DIARRHEA

by Harold Rugnao

ESSENTIAL CONCEPTS OF DIARRHEA

DIARRHEA passage of unusually loose or watery stools, at least 3x in a 24 hr period CLINICAL TYPES OF DIARRHEA Acute watery diarrhea Acute bloody diarrhea Persistent diarrhea Diarrhea with severe malnutrition

ESSENTIAL CONCEPTS OF DIARRHEA

Dehydration Deficit of water and electrolyte Malnutrition
Zinc Deficiency Use of antimicrobials and anti-diarrheal drugs

Important Microbial Causes of Acute Diarrhea in Infants and Children

Rotavirus Escherichia Coli
Enterotoxigenic Localized adherent

Campylobacter jejuni
Vibrio cholerae 01 and

Diffuse Adherent
Enteroinvasive Enterohemorrhagic

Shigella

0139 Salmonella Giardia duodenalis Entamoeba histolytica Cryptosporidium

ASSESSMENT OF CHILD WITH DIARRHEA

1.
2. 3. 4.

History Physical Exam Determine Degree of Dehydration and select treatment plan Diagnose other important problems

ASSESSMENT OF DIARRHEA PATIENTS FOR DEHYDRATION

A LOOK AT: CONDITION EYES THIRST Well, alert Normal Drinks normally, not thirsty B Restless, irritable Sunken Drinks eagerly, thirsty goes back slowly SOME SIGNS OF DEHYDRATION C Lethargic or unconscious Sunken Drinks Poorly or not able to drink goes back very slowly SEVERE SIGNS OF DEHYDRATION

FEEL: DECIDE

SKIN PINCH Goes back quickly NO SIGNS OF DEHYDRATION Use treatment plan A

TREAT

Weigh the patient, use Treatment Plan B

Weigh the patient, use Treatment Plan C URGENTLY

ESTIMATED FLUID DEFICIT

Assessment
No signs of dehydration

Fluid deficit as Fluid deficit in %of body wt ml/kg body wt

<5% < 50ml/kg

Some dehydration 5 10 % Severe dehydration >10%

50 100 ml/kg >100 ml/kg

Management of Acute Diarrhea (without blood)

Objectives: Prevent dehydration, if there are no signs of dehydration Treat dehydration, when it is present Prevent nutritional damage Reduce the duration and severity of diarrhea and the occurrence of future episodes

Plan A Treat Diarrhea at Home

1.

GIVE EXTRA FLUID

TELL THE MOTHER

Breastfeed frequently and for longer at each feed If the child is exclusively breastfed, give ORS or clean water in addition to breastmilk If the child is not exclusively breastfed give one or more of the following: ORS, food base fluids, or clean water Home made solution: 3g/l of table salt (one level tspful) and 18g/l of common sugar

TEACH THE MOTHER HOW TO MIX ORS

 SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN

ADDITION TO THE USUAL FLUID INTAKE

Up to 2 years

50 to 100ml after each loose stool 2 years or more 100 to 200 ml after each loose stool Oldre children as much fluid as they want

Tell the mother to

give frequent small sips from a cup If the child vomits, wait 10 mins. Then continue, but more slowly Continue giving extra fluid until the diarrhea stops

2.
-

GIVE SUPPLEMENTAL ZINC

10 20mg to the child everyday for 10 14 days

3.
-

CONTINUE FEEDING
To prevent malnutrition

4.
-

TAKE THE CHILD TO A HEALTH WORKER IF THERE ARE SIGNS OF DEHYDRATION OR OTHER PROBLEMS
Starts to pass many watery stools Repeated vomiting Becomes very thirsty Eating or drinking poorly Develops fever Blood in the stool Child does not get better in 3 days

Plan in Treat Some Dehydrationof ORS over 4Give B clinic recommended amount with ORS
hour period DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
*AGE
WT

Up to 4 mos 4 mos up to 12 mos to 2 2 yrs to 5 12 mos yrs yrs

< 6 kg 6 < 10 kg 10 <12 kg 12 19 kg

In ml

200 400

400 700

700 900

900 1400

*Use the childs age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the childs weight (in kg) times 75

 AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS

*AGE
Up to 4 mos
< 5 kg

4 mos up 12 mos to 11 to 23 mos mos

5 7.9 kg 400 700 8 10.9 kg 700 900

2 yrs to 4 5 14 yrs yrs

15 yrs or older

WT

11 15.9 16 29.9 30 kg or kg kg more 900 1400 1200 2200 2200 4000

In ml

200 400

 *Use the childs age only when you do not know the weight. The

approximate amount of ORS required (in ml) can also be calculated by multiplying the childs weight (in kg) times 75
for infants under 6 mos who are not breatfed, if using the old

