Diarrhea in

children(बालातिसार)
By Dr.Hardik H Joshi M.D.Ped(Ayu)
 Diarrhea
• Defined as change in consistency and
frequency of stools, i.e. liquid or
watery stools, that occur >3 times a
day.
• However it is the consistency of the stools
rather than the number that is more
important.
• If stools associated with blood it is termed
as dysentery.

• Frequent passage of normal stool is

not
diarrhoea.
 Classification
• Diarrhoea is classified as
• acute if <2 weeks,
• persistent if 2–4 weeks,
• chronic if >4 weeks
Magnitude of the problem: World
 Diarrhoeal disease is the 2nd leading
cause of death in children under 5 yrs of
age.
 Globally, there are about 3-5 Bn cases of
diarrhoeal disease every yr.
 Diarrhoeal disease kills 2 Mn children
every yr.
 Diarrhea accounts for over 20% of all
deaths in under 5 children.
 It is both preventable and treatable.
Consequences

Malnutrition

Dehydration
Risk Factors
• Poor sanitation & personal hygiene
• Contaminated food & drinking water
• Low rates of BF & immunization
• Malnutrition in younger children (2yr)
• For prolonged episodes
• Selective IgA deficiency
• HIV infection
• C.difficile infection (d/t antibiotic usage)
Etiology
• Viral: 70-80% of infectious diarrhea in
developed countries
• Bacterial: 10-20% of infectious diarrhea
but responsible for most cases of severe
diarrhea
• Protozoan: less than 10%
Viral Diarrhea
• Rotavirus
• Norovirus (Norwalk-like)
• Enteric Adenovirus (serotypes 40 & 41)
• Astrovirus
Summary of Viral Diarrhea
• Most likely cause of infectious diarrhea
• Rotavirus and Norovirus are most common
• Symptoms usually include low grade fever,
nausea and vomiting, abdominal cramps,
and watery diarrhea lasting up to 1 week
• Viral shedding can occur for weeks after
symptoms resolve
• Feco-oral transmis
Bacterial Diarrhea
• Escherichia coli (EHEC,ETEC)
• Shigella
• Vibrio cholera (serogroups O1 &O139)
• Salmonella
• Campylobacter
Summary of Bacterial Diarrhea
• Can affect all age groups
• Fecal-oral transmission, often through
contaminated food & water
• Typical symptoms include bloody
diarrhea,
severe cramping, and malaise
• Antibiotic treatment not always
necessary
Parasitic
• Giardia lamblia
• Cryptosporidium parvum
• Entamoeba histolytica
• Cyclospora cayetanensis
• Isospora belli
Clinical Features
• Mild
• Slightly irritable & thirsty
• Moderate
• More irritable, pinched look, depressed
fontanelle, sunken eyes, dry tongue,
distended abd. urine output at longer
intervals
• Extreme case
• Moribund look, weak and thready pulse,
low blood pressure, reduced urine output
Assessment of Child
• Type of diarrhea
• Look for dehydration
• Assess for malnutrition
• Rule out systemic infection
• Assess feeding
History
• Onset, duration and no.of stools per day
• Blood in stools
• No. of episodes of vomiting
• Associated symptoms
• Oral intake
• Drugs or other local remedies taken
• Immunization history
Physical Examination
• Vitals, vitals, vitals!
• Abdominal exam
• Presence of occult blood
• Signs of dehydration
 Laboratory Evaluation
• Can be managed effectively without lab
investigations
• Stool microscopy in selected situations
like
cholera (darting motion)
giardiasis
(trophozoites)
• Stool culture to decide on
antibiotic
therapy in patients with
shigella dysentery
Principles of Management
4 Major components:
• Rehydration and maintaining hydration
• Ensuring adequate feeding
• Oral supplementation of Zn
• Early recognition of danger signs and
treatment of complications
 INTRODUCTION:
• Dehydration resulting from acute diarrheal illness is one of the most
significant causes of morbidity and mortality in the population.
• In some cases, it accounts for more than 50% of the deaths during
the initial stages of a humanitarian emergency.
• Worldwide, over 3 million children under 5 years die from
dehydration every year. (WHO)

