Continuing Nutrition Education Session Saturday, 6th September, 2014

Diarrheal diseases in children(acute diarrhea)

Dr. Sina Aziz PhD.Prof. Paediatrics

Abbasi Shaheed Hospital & KMDC

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Definition

• Diarrhea is best defined as excessive loss of fluid and electrolyte in stool

• ACUTE diarrhea is defined as sudden onset of excessively loose stools of >10mL/kg/day in infants and >200 gms per 24 hr in an adult.

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Severe Dehydration

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PhysiologySmall intestine

Greatest volume of intestinal water is absorbed

absorbs 10-11 L/day (adults)

Disorders – produce voluminous diarrhea

Large intestine concentrates intestinal

contents against a high osmotic gradient

Absorbs approximately 0.5L

Disorders produce lower-volume diarrhea

Dysentry small volume, frequent bloody stools with mucus, tenesmus and urgency- symptom of colitis

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Pathogenesis

• Secretory• Osmotic• Motility

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Secretory diarrhea

• When intestinal epithelial solute transport system is an active state of secretion

• Caused by a secretagogue such as cholera toxin, binding to a receptor on the surface epithelium of the bowel and stimulating intracellular accumulation of cAMP or cGMP

• Intraluminal fatty acids and bile salts cause the colonic mucosa to secrete through this mechanism

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Secretory diarrhea cont….

• Diarrhea not associated with an exogenous secretagogue can also have secretory component (congenital microvillous inclusion disease)

• Secretory diarrhea is usually of a large volume and persists even with fasting

• Stool osmolality is indicated by the electrolytes and the ion gap is 100mOsm/kg or less

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Calculation of ion gap

Ion gap = stool osmolality-[(stool Na + stool K) x 2]

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Osmotic diarrhea

Occurs after ingestion of a poorly absorbed solute

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

one that is not well absorbed because of a disorder of the small bowel (lactose with lactase defiency or glucose with rotavirus diarrhea)

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Osmotic diarrhea

• Malabsorbed CHO is fermented in colon, and short-chain fatty acids (SCFAs) are produced

• SCFAs can be absorbed in the colon and used as energy source, net effect is increase in osmotic solute load

• This form of diarrhea is of less volume than a secretory diarrhea and stops with fasting

• Osmolality of the stool will not be explained by the electrolyte content, because another osmotic component is present and the anion gap is > 100 mOsm

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Motility disorders

• Motility disorders can be associated with rapid or delayed transit and are not generally associated with large volume diarrhea

• Slow motility can be associated with bacterial overgrowth leading to diarrhea

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Mechanism of DiarrheaMechanism Defect Stool Examples Comment

Secretory ↓ absorption,↑ secretion, electrolyte transport

Watery, normal osmolality with ion gap < 100mOsm/kg

Cholera, toxigenic E.coli, carcinoid, VIP, neuroblastoma, congenital chloride diarrhea, clostridium difficile, cryptosporidiosis (AIDS)

Osmotic Maldigestion, transport defects ingestion of unabsorbablesubstances

Watery, acidic and reducing substances; inc. osmolality with ion gap >100mOsm/kg

Lactase deficiency, glucose-galactosemalabsorption,lactulose, laxative abuse

Stops with fasting; ↑ breath hydrogen with CHO malabsorption; no stool leucocytes

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Mechanism of Diarrhea

• Mucosal invasion

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Primarymechanism

Defect Stool examination Examples comment

↑motility ↓transit time Watery, acidic,andreduced substances; increasedosmolalitywith ion gap > 100mOsm/kg

IBD, thyrotoxicosis, postvagotomydumping syndrome

Infection can also contribute to inc. motility

↓motility Defect in neuromuscular unit(s) stasis(bact.overgrowth)

Loose to normal appearing stool

Pseudo-obstruction, blind loop

±bacterial growth

↓ SA(osmotic, motility)

↓ functional capacity

watery Short bowelsyndrome, CD, rotavirus

May require alimental diet plus parenteralalimentation

Mucosal invasion

Inflammation, ↓ colonic reabsorption, ↑ motility

Blood and ↑ WBCs in stool

Salmonella, shigella, infection:amebiasis; yersinia, campylobacter

Dysentery -blood, mucus, WBCs

Causes of Diarrhea in children

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Lactose intoleranceCongenital lactase deficiency

