This document provides information on diarrhea among under-5 children. It discusses the global burden of diarrhea, key facts about diarrhea including causes and prevention. Specific diarrheal pathogens like rotavirus, cholera, and giardiasis are explained. Treatment of acute watery diarrhea and dysentery are also summarized. The document emphasizes continued feeding and oral rehydration therapy in treating diarrhea.

5. WELCOMEWELCOME ALLALL

6. 6

7. Dr Mohammad Nurul Huq

8. 8
ARI
54%
Diarrhoea
85%
Malaria
79%
Measles
89%
Percentage of deaths occurring among:
Global Burden of Diseases Borne by U-5 Children Year 2000

9. 9
Diarrhea Key FactsDiarrhea Key Facts
 Globally: 1.7 billion cases/y.Globally: 1.7 billion cases/y. 2 attacks/child/y2 attacks/child/y
 2nd2nd largest U-5 killerlargest U-5 killer (0.76mn/y: 2013)(0.76mn/y: 2013)
 WWasas No.1No.1 (5mn)(5mn)
Most deaths from dehydrationMost deaths from dehydration
 Preventable/treatable: sPreventable/treatable: safe food & sanitationafe food & sanitation
 BangladeshBangladesh:: 15,000 deaths (2.19% of total deaths)/y15,000 deaths (2.19% of total deaths)/y
 A leading c/of malnutrition in U-5A leading c/of malnutrition in U-5

10. 10
Diarrhea Death is FallingDiarrhea Death is Falling
Successful ORTSuccessful ORT
 Breastfeeding, no bottle, no formulaBreastfeeding, no bottle, no formula
 Safe water & food, hand washingSafe water & food, hand washing
 Health education, improved sanitationHealth education, improved sanitation
 ImmunizationImmunization
 HPVAC, ZnHPVAC, Zn
 Fall in malnutritionFall in malnutrition
 AwarenessAwareness
HPVAC: high potency Vitamin A capsule. Zn: zincHPVAC: high potency Vitamin A capsule. Zn: zinc

11. 11
50 Years of ORS (1968)50 Years of ORS (1968)
 Absorption of salt plus water is enhanced with glucose,Absorption of salt plus water is enhanced with glucose,
amino a.amino a. ⇒⇒ discovery of ORS & later rice ORSdiscovery of ORS & later rice ORS
WHO:WHO:
““ORT is the most rewarding scientificORT is the most rewarding scientific
achievement of 20th century”achievement of 20th century”

12. 12
Definition of DiarrheaDefinition of Diarrhea
Passage of ≥3 loose stools/24h. Loose stool: one that
takes up the shape of the container
Exception!!Exception!!
EBFEBF babiesbabies passpass manymany loose/unformed motions/dloose/unformed motions/d
They doThey do notnot develop dehydration & thrive well!develop dehydration & thrive well!
We call theseWe call these BM stoolsBM stools!!
With itsWith its other unique qualities BMother unique qualities BM
also has ORS like actionalso has ORS like action

13. 13
Breast milk stools

14. 14
Diarrhea Harms ..Diarrhea Harms ..
DehydrationDehydration
 DyselectrolytemiasDyselectrolytemias
 MalnutritionMalnutrition
 VADXVADX
 AnemiaAnemia
 More infxMore infx
 Growth failureGrowth failure
VADX: Vitamin A deficiency & xerophthalmia. Infx.: infectionVADX: Vitamin A deficiency & xerophthalmia. Infx.: infection

15. 15
Diarrhea CausesDiarrhea Causes MalnutritionMalnutrition
 Food intakeFood intake ⇓⇓ byby 1/31/3 ((appetite poor, NVD)appetite poor, NVD)
 MalabsorptionMalabsorption
 Faulty feeds, food fadsFaulty feeds, food fads
 Starvation therapyStarvation therapy (‘rest to bowel’)(‘rest to bowel’)
 VADXVADX ⇔⇔ InfxInfx
 More nutrients to cope with diarrheaMore nutrients to cope with diarrhea
Malnutrition makes D. worse. Mn.Malnutrition makes D. worse. Mn. ⇔⇔ longer, severer D.longer, severer D.
The cycle can be broken by good nutritionThe cycle can be broken by good nutrition
Stress on feeding in D.!Stress on feeding in D.!
D: diarrheaD: diarrhea

16. 16
Diarrhea Kills ..Diarrhea Kills ..
ShockShock, ARF, ARF
 DyselectrolytemiaDyselectrolytemia (hypokalemia)(hypokalemia)
 Severe malnutritionSevere malnutrition
 Associated inf. (pneumonia)Associated inf. (pneumonia)
 HUS (E coli)HUS (E coli)
 GBS (C jejunae)GBS (C jejunae)
How dehydration kills
 HypovolemiaHypovolemia
For each 1% dehydration body function falls by 5%For each 1% dehydration body function falls by 5%
20% dehydration is lethal20% dehydration is lethal

17. 17
Predisposing Factors for D.Predisposing Factors for D.
 Not breast feeding, formula feeds, feedingNot breast feeding, formula feeds, feeding bottlebottle
 NotNot washingwashing handshands
 Unsafe foods, drinks, waste disposalUnsafe foods, drinks, waste disposal
 No immunization, malnutritionNo immunization, malnutrition
 MeaslesMeasles
 VADXVADX
 Zn deficiencyZn deficiency
 ImmunodeficiencyImmunodeficiency