• The use of oral rehydration therapy (ORT) has markedly reduced the
morbidity and mortality associated with dehydration caused by
diarrheal illness regardless of the etiology.
 DEFINITION:
• Dehydration is a condition that can occur with
excess loss of water and other body fluids.
Dehydration results from decreased intake,
increased output (renal, gastrointestinal or
insensible losses), a shift of fluid (eg, ascites,
effusions), or capillary leak of fluid (eg, burns
and sepsis).
 CLASSIFICATION OF DEHYDRATION
SEVERITY BY
WHO
NO DEHYDRATION SOME DEHYDRATION SEVERE DEHYDRATION

Not enough signs to •Two or more of the following •Two or more of the
classify as some or signs: restlessness, irritability following signs:
severe dehydration •sunken eyes lethargy/unconsciousness
•drinks eagerly, thirsty •sunken eyes
•skin pinch goes back slowly •unable to drink or drinks
poorly
•skin pinch goes back very
slowly (≥2 seconds)

National Collaborating Centre for Women's and Children's Health (UK). Diarrhoea and Vomiting Caused by Gastroenteritis: Diagnosis, Assessment and Management in Children Younger
than 5 Years. London: RCOG Press; 2009 Apr. (NICE Clinical Guidelines, No. 84.) 4, Assessing dehydration and shock.
 Degree of Dehydration
Factors Mild Moderate Severe
Older Child Older Child Older Child
3% (30ml/kg) 6% (60ml/kg) 9% (90ml/kg)
Infant Infant
5% (50ml/kg) Infant 15% (150ml/kg)
10% (100ml/kg)

General Condition Well, alert Restless, thirsty, irritable Drowsy, cold extremities, lethargic

Eyes Normal Sunken Very sunken, dry

Anterior fontanelle Normal depressed Very depressed

Tears Present Absent Absent

Mouth + tongue Moist Sticky Dry

Skin turgor Slightly decrease Decreased (1-2 sec) Very decreased (>2sec)

Thirst Normal Drinks eagerly, thirsty Unable to drink or drinks poorly

Pulse (N=110-120 Slightly increase Rapid, weak Rapid, sometime impalpable

beat/min)
BP (N=90/60 mm Hg) Normal Deceased Deceased, may be unrecordable

Respiratory rate Slightly increased Increased Deep, rapid

Urine output Normal Reduced Markedly reduced

Treatment Plan A Plan B Plan C

 Management of Dehydration
• General Principles:

1. Supply Maintenance Requirements

2. Correct volume and electrolyte deficit

3. Replace ongoing abnormal losses

 Ongoing Losses
• Regardless of the degree of dehydration,
give additional 10ml/ kg of ORS for each
additional diarrheal stool.
 Severe Dehydration
• Management of severe dehydration requires
IV fluids.
• Choice of fluid: Normal saline(NS) or Ringer
Lactate (RL)
• Fluid selection and rate should be dictated
by
• The type of dehydration
• The serum Na
• Clinical findings
• Aggressive IV NS bolus remains the mainstay
of early intervention in all subtypes
Monitoring Therapy
• Vital signs:
– Pulse
– Blood pressure
• Intake and output:
– Fluid balance
– Urine output
• Physical examination
– Weight
– Clinical signs of depletion or overload
• Electrolytes
WHO TREATMENT PLANS
 Plan A (No Dehydration)

Oral rehydration therapy to prevent Dehydration

Age ORT fluids to give
Amount of ORS to after each
loose stool provide for use at
home

< 24 months 50 - 100 ml 500 ml/ day

2 – 10 years 100 – 200 ml 1000 ml/ day
> 10 years Ad lib 2000 ml/ day
Give Supplemental Zinc (10-20 mg) to the child, everyday for 10 to 14 days
 Plan B(Some Dehydration)

