This document provides information on the management and complications of acute diarrhea. It discusses assessing patients with acute diarrhea by determining the type, examining for dehydration and complications, and assessing nutrition. It also covers taking a relevant history, examining the patient, assessing hydration status, laboratory investigations to identify the etiological organism, stool examination, and management including oral rehydration therapy. The management is based on rehydration, correcting electrolyte imbalance, ensuring adequate feeding and supplementation with zinc.

1. MANAGEMENT AND
COMPLICATIONS OF
ACUTE DIARRHEA
Presented by -
Ritu Rajan (2012-13)

2. ASSESSMENT OF CHILD WITH
ACUTE DIARRHEA :
The evaluation of a child with acute diarrhea
aims at following :-
i. To determine the type of diarrhea i.e.
acute watery diarrhea(secretory),
dysentry(invasive),
osmotic diarrhea, or
persistent diarrhea.
ii. To look for the degree of dehydrtion and
associated complications.

3. iii. Assessment of nutritional status and
feeding practices ,both preillness and
during illness.
iv. Obtain appropriate contact or exposure
history and rule out non- diarrheal
illnesses especially systemic infections.

4. HISTORY - TAKING RELEVANT TO
DIARRHEA :
History should include following informations :
i. Onset of diarrhea, duration and no. of
stools per day.
ii. Blood in stools.
iii. No. of episodes of vomiting.
iv. Presence of fever, cough, or other
significant symptoms like convulsions
,recent measles.
v. Exposure or contact history i.e.
information about exposure to contacts
with similar symptoms, intake of

5. water, recent travel to a diarrhea-endemic
area.
vi. Type and amount of fluids (including
breast milk) and food taken during the
illness and preillness periods.
vii. Use of anti-microbial agents ,other drugs
or any local remedies (if taken).
vii. Immunization history

6. EXAMINATION OF THE PATIENT :
For prompt treatment, assessment of the
hydration status of child is most important.
In addition to it, following points must also be
examined :
a. Features of malnutrition i.e. anthropometry for
wt. and ht. , examination for wasting, edema
and signs of vitamin deficiency.
b. Features of systemic infections i.e. presence
of cough, high grade fever, fast breathing
and/or chest indrawing suggests pneumonia,
high grade fever with splenomegaly suggests
malaria.

7. c. Signs of fungal infections like oral thrush
or perianal satellite lesions.

8. Hydration status can be assessed as
follows :
I.Clinical
signs :
General
conition
Well-alert Fatigued,
restless,
irritable
Apathetic,
lethargic,
unconsciou
s
Eyes normal Slightly
sunken
Deeply
sunken
Thirst Drinks
normally,
might refuse
fluids
Thirsty
,eager to
drink
Drinks
poorly,
unable to
drink

9. Tears +nt decrease
d
-nt
Mouth
and
tongue
moist dry Very dry
Heart rate normal Normal to
increased
tachycardia;
with
bradycardia
in more
severe
cases
breathing Normal Normal,
fast
deep
Quality of normal decrease Weak,
thready or

10. Skinfold Instant
recoil
Recoil in
<2 sec.
Recoil in >
2 sec.
Capillary
refilling
time
normal prolonged Minimal
refilling
extremitie
s
warm cold Cold,
mottled,
cyanotic
Urine
output
Normal to
decreased
decreased minimal

11. Hydrati-
on
status :
The patient
has NO
signs of
dehydration.
If the pt.has
2 or more
signs, there
is SOME
dehydration
If the pt.has
2 or more
signs, there
is SEVERE
dehydration
Treatme
-nt plan
:
Use t/t
Plan `A`
Weigh the
pt. , use t/t
Plan `B`
Weigh the
pt. , use t/t
Plan `C`.

12. ASSESSMENT OF AMOUNT OF FLUID
LOSS :
Degree of
dehydration
Fluid loss
NO Dehydration <50ml/kg
(<3% loss of body wt.)
SOME Dehydration 50-100ml/kg
(3-9% loss of body wt.)
SEVERE Dehydration >100ml/kg
(>9% loss of body wt.)

