Diarrhoel diseases and dehydration in pediaxtrics

2. DIARRHEA - DEFINITION
 Diarrhea – defined as change in consistency and frequency of stools that is liquid or
watery stools that occurs > 3times a day.
 2 important consequences – malnutrition and dehydration
 RISK FACTORS – Poor sanitation and personal hygiene
Non availability of safe drinking water and unsafe food preparation
Low rate of breastfeeding and immunization
Malnutrition
Others – immunodeficiency (HIV ,selective IgA deficiency)

3. TYPES
Acute diarrhea- subside within 7 days [>10g/kg/day]
Persistent diarrhea- acute onset persisting more than 2 weeks
Chronic diarrhea- insidious onset > 2weeks in children
[>20g/kg/d], >4weeks in adults.

4. ACUTE DIARRHEA

5. ETIOLOGY
 BACTERIAL – E.coli - ETEC ,EIEC, EHEC, EAEC,EPEC
Vibrio cholerae
Shigella – S.flexneri , S.sonnei , S.dysenteriae
Salmonella - S.typhi , S.paratyphi A, B, or C
Campylobacter
 VIRAL – Rotavirus , adenovirus , norovirus ,astrovirus , corona ,CMV
 PARASITE – Giardia lamblia , Cryptosporidium parvum, E.histolytica
 Others – systemic infection , Candida albicans, Antibiotics - Clostridium
difficile

6. PATHOGENESIS
 Fluid present in 2 compartments- ECF and ICF
 Loss of water causes reduction or shrinkage of ECF vol. - results in hyponatremia
and fall in osmolality.
 Movement of water from ECF to ICF – further shrinkage – hyponatremic
dehydration
 Hypo and isonatremic dehydration – impairs skin elasticity
 Hypernatremic dehydration - masks loss of skin turgor, skin appears soggy,
doughy or leather
 Hypokalemia – diarrheal stool contain large amount of potassium
Abdominal distension, paralytic ileus, muscle hypotonia

7. CLINICAL FEATURES
 Abdominal pain
 Weak and thready pulse , low BP with cold extremities
 Mild cases – thirsty and slightly irritable
 If diarrhea continues – child become more irritable with depressed
fontanelle, sunken eyes and dry tongue and inner side of cheeks
 Acidosis – deep and rapid breathing [ Kussmaul breathing ]
 Hypokalemia – ECG shows ST dep and flat T waves
 Low hydrostatic pressure- cause low filtration of urine- oliguria
Urine flow is good indicator severity of diarrhea
Severe cases- acute kidney injury

8. PERSISTENT DIARRHEA

9. ETIOPATHOGENESIS
 Common in malnourished children
 Worsening nutritional status- impairs reparative process in gut-
impairs nutrient absorption- initiates vicious cycle only broken by
proper therapy
 E.coli- EAEC,DAEC
 Associated infections
 Cow milk protein allergy
 Antibiotics
 Cryptosporidium infection

10. CLINICAL FEATURES
Mainly several loose stool daily but hydrated
Dehydration- high stool output or oral intake is reduced
Major consequences – growth faltering, worsening malnutrition, death
Secondary lactose intolerance- stools explosive and in presence of perianal
excoriation , stool pH- low and stool test for reducing substance - +ve
Secondary fungal infection- if extend to groins with or without oral thrush

11. CHRONIC DIARRHEA

12. CAUSES

13. Nature of stool:
3 categories of stool – watery, fatty and bloody
Watery stool- high liquid content
Fatty stool – bulky, foul smelling and pale with visible oil sometimes
Bloody stool- gross blood mixed , suggest large bowel disease
Differentiating small bowel from large bowel diarrhea

14. Response to fasting:
Secretory diarrhea- if stool vol normal or minimally changed
Osmotic diarrhea- if significant reduction in stool output
Site of disease:
Commonly intestinal origin, sometimes pancreatic or hepatobiliary
Pruritis and malabsorption of fat soluble vitamins
Systemic manifestation- immunodeficiency state, diabetes
Others- Zollinger Ellison syndrome, carcinoid or VIPoma