1. Daily fluid requirement:

– Up to 10 kg = 100 ml/ kg
10 – 20 kg = 50 ml/ kg
> 20 kg = 20 ml/ kg

2. Deficit replacement:
75 ml/ kg ORS to be given over 4 hours

3. Replace losses:
ORS should be administered in volumes
equal to diarrheal losses. Maximum of 10
ml/ kg per stool.

4. Give Supplemental Zinc (20 mg) to the

child, everyday for 10 to 14 days
 Plan C (Severe Dehydration)
• Treated with 20 mL/ kg IV of isotonic
crystalloid over 10 to 15 minutes. Repeat as
necessary.
• Monitor pulse strength, capillary refill time,
mental
status, urine output and electrolytes.
• After resuscitation: A total of 100 ml/ kg of fluid
given over 3 hours in children > 12 months
and over 6 hours in children < 12 months.
• Assess the
Age patient every 3 hours accordingly
30 ml/ kg 70 ml/ kg
repeat <Plan C or shift1 hour
12 months to Plan B 5 hour
> 12 months 30 min 2 ½ hour
 ORS

STANDARD WHO ORS LOW OSMOLARITY ORS

Constituent g/ Osmole / ion mmol/ L Constituent g/L Osmole/ion mmol/L
L
Sodium 2.6 Sodium 75
Sodium 3.5 Sodium 90 chloride
chloride
Glucose 13.5 Glucose 75
Glucose 20 Glucose 111 Potassium 1.5 Potassium 20
Potassium 1.5 Potassium 20 chloride
chloride Trisodium 2.9 Citrate 10
Trisodium 2.9 Citrate 10 citrate
citrate Chloride
Chloride Total
65 245
Total
80 311 Osmolarity
Osmolarity
 Other types of ORS
• Zinc fortified ORS
• ORS fortified with amino acids.
• Home made ORS
– 4g salt + 40g sugar in 1 L of water
 Contraindications to ORT

• Ileus or intestinal obstruction

• Unable to tolerate (Persistent vomiting)
 Home available fluids
Acceptable Home available Fluids
Fluids that contain Salt (Preferable) ORS, Salted drinks (Salted rice water/
salted yogurt drink), vegetable or chicken
soup with salt

Fluids that do not contain salt Plain water, water in which cereal has
(Acceptable) been cooked, unsalted soup, yogurt
drinks without salt, green coconut water,
weak unsweetened tea, unsweetened
fresh fruit juice

Unsuitable home available fluids Commercial carbonated beverages,

commercial fruit juices, sweetened tea.
Early Refeeding
• Luminal contents help promote growth of
new enterocytes and facilitate mucosal
repair
• Can shorten duration of the disease
• Lactose restriction is not necessary except
in severe disease
Oral Zn Supplementation
• 3-6 months 10mg daily x 2 weeks.
• >6 months 20mg daily x 2 weeks.
Danger signs
Prevention
• Keep your hands clean
• Boiling water
• Wash fruits and vegetables
• Refrigerate and cover food
• Eat well-cooked foods
Contd…
• Rotavirus and measles vaccination
• Early and exclusive breastfeeding
• Vitamin A supplementation
• Promotion of hand washing with soap
• Improved drinking
water supply and safe storage of
household food & water
• Community-wide sanitation promotion
 बालाति
सार
गुदेन् बहुद्रवसरणमतिसारः
Excess mala nirharan from guda that only known as
अतिसार when it happen to bala that is known as
बालातिसार
 पु
र्व
रुप
ह्यन्नाभिपायूदरकुक्षितोदगत्रावसादानिल
सन्निरोधाः |
विट्सङ्ग आध्मानमथविपाको भविष्यतस्तस्य
पुरःसराणि || मा.नि.3/5

Pricking pain at heart,nabhi, guda, udara,

and kukshi
अधोवायुअवरोध
अन्गशिथिलता
मलप्रवृति अभाव
आध्मान
Indigestion of food
प्रकार & its
1. सामान्य अतिसार
रूप 1. वातातिसार
2. पैतिक अतिसार
3. कफज अतिसार
4. त्रिदोषज अतिसार
5. रक्तातिसार
6. ज्वरातिसार
7. आगन्तुज अतिसार
8. आमातिसार
9. प्कवातिसार

2. बालातिसार
वातातिसार
अरुणं फेनिलं रूक्षमल्पमल्पं
मुहुर्मुहुः |
शक्रुदामं सरुक्शब्दं
मरुतेनातिसार्यते || मा.नि.

