Management of
Diarrhoea in
Paediatric Population
By
Emulo Mampare
Presentation Layout
Definition
Epidemiology
Cause
Complications
Management
Prognosis
Definition
The passage of unusually loose or watery stools, usually at least
three times in a 24 hour period.
However, it is the consistency of the stools rather than the number
that is most important.
Neonate can pass ~10 stools in 24hrs
Clinical types
acute watery diarrhoea which lasts several hours or days(usually
less then 7 day ,but must be less then 14 days)
Dysentery, which is acute bloody diarrhoea
persistent diarrhoea, which lasts 14 days or longer(Start as AWD)
Chronic diarrhoea, which last a month or more
Epidemiology
Diarrhoeal diseases are a leading cause of childhood
morbidity and mortality in developing countries,
and an important cause of malnutrition (esp.
dysentery and PD respectively).
On average, children below 3 years of age in
developing countries experience three episodes of
diarrhoea each year.
Causes
INFECTIOUS Bacterial
Viral (mostly) E coli species
Rotavirus (40 to 80%) Shegella (flexneri and
Norwalk virus, dysenteriae)
Campylobacter jejuni
Calcivirus,
Salmonela
Adenovirus
Vibrio cholera
Fungal
Protozoa
Cryptosporidium
Entamoeba histolytica
Giardia
Causes
Food allergy
Inflammatory bowel diseases (i.e., UC & CD)
Drugs
Pseudomembranous colitis(antibiotic associated)
Metformin, laxatives, etc.
Celiac disease
Lactose intolerance
Complications
Acute watery diarrhoea: Hypovolemic shock, pre-
renal renal failure, electrolyte imbalances.
Dysentery: intestinal mucosal damage(Perforation,
volvulus) severe sepsis, renal failure(HUS),seizure
(Toxin related), malnutrition
Persistent diarrhoea: Severe malnutrition, serious
non-intestinal infection
Diarrhoea with severe malnutrition (PEM): severe
systemic infection, dehydration, heart failure, death.
Management
A child with diarrhea should be assessed for
dehydration, bloody diarrhoea, persistent diarrhoea,
malnutrition and serious non-intestinal
infections(through hx. & PE), so that an appropriate
treatment plan can be developed and implemented
without delay.
Management cont…
MINIMUM/ MODERATE(3- SEVERE (>10%)
NONE (<3%) 9%)
Mental status* Well; alert Normal, fatigued Apathetic,
or restless, lethargic,
irritable unconscious
Thirst* Drinks normally; Thirsty; eager to Drinks poorly;
might refuse drink unable to drink
liquids
Skin turgor* Instant recoil Recoil in <2s Recoil in >2s
Eyes Normal Slightly sunken Deeply sunken
Tears Present Decreased Absent
Capillary refill Normal Prolonged Prolonged and
Minimal
Mild/minimum or no
dehydration
Home-based(educate caregiver)
Rule 1: Give 10ml/kg of ORS for each diarrhoeal
stool or vomiting episode to replace on-going losses
If weight not known, give as follows:
50-100ml for children <2 year;
100-200 ml for children 2-10 years and;
children above 10 years should get as much as they can.
NB: Do not give commercial carbonated beverages,
commercial fruit juices, coffee, sweetened tea and
medicinal tea.
Mild/minimum or no
dehydration
Rule 2: Continue breastfeeding or resume normal diet after initial
rehydration
Exclusively breastfeed or formula feed < 6 months and
complementary feeding after 6 months
A cup or spoon, instead of a bottle, should be used in formula
fed children
Feed at 3-4hrs intervals
Rule 3: Give zinc sulphate (10-20mg) for 10-14 days (start zinc after
vomiting stop)
Rule 4: Take the child to a health worker if there are signs of
dehydration or other problems (e.g., persistent vomiting, lethargy,
seizure)
Moderate dehydration
Treatment is hospital-based
Give ORS 75ml/kg over 3-4 hours to rehydrate
if the weight is not known, use table below to estimate
the amount of ORS solution needed for rehydration
Age* <4 4-11 12-23 2-4 yrs 5-14 yrs >14 yrs
months months Months
Volume 200 – 400 – 600 – 800 – 1200 – 2200 -
(ml) 400 600 800 1200 2200 4000
Moderate dehydration
cont…
Monitor the progress of oral rehydration therapy
(ORT)
If signs of over-hydration (oedematous eyelids)
develop stop ORT and continue feeds
If the child is still moderately dehydration repeat the
ORT and;
If dehydration status worsens despite the ORT treat
the child as severely dehydrated.
Moderate dehydration
cont…
Replace on-going loses as in treatment for children
with minimum/mild dehydration
Continue feeding 3-4hrly after initial rehydration
(i.e., after 4hrs of rehydration)
Breastfeeding should not be stopped for initial
rehydration
Start zinc sulphate 10-20mg/day, initial rehydration
or after vomiting has stopped, for 10-14 days
Severe dehydration
The child must be admitted to hospital
Rehydrate with 100ml/kg RL {or NS+30-40mg KCL (KCL is
added after the first litre) , in case of diarrhoea + vomiting}
divided as
IV in boluses of 30ml/kg over 1 hour followed by 70ml/kg over 5
hours for infants less than 12 months or
IV in boluses of 30ml/kg over 30 minutes followed by 70ml/kg
over 2.5 hours for children over 12 months
Bolus of 30ml/kg may be repeated if radial pulse is still very
weak or undetectable and mental status is not improved
NB: Children who can drink, even poorly, should be given ORS
solution by mouth until the IV drip is running
Management cont…
severe dehydration
Replace on-going losses ORS, if unable to drink give
through NG tube or administer ½ DD IV
Continue normal feeding 3-4hrly after initial
rehydration
Start zinc sulphate 10-20mg/day for 10-14 days
Management
NOTE
Antibiotics should only be given in cases of dysentery, children <6
months, severe suspected extra-intestinal infection, cholera and
malnutrition
Oral cotrimoxazole or nalidic acid
IV cefotaxime
Macrolides for campylobacter jejuni
Metronidazole or vancomycin for C difficile
Stool M/C/S should be done for every patient during hospital
admission
Blood M/C/S may be done in cases of dysentery where extra-intestinal
infection is suspected
Serum electrolytes in cases of suspected imbalances
Management
The treatment of diarrhea for HIV positive children
is generally the same as for HIV uninfected children,
although lactose and monosaccharide intolerances
are more frequently present in these children.
Anti-diarrhoeal drugs have no role in management
of diarrhoea
Prognosis
Many diarrhoeal deaths are caused by dehydration.
Dehydration from acute diarrhoea of any aetiology
and at any age, except when it is severe, can be safely
and effectively treated in over 90% of cases by the
simple method of oral rehydration using a single
fluid.
Reference
World Health Organization. (2005).The Treatment of
diarrhoea : a manual for physicians and other senior
health workers. -- 4th rev.
PMH ( August 2012). Paeds protocol
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