13. Laboratory investigations :
The large majority of acute diarrheal
episodes can be managed effectively
in absence of lab investigations .
If warranted and if facilities and
resources permit, the underlying
etiology can be verified by appropriate
lab testings.
The various methods of lab
investigations for confirming the
suspected etiological organisms

14. Etiology
(bacteri
a)
S/S Duration
of illness
Lab
testing
Enterohe
morrhagic
E.coli(EH
EC)
including
E. coli
O157:H7
and other
Shiga
toxin
producing
E.coli
Severe
diarrhea
often
bloody,
abdomin
al pain
and
vomiting
. More
common
in
children
5-10 days Stool
culture ;
E.coli
O157:H7
requires
special
media.
Shiga
toxin may
tested
using
commerci

15. Contd. :-
Etiology(
bacteria)
S/S Duration
of illness
Lab
testing
Enterotoxige
nic
E.coli(ETEC
)
Watery
diarrhea,
abdominal
cramps,
some
vomiting
3 to >7 days Stool culture
and
identification
requires
special lab
tech.
Salmonella Diarrhea,fev
er,
abdominal
cramps,
vomiting
4-7 days Routine
stool
cultures

16. Contd. :-
etiology S/S Duration
of illness
Lab
testing
Shigella spp. Abdominal
cramps, fever
and diarrhea.
Stool may
contain blood
and mucus.
4-7 days Routine stool
cultures
Staphylococc
us aureus
(preformed
toxin)
Sudden onset
of severe
nausea,
vomiting ,
diarrhea and
fever may be
present
24-48 hrs. Mainly clinical
diagnosis. If
indicated,
stool, vomitus
and food
tested for
toxin.

17. etiology S/S Duration
of illness
Lab
testing
Vibrio cholerae
(toxin)
Profuse watery
diarrhea and
vomiting; may
lead to severe
dehydration
and death
within few hrs.
3-7 days ,
causes life-
threatening
dehydration
Stool culture. If
suspected
requires
special
medium for
growth.
Vibrio
parahemolyticu
s
Watery
diarrhea,
abdominal
cramps,
nausea,
vomiting
2-5 days Stool culture
and specific
testing

18. Etiology
(viral)
S/S Duration
of illness
Lab
testing
Rotavirus Vomiting, watery
diarrhea, low-
grade fever.
Temporary
lactose
intolerance may
occur.
4-8 days Immunoassay
for identification
of viruses in
stool
Noroviruses(
and other
caliciviruses)
Nausea,
vomiting,
abdominal
cramping,
diarrhea, fever,
myalgia and
headache.
12-60 hrs. Routine RT-PCR
and EM on fresh
unpreserved
stool. Clinical
diagnosis,
negative bact.
cultures, WBCs
absent.

19. Etiology(p
arasitic)
S/S Duration
of illness
Lab
testing
Giardia lamblia diarrhea.,
stomach cramps,
gas, wt.loss
Days to wks. Stool
examination for
ova and
parasites -
atleast 3
samples
Entamoeba
histolytica
Diarrhea (often
bloody), frequent
bowel
movements,
lower abdominal
pain
Several wks. To
mnths.
Stool examn. For
cysts and
parasites.
Serology for
long- term infns.
Cryptosporidium Diarrhea( usually
watery ),
stomach cramps,
upset stomach
May be remitting
ans relapsing
over wks. To
mnths.
Specific
examination for
Cryptosporidium.
Also examine
water and food.

20. STOOL EXAMINATION :
Microscopic examination and culture of stool
is most routinely practiced to know the
cause of diarrhea.
Stool specimens or rectal swabs should be
collected from children with acute diarhea in
following cases :
i. watery diarrhea (suspected cholera)
ii. Bloody diarrhea (dysentry)
iii. Malnourished and immuno-compromised children
iv. In outbreaks with suspected HUS.

21. Stool specimens are examined for mucus, blood
& leucocytes.
Fecal leucocytes are indicative of bacterial
invasion of gut mucusa.
In endemic areas, stool microscopy must include
examination for parasites causing diarrhea
such as G.lamblia and E.histolytica .
Stool specimens for culture need to be
transported and plated quickly; if latter is not
available , specimens may need to be
transported in special media k/a TRANSPORT
MEDIA.

22. TRANSPORT MEDIA :
 Cary Blair transport medium -
can be used to transport Shigella , V. cholerae ,
E.coliO157:H7.
because of high ph (8.4), it is the medium of
choice for V. cholerae .
 Amie’s and Stuart’s media -
both are acceptable for Shigella and E. coli
O157:H7 ; but they are inferior to Cary Blair
medium for transport of V. cholerae.
 Buffered Glycerol Saline (BGS) -
used for Shigella, but is unsuitable for V.
cholerae .

23. NOTE : In most previously healthy children
with uncomplicated watery diarrhea, no
laboratory evaluation is needed for
epidemiologic purposes.
If diarrhea is associated with findings
indicative of complications such as pallor,
labored breathing, altered sensorium,
seizures, paralytic ileus or oliguria ,
additional laboratory investigations need
to be performed. They are :-
i. Stool ph
ii. Complete hemogram
iii. Blood gas estimation
iv. Serum electrolytes
v. Renal function tests , etc..