Stool comes out with sound and pain which

is अरुणं in colour with foam and रूक्ष
in nature which comes out frequently within
small amount.
पैतिक अतिसार
पित्तात्पीतं
निलमालोहितं वा
तृष्णामुर्छादाहपाकोपप
न्नम् | मा.नि.
In पैतिक अतिसार stool is of yellowish-green in colour
or reddish colour patient suffers with associated symptoms
like
तृष्णा
मूर्छा
सर्वान्गदाह
गुदपाक
कफज अतिसार
शुक्लं सान्द्रं शलेषमणा
श्लेष्मयुक्तं विस्त्रं शीतं
ह्यष्टरोमा मनुष्यः |
मा.नि.
In कफज अतिसार stool is whitish coloured associated with thick
in consistency , कफयुक्त , दुर्गन्धि and शीत

Patient suffers from रोमहर्ष

त्रिदोषज अतिसार
वराहस्नेहमाम्साम्बुसद्रुशं
सर्वरुपिणम् |
क्रुछसाध्यमतिसारं
विधाद्दोशत्रयोद्भवम् || मा.नि.
In त्रिदोषज अतिसार stool looks like fate of pig, or
water mixed with mamsa (मांसधोवन )

This type of अतिसार is कृच्छसाध्य

 रक्तातिसार
पित्तकृन्ति यदाऽत्यर्थ
द्रव्याण्यश्नाति पैतिके |
तदोपजयतेऽभिक्ष्णं
रक्तातिसार उल्बणः || मा.नि.
 When patient is suffering from पैतिक अतिसार and
the if patient indulge with पैतिक आहार विहार then
he suffers from very dangerous and difficult to treat
रक्तातिसार

 Stoll is looks like blood only or reddish-yellow in colour

and there is symptoms of पैतिक अतिसार also
visible in this type of patient
ज्वरातिसार
ज्वरातिसारयोरुक्तं निदानं
यत् पृथक् पृथक् |
तत्स्याज्ज्वरातिसारस्य तेन
नात्रोदितं पुनः || मा.नि.
There is diffract nidanas for jvara and atisara when
patient indulge with both nidana then he suffers from
ज्वरातिसार
आगन्तुज अतिसार
आगन्तु द्वावतिसारौ मानसौ
भयशोकजौ |
ततयोलंक्षणं
वायोर्यदतीसारलक्षनम् ||
च.चि.19/24
According to आचार्य चरक there is mainly two type of
आगन्तुज अतिसार they are भयाज and शोकज

Bothe are associated with मानस भाव

लक्षण of all आगन्तुज अतिसार are same as वातज

अतिसार
आमातिसार
आमाजिर्णोपद्रुताः क्षोभयन्तः
कोष्ठं दोषाः संप्रदुष्टाः
साभाक्तम् |
नानावर्ण नैकशः सारयन्ति
क्रुच्छाज्जन्तो: षष्ठमेनं वदन्ति ||

सु.उ.40/16
In आमातिसार when pachana of anna does not accurse then
doshas got elivated in kustha and it produce dusana to raktadi
dhatu and mala and produce different coloured stool which is
comes out with pain and repeatedly that is आमातिसार

आमातिसार is कृच्छसाध्य
प्कवातिसार
संस्रुष्ठमेभिर्दोषैस्तु
न्यस्तमप्स्ववसीदति |
पुरीषं भृशदुर्गन्धि विच्छिन्नम्
चामसंज्ञकम् ||

एतान्ये व तु लिङ्गानि विपरीतानि

यस्य तु |
लाघवञ्च मनुष्यस्य तस्य पक्वं
विनिर्दिशेत् ||
सु.उ.40/17-18
When there is no लक्षण of आममल seen and patient feel
free after malanirharana that is known as प्कवातिसार
बालातिसार
क्षिरदोशज बालग्रह व्यधिजन्य अन्य
न्य कारनजन्य

