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Dr. Rajkumar PatilAsstt.Prof.,
Dept. of Community Medicine,AVMC, Pondicherry
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
Acute diarrhoea : <2 weeks, 90% attacks are self limited (resolved by ORS)
Persistent diarrhoea :2-4 weeks
Chronic diarrhoea : >4 weeks
Dysentery: Bloody diarrhoea
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 India 33% of total paediatric admissions
In India 17% of all deaths in indoor paediatric patients
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
Pathogen % of casesVirus Rota virus 15-25
Bacteria ETEC 10-20
EPEC 1-5
Salmonella (Nontyphoid)
1-5
V.Cholerae 01 5-10
Shigella 5-15
Campylobacter jejuni
10-15
Protozoans
Cryptosporidium 5-15
No pathogens found
- 20-30
Important pathogens in children
Viruses: cause for 50% cases of diarrhoea <2 yrCryptosporidium: 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 climatesBacterial diarrhoea: summerViral diarrhoea: winter
In tropical areasViral diarrhoea: whole yearBacterial diarrhoea: summer,rainy season
Social factors
Poverty,ignorance,illiteracy
Mode of transmissionFaeco-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
Look at(CETTT)
Condition
Well,Alert *Restless,Irritable*
*Lethargic or unconscious;Floppy*
Eyes Normal Sunken Very sunken
Tears +nt -nt -nt
Tongue Moist Dry Very Dry
Thirst Not thirsty
*Thirsty,drinks eagerly*
*Drinks poorly or unable to drink*
Feel Skin pinch
Goes back instantly
*Goes back slowly*
*Goes back very slowly*
Decide No dehydration
2 or more signs including atleast one * marked(SOME DEHYDRATION)
2 or more signs including atleast one * marked(SEVERE DEHYDRATION)
Treat Treat. A Weigh the child,Treat.B
Weigh the child,Treat C
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 cupIn 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 (months)
< 4 4-12 12-24 24-60
Weight (kg)
<6 6-<10 10-<12 12-19
Amount (ml)
200-400 400-700
700-900
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 30ml/kg in
Then give 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 treatmentRefer 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 Start rehydration (ORS solution) by tube/mouth : 20 ml/kg/hour for 6 hours.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 areaGive antibiotic for cholera
Naso-gastric tube
ORT
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(gm)
Low osmolarity(gm)
Sodium chloride 3.5 2.6
Glucose 20.0 13.5
Potassium Chloride
1.5 1.5
Trisodium citrate dehydrate
2.9 2.9
27.9 gm(310 mOsm/l)
20.5 gm(245 mOsm/l)SGPT:2.6,13.5,1.5,2.9
Ingredients Low osmolarity(mmol/l)
Sodium 75
Glucose 75
Potassium 20
Citrate 10
Chloride 65
245 mOsm/l
Hypo-osmolar ORS
SGPTC:7575,201065
Benefits of citrate ORS over bicarbonate ORS
1.Trisodium citrate made the ORS stable
2. Resulted in less stool output
Benefits of low-osmolarity ORS over normal ORS
1.Osmolarity reduced to avoid the adverse effects of hyper-tonicity
2.Need for unscheduled IV management reduced 33% in children with hypo-osmolar ORS
2.Stool output and vomiting decreased
3.India-first country in the world to launch new ORS since June 2004
Home made ORS
1 tsp table salt + 4 heaped tsp sugarin 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
I st line antibiotic: Cotrimoxazole, II nd line antibiotic:Nalidixic acid
Age/Wt. Cotrimoxazole(2 times/day for 5 days)
Nalidixic acid(4 times/day for 5 days)
Paediatric tablet20 mg TMP+100 mg SMX
Syrup40 mg+200 mg(per 5 ml)
Tablet 500 mg
2 - < 12 months(4- <10kg)
2 tab 1 tsp 1/4
1 - 5 years(10-19 kg)
3 tab 1.5 tsp 1/2
DOSAGE OF COTRIMOXAZOLE AND NALIDIXIC ACID IN DYSENTERY
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.Purgatives3.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:Boil it,cook it,peel it or forget it
c. Prevention and control of diarrhoeal epidemics
-Strengthening of epidemiological surveillance