24. MANAGEMENT OF A CHILD WITH
ACUTE DIARRHEA :
It is based on following basic principles :
a) Rehydration and maintaining hydration.
b) Correction of electrolyte and acid-base
imbalance.
c) Ensuring adequate feeding.
d) Oral supplementation of Zinc.
e) Early recognition of danger signs and t/t of
complications.
f) Nutritional rehabilitation.
g) Health education for prevention of diarrhea.

25. ORAL REHYDRATION THERAPY
(ORT)
With the discovery of glucose-dependent
sodium pump in the small bowel, which
results in passive absorptin of water and
other electrolytes , the concept of
rehydration has been revolutionaized.
The glucose- dependent sodium and water
absorption is the principle behind replacing
glucose and sodium in 1:1 molar ratio in
WHO-ORS for optimum absorption.

26. NOTE : While making ORT, the
osmolarity of the replacement fluid
should not exceed that of blood (290
mmol/L) ; for maintenance of
concentration gradient b/w intestinal
lumen and blood stream to allow
greater absorption of fluids into blood.

27. ORAL REHYDRATION SALTS (ORS)
SOLUTION :
Home - made or commercially available salt
and sugar solutions for rehydration are k/a
oral rehydration salts (ORS) solutions.
Optimum absorption of glucose takes place
from the intestines b/w a glucose
concentration of 111-165 mmol/L and
sodium :glucose ratio b/w 1: 1 to 1:1.4 .
Moreover, meta-analysis have shown that
use of Low- osmolarity ORS has many
advantages over standard WHO-ORS
(osml. = 311mmol/L).

28. Since 2004, based on the WHO- UNICEF
and IAP recommendations, the Govt. of
India has adopted the Low- osmolarity ORS
(osml. = 245 mmol/L) as the single
universal ORS to be used for al ages and
all types of diarrhea.
Advantages of Low-osmolarity ORS are :
a. Reduction in stool output.
b. Decrease in vomiting.
c. Decrease in use of unscheduled i.v. fluids.
d. Decreased risk of hypernatremia.

29. COMPOSITION & CONCENTRATION OF
STANDARD WHO-ORS :
Ingredients Compositio
n (gms./L)
Ingredients Concentrat
ion
(mmol/L)
Sodium
chloride
3.5 Sodium 90
Potassium
chloride
1.5 Potassium 80
Trisodium
citrate (anhyd.)
2.9 Citrate 10
Glucose
(anhyd.)
20 Glucose 111
Osmolarity
=
311

30. LOW- OSMOLARITY ORS FORMULATION
RECOMMENDED BY WHO/UNICEF :
Ingredients Grams/L Ingredients mmol/L
Sodium
chloride
2.6 Sodium 75
Glucose
(anhyd.)
13.5 Glucose 75
Potassium
chloride
1.5 Potassium
Chloride
20
65
Trisodium
citrate
2.9 Citrate 10
Osmolarity = 245

31. Home- available fluids for acute diarrhea ( can
be used if ORS formulations not available) :
Fluids that contain salt
(preferable)
Salted drinks (e.g. salted rice
water or salted yoghurt drink),
vegetable or chicken soup with
salt.
Fluids that donot contain salt
(acceptable)
Plain water, unsalted rice
water, unsalted soup, yoghurt
without salt, green coconut
water, weak unsweetened tea,
fresh fruit juice .
Unsuitable home available
fluids
Commercial carbonated
beverages, commercial fruit
juices, sweetened tea.

32. Treatment Plan ‘A’ : for ‘NO’ dehydration
The objective of Plan ‘A’ is prevention of
dehydration and malnutrition.
The management can be successfully carried out
at home , by the mother / caretaker who is
advised to :
i. WHO-ORS or other ORT fluids are to be given as per
advise;
ii. Continue feeding; and
iii. Bring the child back after 2 days, or earlier if he has
any of the danger signs (increased volume or
frequency of stools, repeated vomiting, increasing
thirst, irritable/restless, fever, blood in stool, refusal to
feed, lethargic ).

33. ORT as per Plan ‘A’ :
Age Amt. of ORS/ORT
fluids to be given
after each loose
stool
Total amount of
ORS to provide for
use at home
< 24 months 50-100 ml 500ml/day
2-10 yrs. 100-200 ml 1000ml/day
> 10 yrs. As much as child
can take
2000ml/day
NOTE :
-A teaspoonful is given every 1-2 min. for a child <2yrs.
-Frequent sips from a cup are given for older children.
-Following vomiting, wait for 10 mins.and give ORS more slowly.
-If danger signs appear or diarrhea continues, consult doctor.

