Approach to a child with Diarrhoea

Diarrhea- Excessive loss of fluid & electrolyte in the stool.

Passage of 3 or more loose or watery stool in a 24 hour period.

Loose stool-That would take the shape of container.

For practical purpose, recent change in consistency & character of the stool & its water content.

Types of Diarrhea

Acute watery diarrhea- lasts < 14 days.

Dysentery- Diarrhea with visible blood & mucus.

Persistent Diarrhea- Duration >14 days. Cause- infectious.

Chronic diarrhea-Duration >14 days. Cause- non infectious.

Causes

Viruses (e.g., adenovirus, rotavirus, Norwalk virus)

Escherichia coli, Clostridium difficile and Campylobacter, Salmonella, and Shigella spp. are common bacterial causes

Bacillus cereus, Clostridium perfringens, Staphylococcus aureus, Salmonella spp., and others cause food poisoning

Entamoeba histolytica and Giardia, Cryptosporidium, and Cyclospora spp. are parasitic or protozoal agents that cause diarrhea.

Causative agents

Consequences/complication

Dehydration

Dyselectrolytemia

Malnutrition

Acute renal failure

Septicemia & septic shock

Hemolysis, renal failure & haemorrhage

Hemolytic uremic syndrome

Assessment of hydration status

Assessment of hydration status

(IMCI Protocol)

* infant < 2mths of age, thirst is not assessed & decision regarding 'some' or 'severe' dehydration is made if 2 of the 3 signs are present

Plan A- Guidelines for replacement of Fluid & Electrolytes

< 6 months- quarter glass or cup( 50ml)

7 months- 2 years- quarter to ½ glass or cup(50-100ml)

2-5 yrs ½ to 1 glass or cup(100-200ml)

Older children- as much as the child can take.

Plan B

Correction of dehydration- ORS @ 75ml/kg over a period of 4 hours.

Reassess after 4 hours-if still dehydrated, repeat deficit therapy. If rehydrated, treat as “no dehydration” with Plan A

If ORT is not successful, treat as “ severe dehydration” with intravenous fluids as in Plan C.

Plan C

Monitoring – Access for improvement every 1-2 hours

If not improving, give iv infusion more rapidly

Encourage oral feeding by giving ORS @ 5ml/kg/hr along with iv fluid as soon as the child is able to drink.

Reassess hydration status- After 6 hrs/3 hrs assess hydration status & choose appropriate plan(A, B or C)

Clinical evaluation of dehydration

Mild dehydration (<5% in infant,<3% in an older child or adult)- normal or increased pulse, decreased urine output, thirsty, normal physical finding

Moderate dehydration (5-10% in an infant, 3-6% in older child or adult)- tachycardia, little or no urine output, irritable/lethargic, sunken eyes & fontanell, decreased tears, dry mucus membranes, mild delay in elasticity (skin turgor), delayed capillary refill (>1.5 sec) cool & pale

Clinical evaluation of dehydration

Severe dehydration (>10% in an infant; >6% in older child or adult)- rapid & weak or absent peripheral pulses, decreased blood pressure, no urine output, very sunken eyes & fontanelle, no tears, parched mucus membrane, delayed elasticity (poor skin turgor), very delayed CRT (>3 sec), cold & mottled, limp, depressed consciousness

Fluid management of dehydration

Restore intravascular volume- 20ml/kg NS over 20 min. Repeat as needed.

Calculate 24 hrs fluid needs- maintainance + deficit volume

Substract isotonic fluid already

administered from 24 hrs fluid needs

Fluid management of dehydration

Administer remaining volume over 24 hrs using ½ NS + 5% Dextrose & 20meq/l KCl

Replace ongoing loss as they occur

In a child with a known or probable metabolic alkalosis (child with isolated vomiting) RL should not be used as lactate will worsen the alkalosis.

Because dehydration can be associated with acute renal failure & hyperkalemia, potassium is

withheld from IV fluid until the patient

has voided.

Summary of treatment

Oral rehydration salts (ORS) solutions

Preservation of the facilitated glucose-sodium cotransport system in the small-bowel mucosa is the rationale of oral rehydration therapy.

Greater net absorption of an isotonic salt solution with glucose than of one without it.

Potassium replacement during acute diarrhea prevents below-normal serum concentrations of potassium

Bicarbonate and citrate are equally effective in correcting the metabolic acidosis caused by diarrhea and dehydration

Oral Rehydration Salt

Advantages of this new reduced osmolarity ORS solution

1. It reduces stool output or stool volume by about 25% when compared to the original WHO-UNICEF ORS solution

2. It reduces vomiting by almost 30%

3. It reduces the need for unscheduled IV therapy by more than 30%.

4. According to the MOHP and 2001 NDHS, nearly all mothers of children under 5 years old in Nepal know about ORS packets (97.8 percent); however, only 32 percent of mothers administered ORS during a recent bout of diarrhea

Fluids to avoid

* Fluids causing hypernatremia

-most soft drinks

-sweetened fruit drinks

-sweetened tea

* Fluids with stimulant, diuretic or purgative effect

-coffee

-some medicinal teas

Clinical approach to diagnosis

Access in the examination- physical signs of dehydration, nutritional status of child, presence of other infections & signs of shock.

Rotavirus diarrhea- vomiting is early feature & diarrhea is more severe.

Large & watery stool in secretory diarrhea- ETEC or Vibrio cholerae (rice watery)

Fever, abdominal cramps & tenesmus with passing of blood & mucus in dysentery (colitis)