DIARRHEAL DISEASES

IN CHILDREN
University of Cebu School of Medicine
Department of Community Medicine
November 20, 2020

Block 3
Bation | Cempron | Codilla | Duavis | Grado
Mendez | Ramos | Roxas | Susaya | Tardo
Objectives:

1. To define diarrhea and its clinical types

2. To be able to properly assess a child with diarrhea
3. To be able to estimate fluid deficit
4. To discuss the treatment plans and prevention of acute diarrhea
5. To discuss the management of persistent diarrhea
6. To be able to identify the microbial causes of acute diarrhea in infants and children
7. To discuss the management of suspected cholera and dysentery
A.B., a 5-year-old boy, weighing 20 kg, Filipino, Roman Catholic,
from Purok Lubi, Barangay Garing, Consolacion, was brought by
his mother to the barangay health center due to
loose watery stools.
Acute Diarrhea
● the passage of unusually loose or watery stools, usually at least
three times in a 24 hour period
● sudden onset of excessively loose stools of >10 mL/kg/day in
infants and >200 g/24 hr in older children, which lasts <14 days
● it is the consistency of the stools rather than the number that is
most important
 Clinical Types of Diarrhea
❖ Acute Watery Diarrhea (including cholera) ❖ Persistent Diarrhea
➢ lasts several hours or days ➢ lasts 14 days or longer
➢ main danger is dehydration ➢ main danger is malnutrition and
➢ weight loss also occurs if feeding is serious non-intestinal infection
not continued ➢ dehydration may also occur

❖ Acute Bloody Diarrhea ❖ Diarrhea with Severe Malnutrition

➢ also called dysentery (marasmus or kwashiorkor)
➢ main dangers are damage of the ➢ main dangers are severe systemic
intestinal mucosa, sepsis and infection, dehydration, heart failure,
malnutrition and vitamin and mineral deficiency
➢ dehydration may also occur
 ASSESSMENT OF THE
CHILD WITH DIARRHEA
History:
● presence of blood in the stool ● pre-illness feeding practices
● duration of diarrhea ● type and amount of fluid and
● number of watery stools per day food taken during the illness
● number of episodes of vomiting ● drugs or other remedies taken
● presence of fever, cough, or other ● immunization history
important problems
Physical Examination:
1. Check for signs and symptoms of dehydration

● Look at the child’s general condition ● Offer the child fluid

○ alert? ○ taken normally or refused?
○ restless and irritable? ○ taken eagerly, thirsty?
○ lethargic or unconscious? ○ not able to drink or drinking poorly?

● Look for sunken eyes ● Pinch the skin of the abdomen

○ go back immediately?
○ slowly?
○ very slowly? (>2 seconds)
Physical Examination:
2. Check for signs of other important problems

● Does the child’s stool contain red blood? ● Is the child coughing?
○ respiratory rate?
● Is the child malnourished?
○ chest indrawing?
○ marked muscle wasting (marasmus)?
○ edema of the feet? ● Take the child’s temperature
 Assessment of Diarrhea Patients for Dehydration
NO SIGNS OF DEHYDRATION SOME DEHYDRATION SEVERE DEHYDRATION

CONDITION well, alert restless, irritable lethargic or unconscious

EYES normal sunken eyes sunken eyes

TEARS present absent absent

MOUTH & TONGUE moist dry very dry

THIRST drinks normally, not thirsty drinks eagerly, thirsty drinks poorly or
not able to drink

SKIN PINCH goes back quickly goes back slowly goes back very slowly

TREAT use Treatment Plan A weigh the patient, if possible, weigh the patient and use
and use Treatment Plan B Treatment Plan C urgently
Laboratories:
● Complete Blood Count
● Stool Examination (3 collections)
● Electrolytes
● Urinalysis
ESTIMATION OF FLUID
DEFICIT
Patient A.B, 5 years old, 20kg
Assessment: some dehydration