WHO ORS solution containing 90mmol/L of sodium also give 100-200ml clean water during this period. However if using the new reduced (low) osmolarity ORS solution contining 75mmol/L of sodium, this is not necessary
For infants under 6 mos who are not breastfed, also give 100

200 ml of clean water during this period

If the child wants more ORS than shown, give more Note: during initial stages of therapy, while still dehydrated

adults can consume upto 750ml/hr if necessagry, children up to 20ml/kg/hr

 SHOW THE MOTHER HOW TO GIVE ORS

SOLUTION
AFTER 4 HOURS Reassess the child and classify the child for dehydration Select the appropriate plan Begin feeding the child MEET NORMAL FLUID NEEDS

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT

Show her how to prepare ORS Show her how much ORS to give to finish the 4-hour treatment at home Give her enough ORS packets to complete hydration Explain the 3 rules of HOME TREATMENT
1.
2. 3.

Give extra fluid Continue feeding When to return

 WHEN ORAL REHYDRATION FAILS Continuing rapid stool loss (>1520 ml/kg/hr) Insufficient intake of ORS owing to fatigue or lethargy Frequent, severe vomiting
GIVING ZINC GIVING FOOD

Treatment Plan C for patients with severe dehydration 1. GUIDELINES FOR INTRAVENOUS
REHYDRATION

Give 100ml/kg Ringers Lactate Solutiona divided as follows:

Age

First give 30ml/kg in:

Then give 70ml/kg in:

Infants (under 1 hourb 12 months) Older 30 minutesb

5 hours
2 hours

Reassess the patient every 1 2 hrs. If hydration is not improving, give the IV drip more rapidly After 6 hrs (infants) or 3 hrs (older patients), evaluate patient using the assessment chart. Then choose the appropriate Treatment Plan a if Ringers Lactate Solution is not available, nomal saline may be used b Repeat once if radial pulse is still very weak or not detectable

2. MONITOR THE PROGRESS OF INTRAVENOUS REHYDRATION 3. ELECTROLYTE DISTURBANCES

Hypernatremia

Serum Na > 150mmol/L Can cause convulsions

Hyponatremia

Serum Na < 130mmol/L Lethargy, less often, seizures

Serum K+ <3 mmol/L Muscle weakness, paralytic ileus, impaired kidney function and cardiac arrhythmia

Hypokalemia

Management of Suspected Cholera from acute diarrhea of other causes in 3 Cholera differs
ways:
It occurs in large epidemics that involve both children

and adults Voluminous watery diarrhea may occur, leading rapidly to sever dehydration with hypovolemic shock For cases with sever dehydration appropriate antibiotics may shorten the duration of the illness

Antimicrobial Therapy

Management of Acute Bloody Diarrhea (Dysentery)

Shigella is the most common cause of bloody diarrhea
Ciprofloxacin for 3 days

Out Patient Management of Bloody Diarrhea

CHILD WITH LOOSE STOOLS WITH BLOOD REFER TO HOSPITAL

SEVERELY MALNOURISHED?
No
Yes

GIVE ANTIMICROBIAL FOR SHIGELLA COMPLETE 3 DAYS TREATMENT

BETTER IN 2 DAYS?
No Yes

INITIALLY DEHYDRATED AGE< 1Y/O OR MEASLES IN PAST 6 WEEKS

Yes

REFER TO HOSPITAL

CHANGE TO SECOND ANTIMICROBIAL FOR SHIGELLA b COMPLETE 3 DAYS TREATMENT

BETTER IN 2 DAYS?
Yes

No

REFER TO HOSPITAL OR TREAT FOR AMOEBIASIS

Management of Persistent Diarrhea Persistent Diarrhea

Diarrhea, with or without blood, that begins acutely and lasts at

leat 14 days. Usually associated with weight loss, and often, with serious non-intestinal infections

Objective of treatment is to restore weight gain and normal intestinal function by:
Appropriate fluids to prevent or treat dehydration
A nutritious diet that does not cause diarrhea to worsen Supplementaryvitamins and minerals Antimicrobials to treat diagnosed infections

 Treat in the Hospital: Children with serious systemic infection Children with signs of dehydration Infants below 4 months of age
Prevent or treat dehydration Identify and treat specific infections Give a nutritious diet Give supplementary multivitamins and minerals Monitor response to treatment

Management of Diarrhea with Severe Malnutrition

Assess for Dehydration
Manage Dehydration Feeding Use of antimicrobials

Other Problems Associated with Diarrhea

Fever
Convulsions Vitamin A deficiency

Prevention of Diarrhea
Breastfeeding
Improved feeding practices Use of safe water Handwashing Food safety Use of latrines and safe disposal of stools Measles immunization