Purnima chaudhary

Roll no.-77

MBBS 2011

INTRODUCTION Its now obvious that some known and unknown

organism probably causes diarrhoea .

Regardless of the causative agents or age of patient; the sheet anchor of treatment is oral rehydration therapy such as the one advocated by WHO/ UNICEF.

DIARRHOEAL DISEASE CONTROL PROGRAMME The diarrhoel disease control programme was started in 1978

with the objective of reducing the mortality & morbidity due to diarrohoeal diseases.

from 1992-1993 , the programme has become a part of child survival & safe motherhood programme.

At present, it is a part of NRHM

COMPONENT OF A DIARRHOEAL DISEASES CONTROL PROGRAMMEShort Term Appropriate clinical management

Long Term. Better MCH care practices

.preventive strategies

.preventing diarrhoeal epidemics

Appropriate clinical management1. ORAL REHYDRATION THERAPY The main aim of oral fluid therapy is to prevent

dehydration and reduce mortality.

Oral fluid therapy is based on the observation that glucosegiven orally enhances the intestinal absorption of salt andwater and is capable of correcting the electrolyte and water

deficit.

At 1st the composition of ORS ( oral rehydration salt ) recommended by WHO was sodium bicarbonate based

INCLUSION OF TRISODIUM CITRATE IN PLACE OF SODIUM BICARBONATE

made product more stable

reduces stool output

increase intestinal absorption of sodium & water .

This ORS formulation focuses on reducing osmolarity of ORS solution;

. to avoid adverse effects of hypertonicity on net fluid absorption by reducing concentration of glucose and sodium chloride in solution.

Reduce the sodium concentration of ORS solution to 75 mOsmol/ L ,improved the efficacy of ORS regimen for children with acute non-cholera diarhoea.

Since January 2004 new ORS formulation is the only 1procured by UNICEF .

INDIA was 1st country in world to launch ORS formulation since JUNE 2004

Composition of reduced osmolarity ORS

REDUCEDOSMOLALITY ORS

GRAM/ LITRE

SOD.CHLORIDE 2.6

GLUCOSE, ANHYDROUS

13.5

POTASSIUM CHLORIDE

1.5

TRISODIUM CITRATE , DIHYDRATE

2.9

TOTAL WEIGHT 20.5

REDUCEDOSMOLARITY ORS

Mmol/L

SODIUM 75

CHLORIDE 65

GLUCOSE , ANHYDROUS

75

POTASSIUM 20

CITRATE 10

TOTAL OSMOLARITY

245

How to access the dehydration

MILD SEVERE

PATIENT APPEARANCE THIRSTY, ALERT , RESTLESS

DROWSY, LIMP, COLD ,SWEATY, MAY BE COMATOSE .

RADIAL PULSE NORMAL RATE & VOLUME

RAPID , FEEBLE ,SOMETIMES IMPALPABLE

BLOOD PRESSURE NORMAL <80mm Hg

SKIN ELASTICITY PINCH RETRACTS IMMEDIATELY

PINCH RETRACTS VERY SLOWLY

TONGUE MOIST VERY DRY

URINE FLOW NORMAL LITTLE/ NONE

ANTERIOR FONTANELLE NORMAL VERY SHRUKEN

% BODY WEIGHT LOSS 4-5% 10% Or MORE

GUIDELINES FOR ORAL REHYDRATION THERAPY (FOR ALL AGES /DURING FIRST FOUR HOURS )

AGE Under

4 months

4-11months

1-2 yrs. 2-4 yrs. 5-14 yrs. 15 yrs. or over

WEIGHT (KG)

UNDER 5

5-7.9 2-10.9 11-15.9 16-29.9 30 OROVER

ORS SOLUTION ( IN ml)

200-

400

400-

600

600-

800

800-

1200

1200-

2200

2200-

4000

Amt. of ORS sol.= wt. of child X 75 ml / kg

2. INTRAVENOUS REHYDRATION Intravenous infusion is usually required only for initialrehydration of severely dehydration pt. who is in shock or unable to drink . Such patients are besttransferred to nearest hospital or treatment Centre .

Solution recommended by WHO for intravenous infusion are…….

1.RINGER LACTATION SOLUTION Its also known as Hartmamm’s solution for injection. It is the

best commercially available solution . It supplies adequate concentration of sodium and potassium arid the lactate yields bicarbonate for correction of the acidosis.

