SPM PROJECT

CSC PRESENTATION PROFOMA

CASE: ACUTE DIARRHOEAL DISESES

 NAME:
 AGE:
 SEX:
 ADDRESS:
 INFORMANT:
 CHIEF COMPLAINTS:
 Vomiting and loose stools for the past 1 day.

(Must know definition of diarrhea: passage of 3 or more episodes of loose or liquid stools
in 24 hours)

 HISTORY OF PRESENTING ILLNESS :

The patient was apparently normal until the day before symptoms
appeared when he/she developed vomiting after intake of food/drinks.

H/O VOMITING

1. Time of Onset:

2. Nature of Onset: (Insidious/progressive)

3. Duration:

4. Frequency (how many times):

5. Blood stained or bile stained:

 6. Projectile or Non projectile:

7. H/o hematemesis:

8. Evolution or progression over time:

9. Aggravating and relieving Factors:

10. Diurnal variation:

VOMITING

Fever + abdominal cramps + vomiting and blood and mucus in stools-

bacterial infection.

Diarrhoea with excessive vomiting more than 1 member of household or with

history of consumption of outside food or travel suggestive of FOOD
POISONING

Rice water stools with vomiting E.Coli

H/O LOOSE STOOLS

1. Time of Onset:

2. Nature of Onsetssss: (Insidious/progressive)

3. Duration

Acute: < 1-2 weeks

Persistent: >2 weeks - <3 weeks
Chronic: > 3 weeks
4. Frequency (how many times):

5. Blood stained or bile stained:

(Blood in stools indicates dysentery)

Fever + abdominal cramps + vomiting and blood and mucus in stools - bacterial
infection.
Chronic diarrhea with blood and mucus in stools but no fever : Ameobiasis

6. Projectile or Non projectile

7. Evolution or progression over time:

8. Aggravating and relieving Factors:

9. Diurnal variation:

10. Consistency: watery

Watery after consuming milk and milk products associated with flatulence and
perianal excoriation-lactose in tolerance profuse diarrhoea

Rice water stools for more than 5 to 7 days ) : Cholera

11. amount- scanty

12. color - yellow

13. H/o fowl smelling odor:

14. Size of bulk:

15. Presence of mucus in stools : bacterial infection or ameobiasis

H/O ABDOMINAL PAIN

1. Time of Onset:

2. Nature of Onset: (Insidious, progressive or gradual)

3. Duration:

4. Evolution or progression over time:

5. Aggravating and relieving Factors:

6. Diurnal variation:

7. Site of pain:
 8. Radiation of pain: (Radiating or non-radiating)

9. Type of pain: (Shooting, Stabbing, Pricking, and Throbbing)

Fever + abdominal cramps + vomiting and blood and mucus in stools - bacterial
infection.

H/O ABDOMINAL DISTENTION

1. Time of Onset:

2. Nature of Onset: (Insidious, progressive or gradual)

3. Duration:

4. Aggravating and relieving factors:

5. Evolution over time:

6. Diurnal variation:

H/O FEVER

1. Time of Onset:

2. Nature of Onset: (Insidious, progressive or gradual)

3. Duration:

4. Aggravating and relieving factors:

5. Evolution over time:

6. Diurnal variation:

Low grade fever + diarrhea + no mucus in stools suggestive of viral infection

Fever + abdominal cramps + vomiting and blood and mucus in stools- bacterial
infection
H/O WORMS IN STOOL

Ascariasis is onr of the most commonly seen intestinal worm in the stools
due to their infection.

Heliminths like trichuris, schistosomas, ancylostoma .etc are seen in the

stools .

To find whether child is dehydrated or not this helps in course of

treatment

We ask the following histories:-

H/O LETHARGY

1. Time of Onset:

2. Nature of Onset: (Insidious, progressive or gradual)

3. Duration:

4. Aggravating and relieving factors:

5. Evolution over time:

6. Diurnal variation:

H/O CONVULSIONS

1. Time of Onset

2. Nature of Onset: (Insidious, progressive or gradual)

3. Duration:

4. Aggravating and relieving factors:

5. Evolution over time:

6. Diurnal variation:
 7. Frequency:

8. Type:

H/O REFUSAL OF FOOD

H/O INCESSTANT CRYING

H/O OLIGURIA

1. Time of Onset:

2.Nature of Onset: (Insidious , progressive or gradual)