• Symptoms occur on exposure to lactose in milk

• Rare, less than 50 cases reported in the world

Secondary lactase deficiencyFollowing celiac disease, rota

virus infectionTreatment: Infants: lactose free formula, cow

or soya milkOlder children: low lactose milk

can be consumedAddition of lactase to diet

alleviates symptomsLive culture yoghurt contains

bacteria that produce lactase enzymes and is therefore tolerated in most patients with lactase defiency

Hard cheeses have small amount of lactose and are well tolerated

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EHEC -E.coli 0157-H7, STEC-Shiga toxin-producing E.coli

• Incubation period 1-8 days• Signs and symptoms – severe diarrhea -often bloody,

abdominal pain, vomiting, little or no fever• More common in children < 4 yr old.• Duration of illness 5-10 days• Associated foods undercooked beef especially hamburger,

unpasteurized milk and juice, raw fruits and vegetables (e.g., sprouts), salami (rarely), contaminated water

• Lab; stool c/s; positive isolates -public health laboratories• Supportive care, monitor renal function, Hb, platelet • Associated with HUS. ? Studies indicate that treatment with

antibiotic might promote HUS

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Enterotoxigenic E.coli (ETEC)

• Incubation period: 1-3 days• Signs and symptoms: watery diarrhea, abdominal

cramps, some vomiting• Duration of illness: 3 to >7 days• Associated foods: water or food contaminated with

human feces• Laboratory testing: stool C/S, ETEC- specific testing• Treatment: supportive care, antibiotics are rarely

needed except in severe cases. Recommended antibiotics TMP-SMX and quinolones

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Vibrio cholera (toxin)• Incubation period: 24-72 hr• Signs and symptoms: profuse watery diarrhea and

vomiting, which can lead to severe dehydration and death within hours

• Duration of illness: 3-7 days, causes life threatening dehydration

• Associated foods: contaminated water, fish, shellfish, street-vended food typically latin america and asia

• Laboratory testing: stool culture, special media• Treatment: supportive care with aggressive oral and IV

rehydration. TMP-SMX children

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Shigella spp• Incubation period: 24-48 hr• Signs and symptoms: abdominal cramps, fever,

diarrhea, stools might contain blood and mucus• Duration of illness: 4-7 days• Associated foods: food or water contaminated with

human fecal material, person to person, feco-oral. Ready to eat foods touched by infected food workers, e.g raw vegetables, salads, sandwiches

• Laboratory testing: routine stool cultures• Treatment: supportive care. TMP-SMX . Nalidixic acid

or other quinolones in resistant organism especially in developing countries

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Clostridium botulinum (children &adults) preformed toxin• Incubation period: 12-72 hr• Signs and symptoms: vomiting, diarrhea, blurred vision, diplopia,

dysphagia, descending muscle weakness• Duration of illness: days to months. Can be complicated by resp

failure and death• Associated foods: home canned food with low acid content,

improperly canned commercial foods, home canned or fermented fish, herb-infused oils, baked potatoes in aluminium foil, cheese sauce, bottled garlic foods held warm for extended periods (e.g., in a warm oven)

• Laboratory testing; stool, serum and food can be tested for toxin. • Pseudomembranous nodules and charactersitic plaques- on

colonoscopy or sigmoidoscopy• Treatment; supportive care. Botulism antitoxin is helpful, if given

early in the course of illness

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Salmonella spp• Etiology: Salmonella Spp• Inc. period: 1-3 days• Signs symptoms: Diarrhea, Fever, abdominal

pain, cramps, vomiting• Duration of illness: 4-7 days• Associated foods: contaminated eggs, poultry,

unpasteurized milk or juice, cheese,contaminated raw fruits and vegetables (alfa alfasprouts, melons)

• Laboratory: Routine stool c/s• Treatment: supportive care, antibiotics, vaccine

exists S.typhi

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Nutrition

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Caloric requirement

Age Kcal/kg body wt CHO% Protein% Fat %

0-6 months 108 40-60 8-12 30-50

6-11 months 98

1-3 years 102 1-1.2g/kg/day 30-40

4-6 years 90 25-35

7-10 years 70 Same as above

Males 11-14 years 55 0.85g/kg/day Same as above

Males 15-18 years 45 Same as above

Female 11-14 years 47 Same as above

Females 15-18 years 40 Same as above

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Adapted from Brandt L. Clinical Practice of Gastroenerogy. Vol 2. Philadelphphia, PA: Current medicine Inc; 1999: Chapter 182

