1) The document discusses diarrhoea in children, including definitions, disease burden, etiological agents, mechanisms, effects, and principles of management. Diarrhoea is a major cause of childhood death worldwide, with rotavirus identified as the most common cause of severe diarrhoea in young children.
2) Clinical signs of dehydration are described according to WHO classification of hydration status. Management involves rehydration based on hydration assessment, correcting deficits quickly and maintaining fluids to prevent further dehydration. Oral rehydration solution is used to replace ongoing losses and prevent dehydration.
3) Rotavirus is identified as the most frequent cause of severe diarrhoea in children under 5 leading
1) The document discusses diarrhoea in children, including definitions, disease burden, etiological agents, mechanisms, effects, and principles of management. Diarrhoea is a major cause of childhood death worldwide, with rotavirus identified as the most common cause of severe diarrhoea in young children.
2) Clinical signs of dehydration are described according to WHO classification of hydration status. Management involves rehydration based on hydration assessment, correcting deficits quickly and maintaining fluids to prevent further dehydration. Oral rehydration solution is used to replace ongoing losses and prevent dehydration.
3) Rotavirus is identified as the most frequent cause of severe diarrhoea in children under 5 leading
1) The document discusses diarrhoea in children, including definitions, disease burden, etiological agents, mechanisms, effects, and principles of management. Diarrhoea is a major cause of childhood death worldwide, with rotavirus identified as the most common cause of severe diarrhoea in young children.
2) Clinical signs of dehydration are described according to WHO classification of hydration status. Management involves rehydration based on hydration assessment, correcting deficits quickly and maintaining fluids to prevent further dehydration. Oral rehydration solution is used to replace ongoing losses and prevent dehydration.
3) Rotavirus is identified as the most frequent cause of severe diarrhoea in children under 5 leading
1) The document discusses diarrhoea in children, including definitions, disease burden, etiological agents, mechanisms, effects, and principles of management. Diarrhoea is a major cause of childhood death worldwide, with rotavirus identified as the most common cause of severe diarrhoea in young children.
2) Clinical signs of dehydration are described according to WHO classification of hydration status. Management involves rehydration based on hydration assessment, correcting deficits quickly and maintaining fluids to prevent further dehydration. Oral rehydration solution is used to replace ongoing losses and prevent dehydration.
3) Rotavirus is identified as the most frequent cause of severe diarrhoea in children under 5 leading
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01-Nov-10
DIARRHOEA IN CHILDREN 02 November, 2010 E.O.D ADDO-YOBO MD FGCP MWACP MSc DTCH Senior Lecturer/Paediatrician Dept of Child Health SMS-KNUST/KATH, KUMASI, GHANA
Outline Definitions Disease burden Aetiological Agent and Mechanisms Effects of diarrhoea Principles of management ORS, IV fluids, Specific treatment Undesireable Treatment The New Low Osmolarity ORS The role of Zinc
Prevention of Diarrhoea
Definition of diarrhoea 3 or more loose or watery stools within 24 hrs Important considerations: - Usual habit - Increased stool fluidity and frequency often resulting from: gut motility gut secretion gut absorption
Importance of Diarrhoea Worldwide: 10.5 million child deaths each year, 2/3 of which are preventable with low-cost interventions 2 million child deaths from diarrhoea From nuisance to mortality 3rd important cause of childhood morbidity (after malaria and RTIs); approx 3-4x per year Often among top 10 causes of mortality - KATH In epidemics, comes in top 3 for the month Increasing importance as HIV/AIDS cases increase
Aetilogical agents of diarrhoea
Type Acute Watery Diarrhoea (most dangerous) Features No visible blood in stools + Vomiting Lasts less than 14 days (no more than 3 days break) Visible blood in faeces Anorexia Rapid wt loss Intestinal mucosal damage Begins acutely but persists 14 days or more. May start as acute diarrhoea or dysentery. Marked Wt loss Persistent diarrhoea with signs if dehydration Common microbial agents Rotavirus E. coli (ETEC, EPEC) Shigella Campylobacter jejuni Cryptosporiduim Vibrio cholerae 01 Shigella Campylobacter jejuni EIEC Salmonella Entamoeba histolytica ( in young adults) Enteroadherent E.coli (EAEC) Shigella Cryptosporiduim Giardia lamblia
Rotavirus diarrhoea Most common cause of severe diarrhoea in young children >1/3 of all hospitalizations of children < 5 due to rota diarrhoea Primary infection is associated with: severe dehydration and fever profuse watery diarrhoea and vomiting All children infected by age 2-3 years First infections are symptomatic and re-infections are common 43 published studies of the etiology of diarrhoea in hospitalised children in 15 African countries 1975-1992 Rotavirus was detected year-round; generally exhibited distinct seasonal peaks during the dry months.