3. Duration:

4. Aggravating and relieving factors:

5.Evolution over time:

6. Diurnal variation:

H/O LOSS OF WEIGHT

H/O LOSS OF APPATITE

 PAST HISTORY

H/O previous hospitalization: yes /no

H/O similar episodes/recurrent ADD: yes / no
H/O exanthematous fever: yes / no

 CONTACT HISTORY
 H/O similar episodes in neighborhood: yes / no

It is useful to find endemic / epidemic diseases like typhoid and choler

that may emerge anytime
This helps in taking preventive measures and in the course of
management

 TRAVEL HISTORY

Consumption of street food or other contaminated food leads to food

poisoning …. It’s a common cause of diahhorea

 BIRTH HISTORY

Antenatal history
Booked and immunized: yes/no
Immunization status of mother:
TT: taken/not
Iron folic acid tablets: taken/not
H/O Gestational diabetes mellitus (GDM): yes/no
H/O pregnancy induced hypertension (PIH): yes/no
Preeclampsia and eclampsia:

Intranasal history
Male or female baby:

Birth weight of the baby:

Whether the baby cried immediately after birth:

Whether breast fed within one hour:

Postnatal history
 Any postnatal complication:

Any NICU admission:

Whether exclusively breast feeding for 6 months:

When weaning did start:

 DEVELOPMENTAL HISTORY

Milestones attainted to age or not

Growth: normal / not
Socio-personal development:
Motor development:
Language development:
Adaptive development:

 IMMUNIZATION HISTORY

Whether the child is immunized up to age: yes/no

At birth - BCG, OPV (0 dose),

 At 6, 10, 14 weeks -hepatitis B Pentavalent vaccine (DPT, Hepatitis B,
Hemophilus influenza type B), OPV (1st, 2nd and 3rd doses), Rotavirus vaccine
(1st , 2nd and, 3rd doses )

At 9 months -Measles vaccine (M/MR) (first dose) and vitamin A.

Immunization status:
(not immunized/partially immunized/completely immunized)

ROTA VACCCINE

Rota vaccine is a vaccine used to protect against roto virus infections , which
are the leading cause of severe diarrhoea among young children.

NATIONAL IMMUNIZATION SCHEDLE

  DIET HISTORY

Exclusively breast feeding for 6 months with water occasionally.

Feeding of soft solid food started after 6 months.

According to 24hrs recall method.

s.no Item Time K cal Protiens

1
2
3
Total

Required calorie intake =

Total calories intake =

Calorie deficit =

Calorie value of some basic foods

Protein value of some food items

  FAMILY HISTORY

Relevant family history: yes/no

S.NO NAME AGE RELATION EDUCATION OCCUPATION INCOME

1
2
3

No of Adults:

No of children:

Type of family: Nuclear/joint/3 generation

TYPES OF FAMILY
 1. Nuclear family
Nuclear or elementary family consists of married couple and their
children.
2. Joint family
Joint or expanded family consists of a number of married couple and
their children who live together in the same house hold
3. Three generation family
Consists of representatives of three generations where young couple
live with their parents and have their own children.

Composition of family
No of members :
Head of family :
Total annual income of the Family :
Per-capita income :
Socioeconomic status :

According to modified kuppuswamy scale

 Total score:

This child belongs to which class:

 ENIVIRONMENTAL HISTORY

Rural/urban area:

Type of housing: (kachha/semipucca/pucca)

No of rooms:

Adequate light:

Cross ventilation:
 Separate kitchen

Latrine: (separate latrines/open defecation/ public latrines)

Water supply: (coorpetartion / separate)

Water chlorination:

Water contamination:

Garbage disposal: (corporation/open disposal)

Mosquito morlace: (present/not)

Rearing pet animals: yes/ no (if yes, how many)

 MOTHER / INFORMANT’S KAP

Knowledge: identification of diahhorea and dysentery, management of

diahhorea, preparation and use of ORT.

Attitude and practices: restriction of food or breast breeding during

diahhorea, use of latrine open field defecation in community.

Knowledge and practice: Rota virus vaccination.

