Diarrhea Management in the Community
CHILDHOOD DIARRHEA
One in 5* children die of diarrhea or diarrhea related complications every year in India.
Diarrheal illness is the second leading cause of child mortality; among children younger than 5 years, it causes 1.5 to 2 million deaths annually. In developing countries, children experience between three to six episodes of diarrhea annually.
*Predicting the distribution of under-five deaths by cause in countries without adequate vital registration systemsSaul S Morris,1 Robert E Black2 and Lana Tomaskovic3(International Journal of Epidemiology 2003;32:1041–1051)
Magnitude of problem• In India,~380,000 *children die from diarrhea and its
complications every year.• 9.8 million child deaths each year, 2/3 of which are
preventable with low-cost interventions• 2 million child deaths from diarrhea, 88% of Diarrhea
diseases are preventable by easily available interventions.
• Diarrheal diseases are responsible for 18%** of deaths among children under 5 years of age.
• Despite easy and affordable treatment, most patients do not access the recommended treatment.
• Timely use of ORS-Zinc can save over 133,000 lives by 2015***
• *World Health Organization, Global Burden of Disease estimates, 2004 • update. **Causes of Child Deaths - March 26, 2005 The Lancet ***Role of zinc administration in prevention of childhood diarrhea and pneumonia-a meta analysis,Agarwal I R,Sentz J,Miller M A,Paediatrics • 2007,June 119(6)•
Causes of Child Deaths in Low-Income Countries: Diarrhea 18%
Source: WHO, World Health Statistics 2011
What is Diarrhea?
• Any Change in number or consistency of stools in exclusively breast-fed children.
• Passage of 3 or more than 3 loose or watery stools in 24 hours in children over 2 months of age.
• Diarrheal illness may be of the following types- acute watery diarrhea and chronic or persistent diarrhea (lasting for ≥14 days).
• Blood in stools-Dysentery.• Usually seen in children between 2 months and
5 years of age.
When is it NOT Diarrhea?
• Frequent passage of soft, semi-solid stools in an exclusively breast-fed child.
• No change in consistency or number of stools.
Diarrhea and Dehydration
Cause Effect
•Passage of 3 or more than 3 loose or watery stools in 24 hours.•Any Change in number or consistency of stools.•Often associated with vomiting.
•During diarrhea and/vomiting, there is loss of water and electrolytes.•Dehydration occurs when these losses are not replaced adequately and a deficit of water and electrolytes develops.
Consequences of Diarrhoea
The two main dangers: malnutrition and death. Commonest cause of diarrhea related deaths: dehydrationEqually important causes of death are dysentery and prolonged malnourishing diarrheaMalnutrition is associated with nearly two-thirds of diarrhea-related deaths.
Diarrhea & MalnutritionVicious cycle
Absorption Appetite
Voluntary restriction
Immunity Mucosal integrity
Commonpredisposing factors
Losses Catabolism
What are our challenges in the treatment of diarrhea?
• Low ORS use rates
• Use of zinc as an adjunct to ORS
• Inappropriate management of dehydration
• Inadequate emphasis on feeding
• Irrational use of antimicrobials & other
drugs
• Hand washing
CARE SEEKING BEHAVIOUR
Prescription Practices- 10 district survey in India
ORS 47%
Zinc 1.3%
Antibiotics 5.6%
Injections 23.0%
Antidiarrheals 18.2%
Tonic 31.5%
Management Practices for Childhood Diarrhea in India , UNICEF 2009
Two simple rules for effective management of Diarrhea
•ORS
•ZINC
ORSORAL REHYDRATION
SOLUTION
ORS-Benefits• Replaces water and salts lost during
diarrhea.
• Reduces dehydration and need for hospitalization.
• Decrease in severity of diarrhea and vomiting.
• Decrease in duration of illness.
Low osmolarity ORS Composition
Ingredient g/L Dissociates into mmol/L
Glucose, anhydrous
(C6H12O6)
13.5 Glucose 75
Trisodium Citrate,dihydrate
Na3C6H5O7·2H2O
2.9 Sodium 75
Sodium Chloride (NaCl)
2.6 Chloride 65
Potassium Chloride (KCl)
1.5 Potassium 20
TOTAL 20.5 Citrate 10
TOTAL 245
Preparation of ORSThree Important Rules
CLEAN HANDS
CLEAN WATER
CLEAN UTENSILS
Preparation of ORS
WHAT IS ZINC?
What are it’s benefits?
What is Zinc?• Zinc is a micro-nutrient and promotes immunity.• It is an important antioxidant and preserves cellular membrane
integrity.• Promotes the growth and development of the nervous system. • Rich sources of Zinc are foods of animal origin, such as meat and
fish.• Zinc is also present in nuts, seeds, legumes, and whole grain
cereal, but the high phytate content of these foods interferes with its absorption.
• Zinc cannot be stored in the body, and zinc excretion through the gastrointestinal tract is increased during episodes of diarrhea.