18. 18
ComplicationsComplications
DehydrationDehydration
 Shock, ARF, acidosisShock, ARF, acidosis
 HypokalemiaHypokalemia
 HyponatremiaHyponatremia
 HypochloremiaHypochloremia
 Hypocalcemia (more in chronic D)Hypocalcemia (more in chronic D)
 Hypoglycemia, fitHypoglycemia, fit
 HypothermiaHypothermia
 Food intoleranceFood intolerance
 GBS, HUS, anemiaGBS, HUS, anemia
 MalnutritionMalnutrition
 VADXVADX
 Shigella encephalopathyShigella encephalopathy

19. 19
HUS:HUS: Schistocytes (broken RBCs)
Often seen in hemolytic a. & isOften seen in hemolytic a. & is
frequently a consequence of artificialfrequently a consequence of artificial
heart valves & HUS, thromboticheart valves & HUS, thrombotic
thrombocytopenic purpurathrombocytopenic purpura

20. 20
Types of Ac. DiarrheaTypes of Ac. Diarrhea
33 clinical typesclinical types
 Ac.Ac. waterywatery DD (AWD) 75%(AWD) 75% lasts several hours to dayslasts several hours to days
 Ac.Ac. invasiveinvasive DD (AID) 15%(AID) 15% oror ac. bloody D (dysentery)ac. bloody D (dysentery)
 PersistentPersistent DD (PD) 10%(PD) 10% lasts 14d or morelasts 14d or more

21. 21
Ac. Watery DiarrheaAc. Watery Diarrhea
 CommonestCommonest
 Large motions: rapid dehydrationLarge motions: rapid dehydration
 45% of diarrheal deaths45% of diarrheal deaths
 No invasionNo invasion
 Duration ~7 daysDuration ~7 days
 Classical: rotavirus, choleraClassical: rotavirus, cholera

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Cl. Features of AWDCl. Features of AWD

UsuallyUsually starts as astarts as a viral syndrome*viral syndrome*
 Loose/watery stoolsLoose/watery stools
 NVNV
 ++ FeverFever
 +/-+/- Abdominal painAbdominal pain
*Viral syndrome: cold, cough, flushing, red eyes, malaise, bodyache, etc.

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Causes of AWDCauses of AWD
RotavirusRotavirus
 ETECETEC
 EPECEPEC
 V. choleraeV. cholerae
No pathogen detectable in 5%No pathogen detectable in 5%
 GiardiaGiardia
 Nontyph. salmonellaNontyph. salmonella
 CryptosporidiumCryptosporidium
 A. hydrophilaA. hydrophila

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Rota VirusRota Virus
 33% of all D.33% of all D.
 60% of all D. <2yoa60% of all D. <2yoa
 6,000-9,000 deaths in Bangladesh6,000-9,000 deaths in Bangladesh
 Starts as URT catarrhStarts as URT catarrh
 Yellowish/greenish watery stools with flakes of fecesYellowish/greenish watery stools with flakes of feces
 Rapid dehydrationRapid dehydration
 Vaccine preventable: v. effectiveVaccine preventable: v. effective
URT: Upper Resp. TractURT: Upper Resp. Tract

25. 25

26. CholeraCholera
is an extremely pathogenic d.; can cause severe AWD (upis an extremely pathogenic d.; can cause severe AWD (up
to 40 motions/d). IP: 12h-5d. Affects both children &to 40 motions/d). IP: 12h-5d. Affects both children &
adults & can kill within hoursadults & can kill within hours
Inoculum:Inoculum: 101088
(100,000,000) organisms(100,000,000) organisms
C/by food or water contaminated withC/by food or water contaminated with V. choleraeV. cholerae. It is a. It is a
global threat to PH & an indicator of poor social dev.global threat to PH & an indicator of poor social dev.
1.3-4.0 million cases/y, & 21k-143k deaths worldwide1.3-4.0 million cases/y, & 21k-143k deaths worldwide
Most inf. have no or mild SSMost inf. have no or mild SS
Safe water & sanitation is critical to controlSafe water & sanitation is critical to control
A global control strategy target to reduce cholera deathsA global control strategy target to reduce cholera deaths
by 90% was launched in 2017. Oral cholera vax.by 90% was launched in 2017. Oral cholera vax.
should be used with water & sanitation to control itshould be used with water & sanitation to control it
26

27.  It is present in faeces for 1-10dIt is present in faeces for 1-10d
 Many serogroups, but only O1 & O139 cause outbreaks. O1Many serogroups, but only O1 & O139 cause outbreaks. O1
has caused all recent outbreaks. There is no differencehas caused all recent outbreaks. There is no difference
in the illness by serogroupsin the illness by serogroups
 To control:To control: surveillance, water, sanitation & hygiene, socialsurveillance, water, sanitation & hygiene, social
mobilization, Rx, & oral vax.mobilization, Rx, & oral vax.
 Rx.:Rx.: mostly ORT. Some: IVF & ABT (less severity &mostly ORT. Some: IVF & ABT (less severity &
duration)duration)
 With early & proper Rx, the CFR is <1%With early & proper Rx, the CFR is <1%
 Zinc is an imp adjunctive for U-5 (reduces duration & mayZinc is an imp adjunctive for U-5 (reduces duration & may
prevent future episodes of other AWD)prevent future episodes of other AWD)
Case fatality rate (CFR) 27