15. IMPORTANT DIAGNOSTIC CLUES FOR CAUSES
OF CHRONIC DIARRHEA

16. MANAGEMENT OF ACUTE
DIARRHEA

17. ASSESSMENT OF CHILD WITH ACUTE
DIARRHEA
 GOALS OF ASSESSMENT : Determine type of diarrhea
Look for dehydration or other complication
Assess for malnutrition
Rule out non diarrheal illness
Assess feeding – both preillness nd during illness
 HISTORY : Onset , blood in stools , no. Of episodes , presence of fever , cough or other
symptoms , type nd amt of fluid and food intake , drugs taken , immunization history.

18.  EXAMINATION : Child’s general condition and sensorium
appearance of eyes ,
ability to drink water or ORS solution .
For Dehydration – feeling for skin turgor .
Degree of dehydration –
no dehydration - <50ml/kg [fluid loss]
some dehydration – 50-100ml/kg
severe dehydration - >100ml/kg.

20. LABORATORY INVESTIGATIONS
A/c diarrhea can be managed even in the absence of lab investigations.
Stool microscopy – helpful in special situations – V.cholera and
giardiasis.
Hemogram , pH, bicarbonate , electrolytes nd renal function-if child has
pallor , labored breathing , seizures , paralytic ileus or oliguria.

21. PRINCIPLES OF MANAGEMENT
4 COMPONENTS :
Rehydration and maintaining hydration
Ensuring feeding
Oral supplementation of Zinc
Early recognition of danger signs and treatment of complications.

23. TREATMENT PLAN A
TREATMENT OF “NO DEHYDRATION” :
May be treated at home after explanation of feeding and danger signs to
the mother/caregiver
Danger signs requiring medical attention :
continuing diarrhea [>3days]
increased vol/frequency of stools
repeated vomiting
increased thirst , dec urine output ,
refusal to feed , fever or blood in stools.

25. TREATMENT PLAN B
Fluid requirement is calculated under the following headings:
Provision of normal daily fluid requirements : upto 10kg – 100ml/kg
, 10-20kg – 50ml/kg , >20kg – 20ml/kg.
Rehydration to correct the existing water or electrolyte deficits:
75ml/kg of ORS, given over 4 hours.
Oral rehydration therapy may be ineffective in children with a high
stool purge rate of >5ml/kg body wt/hr , persistent vomiting >3/hr ,
incorrect preparation of ORS.
Maintenance to replace ongoing losses to prevent recurrence of
dehydration: w/in 4hrs. ORS –maximum of 10ml/kg per stool.

27. TREATMENT PLAN C
CHILDREN WITH “SEVERE DEHYDRATION” :
IV Ringer lactate soln with 5% dextrose – 100ml/kg over 6 hrs in
children <12 months and over 3 hrs >12 months.
If IV not possible , nasogastric feeding – 20ml/kg/hr for 6 hrs .
Child should be reassessed every 15-30min for pulses and hydration
status after the 1st bolus of IV fluid .

28. MANAGEMENT FOLLOWING THE 1ST BOLUS OF IV HYDRATION :
 Persistence of severe dehydration : IV repeated
 Hydration is improved but some dehydration is present : ORS adm over 4hrs acc to Plan
B .
 There is no dehydration : IV discontinued and Plan A is followed .
UNIQUE PROBLEMS TO INFANTS <2 MONTHS OF AGE :
 Breastfeeding must continue during the rehydration process, whenever the infant is able
to suck.
 Complications – septicemia , paralytic ileus , severe electrolyte imbalance.

29. NUTRITIONAL MANAGEMENT OF DIARRHEA
 In exclusively breastfed infants – breastfeeding continued
 Foods with high fibre content, non breast fed- cow’s milk
 Routine lactose-free feeding.
ZINC SUPPLEMENTATION:
 Intestinal Zn losses aggravate pre-existing Zn deficiency .
 Zn with ORS – helpful in dec severity and duration of diarrhea
 Zn -20mg elemental Zn per day for children >6 months for 14 days.

