MBBS Lecture

5. 5
WELCOMEWELCOME
ALLALL

6. Dr Mohammad Nurul Huq

7. 7
ARI
54%
Diarrhoea
85%
Malaria
79%
Measles
89%
Percentage of deaths occurring among:
Global Burden of Diseases Borne by U-5 Children Year 2000

8. 8
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.Preventable/treatable. Safe food & sanitation canSafe food & sanitation can
largely prevent itlargely prevent it
 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

9. 9
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 MnFall in Mn
 AwarenessAwareness
HPVAC: high potency Vitamin A capsule. Zn: zincHPVAC: high potency Vitamin A capsule. Zn: zinc

10. 10
32 Years of ORS32 Years of ORS
 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”

11. 11
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

12. 12
Breast milk stools

13. 13
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

14. 14
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
Mn. makes D. worse. Mn.Mn. 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

15. 15
Diarrhea Kills ..Diarrhea Kills ..
ShockShock, ARF, ARF
 DyselectrolytemiaDyselectrolytemia (hypokalemia)(hypokalemia)
 Severe malnutritionSevere malnutrition
 Associated infx. (pneumonia)Associated infx. (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

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

17. 17
ComplicationsComplications
DehydrationDehydration
 Shock, ARF, acidosisShock, ARF, acidosis
 HypokalemiaHypokalemia
 HyponatremiaHyponatremia
 HypochloremiaHypochloremia
 HypocalcemiaHypocalcemia
 Hypoglycemia, fitHypoglycemia, fit
 HypothermiaHypothermia
 Food intoleranceFood intolerance
 GBS, HUS, anemiaGBS, HUS, anemia
 MalnutritionMalnutrition
 VADXVADX
 Shigella encephalopathyShigella encephalopathy

18. 18
HUS:HUS: Schistocytes (broken RBCs)

19. 19
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% or(AID) 15% or ac. bloody D (dysentery)ac. bloody D (dysentery)
 PersistentPersistent DD (PD) 10%(PD) 10% lasts 14d or morelasts 14d or more

20. 20
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

21. 21
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.

22. 22
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

23. 23
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

24. 24

25. 25
V cholerae

26. 26

27. 27

28. 28
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

29. 29
Ac. Inv. D. (Dysentery)Ac. Inv. D. (Dysentery)
FeaturesFeatures
 InvasionInvasion
 InflammationInflammation
 System upsetSystem upset
 Characteristic stoolsCharacteristic 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)

30. 30
 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

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

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Rectal prolapse

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

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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

35. 35Intracellular Shigella

36. 36
EM: Salmonella

37. 37E. histolyticaE. histolytica Trophozoite in Stool Showing Ingested RBCsTrophozoite in Stool Showing Ingested RBCs

38. 38E coli, flagella
E coliE coli Diarrhea (Including HUS).Diarrhea (Including HUS).
EMEM ofof E coliE coli O157:H7 showingO157:H7 showing
flagellaflagella

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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

40. 40
Persistent DiarrheaPersistent Diarrhea
30-50% of diarrheal deaths!30-50% of diarrheal deaths!
Almost unknown in EBFBAlmost unknown in EBFB
 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

41. 41
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

42. 42
Effects of PDEffects of PD
AA seriousserious conditioncondition!!
 DehydrationDehydration
 Rapid wt. loss, malnutritionRapid wt. loss, malnutrition
 Malabsorption: nutrient deficiencies,Malabsorption: nutrient deficiencies, VADXVADX

43. 43
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

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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)

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 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

46. 46
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.

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IMCIIMCI
Management ofManagement of
DiarrhoeaDiarrhoea

48. 48
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

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DANGER
SIGNS
CONVULSIONS
INABILITY TO DRINK
OR BREASTFEED
VOMITING
LETHARGY
UNCONSCIOUSNESS

50. 50
4 Signs to4 Signs to classifyclassify::
 General conditionGeneral condition
 Sunken eyesSunken eyes
 ThirstThirst
 Skin pinchSkin pinch
Assessing DehydrationAssessing Dehydration

51. 51
Child’s general condition
Lethargic or unconscious (also a GDS)
or Restless (a child who cannot be consoled)
 or Well & alert