 CLINICAL EXAMINATION

General examination

Mother’s consent: (taken or not)

Child is alert: yes/no

Pallor: seen or not

Icterus: seen or not

Clubbing: seen or not

 Cyanosis: seen or not

Lymphadenopathy: seen or not

Edema: present or not

Head and Face: Normal or not

Eyes: Normal or not

Ears, nose and throat: normal or not

Oral cavity: normal or not

Tongue: normal or not

Skin: normal or not

Hair: normal or not

Nails: normal or not

Bones and joints: normal or not

External genitalia: normal or not

Vitals
Temperature: Normal or not
Pulse: normal or not

Respiratory Rate: Normal or not

Regular / irregular

Anthropometry
Length: (expected around 95cm)
Weight: (expected around 14Kg)
 Mid arm circumference: (15-17Cm)

Head circumference: (46.8-50.3)

Chest circumference:

Weight/length=

SIGNS OF DEHYDRATION

Infants and young kids

1 Lethargic/ unconscious
2 Restless and irritable
3 Sunken eyes
4 Not able to drink/ poor drinking
5 Drinking eagerly due to thirst
6 Pinch the skin of abdomen – goes back slowly
7 Weight loss
No dehydration 5% weight loss
Some dehydration 5-10% weight loss
Severe dehydration >10% weight loss

 SYSTEMIC EXAMINATION

Examination of Abdomen:

Inspection:-

Contour: Normal or not

Umbilicus: Normal or not

All quadrants move EQUALLY or NOT:

Peristalsis: Seen or not

Pulsation: seen or not

 Scars: seen or not

Hernial orifices: Normal or not

External genitalia: Normal or not

Palpation:-

Local rise in temperature SEEN or NOT:

Tenderness: seen or not

Percussion:-

Resonant sound: Heard or not

Auscultation:-

Bowel sounds: Heard or not

Other systems:-

CVS: S1S2 Heard or not

RS: Normal breath sounds or not

added sounds present or not

CNS: Normal or not

 INVESTIGATIONS

Blood test

A complete blood count test can help indicate what's causing your
diarrhea.

Stool test

Your doctor might recommend a stool test to see if a bacterium or

parasite is causing your diarrhea.
 Flexible sigmoidoscopy or colonoscopy

Using a thin, lighted tube that's inserted in your rectum, your doctor
can see inside your colon. The device is also equipped with a tool that allows
your doctor to take a small sample of tissue (biopsy) from your colon. Flexible
sigmoidoscopy provides a view of the lower colon, while colonoscopy allows
the doctor to see the entire colon.

 DIAGNOSIS

Duration of diahhorea:

Acute (usually < 1 week, may be up to 2 weeks )

Persistent (2 weeks)

Chronic ( 3-4 ) weeks ( it is mostly non-infective diarrhoea )

Symptoms and suggestive diagnosis:

 Diarrhoea with vomiting, low grade fever with no mucus in stools: viral
infection
 Diahhorea with vomiting, abdominal cramps, blood and mucus in the
stools with fever (blood indicates dysentery): bacterial infection
 Chronic diarrhoea with blood and mucus in the stools without fever:
ameobiasis.
 Watery stools: mostly E.Coli infection
 Profuse diarrhoea (rice water stools) with vomiting : cholera
 Diarrhoea with excessive , especially if it is in more than one member of
the household or group : food poisoning
 Watery diahhorea ( after consuming milk or milk product ) associated
with excessive flatulence and perianal excoriation: lactose intolerance .

 TREATMENT AND MANAGEMENT

Classification of management as per IMNCI for DEHYDRATION

Does the child have diahhorea ? SEVERE DEHYDRATION
If yes ask: for how long ?
Look and feel: Signs : lethargic/ unconscious ,
Look at the child’s general condition sunken eyes, not able to drink or
drinking poorly, skin pinch goes back
very slowly.
Treatment : PLAN C

SOME DEHYDRATION

Signs: restless, irritable, sunken eyes,

drinking eagerly, thirsty, skin pinch
goes back slowly
Treatment: PLAN B

NO DEHYDRATION

Signs : no signs
Treatment: PLAN A

If diarrhoea is for 14 days or more SEVERE PERSISTENT DIARRHOEA

dehydration is present
Advice: to treat dehydration before
the child have another severe
diarrhoea .

PERSISTENT DIARRHOEA

no dehydration
advice: on feeding vit A single dose ,
zinc sulphate 20mg daily for 14 days :
follow up in 5 days
  TREATMENT

Individual treatment as per the dehydration status: PLAN A/ B/ C.

Dehydration in children aged 2 months – 5 years : if the child is

younger than 2 months then thirst criterion is not assessed for dehydration :
instead, movement only on stimulation or no movement at all is the criterion
used.

