MANAGEMENT OF DIARRHEA IN CHILDREN

1. DIARRHOEA
IN CHILDREN
12/26/2018 DR BRIGHT.R SIAMUNYANGA 1

2. EPIDIMIOLOGY
Diarrhoeal disease is the second leading cause of death in
children under five years old. It is both preventable and
treatable.
Each year diarrhoea kills around 760 000 children under
five.
A significant proportion of diarrhoeal disease can be
prevented through safe drinking-water and adequate
sanitation and hygiene.
Globally, there are nearly 1.7 billion cases of diarrhoeal
disease every year.
Diarrhoea is a leading cause of malnutrition in children
under five years old.
12/26/2018 DR BRIGHT.R SIAMUNYANGA 2

3. Definition
12/26/2018 DR BRIGHT.R SIAMUNYANGA 3
• Passage of loose stool more than 3 times in 24
hours. A loose stool is one which takes the shape
of the receiving container.
• Passage of one bulky loose stool leading to
dehydration can still be considered as Diarrhoea.

4. ERTIOLOGY
Infectious and Non infectious
12/26/2018 DR BRIGHT.R SIAMUNYANGA 4
Mode of Transmission
• person to person through the fecal-oral
route
• by ingestion of contaminated food or water.

5. 12/26/2018 DR BRIGHT.R SIAMUNYANGA 5

6. Non infectious causes
12/26/2018 DR BRIGHT.R SIAMUNYANGA 6
• Inflammatory
Milk protein allergy
Food allergies
IBD
• Malabsorption
Celiac disease
Cystic fibrosis
steatorrhea
• Osmotic
Lactase deficiency
Primary
Secondary post-
infectious
Excessive fructose intake
Laxative overuse

7. Diarrhoea Classification
12/26/2018 DR BRIGHT.R SIAMUNYANGA 7
• Mechanism
Osmotic
Secretory
Exudation
Abnormal motility
• Duration
Acute Diarrhea
• Usually lasts <2 weeks
• Infants: stool volume >10g/kg/day
• Children>3: stool volume >200g/day
Chronic diarrhea: lasts more than 2 weeks, should seek medical care

8. Acute Diarrheal disease (ADD)
12/26/2018 DR BRIGHT.R SIAMUNYANGA 8
Infection
Viral gastroenteritis
Rotavirus
Enterovirus, adenovirus
Norwalk virus
Bacterial enterocolitis
Shigella, Salmonella
Yersinia, Campylobacter
E.coli – enteroinvasive
C. difficile
Foodborne
S.aureus, Bacillus cereus
E. coli – enterotoxigenic
Other: UTI, OM
•Inflammatory
Hemolytic Uremic Syndrome
(HUS)
Henoch-Schonlein Purpura
(HSP)
•Anatomic
Intussusception
Appendicitis
•Toxic Ingestion
Iron, mercury, lead
•Other
Antibiotic-induced
Hyperconcentrated infant
formula
Overfeeding infants

9. evaluation
12/26/2018 DR BRIGHT.R SIAMUNYANGA 9
History
Stool character
Frequency, amount, color,
consistency
Blood/mucus vs. watery
Drugs
Diet
Water source
Travel/ill contacts
Physical exam
Weight changes
Abnormal growth
Resting tachycardia
Signs of dehydration
Abdominorectal
Bowel sounds, mass, tenderness,
distention ,peripheral wasting
-Mucous
membranes
-Mental status
- Tears
- Skin turgor
- HR, BP
- Fontanel, eyes
- Urine output
•Lab studies
–Stool
•Guaiac (occult blood)
•WBC
•Culture/Gram stain
•Rotazyme test
•Ova & parasites
•C. difficile toxin
•pH, fats, reducing
substances
-CBC/d, electrolytes,
UA,ESR,CRP

10. ROTA VIRUS
12/26/2018 DR BRIGHT.R SIAMUNYANGA 10
TRANSMISSION
• Fecal-oral
• Contaminated water supplies
• Poor hygiene
• Food
• Fomite
Most common cause of viral
diarrhea
35% hospitalized, 10%
community

11. Rotavirus Clinical Manifestations
12/26/2018 DR BRIGHT.R SIAMUNYANGA 11
Asymptomatic carriers
Infections in neonates and in adults in close contact with
infected children are generally asymptomatic.
Diarrheal illness
2-3 day incubation period
Vomiting and mild to moderate fever followed by the onset
of frequent watery stools.Vomiting and fever typically abate
during the second day of illness, diarrhea often continues for
5-7 days
Without gross blood or white cells in stool
high infectivity
More severe between 3 and 24mo of age

12. ASSESMENTOF DEHYDRATION
12/26/2018 DR BRIGHT.R SIAMUNYANGA 12
Parametersused:
• General conditionof patient
• Eyes
• Anterior fontanelle if open
• Mucous membranes
• Skin elasticity.
• Urine out put
• ,pulse, BP/CRT

13. CLASSIFICATION OF DEHYDRATION
• No dehydration
• Some dehydration
• Severe dehydration
No dehydration
Not enough signs to classify as some or severe
dehydration
12/26/2018 DR BRIGHT.R SIAMUNYANGA 13

14. Some dehydration
12/26/2018 DR BRIGHT.R SIAMUNYANGA 14
If the child has two or more of the following signs, the child
has some
dehydration:
• restlessness/irritability
• thirsty and drinks eagerly
• sunken eyes
• skin pinch goes back slowly.
Note that if a child has only one of the above signs and one of
the signs of
severe dehydration (e.g. restless/irritable and drinking
poorly), then that child
also has some dehydration.