28. 28
V cholerae

29. 29

30. GiardiasisGiardiasis
is an inf. in small gut, c/byis an inf. in small gut, c/by G lamblia:G lamblia: found in animal &found in animal &
human feceshuman feces;; spreads P2P, by contaminated food. Petspreads P2P, by contaminated food. Pet
dogs & cats frequently have itdogs & cats frequently have it
Acquired most commonly by water (water bodiesAcquired most commonly by water (water bodies
contaminated by animal feces, diapers, & agriculturalcontaminated by animal feces, diapers, & agricultural
runoff. Children are more likely to encounter fecesrunoff. Children are more likely to encounter feces
with diapers or potty trainingwith diapers or potty training
Cooked food is safe. Unhealthy handling food or rawCooked food is safe. Unhealthy handling food or raw
produce can cause itproduce can cause it
Found all over the world; more common in overcrowdingFound all over the world; more common in overcrowding
with poor sanitation; can thrive in soil for long periodwith poor sanitation; can thrive in soil for long period
May asymptomatic.May asymptomatic. IP: 1-2w. Common SS:IP: 1-2w. Common SS:
Fatigue, ANVD (greasy stools), APFatigue, ANVD (greasy stools), AP
Bloating, wt. loss, excessive gas, headacheBloating, wt. loss, excessive gas, headache
30

31. 31

32. DxDx
Stool ME. Multiple samples may be neededStool ME. Multiple samples may be needed
EndoscopyEndoscopy
RxRx
Mostly clears up on its ownMostly clears up on its own
Metronidazole for 5-7d, Tinidazole single doseMetronidazole for 5-7d, Tinidazole single dose
Nitazoxanide is for 3dNitazoxanide is for 3d
Paromomycin in pregnancyParomomycin in pregnancy
ComplicationsComplications
Wt loss, dehydration, lactose intolerance, malnutritionWt loss, dehydration, lactose intolerance, malnutrition
Washing hands, not swallowing water on swimming,Washing hands, not swallowing water on swimming,
avoiding drinking untreated surface water, uncookedavoiding drinking untreated surface water, uncooked
local produce can preventlocal produce can prevent
Usually last 6-8w, but lactose intolerance can persistUsually last 6-8w, but lactose intolerance can persist
32

33. 33
Remember AWD..Remember AWD..
CommonestCommonest
 Rapid severe dehydrationRapid severe dehydration
 Rx only by ORTRx only by ORT
 No ABT (antibiotic therapy)*No ABT (antibiotic therapy)*
 Self- limitingSelf- limiting
Wrong Rx may lead to PDWrong Rx may lead to PD
 Increased fluid & continued feeding is v. imp.Increased fluid & continued feeding is v. imp.
*ABT recommended in cholera*ABT recommended in cholera

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Ac. Inv. D. (Dysentery)Ac. Inv. D. (Dysentery)
FeaturesFeatures
 Invasion:Invasion:
 Inflammation:Inflammation:
 System upset:System upset:
 Characteristic stools:Characteristic stools:
Dysentery:Dysentery: loose s. mixed with mucus & blood; AP & tenesmus (urgeloose s. mixed with mucus & blood; AP & tenesmus (urge
to purge with little output: irritation of internal anal sphincter)to purge with little output: irritation of internal anal sphincter)

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 InvasionInvasion :: inflammation, spreadinflammation, spread
 InflammationInflammation :: congestion, edema,congestion, edema, mucusmucus,,
ulcer,ulcer, bleedbleed,, AP,AP, tenesmustenesmus,,
distensiondistension
 Sys. UpsetSys. Upset :: HGF, NV, HA, toxic,HGF, NV, HA, toxic,
prostrationprostration
 StoolsStools :: Dysenteric: frequent (>6/d),Dysenteric: frequent (>6/d),
plentyplenty pus cellspus cells,, RBCRBC,,
macrophagesmacrophages,,
epithelial cells, bacilliepithelial cells, bacilli

36. 36
Colitis in Ac. Inv. DiarrheaColitis in Ac. Inv. Diarrhea

37. 37
Rectal prolapse

38. CT of Amebic L. Abscess (F, RUQ Pain & Pleuritic Pain)

39. 39
C/of Ac. Invasive DiarrheaC/of Ac. Invasive Diarrhea
Shigella (60%)Shigella (60%)
 Salmonella (some strains)Salmonella (some strains)
 EIEC, otherEIEC, other E coliE coli
 CampylobacterCampylobacter
 HelicobacterHelicobacter
 E. histolyticaE. histolytica

40. ShigellosisShigellosis
c/by Shigella. Shigella.Shigella. Very contagious:Very contagious: only 10 bacteriaonly 10 bacteria
SS: D, F, cramps, tenesmus 1-2d post-exposure. Duration 5-
7d. (4 or more weeks). Commonly young children
May be asymptomatic, but spreads
2% with S flexneri will have post-inf. arthritis, eye
irritation, & dysuria for months or years, & can be chr. It
usually does not occur with other types
RxRx
Most recover without Rx.Most recover without Rx.
ORT. Ciprofloxacin for adults, & azithromycin for childrenORT. Ciprofloxacin for adults, & azithromycin for children
There may be AB ResistanceThere may be AB Resistance
40

41. 41
Intracellular Shigella

42. 42
EM: Salmonella

43. 43E coli, flagella
E coliE coli Diarrhea (Including HUS).Diarrhea (Including HUS).
EMEM ofof E coliE coli O157:H7 showingO157:H7 showing
flagellaflagella

