Acute Diarrhea in Acute Diarrhea in childrenchildren

PRESENTED BY:PRESENTED BY:A.PRIYADHARSHINI M.Sc(N),A.PRIYADHARSHINI M.Sc(N),LECTURER,LECTURER,DEPT. OF PAEDIATRIC NURSING,DEPT. OF PAEDIATRIC NURSING,GWALIORGWALIOR

Is just a little case of Is just a little case of diarrhea…diarrhea… Second leading causes of all death Second leading causes of all death

worldwide worldwide

Most common cause of morbidity Most common cause of morbidity and mortality in children worldwideand mortality in children worldwide

Definition Definition

Stool weight in excess of 200 gm/dayStool weight in excess of 200 gm/day

3 or more loose or watery stools/day3 or more loose or watery stools/day

Alteration in normal bowel movement Alteration in normal bowel movement characterized by decreased characterized by decreased consistency and increased frequencyconsistency and increased frequency

Less than 14 days in durationLess than 14 days in duration

EpidemiologyEpidemiology

1.2-1.9 episodes per person 1.2-1.9 episodes per person annually in the general populationannually in the general population

2.4 episodes per child <3 years 2.4 episodes per child <3 years old annuallyold annually

5 episodes per year for children 5 episodes per year for children <3 years old and in daycare<3 years old and in daycare

Seasonal peak in the winterSeasonal peak in the winter

EtiologyEtiology

ViralViral: 70-80% of infectious : 70-80% of infectious diarrhea in developed countriesdiarrhea in developed countries

BacterialBacterial: 10-20% of infectious : 10-20% of infectious diarrhea but responsible for most diarrhea but responsible for most cases of severe diarrheacases of severe diarrhea

ProtozoanProtozoan: less than 10%: less than 10%

Viral DiarrheaViral Diarrhea

RotavirusRotavirus

Norovirus (Norwalk-like)Norovirus (Norwalk-like)

Enteric AdenovirusEnteric Adenovirus

AstrovirusAstrovirus

RotavirusRotavirus

Leading cause of hospitalization for Leading cause of hospitalization for diarrhea in children diarrhea in children

Most prevalent during winter seasonMost prevalent during winter season

Fecal-oral transmission: viral Fecal-oral transmission: viral shedding can persist for 21 daysshedding can persist for 21 days

Acute onset of feverAcute onset of fever followed by followed by watery diarrheawatery diarrhea (10-20 BM/day) and (10-20 BM/day) and can can persist for up to a weekpersist for up to a week

NorovirusNorovirus

Most common cause of diarrheal Most common cause of diarrheal outbreaks/epidemicsoutbreaks/epidemics

Multiple modes of fecal-oral Multiple modes of fecal-oral transmissiontransmission

Acute onset of nausea and Acute onset of nausea and vomiting, watery diarrheavomiting, watery diarrhea with with abdominal crampsabdominal cramps and can and can persist for 1-3 dayspersist for 1-3 days

Enteric AdenovirusEnteric Adenovirus

Primarily affects children < 4 Primarily affects children < 4 years oldyears old

Fecal-oral transmission Fecal-oral transmission

Clinical picture similar to rotavirus Clinical picture similar to rotavirus ((fever and watery diarrheafever and watery diarrhea))

AstrovirusAstrovirus

Primarily affects children < 4 years old Primarily affects children < 4 years old and immunocompromisedand immunocompromised

Seasonal peak in the winterSeasonal peak in the winter

Fecal-oral transmission: viral shedding Fecal-oral transmission: viral shedding can occur for several weeks can occur for several weeks

Fever, nausea and vomiting, abdominal Fever, nausea and vomiting, abdominal painpain, and , and diarrheadiarrhea lasting up to a week lasting up to a week

Summary of Viral Summary of Viral DiarrheaDiarrhea Most likely causeMost likely cause of infectious diarrhea of infectious diarrhea

Rotavirus and Norovirus are most Rotavirus and Norovirus are most commoncommon

Symptoms usually include Symptoms usually include low grade low grade fever, nausea and vomiting, abdominal fever, nausea and vomiting, abdominal cramps, and watery diarrheacramps, and watery diarrhea lasting up lasting up to 1 weekto 1 week

Viral shedding can occur for weeks after Viral shedding can occur for weeks after symptoms resolvesymptoms resolve

Bacterial DiarrheaBacterial Diarrhea

Campylobacter Campylobacter

SalmonellaSalmonella

ShigellaShigella

Enterohemorrhagic Escherichia Enterohemorrhagic Escherichia colicoli

CampylobacterCampylobacter

Most common bacterial pathogenMost common bacterial pathogen Transmitted through ingestion of Transmitted through ingestion of

contaminated food or by direct contaminated food or by direct contact with fecal materialcontact with fecal material

Symptoms include Symptoms include diarrhea (+/- diarrhea (+/- blood), abdominal cramps (can be blood), abdominal cramps (can be severe), malaise, feversevere), malaise, fever

