MANAGEMENT AND COMPLICATIONS OF ACUTE DIARRHEA

Presented by - Ritu Rajan (2012-13)

ASSESSMENT OF CHILD WITH ACUTE DIARRHEA :The evaluation of a child with acute

diarrhea aims at following :-i. To determine the type of diarrhea i.e. acute watery diarrhea(secretory), dysentry(invasive), osmotic diarrhea, or persistent diarrhea.ii. To look for the degree of dehydrtion

and associated complications.

iii. Assessment of nutritional status and feeding practices ,both preillness and during illness.

iv. Obtain appropriate contact or exposure history and rule out non- diarrheal illnesses especially systemic infections.

HISTORY - TAKING RELEVANT TO DIARRHEA :History should include following informations :i. Onset of diarrhea, duration and no. of stools

per day.ii. Blood in stools.iii. No. of episodes of vomiting.iv. Presence of fever, cough, or other

significant symptoms like convulsions ,recent measles.

v. Exposure or contact history i.e. information about exposure to contacts with similar symptoms, intake of contamintated food/

water, recent travel to a diarrhea-endemic area.

vi. Type and amount of fluids (including breast milk) and food taken during the illness and preillness periods.

vii. Use of anti-microbial agents ,other drugs or any local remedies (if taken).

vii. Immunization history

EXAMINATION OF THE PATIENT :For prompt treatment, assessment of the

hydration status of child is most important.In addition to it, following points must also be

examined : a. Features of malnutrition i.e. anthropometry

for wt. and ht. , examination for wasting, edema and signs of vitamin deficiency.

b. Features of systemic infections i.e. presence of cough, high grade fever, fast breathing and/or chest indrawing suggests pneumonia, high grade fever with splenomegaly suggests malaria.

c. Signs of fungal infections like oral thrush or perianal satellite lesions.

Hydration status can be assessed as follows :I.Clinical signs :General conition

Well-alert

Fatigued, restless, irritable

Apathetic, lethargic, unconscious

Eyes normal Slightly sunken

Deeply sunken

Thirst Drinks normally, might refuse fluids

Thirsty ,eager to drink

Drinks poorly, unable to drink

Tears +nt decreased

-nt

Mouth and tongue

moist dry Very dry

Heart rate

normal Normal to increased

tachycardia; with bradycardia in more severe cases

breathing

Normal Normal,fast

deep

Quality of pulse

normal decreased

Weak, thready or impalpable

Skinfold Instant recoil

Recoil in <2 sec.

Recoil in > 2 sec.

Capillary refilling time

normal prolonged

Minimal refilling

extremities

warm cold Cold, mottled, cyanotic

Urine output

Normal to decreased

decreased

minimal

Hydrati-on status :

The patient has NO signs of dehydration.

If the pt.has 2 or more signs, there is SOME dehydration

If the pt.has 2 or more signs, there is SEVERE dehydration

Treatme-nt plan :

Use t/t Plan `A`

Weigh the pt. , use t/t Plan `B`

Weigh the pt. , use t/t Plan `C`.

ASSESSMENT OF AMOUNT OF FLUID LOSS :Degree of dehydration

Fluid loss

NO Dehydration <50ml/kg (<3% loss of body wt.)

SOME Dehydration 50-100ml/kg(3-9% loss of body wt.)

SEVERE Dehydration >100ml/kg(>9% loss of body wt.)

Laboratory investigations :The large majority of acute

diarrheal episodes can be managed effectively in absence of lab investigations .

If warranted and if facilities and resources permit, the underlying etiology can be verified by appropriate lab testings.

The various methods of lab investigations for confirming the suspected etiological organisms causing diarrhea are :-

Etiology (bacteria)

S/S Duration of illness

Lab testing

Enterohemorrhagic E.coli(EHEC) including E. coli O157:H7 and other Shiga toxin producing E.coli (STEC)

Severe diarrhea often bloody, abdominal pain and vomiting. More common in children <4yr.old

5-10 days Stool culture ; E.coli O157:H7 requires special media. Shiga toxin may tested using commercial kits.