44. AmebiasisAmebiasis
is an gut inf. typically by contaminated food; c/by E
histolytica: a single-celled parasite (protozoon)
Often it lives in large gut without SS. Causes dysentery
with F., rarely spreads into liver, lungs, brain
Typically occurs in areas of poor sanitation
CF in children
Mostly minimal/no symptoms. Gradual AP, loose/watery
motions, cramps, AN. Sometimes F & dysentery
IP: days-weeks; may be months
44

45. DxDx
 Stool ME (3 samples), blood tests
Rx
Metronidazole (DoC) for 5d, tinidazole
Paromomycin & diloxanide furoate: used along withParomomycin & diloxanide furoate: used along with
metronidazole when gastrointestinal GI symptomsmetronidazole when gastrointestinal GI symptoms
are present. Asymptomatic stool carriage can beare present. Asymptomatic stool carriage can be clearedcleared
by these aloneby these alone
PreventionPrevention
Cooked food, hand washing, safe waterCooked food, hand washing, safe water
45

46. 46

47. 47E. histolyticaE. histolytica Trophozoite in Stool Showing Ingested RBCsTrophozoite in Stool Showing Ingested RBCs

48. 48

49. 49
Remember AID may cause:Remember AID may cause:
 Complications: HUS (E. coli), GBS (Campylobacter)Complications: HUS (E. coli), GBS (Campylobacter)
 MalnutritionMalnutrition
 AnemiaAnemia
 Persistent diarrheaPersistent diarrhea
 DeathDeath

50. 50
Persistent DiarrheaPersistent Diarrhea
30-50% of diarrheal deaths!30-50% of diarrheal deaths!
Almost unknown in E B F BAlmost unknown in E B F B
 Starts as AWD/AID; but predisposingStarts as AWD/AID; but predisposing
factors prolong itfactors prolong it >> 1414dd
 Child is malnourished, develops VADXChild is malnourished, develops VADX
 Often with serious non-GIT infx.Often with serious non-GIT infx.
EBFB: exclusively breastfed babies

51. 51
Predisposing Factors for PDPredisposing Factors for PD
 Not breastfeedingNot breastfeeding
 Bottle feedingBottle feeding
 Unjustified ABTUnjustified ABT
 MalnutritionMalnutrition
 VADXVADX
 ImmunodeficiencyImmunodeficiency
 Starvation therapyStarvation therapy
 Food intoleranceFood intolerance
Preventing these can avert PDPreventing these can avert PD

52. 52
Effects of PDEffects of PD
AA seriousserious conditioncondition!!
 DehydrationDehydration
 Rapid wt. loss, malnutritionRapid wt. loss, malnutrition
 Malabsorption: nutrient deficiencies,Malabsorption: nutrient deficiencies, VADXVADX

53. 53
Causes of PDCauses of PD
No single microbial causeNo single microbial cause
SomeSome maymay play a role:play a role:
 CryptosporidiumCryptosporidium
 EnteroaggregativeEnteroaggregative E. coliE. coli
 ShigellaShigella

54. 54
Chronic vs. PDChronic vs. PD
Don’t confuse chr. D with PDDon’t confuse chr. D with PD
Chr. diarrhea is:Chr. diarrhea is:
 insidiousinsidious
 long lasting/recurrentlong lasting/recurrent
 usuallyusually non-infx. causes (eg thyrotoxicosis)non-infx. causes (eg thyrotoxicosis)

55. 55
 History.History. Volume ofVolume of urineurine (never forget).(never forget). Looking atLooking at
the stoolthe stool
Physical ExamPhysical Exam
S/S/of dehydrationof dehydration && malnutritionmalnutrition
Assessing DiarrheaAssessing Diarrhea

56. 56
HistoryHistory
 Duration & onsetDuration & onset
 Stool:Stool: times, vol., form,times, vol., form,
color, blood +/-mucuscolor, blood +/-mucus
 AP, feverAP, fever
 DistensionDistension
 TenesmusTenesmus
 NV, appetite, activityNV, appetite, activity
 Urine vol.Urine vol.

57. 57
IMCIIMCI
Management ofManagement of
DiarrhoeaDiarrhoea

58. 58
History takingHistory taking
1. General Danger Signs1. General Danger Signs
2. Main Symptoms2. Main Symptoms
a. Cougha. Cough
b.b. DiarrheaDiarrhea √√
c. Feverc. Fever
d. Ear Problemsd. Ear Problems
3. Nutritional Status3. Nutritional Status
4. Immunization Status4. Immunization Status
5. Other Problems5. Other Problems IMCI record form

59. 59
DANGER
SIGNS
CONVULSIONS
INABILITY TO DRINK
OR BREASTFEED
VOMITING
LETHARGY
UNCONSCIOUSNESS

60. 60
4 Signs to4 Signs to classifyclassify::
 General conditionGeneral condition
 Sunken eyesSunken eyes
 ThirstThirst
 Skin pinchSkin pinch
Assessing DehydrationAssessing Dehydration

61. 61
Child’s general condition
Lethargic or unconscious (also a GDS)
or Restless (a child who cannot be consoled)
 or Well & alert

62. 62Consoled

63. 63
Sunken eyes:
– Dehydration
– Visible wasting
– Old age
 Though less reliable it is still useful

64. 64
Signs of DehydrationSigns of Dehydration

65. 65
Thirst: 3 stagesThirst: 3 stages
 Not able to drink or drinks poorlyNot able to drink or drinks poorly
weak, drinks with help, swallows only if fluid isweak, drinks with help, swallows only if fluid is
put in mouthput in mouth
 Drinking eagerly, thirstyDrinking eagerly, thirsty
wants to drink morewants to drink more
 Drinks normallyDrinks normally