20 kg x 50-100ml/kg = 1000-2000ml
Fluid Maintenance: 1500cc/hr
10 x 100cc/kg/hr = 1000cc/hr
10 x 50cc/kg/hr= 500cc/hr
Treatment Plan
Treatment Objectives

● Prevent dehydration
● Treat dehydration
● Prevent nutritional damage
● Reduce the duration and severity of diarrhea, and the occurrence of episodes
No Dehydration Treatment Plan A
Some Dehydration Treatment Plan B
Severe Dehydration Treatment Plan C
Treatment Plan A: Home Therapy to Prevent
Dehydration and Malnutrition
4 Rules of Home Treatment:

1. Give extra fluid

2. Give zinc supplement
3. Continue feeding
4. When to return
Rule 1: Give the child more fluids than usual, to
prevent dehydration
Suitable Fluids Unsuitable Fluids

Salt containing Non-salt containing ● Commercial

carbonated
● ORS solution ● Plain water beverages
● Salted drinks (e.g. ● Unsalted rice water ● Commercial fruit
salted rice water, ● Unsalted soup juices
salted yoghurt drink) ● Unsalted yoghurt ● Sweetened tea
● Vegetable or chicken drinks ● Coffee
soup with salt ● Green coconut water ● Medicinal teas or
● Unsweetened fresh infusions
fruit juice
 How much fluid to give?

General Rule: Give as much fluid as the child wants until diarrhea stops.

Children under 2 years of age 50-100 ml (a quarter to half a large cup) of

fluid

Children aged 2 up to 10 years 100-200 ml (a half to one large cup)

Older children and adults As much fluid as they want

Giving of fluid instructions:

● 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 diarrhea stops.
Rule 2: Give supplemental zinc (10 - 20 mg) to
the child, every day for 10 to 14 days
How much to give?

Age Zinc Syrup Zinc Drops 10mg/ml Zinc Tablet 20mg

20mg/5ml tablet

2 months up to 6 ½ tsp (2.5ml) daily 1.0 ml daily for 14 ½ tablet daily for 14
months for 14 days days days

6 months or more 1 tsp (5ml) daily for 2.0 ml daily for 14 1 tablet daily for 14
14 days days days

How to give?

● Infants: dissolve tablet in a small amount of expressed breast milk, ORS, or clean
water in a cup.
● Older Children: tablets can be chewed or dissolved in a small amount of water.
Rule 3: Continue to feed the child, to prevent
malnutrition
What to give?
In general, foods suitable for a child with diarrhea are the same as those required by
healthy children.

Milk Other Foods

● Infants of any age who are breastfed ● If the child is at least 6 months old or
should be allowed to breastfeed as is already taking soft foods
often and as long as they want. (complementary foods), he or she
● Infants who are not breastfed should should be given cereals, vegetables
be given their usual milk feed (or and other foods, in addition to milk.
formula) at least every three hours, if ● If the child is over 6 months and such
possible by cup. foods are not yet being given, they
● Infants below 6 months of age who should be started during the diarrhea
take breastmilk and other foods episode or soon after it stops.
should receive increased
breastfeeding.
 How much and how often?

● every three or four hours (six times a day)

● frequent, small feedings
● continue giving the same energy-rich foods and provide one more meal than usual
each day for at least two weeks (after diarrhea stops)
● extra meals should be given until the child has regained normal weight-for-height (if
the child is malnourished)
Rule 4: Take the child to a health worker if there
are signs of dehydration or other problems

The mother should take her child to a health worker if the child:

● starts to pass many watery stools;

● has repeated vomiting;
● becomes very thirsty;
● is eating or drinking poorly;
● develops a fever;
● has blood in the stool; or
● the child does not get better in three days.
Treatment Plan B: Oral Rehydration Therapy for
Children w/ Some Dehydration
How much ORS solution is needed?

● If the child's weight is known, this should be used to determine the approximate
amount of solution needed.
○ The amount may also be estimated by multiplying the child's weight in kg
times 75 ml.
● If the child's weight is not known, select the approximate amount according to the
child's age.
How to give ORS?

● Give frequent small amount.

