the eyes known as
Xerophthalmia, and reproductive disorders.
Sources: whole milk, meat especially liver, carotene,Carrots,
mangos, Papayas animal body oils (cod fish and tuna), legume
forages and can be synthetically produced. 163

164. Vitamin A - Retinol
Retinol (vitamin A)
Some uses:
- Vision (11-cis-retinol bound to rhodopsin detects light in our eyes).
- Regulating gene transcription (retinoic acid receptors on cell nuclei are part of a
system for regulating transcription of mRNAs for a number of genes).
164

165. Xerophthalmia
• Xerophthalmia - is a term used to describe milder form
of ocular changes resulting from Vitamin A deficiency.
• Xerosis - means drying of the conjunctiva and corneal
epithelium.
• Keratomalacia - (softening and melting of the cornea) is
the most severe form of Vitamin A deficiency.
165

166. Classification of Xerophthalmia
• XN - Night blindness
• X1A - Conjunctival xerosis
• X1B - Bitot's spots
• X2 - corneal xerosis
• X3A- Corneal ulceration/keratomalasia involving less
than one third of the corneal surface
• X3B - Corneal ulceration/keratomalasia involving one
third or more of the corneal surface
• XS - Corneal scars presumed secondary to xerophthalmia
• XF - Xerophthalmic fundus
166

167. Clinical manifestation of vit-A
• Night blindness is earliest symptom
• Bulbar conjunctiva become dry (Xerosis)
• Bitots spot.
• Corneal ulceration (keratomalacia) in sever (series) deficiency
not reversible.
Dx;- Low plasma level of vit –A .
Treatment
• Given vit –A in all stage of Vit. –A deficiency
.<1years 100.000 IU capsules po D1, D2,&D8
. >1 years 200.000 IU capsules po D1, D2,&D8
2/10/2024 167

168. RX of Vit-A…Cont…
• In measles infection D1,D2,&day 30(d14)
Prevention Strategy
1. Vit. –A supplementations.
• Children 6 to 59 months 2 times a year
<12 months 100.000 Iu capsule
 >12 months 200.000 Iu capsule
2 Exclusive B/F up to 6 month & continue up 2 yrs.
2/10/2024 168

169. RX of Vit-A…Cont…
3. Food fortification e.g sugar, oil.
4. Diet good source of vitamin – A (food
diversification vitamin –A rich foods)
2/10/2024 169
Problems of vitamin A deficiency.
-Is not synthesized by the body.
-Has to come from food or it’s supplements.
-Builds the epithelial cells.
-Important immune system.

170. 2. 2 Vit –C deficiency (scurvy)
• Incidence- high 6-12 months
Cause;- dietary vit –c deficiency
• Vitamin C (Ascorbic acid)
• Function: - has an effect on the metabolism of calcium in the body
• Required for collagen synthesis, and
• a cofactor for several enzymes
• Helps the formation of various body tissues, particularly
connective tissues, bones, cartilage and teeth.
• Stimulates the production of red blood cells,
• Helps resistance to infection and neutralizes poisons.
- It is an anti - oxidant
• Deficiency signs: scurvy (swollen and painful joints and bleeding
gums) and brittleness of bones.
• Sources: fruits, tomatoes, leafy vegetables, potatoes, and fresh
meat
•
2/10/2024 170

171. C/M
• Bleeding gums.
• Bleeding under the skin
• Anemia
• Slow wound healing
• Anorexia & irritability
• Joint pain in the lower limbs
2/10/2024 171

172. Rx
• Vitamin –C –for two weeks(100 -300 mg/day BID
• Preventive measure
• Vit –C prophylaxis
N/care
• prevention of infection.
• oral hygiene
- Frequent change position
2/10/2024 172

173. vitamin D
Functions of vitamin D
• Absorption of calcium and phosphorous
• The presence of vitamin D is essential to the activity of the
parathyroid hormone in removing calcium and Phosphorous
from the bone in order to maintain normal serum levels of
calcium.
• Stimulates the reabsorption of Calcium by the kidney when
serum calcium level is low.
• Bone formation
173

