Acute Diarrhea Acute Diarrhea Management Management

Reduce Child mortality

What is Diarrhea ?

It is defined as 3 or more watery stool in 24 hrs

Other names

More common when child is on cow’s milk/formula feed

What is and what is not diarrhea?What is and what is not diarrhea?

0-2 months

BF Infant Semisolid /not

watery Every time after

feeding

2months-5 years

Many times but not watery

Types of serious diarrhoea in Types of serious diarrhoea in childrenchildren

Acute watery diarrhea- If <14 days ,sever dehydration Ecoli,cholera ,malnutrition

Persistent diarrhea-If >14 days, 20-30 % death, under nourished and HIV exposed

Dysentery-(atisar) with blood ,with or without mucus 10%-15 % of deaths

Why are children more prone to Why are children more prone to diarrhoeadiarrhoea

Proportion of water is more in children ,so dehydration occur early.

Child can loose 5ml-200 ml liquid in 24 hrsMetabolic rate is high and use more water

as compared to adultsKidney can conserve less water ,so loss is

more Sodium loss can be 70-110 m mol/kgChloride and potassium loss is balanced

&same

Assessment of diarrheaAssessment of diarrhea

Did child vomit in past 6-8 hrs? Did child pass urine in past 6-8 hrs? What type of liquids did the child get ?Did the child get sufficient food before this

episode ?During diarrhea is child getting food that is

different and is less calorie dense? Look for cough ,fever ,otitis

media ,sepsis ,h/o measles Weight /nutrition

ASSESS: Degree of Dehydration

DECIDE: Plan of treatment

Does the child have diarrhea?

If yes, ask:◦For how long? How many? ◦Has the child been vomiting ◦Is there blood in stool?

LOOK AT THE CHILD’S GENERAL CONDITIONIS THE CHILD◦ Lethargic or Unconscious?◦ Restless or Irritable?

LOOK FOR SUNKEN EYES Look for skin pinch -goes back

promptly/slowly/ very slowly OFFER THE CHILD FLUID TO DRINK –THIRSTY Not able to drink or drinking poorly?

Drinking eagerly, appears thirsty?

Drinking normally?

LOOK

Look at Eyes for Dehydration Look at Eyes for Dehydration Shrunken Eyes Normal eyes

Degree of DehydrationDegree of Dehydration

Two or more of the following

Degree of dehydration decided on:

•Restless, Irritable

•Sunken Eyes

•Drinks eagerly, Thirsty

•Skin Pinch goes back “slowly”

Some Dehydration Severe Dehydration

•Lethargic or unconscious

•Sunken Eyes

•Not able to drink or drinking poorly

•Skin Pinch goes back “very slowly”

OR NO DEHYDRATION

Film Clip: assessment of dehydration

No Dehydration: PLAN-A

Some Dehydration: PLAN-B

Severe Dehydration: PLAN-C

Treat Diarrhea at Home.

4 Rules of Home Treatment:

GIVE EXTRA FLUID

CONTINUE FEEDING

WHEN TO RETURN [ADVICE TO

MOTHER]

GIVE ORAL ZINC FOR 14 DAYS

PLAN – A

TELL THE MOTHER:Breastfeed frequently and for longer at each feed

If exclusively breastfeed give ORS for replacement of stool losses

If not exclusively breastfed, give one or more of the following:

ORS, food-based fluid (such as soup, rice water, coconut water and yogurt drinks), or clean water.

TEACH THE MOTHER HOW TO MIX AND GIVE O.R.S

AMOUNT OF FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE:

Up to 2 years: 50 to 100 ml after each loose stool.2 years or more: 100 to 200 ml after each loose stool.

