Diarrhea is the second leading cause of death in children worldwide. It can be caused by viruses like rotavirus and norovirus, bacteria such as campylobacter and salmonella, or parasites. Symptoms typically include fever, abdominal cramps, and watery diarrhea lasting up to one week. Complications may include dehydration, nutritional deficiencies, and persistent diarrhea. Proper diagnosis and treatment focuses on rehydration and identifying signs of dehydration or bacterial infection.

1. DiarrheoaDiarrheoa
Haseeb Ahmed BhattiIHaseeb Ahmed BhattiI

2.  Second leading causes of all deathSecond leading causes of all death
worldwideworldwide
 Most common cause of morbidity andMost common cause of morbidity and
mortality in children worldwidemortality in children worldwide
 Accounts for 9% of hospitalizations inAccounts for 9% of hospitalizations in
children <5 years old in the United Stateschildren <5 years old in the United States

3. Source: World Health Statistics 2011, WHO
Major causes of death in neonates and children under five globally - 2011

4. Major Killers ofMajor Killers of
Children < 5Children < 5
1. ARI (Pneumonia)1. ARI (Pneumonia)
2. Diarrhoea2. Diarrhoea
3. Malnutrition3. Malnutrition
4. Vaccine Preventable4. Vaccine Preventable
DiseasesDiseases
5. Malaria5. Malaria

5. DefinitionDefinition
 3 or more loose or watery stools/day3 or more loose or watery stools/day
 Alteration in normal bowel movement characterizedAlteration in normal bowel movement characterized
by decreased consistency and increased frequencyby decreased consistency and increased frequency
 WHO’s Definition of DiarrheaWHO’s Definition of Diarrhea1
Passage of unusually loose or wateryPassage of unusually loose or watery
stools usually at least three times in astools usually at least three times in a
24 hour period. However it is the24 hour period. However it is the
consistency of the stools rather thanconsistency of the stools rather than
the number that is most important. the number that is most important.

6. Types of DiarrheaTypes of Diarrhea22
 Acute watery diarrhea (includingAcute watery diarrhea (including
cholera)cholera)
 -Acute bloody diarrhea (dysentery)-Acute bloody diarrhea (dysentery)
 -Persistent diarrhea (lasts 14 days or-Persistent diarrhea (lasts 14 days or
longer)longer)
 -Diarrhea with severe malnutrition-Diarrhea with severe malnutrition
(Marasmus or Kwashiorkar)(Marasmus or Kwashiorkar)
2) http://whqlibdoc.who.int/publications/2005/a85500.pdf

7. Mechanisms of DiarrheaMechanisms of Diarrhea
 OsmoticOsmotic
 SecretorySecretory
 ExudativeExudative
 Motility disordersMotility disorders

9. Mechanisms of DiarrheaMechanisms of Diarrhea
 OsmoticOsmotic occurs when too much water is drawn into the bowelsoccurs when too much water is drawn into the bowels
Defect present:Defect present:
Digestive enzyme deficienciesDigestive enzyme deficiencies
Ingestion of unabsorbable soluteIngestion of unabsorbable solute
Examples:Examples:
Viral infectionViral infection
Lactase deficiencyLactase deficiency
Sorbitol/magnesium sulfateSorbitol/magnesium sulfate
InfectionsInfections
Comments:Comments:
Stop with fastingStop with fasting
No stool WBCsNo stool WBCs

10. Mechanisms of DiarrheaMechanisms of Diarrhea
 Secretory:Secretory: increase in the active secretionincrease in the active secretion
Defect:Defect:
Increased secretionIncreased secretion
Decreased absorptionDecreased absorption
Examples:Examples:
CholeraCholera
Toxinogenic E.coliToxinogenic E.coli
Comments:Comments:
Persists during fastingPersists during fasting
No stool leukocytesNo stool leukocytes

11. Mechanisms of DiarrheaMechanisms of Diarrhea
 Exudative Diarrhea:Exudative Diarrhea:
Defects:Defects:
InflammationInflammation
Decreased colonic reabsorptionDecreased colonic reabsorption
Increased motilityIncreased motility
Examples:Examples:
Bacterial enteritisBacterial enteritis
Comments:Comments:
Blood, mucus and WBCs in stoolBlood, mucus and WBCs in stool

12. Mechanisms of DiarrheaMechanisms of Diarrhea
 Increased motility:Increased motility:
Defect:Defect:
Decreased transit timeDecreased transit time
ExampleExample::
Irritable bowel syndromeIrritable bowel syndrome