174. 2.3 Vitamin -D deficiency
• Rickets ;-is caused by lack of vit – D.
• rickets in adults called osteomlacia
Cause: -lack of sunshine
-In adequate diet in vit –D
Incidence –common from 3 month to 3yrs.
Clinical manifestation
• Delayed closure of the fontanels
• Delayed Dentition
• Bowed legs & knocked knees.
2/10/2024 174

175. Vit-D deficiency cont…
• As the disease advances: Thoracic deformities
• Lord sis _ Scoliosis
• Kyphosis
• Softening of the bone
• Pelvic deformities
• Delayed standing & walking
• Anemia
• Pot belly
• Rachitic rosary (rounded knobs of the ribs)
2/10/2024 175

176. Vit-D deficiency Cont…
Dx
-X-ray
-Based on c/m & Hx.
Rx
• -Vit –D 2000- 6000 Iu of daily for 1 month or
• 50.000 Iu once a week for 8wks
Prevention
• H.E about proper nutrition.
• exposure to sunlight for 15 minutes daily
2/10/2024 176

177. Thank you

178. AFI (acute febrile illness)
Acute febrile illness : is when a fever develops suddenly; specifically, the body
temperature rises above 37.5 degrees Celsius (99.5 degrees Fahrenheit).
This happens when the body is invaded by a pathogen and the immune system is
activated to fight it off.
1. Malaria
Def.;- malaria is an acute infection of the blood caused by the protozoa called
plasmodia through the bite of an infected female anopheles mosquito.
Etiology
 Four plasmodium species.
• Plasmodium falciparum (70%) ( killer among the species.)
• Plasmodium vivax  30%
• Both plasmodium ovale &
• plasmodium malaria < 1%
2/10/2024 178

179. Clinical manifestation un complicated malaria
High grade fever
- Backache
-Chills
-Headache
-Sweating.
-Splenomegally
-Joint pain.
-Shivering
-Malaise
-Nausea and vomiting
-Anorexia
-Diarrhea etc.
-Hepatomegaly.
2/10/2024 179

180. Malaria…Con’t…
Transmission
• Through blood transfusion.
• Through placenta.
• By bite the of female anopheles mosquito
Risk groups to malaria
• Pregnant mother
• Children <5 years
2/10/2024 180

181. Clinical manifestation of sever or complicated malaria
• Cerebral malaria impaired level of consciousness,
convulsion and coma,.
• Normocytic anemia (HCT <15%)
• Renal failure.
• Hypoglycemia blood glucose level <40 mg/dl
• Pulmonary edema
• Fluid Electrolyte and acid base disturbance.
• Hyper parasiteamia ( >5% load)
• Disseminated intravascular (coagulation)
• Hyper pyrexia ( Rectal Tc0 >39c
0
)
2/10/2024 181

182. Malaria …Cont…
Diagnosis:
• The HX of travel to malaria‘s area.
• Suggestive physical finding.
• Laboratory finding (B/F)
Treatment :
RX depends
- Availability of drugs
-Policies of government.
-The effectiveness of drug
I. For uncomplicated P. Falciparum malaria
• Artemeter lumefantrine (coarthem) the drug of choice
the first line of RX.
2/10/2024 182

183. 2/10/2024 183
Dose of coarthem by age/Wt.
Wt Age Coarthem
1. 5-14kg 3 month-2years 1 tab po BID for 03
days
2. 15-24kg 3-7 years 2 tab po BID for 03
days
3. 25-34kg 8-10years 3 tab po BID for
03days
4, 35kg + >10 years 4 tab po BID for 03
days
Contraindication
-Infant < 5k.g or less than 3 month
-Pregnant women
Coarthem = Artemether 20 mg + 120 lumefantrine.