Give extra fluid

Continue usual feeding, which the child was taking before becoming sick 3-4 times (6 times)

Up to 6 months of age: Exclusive Breast feeding

6 months to 12 months of age: add Complementary Feeding

12 months and above: Family Food

Continue feeding

Advise mother to return immediately if the child has any of these signs:

Not able to drink or breastfeed or drinks poorly

Becomes sicker

Develops a fever

Blood in stool [IF IT WAS NOT THERE EARLIER]

When to Return [Advice to mother]

Plan-B is carried out at ORT Corner in

OPD/clinic/ PHC

Treat ‘some’ dehydration with ORS (50-100

ml/kg

Give 75 ml/kg of ORS in first 4 hours

If the child wants more, give more

After 4 hours:

Re-assess and classify degree of dehydration.

PLAN – B

PLAN -CPLAN -C

Signs of sever dehydration Child not improving after 4 hours

Refer to higher center –give ORS on way /keep warm /BF

When child comes back follow up as other children

Start I. V. Fluid immediatelyGive 100 ml/kg of Ringer’s Lactate

Age First give 30ml/kg in

Then give 70 ml/kg in

Under 12 months 1 hour 5 hours

12 months and older

½ hour 2½ hour

PLAN – C

Use intravenous or intraosseus route

Ringers Lactate with 5% dextrose or ½ normal saline with 5% dextrose at 15 ml/kg/hour for the first hour

* do not use 5% dextrose alone

Fluid therapy in severe dehydration

Continue monitoring every 5-10 min.

Assess after 1 hour

If no improvement or worsening If improvement(pulse slows/fastercapillary refill /increase in blood pressure)

Consider septic shock Consider severe dehydration with shockRepeat Ringers Lactate 15 ml/kg over 1 h

Switch to ORS 5-10ml/kg/hr orally or bynasogastric tube for up to 10 hrs

Classify and Treat DiarrheaClassify and Treat DiarrheaClassify and Treat DiarrheaClassify and Treat Diarrhea

Diarrhea Lasting 14 days or more

•Persistent diarrhea

•Sever Persistent diarrhea

•Do HIV RAPID TEST

•Give first dose of COTRIM/CIPROFLIX • Treat to prevent low sugar•Home foods •ORS/ZN /BF/Vit A•Keep warm •Refer to Hospital if sever

Blood in Stool •Dysentery

•Sever Dysentery

Give COTRIM/CIPROFLOX for 3 days Change if no improvement after 2 days Prevent low blood sugarKeep warmRefer to Hospital if sever

Dysentery

Cholera

Severe malnutrition

Associated systemic infection

Antimicrobials should be given during diarrhea only for:

Feeding does not worsen diarrhea

Prevents malabsorption & facilitates

mucosal repair Isolauri et al. 1989. JPGN

Prevents growth faltering and malnutrition Brown et al. 1988. J Pediatr

Some key facts about feeding during diarrhea

• There is no basis for fasting in diarrhea

• Continue to breastfeed

• Encourage the child to drink & eat

• Be patient while feeding

• Feed small amounts frequently

• Give foods that the child likes

• Give a variety of nutrient-rich foods

• Do not dilute milk Brown et al. 1988. J Pediatr

• Routine lactose free feeding not required

• Do not give sugary drinks

Some key facts about feeding during diarrhea

Increase amount of calories during convalescence with

energy dense foods (enrich foods with fats and sugar)

•Feed an extra meal (for at least 2 weeks after diarrhea

stops)

•Give an extra amount

•Use extra rich foods

•Feed with extra patience

•Give extra breastfeeds as often as child wants

Increase amount of calories during convalescence with

energy dense foods (enrich foods with fats and sugar)

•Feed an extra meal (for at least 2 weeks after diarrhea

stops)

•Give an extra amount

•Use extra rich foods

•Feed with extra patience

•Give extra breastfeeds as often as child wants

What Is ORSWhat Is ORS

Safe & effectiveCan alone successfully rehydrate 95-97% patients with diarrhea,

Reduces hospital case fatality rates by 40 - 50%

Cost savingReduces hospital admission rates by 50% and cost of treatment by 90%

BUT

> 50% Goa, Himachal, Meghalaya, Tripura, Manipur

> 40% West Bengal, J&K, Mizo, Chhattisgarh

> 20% Bihar, Orissa, Uttaranchal, Punjab, Gujarat, MP, Southern States

< 20% Rajasthan, UP, Assam, Jharkhand, Nagaland

Recent NFHS 3 data

ORS use rates are dismally low in some regions

Standard ORS Solution Low Osmolarity ORS (mEq or mmol/L)

