02.Diarrhoea in Children

7/30/2019 02.Diarrhoea in Children

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Diarrhoea in children

Dr. K.A.W.Karunasekera

Department of Paediatrics

Faculty of Medicine

University of Kelaniya


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Clinical impact

A major cause of childhoodmorbidity and mortality

3 million die each year in the world

80% deaths occur < 2 years of age

Most die due to severe dehydrationRepeated attacks causemalnutrition


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DefinitionPassage of 3 or more liquid motions

/day

Acute diarrhoea usually for 7 days

Persistent diarrhoea (3-10%) >14 days

Watery (AGE)

Acute diarrhoeaInvasive diarrhoea

Bloody (Dysentery)


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Aetiology - AGEViruses: rotavirus , adenovirus,calicivirus, Astor & measlesviruses

Bacteria: Vibrio cholarae, ETEC,Campylobacter jejuni, Shigella, EPEC

Parasitic: Cryptosporidium, giardiaMixed infection with 2 or more up to20%


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Aetiology- invasive diarrhoea

Bacteria:Shigella spp. Shiga toxins

EIEC, EHEC, Campylobacter

jejuni, Yersiniaenterocolitica,

non-typhoidal salmonella

Parasites: Entamoeba histolytica


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Site of pathology

Small intestine: secretory diarrhoealpathogens e.g. rotavirus, vibrio, ETEC

Large intestine: invasive diarroealpathogens e.g. Shigella spp. Rectosigmoid and progress up, Entamoeba

caecum and adjacent colon

Both small and large bowel e.g. C.jejuni


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Rotavirus

The commonest pathogen for AGEbetween 6-24 months of age

More common during dry season, andduring monsoons

Neonatal and adult infections are mild

Faeco-oral transmissionPatchy damage to the epitheliumcauses blunting of villi watery D


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Rotavirus contd.Results in transient lactase deficiency

Intestine regenerates in 2-3 days, longer inmalnourished

IP 2-3 days

Abrupt onset vomiting and D

Severity vary mild to severeLasts up to a week, improves in 2-3 days

Low grade fever


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Stool macroscopy, microscopy

Management of dehydration

Continuation of BFContinuation of solid food

No AB

No antidiarrhoeal agentsExtra meal for 2-3 weeks to catch-upWt.

Rotavirus - management


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Vibr io choleraeThe most important cause forsevere dehydration

Outbreaks occur in Sri Lanka fromtime to time

Common age is 2-9 years

A large infective dose is requiredOrganisms adhere to the intestine,X and produce enterotoxin D


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Cholera contd.

2 biotypes: El tor & classical2 serotypes: Ogava & Inaba

Enterotoxins secrete water,Na & Cl in to small intestine

Exchange of K with Na and HCO3with Cl in large intestine

Hence net loss of water, Na, K, Cl,Hco3


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Cholera contd.

IP hours to few days

Mild to severe disease

Rice water stoolMuscle cramps

Notifiable disease to regionalepidemiologist by telephone


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Cholera management

Stool culture

Management of dehydrationContinuation of food

Notification

Antibiotics furazolidone,chloramphenicol


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Shigella spp.

S. dysenteriae has 15 serotypes.responsible for epidemics. Type 1 is themost severe form

S. flexneri - responsible for endemic disease

S. boydii

S. sonneiInfective dose is very small (10 organisms)


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Shigella spp.

Faeco-oral transmission

Shigella can survive in gastric juice

Shiga toxin an endotoxin, whichhas a cytotoxic property fluidsecrete in to small intestine


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ShigellosisCommon under 5 years

Uncommon under 6 months asthere is no specific enterocytereceptors

IP 2-3 days

Severity varies from very mild tofulminating disease

Prominent systemic symptoms


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Shigellosis contd.High fever, anorexia, headache,malaise

Frequent passage of small volumestool mixed with blood and mucous& less amount of stool particles

Intense cramps in LIF, tenesmus,tender abdomen

Rectal prolapse in malnourished


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Stool macroscopy and microscopy

Stool culture & ABST

Management of dehydrationDietary management: loss of protein ishigh. Thus continue feeding during acute

illness and extra meal duringconvalescence. Near normal energyintake can be ensured by small, butfrequent feeding.