184. Rx of malaria…Cont…
II. Chloroquine is the drug of choice for p. vivax
uncomplicated malaria.
• (Chloroquine 10 mg base per kg for D1 &D2 then 5mg per
kg for D3. Total dose 25 mg/K.g
• If the DX is made clinical base combined Rx of coarthem
and chloroquine is recommended,
III. Oral quinine:- is the drug of choice for
• Pregnant women
• Infant <5kg(< 3 months).
2/10/2024 184

185. Rx of malaria…Cont…
RX of complicated malaria
• I.V quinine 20 mg/ k.g over 4 hours as loading dose then 10
mg/k.g in 10% dextrose solution Q 8Hrs until the pt able to take
oral drug.
• Artesunate 2.4 mg/kg IV, or IM (alternative) on admission (time =
0), then at 12 h and 24 h, then once a day for 5-7 days.
• After a minimum of 24 hours of parenteral Artesunate treatment,
and able to take tablets, complete treatment with full dose of oral
Coartem.
• Artesunate 2.4 mg/kg IV or IM can be given as pre-referral dose
when Artesunate suppository is not available
• Artemether 3.2 mg/kg ,IM: is an Alternative Pre-referral drug,
where Artesunate suppository is not available.
2/10/2024 185

186. Nursing intervention
• Check V/S & record.
• Control fever
• Encourage fluid intake.
• Ventilated the room.
• Administer anti-malarial drug.
• Insert N.G tube.
• Psychological reassurance
2/10/2024 186

187. Prevention &control of malaria
• Mosquito bed net
• Chemoprophylaxis;- mefloquine 5mg/kg/ a week >3
month of age or
• Chloroquine 5 mg/ k.g /wks beginning 2 wks before
entering malaria area & continuing for 8 wks after return.
• Drain stagnant water frequently
• Proper waste disposal.
• Vector control
• Use of larvacide’s(DDT)
• Biological control.
2/10/2024 187

188. 2. Meningitis
• It is an inflammation of meninges.
Epidemiology
* Epidemic out break: Neisseria meningitis is the most
common cause .
-Globally, around 170,000 people die each year
* un treated bacteria meningitis mortality rate 100%.
2/10/2024 188

189. Meningitis… Cont…
Risk factor
- Young age <1 year
- Immunodeficiency
- (basilar skull fracture)
Cause: A. viral (aseptic meningitis)
B. Bacteria; - (septic meningitis) are more
common & serious infection in children.
C. Fungus
2/10/2024 189

190. Meningitis…Cont…
Age group common etiology
-New born - Esherichia.coli
(Birth –2 month ) - Group –B, Beta
hemolytic streptococcus
- Other gram negative
-2 month –10yrs - Heamophilus influenza type- b
- Streptococcus pneumonia
- Neisseria meningitis
-Adult--------------- - Nesseria meningitis
- Streptococcus neumonia
2/10/2024 190

191. Meningitis…Cont…
• Septic meningitis (caused by bacteria)
• If the cause by mycobacterium tuberculosis (T.B
meningitis )
Clinical manifestation
_Fever - Lethargy
• Irritability - Convulsion
• Vomiting - Unconscious
• Poor feeding - Petechial rash
• Bulging fontanel - neck stiffness
2/10/2024 191

192. Diagnosis
• Based C/m
• P/E - Sign of meningeal irritation in older children
- (+ve kerning & + Ve Brudzinski signs ) etc
• laboratory result of C.S.F.
C. S.F:- suggestive bacterial meningitis, if
- C.S.F. pressure >180mm H20.
- Cloudy S.C.F.
• ↑ WBC count mainly neutrophils
• ↑C.S.F protéine.(> 100mg/dl.
• ↓C.S.F glucose(<40%)
• C.S.F gram stein e.g. (Gram –Ve Diplococci if Neisseria
meningitis )
2/10/2024 192