• Young children who have frequent episodes of diarrhea and have diets low in animal products and high in phytate-rich foods are most at risk of Zinc deficiency.
ZINC- Benefits• Zinc reduces the fluid and salt loss in stools by
improving mucosal permeability. • Accelerated regeneration of mucosa• Increased levels of brush-border enzymes• Enhanced cellular immunity • Higher levels of secretory antibodies• Zinc improves absorption of ORS.• Reduces the severity and duration of illness.• Reduces need for antibiotics.• Reduces the chances of complications.• Full dose for 14 days protects against diarrhea and
pneumonia for next 3 months.• Acts as a general tonic-improves appetite and
promotes growth.
Research Studies on efficacy of Zinc
• A study conducted by an international team of scientists working in Bangladesh and led by researchers from the Johns Hopkins Bloomberg School of Public Health.
• The researchers treated 8,070 children with diarrhea
living in areas of Bangladesh.
• Groups of children were randomized by region to receive zinc in addition to standard treatments and compared to children who did not receive zinc.
• The children in the zinc areas received 20 mg elemental zinc daily for 14 days during each episode of diarrhea in addition to ORS therapy.
Research Studies-Contd.
• The researchers found the incidence of diarrhea was significantly less and non-injury deaths were 50 percent less in children who received zinc compared to those who did not.
• In addition, it was found that oral rehydration solution therapy (ORS) use, which is one of the standard treatments for diarrheal disease, increased by 20 percent among the children who received zinc. Antibiotic use decreased by 60 percent among the same group. These findings are published in the November 9, 2002, of the British Medical Journal.
Recommendations for Use of Zinc in
Acute Diarrhea• WHO/UNICEF Joint Statement (2001)• Endorsed by Indian Academy of
Pediatrics (2003)• Endorsed by Government of India
(2006)• Zinc has been included in the WHO
and India Essential Medicines List for the treatment of diarrhoea
• Zinc tablets included in Kit-A
Evidence of Efficacy of ZINC
• 15% faster recovery during the episode of diarrhea*.• 16 % decrease in duration of diarrhea*.• 24% decrease in frequency of episodes lasting more
than 7 days*.• 9-23% decrease in frequency of stools*.• Up to 31% reduction in stool output during the episode
of diarrhea**.• 42% reduction in treatment failure or death in persistent
diarrhea*ACUTE CHILDHOOD DIARRHEA: A REVIEW OF RECENT ADVANCES IN THE STANDARD MANAGEMENTSeema Alam, Rajeev Khanna, Uzma FirdausPediatric Gastroenterology Section, Department of Pediatrics, JNMC, AMU, Aligarh**Zinc with ORT reduces the stool output and duration of diarrhea in hospitalized children -a randomized controlled trial;S Bhatnagar et al, Dept of Paediatrics at AIIMS and Kasturba Hospital ,New Delhi***Zinc Investigators’ Collaborative Group. AJCN 2000.
Long Term Effects of Zinc
• Zinc supplementation for 10-14 has longer term effects on childhood illnesses in the 2-3 months after treatment
• 34% reduction in prevalence of diarrhoea
• 26% reduction in incidence of pneumonia
Zinc Investigators’ Collaborative Group. Pediatrics. 1999.
Cost Effectiveness of ORS and Zinc Supplementation
• Decreases the duration and severity of the episode
• Decreases the need for expensive hospitalization
• Decreases the use of unnecessary antibiotics and other drugs
• Further cost-benefit analyses are underway
Robberstad, Strand, Sommerfelt, and Black. Bull WHO 2004.Baqui, Black, Arifeen. J Health Pop Nutr. 2004.
Current total costs of treating a case of diarrhea higher than the
cost of Zinc treatment
Location of treatment
Reported total costs of treating a case of diarrhea, for differing levels of perceived severityMild Moderate Severe
At home <Rs. 50 Rs. 50-100
Private clinic
Rs.100-200 Rs. 300-500 Rs.500-1500
ORS sachets are sold for Rs 5-7 in the private sector ($0.10-$0.14). Zinc treatment for 10-14 day regimen costs ~Rs.28-33 in the private sector ($0.56-$0.66)Source: Formative research in preparation for promotion of zinc treatment for childhood diarrhea: Cross-country comparison of diarrhea treatment practices and implications for programs; June 2004
Dosage of Zinc
• Available as ZINC Tablets.
• Given for 14 days for full benefits.
• 20 milligrams per day for children older than six months.
• 10 mg per day in those younger than six months.
Administration of ZINC
Age Tablet Preparation Duration
Less than 2 months
Not required
2 months – 6 months
½ tablet
(10 mg)
Dissolved in 1 tsp of breast
milk
14 days
6 months- 5 years
1 tablet
(20 mg)
Dissolved in 1 tsp of breast
milk/ORS/clean drinking water
14 days
Objective of Treatment
• Prevent dehydration, if no signs of dehydration are present.
• Treat dehydration, if present.
• Reduce duration and severity of illness.
• Prevent nutritional damage.