PLAN A (NO DEHYDRATION)

1. Give extra fluid:

Brest feed frequently
Give one/ more: ORS solution,
Food based fluids,
Clean water.

Give mother ORS preparation and also give her 2 ORS packets for home
use.

Teach mother how to give ORS (after each loose stools and between
them).
Up to 2 years: 50-100 ml
2 years or more: 100-200 ml
> 10 years: as much as desired

Tell the mother to:

a) Give frequent small sips from a cup: in case of vomiting, wait for 10
mins and then continue but slowly.
b) Continue giving extra fluids until the diarrhoea stops.

2. Give zinc supplements (20 mg tablets ):

Less than 6 months (dose 10 mg/ day): 1/2 tablets x 14 days

6 months / more (dose 20 mg/ day): 1 tablet x 14 days
 3. Continue feeding

4. Tell the mother to come after 2 days in case of dysentery or 5 days in

case of diaarhoea or if condition worsens.

PLAN B ( SOME DEHYDRATION )

1. Amount of ORS over 4 hour period: 75ml/kg wt.

If the child wants more ORS, then give more for infants younger then 6
months ( if not breastfed ) and give 100-200ml of clean water as well .

Tell to mother to

1 Give frequent small sips from a cup: in case of vomiting, wait for 10
mins and then continue but slowly.
2 Continue giving extra fluids until the diarrhoea stops.

After 4 hours: reassess as per the assessment chart and treat accordingly

 If the mother must leave the health facility before completing

treatment
 Show her how to prepare ORS to be given to finish it in 4-hours
treatment .
 Teach her how to prepare ORS solution at home : also give 2
packets of ORS .

Explain 4 rules of home treatment

1. Give extra fluid
2. Give zinc supplement
3. Continue feeding
4. Tell the mother to come after 2 days in case in case of dysentery or 5
days in case of diarrhoea or if the condition worsens

PLAN C ( SEVERE DEHYDRATION)

1. give IV fluids ( ringer’s lactate: others :5 % DNS , normal saline)

 2. reassess the child every 1-2 hours , if hydration status is not
improving, give IV drip more rapidly and also give ORS (5ml/ kg/ hour)
as soon as the child is ablr to drink.
3. Reassess an infant after 6 hours and a child after 3 hours: decide
the treatment .
4. If the child can drink , give ORS orally while the drip Is set up.

A childolder than 2 years with severe dehydration should be

prescribed antibiotic for cholera if there is a cholera out break in the
area

Explain 4 rules of home treatment

a. Give extra fluid
b. Give zinc supplement
c. Continue feeding
d. Tell the mother to come after 2 days in case in case of
dysentery or 5 days in case of diarrhoea or if the condition
worsens.

Other management

 Rational use of appropriate antibiotics ( amoxicillin, co-trimoxazole,

chloramphenicol, ampicillin, etc )

 The mother should return immediately if the child develops any of the
following signs:- not able to dribl/ breastfeed, become sicker, develops
fever or rapid breathing or chest indrawing or difficult breathing.

 Adequeate nutrition.

 Creating awareness and motivating family and community to immunize

the children specifically against Hiv, measles and PCV : and use the
anganwadi services .

 Creating awareness and motivating family and community to prevent air

pollution by alternative no or less smoke producing fuel for cooking
instead of wood, coal orr kerosene, avoidance of passive smoking,
avoidance of burning of waste material .
  Short term: ORS, clinical management

 Long term: Maternal and child health care improvement

Decreased outbreak of diarrhea by promoting health education and

sanitation.

ORT (oral rehydration therapy)

1. Reduced osmolarity ORS

Composition: Na 75mmol/l

Glucose 75mmol/l

Cl 65mmol/l

K 20mmol/l citrate 10mmol/l

=245mmol/l

2. Super ORS :

ORS with energy providing food products

Food products – starch (rice), starch free (glycine/glucose polymer)

Advantage: decrease dehydration

decrease stool frequency

Provide calories = 180kcal/l

3. Resomal:

Rehydration solution for severely malnourished children

 Composition: ORS pack +2litres water =sucrose (50gm) + mineral
electrolyte solution (40 ml) K, Cl, Mg, Zn, Cu

*Generally ORS is given at 75ml/kg +for every stool episode add

100ml/stool
* Home based ORS –salt and sugar in ratio 1:6
 WEIGHT OF CHILD <5 5-8 8-11 11-16 16-30 >30
(kg)