193. Treatment
• Crystalline pencilline for Neisseria meningitis 5-7 days
• Chloramphnicol for H. influenza type b. 7-10days.
• Crystalline Pencil line – streptococcus pneumonia 10-14
day
• Ampcilline & gentamycin for - E. coli, Enterobacteriace
for 21 day
• vancomycin & gentamycin- for Psudomonas Aeruginsa -
for 21 day
• If resistance the above Rx 3rd generation ceftriaxone the
drug of choice
2/10/2024 193

194. Nursing care meningitis
• N/care for comatose pt -Maintain air patency
- V/S
- Skin care
• Reduce fever
• Emotional support
• Attaining fluid & nutritional requirement
• Prevention of spreading infection
• ↓ICP by elevating the head
• Administration of drug.
2/10/2024 194

195. Prevention and Control
• Chemoprophylaxis for all close contacts
-Rifampicin 10mg/kg Po Bid for 2 days
-Ciprofloxacin 500 mg po stat.
• Vaccination
• Control seizure.
• Preparedness focus on surveillance.
• H.E about - To reduce over crowding
- Early Detection of disease & Rx
- Personal hygiene
• Report to the concerned health authorities
2/10/2024 195

196. meningitis cont…
What is the complication of meningitis?
• Hydrocephalus
• Hearing and visual loss.
• Mental retardation.
• Facial paralysis…..
• Hemi paresis
• Seizure
2/10/2024 196

197. 3. MEASLES:
• Measles is highly contagious viral febrile illness during
childhood cased by measles virus.
• It affects the skin & the layer of cell that lines the lung,
gut , eye and throat.
• The measles virus damages the immune system.
• Etiology: Measles virus is a single-stranded lipid
enveloped RNA virus. (humans are the only host of
measles virus)
• Transmission: The portal of entry is through the
respiratory tract or conjunctiva contact with droplet
aerosols.
• Patients are infectious from 3 days before the rash up to
4–6 days after its onset.
•

198. • Pathology: Measles infection causes necrosis of the
respiratory tract epithelium and lymphocytic infiltrate.
• Measles consists of 4 phases:
• Incubation period: virus migrates to regional lymph
nodes. primary viremia, and disseminates to the
reticuloendothelial system
• Prodromal illness: associated with epithelial necrosis and
giant cell formation in body tissues. Cells are killed by
cell-to-cell plasma membrane fusion and Virus shedding
begins.
• Exanthematous phase: With onset of the rash, antibody
production begins and viral replication and symptoms
begin to subside.
• Recovery: subsides the sign and symptom.

199. • Clinical Manifestations:
• high fever, cough, an enanthem, coryza, conjunctivitis
with photophobia, and a prominent exanthem/rash.
• The exanthema or Koplik spots is discrete red lesions
with bluish white spots in the center on the inner aspects
of the cheeks.
• it is the indicative sign of measles (1 to 4 days prior to the
onset of the rash).
• The rash begins around the forehead behind the ears,
and on the upper neck as a red maculopapular eruption,
then spreads downward.
• Fever & generalized rash are the main sign of measles.

200. Complications.
30% of all cases of develop complication
• Lowers serum retinol,
• immune suppression,
• Pneumonia (58%),
• encephalitis - rare (20%).
• Diarrhea
• Blindness
• Mouth ulcer
• Otitis-media
• Stridor
• Malnutrition
2/10/2024 200

201. Diagnosis:
• Clinical and epidemiologic findings
• Reduction in the total WBC count.
• ESR are normal, if no bacterial infection.
• Serologic - identification of Ig-M antibody. (appears 1–2
days after the onset of the rash)
• Viral isolation from blood, urine, or respiratory secretions
(by culture at the CDC)
• Molecular detection by polymerase chain reaction is
possible

202. • Treatment: Management is supportive.
• Antipyretics-
• Airway humidification and supplemental oxygen
• Oral rehydration and may require intravenous therapy.
• Ribavirin is active in vitro against measles virus.
• Vitamin A several controlled trials of vitamin A therapy
reduced morbidity and mortality from measles.
• Prevention:
• Isolation at shedding period. (standard and airborne
precautions)
• Vaccination

203. Thank you !
2/10/2024 203