Diarrhea
WHO and IMCI Guidelines
Jose Gianni C. Espada
Clinical Clerk
Diarrhea
excess loss of water, electrolytes and zinc in
liquid stools
During diarrhea, decreased food intake and
nutrient absorption and increased nutrient
requirements often combine to cause weight
loss and failure to grow
Malnutrition can make diarrhea more severe.
Etiology
Persistent Diarrhea
Enteropathogenic E. coli
Enteroaggregative E. coli
Nontyphoidal Salmonella
Cryptosporidium
Microsporidia
Giargia lamblia
Ascaris lumbricoides
Cytomegalovirus
Other viruses
Etiology
Bloody Diarrhea
Shigella
Nontyphoidal Salmonella
Campylobacter
Enteroaggregative E. coli
Enteroinvasive E. coli
Shiga-toxin producing E. coli
Entamoeba histolytica
Dehydration
Degree of dehydration is graded according to
signs and symptoms that reflect the amount
of fluid lost.
The rehydration regimen is selected
according to the degree of dehydration.
All children with diarrhea should receive zinc
supplements
Dehydration
Classification
Signs or Symptoms
Severe dehydration
Two or more of the following signs:
Lethargy or unconsciousness
Sunken eyes
Unable to drink or drinks poorly
Slow pinch goes back very slowly
(>2 seconds)
Some dehydration
Two or more of the following signs:
Restlessness, irritability
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back slowly
No dehydration
Not enough signs and symptoms to
classify as some or severe dehydration
Antibiotics
- Should not be used.
- Except in
- Children with bloody diarrhea (probably
Shigellosis)
- Suspected Cholera with severe dehydration
- Other serious non intestinal infections (e. g.
pneumonia, UTI)
- Antiprotozoal drugs are rarely indicated.
Antidiarrheals and Antiemetics
- Should not be given to young children with
acute or persistent diarrhea or dysentery
- They do not prevent dehydration or improve
nutritional status and some have dangerous,
sometimes fatal, side effects.
Child presenting with diarrhea
History
-
Careful feeding history
Frequency of stools
Number of days of diarrhea
Blood in stools
Report of a cholera outbreak in the area
Recent antibiotic or other drug treatment
Attacks of crying with pallor in an infant
Child presenting with diarrhea
Physical Examination
- Signs of some or severe dehydration:
-
Restlessness or irritability
Lethargy or reduced level of consciousness
Sunken eyes
Skin pinch returns slowly or very slowly
Thirsty or drinks eagerly, or drinking poorly or not able
Blood in stools
Signs of severe malnutrition
Abdominal mass
Abdominal distention
There is no need for routine stool microscopy or
culture in children with non bloody diarrhea
Differential Diagnosis
Diagnosis
Acute (watery) diarrhea
-More than three loose stools per day
-No blood in stools
Cholera
-Profuse watery diarrhea with severe
dehydration during cholera outbreak
-Positive stool culture for Vibrio
cholera O1 or O139
Dysentery
-Blood mixed with the stools (seen or
reported)
Persistent diarrhea
-Diarrhea lasting for 14 or more days
Diarrhea with severe
malnutrition
-Any diarrhea with signs of severe
acute malnutrition
Diarrhea associated with
recent antibiotic use
-Recent course of broad spectrum oral
antibiotics
Intussusception
-Blood or mucus in stools
-Abdominal mass
-Attacks of crying with pallor in infant
or young child
Acute diarrhea
Classify hydration status
Give appropriate treatment
Look for sunken eyes
Make a skin pinch
Offer the child fluid to see if thirsty or
drinking poorly
Severe Dehydration
Children with severe dehydration require
rapid IV rehydration with close monitoring,
followed by oral rehydration and zinc once
the child starts to improve sufficiently
Start IV fluids immediately. While the drip
is being set up, give ORS solution if the child
can drink.
Severe Dehydration
The best IV fluids for rehydration are
isotonic solutions
Plain Lactated Ringers (Hartmanns solution)
Normal Saline Solution (0.9% NaCl)
Do not use 5% Glucose solution or 0.18%
saline dextrose solution as they increase the
risk for hyponatremia which can cause
cerebral edema.
Severe Dehydration
Give 100 cc/kg of the chosen solution,
divided as:
Age in months
First, give 30
cc/kg in:
Then, give 70
cc/kg in:
<12
1 hour
5 hours
>12
30 minutes
2.5 hours
Severe Dehydration: Monitoring
- Reassess the child every 15-30 mins until a
strong radial pulse is present.
- Reassessing skin pinch, Level of
consciousness and ability to drink every hour
thereafter to confirm improvement of
hydration.
- Sunken eyes recover more slowly and is less
useful in monitoring.
Severe Dehydration: Monitoring
- If signs of severe dehydration are still
present, repeat IV fluid infusion.
- If improving but still showing signs of severe
dehydration, discontinue IV treatment and
give ORS solution for 4 hours
- Encourage the mother to continue
breastfeeding frequently.
Severe Dehydration: Monitoring
Observe the child for another 6 hours
before discharge to confirm that the mother
is able to maintain the childs hydration by
giving ORS solution.