पैतिक नागमैष विभिन्न म्रुतिकाभ

क्षिरदोष पितृग्रह व्यधि क्शन जन्य
त्रिदोषज शकुनिग्रह उपद्रव त्रास जन्य
वैवर्ण्य पुतना ग्रह उत्फ़्फ़ुल् दन्तोद्भेद
पारिगर्भिक शितपुतना लिका जन्य
ग्रह क्रुमि
अन्धपुतना तालुकन्तक
रेवतिग्रह
सुश्करेवति
ग्रह
सामान्य
सम्प्राप्ति
सम्शम्यपां धातुरग्निं प्रवृध्दः
शक्रुन्मिश्रो वयुनाऽधः प्रणुन्नः
सरत्यतिवातिसरं तमाहुर्व्याधिं धोरं
षड्विधं तं वदन्ति || मा .नि.3/4
When increase jaliya dhatu decreased pachakangni and got
mixed up with mala whith the help of prakupita vayu it comes out
from guda marga this type of bhyankar vyadhi known as atisara
 चिकि
चिकित्सात्सा
सिद्धान्त
1) निदान परिवर्जन
2) in सामावस्था - first दीपन पाचन with
बालचतुर्भद्र , लवन्भास्कर चूर्ण ,
3) in निरामवस्था - गङ्गाधर चूर्ण , कर्पूर रस etc
4) लघुसंशोधन
5) पोषक युष is use full as पानक
औषधि विवेचन
in रावणकृत कुमर्तन्त्र there is many योग are explained

बिल्वं च पुष्पाणि च धातकिनां जलं सलोध्रं

गजपिप्पली च |
क्वथोടवलेहो मधुना विमिश्रो बालेषु योज्यः
कटीधारितेषु ||

We can use kwath or avaleha of bilva, dhataki pushpa,

sugandhbala,lodra and gajapipali for katidharana in Balatisara.

काकोली गजकृष्णा च लोध्रमेषं समांशतः |

क्वथो मध्यान्वितः पितो बलातिसार हन्मतः||

Take equal part of kakoli, gajakrushna, and lodhra, make kwath

of it and use with honey for the treatment of Balatisara
लाजा सैन्धवमांरास्थिचुर्णमेषां
समांशतः |
हन्ति छर्दिमतिसारं मधुना सह भक्षितम् ||

Take laja , saindhava and aamaraasthi make churna and

use with honey for chardi and atisara in children

आम्रबिजं तथा लोध्रं धात्रिफलरसं तथा |

पीत्वा महिषतक्रेण बालातिसारनाशनम् ||

Amrabija, lodhra and dhataki rasa is helpful with mahish

takra in balatisara

समङ्गाधातकीलोध्रसारिवाभिः श्रुतं
जलम् |
दुर्धरेडपि शिशोर्देयमतिसारे
समक्षिकम् || यो.र.बा.रो.चि.पृ.441


घनक्रुष्णारुणाश्रुन्गिचुर्णं
क्षौद्रेण संयुतम् |
शिशोर्ज्वरातिसारघ्नं कासं श्वासं वमिं
हरेत् || यो.र.बा.रो.चि.पृ.441

Nagmotha ,karkatshrungi, pipali, atisha mixed all in equal

quantite make churna out of it and use it with honey for
removal of jwaratisara, kasha,swasha, vamana(in bhiajya
ratnavali it is known as balachaturbhadrachurana)

 चूर्ण - धातक्यादि चूर्ण ,

बालचातुरभद्र चूर्ण , लवङ्गचतुःसम
चूर्ण , दाडिमचतुःसम चूर्ण
 क्वाथ -धातक्यदि , कर्करादि
 घृत - चाङ्गेरी घृत
 लेह- बालकुटजावलेह, लवङ्गचतुःसम
अवलेह , धातक्यादि अवलेह
