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by
Harold Rugnao
DIARRHEA
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ESSENTIAL CONCEPTS OF DIARRHEA DIARRHEA
passage of unusually loose or watery stools, at least 3x ina 24 hr period
CLINICAL TYPES OF DIARRHEA
Acute watery diarrhea
Acute bloody diarrhea
Persistent diarrhea Diarrhea with severe malnutrition
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ESSENTIAL CONCEPTS OF DIARRHEA Dehydration
Deficit of water and electrolyte
Malnutrition Zinc Deficiency
Use of antimicrobials and anti-diarrheal drugs
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Important Microbial Causes of Acute Diarrhea
in Infants and Children Rotavirus
Escherichia Coli
Enterotoxigenic
Localized adherent
Diffuse Adherent
Enteroinvasive
Enterohemorrhagic
Shigella
Campylobacter jejuni
Vibrio cholerae 01 and0139
Salmonella
Giardia duodenalis
Entamoeba histolytica
Cryptosporidium
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ASSESSMENT OF CHILD WITH DIARRHEA1. History
2. Physical Exam
3. Determine Degree of Dehydration and selecttreatment plan
4. Diagnose other important problems
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ASSESSMENT OF DIARRHEA PATIENTS FOR
DEHYDRATION
A B C
LOOK AT: CONDITION
EYES
THIRST
Well, alert
Normal
Drinksnormally, notthirsty
Restless, irritable
Sunken
Drinks eagerly,thirsty
Lethargic orunconscious
Sunken
Drinks Poorly or not
able to drink
FEEL: SKIN PINCH Goes backquickly
goes back slowly goes back very slowly
DECIDE NO SIGNS
OFDEHYDRA-TION
SOME SIGNS OF
DEHYDRATION
SEVERE SIGNS OF
DEHYDRATION
TREAT Usetreatment
plan A
Weigh the patient,use Treatment
Plan B
Weigh the patient, useTreatment Plan C
URGENTLY
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ESTIMATED FLUID DEFICIT
Assessment Fluid deficit as%of body wt
Fluid deficit inml/kg body wt
No signs of
dehydration
10% >100 ml/kg
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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 theoccurrence of future episodes
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Plan A
Treat Diarrhea at Home1. GIVE EXTRA FLUID TELL THE MOTHER
Breastfeed frequently and for longer at each feed
If the child is exclusively breastfed, give ORS or clean waterin addition to breastmilk
If the child is not exclusively breastfed give one or more ofthe following: ORS, food base fluids, or clean water
TEACH THE MOTHER HOW TO MIX ORS
Home made solution: 3g/l of table salt (one level tspful)and 18g/l of common sugar
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SHOW THE MOTHER HOW MUCH FLUID TO GIVE INADDITION 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
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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 OROTHER 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
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Plan B
Treat Some Dehydration with ORSGive in clinic recommended amount of ORS over 4-hour period
DETERMINE AMOUNT OF ORS TO GIVE
DURING FIRST 4 HOURS*AGE Up to 4 mos 4 mos up to
12 mos12 mos to 2yrs
2 yrs to 5yrs
WT < 6 kg 6 < 10 kg 10
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AMOUNT OF ORS TO GIVE DURING FIRST 4HOURS
*AGE Up to 4mos
4 mos upto 11mos
12 mosto 23mos
2 yrs to 4yrs
5 14yrs
15 yrs orolder
WT < 5 kg 5 7.9kg
8 10.9kg
11 15.9kg
16 29.9kg
30 kg ormore
In ml 200
400
400
700
700
900
900
1400
1200
2200
2200
4000
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*Use the childs age only when you do not know the weight. Theapproximate amount of ORS required (in ml) can also becalculated by multiplying the childs weight (in kg) times 75
for infants under 6 mos who are not breatfed, if using the oldWHO ORS solution containing 90mmol/L of sodium also give100-200ml clean water during this period. However if using thenew 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 dehydratedadults can consume upto 750ml/hr if necessagry, children up to20ml/kg/hr
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SHOW THE MOTHER HOW TO GIVE ORSSOLUTION
AFTER 4 HOURS
Reassess the child and classify the child for dehydration
Select the appropriate plan
Begin feeding the child
MEET NORMAL FLUID NEEDS
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IF THE MOTHER MUST LEAVE BEFORECOMPLETING 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 TREATMENT1. Give extra fluid
2. Continue feeding
3. When to return
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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
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Treatment Plan C for patients with severe
dehydration1. GUIDELINES FOR INTRAVENOUSREHYDRATION
Give 100ml/kg Ringers Lactate Solutiona divided asfollows:
Age First give 30ml/kg in: Then give 70ml/kg in:
Infants (under12 months)
1 hourb 5 hours
Older 30 minutesb
2 hoursReassess the patient every 1 2 hrs. If hydration is not improving, give the IV dripmore rapidlyAfter 6 hrs (infants) or 3 hrs (older patients), evaluate patient using the assessmentchart. Then choose the appropriate Treatment Plana
if Ringers Lactate Solution is not available, nomal saline may be usedb Repeat once if radial pulse is still very weak or not detectable
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2. MONITOR THE PROGRESS OF INTRAVENOUSREHYDRATION
3. ELECTROLYTE DISTURBANCES Hypernatremia
Serum Na > 150mmol/L
Can cause convulsions
Hyponatremia Serum Na < 130mmol/L
Lethargy, less often, seizures
Hypokalemia
Serum K+
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Management of Suspected
Cholera Cholera differs from acute diarrhea of other causes in 3ways: It occurs in large epidemics that involve both children
and adults
Voluminous watery diarrhea may occur, leading rapidlyto sever dehydration with hypovolemic shock
For cases with sever dehydration appropriate antibioticsmay shorten the duration of the illness
Antimicrobial Therapy
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Management of Acute Bloody Diarrhea
(Dysentery) Shigella is the most common cause of bloody diarrhea
Ciprofloxacin for 3 days
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Out Patient Management of Bloody Diarrhea
CHILD WITH LOOSE STOOLSWITH BLOOD
SEVERELY MALNOURISHED?
GIVE ANTIMICROBIAL FORSHIGELLA
BETTER IN 2 DAYS?
No
No
REFER TO
HOSPITALYes
COMPLETE 3DAYSTREATMENTYes
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INITIALLY DEHYDRATEDAGE< 1Y/O OR MEASLES
IN PAST 6 WEEKS
CHANGE TO SECONDANTIMICROBIAL FORSHIGELLA b
BETTER IN 2 DAYS?
No
COMPLETE 3DAYS
TREATMENTYes
REFER TOHOSPITALYes
REFER TO HOSPITAL ORTREAT FOR AMOEBIASIS
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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 seriousnon-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
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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
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Management of Diarrhea with Severe
MalnutritionAssess for Dehydration
Manage Dehydration
Feeding Use of antimicrobials
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Prevention of Diarrhea Breastfeeding
Improved feeding practices
Use of safe water Handwashing
Food safety
Use of latrines and safe disposal of stools
Measles immunization
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