66. 66
Drinks eagerly

67. 67
Skin PinchSkin Pinch
 Middle of umbilicus & flankMiddle of umbilicus & flank
 Pinch all layers with thumb + index in long axis forPinch all layers with thumb + index in long axis for
1 sec & release suddenly:1 sec & release suddenly:
– goes backgoes back very slowlyvery slowly (>2 sec)(>2 sec)
– sslowlylowly
– oror immediatelyimmediately

68. 68

69. 69

70. 70
Exception!Exception!
 Marasmic & elderly: pinchMarasmic & elderly: pinch goes back slowlygoes back slowly
 Obesity/edema:Obesity/edema: goes back immediatelygoes back immediately thoughthough
dehydrated!dehydrated!
ThoughThough lessless reliable it is usefulreliable it is useful

71. 71

72. 72
Any 2 signs:Any 2 signs:
• Lethargic or unconsciousLethargic or unconscious
• Sunken eyesSunken eyes
• Unable to drink/drink poorlyUnable to drink/drink poorly
• Skin pinch returns v. slowlySkin pinch returns v. slowly
SevereSevere
dehydrationdehydration
(Rx plan A)(Rx plan A)
Any 2 signs:Any 2 signs:
• Restless, irritableRestless, irritable
• Sunken eyesSunken eyes
• Drinks eagerly, thirstyDrinks eagerly, thirsty
• Skin pinch returns slowlySkin pinch returns slowly
SomeSome
dehydrationdehydration
(Rx plan B)(Rx plan B)
Not enough signs to classify asNot enough signs to classify as
aboveabove
NoNo
dehydrationdehydration
(Rx plan C)(Rx plan C)

73. 73
NoNo
dehydrationdehydration
Plan APlan A
SomeSome
dehydrationdehydration
Plan BPlan B
SevereSevere
dehydrationdehydration
Plan CPlan C
Look:Look:
Gen.Gen.
Con.Con.
EyesEyes
ThirstThirst
Well, alertWell, alert
Not sunkenNot sunken
Drinks wellDrinks well
Restless, irritableRestless, irritable
SunkenSunken
Thirsty, drinksThirsty, drinks
eagerlyeagerly
Lethargic/comaLethargic/coma
SunkenSunken
Drinks poorly orDrinks poorly or
not able tonot able to
Feel:Feel:
SkinSkin
pinchpinch
Goes backGoes back
quicklyquickly
Goes backGoes back
slowlyslowly
Very slowlyVery slowly
Classifying DehydrationClassifying Dehydration

74. 74
Principles of RxPrinciples of Rx
Only rehydration in most casesOnly rehydration in most cases
 Correct existing deficitCorrect existing deficit
 Replace further lossReplace further loss
 IVF in severe dehydrationIVF in severe dehydration
 FeedingFeeding, specially BM continued, specially BM continued
 AntimicrobialsAntimicrobials if warrantedif warranted

75. 75
 SSevere ....:evere ....: immediate replacement with IVF, NGTimmediate replacement with IVF, NGT
or ORTor ORT (Plan C)(Plan C)
 Some ......:Some ......: ORTC/at homeORTC/at home (Plan B)(Plan B)
 No .....:No .....: at homeat home (Plan A)(Plan A)
Rehydration PlanRehydration Plan

76. 76
Rx PlanRx Plan
AA
 Rx atRx at
homehome
 TeachTeach
 IF/CFIF/CF **
BB
ORS in 4h: 70 ml/kgORS in 4h: 70 ml/kg
<4 mo 200- 400ml<4 mo 200- 400ml
4-12 mo 400- 600ml4-12 mo 400- 600ml
1-2y 600- 800ml1-2y 600- 800ml
2-4y 800-1200ml2-4y 800-1200ml
5-14y 1200-2200ml5-14y 1200-2200ml
Reassess after 4 h: selectReassess after 4 h: select
plan A, B, or Cplan A, B, or C
CC
Start IVF @ 100ml/kgStart IVF @ 100ml/kg
50% in first 2h50% in first 2h
50% next 3-4h50% next 3-4h
Replace further loss;Replace further loss;
ORT if can drinkORT if can drink
Assess pulse, BP, UOPAssess pulse, BP, UOP
frequently & review Rxfrequently & review Rx
planplan**
IF/CF: increased fluid & continued feedingIF/CF: increased fluid & continued feeding

77. 77
Some dehydration

78. 78
Feeding in DiarrheaFeeding in Diarrhea
 Growth slows during diarrhea but children catch upGrowth slows during diarrhea but children catch up laterlater
 Give an extra meal for 2wGive an extra meal for 2w
 ContinueContinue BM+ORTBM+ORT, family foods, family foods
 Severe malnutrition: feed during ORT, rehydrate slowlySevere malnutrition: feed during ORT, rehydrate slowly

79. 79
Any dehydrationAny dehydration SevereSevere PDPD
No dehydrationNo dehydration Persistent diarrheaPersistent diarrhea
Classification of PDClassification of PD

80. 80
 Severe PD:Severe PD: hospitalisehospitalise
 FeedingFeeding is most important:is most important:
– tempo.tempo. ⇓⇓ animal milkanimal milk
– energy, protein, vitamins, mineralsenergy, protein, vitamins, minerals
– avoidavoid aggravatingaggravating foodsfoods
– enoughenough food during convalescencefood during convalescence
 No routine ABTNo routine ABT
Treatment of PDTreatment of PD

81. 81
Remember! PD meansRemember! PD means
 MalabsorptionMalabsorption
 Weight loss, malnutrition, VADXWeight loss, malnutrition, VADX
 Hidden infxHidden infx
 Death!Death!

