MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN

Dr.B.Anjaiah, MD., DCh.,Director, RIMS, Ongole

INVESTIGATIONS STOOL- Macroscopy Microscopy- WBC>10/hpf Ova,cysts,throphozoites Hanging drop C/S for shigella & salmonella

BLOOD- CBC Electrolytes, creatinine,BUN C/S

MANAGEMENT PREVENTION

TREATMENT

SUPPORTIVE TREATMENT

PREVENTION HAF Good liquids without

salt -clean water -unsalted rice water -unsalted yoghurt

drinks -coconut water -weak tea -unsweatened fresh

fruit juice

Good liquids with salt

-ORS -Salted soup -salted yoghurt

drinks -salted rice water

DO NOT GIVE Soft drinks Sweetened tea Sweet fruit juices coffee

TREATMENT CORNERSTONE of Rx

ORT

ORT ORS

Solution made from sugar &salt

Food based solutions

Continued feeding

PLAN A (NO DEHYDRATION)

Rule 1 --- Fluids - HAF,SSS

Rule 2 --- Zn supplementation

Rule 3 --- continued feeding

Rule 4 --- return to clinic

Rule 1 --- Fluids WHO Guidelines

AGE QUANTITY WITH EACH STOOL

<6 mon 50 ml(1 cup)7 mon – 2 yrs 50-100 ml2 yrs- 5 yrs 100-200mlOlder child As much as they

take

ORS is optional in

PLAN A

Rule 2 --- Zn supplementation Improves immune function

Improves intestinal permeability

Regulation of intestinal water & electrolyte transport & brush border enzymatic function

Intestinal tissue repair

Rule 2 --- Zn supplementation

<6 mon ---- 1/2 tab / day

>6 mon ---- 1 tab / day

for 10 – 14 days

Rule 3 --- continued feeding < 6 mon - breast / top fed

Older children – cereals & beans, meat & fish , oil, dairy products & eggs, fruit juices & bananas

What is the use of continued feeding?

Rule 4 --- return to clinicWhen the child -passes many stools -very thirsty -sunken eyes -fever -does not eat/drink normally

PLAN B (Some dehydration)

AGE Weight ORS Glass< 4 mon <5 kgs 200-400 ml 1-24-11mon 5-8 kgs 400-600 ml 2-312-23 mon 8-11 kgs 600-800 ml 3-42-4 yrs 11-16 kgs 800-1200 ml 4-65-14 yrs 16-30 kgs 1200-2200ml 6-11>15 yrs >30 kgs >2200 ml 12-20

ORS given at 75 ml / kg over 4 hrs Continue breast feeding 100-200 ml of water + ORS (in those

who are not breastfed)

REASSESS after 4 hrs

Signs of dehydration --- follow NIL - PLAN A PERSISTS - PLAN B SEVERE - PLAN C

PLAN C (Severe dehydration) AGE First give

30 ml / kg in Then give70 ml / kg in

< 1 year 1 hour 5 hrs

> 1 year 30 min 2 ½ hrs

TYPE OF FLUID BEST ----- RL

IDEAL ----- RL + 5% D

IF RL not available ---- NS

INDICATIONS FOR IV FLUIDS Severe dehydration with/with out shock Persistent vomiting(>3/hr) Failure to correct / worsening of dehydration on

ORT High purge rate Failure of acceptance of ORS in dehydrated child Abdominal distension Deranged sensorium

GUIDELINES for the total amount of fluids to be replaced in some & severe dehydration

Usual fluid Deficit(ml/kg)

Deficit fluid replaced(ml/kg)

Maintainence fluid required in 8 hrs(ml/kg)

Total amount of IV fluids for correction of dehydration to be given in 8 hrs (ml/kg)

Some 70-100 50 50 100

Severe 120-180ml 100 50 150

CONTINUATION OF IVF AFTER CORRECTION OF DEHYDRATION Children - >3 mon N/4 NS -<3 mon N/6 NS

Maintenance fluids must contain K+ in the con of 20 meq/l

TYPE OF FLUID GIVEN AS REHYDRATION THERAPY Initial fluid of choice-N/2 NS(1 PART

OF ISOTONIC SALINE+1 PART 5% DEXTROSE)

Isotonic saline & RL - severe dehydration

->6y high purge rate

Start ORS -5ml/kg/hr when child able to drink

what to do if IV LINE not accessible?