34. Treatment Plan ‘B’ : for ‘SOME’
dehydration
The objective of Plan ‘B’ ia to treat
dehydration and electrolyte imbalance; and
to continue feeding.
These cases need to be treated in a health
center or hospital.
While transporting, ORT must be promptly
started and continued.
Fluid requirement is calculated as per :
i) Normal daily fluid requirement (+)
ii) Deficit replacement or rehydration therapy (+)
iii) Maintenance fluid therapy to compensate losses .

35. i. Daily fluid requirement :- It is calculated as
follows -
- upto 10 kg = 100ml/kg
- 10-20 kg = 50ml/kg
- >20 kg = 20ml/kg
ii. Deficit fluid or rehydration therapy :- It is calculated as
75ml/kg of ORS , to be given over 4 hrs.. If ORS cannot
be taken orally then nasogastric tube can be used.
If after 4 hrs. , child still has some dehydration then
another t/t of ORS is to be given. This is effective in
95% cases.
For infants<6mo.who are not breastfed, along with
WHO-ORS 100-200 ml plain water must be given in
addition. Breast -feeding must be encouraged.
When body wt. is not known , amount of ORS required
can be calculated according to age as follows :

36. Fluid calculation acc.to age as per Plan ‘B’ :-
Age <4m
o.
4-
11m
o.
12-
23m
o.
2-
4yr.
5-
14yr.
>=
15yr.
weight <5kg 5-8kg 8-
11kg
11-
16kg
16-
20kg
>30kg
ORS,
ml
200-
400
400-
600
600-
800
800-
1200
1200-
2200
>2200
No. of
glasse
s
1-2 2-3 3-4 4-6 6-11 12-30

37. iii. Maintenance fluid therapy :- If patient
becomes rehydrated i.e. signs of
dehydration disappear, continue treatment
with ORS as per Plan ‘A’ for NO
dehydration.
Breastfeeding and semi-solid food should
be continued and plain water can be
offered in between.
If ORT is not successful, treat as SEVERE
dehydration with i.v. fluids as per Plan ‘C’ .

38. Treatment Plan ‘C’ : for ‘SEVERE’
dehydration
The primary objective of Plan ‘C’ is to quickly
rehydrate the child in a hospital with
facilities for I.V. fluid therapy .
Ringer’s lactate with 5% dextrose is the
preferred solution for rehydration . Normal
saline or plain Ringer solution may be used
as an alternative ,but 5% dextrose alone is
not effective.
A total of 100ml/kg of fluid is given ,over
6hr.in children < 12months and over 3hr.in
children >12 months . ORS solution be
started simultaneously if the child can take
orally.

39. If i.v. fluids cannot be given , nasogastric
feeding is given at 20ml/kg/hr. for 6hr. (total
120ml/kg) .
The child should be reassessed every 1-2 hr;
if there is repeated vomiting or abdominal
distension , the oral or nasogastric fluids are
given more slowly . If there is no
improvement in hydration after 3hr. , IV fluids
should be started at the earliest.
MONITORING :
 Assess for improvement every 1-2 hr. :-
- If not improving, give IV infusion more rapidly.
- Encourage oral feeding by giving ORS 5ml/kg/hr,
along with IV fluids ,as soon as child is able to take.

40.  Reassess hydration status :-
- The child should be reassessed every 15-30 min.
for pulses and hydration status after the first bolus
of 100ml/kg of IV fluid.
- The child should be observed for atleast 6 hr.
before discharge, to confirm that the mother is able
to maintain the child’s hydration by giving ORS
solution.
- It is recommended that severely malnourished
children should be slowly rehydrated, carefully
monitored and feeding to be started early.
- Infants below 2 months of age must be carefully
monitored as they are prone to septicemia and
severe electrolyte imbalance.

41. ZINC SUPPLEMENTATION :
Zinc supplementation is now part of the standard
care along with ORS in children with acute
diarrhea.
Zinc deficiency and intestinal losses during
diarrhea aggravate the deficit .
Zinc is helpful in decreasing severity and
duration of diarrhea and also the risk of
persistence.
DOSE : Zinc is recommemded to be
supplemented as sulphate , acetate or
gluconate formulations ; at a dose of 10mg of
elemental Zn per day for children< 6mo. &
20mg per day for >6mo. For a period of 14
days.