82. 82
Dysentery SyndromeDysentery Syndrome
BasicallyBasically Invasive DiarrhoeaInvasive Diarrhoea
Bloody mucoid stools, F, cramps, tenesmus. High MMBloody mucoid stools, F, cramps, tenesmus. High MM
Stool CS is rarely possibleStool CS is rarely possible
More severe in malnourished, not breast-fed, or bottle fedMore severe in malnourished, not breast-fed, or bottle fed
babies.babies. ⇑⇑ frequent & severe in measlesfrequent & severe in measles
 ⇑⇑ likely to become PDlikely to become PD
MM: morbidity & mortalityMM: morbidity & mortality

83. 83
Classification of Dysentery (IMCI)Classification of Dysentery (IMCI)
 ClassifyClassify dysenterydysentery if blood is in stoolif blood is in stool
 15% diarrheas in U-5y are dysentery15% diarrheas in U-5y are dysentery
 15% of diarrheal deaths15% of diarrheal deaths
Blood in the stool Dysentery

84. Other Causes of Bloody StoolsOther Causes of Bloody Stools
 Rectal polypRectal polyp
 Anal fissureAnal fissure
 Meckel diverticulumMeckel diverticulum
 Diverticulosis/diverticulitisDiverticulosis/diverticulitis
 Cow’s milk protein intoleranceCow’s milk protein intolerance
 AV malformationAV malformation
 Hemorrhagic diseaseHemorrhagic disease
84

85. 85
3 Types of Dehydration3 Types of Dehydration
Serum Na
Isotonic 130-150 mmol/l
Hypertonic >160 mmol/l
(hypernatremic)
Hypotonic <130 mmol/l
(hyponatremic)

86. 86
Isotonic:Isotonic: commonestcommonest
 Fluid lost in DV is isotonicFluid lost in DV is isotonic
 Plasma osmolality 275-295mOsmol/lPlasma osmolality 275-295mOsmol/l
 Serum Na isSerum Na is 130-150 mmol/ l130-150 mmol/ l
The patientThe patient
Proportionately dehydratedProportionately dehydrated

87. 87
HypertonicHypertonic
 Caused by rCaused by rehydration by hypertonic fluidehydration by hypertonic fluid
 Serum Na isSerum Na is >160 mmol/l>160 mmol/l
 Osmolality is >295 mOsmol/lOsmolality is >295 mOsmol/l
The patient isThe patient is
 sseverely dry, thirsty, irritable, bounding pulseeverely dry, thirsty, irritable, bounding pulse
 fits at Na >165mmol/lfits at Na >165mmol/l

88. 88
HypotonicHypotonic
 caused bycaused by rehydrated with hypotonic fluidrehydrated with hypotonic fluid
 Serum NaSerum Na <130 mmol/l<130 mmol/l
 OsmolalityOsmolality <275 mOsmol/l<275 mOsmol/l
The patient isThe patient is
 Lethargic, feeble pulseLethargic, feeble pulse
 Postural hypotensionPostural hypotension
 May have fits: Na 120 mmol/lMay have fits: Na 120 mmol/l

89. 89
OLD ORS

90. New ORS (WHO):
 All ingredients except K +
& alkali are
reduced: 27.9 ⇒ 20.5 g
 It is hypo-osmolar: 311 ⇒ 245mmol/L

91. NewNew OldOld
NaClNaCl 2.6 g/l2.6 g/l 3.5 g/l3.5 g/l
GlucoseGlucose 13.513.5 2020
KClKCl 1.51.5 1.51.5
Trisodium citrateTrisodium citrate 2.92.9 2.92.9
TotalTotal 20.5g20.5g 27.9g27.9g
OsmolarityOsmolarity mmol/Lmmol/L mmol/Lmmol/L
NaNa 7575 9090
ClCl 6565 8080
GlucoseGlucose 7575 111111
KK 2020 2020
BaseBase 1010 1010
TotalTotal 245245 311311
Old & New ORSOld & New ORS (1L)(1L)

92. 92
Old vs. New ORSOld vs. New ORS
OldOld
 HypertonicHypertonic
 More vomitingMore vomiting
 More stoolsMore stools
 IVFIVF
NewNew
 HypotonicHypotonic
 -20%-20%
 -30%-30%
 -33%-33%

93. 93
Rice based ORSRice based ORS
 WaterWater 500ml500ml
 Rice powderRice powder 30-40 g30-40 g
 NaClNaCl 2.5 g2.5 g
Boil for 5-7 minBoil for 5-7 min
Rice ORS is equally effectiveRice ORS is equally effective
Don’t consider it as food!Don’t consider it as food!

94. 94
Home Made SSSHome Made SSS (salt sugar solution)(salt sugar solution)
 Water 500 ml
 Table salt 3 finger pinch
 Sugar/molasses 4 finger grip
3 finger pinch
4 finger grip

95. 95
Use of ORSUse of ORS
Only for diarrhea or V+D
 Not for vomiting alone
 Never as soft drink nor tonic or water
 Do not use in excess
Rice ORS is not a food!