13. EpidemiologyEpidemiology3-53-5
 1.2-1.9 episodes per person annually1.2-1.9 episodes per person annually
in the general populationin the general population44
 National survey shows every child inNational survey shows every child in
Pakistan has average 5 episodes /Pakistan has average 5 episodes /
yearyear33
 200,000 children < 5 years died200,000 children < 5 years died
/ year/ year
 Seasonal peak in the winterSeasonal peak in the winter

14. EtiologyEtiology
 ViralViral: 70-80% of infectious diarrhea in: 70-80% of infectious diarrhea in
developed countriesdeveloped countries
 BacterialBacterial: 10-20% of infectious: 10-20% of infectious
diarrhea but responsible for mostdiarrhea but responsible for most
cases of severe diarrheacases of severe diarrhea
 ProtozoanProtozoan: less than 10%: less than 10%

15. Viral DiarrheaViral Diarrhea
 Rotavirus (57%)Rotavirus (57%)
 Norovirus (Norwalk-like)Norovirus (Norwalk-like)
 Enteric AdenovirusEnteric Adenovirus
 AstrovirusAstrovirus

16. RotavirusRotavirus
 Leading cause of hospitalization forLeading cause of hospitalization for
diarrhea in childrendiarrhea in children
 Most prevalent during winter seasonMost prevalent during winter season
 Fecal-oral transmission: viral sheddingFecal-oral transmission: viral shedding
can persist for 21 dayscan persist for 21 days
 Acute onset of feverAcute onset of fever followed byfollowed by waterywatery
diarrheadiarrhea (10-20 BM/day) and can(10-20 BM/day) and can persistpersist
for up to a weekfor up to a week

17. NorovirusNorovirus
 Most common cause of diarrhealMost common cause of diarrheal
outbreaks/epidemicsoutbreaks/epidemics
 Fecal-oral transmissionFecal-oral transmission
 Acute onset of nausea and vomiting,Acute onset of nausea and vomiting,
watery diarrheawatery diarrhea withwith abdominalabdominal
crampscramps and can persist for 1-3 daysand can persist for 1-3 days

18. Enteric AdenovirusEnteric Adenovirus
 Primarily affects children < 4 years oldPrimarily affects children < 4 years old
 Fecal-oral transmissionFecal-oral transmission
 Clinical picture similar to rotavirusClinical picture similar to rotavirus
((fever and watery diarrheafever and watery diarrhea))

19. AstrovirusAstrovirus
 Primarily affects children < 4 years oldPrimarily affects children < 4 years old
and immunocompromisedand immunocompromised
 Seasonal peak in the winterSeasonal peak in the winter
 Fecal-oral transmission: viral sheddingFecal-oral transmission: viral shedding
can occur for several weekscan occur for several weeks
 Fever, nausea and vomiting, abdominalFever, nausea and vomiting, abdominal
painpain, and, and diarrheadiarrhea lasting up to a weeklasting up to a week

20. Summary of ViralSummary of Viral
DiarrheaDiarrhea
 Most likely causeMost likely cause of infectious diarrheaof infectious diarrhea
 Rotavirus and Norovirus are mostRotavirus and Norovirus are most
commoncommon
 Symptoms usually includeSymptoms usually include low gradelow grade
fever, nausea and vomiting, abdominalfever, nausea and vomiting, abdominal
cramps, and watery diarrheacramps, and watery diarrhea lasting up tolasting up to
1 week1 week

21. Bacterial DiarrheaBacterial Diarrhea
 Campylobacter (17.6%)Campylobacter (17.6%)
 Salmonella (30%)Salmonella (30%)
 ShigellaShigella
 Enterohemorrhagic Escherichia coliEnterohemorrhagic Escherichia coli
(27%)(27%)

22. U.S. DEPARTMENT OF HEALTH AND HUMANU.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICESSERVICES
Centers for Disease Control and PreventionCenters for Disease Control and Prevention
National Center for Health StatisticsNational Center for Health Statistics
National Vital Statistics SystemNational Vital Statistics System

23. CampylobacterCampylobacter
 Most common bacterial pathogenMost common bacterial pathogen
 Transmitted through ingestion ofTransmitted through ingestion of
contaminated food or by direct contactcontaminated food or by direct contact
with fecal materialwith fecal material
 Symptoms includeSymptoms include diarrhea (+/- blood),diarrhea (+/- blood),
abdominal cramps (can be severe),abdominal cramps (can be severe),
malaise, fevermalaise, fever
 Usually self-limited and does not requireUsually self-limited and does not require
antibioticsantibiotics

