DIARRHOEA IN CHILDREN

 Leading cause of morbidity and mortality in

children
 World over - > 3milliion deaths of under 5s
per year
- 80% of these deaths in first 2
years of life
- main cause - dehydration
 Passage of 3 or more loose/ watery stools in
a 24 hrs period
(loose stool – one that takes the shape of the
container)
 Imp - Recent change in consistency and
character of stool and it’s water content
rather than the number of stools
Types of diarrhea
 Ac watery diarrhea – Ac onset – 14 days, loose
watery stools without visible blood. Vomiting, fever,
dehydration, dyseletrolytemia

 Dysentery – Diarrhea with visible blood, fever,

tenesmus. Anorexia, rapid wt loss. Complications –
renal failure, encephalopathy

 Persistent diarrhea – Ac onset - >14 days. Wt loss,

dehydration
Risk factors
 Occurrence – First 2 years of life (6 – 11
months)
 Low socio-economic status
 Non breast fed babies
 Associated with measles, severe
malnutrition, immunodeficiency
Etiology
 Common - Rotavirus, Enterotoxigenic Escherichia
coli (ETEC), Enteropathogenic Escherichia coli
(EPEC), Shigella, Campylobacter jejuni

 Vibrio cholerae (in epidemics)Dysentery – shigella,

Campylobacter jejuni, enteroinvasive E coli,
Salmonella dysenteriae

 Drugs – Ampicillin, Cotrimoxazole, Amoxicillin,

Chloramphenicol
Clinical features
Based on the mechanism -
 Secretory diarrhea – ETEC, Vibrio Cholerae. Toxins cause Na pump
failure. Ac watery diarrhea with profound losses of water and elect.
Risk - rapid water & elect imbalance.

 Invasive diarrhea (Dysentery)- Shigella. Intestinal mucosa invaded

by enteropathogens>> inflammatory reaction >>blood & mucus in
stools. Complications – Intestinal perforation, toxic megacolon, rectal
prolapse, encephalopathy, septicemia, hemolytic uremic syndrome

 Osmotic diarrhea – Carbonated soft drinks, ORS with high sugar

content. Injury to enterocytes >>epithelial destruction >> <ed
mucosal disaccharidse activity. Passage of large, frothy, explosive
and acidic stools. Dehydration, hypernatremia.
Osmotic diarrhea
 Consequences of diarrhea
 Dehydration – Most common and life
threatening. Young children more
susceptible. Depletion of ECF vol, elect
imbalance (< Na & K). First symptom at
loss of 5% body wt. At loss of 10% body wt
– shock…

 Malnutrition – Low intake of food, <ed

nutrient absorption, >ed req due to
infection. Repeated & prolonged –serious
effects, growth failure, intercurrent
infections
Management of diarrhea
Principles of treatment
 General assessment of child
 Assessment of dehydration status & administration
of fluids for prevention & treatment of dehydration
 Correction of elect & acid- base imbalance
 Proper feeding – Provide normal nutritional
requirements
 Treatment of associated problems – Dysentery,
persistent diarrhea
 Nutritional rehabilitation
 Health education
 Assessment of dehydration
Clinical signs No dehydration Some Severe
dehydration dehydration
General condition Well, alert Restless, irritable Lethargic/
unconscious/
floppy
Eyes Normal Sunken Very sunken, dry
Tears Present Absent Absent
Mouth & tongue Moist Dry Very dry
Thirst Drinks normally, Thirst, drinks Drinks poorly, not
not thirsty eagerly able to drink
Skin pinch Goes back quickly Goes back slowly Goes back very
slowly
Dehydration status No signs 2/ more signs + 1 2/ more signs + 1
key sign key sign