2.DIARRHOEAL TREATMENT SOLUTION ( DTS )

Recommended by WHO as ideal polyelectrolyte solution for intravenous infusion . It contains in one litre

Sodium Acetate- 6.5g,

Sodium Chloride- 4g,

Potassium Chloride- 1g

Glucose- 10g.

Normal saline can also be given but its poorest fluid because it will not correct the acidosis and will not replace the potassium losses.

.

Plain glucose and dextrose solution should not be used as they provide only water & glucose.

The initial rehydration should be fast until an easily palpable pulse is present . Reasses the patient every 1-2 hours.

After infusing 1-2 litres of fluid , rehydration should be carried out at a somewhat slower rate until pulse and blood pressure return to normal.

It is most helpful to examine skin elasticity and pulse strength ,both of which should be normal.

3.MAINTENANCE THERAPY After the sign of dehydration has been corrected

oral fluid should be used for maintenance therapy .

AMOUNT OF DIARRHOEA

AMOUNT OF ORAL FLUID

Mild diarrhoea (not more than one stool every

2hrs or longer, or less than 5mlstool per kg)

100 ml /kg body weight per day until diarrhoea stops

Severe diarrhoea

(more than one stool every 2

hours, or more than 5 ml of stool per kg per hour)

Replace stool losses volume for volume , if not measurable give

10-15 ml/kg body weight per hour

4 . APPROPRIATE FEEDING

• Especially relevant for the exclusively breast-fed infants. If the child is breast-fed , nursing should be pursued during treatment with ORS solution.

• Non-breast-fed infants under age 6 months should be given

an additional 100-200 ml of clean water during the first four hour ,when old ORS containing 90 mmol/L is given.

• But additional water is not given along with 75 mmol/L.

• Commercially carbonated beverages , commercial fruits & sweetened tea should not be given as it causes osmotic diarrhoea and hypernatraemia.

• Rice water ,unsalted soup ,yoghurt drinks , green coconut water should be given.

5 . Chemotherapy

• Drug of choice for choleraDOXICYCLINE

TETRACYCLINE,

TMP-SMX

Drug of choice For diarrhoea due to shigellaciprofloxacin.

As shigella resistant to ampicillin & TMP-SMX.

6 . ZINC SUPPLEMENT It reduces episodes duration and severity so recommended

by WHO & UNICEF

10 mg of Zn for infants under 6 months of age 20 mg

for children older than 6 months for 10-14 days

B. BETTER MCH CARE PRACTICES .

a . Maturation nutrition

Improving prenatal nutrition will reduce the low birth weight problem

Prenatal & postnatal nutrition will improve the quality of beast milk .

b. child nutrition

. Promotion of Breast feeding

. Appropriate weaning practices

.Supplementary Feeding

.vitamin A supplementation

C. PREVENTIVE STRATEGIES

1 . SANITATION

2 .HEALTH EDUCATION

3 . IMMUNISATION

4 . FLY CONTROL

Sanitation

It emphasis on personal & domestics hygiene like hand washing

with soap before preparing food

before eating ,

before feeding a child,

after defecation ,

after cleaning a child who has defecated and

after disposing off a child’s stool .

Health Education An important job of health worker is to prevent diarrhoea

by convincing and helping community members to adopt and maintain preventive measures like breast feeding,

improved weaning ,

clean drinking,

use of plenty of water for hygiene,

use of latrine,

proper disposal of stools of young children etc.

IMMUNISATION

Immunization against measles is a potential intervention for diarrhoea control.

Measles vaccine can prevent 25% of diarrhoeal deaths in children under 5 yrs. of age

ROTAVIRUS VACCINE

There are two vaccines ROTARIX –TM ( monovalent human rotavirus vaccine)

ROTA Teq-TM ( pentavelent bovine-human vaccine)

Rotarix-TM …… 2 -dose schedule to 2 -4 months aged child

1 . DOSE - 6 weeks - 12 weeks

2 . DOSE - upto 16 weeks & no later than 24

weeks.

Rota Teq-TM……3 oral dose at ages 2,4,6 months.

FLY CONTROL

Flies breeding in association with human or animal faeces should be controlled.

Control and prevention of diarrhoeal epidemics An intersectoral approach centered upon PHC involving

activities

in fields of water supply & excreta disposal ,communicable disease control,

mother & child health ,

nutrition & health education is regarded as essential for ultimate for ultimate control of diarrhoeal diseases.

THANK U