Diarrhoea, acute respiratory infections (ARIs), and malnutrition are leading causes of under-5 mortality. Diarrhoea is assessed based on dehydration level and treated according to WHO plans A, B or C. Persistent diarrhoea or dysentery may require antibiotics. ARIs are classified by fast breathing, chest indrawing, or stridor and treated with antibiotics. Malnutrition is assessed by weight-for-age and may indicate feeding problems requiring counselling or severe malnutrition requiring urgent care. Infections and malnutrition frequently interact, requiring treatment of both.

1. DIARRHOEA, ARIs & MALNUTRITION
–OVERVIEW FOR UNDERGRADUATES
DR AJAY TYAGI,
DEPTT. OF COMMUNITY MEDICINE
PGIMS, ROHTAK

3. Causes of U5MR
OTHER, 27%
NEONATAL
DEATH, 41%
MALARIA, 8%
DIARRHOEA, ARI, 14%
14%
Source: Partnership for maternal, neonatal and child health (2011) MDG 4.
Geneva: WHO.

4. DIARRHOEA
Clinical Assessment
• All children with diarrhoea should be assessed to
determine
– The duration of diarrhoea,
– If blood is present in the stool and
– If dehydration is present.
• A number of clinical signs are used to determine the level
of dehydration
– Infant’s general condition
– Sunken eyes
– Elasticity of skin

5. DIARRHOEA
FLUID DEFICIT CLINICAL SIGNS TREATMENT
SEVERE greater than 10 • Lethargic or unconscious WHO Treatment
DEHYDRATION
percent of their • Sunken eyes Plan C
body weight • Skin pinch goes back very
Slowly (longer than 2
seconds)
SOME 5 to 10 percent of Two of the following signs: WHO Treatment
DEHYDRATION
their body weight • Restless, irritable Plan B
• Sunken eyes
• Skin pinch goes back
slowly (skin stays up
even for a brief instant)
NO Less than 5 percent • No sign to classify as WHO Treatment
of their body weight some or severe Plan A
DEHYDRATION
dehydration
• Skin pinch goes back
immediately.

6. DIARRHOEA
WHO Treatment Plan C
• Severe dehydration require immediate IV
infusion, nasogastric or oral fluid replacement according
to WHO treatment guidelines
• Give 100 ml/kg IV fluids.
Age 30 ml/kg 70 ml/kg
Infant 100 ml/kg In 6 hrs First hour Next 5 hrs
Older
100 ml/kg In 3 hrs First 30 mins Next 2.5 hrs
children

7. DIARRHOEA
• Ringer's lactate solution is the preferred commercially
available solution.
• If IV infusion is not possible, urgent referral to the
hospital for IV treatment is recommended.
• When referral takes more than 30 minutes, fluids should
be given by nasogastric tube.
• If none of these are possible and the child can drink, ORS
must be given by mouth.

8. DIARRHOEA
WHO Treatment Plan B
• Some dehydration
• The approximate amount of ORS required is 75 ml/kg;
during first four hours, the mother slowly gives the
recommended amount of ORS by spoonfuls or sips.
• After four hours, the child is reassessed and reclassified
for dehydration, and feeding should begin
• If dehydration persists- the same amount of ORS may be
repeated for another 4 hours.
If the child is breastfed, breast-feeding should continue

9. DIARRHOEA
WHO Treatment Plan A
• Plan A focuses on the three rules of home treatment:
– Give extra fluids,
– Continue feeding, and
– Advise the caretaker when to return to the health
facility
if the child develops blood in the stool, drinks
poorly, becomes sicker, or is not better in 48 hours

10. DIARRHOEA
PERSISTENT DIARRHOEA
(diarrhoea that lasts more than 14 days)
• Encourage the mother to continue breastfeeding.
• At least half of the child's energy intake should come
from foods other than milk or milk products.
• Food needs to be given in frequent, small meals, at least
six times a day.
• All children with persistent diarrhoea should receive
supplementary multivitamins and minerals
(copper, iron, magnesium, zinc) each day for two weeks.

11. DIARRHOEA
DYSENTERY
(bloody diarrhoea)
• The four key elements of dysentery treatment are:
– Antibiotics
– Fluids
– Feeding
– Follow-up

12. DIARRHOEA
• Selection of an antibiotic is based on sensitivity patterns
of strains of Shigella isolated in the area (nalidixic acid is
the drug of choice in many areas).
• Recommended duration of treatment is five days. If after
two days (during follow-up) there is no
improvement, the antibiotic should be stopped and a
different one used.
Indication of Antibiotics in Diarrhoea
• Malnourished or premature infant
• Blood in stool
• Associated non-GI infection e.g. pneumonia

13. DIARRHOEA
LOW OSMOLARITY ORS
grams Composition mmol/
Composition
/Litre Litre
Glucose, Glucose 75
13.5
anhydrous
Sodium 75
Trisodium citrate,
2.9
dihydrate Chloride 65
Sodium chloride 2.6 Potassium 20
Potassium
1.5 Citrate 10
chloride
Total weight 20.5 Total osmolarity 245

14. DIARRHOEA
RICE BASED ORS
• Tastes better and provides more calories than the glucose-
based ORS
• Culturally acceptable,
• Reduces stool volume (by about 40 %)
• Shortens the duration of diarrhea in both cholera and other
severe diarrheal diseases.
• Starches other than rice, including wheat flour and
maize, have also been shown to reduce stool volume in
patients with cholera.
• Reduce diarrhea by adding more substrate to the gut lumen
without increasing osmolality, thus providing additional
glucose molecules for glucose-mediated absorption.