○ for babies, a dropper or syringe (without the needle) can be used to put small
amounts of solution into the mouth
○ children under 2 years of age should be offered a teaspoonful every 1-2
minutes
○ older children (and adults) may take frequent sips directly from the 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 the treatment.
● Begin feeding the child in clinic.
If oral rehydration therapy must be interrupted:

If the mother and child must leave before rehydration with ORS solution is completed:

● show the mother how much ORS solution to give to finish the four-hour treatment
at home;
● give her enough ORS packets to complete the four hour treatment and to continue
oral rehydration for two more days, as shown in Treatment Plan A
● show her how to prepare ORS solution;
● teach her the four rules in Treatment Plan A for treating her child at home.
 When oral rehydration fails:

Causes: Remedy:
● continuing rapid stool ● give ORS solution by
loss (more than 15-20 nasogastric (NG) tube or
ml/kg/hour), as occurs Ringer's Lactate Solution
in some children with intravenously (IV) (75
cholera; ml/kg in four hours),
● insufficient intake of usually in hospital
ORS solution owing to ● after confirming that the
fatigue or lethargy; signs of dehydration have
● frequent, severe improved, it is usually
vomiting possible to resume ORT
successfully
Cases(rare) when ORT should not be given:

In children with:
● abdominal distension with paralytic ileus, which may be caused by opiate drugs
(e.g. codeine, loperamide) and hypokalaemia;
● glucose malabsorption, indicated by a marked increase in stool output when ORS
solution is given, failure of the signs of dehydration to improve and a large amount
of glucose in the stool when ORS solution is given
In these situations, rehydration should be given IV until diarrhea subsides; NG therapy
should not be used.
Treatment Plan C: Patients with Severe
Dehydration
Guidelines for Intravenous Rehydration:

● If possible, the child should be admitted to hospital.

● Children who can drink, even poorly, should be given ORS solution by mouth until
the IV drip is running. In addition, all children should start to receive some ORS
solution (about 5 ml/kg/h) when they can drink without difficulty, which is usually
within 3-4 hours (for infants) or 1-2 hours (for older patients). This provides
additional base and potassium, which may not be adequately supplied by the IV
fluid.
Management of Suspected
Cholera
Key Clinical Differences

● It occurs in large epidemics that involve both children and adults;

● Voluminous watery diarrhoea may occur, leading rapidly to severe dehydration
with hypovolemic shock;
● Appropriate antibiotics may shorten the duration of the illness.
● Cholera should be suspected if:
○ Child >5 years old or adult developing severe dehydration from acute watery
diarrhea
○ Child >2 years old, with a known cholera outbreak in area
○ Characteristic “rice water” appearance of stools
Treatment

● Rapid IV infusion needed for severe dehydration

● Average fluid requirement during first 24 hours is 200-350 ml/kg of body weight,
using Ringer’s Lactate with potassium chloride
● Patients should be treated under observation until diarrhea stops or is infrequent
and of small volume
● Antimicrobial therapy targeted against Vibrio cholerae given as soon as vomiting
stops.
Management of Dysentary
Key Clinical Differences

● Diarrhea is bloody
● Most likely causative organism is Shigella sp.
○ May progress to hemolytic-uremic syndrome (HUS)
● 3% of cases caused by E. histolytica infection
 Treatment

● Patient should be treated for dehydration

● First Line antibiotic: Oral Ciprofloxacin 15mg/kg BID x 3
days
● Young children with bloody diarrhea should NOT be
treated for amoebiasis
Reassessment

● After 2 days, patient should be reassessed for signs of

clinical improvement
● Second antibiotic should be considered if no
improvement is noted
● Refer to the hospital if:
○ Second line antibiotic is not available
○ Patient is less than 12 months old
○ Patient was dehydrated on the first visit
○ Patient had measles within the last 3 months
 MANAGEMENT OF
PERSISTENT DIARRHOEA
● Persistent Diarrhoea
○ Diarrhea with or without blood that begins acutely and lasts at least 14 days.