96. 96
ORS may be IneffectiveORS may be Ineffective
 Severe dehydration, vomitingSevere dehydration, vomiting
 Lethargic, unconsciousLethargic, unconscious
 Rapid loss of waterRapid loss of water
 Sugar malabsorption (large stools, reducing substance)Sugar malabsorption (large stools, reducing substance)

97. 97

98. 98
 WHO:WHO: increased fluidsincreased fluids (ORS or home-made SSS plus(ORS or home-made SSS plus
continued feedingcontinued feeding (IF/CF)(IF/CF)
 It is the key program to control diarrhea dehydrationIt is the key program to control diarrhea dehydration
Sugar-salt soln. (SSS)Sugar-salt soln. (SSS)
Oral Rehydration Therapy (ORT)?Oral Rehydration Therapy (ORT)?

99. 99
ORT CornerORT Corner
 OPD room for ORTOPD room for ORT
 Trained person, ORS & toolsTrained person, ORS & tools
 ForFor ‘No- & Some- dehydration’‘No- & Some- dehydration’
 4 - hr stay4 - hr stay ⇒⇒ reassessedreassessed
 Mostly return homeMostly return home
 Some may need admissionSome may need admission
 Training & counseling mothersTraining & counseling mothers

100. 100

101. 101
Antimicrobials in DiarrheasAntimicrobials in Diarrheas
 Not used routinely, mostlyNot used routinely, mostly NONENONE
 Kills commensalsKills commensals
 Secondary/superinfectionSecondary/superinfection
 Expensive, toxic, allergicExpensive, toxic, allergic

102. 102
Indications of ABTIndications of ABT
 ShigellosisShigellosis
 Inv.Inv. ssalmonellosisalmonellosis
 CholeraCholera
 GiardiasisGiardiasis
 E. histolyticaE. histolytica
 C. jejuniC. jejuni
 Y. enterocoliticaY. enterocolitica

103. 103
Do not use:
 Loperamide, diphenoxylate:Loperamide, diphenoxylate: not effective: SoB &not effective: SoB &
severe distensionsevere distension
 Antispasmodics:Antispasmodics: inhibit peristalsisinhibit peristalsis
 Kaolin, pectin, charcoal, attapulgite:Kaolin, pectin, charcoal, attapulgite: ⇑⇑ consistency, butconsistency, but
nono ⇓⇓ fluid loss. They canfluid loss. They can ⇓⇓ action of other drugsaction of other drugs

104. 104
ZINC IN DIARRHEAZINC IN DIARRHEA (ICCDR’B)(ICCDR’B)
 Significant role in the MDG #4Significant role in the MDG #4
 Globally, 400,000 lives could be saved:Globally, 400,000 lives could be saved:
 ⇓⇓ severity, duration, recurrence, admissionseverity, duration, recurrence, admission
 positive impact on pneumoniapositive impact on pneumonia
 Entire U-5 of Bangladesh is targeted:Entire U-5 of Bangladesh is targeted:
It could save 75,000 lives/yIt could save 75,000 lives/y

105. 105
Why Zinc Rx. In Bangladesh?Why Zinc Rx. In Bangladesh?
 It is rich in protein foods: poor haveIt is rich in protein foods: poor have ↓↓ ZnZn
 Soil is poor in ZnSoil is poor in Zn
 U-5 are the most vulnerableU-5 are the most vulnerable
 Evidence of benefit existsEvidence of benefit exists
 Essential for growth, immunityEssential for growth, immunity
 Supplement till ideal foods for all attainedSupplement till ideal foods for all attained

106. 106
Prevention of DiarrheaPrevention of Diarrhea
 EBF, no bottle nor formulaEBF, no bottle nor formula
 Hand washingHand washing
 Safe food, waterSafe food, water
 Safe eatingSafe eating
 Disposal of excretaDisposal of excreta
 ImmunizationImmunization
 HPVACHPVAC
 Safe complementary feedsSafe complementary feeds
 No overcrowdingNo overcrowding
All are virtually low-cost interventionsAll are virtually low-cost interventions

107. 107

108. 108
Vaccines for DiarrheaVaccines for Diarrhea
 Cholera (Dukoral)Cholera (Dukoral)
 Rota virusRota virus
 ETEC (Dukoral)ETEC (Dukoral)
 TyphoidTyphoid
 MeaslesMeasles

109. 109
MESSAGEMESSAGE
 ORTORT ⇓⇓ diarrheal MR by 70%diarrheal MR by 70%
 No ABT in most diarrheasNo ABT in most diarrheas
 Feeding is v. importantFeeding is v. important
 Prevention is low-costPrevention is low-cost
 Zn has a roleZn has a role
 Vitamin A in prolonged diarrheaVitamin A in prolonged diarrhea

110. HUSHUS
destroys RBCs. It is the commonest c/of ARF in children.destroys RBCs. It is the commonest c/of ARF in children.
Although it can cause serious complications, mostAlthough it can cause serious complications, most
children recoverchildren recover
 Healthy RBC are smooth & round. In HUS, toxins destroyHealthy RBC are smooth & round. In HUS, toxins destroy
RBC & render them misshapen (schistocyte): mayRBC & render them misshapen (schistocyte): may
clog the tiny BV in the kidneysclog the tiny BV in the kidneys
110

111. 111
Healthy RBCs (left) are smooth & round. In HUS, toxins
destroy them (right). These misshapen cells may clog the