Contd. :-

Etiology(bacteria)

S/S Duration of illness

Lab testing

Enterotoxigenic E.coli(ETEC)

Watery diarrhea, abdominal cramps, some vomiting

3 to >7 days

Stool culture and identification requires special lab tech.

Salmonella Diarrhea,fever, abdominal cramps, vomiting

4-7 days Routine stool cultures

Contd. :-etiology

S/S Duration of illness

Lab testing

Shigella spp.

Abdominal cramps, fever and diarrhea. Stool may contain blood and mucus.

4-7 days Routine stool cultures

Staphylococcus aureus (preformed toxin)

Sudden onset of severe nausea, vomiting , diarrhea and fever may be present

24-48 hrs. Mainly clinical diagnosis. If indicated, stool, vomitus and food tested for toxin.

etiology S/S Duration of illness

Lab testing

Vibrio cholerae (toxin)

Profuse watery diarrhea and vomiting; may lead to severe dehydration and death within few hrs.

3-7 days , causes life- threatening dehydration

Stool culture. If suspected requires special medium for growth.

Vibrio parahemolyticus

Watery diarrhea, abdominal cramps, nausea, vomiting

2-5 days Stool culture and specific testing

Etiology (viral)

S/S Duration of illness

Lab testing

Rotavirus Vomiting, watery diarrhea, low-grade fever. Temporary lactose intolerance may occur.

4-8 days Immunoassay for identification of viruses in stool

Noroviruses( and other caliciviruses)

Nausea, vomiting, abdominal cramping, diarrhea, fever, myalgia and headache.

12-60 hrs. Routine RT-PCR and EM on fresh unpreserved stool. Clinical diagnosis, negative bact. cultures, WBCs absent.

Etiology(parasitic)

S/S Duration of illness

Lab testing

Giardia lamblia diarrhea., stomach cramps, gas, wt.loss

Days to wks. Stool examination for ova and parasites - atleast 3 samples

Entamoeba histolytica

Diarrhea (often bloody), frequent bowel movements, lower abdominal pain

Several wks. To mnths.

Stool examn. For cysts and parasites. Serology for long- term infns.

Cryptosporidium

Diarrhea( usually watery ), stomach cramps, upset stomach

May be remitting ans relapsing over wks. To mnths.

Specific examination for Cryptosporidium. Also examine water and food.

STOOL EXAMINATION :Microscopic examination and culture of

stool is most routinely practiced to know the cause of diarrhea.

Stool specimens or rectal swabs should be collected from children with acute diarhea in following cases :

i. watery diarrhea (suspected cholera)ii. Bloody diarrhea (dysentry)iii. Malnourished and immuno-compromised

childreniv. In outbreaks with suspected HUS.

Stool specimens are examined for mucus, blood & leucocytes.

Fecal leucocytes are indicative of bacterial invasion of gut mucusa.

In endemic areas, stool microscopy must include examination for parasites causing diarrhea such as G.lamblia and E.histolytica .

Stool specimens for culture need to be transported and plated quickly; if latter is not available , specimens may need to be transported in special media k/a TRANSPORT MEDIA.

TRANSPORT MEDIA : Cary Blair transport medium - can be used to transport Shigella , V.

cholerae , E.coliO157:H7. because of high ph (8.4), it is the medium of

choice for V. cholerae . Amie’s and Stuart’s media - both are acceptable for Shigella and E. coli

O157:H7 ; but they are inferior to Cary Blair medium for transport of V. cholerae.

Buffered Glycerol Saline (BGS) - used for Shigella, but is unsuitable for V.

cholerae .

NOTE : In most previously healthy children with uncomplicated watery diarrhea, no laboratory evaluation is needed for epidemiologic purposes.

If diarrhea is associated with findings indicative of complications such as pallor, labored breathing, altered sensorium, seizures, paralytic ileus or oliguria , additional laboratory investigations need to be performed. They are :-

i. Stool phii. Complete hemogramiii. Blood gas estimationiv. Serum electrolytesv. Renal function tests , etc..

MANAGEMENT OF A CHILD WITH ACUTE DIARRHEA :It is based on following basic principles :a) Rehydration and maintaining hydration.b) Correction of electrolyte and acid-base

imbalance.c) Ensuring adequate feeding.d) Oral supplementation of Zinc.e) Early recognition of danger signs and t/t of

complications.f) Nutritional rehabilitation.g) Health education for prevention of diarrhea.