● Objective of Treatment:
○ Restore weight gain and normal intestinal function
■ Treatment of persistent diarrhoea consists of giving:
● appropriate fluids to prevent or treat dehydration
● a nutritious diet that does not cause diarrhoea to worsen
● supplementary vitamins and minerals, including zinc for 10 - 14 days.
● antimicrobial(s) to treat diagnosed infections
Where to give treatment?
● Home - most children
● Hospital:
○ children with a serious systemic infection, such as
pneumonia or sepsis
○ children with signs of dehydration
○ infants below 4 months of age.
Prevent or Treat Dehydration
● Assess the child for signs of dehydration and give fluids
according to Treatment Plan A, B or C, as appropriate.

○ ORS solution
○ IV rehydration
Identify and Treat Specific Infections
● Non-intestinal Infections:
○ Examine for non-intestinal infections, such as:
■ Pneumonia
■ Sepsis
■ Urinary tract infection and
■ Otitis media
○ Treatment: Antimicrobials (should follow standard guidelines)
● Intestinal Infections
● Hospital-acquired Infections:
○ May include pneumonia, rotavirus diarrhoea and cholera
○ Considered in any child who is:
■ lethargic and eats or drinks poorly (but is not dehydrated)
■ or who develops fever, cough, worsening diarrhoea or other signs of
serious illness at least two days after being admitted.
○ Treatment should follow standard guidelines.
Give a Nutritious Diet
● Feeding of Outpatients
○ The following feeding recommendations should be given:
■ Continue breastfeeding.
■ If yoghurt is available, give it in place of any animal milk usually
taken by the child; Otherwise, limit animal milk to 50
ml/kg/day; greater amounts may aggravate the diarrhoea. Mix
the milk with the child's cereal. Do not dilute the milk.
■ Give other foods that are appropriate for the child's age.
■ Give frequent small meals, at least six times a day.
Feeding in Hospital
● Infants below age 6 months:
○ Encourage exclusive breastfeeding. Help mothers who are not breastfeeding exclusively to
re-establish lactation.
○ If animal milk must be given, replace it with yoghurt (given with a spoon). If this is not
possible, give a lactose free milk formula (given from a cup).
● Older infants and young children:
○ The first diet: reduced lactose
■ started as soon as the child can eat and should be given six times a day.
■ The diet should contain at least 70 Kcal/100g, provide milk or yoghurt as a source of
animal protein, but no more than 3.7 g lactose/kg body weight/day, and provide at
least 10% of calories as protein.
○ The second diet: lactose-free with reduced starch
■ from egg, cooked cereal, vegetable oil and glucose, and providing at least 10% of
calories as protein.
Give supplementary Multivitamins and Minerals
● All children with persistent diarrhoea should receive supplementary
multivitamins and minerals each day for two weeks.
● These should provide as broad a range of vitamins and minerals as possible,
including at least two recommended daily allowances (RDAs) of folate, vitamin
A, zinc, magnesium and copper.
● As a guide, one RDA for a child aged one year is:
○ Folate 50 ug
○ Zinc 10 mg
○ Vitamin A 400 ug
○ Copper 1 mg
○ Magnesium 80 mg
Monitor the Response to Treatment
● Children treated as Outpatients
○ Children should be re-evaluated after seven days, or earlier if diarrhoea
worsens or other problems develop.
○ Those who have gained weight and who have < 3 loose stools per day
■ May resume a normal diet for age.
○ Those who have not gained weight or whose diarrhoea has not
improved
■ Should be referred to hospital
● Children treated in Hospital
○ The following should be measured and recorded in a standard manner, at
least daily:
■ body weight
■ Temperature
■ food taken, and
■ number of diarrhoea stools.
● Successful treatment with either diet
is characterized by: ● Dietary failure is manifested by:
○ adequate food intake ○ an increase in stool frequency (usually
○ weight gain to more than 10 watery stools/day),
○ fewer diarrhoeal stools often with a return of signs of
○ lack of fever dehydration;
○ a failure to establish daily weight gain
within seven days.
● There should be at least three
successive days of increasing
weight to conclude that weight gain is
occurring.