ERR-Estimate Energy Requirement

Equations to estimate energy requirement

INFANTS AND YOUNG CHILDREN: EER (Kcal/day) = TEE + ED

0-3 mo EER = (89 x weight[kg] -100) + 175

4-6 mo EER = (89 x weight[kg] -100) + 56

7-12 mo EER = (89 x weight[kg] -100) + 22

13-35 mo EER = (89 x weight[kg] -100) + 20

CHILDREN AND ADOLESCENTS 3-18 yr: EER (kcal/day) = TEE + ED

Boys EER = (88.5-(61.9x age[yr]+Pax [(26.7x weight[kg] +(903Xheight[m])])+ 20

Physical activity coefficient for use in EER equation e.g boys 3-18 yr = 1.00

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Nutrition in diarrhea

• Depends on the age of the child

• Severity of diarrhea• Cause of diarrhea

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Early feeding in Diarrhea• Both clinical and nutritional benefits • Induce digestive enzymes• Improve absorption of nutrients• Enhance enterocyte regeneration• Promote recovery of disaccharidases• Reduce the duration of diarrhea• Maintain growth and improve nutritional outcomes • For infants who are breastfed, breastfeeding should be continued

throughout, even during the initial rehydration phases • Not necessary to dilute formula or to give lactose free formula in

refeeding nonbreastfed infants • Children without dehydration should continue to be fed an age-

appropriate diet. • Children with dehydration should be fed an age-appropriate diet as soon

as they have been rehydrated

A Leung, T Prince; Canadian Paediatric Society, Nutrition and Gastroenterology CommitteePaediatr Child Health 2006;11(8):527-31

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Viral gastroenteritis

Components of food in diarrheaORSOral Zinc- 10 mg/day (infants

< 6 mon & 20 mg/day > 6mo)Khitchri, yoghurt, banana- KYB

dietGradually increase to include

all food components.MultivitaminVitamin A

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ORS- scientific basis

• Cotransport of glucose and sodium across the intestinal membrane

• The sodium-potassium-ATP pump on the basolateralmembrane of the enterocyte provides the gradient that drives the process.

• The cotransport system is relatively intact in infective diarrhea due to viruses or enteropathogenic bacteria, whether invasive or enterotoxigenic

• Glucose enhances sodium and, secondarily, water absorption. The optimal glucose to sodium ratio to ensure maximal sodium absorption is 1:1

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Composition of ORS & commonly consumed beveragesSolution CHO g/L Na K Cl BASE Osmolarity

ORS Mmol/L

Low osmolality 13.5 75 20 65 10 245

WHO 2005

WHO 2002 13.5 75 20 65 30 245

WHP 1975 20 90 20 80 10 311

ESPGHN 16 60 20 60 30 240

Enfalyte 30 50 25 45 34 200

Pedialyte 25 45 20 35 30 250

Rehydralyte 25 75 20 65 30 305

CeraLyte 40 50-90 20 NA 30 220

Commonly used beverages (not appropriate for diarrhea treatment)

Apple juice 120 0.4 44 45 NA 730

Coca-Cola classic 112 1.6 NA NA 13.4 650

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From centers of disease control and prevention: diagnosis and management of food borne illness, MMWR 53:1-33, 20014

Energy density food

• 1 kcal/kg/day• Protein intake: 2-3 g/kg/day• If energy food is problematic ± Amylase to diet

through germination technique

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Introduction of food after a bout of severe diarrhea• Childs hydration status and stool output must be closely

watched• Continue breast feeding or non diluted formula• Introduce one food at a time and in small amounts , adding

KYB to each food item• CHO foods- rice, wheat, potatoes, bread,cereals,lean meat,

yogurt, fruits, and vegetables are well tolerated• Calories per kg to be increased slowly, so that the child can

tolerate and absorb the food being given• Counseling of the parents extremely important during stay

in hospital and on discharge• Advise against myths• MV and supplement is required can be added, after

discussion

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Thank you

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