24. SalmonellaSalmonella
 Most common in children <4 years oldMost common in children <4 years old
and a peak in the first few months of lifeand a peak in the first few months of life
 Transmitted via ingestion ofTransmitted via ingestion of
contaminated food and contact withcontaminated food and contact with
infected animalsinfected animals
 Symptoms includeSymptoms include fever, diarrhea, andfever, diarrhea, and
abdominal crampingabdominal cramping
 Antimicrobial therapy can prolong fecalAntimicrobial therapy can prolong fecal
sheddingshedding

25. ShigellaShigella
 Fecal-oral transmissionFecal-oral transmission
 Symptoms includeSymptoms include fever, abdominalfever, abdominal
cramps, tenesmus, and mucoid stoolscramps, tenesmus, and mucoid stools
with or withoutwith or without bloodblood
 Can lead to serious complicationsCan lead to serious complications
 Antimicrobial treatment shortensAntimicrobial treatment shortens
duration of illness and limits fecalduration of illness and limits fecal
sheddingshedding

26. E. ColiE. Coli O157:H7O157:H7
 Transmission via contaminated food andTransmission via contaminated food and
waterwater
 Symptoms includeSymptoms include bloody diarrheabloody diarrhea,,
severe abdominal pain, and sometimessevere abdominal pain, and sometimes
feverfever
 Can lead to serious complicationsCan lead to serious complications
 Antibiotics have no proven benefit andAntibiotics have no proven benefit and
may increase the risk of complicationsmay increase the risk of complications

27. Summary of BacterialSummary of Bacterial
DiarrheaDiarrhea
 Can affect all age groupsCan affect all age groups
 Fecal-oral transmission, often throughFecal-oral transmission, often through
contaminated foodcontaminated food
 Typical symptoms include bloodyTypical symptoms include bloody
diarrhea, severe cramping, and malaisediarrhea, severe cramping, and malaise
 Antibiotic treatment not always necessaryAntibiotic treatment not always necessary

28. PARASITESPARASITES
 Giardia Lambia.Giardia Lambia.
 Entamoeba Histolitica.Entamoeba Histolitica.
FUNGIFUNGI
Candida AlbicansCandida Albicans
DIETARY FACTORSDIETARY FACTORS
Over Feeding.Over Feeding.
Starvation.Starvation.
Food Poisoning.Food Poisoning.
Food IntoleranceFood Intolerance
DRUGSDRUGS
AntibioticsAntibiotics
Giardia lamblia
• in contaminated water
•Usually not associated
with inflammation

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

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

31. Complications ofComplications of
DiarrheaDiarrhea
 DehydrationDehydration
 Metabolic AcidosisMetabolic Acidosis
 Gastrointestinal complicationsGastrointestinal complications
 Nutritional complications(electrolytes,Nutritional complications(electrolytes,
micro & macro nutrients)micro & macro nutrients)

32. Complications ofComplications of
DiarrheaDiarrhea
Metabolic AcidosisMetabolic Acidosis
 Reduced serum bicarbonateReduced serum bicarbonate
 Reduced arterial PHReduced arterial PH
 Compensating respiratory alkalosisCompensating respiratory alkalosis

33. Complications ofComplications of
DiarrheaDiarrhea
Gastrointestinal complicationsGastrointestinal complications
 Secondary carbohydrateSecondary carbohydrate
malabsorptionmalabsorption
 Protein intoleranceProtein intolerance
 Persistent diarrheaPersistent diarrhea

35. History and PhysicalHistory and Physical
ExamExam
 3 main goals3 main goals
– Estimate the level of dehydrationEstimate the level of dehydration
– Identify likely causes on the basis ofIdentify likely causes on the basis of
history and clinical findingshistory and clinical findings
– Determine if additional studies and/orDetermine if additional studies and/or
medications are necessarymedications are necessary

36. CHECK FOR GENERAL DANGER SIGNS
A child with any general danger sign needs URGENT attention;
complete the assessment and
any pre-referral treatment immediately so referral is not delayed.
ASK:
● Is the child able to drink
or breastfeed?
● Does the child vomit
everything?
● Has the child had
convulsions?
LOOK:
● See if the child is
lethargic or unconscious.
See if the child is having
siezure now?
ASSESS the child: Check for danger signs (or possible bacterial infection). Ask
about main symptoms. Check nutrition and immunization status. Check for
other problems.
CLASSIFY the child’s illness.
Classify dehydration for any child with diarrhea.
DANGER
SIGNS