15. DIARRHOEA
ZINC THERAPY
• 10 mg/day orally for 14 days in
children <6 months of age
• 20 mg/day orally for 14 days in
children ≥6 months of age
• It is used as adjunct therapy (in all
cases of diarrhoea) that decreases
the duration and severity of the
episode and the likelihood of
subsequent infections on the 2-3
months following treatment.

17. Causes of U5MR
OTHER, 27%
NEONATAL
DEATH, 41%
MALARIA, 8%
DIARRHOEA, 14%
ARI, 14%
Source: Partnership for maternal, neonatal and child health (2011) MDG 4.
Geneva: WHO.

18. ARIs
• Respiratory infections can occur in any part of the
respiratory tract such as the
nose, throat, larynx, trachea, air passages or lungs.
• A child with cough or difficult breathing may have
pneumonia or another severe respiratory infection.
• Both bacteria and viruses can cause pneumonia.
• In developing countries, pneumonia is often due to
bacteria. The most common are
Streptococcus pneumoniae and Hemophilus influenzae
Pneumonia is an infection of the lungs

19. ARIs
• Children with bacterial pneumonia may die from
hypoxia (too little oxygen) or sepsis (generalized
infection).
• you can identify almost all cases of pneumonia by
checking for these two clinical signs:
– fast breathing and
– chest indrawing
Chest indrawing is a sign of severe pneumonia

20. ARIs
• Clinical Assessment
• Three key clinical signs are used to assess a sick child
with cough or difficult breathing:
– Respiratory rate
– Lower chest wall indrawing
– Stridor
Respiratory rate, distinguishes children who have
pneumonia from those who do not

21. ARIs
• Lower chest wall indrawing, which indicates severe
pneumonia (it is defined as the inward movement of the
bony structure of the chest wall with inspiration)
• Chest indrawing should only be considered present if it is
consistently present in a calm child

22. ARIs
• Stridor , which indicates those with severe pneumonia
who require hospital admission. (Stridor is a harsh noise
made when the child breathes in ).
• A child who has stridor when calm has a dangerous
condition.

23. ARIs
• Child’s Age Cut-off Rate for Fast Breathing
Cut Off BR
Age Of The Child (Breaths Per Minute
Or More)
0 To 2 Months 60
2 Months To 12 Months 50
12 Months To 5 Years 40

24. ARIs
SEVERE PNEUMONIA
– Chest indrawing or
– Stridor in calm child
• Give first dose of IV or intramuscular chloramphenicol (40
mg/kg).
• Options for an intramuscular antibiotic for pre-referral
use include ampicillin plus gentamicin combination, OR
ceftriaxone.

25. ARIs
PNEUMONIA
– Fast breathing
• Give appropriate antibiotic for five days. The treatment
of non-severe pneumonia can utilise a five-day course of
either oral cotrimoxazole or amoxicillin.
• These two oral antibiotics are usually effective treatment
for Streptococcus pneumoniae and Haemophilus
influenzae.

26. ARIs
• The advantages of cotrimoxazole are that it is used twice
a day, is affordable and compliance is good.
• Amoxicillin is almost twice as expensive as cotrimoxazole
and standard dosages are usually given three times a
day.
• Soothe the throat and relieve the cough with a safe
remedy.

27. ARIs
NO PNEUMONIA
– Cough or cold
– No signs of pneumonia
• Soothe the throat and relieve the cough with a safe
remedy.

29. MALNUTRITION
INFECTIONS MALNUTRITION

30. MALNUTRITION
All sick young infants seen in outpatient health facilities
should be assessed for weight and adequate feeding, as
well as for breast-feeding technique
Breastfeeding: Signs of Good
Attachment
– Chin touching breast;
– Mouth wide open;
– Lower lip turned outward; and
– More areola visible above than
below the mouth.

31. MALNUTRITION
• Determine weight for age. Weight for age
compares the young infant's weight with the
infants of the same age in the reference
population .
• The VERY LOW WEIGHT FOR AGE identifies
children whose weight is –3 standard
deviations below the mean weight of infants LW
in the reference population (Z score <-3).
• The LOW WEIGHT FOR AGE identifies VLW
children whose weight is –2 standard
deviations below the mean weight of infants
in the reference population (Z score <-2).

32. MALNUTRITION
SEVERE MALNUTRITION
(Visible severe wasting or Oedema of both feet)
– Not able to feed or
– No attachment at all or
– Not suckling at all or
– Possible Serious bacterial infection

33. MALNUTRITION
• Vitamin A is given to a child with measles or severe
malnutrition.
• Vitamin A helps resist the measles virus infection in the
eye as well as in the layer of cells that line the
lung, gut, mouth and throat.
• It may also help the immune system to prevent other
infections.
• Treat the underlying causes (e.g. Infections –
Diarrhoea, Respiratory Infections, Malaria etc. ;
Infestations)

34. MALNUTRITION
LOW WEIGHT
• Feeding problem
• Not well attached to breast or
• Not suckling effectively or
• Less than 8 breastfeeds in 24 hours or
• Receiving other foods or drinks or
• Thrush (ulcers or white patches in mouth)
• Breast or nipple problems

35. MALNUTRITION
NO FEEDING PROBLEM
• Not low weight for age and no other signs of inadequate
feeding
• Assess the child’s feeding and counsel the mother
accordingly on feeding.

36. THANK YOU