● Children responding satisfactorily to either diet should be given additional fresh fruit and
well cooked vegetables as soon as improvement is confirmed.
● After seven days' treatment with the effective diet, they should resume an appropriate diet
for age, including milk, that provides at least 110 Kcal/kg/day.
PREVENTION OF DIARRHEA
Breastfeeding
● Exclusive breastfeeding during the first 6 months of life
○ No other foods or fluids, such as water, teas, juice,
cereal drinks, animal milk or formula
● Breastfeeding should continue until at least 2 years of age
● Exclusively breastfed babies are much less likely to get
diarrhea or to die from it than are babies who are not
breastfed or are partially breastfed
● Protects against the risk of allergy early in life
● Aids in child spacing
● Provides protection against infections other than diarrhea
(e.g. pneumonia)
Advantages of Breastfeeding
1. Breastmilk is a complete food
○ It provides all the nutrients and water needed by a healthy infant
2. The composition of breastmilk is always ideal for the infant
○ Formula or cow's milk may be too dilute (which reduces its nutritional value) or too concentrated (so that it
does not provide enough water), and the proportions of different nutrients are not ideal.
3. Breastmilk has immunological properties
○ Protect the infant from infection, especially diarrhea; these are not present in animal milk or formula.
4. Breastfeeding is clean
○ It does not require the use of bottles, nipples, water and formula which are easily contaminated with
bacteria that can cause diarrhea.
5. Breastfeeding immediately after delivery encourages the "bonding" of the mother to her infant
○ Has important emotional benefits for both and helps to secure the child's place within the family.
6. Milk intolerance is very rare in infants who take only breastmilk.
7. Breastfeeding helps with birth spacing
○ Mothers who breastfeed usually have a longer period of infertility after giving birth than do mothers who do
not breastfeed.
● If breastfeeding is not possible, cow's milk (modified if given to infants
younger than 6 months) or milk formula should be given from a cup.
● Feeding bottles and teats should not be used
● Careful instructions should be given on the correct hygienic preparation of
milk formula using water that has been boiled briefly before use.
Improved feeding practices
● Complementary feeding - started when a child is 6 months old.
○ after 4 months of age if the child is not growing satisfactorily
● Involve selecting nutritious foods and using hygienic practices when preparing them
● In addition to breastmilk (or animal milk),
○ soft mashed foods (e.g. cereals)
○ eggs, meat, fish and fruit, when possible
○ well-cooked pulses and vegetables, to which some vegetable oil (5-10 ml/serving)
has been added
Use of safe water
The risk of diarrhea can be reduced by using the cleanest available water and protecting it from contamination.

Families should:

1. Collect water from the cleanest available source.

2. Not allow bathing, washing, or defecation near the source. Latrines should be located more than 10
meters away and downhill.
3. Keep animals away from protected water sources.
4. Collect and store water in clean containers; empty and rinse out the containers every day; keep the
storage container covered and not allow children or animals to drink from it; remove water with a long
handled dipper that is kept especially for the purpose so that hands do not touch the water.
5. If fuel is available, boil water used for making food or drinks for young children. Water needs only to be
brought to a rolling boil (vigorous or prolonged boiling is unnecessary and wastes fuel).
Handwashing
● All diarrheal disease agents can be spread by hands that have been contaminated by fecal material.
● The risk of diarrhea is substantially reduced when family members practice regular handwashing.
● All family members should wash their hands thoroughly
○ after defecation
○ after cleaning a child who has defecated
○ after disposing of a child's stool
○ before preparing food, and before eating
● Good handwashing requires the use of soap or a local substitute, and enough water to rinse the
hands thoroughly.
Food Safety
Individual food safety practices
● Do not eat raw food, except undamaged fruits and vegetables that are peeled and eaten
immediately
● Wash hands thoroughly with soap after defecation and before preparing or eating food
● Cook food until it is hot throughout
● Eat food while it is still hot, or reheat it thoroughly before eating
● Wash and thoroughly dry all cooking and serving utensils after use
● Keep cooked food and clean utensils separately from uncooked food and potentially
contaminated utensils
● Protect food from flies by means of fly screen
Use of Latrines and Safe Disposal of Stools
● Proper disposal of feces can help to interrupt the
spread of infection.
● Fecal matter can contaminate water where children
play, where mothers wash clothes, and where they
collect water for home use.
● Every family needs access to a clean, functioning
latrine.
○ If one is not available, the family should
defecate in a designated place and bury the
feces immediately.
● Stools should be collected soon after defecation
and disposed of in a latrine or buried.
Measles Immunization