AGE <4mnths 4- 1-2yrs 2-5yrs 5- >14yrs

12mnth 14yrs
ORS 200-400 400- 600- 800- 1200- 2200-
QUANTITY(ml/day 600 800 1200 2200 4000
)

4. In severe dehydration – prefer IV rehydration

RL>DRS (diarrhoeal rehydration treatment solution)} given at 100ml/kg

FOR AGE: <1yr = within 6hrs , 30ml given within first hour , 70ml given in next 5
hours.
>1yr = within 3hours , 30ml given within 30mins, 70ml given in next 150mins.

OTHER MEASURES: * increased feeding

*chemoprophylaxis (doxycycline – cholera)

* Zinc supplement (oral) at 20mg for 14days

 ADVICE

To mother
Continue breast feed
Give healthy food
Give correct amount of ORS
Hygiene measures
Adequate water to be taken
Cover food stuffs properly
 To family members

Use latrines for defecation

Proper waste disposal
Prevent mosquito and fly breeding
Drink boiled water
Hand washing habit before lifting baby

 SUMMARY

Name of the patient , age , sex , guardian who came

along with presented with C/O diarrhoea, vomiting and fever for 3days ,
from which type of family and class socioeconomic status , has no other
complications .

 CONTROL OF DIARRHOEAL DISEASES

The diarrhoeal diseases control (DDC) programee of WHO has since its
inception in 1980

Components of a diarrhoeal diseases control programme

1. Short- term
Appropriate clinical management
2. Long- term
Better MCH care practices
Preventive strategies
Preventing diarrhoeal epidemics

 REMEDIAL ACTIONS TO BE TAKEN AT DIFFERENT LEVELS

Individual level
 Oral hygiene
 Bathing
  Cutting of nails
 Hand washing with soap before preparing food, before eating, before
feeding a child, after defecation, after cleaning a child who has
defecated and after disposing off child’s stool should be promoted.
 Exclusive breast feeding for first 6 months of life as breast milk contain
anti-infective factors which protect the baby from enteral infections.
 Weaning food should be supplemented
 With suitable foods rich in proteins and other nutrients.
 Immunization against measles is a potential intervention for diarrhoea
control.
 Immunization against Rota virus.
 Be sure that all foods you eat are thoroughly cooked and served
steaming hot. Never eat raw or undercooked meat.

Family level
 Provision of improved water supply
 Improved excreta disposal.
 All families should have a clean and functioning latrine.
 The latrine should be kept clean by regular washing of dirty surface.
 If there is no latrine, family members should defecate at a distance from
the house, paths or areas where children play and at least 10m away
from water supply source.

Community level
 Educational support to convince and help community members to adopt
and maintain certain preventive practices such as breast feeding,
improved weaning, clean drinking water, use of plenty of water for
hygiene, use of latrine, proper disposal of stools of young children.
 Fly control
 There should be appropriate disposal of excreta.
 Dry and wrap organic waste before placing it in the garbage can.
 Seal the garbage cans with tight fitting lids.
 Use indoor fly traps or sticky tape to control pests inside the house
 Screen windows and doors to keep pests out.
 Primary health care facility to ensure proper availability of treatment to
people of all socio economic class.
 NATIONAL HEALTH PROGRAMMES

1. DIARRHOEAL DISEASES CONTROL PROGRAMME

 The diarrhoeal disease control programme (DDCP) was started first in
1978 by WHO with the objective of reducing the mortality and
morbidity due to diarrhoeal disease
 After the oral rehydration therapy programme (1985-86),the DDCP has
shifted its focus on strengthening case management of diaarhoea under
the age of 5
 Researches of causes , prevention, treatment is also being incorporated
in this programme
 At present, it is a part of NATIONAL RURAL HEALTH PROGRAMME
(NRHM) of 2013.

2. THE INTERGRATED GLOBAL ACTION PLAN FOR THE PREVENTION AND

CONTROL OF PNEUMONIA AND DIARRHOEA (GAPPD)

It mainly aims to prevent the deaths caused by pneumonia and diarrhoea.