37. HISTORY - Diarrhea
Duration , Onset , Frequency
Consistency , Colour, Volume , Blood or mucous?
Associated symptoms: abdominal pain, nausea, fever,
headache, fatigue?
What and where has he eaten recently?
Travel history?
Are any other family members complaining of the
same symptoms?
Aggravating or relieving factors
Ask the mother if the child has vomiting present?
Ask about micturition?
- > Signs / Symptomms of Dehydration??
Thirst

38. Physical ExamPhysical Exam
 VITALSVITALS
 Anthropometric MeseauresAnthropometric Meseaures
 GPE (+Signs of dehydration)GPE (+Signs of dehydration)
 Abdomen ExamAbdomen Exam
 Systemic ExamSystemic Exam
CONT. in Assessment

39. Laboratory EvaluationLaboratory Evaluation
 Unnecessary for patients who presentUnnecessary for patients who present
within 1 day from onset of diarrheawithin 1 day from onset of diarrhea
 Warning signs/symptoms: bloodyWarning signs/symptoms: bloody
diarrhea, high fever, severe abd pain,diarrhea, high fever, severe abd pain,
dehydration, or comorbid conditiondehydration, or comorbid condition
 Fecal leukocytes followed by bacterialFecal leukocytes followed by bacterial
culture, ova & parasites, viral antigensculture, ova & parasites, viral antigens
 CBC, chemistriesCBC, chemistries

40. AssessmentAssessment
No dehydration Some
dehydration
Severe
dehydration
Condition Well, alert Restless, irritable Lethargic or
unconscious
Eyes Normal Sunken Sunken
Thirst Drinks normally,
not thirsty
Thirsty, drinks
eagerly
Drinks poorly, or
not able to drink
Skin pinch Goes back quickly Goes back slowly Goes back very
slowly
Treatment Plan A Plan B Plan C
Fluid deficit < 5% of body wt or
< 50 ml/kg body wt
5-10% of body wt
or 50-100 ml/kg of
body wt
> 10% of body wt
or > 100 ml/kg of
body wt

41. Degree of DehydrationDegree of Dehydration
Factors Mild < 5% Moderate
5-10%
Severe >10%
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
Respiratory rate Slightly
increased
Increased Deep, rapid

43. PLAN APLAN A
1.1. Give extra fluids, ORS solution orGive extra fluids, ORS solution or
recommended home fluids.recommended home fluids.
2.2. Continue feeding, encourage ongoingContinue feeding, encourage ongoing
breastfeeding when applicable.breastfeeding when applicable.
3.3. Give zinc supplementation for 10-14 daysGive zinc supplementation for 10-14 days
in the recommended dose for the child’sin the recommended dose for the child’s
age.age.
4.4. Advise the mother on when to return to theAdvise the mother on when to return to the
health facility.health facility.

44. 1. GIVE EXTRA FLUID (As much
as the child will take)

46. 3. Continue Feeding3. Continue Feeding

47. 1. Does not get better in 3 days
2. Passes many watery stools
3. Vomits repeatedly
4. Is very thirsty
5. Eats or drink poorly
6. Has a fever
7. Has blood in stool
4. When to return:4. When to return:

50. Types of ORSTypes of ORS
1.1. PACKET ORSPACKET ORS
2.2. HOMEMADE ORSHOMEMADE ORS
3.3. READYMADE ORSREADYMADE ORS
In 1 litre
Na 90 mmol/L
K 20 mmol/L
Glucose 110 mmol/L
Chloride 80 mmol/L
Citrate 10 mmol/L

51. OR
Squeeze one lemon
one pinch – Baking
soda
1) 4 glasses of water
HOMEMADE ORS
2)
3)
4)

53. PLAN C : FOR SEVERE DEHYDRATION
Follow the arrows. If the answer to the question is Yes, go across.
If it is no, go down.
Start Here
Can you give intravenous
(IV) fluids?
Yes
1.Give IV fluids.
2.After 3-6 hours, reassess the child and
choose the suitable treatment plan.
No
Can the child drink? Yes
1.Start treatment with ORS solution, as in
Treatment Plan B
2.Send the child for IV treatment
No
Are you trained to use a
nasogastric tube for
rehydration?
Yes
1.Start rehydration using the tube
2.If IV treatment is available nearby,
send the child for immediate IV
treatment.
No
URGENT:
Send the child for IV
treatment