Reasses after 1-2 hrs

COMPLICATIONS Dehydration Dyselectrolytaemia Precipitation of malnutrition Secondary lactose intolerence Persistent diarrhoea HUS DIC Cortical vein thrombosis

HYPONATRAEMIASevere-<125meq/lClinical featuresDeranged sensorium&convulsionsDiminished urine outputCorrection-N/2 NS (or) RL [Na-125-135] -3N NS [Na-<125]

Amount of Na required=Na deficit x 0.6 x wt

Half of it corrected as 3N over ½-1hr

Remaining corrected as RL (or) N/2 NS slowly

HYPERNATRAEMIA

Etiology Clinical features Usual signs of dehydration are absent Management If in shock-20-30ml/kg RL Confirm hypernatraemia Give N/3 NS in maintenance amounts

METABOLIC ACIDOSIS Etiology Clinical features-deep fast breathing with plasma

HCO3 <15 meq/lit

Management Amount of NaHCO3= HCO3 deficit x 0.6 x wt (OR) 3ml/kg of 7.5% NaHCO3 diluted 6 times 5% Dextrose [total of 20ml/kg] over 30-60 min

HYPOKALEMIA Serum K- <3 Meq/l Clinical features Management- ORS -K rich food Oral potassium supplementation -2meq/kg/d in PEM

WHO Formulagm/ lit component Mmol/lit

NaCl 3.5 Na 90

KCl 1.5 K 20

Tri sodium citrate

2.9 Cl 80

Glucose 20 Citrate 10

water 1Lit Glucose 111

Various measures to reduce Na Lower Na content in ORS

Alternating breast milk and ORS(2:1)

Diluting ORS in 1.5 lit of water

Limitations of ORS Does not decrease the volume frequency severity of diarrhoea

Does not stop diarrhoea

IMPROVED ORS Should reduce amount & rate of

purging

Should stop diarrhoea

Should provide nutritional support (SUPER ORS)

FORMULATIONS Amino acid Glycine / L-alanine / L-

glutamine added to glucose ORS Decreasing conc. Of glucose & sodium Cooked cereal powder esp. rice to

replace glucose Combining glucose polymers & AA’s to

replace glucose Polymers like maltodextrine to replace

glucose

CEREAL baesed ORS 50 gm/lit of cooked rice added to salt

ADVANTAGES?

REDUCED OSMOLARITY ORS Principle?

Gms/lit Mmol/litNaCl 2.6 Na 75Glucose 13.5 Cl 65KCl 1.5 Glucose 75Tri Na cit 2.9 K 20

Citrate 10Osm 245

Amylase resistant starch in ORS Add 50 gm/lit of starch to standard

glucose ORS

Increases absorption efficiency

ReSoMalComponent Standard ORS ReSoMalGlucose 111 mmol/lit 125mmol/litNa 90 45K 20 40Cl 80 70Citrate 10 7Mg - 3Zn - 0.3Cu - 0.045Osmolarity 311 300

DRUG THERAPY SHIGELLA Cotrimoxazole(5d)

CHOLERA Tetracycline/ Doxy(3-5d) (1dose)

AEROMONAS cotrimoxazole

ETEC & EPEC -do-

Campylobacter Erythromycin(5-7d)

Clostridium difficile Vancomycin/metronidazole

Salmonella Ampicillin/Cefotaxime(5-7d)

Giardiasis Metronidazole(5d)

Amoebiasis Metronidazole(7-10d)

RACECADORTIL Mode of action Comparing with Loperamide

MULTIVITAMINS Vit A- on day 1,2 and 14

Folic acid- 5 mg on day 1 then 1mg/d for 2 wks

Other vitamins and trace elements double the maintanance dose

MICRONUTRIENTS Potassium-5-6 meq/kg/d for few days 2-3 meq/kg/d orally for 2wks MgSO4-0.2ml/kg Zinc-10 mg for 2wks Copper-0.3 mg/kg/d Iron

PROBIOTICS IN DIARRHOEA Viable microbial supplements / live

microorganisms given to confer beneficial health effects on the growth of the host

Lactobacillus acidophilus/ L.casei Bifidobacterium Streptococcus thermophilius Saccharomyces

PREBIOTICS IN DIARRHOEA Food ingredients or part of bacteria

largely undergraded in small bowel and can beneficially affect the host by stimulating colonic bacteria

Lactulose alfa disaccharide Fructo-oligosaccharide In some vegetables and fruits

USES OF PRE/PROBIOTICS Establishes normal microbial flora

Enhancement of immunity Nutritioal benefits-vit B Production -improved digestibility -body growth

MECHANISMS OF ACTION Competing for receptor sites Growth inhibition Immune modulation Production of short chain fatty acids Modification of toxin receptors Disaccharidases Decreases permeability

DIARROEA IN PEM Clinical features MANAGEMENT Mild to moderate-ORS 70-100 ml/kg over 6-12 hrs Severe – N/2 NS+5%D 30ml/kg – 2hr -N/6 NS+5%D 10ml/kg- 10hr -N/6 NS+5%D 5ml/kg/hr –12hrMAINTENANCE FLUIDS-N/6 NS in 5% D -75-100 ml/kg/d

NUTRITION IN PEM The goal – 150-200 kcal -3-4g protein -6-8 feeds Micronutrients & multi vitamins

Trace elements