Glucose 111 75

Sodium 90 75

Chloride 80 65

Potassium 20 20

Citrate 10 10

Osmolarity 311 245

Composition of standard and low osmolarity ORS solutions

39% reduction in need for unscheduled IV fluids

19% reduction in stool output

29% reduction in vomiting

Hahn et al, 2001; WHO/FCH/CAH 0.1.22, 2001

Summary of results of published meta-analysis of all randomized clinical trials (12) comparing low osmolarity ORS (245mosmol/l) with standard WHO ORS (311mosmol/l) in children with acute non-cholera diarrhea:

Should be given to young infants (< 2m) including neonates

if there is dehydration

In exclusively breastfed young infants with no dehydration

encourage exclusive breastfeeding more frequently and for

longer

Low osmolarity ORS is safe and effective for all ages

Film clip: ammaji kehti hain

Film clip: ammaji kehti hain

Making ORS Making ORS PAGE -20PAGE -20

How much fluids How much fluids (p 17)(p 17)

0-4 m 200-400 ml 2 glasses4-12 m 400-600ml 3 glasses12-24 m 600-1000ml 5 glasses2-5 yrs 1.0 -1.4 litres 7 glasses

Small sips from glass If vomits wait for 10 min and give againContinue BF Revaluate after 4 hours

Cholera managementCholera management

Caused by Vibero CholeraOccur in Epidemic Rice water stool and sever dehydration Loss of fluid may be 200-350 ml/kg Usually IV fluids required /IG fluids Doxycycline 6 mg/kg single dosage

Dysentery managementDysentery management

Diarrhea with blood in stool (Shigellae ,E Histolytica )

Assess dehydration ,if sever refer

Give ORS ,DIET

AB –Ciprofloxacin -15 mg/kg orally 2 times a day/Cotrim (ped )

Reassess after 2 days

Management of persistent Management of persistent diarrhoeadiarrhoea

Diarrhea more than 14 days Malnutrition /multiple deficiencies Prevent dehydration High calorie food Zinc ,vitamins, minerals for 14 days No iron

preparation AB –cotrimoxazole /ciprofloxacin 5 -7 days HIV testing Severe Acute Malnutrition –IN HOSPITAL

WHY ZINC?

IZiNCG advocacy statement (http://www.izincg.org/pdf/IZiNCG_Advocacy-PrintingFormat.pdf)

Zinc deficiency is widespread in low and middle income countries like India

• Breast milk not sufficient source >6 mo

• Intake of complementary foods low, particularly

animal foods

• Limited bioavailability; phytates from cereals

• High fecal losses during diarrheal illness

• Low content of soil, of foods

Why zinc deficiency is common in children from developing countries?

Disrupts intestinal mucosa

Reduces brush border enzymes

Increases mucosal permeability

Increases intestinal secretion

Roy 1992, Hoque 2005

Zinc deficiency has direct effects on mucosal functions

20 mg/day (10 mg/day for infants 2-6 mo) of zinc supplementation for 14 days starting as early as possible after onset of diarrhea

WHO/UNICEF Joint statement (2001), IAP 2003, GOI 2007

Recommendations for Use of Zinc in Acute Diarrhea

Dose of ZincDose of Zinc

2- 6 months 10 mg for 14 days

6 mo-5 yrs 20 mg for 14 days

Prevention of Diarrhea Prevention of Diarrhea

Exclusive Breastfeeding

Improved dietary Habits

Safe and clean water

Zinc PreparationZinc Preparation

Compliance cardCompliance card

Hand Washing Hand Washing

Key messagesKey messages

Zinc along with ORS is more effectiveZinc acts like tonic and not medicine6mo and more children should get 20

mg/d for 14 days2-6 mo children to get 10 mg for 14

daysHome cooked foods like rice water,

lemon water,dal soup, fresh fruit juice without sugar should be given .

Questions?