55. USE OF DRUGS FOR CHILDREN WITHUSE OF DRUGS FOR CHILDREN WITH
DIARRHOEADIARRHOEA
• ANTIBIOTICS: Dysentery and suspected choleraANTIBIOTICS: Dysentery and suspected cholera
• ANTIPARASTIC:ANTIPARASTIC:
AMOEBIASIS:AMOEBIASIS: After antibiotic Rx of bloodyAfter antibiotic Rx of bloody
diarrhoea for Shigella has failed ORdiarrhoea for Shigella has failed OR
Tropozoites of E. histolytica seen in stool.Tropozoites of E. histolytica seen in stool.
GIARDIASIS:GIARDIASIS: when diarrhoea has lasted atleastwhen diarrhoea has lasted atleast
14 days and cyst or trophozoites of Giardia14 days and cyst or trophozoites of Giardia
are see in stool.are see in stool.
• ANTIDIARRHOEAL DRUGS and ANTIEMETICS: notANTIDIARRHOEAL DRUGS and ANTIEMETICS: not
used. None has proven practical value even some areused. None has proven practical value even some are
dangerousdangerous

56. PREVENTIOPREVENTIO
NN
1. Giving breast milk for the first 6 months1. Giving breast milk for the first 6 months
and continuing to breast-feed atleast oneand continuing to breast-feed atleast one
year.year.
2. Weaning Start at 6 months of age.2. Weaning Start at 6 months of age.
3. Giving freshly prepared food & clean3. Giving freshly prepared food & clean
drinking water.drinking water.
4. Giving milk & other fluids by cup & spoon4. Giving milk & other fluids by cup & spoon
instead of bottle feeding.instead of bottle feeding.

57. 5. All family members wash hands
after
passing stool and before preparing
or
eating food.
6. All family members use a latrine.
7. Proper disposal of young child’s
stools.
8. Child immunized against measles
as
soon after 9 months of age as
PREVENTIOPREVENTIO
NN

58. In SummaryIn Summary
 ExtremelyExtremely commoncommon
 Most isMost is viralviral in origin and self-limitedin origin and self-limited
 AA good H&Pgood H&P is crucialis crucial
 Warning signs includeWarning signs include high fever, severehigh fever, severe
abd. pain, dehydration, and bloody stoolabd. pain, dehydration, and bloody stool
 Fluid replacementFluid replacement is most importantis most important
 Antibiotics are usuallyAntibiotics are usually notnot necessarynecessary

59. ReferencesReferences
 http://www.pediatriconcall.com/fordoctor/diarrhehttp://www.pediatriconcall.com/fordoctor/diarrhe
 http://whqlibdoc.who.int/publications/2005/a8550http://whqlibdoc.who.int/publications/2005/a8550
The MOST Project, 1820 N. Fort Myer Drive, Suite 600 Arlington, VA 22209 USA,Telephone: (703)The MOST Project, 1820 N. Fort Myer Drive, Suite 600 Arlington, VA 22209 USA,Telephone: (703)
807-0236, Fax: (703) 807-0278, Web site:807-0236, Fax: (703) 807-0278, Web site: http://www.mostproject.orghttp://www.mostproject.org, E-mail: most@istiinc.com, E-mail: most@istiinc.com
 David S, Lobo ML. Childhood diarrhea andDavid S, Lobo ML. Childhood diarrhea and
malnutrition in Pakistan, Part I: Incidencemalnutrition in Pakistan, Part I: Incidence
and prevalence. J Pediatr Nurs. 1995and prevalence. J Pediatr Nurs. 1995
Apr;10(2):131-7. PubMed PMID: 7752042.Apr;10(2):131-7. PubMed PMID: 7752042.
 Dennehy P.H., Acute Diarrheal Disease in Children:Dennehy P.H., Acute Diarrheal Disease in Children:
Epidemiology, Prevention, and Treatment.Epidemiology, Prevention, and Treatment. Infect DisInfect Dis
Clin North AClin North A 2005;(19) 3:2005;(19) 3:
 Thielman N.M., (2004) Acute Infectious Diarrhea.Thielman N.M., (2004) Acute Infectious Diarrhea. N EnglN Engl
J MedJ Med 2004;350:38-47.2004;350:38-47.
 Burkhart D.M., Management of Acute Gastroenteritis inBurkhart D.M., Management of Acute Gastroenteritis in
Children.Children. Am Fam PhysicianAm Fam Physician. 1999 Dec;60(9):2555-63. 1999 Dec;60(9):2555-63