Diarrhea in Children
Two million children die each year in
Developing Countries from Diarrhoea
Source : WHO
Definitions
A change in Stool Consistency, Volume and
increased frequency of Defecation
Classification
Acute if < 2 weeks
Persistent if acute in onset but persists >2
weeks
Recurrent if the episodes are distinctly
separated by a completely normal intervening
period ( 48-72 hrs)
What is not diarrhea
Passage of frequent formed stools
Passage of frequent watery motions in a well
looking neonate from Day 4-7
Passage of loose golden-brown pasty stools in a
breastfed child
Defecation (formed stools) immediately after
meals in older children.
Etiology of Diarrhea
Viruses
– Rotavirus, Norwalk virus, Adenoviruses
Bacteria
– E. coli (ETEC, EPEC, EAEC, EHEC)
– Vibrio cholerae
– Salmonella spp., Shigella, Campylobacter
Protozoa
– Entamoeba histolytica
– Giardia spp., Cryptosporidium
Systemic Infection (Parenteral Diarrhea)
– Pneumonia, UTI, Septicemia, Otitis media
Predisposing Factors
More in Summers and rainy season
Poor hygiene
Unhygienic feeding
Malnutrition
– More chances of persistent diarrhea
– More chances of mortality (15-20 times)
– More chances of systemic infection
Diarrhea & malnutrition
Vicious cycle
Diarrhea
Losses
Immunity Catabolism
Mucosal integrity Absorption
Common Appetite
predisposing factors Voluntary restriction
Malnutrition
Assessment
History
Diarrhea or not?
Acute or persistent or recurrent?
Watery/Rice watery/ bloody/mucoid
Associated features (vomiting, fever, tenesmus)
Clues of systemic infection
Mode of feeding/ type of treatment given
Examination
State of Dehydration (No, Some, Severe)
State of Nutrition (Weight, Anthropometry)
Signs of systemic infection
– Fever preceding (>24 hours) onset of diarrhea
– Fever persisting for > 72 hours
– General condition poorer than state of dehydration
– Specific clues (crepitations, bulging fontanelle etc.)
Investigations
Not Much role
Stool microscopy (history of mucus in stools ,
non response to therapy in dysentery)
Stool culture (Only of pragmatic interest)
Serum electrolytes/ Blood gas (in altered
sensorium, marked irritability, seizures,
abdominal distension)
Screening for systemic infection if some clue
Look and feel Signs Dehy. Plan
1. General Condition 2 of the following: SEVERE Plan
-Lethargic or unconscious -Lethargic or unconscious C
-Restless and irritable -Sunken eyes
2. Look for sunken -Not able to drink
eyes -Skin pinch goes back very
slowly
3. Offer the child fluid
2 of the following: SOME Plan
-Not able to drink or
drinking poorly -Restless, irritable B
-Drinking eagerly (thirsty) -Sunken eyes
-Drinks eagerly, thirsty
4. Skin pinch
-Skin pinch goes back slowly
-goes back slowly
Not enough signs to classify NO Plan
-goes back very slowly
as some or severe A
dehydration
Wrong method of skin pintch
What to Give in Diarrhea?
Oral Rehydration
Therapy
The Mainstay Of
Treatment
However
Does not offer rapid
relief of diarrheal
symptoms
What is ORT
WHO ORS Solution
Home made sugar-salt solution
Food based fluids (Rice water + salt, Lassi +
Salt)
Culturally acceptable home fluids (Coconut
water, lemon water, plain water, dal water,
soups)
Advantages of new formula
Sodium and glucose in same molar
concentration facilitates Na absorption
Significant reduction of stool output
Reduction of duration of diarrhea
Reduction of vomiting
Significant reduction of use of unscheduled IV
fluid
Home made ORS
What is NOT ORT
Glucose water without salt
Aerated beverages
Fruit juices
Tea/Coffee
How to mix and give ORS
How to mix and give ORS
How much to give?