• Reduce the occurrence of future episodes.
WHO-UNICEF recommended policies
• Caregivers/ mothers should start treatment with new low osmolarity ORS solution immediately upon onset of diarrhea in a child.
• Zinc supplementation with 20 mg per day of zinc supplementation for 14 days (10 mg per day for infants under six months old).
• Emphasize continued feeding or increased breastfeeding during, and increased feeding after, the diarrheal episode.
• Emphasize handwashing.
Zinc LossWater + Electrolytes Loss
Lessen absorption capacityDecreases Immunity
Dehydration
Faster Recovery of Intestine Mucosa Increase in absorption capacity
Increase in immunityRehydration
ORS Zinc Tablets
Diarrhea
Management of Diarrhea and Dehydration
ASK How long?
How many?
Is the child passing urine?
3-7 days
Yes, freely
7-14 days
Yes, but in decreased quantity
More than 14 days
Blood in stool
Greatly reduced urine output
No Dehydration Some Dehydration
Severe Dehydration
SEE Condition Well , Alert Restless , Irritable
Lethargic, unconscious
Eyes Normal Sunken Sunken
Thirst Drinks normally, Not thirsty
Thirsty, drinks eagerly
Drinks poorly or not able to drink
Skin pinch Goes back quickly
Goes back slowly bit in less than 2 seconds
Goes back very slowly, in more than 2 seconds
Fluid deficit <5 % of body wt or 50 ml./ kg
body wt
5-10% of body wt or 50-100 ml / kg
body wt
>10% of body wt or 100 ml / kg
body wt
DO PLAN A PLAN B PLAN C
Assessment of a child with Diarrhea
PLAN A Home therapy to prevent dehydration and malnutrition Children with no signs of dehydration need extra fluid and salt to replace their losses of
water and electrolytes due to diarrhea.
Fluids to be givenORS
Salted drinks e.g. salted rice water, salted yoghurt drink ,green coconut water. Home based ORS.
Plain water should also be given. Commercial fizzy drinks, fruit juices, sweetened tea, coffee, medicinal tea should be
avoided.
How much to give?
Give as much fluid as the child wants until diarrhea stops. Children < 2 years of age : 50-100 ml of fluid. Children 2 years - 10 years : 100-200 ml.
Older children and adults : As much as they want.
Zinc supplement Give 10 / 20 mg (depending on age of the child) every day for 14 days.
What feeds to give?
Breastfeeding should always be continued. The infant's usual diet should be continued during diarrhea and increased afterwards.
.Emphasize washing of Hands
PLAN B
For children with some dehydration• Approximate amount of ORS required (in ml) can be calculated by multiplying
the patient's weight in kg by 75.• More can be given, if required.• Breast feeding should be continued. • No other foods are to be given during the initial period.• After 4 hours, the child should be given some food every 3-4 hours.• After 4 hours, reassess the child and decide what treatment to be given next as
per level of dehydration.• Referred for IV rehydration if dehydration persists.
AGE <4 months
4-11
months
12-23 months
2-4 years 5-15 years >15 years
WEIGHT
<5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9 kg 30 kg or more
ML 200-400 ml
400-600 ml
600-800 ml
800-1200 ml
1200-2400 ml
2400-4000 ml
CUPS(200 ml)
2 3 5 7 12 20
Signs of Dehydration
PLAN C
For children with severe dehydration
• Refer the patient.
• Preferred treatment is rapid intravenous rehydration.
Skin pinch test for dehydration
Why are drugs prescribed in Diarrhea?
•Lack of Knowledge•Lack of confidence in ORS
and Zinc•Families demand drugs and
Injections•Consultation/ Dispensing
fees
Irrational use of drugs• Increases the cost of therapy• Diverts attention from main therapy- ORS, feeding and Zinc• Side-effects - antibiotic induced diarrhea• Complications- Simple infection converted into a life- threatening infection due to - - Abdominal distension, - Paralytic ileus - Respiratory depression - Septicemia - Pseudomembranous entero-colitis• Drug resistance
Antibiotics, Adsorbents and Anti-motility drugs are NOT indicated in the routine treatment of acute childhood diarrhea.
Danger Signs
Refer immediately if-• Does not improve within 3 days.• Increase in the number of stools.• Develops very watery or bloody stools.• Severe vomiting.• Marked reduction in urine output.• Develops high grade fever.• Decrease in alertness or consciousness.
Prevention of diarrhea
• Exclusive breast feeding for 6 months
• Complementary feeding at 6 months
• Hand washing
• Safe drinking water
• Environmental sanitation and safe disposal of excreta
• Measles vaccination
CONCLUSION• A substantial reduction in the diarrhea burden will require
greater emphasis on the following actions:• Reinstate diarrhea prevention and treatment as a cornerstone
of community-based primary health care. • Reach every child with effective interventions.• Ensure wide availability of low-osmolarity ORS.• Ensure wide availability and use of zinc.
THERE IS NO BETTER TIME THAN NOW
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