● Substantially reduce the incidence and severity of diarrheal diseases.

● Every infant should be immunized against measles at the recommended age.
 MICROBIAL CAUSES OF ACUTE
DIARRHEA IN INFANTS AND CHILDREN
VIRUSES
1. Rotavirus
● 15-25% of diarrhoea episodes in children (6-24 months) visiting treatment facilities; 5-10% of cases (6-
24 months) in the community.
● faecal/oral transmission or possibly by airborne droplets
● Rotavirus causes patchy damage to the epithelium of the small intestine ➡️blunting of the villi ➡️
reduction in the activity of lactase and other dissacharidases ➡️reduced absorption of carbohydrates
● return to normal within 2-3 weeks

BACTERIA
1. Escherichia coli
○ Enterotoxigenic E. coli (ETEC)
■ most common cause of diarrhoea in travellers; major cause of acute watery diarrhoea in
children and adults
■ 2 virulent factors of ETEC
● colonisation factors that allow ETEC to adhere to enterocytes of the small bowel
● enterotoxins
■ ETEC produce heat-labile (LT) and/or heat stable (ST) enterotoxins ➡️secretion of fluid and
electrolytes ➡️watery diarrhoea
■ ETEC do not destroy the brush border or invade the mucosa
○ Localized-adherent E. coli (LA-EC)
■ 30% of cases in young infants
■ common in formula-fed infants under 6 months of age
■ LA-EC are detected by patchy adherence to the HeLA cells or by specific gene probes.
Enteroadherence and production of a potent cytotoxin (disease mechanism)

○ Diffuse-adherent E. coli (DA-EC)

■ DA-EC are detected by typical diffuse adherence to HeLa cells

○ Enteroinvasive E. coli (EIEC)

■ sporadic food-borne outbreaks that affect children and adults
■ symptoms are similar to those of shigellosis
■ invade and multiply within colonic epithelial cells, causing cell death and mucosal ulcers

○ Enterohaemorrhagic E. coli (EHEC)

■ EHEC produce a Shigalike toxin that may be responsible for oedema and diffuse bleeding in
the colon and haemolytic-uraemic syndrome that sometimes develops in children
■ acute onset of cramps, absent or low-grade fever, and watery diarrhoea that may rapidly
become bloody
■ Type O157:H7 - most common serotype (haemolytic-uraemic syndrome)
1. Shigella
○ 10-15% of cases in children under 5 years; most common cause of bloody diarrhoea in children
○ person-to-person contact, food borne and waterborne transmission
○ Shigella invade and multiply within colonic epithelial cells ➡️cell death and mucosal ulcers
○ Shigella occasionally invade the bloodstream
○ virulence factors
■ smooth lipopolysaccharide cell-wall antigen - antigens that promote cell invasion
■ Shiga toxin - cytotoxic, neurotoxic and causes watery diarrhoea
○ 4 serogroups
■ S. flexneri - the most common serogroup in developing countries
■ S. sonnei - the most common in developed countries
■ S. dysenteriae type 1 - which causes epidemics of severe disease with high mortality
■ S. boydii - less common

