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    Childhood Diarrhoea

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    ALok Acharya

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    Childhood Diarrhoea

    Uploaded by

    ALok Acharya
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    2 views38 pages

    Childhood Diarrhoea

    Uploaded by

    ALok Acharya

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 38

    Childhood Diarrhoeal disease &

    Management

    Dr. Alok Acharya


    MBBS, MD Community Medicine
    Assistant Professor
    Department of Community Medicine
    What is diarrhoea?
    Passage of 3 or more loose, liquid or watery stools
    in a day

    What is not a diarrhoea?

    1.Frequent formed stools

    2.Pasty stools in breastfed child

    3.Stools during or after feeding

    4.PSEUDODIARRHOEA:Small volume of stool frequently


    (IBS)
    Types

    1. Acute watery diarrhoea : <2 weeks, 90% attacks are self limited
    (resolved by ORS)
    Lasts several hours to days ;Main danger is dehydration, weight loss
    Pthogen V. cholera, E.coli, rotavirus.

    2. Acute Bloody diarrhoea: Dysentry ;damage intestinal mucosa,-


    sepsis and malnurtition, dehydration; pathogen common is Shigella

    3. Persistent diarrhoea :2-4 weeks danger is malnutrition, serious non-


    intestinal infection,dehydration, e.g person with AIDS

    4. Diarrhoea with severe malnutrition (marasmus and kwashiorkar):


    dangers are systemic infection, dehydration, heart failure and vitmin
    and mineral deficiency.
    Problem statement

    Worldwide-children deaths : 1.6 million every yr

    World-wide 4% of all deaths

    Worldwide 18% of under five deaths

    In Southeast Asia -nearly 8% of all deaths

    IN NEPAL “Incidence of diarrhoea per 1,000 under‐five


    years' children has considerably decreased to 501/1,000
    under 5 year children in FY 2071/72 from
    528/1,000 in 2069/70 and 629/1,000 in 2070/71.”
    Agent factors

    Virus
    Rota,Astro,Adeno,Calci,Corona,Norwalk,Entero

    Bacteria
    Campylobacter Jejuni,E.Coli,Shigella,Salmonella,
    V.cholerae,V.parahaemolyticus,Bacillus cereus

    Others
    E.Histolytica,Giardia,Trichuriasis
    Cryptosporidium,Intestinal worms
    Important pathogens in children
    Pathogen % of cases
    Virus Rota virus 15-25
    Bacteria ETEC (Entero toxigenic 10-20
    Ecoli)
    EPEC (Entero 1-5
    pathogenic Ecoli)
    Salmonella (Nontyphoid) 1-5
    V.Cholerae 01 5-10
    Shigella 5-15
    Campylobacter jejuni 10-15
    Protozoans Cryptosporidium 5-15
    No - 20-30
    pathogens
    Viruses: cause for 50% cases of diarrhoea <2 yr
    found
    Cryptosporidium: diarrhoea in infants and immuno-defficients
    Reservoir of infection
    • Humans
    • Humans and animals: Campylobacter,salmonella,
    yersinia enterocolitica

    Host factors

    • Most common age: 6 months- 2 yr


    • Highest at the time of weaning
    (contaminated food,
    contact with feces as infant starts to crawl)
    • Common in non-breast fed infants
    • Malnutrition, Measles
    • Incorrect feeding practices
    • Lack of hygiene
    Environmental factors

    In temperate climates
    Bacterial diarrhoea: summer
    Viral diarrhoea: winter

    In tropical areas
    Viral diarrhoea: whole year
    Bacterial diarrhoea: summer,rainy season

    Social factors

    Poverty,ignorance,illiteracy

    Mode of transmission
    Faeco-oral
    (water borne,food borne,fomites,fingers,dirt)
    Poverty, water and diseases
    MANAGEMENT

    ORAL REHYDRATION THERAPY

    DRUGS
    (ANTIBIOTICS,ANTIMOTILITY DRUGS)

    NUTRITIONAL MANAGEMENT
    ASSESSMENT
    OF
    HYDRATION STATUS
    Look, Feel and Decide Chart for assessment of Dehydartion in diarrhoea