30. SYMPTOMATIC TREATMENT
 If vomiting is severe or recurrent and interferes with ORS intake, then a single dose of
Oral Ondansetron [0.15mg/kg/dose].
 Abdominal distension- does not require specific treatment, if bowel sounds are present
and distension is mild .
 Paralytic ileus – require IV fluids , nasogastric aspiration , correction of hypokalemia and
no oral feeding.
KCl- 30-40mEq/L – adm IV with parenteral fluids , provided the child is passing urine .
Convulsions may be due to – hypo or hypernatremia, hypoglycemia, hypocalcemia ,
encephalitis , meningitis , febrile seizures , cerebral venous or sagittal sinus thrombosis
.

31. DRUG THERAPY :
 Antimicrobials are indicated in bacillary dysentry, cholera, amoebiasis, giardiasis.
 Antimotility agents – synthetic analogues of opiate [loperamide] reduce peristalsis or gut
motility – not to be used in diarrhea
These drugs cause bact overgrowth nd sepsis .
 Antisecretory agents – Racecadotril – inhibits intestinal enkephalinase .
 Probiotics – microorganisms that exert beneficial effects when they colonize the bowel.

32. PREVENTION
 PROPER NUTRITION
 ADEQUATE SANITATION : clean water supply , adeq sewage disposal system
,protection of food from exposure to bact contaminants.
Clean hands , Clean container , Clean envt – key messages
 VACCINATION - Rotavirus vaccine – effective strategy for preventing a/c diarrhea.

33. MANAGEMENT OF PERSISTANT
DIARRHEA
Principles of management :
 Correction of dehydration ,electrolytes , hypoglycemia
 Evaluation for infections and their management
 Nutritional therapy
PATIENTS IN NEED OF HOSP. ADM. :
 Age< 4 months nd breastfed
 Presence of dehydration
 Severe malnutrition
 Presence or suspicion of systemic infections.

34. NUTRITION
To ensure absorption and dec stool output – overcome carbohydrate
maldigestion by using different degree of carbohydrate exclusion in the
form of diet A [lactose reduced],diet B [lactose free], diet C [complex carb
free] diets.
Initial diet A – reduced lactose diet ; milk rice gruel , milk sooji gruel ,
rice with curds , dalia
Second diet – lactose free diet with reduced starch
Third diet – monosaccharide based diet

36. INDICATIONS FOR CHANGE FROM THE INITIAL DIET [A] TO THE NEXT DIET [B OR C] :
Diet is changed , if child shows
- marked inc in stool freq [>10 watery stools/d]
- features of dehydration
- failure to gain wt by day 7 in the absence of
initial or hosp acquired infections .
RESUMPTION OF REGULAR DIET AFTER DISCHARGE :
Children discharged on totally milk-free diet should be given small amt of milk as part of a
mixed diet after 10 days .
SUPPLEMENT VITAMINS AND MINERALS :
Supplemental multivit – at about twice RDA, should be given daily to all children for at least
2-4 weeks .
Iron – only after diarrhea has ceased

37. Vit A – oral single dose – severe a/c malnutrition or vit A def at 2,00,000 IU
for children >12 months or 1,00,000 IU for children 6 -12 months .
Children < 8kg – 100,000 IU - irrespective of age
Zinc – 10-2-mg /day [2weeks] – b/w 6m and 3yrs of age.
ADDITIONAL SUPPLEMENTS :
Mg – IM route – 0.2ml /kg/dose of 50% Mg sulfate BD 2-3 days
Potassium – 5-6mEq /kg/day orally or as a part of IV infusion.
ROLE OF ANTIBIOTICS :
Combination of cephalosporin and aminoglycoside can be started empirically .

38. MONITORING RESPONSE TO TREATMENT :
Successful treatment – characterized by adequate food intake ,
reduced freq of diarrheal stools [ <2 stools /day ], wt gain .
Followed regularly – to ensure continued wt gain and compliance with
feeding advice .