112. Causes of HUSCauses of HUS
 E. coliE. coli toxinstoxins destroy RBCsdestroy RBCs
 It is found in contaminated meat, dairies, & juice.It is found in contaminated meat, dairies, & juice.
Swimming pools or lakes can be contaminatedSwimming pools or lakes can be contaminated
 Most E coli AGE recover fully & do not develop HUSMost E coli AGE recover fully & do not develop HUS
112

113. CF of HUSCF of HUS
 The child is pale, tired, irritable. May have small bruises,The child is pale, tired, irritable. May have small bruises,
epistaxis, haematuria. SS may not develop till a weekepistaxis, haematuria. SS may not develop till a week
 ARF (>50%). Damaged RBCs, acid hematin clog the tiny BVARF (>50%). Damaged RBCs, acid hematin clog the tiny BV
in the kidneys. CF of AGN may appear. UOP falls. HTNin the kidneys. CF of AGN may appear. UOP falls. HTN
 Anuria for 12h should attend EDAnuria for 12h should attend ED
DiagnosisDiagnosis
 H/o & PE. Dx is confirmed by PBF study to see if the RBCH/o & PE. Dx is confirmed by PBF study to see if the RBC
are misshapenare misshapen
CF: cl. features. ED: emergency dept.CF: cl. features. ED: emergency dept.
113

114. RxRx
 Maintaining FEB to ease SS & prevent further problemsMaintaining FEB to ease SS & prevent further problems
 BT may be neededBT may be needed
 In severe cases: dialysisIn severe cases: dialysis
 Some children may develop CKDSome children may develop CKD
 Limiting protein in diet & treating HTN with ACEI helpsLimiting protein in diet & treating HTN with ACEI helps
delay/prevent the onset of CKDdelay/prevent the onset of CKD
 Most children recover completelyMost children recover completely
114

115. PreventionPrevention
 Food hygiene especially for meats; avoiding uncleanFood hygiene especially for meats; avoiding unclean
swimming areas are the best waysswimming areas are the best ways
Points to PonderPoints to Ponder
 HUS is the commonest c/of short-term-ARF in children.HUS is the commonest c/of short-term-ARF in children.
Most children recoverMost children recover
 Most cases of HUS follow an AGE by E. coliMost cases of HUS follow an AGE by E. coli
 Maintaining FEB eases SS & prevents further problemsMaintaining FEB eases SS & prevents further problems
 A child may need BTA child may need BT
 Only the most severe cases require dialysisOnly the most severe cases require dialysis
115

116. 116
MCQMCQ
 Diarrhea is the biggest child killerDiarrhea is the biggest child killer
 Ac. ID causes more dehydration than AWDAc. ID causes more dehydration than AWD
 Shigella is the commonest c/of Ac. IDShigella is the commonest c/of Ac. ID
 Diarrhea can cause ARFDiarrhea can cause ARF
 Glucose in ORS is meant for providing nutritionGlucose in ORS is meant for providing nutrition
 C jejuni can cause GBSC jejuni can cause GBS

117. 117
MCQMCQ
 Most diarrheas do not need ABTMost diarrheas do not need ABT
 Cholera is an example of ac. invasive DCholera is an example of ac. invasive D
 In EBF babies diarrhea is virtually nilIn EBF babies diarrhea is virtually nil
 Persistent D is synonymous with chr. DPersistent D is synonymous with chr. D
 Giardia causes ac. invasive DGiardia causes ac. invasive D
 Breast milk stools can cause dehydrationBreast milk stools can cause dehydration

118. 118
MCQMCQ
 Persistent D with mild dehydration is severe PDPersistent D with mild dehydration is severe PD
 Zinc Rx reduces diarrheal mortalityZinc Rx reduces diarrheal mortality
 Breast milk is discontinued if there is lactose intoleranceBreast milk is discontinued if there is lactose intolerance
 Vitamin A is supplemented in prolonged diarrheaVitamin A is supplemented in prolonged diarrhea
 Diarrhea prevention interventions are expensiveDiarrhea prevention interventions are expensive

119. 119
OSPEOSPE
 A 3 mo old formula fed child had mild runny nose &A 3 mo old formula fed child had mild runny nose &
cough for 1 d. It was f/by passage of frequent loosecough for 1 d. It was f/by passage of frequent loose
watery motions containing flakes of feces.watery motions containing flakes of feces.
– What is the most probable Dx?What is the most probable Dx?
 He was lethargic & could not drink. He had sunken eyesHe was lethargic & could not drink. He had sunken eyes
& skin pinch went back v. slowly& skin pinch went back v. slowly
– Classify his dehydration according to IMCIClassify his dehydration according to IMCI
– How do you treat this child?How do you treat this child?

120. 120
 A 2y old child had ac. HGF with V & AP immediately f/byA 2y old child had ac. HGF with V & AP immediately f/by
frequent loose mucoid & bloody stools. He had tenesmus.frequent loose mucoid & bloody stools. He had tenesmus.
– What is the most probable Dx?What is the most probable Dx?
– How can you confirm it?How can you confirm it?
 He was restless with sunken eyes but drank eagerly; skinHe was restless with sunken eyes but drank eagerly; skin
pinch went back slowly.pinch went back slowly.
– Classify his dehydration according to IMCIClassify his dehydration according to IMCI
– How do treat it?How do treat it?
– What ABT do you suggest?What ABT do you suggest?
OSPEOSPE

123. 123
Next Lec.Next Lec.
Infant FeedingInfant Feeding

124. 124
THANK YOUTHANK YOU