42. FEEDING DURING DIARRHEA :
Recommended
schedule of feeding
Breastfed infants Continue breastfeeding
non-breastfed infants Shld .be preferably given
only ORS till they are
rehydrated.
Animal milk/food sld.be
offered .
Severely malnourished
children
As soon as possible , food
should be offered i.e.
energy-giving foods .
During rehydration phase -

43. After rehydration phase -
Recommended feeding
Breastfed infants Breastfeed more frequently
non-breastfed infants Offer undiluted milk as before
Infants (6-12 months) Give easily digestible energy-
rich complementary foods in
addition to breast/animal milk.
Encourage to increase
frequency of feeding.
Older children Staple foods enriched with
fat,oil and sugar. Fruits like
banana ,legumes (rich in K ).
Vit. A rich foods.
Encourage to eat atleast 6
times a day.

44. ANTI-MICROBIAL THERAPY :
Causes Drugs of
choice
Doses
Cholera Doxycycline or
Furazolidone or
Trimethoprim -
sulfamethoxazol
e
Single dose of
5mg/kg (max. =
200 mg)
5-8mg/kg/day in
4 divided doses
* 3 days
TMP 10mg/kg
and SMX
50mg/kg in 2
divided doses *3
days

45. Causes D.O.C. Doses
Dysentery TMP + SMX or
Nalidixic acid or
Ciprofloxacin
(resistant-cases)
TMP 10mg/kg and
SMX 50mg/kg in 2
divided doses * 5
days
60mg/kg/day in 4
divided doses *
5days
Amoebic dysentery Metronidazole 30mg/kg/day in 3
divided doses * 5-10
doses
Acute giardiasis Metronidazole or
Tinidazole
15mg/kg/day in 3
divided doses *5
days
10-15 mg/kg/day in 3
divided doses * 5
days

46. ADDITIONAL DRUG THERAPY FOR
ASSOCIATED SYMPTOMS :
 Severe or recurrent vomiting - single dose of
Ondansetron (0.1-0.2 mg/kg/dose ) can be given.
 Abdominal distension - no specific treatment
required.
 Paralytic ileus - (if bowel sounds absent ) may
occur d/t hypokalemia, antimotility drugs or
septicemia ; oral intake should be stopped.
 Hypokalemia with paralytic ileus - IV fluids only and
nasogastric aspiration , along with KCl (30-
40mEq/L) I.V. ; provided child is passing urine.
 Convulsions - to be treated as per the underlying
etiology.

47. PREVENTION OF DIARRHEA AND
MALNUTRITION :
The three important measures are :
1. Improving infant feeding practices and
personal and domestic hygiene which
includes:
• Promotion of exclusive breast-feeding
upto 6 months of age.
• Improved complementary feeding
practices.
• Use of clean drinking water .
• Three Cs : clean hands,clean container
and clean envt..
• Adequate sewage disposal system and

48. II. Proper nutrition and care of mother as well
as child during the antenatal, natal and
post-natal periods. Adequate awareness
of the mother about symptoms of diseases
and vigilance to consult doctor .
III. Vaccination : Recent studies have
demonstrated safety and efficacy of RVV
(RotaVirus Vaccine) and thereby
suggesting a combined preventive and t/t
strategy ( vaccine, ORS and Zn
supplements) to reduce child mortality d/t
diarrhea. RVV has been scheduled as
routine vaccine as per IAP
recommendation at 6, 10 and 14 wks.of
age.

49. COMPLICATIONS OF ACUTE
DIARRHEA :
Majority of the ccomplications associated with
diarrhea are related to delays in diagnosis
and early institution of prompt treatment.
Without early and appropriate rehydration
,children may develop complications ; which
can be life- threatening.
Inappropriate t/t can lead to prolongation of
episode of illness , consequent malnutrition
, secondary infections and micronutrient
deficiencies.

50. Thus , various complications associated
with diarrhea can be listed as follows :
1. Persistent diarrhea
2. Malnutrition
3. Vitamins and mineral deficiencies
4. Hypoglycemia resulting in convulsions
and permanent brain damage.
5. Hypo- or hyper- natremic seizures
6. Focal infections d/t systemic spread of
pathogens like UTI, endocarditis,
pneumonia, meningitis, osteomyelitis,
encephalitis, etc..

51. 7. Reactive arthritis
8. Glomerulonephritis and IgA
nephropathy
9. Hemolytic Uremic Syndrome (sudden
onset ,short - term renal failure )
10. Heart failure due to severe electrolyte
imbalances .

52.  THANK YOU 
 HAVE A GREAT DAY