PROJECT BY

ROLL NO NAMES WORKS DONE

71 RAJALAKSHMI K advice, summary and control of diseases

72 REBEKHA BARTON H/O taking and family composition table

73 RISHIKESH types of family and socioeconomic assets

74 ROHINI A S birth history with immunization

75 ROHINI PRIYA Y R diet and environment history

76 ROHITH S clinical examination

77 ROOPSHIKA V investigation and diagnosis

78 RUBADEVI T S treatment

79 SHALINI EDAMANA remedial actions at different level

80 SAM DEEPAK national health programme

 SPM ASSIGNMENT

ACUTE DIARRHOEAL DISEASES

DEFENITION

Diarrhoea is defined as the pasage of three of more episodes of

loose, liquid, or watery stools.

CLASSIFICATION

Clinical types of diarrhoeal disease

1. ACUTE WATERY DIARRHOEA

Which lasts several hours to days; the main danger is
dehydration, weight loss also occurs if feeding is not continued. The
pathogens that usually cause acute diarrhoea include Vibrio cholera or
E.coli, as well as rotavirus.

2. ACUTE BLOODY DIARRHOEA

Also called as DYSENTRY -the main dangers are damage of
the intestinal mucosa, sepsis and malnutrition; dehydration may also
occur. It is marked as visible blood in the stools. The most common
causative organism is shigella.

3. PERSISTENT DIARRHOEA-
This lasts for 14 days / longer. The main danger is
malnutrition and serious non intestinal infection, dehydration may also
occur. Persons with other diseases such as AIDS are likely to develop
persistent diarrhoea.

4. DIARRHOEA WITH SEVERE MALNUTRITION

(Marasmus and kwashiorkor)- the main danger signs are
severe systemic infection ,dehydration ,heart failure and vitamin and
mineral deficiency.
 Acute: < 1-2 weeks
Persistent: >2 weeks - <3 weeks
Chronic: > 3 weeks

EPIDEMIOLOGICAL DETERMINANTS

AGENT FACTORS

➢ Four pathogens are significantly associated with moderate to severe

diarrhoea -rotavirus, Cryptosporidium, shigella and ST- ETEC.

➢ Rotavirus had the highest number of cases compared to any pathogen

during infancy.

➢ Estimated incidence of moderate to severe diarrhoea is highest in india.

➢ Moderate to severe diarrhoea was common in the pediatric population

studied .

➢ Cryptosporidium was a significant pathogen at all sites regardless of HIV

prevelance.
CLINICAL FEATURES

a. E.COLI

• Watery stools
• Vomiting is common
• Dehydration moderate to severe
• Fever -often of moderate grade
• Mild abdominal pain

b. ROTAVIRUS

• Insidious onset
• Prodromal symptoms including fever cough and vomiting
precedes diarrhoea
• Stools are watery or semiliquid – the colour is greenish or
yellowish- typically looks like yoghurt mixed in water.
• Mild to moderate dehydration.
• Fever-moderate grade.

c. SHIGELLOSIS
 • Frequent passage of scanty amount of stools, mostly mixed
with blood and mucus.
• Moderate to high grade fever-modsevre abdominal cramps
Tenesmus-pain around anus during defecation.
• Usually no dehydration.

d. AMOEBIASIS

• Offensive and bulky stools containing mostly mucous and

sometimes blood.
• Lower abdominal cramp.
• Mild grade fever.
• No dehydration.

HOST FACTORS

5. Diarrhoea is more common in children especially between 6 months and

2 years of age.
 Highest incidence in 6-11 months which is the period of weaning

 low level of maternally aquired antibodies

 Lack of active immunity in infants
 Introduction of contaminated food
 Direct contact to human and animal faeces, when infant
crawls.
 Malnutrition.
 Poverty.
 Lack of personal and domestic hygiene.
 Incorrect feeding practices.

ENVIRONMENTAL FACTORS

Seasonal pattern
• Tropical areas- rotavirus throughout the year and bacteria in summer
• Temperate areas- bacteria in summer and viruses especially rotavirus
during winter.
ASSESSMENT OF DEHYDRATION

MODE OF TRANSMISSION

• FECO-ORAL ROUTE

IMNCI CLASSIFICATION
MANAGEMENT

ORAL REHYDRATION THERAPY

✔ ORS( ORAL REHYDRATION SALT SOLUTION)

✔ Dehydration was the major cause of death in 1829 pandemic of cholera.
✔ I/V fluids were the major and standard line of therapy for dehydration.
✔ The WHO in 1978launched the global diarrhoea disease control program
with ORS and a short term objective of reducing mortality due to diarrhoea.
✔ During the 1980s, the UNICEF launched the ‘child survival and development
revolution’ concentrating its efforts on four ptent methods of saving children’s
live’s- growth monitoring, breast feeding, immunisation and the use of ORS.
✔ Oral fluid therapy is based on the observation that glucose given orally
enhances the intestinal absorption of salt and water, and is capable of
correcting the electrolyte and water deficit.