Treatment plan Plan A Plan B Plan C

Oral rehydration therapy
(ORT)
 ORS solution of recommended
composition
 Solution made from sugar & salt
 Food based solutions with salt – Lentil
soup, rice kanji, butter milk
 Given along with continued feeding
ORT
 Rapid transport of glucose and Na in small
bowel, with passive absorption of water &
elect even during copious diarrhea
 Optimum absorption of glucose at glucose
conc 111 – 165 mmol/l and Na: glucose
ratio – 1:1 - 1:1.4
 So, the WHO/ UNICEF formula for rapid
rehydration in dehydration
 Used also for maintenance therapy, with
equal amounts of plain water/ breast feeding
Composition of WHO/ UNICEF
recommended Oral Rehydration Salts
(ORS)

Ingredients in gms/l of Conc in mmol/l of

ORS solution water
NaCl 3.5 Na++ 90
KCl 1.5 K+ 20
Cl-- 80
NaHCO3 OR 2.5 HCO3-- OR 30
Trisodium 2.9 Citrate 10
Citrate
Glucose 20.0 Glucose 111
(anhydrous)
Dissolve in 1 liter of clean drinking water
Home made ORS
Prevention and treatment of
dehydration
Management of ‘No’
dehydration – Plan A
 Objective – Prevent dehydration &
malnutrition
 By Mother/ caretaker (advice)
 Give more fluids than normal
 Continue feeding
 Bring to hosp after 2 days, or earlier (if
thirst, high fever, high pulse rte,
excessive vomiting, visible blood in stool,
abd.al distension, poor intake or lethargy)
Guidelines for fluid & electrolytes
replacement - Plan A

Age After each loose stool, offer-

< 6 months Quarter glass or cup (50 ml)
7 months – 1 year Quarter – half glass or cup (50 – 100 ml)
2 – 5 years Half – one glass or cup (100 – 200 ml)
Older children As much as child can take
Choice of fluds – ORS, lemon water, butter milk, rice kanji, lentil
soup, light tea etc.
Management of ‘some’
dehydration - Plan B
 Objective – Treat dehydration & elect imbalance
and continue feeding
 Rehydrated with ORS under supervision of a health
facility
 Correction of dehydration –
 50 – 100ml/kg body wt (av 75 ml/kg) ORS over a period of
4 hrs. Give more if child wants, continue br feed
 Infants <6 months not on br feed – 100 – 200 ml plain
water in addition to ORS
 Older children – Free access to plain water
 Monitor closely – Acceptance of ORS, vomiting , stools,
fever
 Reassess after 4 hrs –
 If still dehydrated, repeat ‘deficit therapy’
and start to other milk/ food.
 If rehydrated, treat as in Plan A
 If ORT not successful, treat as ‘severe
dehydration’ with IV fluids by Plan C
Management of ‘severe’
dehydration – Plan C
 Objective – Quickly rehydrate in
hospital with IV fluids
 Preferred solution – Ringer’s lactate
 If RL not available- N Saline and half
strength Darrow’s solution may be
used
 Deficit fluid therapy -Plan C for
severe dehydration
Age Type of Vol of fluid & duration Monitoring
fluid
Infants Ringer’s 30 ml/kg wt in first hr, Reassess after 1 – 2 hrs
< 1year lactate followed by 70ml/kg wt -If no improvement – IV drip
over next 5 hrs more rapidly
-ORS 5ml/kg/hr, along with IV
fluids as soon as baby can
Children Ringer’s 30 ml/kg wt within ½ hr,
drink
< 1year lactate followed by 70ml/kg wt
over next 2½ hrs Reassess hydration status
After 6 hrs (infants) & 3 hrs
(older children)
Choose appropriate plan – A,B
and C
Feeding during acute diarrhea
and dysentry
 Take optimal advantage of present
intestinal absorption capacity –
 Offer small, freq, energy dense food
 Consider age, pre-illness feeding pattern
an hydration of child
 If no dehydration – continue feeding
 When severe dehydration – Resume
feeding as early as possible
 Feeding during diarrhea
Stage of hydration Recommended schedule of feeding
During rehydration phase -
Beast fed infants Continue breast feeding