Usually self-limited and does not Usually self-limited and does not require antibioticsrequire antibiotics

SalmonellaSalmonella

Most common in children <4 years old Most common in children <4 years old and a peak in the first few months of lifeand a peak in the first few months of life

Transmitted via ingestion of Transmitted via ingestion of contaminated food and contact with contaminated food and contact with infected animalsinfected animals

Symptoms include Symptoms include fever, diarrhea, and fever, diarrhea, and abdominal crampingabdominal cramping

Antimicrobial therapy can prolong fecal Antimicrobial therapy can prolong fecal sheddingshedding

ShigellaShigella

Fecal-oral transmissionFecal-oral transmission Symptoms include Symptoms include fever, fever,

abdominal cramps, tenesmus, and abdominal cramps, tenesmus, and mucoid stoolsmucoid stools with or without with or without bloodblood

Can lead to serious complications Can lead to serious complications Antimicrobial treatment shortens Antimicrobial treatment shortens

duration of illness and limits fecal duration of illness and limits fecal sheddingshedding

E. ColiE. Coli O157:H7 O157:H7

Transmission via contaminated food Transmission via contaminated food and waterand water

Symptoms include Symptoms include bloody diarrheabloody diarrhea, , severe abdominal pain, and severe abdominal pain, and sometimes feversometimes fever

Can lead to serious complicationsCan lead to serious complications

Antibiotics have no proven benefit and Antibiotics have no proven benefit and may increase the risk of complicationsmay increase the risk of complications

Summary of Bacterial Summary of Bacterial DiarrheaDiarrhea Can affect all age groupsCan affect all age groups

Fecal-oral transmission, often Fecal-oral transmission, often through contaminated foodthrough contaminated food

Typical symptoms include bloody Typical symptoms include bloody diarrhea, severe cramping, and diarrhea, severe cramping, and malaise malaise

Antibiotic treatment not always Antibiotic treatment not always necessarynecessary

Physical ExamPhysical Exam

Vitals, vitals, vitals!Vitals, vitals, vitals!

Abdominal examAbdominal exam

Presence of occult bloodPresence of occult blood

Signs of dehydrationSigns of dehydration

Laboratory EvaluationLaboratory Evaluation

Unnecessary for patients who present Unnecessary for patients who present within 1 day from onset of diarrhea within 1 day from onset of diarrhea

Warning signs/symptoms: bloody Warning signs/symptoms: bloody diarrhea, high fever, severe abd pain, diarrhea, high fever, severe abd pain, dehydration.dehydration.

Fecal leukocytes followed by bacterial Fecal leukocytes followed by bacterial culture, ova & parasites, viral culture, ova & parasites, viral antigensantigens

CBC, chemistriesCBC, chemistries

TreatmentTreatment

Fluid replacementFluid replacement– Fluids or Oral Rehydration Solutions (ORS)Fluids or Oral Rehydration Solutions (ORS)

– Parenteral rehydrationParenteral rehydration

Early refeedingEarly refeeding Symptomatic TreatmentSymptomatic Treatment

– Oral bismuthOral bismuth

– LoperamideLoperamide

AntibioticsAntibiotics

Fluid ReplacementFluid Replacement

ORS: Infalyte, Pedialyte, ORS: Infalyte, Pedialyte, Naturalyte and RehydralyteNaturalyte and Rehydralyte

Must be used or thrown out 24 Must be used or thrown out 24 hours after opening/mixinghours after opening/mixing

AAP GuidelinesAAP Guidelines

Diarrhea with no dehydrationDiarrhea with no dehydration – – normal diet and supplemental ORS normal diet and supplemental ORS with each diarrheal episode. with each diarrheal episode.

Diarrhea with some dehydrationDiarrhea with some dehydration – – seek medical care, give ORS in the seek medical care, give ORS in the doctor's office, and cont. ORS and doctor's office, and cont. ORS and normal diet at home. normal diet at home.

Moderate - severe dehydrationModerate - severe dehydration – – consider intravenous hydration, consider intravenous hydration, especially if patient is also vomiting especially if patient is also vomiting

Early RefeedingEarly Refeeding

Luminal contents help promote Luminal contents help promote growth of new enterocytes and growth of new enterocytes and facilitate mucosal repair facilitate mucosal repair

Can shorten duration of the diseaseCan shorten duration of the disease

Lactose restriction is not necessary Lactose restriction is not necessary except in severe diseaseexcept in severe disease

Symptomatic Symptomatic TreatmentTreatment Only in patients who are Only in patients who are afebrileafebrile

and have and have nonbloodynonbloody diarrhea diarrhea LoperamideLoperamide – inhibits peristalsis and – inhibits peristalsis and

has antisecretory propertieshas antisecretory properties Bismuth subsalicylateBismuth subsalicylate – may help – may help

with nausea, vomiting, and with nausea, vomiting, and abdominal pain, as well as shorten abdominal pain, as well as shorten duration of illnessduration of illness

AntibioticsAntibiotics

antibiotic therapy generally not antibiotic therapy generally not beneficial and beneficial and can be harmfulcan be harmful

Those with more than eight Those with more than eight stools/day, diarrhea >1 wk, volume stools/day, diarrhea >1 wk, volume depletion, immunosuppresion, or depletion, immunosuppresion, or warning signs warning signs

Fluoroquinolone or Azithromyzin Fluoroquinolone or Azithromyzin

Specific Antibiotic Specific Antibiotic TherapyTherapy

Viral – of course not!Viral – of course not!