ORAL REHYDRATION THERAPY (ORT)With the discovery of glucose-dependent

sodium pump in the small bowel, which results in passive absorptin of water and other electrolytes , the concept of rehydration has been revolutionaized.

The glucose- dependent sodium and water absorption is the principle behind replacing glucose and sodium in 1:1 molar ratio in WHO-ORS for optimum absorption.

NOTE : While making ORT, the osmolarity of the replacement fluid should not exceed that of blood (290 mmol/L) ; for maintenance of concentration gradient b/w intestinal lumen and blood stream to allow greater absorption of fluids into blood.

ORAL REHYDRATION SALTS (ORS) SOLUTION :Home - made or commercially available salt

and sugar solutions for rehydration are k/a oral rehydration salts (ORS) solutions.

Optimum absorption of glucose takes place from the intestines b/w a glucose concentration of 111-165 mmol/L and sodium :glucose ratio b/w 1: 1 to 1:1.4 .

Moreover, meta-analysis have shown that use of Low- osmolarity ORS has many advantages over standard WHO-ORS (osml. = 311mmol/L).

Since 2004, based on the WHO- UNICEF and IAP recommendations, the Govt. of India has adopted the Low- osmolarity ORS (osml. = 245 mmol/L) as the single universal ORS to be used for al ages and all types of diarrhea.

Advantages of Low-osmolarity ORS are :a. Reduction in stool output.b. Decrease in vomiting.c. Decrease in use of unscheduled i.v. fluids.d. Decreased risk of hypernatremia.

COMPOSITION & CONCENTRATION OF STANDARD WHO-ORS :Ingredients

Composition (gms./L)

Ingredients

Concentration (mmol/L)

Sodium chloride

3.5 Sodium 90

Potassium chloride

1.5 Potassium 80

Trisodium citrate (anhyd.)

2.9 Citrate 10

Glucose (anhyd.)

20 Glucose 111

Osmolarity =

311

LOW- OSMOLARITY ORS FORMULATION RECOMMENDED BY WHO/UNICEF :Ingredients

Grams/L Ingredients

mmol/L

Sodium chloride

2.6 Sodium 75

Glucose (anhyd.)

13.5 Glucose 75

Potassium chloride

1.5 PotassiumChloride

2065

Trisodium citrate

2.9 Citrate 10

Osmolarity = 245

Home- available fluids for acute diarrhea ( can be used if ORS formulations not available) :Fluids that contain salt (preferable)

Salted drinks (e.g. salted rice water or salted yoghurt drink), vegetable or chicken soup with salt.

Fluids that donot contain salt (acceptable)

Plain water, unsalted rice water, unsalted soup, yoghurt without salt, green coconut water, weak unsweetened tea, fresh fruit juice .

Unsuitable home available fluids

Commercial carbonated beverages, commercial fruit juices, sweetened tea.

Treatment Plan ‘A’ : for ‘NO’ dehydration The objective of Plan ‘A’ is prevention of

dehydration and malnutrition.The management can be successfully carried

out at home , by the mother / caretaker who is advised to :

i. WHO-ORS or other ORT fluids are to be given as per advise;

ii. Continue feeding; andiii. Bring the child back after 2 days, or earlier if he

has any of the danger signs (increased volume or frequency of stools, repeated vomiting, increasing thirst, irritable/restless, fever, blood in stool, refusal to feed, lethargic ).

ORT as per Plan ‘A’ :Age Amt. of

ORS/ORT fluids to be given after each loose stool

Total amount of ORS to provide for use at home

< 24 months 50-100 ml 500ml/day2-10 yrs. 100-200 ml 1000ml/day> 10 yrs. As much as child

can take 2000ml/day

NOTE : -A teaspoonful is given every 1-2 min. for a child <2yrs.-Frequent sips from a cup are given for older children.-Following vomiting, wait for 10 mins.and give ORS more slowly.-If danger signs appear or diarrhea continues, consult doctor.