GUIDELINES FOR ORS THERAPY (FOR ALL AGES ) DURING THE FIRST 4 HOURS

WEIGHT OF <5 5-8 8-11 11-16 16-30 >30

CHILD (kg)

AGE <4mnths 4-12 1- 2-5yrs 5- >14yrs

2yrs
Month 14yrs
ORS 200-400 400- 600- 800- 1200- 2200-
800 2200
QUANTITY 600 1200 4000

(ml/day)

HAF- HOME ACQUIRED FLUID

TREATMENT OF DIARRHOEA AT HOME

TREATMENT PLAN A
The management of acute watery diarrhoea at home (Treatment Plan A) This
plan should be used to treat children:
✓who have been seen at a health facility and found to have no signs of
dehydration;
✓who have been treated at a health facility with Treatment Plans B or C until
dehydration is corrected; or
✓who have recently developed diarrhoea, but have not visited a health
facility.

The three basic rules of home therapy are considered below. These are:
 give the child more fluids than usual, to prevent dehydration;
 give the child plenty of food, to prevent undernutrition; and
 take the child to a health facility if the diarrhoea does not get better, or
if signs of dehydration or another serious illness develop.

What fluids to give

 Fluids that should be used at home to prevent dehydration include

"recommended home fluids", certain other drinks usually available in
the home, and in some instances ORS solution.

 Many countries have recommended specific home fluids for use in ORT;
these are usually food-based drinks, such as undiluted cereal gruel, or
sugar-salt solution (SSS).

 These fluids are suitable for home treatment of most children with
diarrhoea. However, for patients who have been treated for dehydration
at a health facility using Treatment Plans B or C, ORS solution should be
used .

 Some countries also advise the use of ORS solution for home treatment
of all patients who are seen at a health facility and found not to be
dehydrated, or for early home therapy of diarrhoea.

The following is a general guide for the amount of fluid to be given at home
after each loose stool:

children under 2 years: 50-100 ml

children aged 2 up to 10 years: 100-200 ml
 children 10 years of age or older and adults should take as
much as they want.
TYPES OF ORS

1. SODIUM BICARBONATE BASED

2. TRISODIUM CITRATE BASED

3. REDUCED OSMOLARITY ORS

 4. SUPER ORS

RESOMAL

• Rehydration solution for severely malnourished children.

• Composition: ORS pack +2litres water =sucrose (50gm) + mineral
electrolyte solution (40 ml) K, Cl, Mg, Zn, Cu.
*Generally ORS is given at 75ml/kg +for every stool episode add 100ml/stool
* Home based ORS –salt and sugar in ratio 1:6

ROLE OF ANTIBIOTICS

✔ unnecessary prescription of antibiotics and other drugs will do more

harm than good in the treatment of diarrhoea.
✔ Antibiotics should be considered where the cause of diarrhoea has
been clearly identified as shigella, typhoid or cholera.
✔ for diarrhoea due to cholera the drug of choice is doxycycline,
tetracycline, TMP-SMX and erythromycin.
✔ for diarrhoea due to shigella, the drug of choice is ciprofloxacin as
shigella is usually resistant to ampicillin and TMP-SMX.

The medicines that should not be used in the treatment of diarrhoea are;

✗ NEOMYCIN- damages the intestinal mucosa and can cause

malabsorption
✗ Purgatives-worsen diarrhoea and dehydration
✗ Cardio tonics such as Cora mine- shock in diarrhoea must be
corrected by IV fluids and not by drugs.
✗ Steroids
✗ Oxygen.
✗ Charcoal, caolin, pectin, bismuth
✗ mexaform

ZINC SUPPLEMENTATION

➔ Zinc benefits children with diarrhoea , because it is avital micronutrient

essential for
• Protein synthesis.
• Cell growth and differentiation
• Immune function
• Intestinal transport of water and electrolyte
➔ Zinc is also important for normal growth and development of children
➔ Zinc deficiency is associated with increased risk of gastrointestinal
infections, adverse effects on structure and function of GIT and impaired
immune function.
➔ When a zinc supplement is given during an episode of acute diarrhoea, it
reduces the episode’s duration and severity.
➔ Zinc supplements given for 10 to 14 days reduce the incidence of diarrhoea
in the following 2- 3 months.
➔ WHO and UNICEF therefore reccomends10 mg of zinc daily for infants
under 6 months of age and 20 mg for children older than 6 months for 10 -14
days.

