Seminar On

“APPROACH TO DIARRHEOA IN CHILDREN”Presented by

Vijay kr. SinghDNB PGT (Pediatrics)Under guidance of

Dr T K MAITY MD(PEDIATRICS)

Consultant pediatrician M R Bangur HospitalDate 18 june 2013

VenueDNB Seminar hall M R Bangur hospital Kolkata-33

DIARRHEOA

Diarrhea is best defined as excessive stool loss of fluid and electrolyte more than three within 24hrs period. Recent change of consistency is more important than frequency

Types of diarrheaAcute watery diarrhoea-start suddenly and last for hours or days.

Dysentery- it is similar to acute diarrhea but associated blood loss in stool.

Persistent diarrhea- if diarrhea persist more than 14days

WHO and UNICEF estimate that almost 2.5billion episode of diarrhea in children less than 5 years of age in developing countries. More than 80%occring in Africa and south Asia. Globally mortality dicrease significantly but incidence remain unchanged.

Epidemiology of diarrheaDiarrhoeal disorder in childhood account for a large proportion 18% of childhood death about 1.5 million deaths per year globally and making second most common cause of childhood mortality

Diarrhea can cause undernutrition and worsen

the milder form of malnutrition because

Impaired intestinal absorption of macro and micronutrient.

Urinary loss of specific nutrient Vit A.

Increase catabolism due to infection.

A child with diarrhea is often not hungry.

Mother often make the mistake of not to feed during diarrhea.

Etiology of diarrhea

Organism causes non inflammatory(enterotoxin or

adherence / superficial invasion)Location- Proximal small intestineCauses watery diarrheaThese areE.coli(ETEC,LT,ST)Clostiridum perfringensBacillus cereusStaph. Aureus, giadia lambia, Rota virus,

Norwaklike virus,Crytosporidium,Microsporidia,

Enteropathogens elicit noninflamatory diarrheoa through entrotoxine production by some bacteria, destruction of villous surface by viruses, adherence by parasite and adherence and translocation by bacteria. Bacterial enterotoxin can selectively activate enterocyte intracellular signal transduction and cause alteration in the water and electrolyte fluxes across enterocyte.

Location- colonDysentery

Organisms Shigella E.coli(EIEC,EHEC)Salmonella enteridisVibrio parahemolyticusClostiridum difficilue, campylobacter jejuni,

Entaemaeba hitolytica.Inflammatory diarrhea is usually caused by

bacteria and directly invade the intestine or produce cytotoxin with consequent fluid, protein, and cells. That inter the intestine

Inflammtory(invasive, cytotoxin)

PenetratingLocation- Distal small intestine

Salmonella typhiYersinia enteropathicaCampylobacter fetus

Risk factors of gastroenteritis

Envinmental contamination and increased exposure to pathogens

MalnutritionLack of exclusive breast feeding or prolong and predominant breastfeeding

MeaslesImmunodeficiency

Clinical evaluation of diarrhea

Child dehydration can be classified according to WHO criteria

No dehydration Treatment planA

Some dehydration Treatment Plan B

Severe dehydration Treatment Plan C

Signs of dehydration:

Decreased urination (fewer than 4 wet diapers in 24 h),

Increased thirst,   No tears,   Dry skin, mouth and tongue,   Faster heart beat,   Sunken eyes,   Grayish skin,   Sunken soft spot (Anteriar fontanelle) on

baby’s head

Treatment PLAN A

•Age less than 24 months•50-100ml per each loose stool•Age between 2yrs to 10yrs•100 to 200 ml after each stool•Age more than 10 yrs•As much as wants

Treatment Plan B The fluid therapy has three

component.Correction of the existing water and electrolyte deficient.

Replacement of ongoing loss due to continuing diarrhea

Deficient replacement 

 

75 ml/ kg of ORS In first 4 yrs 

Maintenance therapy 

This begins when dehydration corrected over 4hrs

ORS 10-20 ml/kg after each stool .

Offer plan water in between 

High stool purge- 5ml/ kg/hr Persistent vomiting > 3episode per hr Incorrect preparation Abdominal distention Glucose malabsorption

When ORT therapy is ineffective

Treatment Plan C

Start IV fluid immdiatelyAge <12months30ml/kg in 60 minutes  Then 70ml/ kg in 5hrsAge between 12months to 5 years

30ml/kg in 30 minutesThen 70 ml/kg in2.5 hrs

Monitoring

Reassess the child every 15-30 minutes until a strong radial pulse is present.

Repeat IV fluid is severe dehydration still present.

If child is improving but still shows sign of dehydration.

Discontinue IV fluid and give ORS for 4hrs

Secretory diarrhea Secretory diarrhea is often caused by a

secretagogue, such as cholera toxin, binding to a receptor on the surface epithelium of the bowel and thereby stimulating intracellular accumulation of cyclic adenosine monophosphate or cyclic guanosine monophosphate. Some intraluminal fatty acids and bile salts cause the colonic mucosa to secrete through this mechanism.

Secretory diarrhoea occurs after ingestion of a poorly absorbed solute. The

solute may be one that is normally not well absorbed (magnesium, phosphate, lactulose, or sorbitol) or one that is not well absorbed

because of a disorder of the small bowel (lactose with lactase deficiency or glucose

with rotavirus diarrhea). Malabsorbed carbohydrate is fermented in the colon, and

short-chain fatty acids (SCFAs) are produced.

ROLE OF DRUGS IN DIARRHOEAORSAntibioticsZinc supplementAntimotility drugsProbioticsEnkephaline inhibitor

ORSAn oral rehydration solution (ORS)low

osmolility is an exact mixture of water, salts and sugar. These solutions can be absorbed even when your child is vomiting. The key is to give small amounts of ORS often (for example, 1 teaspoon every 5 minutes), gradually increasing the amount until your child can drink normally.

AntibioticsAntibiotics have very minor roll in diarrhoea.

It is only in bacterial infective diarrhoea and dysentry.

ZincIt increase recovery rateDecrese stool out putMaintain mucusal layerIncrese immunityDose 20mg/ day in case of age less than 6month 10mg once a day

Antimotility agentsIt is contra indicated in dysentry.

No role in management of acute watery diarrhoea.

ProbioticsIt restore the beneficial bacterial intestinal flora and enhance host protective immunity such as down regulation of pro- inflammatory cytokines and up- regulate anti – inflammatory cytokines.

ENKEPHALINSE INHIBITOR

It consistently has been shown to reduce stool out put.

But experience with this drug is limited.

Foods to avoidDo not give your child sugary drinks such as: fruit juice or sweetened fruit drinks, carbonated drinks (pop/soda), sweetened tea, broth or rice water. These have the wrong amounts of water, salts and sugar and can make your child’s diarrhea worse.

Preventive measure for diarrhoeal disease

Improve domestic & food hygiene.

Improve water supply.Improve excreta disposalMaintain good nutrition. Health education.Immunization