    Condition Well,Alert *Restless, *Lethargic or


    Irritable* unconscious;Floppy*
    Eyes Normal Sunken Very sunken
    Look at
    Tears +nt -nt -nt
    (CETTT)
    Tongue Moist Dry Very Dry
    Thirst Not thirsty *Thirsty, *Drinks poorly or
    drinks eagerly* unable to drink*

    Feel Skin Goes back *Goes back slowly* *Goes back very
    pinch instantly slowly*

    Decide No 2 or more signs 2 or more signs


    dehydration including atleast including atleast one
    one * marked * marked
    (SOME (SEVERE
    DEHYDRATION) DEHYDRATION)
    Treat Treat. A Weigh the Weigh the
    Skin Pinch
    sunken eyes
    TREATMENT PLAN A

    4 Rules of home treatment

    1.Give extra fluid-

     Breastfed frequently,

     Give one or more : ORS solution, food based fluids (such as


    soup,rice water and yoghurt drinks), clean water

     Teach the mother how to mix and give ORS.Give the mother 2
    packets of ORS to use at home.

     Show the mother how much fluid to give (After each loose stool
    and between them) in addition to the usual fluid intake:

     Up to 2 years : 50-100 ml
     2 years or more:100-200 ml
     >10 years: as much as wanted
    Tell the mother to:

     Give frequent small sips from cup


     In case of vomiting: Wait 10 min.then continue but slowly,
     Continue giving extra fluids until the diarrhoea stops

    2.Give Zinc Supplements:

    Tell the mother how much zinc to give:


    < 6 months (dose 10 mg/day): ½ tab x 14 days
    >6 months (dose 20 mg/day): 1 tab x 14 days

    3. Continue feeding

    4. Tell the mother when to return


    TREATMENT PLAN B

    • Determine amount of ORS over 4 hour period:


    75 ml/kg body
    • If the child wants more ORS then give more
    • For infants < 6 months (not breastfed):
    give 100-200 ml clean water also

    Age < 4 4-12 12-24 24-60


    (months)
    Weight (kg) <6 6-<10 10-<12 12-19

    Amount (ml) 200-400 400- 700- 900-


    700 900 1400
    Tell the mother to:

     Give frequent small sips from cup


     In case of vomiting: Wait 10 min.then continue but slowly,
     Continue giving extra fluids until the diarrhoea stops

    After 4 hours

     Reassess as per assessment chart and treat accordingly


    (Plan A,B or C)

     If the mother must leave before completing treatment:


    • Show her how to prepare ORS solution at home
    • Show her how to prepare ORS to give to finish 4 hr treatment
    • Also give 2 packets ORS

     Explain the 4 rules of home treatment:

    1.Give extra fluid 2.Give zinc supplements


    3.Continue feeding 4.When to return
    TREATMENT PLAN C

    Can you give the IV fluid immediately? YES

    If the child can drink, give ORS orally while the drip is set up.

    Age First give Then give


    30ml/kg in 70 ml/kg in
    < 12 months 1 hour* 5 hour*
    12 months - 5 years 30 min.* 2 ½ hours*
    * Repeat once if radial pulse is still very weak or not detectable

    • Reassess the child every 1-2 hours.


    If hydration status is not improving give the IV drip more rapidly

    • Also give ORS (5 ml/kg/hour) as soon as the child can drink.

    • Reassess an infant after 6 hours and child after 3 hours:


    Decide the treatment
    Can you give the IV fluid immediately? NO

    Is IV treatment available nearby (within 30 min.) YES

    Refer urgently to hospital for IV treatment


    (If the child can drink. Provide the mother with ORS solution and show her how
    to give frequent sips during the trip)
    Is IV treatment available nearby (within 30 min.) NO

    Are you trained to use a nasogastric tube for rehydration? YES

    Start rehydration (ORS solution) by tube/mouth : 20 ml/kg/hour for 6


    hours.
    Reassess the child every 1-2 hours
    • If vomiting or increasing abdominal distension, give the fluid more slowly
    • If hydration status is not improving after 3 hours, send the child for IV therapy
    • After 6 hours, reassess the child and treat (A,B or C)
    Are you trained to use a nasogastric tube for rehydration?