Treatment Plan ‘B’ : for ‘SOME’ dehydrationThe objective of Plan ‘B’ ia to treat

dehydration and electrolyte imbalance; and to continue feeding.

These cases need to be treated in a health center or hospital.

While transporting, ORT must be promptly started and continued.

Fluid requirement is calculated as per :i) Normal daily fluid requirement (+)ii) Deficit replacement or rehydration therapy (+)iii) Maintenance fluid therapy to compensate losses .

i. Daily fluid requirement :- It is calculated as follows -

- upto 10 kg = 100ml/kg - 10-20 kg = 50ml/kg - >20 kg = 20ml/kgii. Deficit fluid or rehydration therapy :- It is calculated as

75ml/kg of ORS , to be given over 4 hrs.. If ORS cannot be taken orally then nasogastric tube can be used.

If after 4 hrs. , child still has some dehydration then another t/t of ORS is to be given. This is effective in 95% cases.

For infants<6mo.who are not breastfed, along with WHO-ORS 100-200 ml plain water must be given in addition. Breast -feeding must be encouraged.

When body wt. is not known , amount of ORS required can be calculated according to age as follows :

Fluid calculation acc.to age as per Plan ‘B’ :-

Age <4mo.

4-11mo.

12-23mo.

2-4yr.

5-14yr.

>= 15yr.

weight

<5kg 5-8kg 8-11kg

11-16kg

16-20kg

>30kg

ORS, ml

200-400

400-600

600-800

800-1200

1200-2200

>2200

No. of glasses

1-2 2-3 3-4 4-6 6-11 12-30

iii. Maintenance fluid therapy :- If patient becomes rehydrated i.e. signs of dehydration disappear, continue treatment with ORS as per Plan ‘A’ for NO dehydration.

Breastfeeding and semi-solid food should be continued and plain water can be offered in between.

If ORT is not successful, treat as SEVERE dehydration with i.v. fluids as per Plan ‘C’ .

Treatment Plan ‘C’ : for ‘SEVERE’ dehydration The primary objective of Plan ‘C’ is to quickly

rehydrate the child in a hospital with facilities for I.V. fluid therapy .

Ringer’s lactate with 5% dextrose is the preferred solution for rehydration . Normal saline or plain Ringer solution may be used as an alternative ,but 5% dextrose alone is not effective.

A total of 100ml/kg of fluid is given ,over 6hr.in children < 12months and over 3hr.in children >12 months . ORS solution be started simultaneously if the child can take orally.

If i.v. fluids cannot be given , nasogastric feeding is given at 20ml/kg/hr. for 6hr. (total 120ml/kg) .

The child should be reassessed every 1-2 hr; if there is repeated vomiting or abdominal distension , the oral or nasogastric fluids are given more slowly . If there is no improvement in hydration after 3hr. , IV fluids should be started at the earliest.

MONITORING : Assess for improvement every 1-2 hr. :- - If not improving, give IV infusion more rapidly. - Encourage oral feeding by giving ORS 5ml/kg/hr,

along with IV fluids ,as soon as child is able to take.

Reassess hydration status :- - The child should be reassessed every 15-30 min.

for pulses and hydration status after the first bolus of 100ml/kg of IV fluid.

- The child should be observed for atleast 6 hr. before discharge, to confirm that the mother is able to maintain the child’s hydration by giving ORS solution.

- It is recommended that severely malnourished children should be slowly rehydrated, carefully monitored and feeding to be started early.

- Infants below 2 months of age must be carefully monitored as they are prone to septicemia and severe electrolyte imbalance.

ZINC SUPPLEMENTATION :Zinc supplementation is now part of the standard

care along with ORS in children with acute diarrhea.

Zinc deficiency and intestinal losses during diarrhea aggravate the deficit .

Zinc is helpful in decreasing severity and duration of diarrhea and also the risk of persistence.

DOSE : Zinc is recommemded to be supplemented as sulphate , acetate or gluconate formulations ; at a dose of 10mg of elemental Zn per day for children< 6mo. & 20mg per day for >6mo. For a period of 14 days.

FEEDING DURING DIARRHEA :

Recommended schedule of feeding

Breastfed infants Continue breastfeeding

non-breastfed infants Shld .be preferably given only ORS till they are rehydrated.Animal milk/food sld.be offered .