ORS solution (5cc/kg per hour) with 3-4
hours for infants and 1-2 hours for older
children. ORS also provides additional
potassium.
When SD is corrected, prescribe zinc
Cholera
Suspect in children > 2years old who have
acute watery diarrhea and signs of severe
dehydration or shock, if cholera is present in
the area
Assess and treat dehydration as for other
acute diarrhea.
Cholera
Give an oral antibiotic to which strains of V.
cholera in the area are known to be sensitive.
Erythromycin
Ciprofloxacin
Co-trimoxazole
Prescribe zinc supplementation as soon as
vomiting stops
Some Dehydration
Diagnosis
Restlessness or irritability
Thirsty and drinks eagerly
Sunken eyes
Skin pinch goes back slowly
Two or more of the above signs
One of the above signs or one of the signs of
severe dehydration, then diagnosis can be
made.
Some Dehydration
In general, children with Some Dehydration
should be given ORS solution for the first 4
hours at a clinic, while the child is monitored
and the mother is taught how to prepare and
give ORS solution.
A teaspoonful every 1-2 mins if the child is
<2 years.
Frequent sips from a cup for an older child.
Some Dehydration
Age
<4 months
4 to <12
months
12 months
to <2 years
2 years to
< 5 years
Weight
<6 kg
6 to < 10 kg
10 to < 12 kg
12 to 19 kg
200-400 cc
400-700 cc
700-900 cc
900-1400 cc
Zinc supplementation
Replacement helps the childs recovery,
reduces the duration and severity of the
episode, and lowers the incidence of diarrhea
in the following 2-3 months.
Give zinc and advise the mother how much to
give:
<6 months: half tablet (10 mg) per day for 10-14
days.
>6 months: one tablet (20 mg) per day for 10-14
days.
No Dehydration
Diagnosis
No 2 or more signs that characterize some or
severe dehydration.
Treatment
Treat the child as an outpatient
Counsel the mother on the 4 rules of home
treatment
Give extra fluids
Give zinc supplements for 10-14 days
Continue feeding
Know when to return to the clinic
No Dehydration
To prevent dehydration, advise the mother
to give as much extra fluids as the child will
take
For children <2 years, about 50-100 ml after each
loose stool
For children >2 years, about 100-200 ml after
each loose stool
If the child vomits, wait 10 mins and then
give more slowly.
Give zinc supplements.
Persistent Diarrhea: Severe
Diagnosis
Children with diarrhea lasting >14 days with signs
of dehydration or severe malnutrition
Assess the child for signs of dehydration
Examine the child for non-intestinal infections
Treatment
ORS solution is effective for most children with
persistent diarrhea
Children with impaired glucose absorption require
IV rehydration
Persistent Diarrhea: Severe
Supplementary Multivitamins and Minerals
Daily for 2 weeks
Folate 50 g
Zinc 10 mg
Vitamin A 400 g
Iron 10 mg
Copper 1 mg
Magnesium 80 mg
Persistent Diarrhea: Non-Severe
Diagnosis
Children with diarrhea lasting >14 days but with no
signs of dehydration or severe malnutrition
Treatment
Treat the child as an outpatient
Give supplementary multivitamins and minerals.
Persistent Diarrhea: Non-Severe
Follow up children after 5 days, or earlier if
diarrhea worsens and other problems
develop.
Dysentery
Diarrhea presenting with frequent loose
stools mixed with blood (not just a few
smears on the surface). Most episodes are
due to Shigella, and nearly all require
antibiotic treatment.
Shigellosis can lead to life-threatening
complications like intestinal perforation,
toxic megacolon and hemolytic uremic
syndrome.
Dysentery
Diagnosis:
Frequent loose stools mixed with visible red blood.
Abdominal pain
Fever
Convulsions
Lethargy
Dehydration
Rectal prolapse
Treatment:
Most children can be treated at home.
Dysentery
Admit to hospital
Young infants (<2 months old)
Severely ill children, who look lethargic, have
abdominal distension and tenderness or
convulsions
Children with any another condition requiring
hospital treatment
Dysentery
Give an oral antibiotic (for 5 days) to which
most local strains of Shigella are sensitive.
Give Ciprofloxacin at 15 mg/kg BID if antibiotic
sensitivity is unknown.
Give Ceftriaxone IV or IM 50-80 mg/kg per day
for 3 days to severely ill children or as secondline treatment.
Give zinc supplements as for children with
watery diarrhea.
Dysentery: Follow up
Follow up children after 2 days, and look for
signs of improvement such as no fever, fewer
stools with less blood, improved appetite.
If no improvement,
Check for other conditions
Stop the first antibiotic and give a second line
antibiotic or a known effective against Shigella in
the area.
If amoebiasis is possible, give Metronidazole
10 mg/kg TID for 5 days.
Dysentery: Infants and young children
Consider Surgical causes of blood in the
stools (e.g. intussusception) and refer to a
surgeon if appropriate.
Dysentery is unusual and young infants,
therefore consider life-threatening bacterial
sepsis.
For suspected sepsis give IM or IV
Ceftriaxone at 100 mg/kg once daily for 5
days.
THANK YOU!!