    NO

    Can the child drink YES Give ORS orally

    NO

    Refer urgently to hospital for IV/NG treatment

    If the child is >2 years and there is cholera epidemic in the area
    Give antibiotic for cholera
    ORT

    Naso-gastric tube
    FOLLOW UP

    • Follow up after 2 days in dysentery, after 5 days in


    acute diarrhoea

    • Return immediately if the child develops:

     Many watery stools,


     Repeated vomiting,
     Fever,
     Poor or unable to drink and eat/ breastfeed,
     Blood in stool
    Composition of WHO -ORS

    Ingredients Normal Low osmolarity


    (gm) (gm)
    Sodium chloride 3.5 2.6

    Glucose 20.0 13.5

    Potassium Chloride 1.5 1.5

    Trisodium citrate 2.9 2.9


    dehydrate
    27.9 gm 20.5 gm
    (310 mOsm/l) (245 mOsm/l)
    SGPT:2.6,13.5,1.5,2.9
    Home made ORS

    1 tsp table salt + 4 heaped tsp sugar


    in 1 litre of water

    SUPER ORS

     Amino acid based ORS

     Amino acids (Alanine, Glycine co-transport the Na+) are used


    in place of glucose

     Powder of boiled rice (50 mg/L) can be used in place of amino acids

     Decrease purging rates and improve absorption


    ORS
    DRUGS IN DIARRHOEA

    Antibiotics in Dysentery and Cholera

    In Dysentery:
    Cotrimoxazole

    Better in 2 days

    No Yes

    Look for trophozites of E.Histolytica in stool Complete the 5 days treatment

    Absent Present

    Refer to hospital Treat with Metronidazole


    /Give Ciprofloxacin
    DOSAGE OF COTRIMOXAZOLE AND NALIDIXIC ACID IN DYSENTERY

    Age/Wt. Cotrimoxazole Nalidixic acid


    (2 times/day (4 times/day
    for 5 days) for 5 days)
    Paediatric tablet Syrup Tablet
    20 mg TMP+ 40 mg+ 500 mg
    100 mg SMX 200 mg
    (per 5 ml)
    2 - < 12 2 tab 1 tsp 1/4
    months
    (4- <10kg)
    1 - 5 years 3 tab 1.5 tsp 1/2
    (10-19 kg)
    Anti-diarrhoeals

    Loperamide

    Useful in: Mild to moderate diarrhoea

    C/I: Bloody dirrhoea, high fever,


    worsening of diarrhoea inspite of
    antidiarrhoeals, children

    Dose :4 mg (2 tabs. Stat) ,


    then 1 tab after each loose stool (max. 16 mg/day)
    DRUGS WHICH SHOULD NOT BE USED IN DIARRHOEA

    1.Neomycin(Damages the intestinal mucosa)


    2.Purgatives
    3.Atropine(Dangerous for children and dysentery patients)
    4.Steroids(Useless)
    5.Oxygen(Unnecessary)
    6.Charcoal(No value)
    NUTRITIONAL MANAGEMENT OF DIARRHOEA

    1.Continue feeding

    2.Energy dense foods should be given:


    Khichri , rice with milk, curd and sugar,
    mashed banana with milk, mashed potatoes and lentils

    3.Foods with high fibre content should be avoided

    4.During recovery, an intake of at least 125% of


    normal requirement should be attempted
    National diarrhoea diseases control programme

    1.Short term: Appropriate clinical management

    -ORT
    -Appropriate feeding
    -Chemotherapy

    2.Long term

    a. Better MCH practices

    -Maternal nutrition
    -Child nutrition: breast feeding, proper weaning,
    supplementary feeding
    b. Preventive strategies

    -Sanitation
    -Health education
    -Immunization
    -Fly control
    -Food Hygiene

    c. Prevention and control of diarrhoeal epidemics

    -Strengthening of epidemiological surveillance


    THANKS !!!   

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