Shigel losis- management


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Symptomatic therapy for fever

AB for 5 days: furazolidone, nalidixic

acid 15 mg/kg 6 hrly, pivmecillinam 15mg/kg 6 hrly, aminoglycosides, 3rdgene. Cephalosporines

Antispasmodic or constipating agentshave no role & it may worsen severityof the disease

Notification

Shigel losis management contd.


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Entamoeba histolyticaCauses dysentery

Extra-intestinal manifestations canoccur

Diagnosis by direct visualization of

tropozoitesMetronidazole


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E.coli

5 types: EIEC, EHEC, EPEC,ETEC,EAEC

Faeco-oral transmissionETEC causes travelers diarrhoea

Clinical features of EIEC similar to

Shigella


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CampylobacterPeak occurs in infancy

Infects through infected animals,their faeces, food or water

Causes AGE or dysentery (1/3)


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Non-typhoidal salmonellaeUncommon in developing countries

Through contaminated animalproducts

Causes watery D, vomiting and

cramps


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Complications of diarrhoea

Dehydration, hypovolaemic shock &ARF

Electrolyte imbalance: Na low or high,hypokalaemia, met. Acidosis, low Mg

Septicaemia and shock with invasive D,DIC

Hypoglycaemia, common withshigellosis


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Complications contd.

PEM: diarrhoeal disease and PEM makea vicious cycle

Haemolytic uraemic syndrome

Abnormal CNS status e.g. convulsions,encephalitis

Intestinal such as rectal prolapse,bleeding due to stress ulcers, perforation& peritonitis, paralytic ileus, persistentD, NEC


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HUSMicroangiopathic anaemia, lowplatelets & ARF

S.dysenteriae type 1 & E.coli0157:H 7

Bi-phasic illness

Crenated RBCs, neutrophilia, lowplt.

Symptomatic management


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F luid management in diarrhoeaPrinciples:

Correction of dehydrationReplacement of on-going loses

Continuation of normal requirement


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Important questions to be asked

Duration of illness

Quantity & frequency of stool

Presence of blood or mucousFrequency of vomiting

Degree of thirst

When did the child pass urine last?

Is the urine darker than usual?


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Questions to be asked contd.

Presence of fever or convulsions

Presence of other illness

Pre-illness and during illness feeding

Contact H/O diarrhoeaAny medication given

Then assess the degree of dehydration(see transparencies for assessmentand management of dehydration)


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Home managementRules of home management:

Rehydration with appropriate fluidsContinue feeding

Recognition of referral signs to a

doctor


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Rehydration at home

Suitable fluids: ORS, rice kanji,king/young coconut water, puffed rice

water, plain water, weak plain tea.(best if prepared with salt)

Substantially reduces the requirement

of hospital admission and severedehydration


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Continuation of feeding

This helps early recovery and preventsmalnutrition

Continue BF

Continue formula if the child is on (if theindication to start formula is correct)

Solid/semi-solid food 5-6 times, smallfrequent feeds are better tolerated

One additional meal for 2-3 weeks


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Warning signs for referral

Many watery stool

Repeated vomiting

Marked thirstEating or drinking poorly

Fever

Blood in the stool

Reduced UOP


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I ndications for admission

Severe dehydration

Persistent vomiting

High rate of purgingInability or refusal to drink

Ill child with complicationsBlood and mucous in stool


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Rehydration solutionsOral rehydration solution (ORS

Jeevani)Used from 1971 onwards

Composition of a packet Nacl 3.5

g, Na-citrate 2.9 g, Kcl 1.5 g &glucose 20 g.


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ORSmolar concentration mmol/L

Na 90, Cl 80, citrate 10, K 20, glucose111

Physiological basis of ORT:

Glucose & other carrier-mediatedabsorption is intact even in severe D.Citrate and K are absorbed

independently of glucose during D.Citrate absorption appears to increase Na& Cl absorption.


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Advantage of ORT over IV

> 95% of some dehydration can betreated

Less cost

Does not need much training

Easily available

Over-hydration is less likelyMothers are actively participated inmanagement


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Reasons for fai lure of ORT

High rate purging

Persistent vomiting

Severe dehydrationInability or refusal to drink

Glucose malabsorption

Incorrect preparation

Abdominal distension or ileus


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Suitable intravenous fluidsHartman (Na 130, K 4, Cl 109,

Lactate 28)N.saline (Na 154, Cl 154)

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02.Diarrhoea in Children