2. Campylobacter jejuni
○ 5-15% of diarrhoea in infants worldwide
○ most children acquire immunity during the first year of life; the pathogen is frequently found in stools
of healthy older children
○ spread is by chickens, other animals
○ produce diarrhoea by invasion of the ileum and the large intestine
○ 2 types of toxin are produced
■ cytotoxin, heat-labile enterotoxin
 1. Vibrio cholerae O1 and O139
○ most often in children 2-9 years of age
○ contaminated water and food can transmit cholera; person-to-person spread (less common)
○ V. cholerae adhere to and multiply on the mucosa of the small intestine where they produce an
enterotoxin ➡️diarrhoea
○ Cholera is caused by V. cholerae O1 and O139 [V. cholerae O1 has two biotypes (El Tor and
classical) and two serotypes (Ogawa, Inaba)]

2. Salmonella (non-typhoid)
○ 1-5% of gastroenteritis usually from ingestion of contaminated animal products
○ Salmonella invade the ileal epithelium ➡️enterotoxin causes watery diarrhoea (mucosal damage
occurs, diarrhoea may be bloody) ➡️(bacteraemia may occur and can lead to localized infection in
other tissues, such as bone and meninges)

PROTOZOA
3. Giardia duodenalis
○ foodborne, waterborne, or spread by faecal-oral route (latter occurs in children living in crowded
circumstances or attending day-care centres)
○ infects the small bowel; flattening of the intestinal epithelium (severe cases
1. Entamoeba histolytica
○ invades the mucosa of the large intestine ➡️intestinal secretion and damage (neurohumoral
substances that cause resulting in an inflammatory type of diarrhoea
○ 90% of infections are asymptomatic, (from nonpathogenic); they should not be treated
○ diagnosis of invasive disease - identification of haematophageous trophozoites in faeces or
colonic ulcers
○ symptomatic amoebiasis ranges from persistent mild diarrhoea to fulminant dysentery to liver
abscess

2. Cryptosporidium
○ 5-15% of childhood diarrhoea.
○ faecal-oral route
○ attach to the microvillous surface of enterocytes ➡️mucosal damage ➡️malabsorption and fluid
secretion
○ self-limited in persons who are not immuno-deficient
ANTIMICROBIALS AND
DRUGS
Antimicrobials

Antimicrobial therapy should NOT be given routinely because it is ineffective and may be dangerous, except
in:

● Cases of bloody diarrhea (dysentery)

○ Oral Ciprofloxacin (15 mg/kg BID for 3 days)
● Suspected cases of cholera with severe dehydration
○ First-line: Cotrimoxazole (5 mg/kg/day in 2 divided doses for 3 days)
○ Alternative: Flurazolidone (1.25 mg/kg QID for 3 days)
● Laboratory proven, symptomatic infection with Giardia duodenalis

When diarrhea is associated with another acute infection, treat with specific antimicrobial therapy.
“Antidiarrheal” drugs

These have NO practical benefit and are NEVER indicated for the treatment of acute diarrhea in children.
Some of them are dangerous.

Antidiarrheal drugs include:

● Adsorbents (e.g., kaolin, activated charcoal, cholestyramine)

● Antimotility drugs (e.g., loperamide hydrochloride, diphenoxylate with atropine, tincture of opium,
codeine)
● Bismuth subsalicylate
● Combinations of drugs
Other drugs
● Antiemetics (e.g., prochlorperazine and chlorpromazine)
○ Should NEVER be given to children with diarrhea
○ Cause sedation that can interfere with ORT
○ Vomiting stops when a child is rehydrated

● Cardiac stimulants
○ Cardiac stimulants and vasoactive drugs (e.g., adrenaline, nicotinamide) are NEVER indicated
○ Shock in acute diarrheal disease is caused by dehydration and hypovolemia
○ Correct treatment is rapid IV infusion of a balanced electrolyte solution

● Blood or plasma
○ NEVER indicated for children with dehydration due to diarrhea
○ Used for patients with hypovolemia due to septic shock
Other drugs (cont’d)
● Steroids
○ NEVER indicated
○ No benefit

● Purgatives
○ Should NEVER be used
○ Can make diarrhea and dehydration worse
Resources

World Health Organization: Integrated Management of Childhood Illness. 2014

World Health Organization. The Treatment of diarrhoea : a manual for physicians and other senior health
workers. 4th rev.