Campylobacter – only if severeCampylobacter – only if severe

Salmonella – can prolong fecal Salmonella – can prolong fecal shedding, only prescribe if severeshedding, only prescribe if severe

Shigella – proven beneficialShigella – proven beneficial

E. Coli O157:H7 – can be harmful E. Coli O157:H7 – can be harmful

Zinc Supplementation in ADZinc Supplementation in AD

! Responsible for > 200 enzymes in body. Responsible for > 200 enzymes in body.

! Improves the immune function & Improves the immune function &

absorption.absorption.

! Supplementation in AD and PD helpful in 20-Supplementation in AD and PD helpful in 20-

30% reduction in diarrhea.30% reduction in diarrhea.

! 42% lower rate of treatment failure or 42% lower rate of treatment failure or

death.death.

– DosagesDosages

– oo Infants 10mg daily x 2 weeks.Infants 10mg daily x 2 weeks.

– oo Older children 20mg daily x 2 weeks.Older children 20mg daily x 2 weeks.

– o o Persistent diarrhea x 4 weeksPersistent diarrhea x 4 weeks

Home Available FluidsHome Available Fluids

RecommendedRecommended Salt sugar solutionSalt sugar solution Lemon water(Sikanjabi)Lemon water(Sikanjabi) Rice water / KanjeeRice water / Kanjee Soups Soups Dal waterDal water LassiLassi Coconut waterCoconut water Plain waterPlain water

Not recommendedNot recommended Simple sugar solutionSimple sugar solution Glucose solutionGlucose solution Carbonated soft drinksCarbonated soft drinks Fruit juices-tinned or freshFruit juices-tinned or fresh Fluids for athletesFluids for athletes Gelatin dessertsGelatin desserts Tea/CoffeeTea/Coffee

Nursing management:Nursing management:

Restoring fluid and electrolyte Restoring fluid and electrolyte balance by ORS and IV therapy.balance by ORS and IV therapy.

Prevention of spread of infection Prevention of spread of infection by good hand washing practices, by good hand washing practices, hygienic disposal of stools, care hygienic disposal of stools, care of diapers, general cleanliness of diapers, general cleanliness and universal precautions.and universal precautions.

Preventing skin breakdown by Preventing skin breakdown by frequent change of diaper, frequent change of diaper, keeping the perineal area dry and keeping the perineal area dry and cleanclean

Providing adequate nutritional Providing adequate nutritional intake by appropriate dietary intake by appropriate dietary managementmanagement

Reducing fear and anxiety by Reducing fear and anxiety by explanation, reassurance, explanation, reassurance, answering questions and answering questions and providing necessary informations.providing necessary informations.

Giving health education for Giving health education for prevention of diarrhea, home prevention of diarrhea, home management of diarrheal management of diarrheal diseases, importance of ORS, diseases, importance of ORS, dietary management etc..dietary management etc..

ReferencesReferences

Dennehy P.H., Acute Diarrheal Disease in Children: Dennehy P.H., Acute Diarrheal Disease in Children: Epidemiology, Prevention, and Treatment. Epidemiology, Prevention, and Treatment. Infect Dis Infect Dis Clin North AClin North A 2005;(19) 3: 2005;(19) 3:

Wanke C.A., Approach to the patient with acute Wanke C.A., Approach to the patient with acute diarrhea. diarrhea. Up To DateUp To Date (updated Jan. 4, 2005) (updated Jan. 4, 2005) www.uptodate.com/

Blacklow N.R., Epidemiology of viral gastroennteritis Blacklow N.R., Epidemiology of viral gastroennteritis in adults. in adults. Up To DateUp To Date (updated March 3, 2005) (updated March 3, 2005) www.uptodate.com/www.uptodate.com/

Thielman N.M., (2004) Acute Infectious Diarrhea. Thielman N.M., (2004) Acute Infectious Diarrhea. N N Engl J MedEngl J Med 2004;350:38-47. 2004;350:38-47.

Burkhart D.M., Management of Acute Gastroenteritis Burkhart D.M., Management of Acute Gastroenteritis in Children. in Children. Am Fam PhysicianAm Fam Physician. 1999 . 1999 Dec;60(9):2555-63 Dec;60(9):2555-63