Severely malnourished children

As soon as possible , food should be offered i.e. energy-giving foods .

During rehydration phase -

After rehydration phase -Recommended feeding

Breastfed infants Breastfeed more frequentlynon-breastfed infants Offer undiluted milk as

before Infants (6-12 months) Give easily digestible

energy-rich complementary foods in addition to breast/animal milk.Encourage to increase frequency of feeding.

Older children Staple foods enriched with fat,oil and sugar. Fruits like banana ,legumes (rich in K ). Vit. A rich foods.Encourage to eat atleast 6 times a day.

ANTI-MICROBIAL THERAPY :Causes Drugs of

choiceDoses

Cholera Doxycycline or

Furazolidone or

Trimethoprim - sulfamethoxazole

Single dose of 5mg/kg (max. = 200 mg)5-8mg/kg/day in 4 divided doses * 3 daysTMP 10mg/kg and SMX 50mg/kg in 2 divided doses *3 days

Causes D.O.C. DosesDysentery TMP + SMX or

Nalidixic acid or

Ciprofloxacin (resistant-cases)

TMP 10mg/kg and SMX 50mg/kg in 2 divided doses * 5 days60mg/kg/day in 4 divided doses * 5days

Amoebic dysentery

Metronidazole 30mg/kg/day in 3 divided doses * 5-10 doses

Acute giardiasis Metronidazole or

Tinidazole

15mg/kg/day in 3 divided doses *5 days10-15 mg/kg/day in 3 divided doses * 5 days

ADDITIONAL DRUG THERAPY FOR ASSOCIATED SYMPTOMS : Severe or recurrent vomiting - single dose of

Ondansetron (0.1-0.2 mg/kg/dose ) can be given.

Abdominal distension - no specific treatment required.

Paralytic ileus - (if bowel sounds absent ) may occur d/t hypokalemia, antimotility drugs or septicemia ; oral intake should be stopped.

Hypokalemia with paralytic ileus - IV fluids only and nasogastric aspiration , along with KCl (30-40mEq/L) I.V. ; provided child is passing urine.

Convulsions - to be treated as per the underlying etiology.

PREVENTION OF DIARRHEA AND MALNUTRITION :The three important measures are : 1. Improving infant feeding practices and

personal and domestic hygiene which includes:

• Promotion of exclusive breast-feeding upto 6 months of age.

• Improved complementary feeding practices.• Use of clean drinking water .• Three Cs : clean hands,clean container and

clean envt.. • Adequate sewage disposal system and clean

water supply.

II. Proper nutrition and care of mother as well as child during the antenatal, natal and post-natal periods. Adequate awareness of the mother about symptoms of diseases and vigilance to consult doctor .

III. Vaccination : Recent studies have demonstrated safety and efficacy of RVV (RotaVirus Vaccine) and thereby suggesting a combined preventive and t/t strategy ( vaccine, ORS and Zn supplements) to reduce child mortality d/t diarrhea. RVV has been scheduled as routine vaccine as per IAP recommendation at 6, 10 and 14 wks.of age.

COMPLICATIONS OF ACUTE DIARRHEA : Majority of the ccomplications associated

with diarrhea are related to delays in diagnosis and early institution of prompt treatment.

Without early and appropriate rehydration ,children may develop complications ; which can be life- threatening.

Inappropriate t/t can lead to prolongation of episode of illness , consequent malnutrition , secondary infections and micronutrient deficiencies.

Thus , various complications associated with diarrhea can be listed as follows :

1. Persistent diarrhea2. Malnutrition 3. Vitamins and mineral deficiencies4. Hypoglycemia resulting in convulsions

and permanent brain damage.5. Hypo- or hyper- natremic seizures6. Focal infections d/t systemic spread of

pathogens like UTI, endocarditis, pneumonia, meningitis, osteomyelitis, encephalitis, etc..

7. Reactive arthritis8. Glomerulonephritis and IgA

nephropathy9. Hemolytic Uremic Syndrome

(sudden onset ,short - term renal failure )

10.Heart failure due to severe electrolyte imbalances .

THANK YOU HAVE A GREAT DAY