Plan A : for No Dehydration
Continue feeding
ORT
– Home available fluids
– Sugar salt solution/food based solutions
– ORS
< 2 yrs: 50-100 mL/loose stool
2-10 yrs: 100-200 mL/loose stool
>10 yrs: As much as child wants
Plan B : for Some Dehydration
Rehydration Therapy
- ORS 75 mL/Kg over 4 hours
- Preferably manage in health facility
- If child wants more, give more
- If eyelids turn puffy, stop & give other fluids
Continue giving ORS when eyes turn normal
Continue Feeding
ORS and instructions as in Plan A
Plan C : for Severe Dehydration
Yes 1. Give IV fluids.
Can you give intravenous (IV)
2. After 4-6 hours, reassess the child
fluids?
and choose the suitable treatment plan.
No
Yes 1. Start treatment with ORS solution,
Can the child drink? as in Plan B
2. Send the child for IV treatment
No
1. Start rehydration using the tube
Are you trained to use a Yes
2. If IV treatment is available nearby,
nasogastric tube for
send the child for immediate IV
rehydration?
treatment.
No
URGENT:
Send the child for IV t/t
I/V correction of Severe dehydration
Ringer Lactate or Normal saline or N/2 saline in
dextrose (100 mL/Kg)
– < 1 yr: 30 mL/Kg in first hour and 70 mL/Kg in next 5
hrs
– > 1 Yr: 30 mL/Kg in first 30 min. and 70 mL/Kg in
next 2.5 hrs
Start ORS and feeding when able to drink
Frequent monitoring for signs of dehydration/
complications
Indications of I/V fluids
Severe Dehydration
Persistent vomiting (Not retaining anything)
Abdominal distension/Paralytic ileus
Unconscious child
Increased purge rate (>5ml/kg/hr)
Oral ulcer
Glucose malabsorption (Very rare)
Diarrhea - Treatment
Antibiotics not indicated in most cases
Indications
Dysentery – Nalidixic acid / Cotrimoxazole /
Quinolones
Cholera - Tetracycline / ciprofloxacin
Systemic infections (Parenteral diarrhea)
Routinely in severely malnourished
Diarrhoea - Treatment
Zinc
16% faster recovery
Reduction in duration of diarrhea
Reduction in stool output by 30%
Reduction in antibiotic prescriptions
Recommendation:
20 mg elemental zinc/day for up to 10 days .
Symptomatic Therapy -
Loperamide & Diphenoxylate
Drawbacks
Leads to Post Treatment Constipation
May worsen certain forms of Invasive Bacterial
Diarrhoea
Severe adverse effect of Paralytic Ileus
Contraindicated in most childhood diarrheas
Diarrhoea - Treatment
Racecadotril
Represents a new class of drugs – Oral Enkephalinase
Inhibitors
has a specific antisecretory action & does not prolong
intestinal transit time
Well tolerated in children; no significant adverse effects
documented till date
Limited data in artificial settings demonstrate reduction in
stool output in secretory diarrhea
Overall evidence insufficient to recommend routine use
Diarrhoea - Treatment
Probiotics
Lactobacillus, Bifidobacterium, Saccharomyces
Enteroprotective by competing for attachment
with pathogenic bacteria
Strengthen junction between enterocytes
Enhance immune response to pathogens
Overall a trend towards benefit in diarrhea
Diarrhoea - Treatment
Probiotics
Most data from developed countries
Can not be replicated in Indian setting
– High breastfeeding rates
– Different and higher intestinal flora
– Benefit shown mainly in rotavirus; relative
contribution of which is less in India
Good quality studies required in setting of
developing countries
Nutritional Management
Very Important Aspect
Feeding does not worsen diarrhea
Prevents malabsorption & facilitates
mucosal repair
– Continue feeding during diarrhea
– Do not dilute milk during diarrhea
– Routine lactose free feeding not required
– Increase amount of calories during convalescence
with energy dense foods (enrich foods with fats and
sugar)
Prevention of Diarrhea
Exclusive breastfeeding for six months
Timely and safe complementary feeding after 6 months
Hand washing
– Before cooking and serving food
– Before feeding the child
– After toilet
Safe drinking water
Food hygiene
Safe waste/ excreta disposal
Immunization
Thank
You