Non Breast fed infants Preferably only ORS till rehydrated

If rehydration takes > 4 hrs – Offer animal milk/ food
Severely malnourished children Offer some food as soon as possible

After rehydration phase -

Beast fed infants Breast feed more frequently

Non Breast fed infants Offer undiluted milk as before

Infants 4 – 6 months of age Energy rich rice mixture of soft weaning foods, in additin to breast/
animal milk
Older children Give energy rich food (thick prep of staple food with extra vegetable
oil/ animal fats), rich in K (legumes, banana), carotene (dark green
leafy veg, red palm oil, carrots, pumpkins)
Encourage to eat at least 6 times a day
Antimicrobials
 Carefully evaluate every case for blood in
stools or suspected cholera
 Antimicrobials only for dysentery and
suspected cholera
 Also for associated non GI infection –
pneumonia, septicemia, meningitis, UTI –
especially in infants <3 months and those
with severe malnutrition
Antimicrobials used for specific
causes of diarrhea
Causes Drugs of choice Dose
Cholera Tetracycline 30 mg/day in 4 divided doses x 2 – 3 days
Furazolidine OR 5 mg/day in 4 divided doses x 3 days
Trimethoprim - TMP 5 mg/kg & SMX 25 mg/kg, in 2 divided
Sulfamethoxazole doses x 3 days
Dysentery TMP – SMX TMP 5 mg/kg & SMX 25 mg/kg, in 2 divided
OR doses x 5 days
Nalidixic acid OR 15 mg/kg 4 times a day x 5 days
Ampicillin 25 mg/kg 4 times a day x 5 days
Amoebic Metronidazole 30 mg/kg in 3 divided doses x 5 - 10 days
dysentery
Ac Metronidazole 15 mg/kg in 3 divided doses x 5 days
Giardiasis Tinidazole 10 - 15 mg/kg in 3 divided doses x 5 days
Persistent diarrhea
 Impaired absorption of nutrients
(lactose , other disaccharides)
 Persistent gut infection
 Associated non GI infections
Management of persistent
diarrhea
 Assess hydration status & manage
 Inv stool – pH, reducing substances,
ova or cyst, RBC
 Continue breast feeding. Low lactose
diet for non breast fed babies
 Treat dysentry, if blood visible in stool
 Treat amoebiasis & giardiasis, if cysts
or trophozoites of parasites in stool
Hospitalization
 Indications - <6yrs, dehydration, severe malnutrition,
associated infections, severe lactose malabsorption
 Treat associated infections – URI, ARI, Septicemia..
 Treat persistent infections due to enteropathogens (as
diagnosed)
 Dietary management –
 If lactose malabsorption – Low lactose diet – kheer, dalia, phirni,
yoghurt, khichri
 If no improvement in 2 – 3 days
– Lactose free diet – Khichri with egg inolder children
- Commercial lactose free formula in non breast fed infants<4
months of age
 If still no response -
- Change over to lactose and other disaccharide free feeding
(chicken- glucose puree)
Nutritional rehabilitation
 Focus on catch-up growth – One extra
meal for …
- at least 2 weeks, after acute diarrhea
and
- for 1 month after persistent diarrhea.
Diarrhea training and treatment
units (DTTU) and ORT corners
 In community level - By trained health workers
 Involvement of mothers and caretakers
 Referral services x sos

DTTUs in all hospitals in a phased manner

 Practice & promote std case management of diarrhea (SCMD)
as routine
 Train faculty members ad other health personnel in SCMD
 Train medical students in SCMD
 Educate mothers/ care takers about home management of
diarrhea
 ORT corners for practice and education
Diarrhea prevention
 Improve infant feeding practices
 Improve personal & domestic hygiene
 Exclusive breast feeding upto 4-6 months
 Improved weaning practices
 Clean drinking water
 Sanitary toilets
 Safe disposal of stool of young children
 Measles immunization
ThanQ