DIET ADVICE

• The infant usual diet should be continued during diarrhoea and food should
never be withheld.
• In case of breast feeding child, breast feeding should be continued.
• When food is given, sufficient nutrients are usually absorbed to support
continued growth and weight gain.
• Continued feeding also speeds the recovery of normal intestinal function,
including the ability to digest and absorb nutrients

 ADVICE

To mother
✗ Continue breast feed
✗ Give healthy food
✗ Give correct amount of ORS
✗ Hygiene measures
✗ Adequate water to be taken
✗ Cover food stuffs properly

To family members
✗ Use latrines for defecation
✗ Proper waste disposal
✗ Prevent mosquito and fly breeding
✗ Drink boiled water
✗ Hand washing habit before lifting baby
CONTROL OF DIARRHOEAL DISEASES

The diarrhoeal diseases control (DDC) programee of WHO has since its
inception in 1980

Components of a diarrhoeal diseases control programme

1. Short- term
Appropriate clinical management
2. Long- term
Better MCH care practices
Preventive strategies
Preventing diarrhoeal epidemics

PREVENTIVE STRATEGIES

1. SANITATION
2. HEALTH EDUCATION
3. IMMUNISATION

REMEDIAL ACTIONS TO BE TAKEN AT DIFFERENT LEVELS

Individual level

 Oral hygiene
 Bathing
 Cutting of nails
 Hand washing with soap before preparing food, before eating, before
feeding a child, after defecation, after cleaning a child who has
defecated and after disposing off child’s stool should be promoted.
 Exclusive breast feeding for first 6 months of life as breast milk contain
anti-infective factors which protect the baby from enteral infections.
 Weaning food should be supplemented
 With suitable foods rich in proteins and other nutrients.
 Immunization against measles is a potential intervention for diarrhoea
control.
 Immunization against Rota virus.
  Be sure that all foods you eat are thoroughly cooked and served
steaming hot. Never eat raw or undercooked meat.

Family level

 Provision of improved water suppl

 Improved excreta disposal.
 All families should have a clean and functioning latrine.
 The latrine should be kept clean by regular washing of dirty surface.
 If there is no latrine, family members should defecate at a distance from
the house, paths or areas where children play and at least 10m away
from water supply source.

Community level

 Educational support to convince and help community members to adopt

and maintain certain preventive practices such as breast feeding,
improved weaning, clean drinking water, use of plenty of water for
hygiene, o keep pests out.
 Primary health care facility to ensure proper availability of treatment to
people of all socio economic class.use of latrine, proper disposal of
stools of young children.
 Fly control
 There should be appropriate disposal of excreta.
 Dry and wrap organic waste before placing it in the garbage can.
 Seal the garbage cans with tight fitting lids.
 Use indoor fly traps or sticky tape to control pests inside the house
 Screen windows and doors to keep pests out.
 Primary health care facility to ensure proper availability of treatment to
people of all socio economic class.

ROTAVIRUS VACCINATION
➢ Rotavirus vaccine should be considered as a priority particularly in countries
with high rotavirus gastroenteritis associated fatality rates such as i south and
southeatern asia and subsaharan africa.
➢ The first oral rotavirus vaccine was licenced in USA.
➢ Two live ,oral,attenuated rotavirus vaccines were licenced in 2006 ; the
monovalent human rotavirus vaccine (ROTATRIX) , and the pentavalent
bovine-human reassortant vaccine(ROTA TEQ)
➢ ROTATRIX vaccine should be administered orally in a 2 dose shedule. The
first dose can administered at the age of 6 weeks and the second dose should
be given no later than 12 weeks. The interval between 2 doses should be
atleast 4 weeks.
➢ For ROTA TEQ , the recommended shedule is 3 oral doses at ages 2, 4 and 6
months. The first dose should be administered between ages 6-12 weeks and
subsequent doses at interval of 4-10 weeks.

SDONE BY : ROLLNO 71- 80