15. Severe Dehydration
12/26/2018 DR BRIGHT.R SIAMUNYANGA 15
If any two of the following signs are present in
a child with diarrhoea, severe dehydration should be
diagnosed:
• lethargy or unconsciousness
• Very sunken eyes and A.Fontanelle (If not closed)
• Very dry mucous membranes
• skin pinch goes back very slowly (2 seconds or more)
• not able to drink or drinks poorly.

16. Management
Principles of management
The 3 essential elements in the management
of all children with diarrhoea include
• Rehydration therapy,
• zinc supplementation,
• continued feeding.
12/26/2018 DR BRIGHT.R SIAMUNYANGA 16

17. FLUID MANAGEMENT
12/26/2018 DR BRIGHT.R SIAMUNYANGA 17
deficit + maintainance

18. PLAN A-FOR NO DEHYDRATION
12/26/2018 DR BRIGHT.R SIAMUNYANGA 18
• Use ORS
• Show the mother how much fluid to give in addition to the
usual fluid intake:
• Give 10mls/kg
Or
Up to 2 years 50 to 100 ml after each loose stool
2 years or more 100 to 200 ml after each loose stool
• Tell the mother to:
— Give frequent small sips from a cup.
— If the child vomits, wait 10 minutes. Then continue, but more
slowly.
— Continue giving extra fluid until the diarrhoea stops.

19. PLAN B-FOR SOME DEHYDRATION
12/26/2018 DR BRIGHT.R SIAMUNYANGA 19
Give ORS 75mls/kg for 4 hours
• Show the mother how to give ORS solution.
• Give frequent small sips from a cup.
• If the child vomits, wait 10 minutes. Then continue,
but more slowly.
• Continue breastfeeding whenever the child wants.
After 4 hours:
• Reassess the child and classify the child for
dehydration.
• Select the appropriate plan to continue treatment.
• Begin feeding the child in clinic.

20. PLAN C-FOR SERVERE DEHYDRATION
Children with severe dehydration should be given rapid IV rehydration
followed by oral rehydration therapy.
• Start IV fluids immediately. While the drip is being set up, give ORS
solution if the child can drink.
Note: The best IV fluid solution is Ringer's lactate Solution (also called
Hartmann’s Solution for Injection). If Ringer's lactate is not available, normal
saline solution (0.9% NaCl) can be used.
• Give 100 ml/kg of the chosen solution divided as shown in the Table
12/26/2018 DR BRIGHT.R SIAMUNYANGA 20

21. Maintenance fluid in 24 hours.
• For a Neonate - 120mls/kg b/wt.
• Up to 10kg - 100mls/kg b/wt.
• Between 10-20kg - 50mls/kg b/wt.
• More than 20kg - 20mls/kg b/wt.
12/26/2018 DR BRIGHT.R SIAMUNYANGA 21

22. ZINC SUPPLIMENTATION
12/26/2018 DR BRIGHT.R SIAMUNYANGA 22
• Zinc is an important micronutrient for a child’s
overall health and development.
• Zinc is lost in greater quantity during diarrhoea.
• It has been shown that zinc supplements given
during an episode of diarrhoea reduce the duration
and severity of the episode, and lower the
incidence of diarrhoea in the following 2–3 months.
For these reasons, all patients with diarrhoea
should be given zinc supplements as soon as
possible after the diarrhoea has started.
GIVE ZINC SUPPLEMENTS
Up to 6 months 1/2 tablet (10 mg) per day for 10–14 days
6 months and more 1 tablet (20 mg) per day for 10–14
days

23. NUTRITION
12/26/2018 DR BRIGHT.R SIAMUNYANGA 23
• During diarrhoea, a decrease in food intake and
nutrient absorption and increased nutrient
requirements often combine to cause weight loss
and failure to thrive.
• In turn, malnutrition can make the diarrhoea more
severe, more prolonged and more frequent,
compared with diarrhoea in non-malnourished
children.
• This vicious circle can be broken by giving
nutrient-rich foods during the diarrhoea and when
the child is well.

24. PREVENTION
• Vaccination
Rota Vaccine-Given orally at 6 weeks and 10 weeks
• safe drinking-water
• adequate sanitation and hygiene.
12/26/2018 DR BRIGHT.R SIAMUNYANGA 24

25. Differential diagnosis of the child presenting with
diarrhoea
12/26/2018 DR BRIGHT.R SIAMUNYANGA 25
• Acute (watery) diarrhoea —More than 3 stools per day
No blood in stools
• Cholera —Diarrhoea with severe dehydration during cholera
outbreak
• Dysentery —Blood in stool (seen or reported)
• Persistent diarrhoea —Diarrhoea lasting 14 days or longer
• Diarrhoea with severe malnutrition
Any diarrhoea with signs of severe malnutrition
• Diarrhoea associated with recent antibiotic use
Recent course of broad-spectrum oral antibiotics
• Intussusception —Blood in stool
Abdominal mass (check with rectal examination)
Attacks of crying with pallor in infant

26. COMPLICATIONS OF DIARRHOEA
12/26/2018 DR BRIGHT.R SIAMUNYANGA 26
1-dehydration
2- prolongation of the diarrheal episodes
3-malnutrition
4- secondary infections
5-In developing countries and HIV-infected populations,
associated bacteremias are well-recognized complications in
malnourished children with diarrhea.
6-micronutrient deficiencies (iron, zinc).

27. 12/26/2018 DR BRIGHT.R SIAMUNYANGA 27
TAKE HOME MESSAGE
• if not promptly managed, Diarrhoea can lead
mortality in under 5 children
• Rota virus is the leading cause of ADD
• Dehydration is classified into No ,Some, and Severe
• Fluid replacement managed according to plans A,B
and C
• Zinc supplementation should be part of the
treatment
• Rota vaccine is given as a preventive measure

28. 12/26/2018 DR BRIGHT.R SIAMUNYANGA 28