52. 52Consoled

53. 53
Sunken eyes:
– Dehydration
– Visible wasting
– Old age
 Though less reliable it is still useful

54. 54
Signs of DehydrationSigns of Dehydration

55. 55
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

56. 56
Drinks eagerly

57. 57
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

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59. 59

60. 60
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

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62. 62
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)

63. 63
NoNo
dehydrationdehydration
Plan APlan A
SomeSome
dehydrationdehydration
Plan BPlan B
SevereSevere
dehydrationdehydration
Plan CPlan C
Look:Look:
Gen. Con.Gen. 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:
Skin pinchSkin pinch Goes backGoes back
quicklyquickly
Goes backGoes back
slowlyslowly
Very slowlyVery slowly
Classifying DehydrationClassifying Dehydration

64. 64
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

65. 65
 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

66. 66
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

67. 67
Some dehydration

68. 68
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

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

70. 70
 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

71. 71
Remember! PD meansRemember! PD means
 MalabsorptionMalabsorption
 Weight loss, malnutrition, VADXWeight loss, malnutrition, VADX
 Hidden infxHidden infx
 Death!Death!

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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

73. 73
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

74. 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
74

75. 75
3 Types of Dehydration3 Types of Dehydration
Serum Na
Isotonic 130-150mmol/l
Hypertonic >160 mmol/l
(hypernatremic)
Hypotonic <130 mmol/l
(hyponatremic)

76. 76
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

77. 77
HypertonicHypertonic
 Rehydration by hypertonic fluidRehydration by hypertonic fluid
 Serum Na isSerum Na is >160 mmol/l>160 mmol/l
 Osmolality is >295mOsmol/lOsmolality is >295mOsmol/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

78. 78
HypotonicHypotonic
 Rehydrated with hypotonic fluidRehydrated with hypotonic fluid
 Serum NaSerum Na <130 mmol/l<130 mmol/l
 OsmolalityOsmolality <275mOsmol/l<275mOsmol/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

79. 79
OLD ORS

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

81. 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 20.520.5 27.927.9
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)

82. 82
Old vs. New ORSOld vs. New ORS
OldOld
 HypertonicHypertonic
 More vomitingMore vomiting
 More stoolsMore stools
 IVFIVF
NewNew
 Hypo-osmolarHypo-osmolar
 -20%-20%
 -30%-30%
 -33%-33%

83. 83
Rice based ORSRice based ORS
 WaterWater 500ml500ml
 Rice powderRice powder 30-40g30-40g
 NaClNaCl 2.5g2.5g
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!

84. 84
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

85. 85
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!

86. 86
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)

87. 87

88. 88
 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)?

89. 89
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

90. 90

91. 91
Antimicrobials in DiarrheasAntimicrobials in Diarrheas
 Not used routinely, mostlyNot used routinely, mostly NONENONE
 Kills commensalsKills commensals
 Secondary/superinfectionSecondary/superinfection
 Expensive, toxic, allergicExpensive, toxic, allergic

92. 92
Indications of ABTIndications of ABT
 ShigellosisShigellosis
 Inv.Inv. ssalmonellosisalmonellosis
 CholeraCholera
 GiardiasisGiardiasis
 E. histolyticaE. histolytica
 C. jejuniC. jejuni
 Y. enterocoliticaY. enterocolitica

93. 93
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

94. 94
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

95. 95
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

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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

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98. 98
Vaccines for DiarrheaVaccines for Diarrhea
 Cholera (Dukoral)Cholera (Dukoral)
 Rota virusRota virus
 ETEC (Dukoral)ETEC (Dukoral)
 TyphoidTyphoid
 MeaslesMeasles

99. 99
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

100. 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
100

101. 101
Healthy RBCs (left) are smooth & round. In HUS, toxins
destroy them (right). These misshapen cells may clog the

102. 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
102

103. 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.
103

104. 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
104

105. 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
105

106. 106
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

107. 107
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

108. 108
MCQMCQ
 Persistent D with mild dehydration is classified as severePersistent D with mild dehydration is classified as severe
PDPD
 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

109. 109
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?

110. 110
 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

113. 113
Next Lec.Next Lec.
Infant Feeding

114. 114
THANK YOUTHANK YOU