Dysentery
Persistent diarrhoea
Severe Persistent Diarrhoea
NB: Chronic diarrhoea = recurrent, not due to infectious causes (e.g.metabolic disorders)
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Pathogenetic mechanisms for diarhoea -1
Viruses Replication within epithelial cell Villous destruction and shortening with loss of dissaccharidase enzymes Replacement by immature cells
Pathogen multiplies in ileum T oxin production A TP
Examples of pathogens causing secretory diarrhoea: Pathogens producing enterotoxins - V. Cholera - ETEC - Salmonella - Shigella - Campylobacter Secretory diarrhoea not due to toxin production: e.g. Rotavirus
T oxin attachment to mucosal cell cA M P Cl- secretion N a absorption
H 2 O , K + , H CO 3 movement from tisssues into gut lumen
Mechanism for osmotic diarrhoea:
Presence of osmotically active substance in gut
Agents of osmotic diarrhoea
Purgatives e.g. epsom salt. Etc Improperly prepared ORS/Salt Sugar Solutions Lactose in lactose intolerance Glucose in glucose malabsorption
Movement of fluid from tissues into gut
Types of diarrhoea Acute Watery diarrhoea (<14 days duration)
Effects of diarrhoea Fluid & Electrolyte loss Dehydration Tissue Hypoperfusion Multiple organ failure
Dysentery (bloody diarrhoea) Persistent diarrhoea
(>14 days duration)
DEATH
Malnutrition
Severe Persistent diarrhoea
(Persistent diarrhoea with signs of dehydration)
Nutrient Deficit Infection
(Chronic diarrhoea)
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Effects of Dehydration Hypovolaemia, cardiovascular collapse, failure death Multiple organ failure from tissue hypoxia Tissue Damage by Chemical mediators released which amplify damage done by hypoperfusional state (i.e. complement, lipopolyasaccharides, leucotrienes, interleukins, TNF, coagulation cascade, leucocytes endorphins, platelet activating factor) Abnormal Physiology: Plugged capillaries, altered intestitium, damaged barrier function, abnormal smooth muscle contraction (ileus), AV shunting, Coagulation cascade, Abnormal Starling mechanism, Blood viscosity changes. multiple organ
Types of Dehydration -1 Isotonic Dehydration: Commonly result from diarrhoea and vomiting Most common type of diarrhoeal dehydration Net losses of water and Na+ are in same proportion as found in ECF Ser Na+ = 130 - 150 mEq/L, Normal Ser osmolarity ( 275-295 mOsmol/l) Hypovolaemia results from substantial loss of ECF Signs of dehydration appear at lesser degrees of dehydration
Types of Dehydration -2 Hypotonic Dehydration: Commonly results from ingestion of large amounts of water, other hypotonic fluids, from receiving 5% glucose infusions Deficit of both water and sodium, but sodium deficit greater. Ser Na+: < 130 mEq/L; Low Ser osmolality (< 275 mOsmol/l). Signs of dehydration appear at lesser degrees of dehydration Lethargy, occasionally seizures
Types of Dehydration -3 Hypertonic Dehydration: Results from ingestion of hypertonic fluids (e.g. SSS), insufficient water intake, low solute drinks. Deficit of both water and sodium, but water deficit greater Ser Na+: > 150 mEq/L; Low Ser osmolality ( > 295 mOsmol/l). Signs of dehydration appear at greater degrees of dehydration Severe thirst out of proportion to apparent degree of dehydration, irritability Seizures, especially with Ser Na+ > 165 mmol/l Blood volume sustained longer
Other Effects of Diarrhoea
Acidosis (base-deficit) Not a problem if renal function (perfusion) is normal, otherwise acidosis develops rapidly Ser bicarb < 10 mmol/l Arterial pH < 7.10; Deep, rapid breathing - compensatory respiratory alkalosis Increased vomiting Potassium depletion: Follows large faecal loss of K+ Losses greatest in infants, and especially so in undernourished children Not a problem if K+ and HCO3 are lost together Could worsen by correcting base deficit with Bicarb alone unless K+ depletion corrected simultaneously General muscle weakness, cardiac arrythmias, paralytic ileus (especailly, with antimotility drugs)
Principles of diarrhoea management
Rehydration (based on assessment of hydration status)
Signs of Dehydration: KEY SIGNS: Thirst Sunken Eyes Late signs Diminished skin turgor Altered Sensorium Rapid Pulse Low BP Sunken fontanelle
WHO Assessment and classification for hydration status
Dry Mouth and Tongue Absence of Tears on crying
Others: Sign General condition Eyes Thirst Skin pinch (turgor) No Dehydration (< 5% loss) Well, alert Normal Drinks normally Fast recoil Mildmoderate dehydration Severe (Some dehydration) Dehydration (5-10% loss) (>10% loss) Irritable Lethargic or unconscious Sunken Very sunken Drinks eagerly Drinks poorly or unable to drink Returns slowly Returns very slowly
Need 2 or more signs per category to decide: Work Right towards Left
WHO Assessment and classification for hydration status
EXAMPLE 1 Sign General condition Eyes Thirst Skin pinch (turgor) No Dehydration (< 5% loss) Well, alert Normal Drinks normally Fast recoil Mildmoderate dehydration Severe (Some dehydration) Dehydration (5-10% loss) (>10% loss) Irritable Lethargic or unconscious Sunken Very sunken Drinks eagerly Drinks poorly or unable to drink Returns slowly Returns very slowly
WHO Assessment and classification for hydration status
EXAMPLE 2 Sign General condition Eyes Thirst Skin pinch (turgor) No Dehydration (< 5% loss) Well, alert Normal Drinks normally Fast recoil Mildmoderate dehydration Severe (Some dehydration) Dehydration (5-10% loss) (>10% loss) Irritable Lethargic or unconscious Sunken Very sunken Drinks eagerly Drinks poorly or unable to drink Returns slowly Returns very slowly
WHO Assessment and classification for hydration status
EXAMPLE 3 Sign General condition Eyes Thirst Skin pinch (turgor) No Dehydration (< 5% loss) Well, alert Normal Drinks normally Fast recoil Mildmoderate dehydration Severe (Some dehydration) Dehydration (5-10% loss) (>10% loss) Irritable Lethargic or unconscious Sunken Very sunken Drinks eagerly Drinks poorly or unable to drink Returns slowly Returns very slowly
WHO Assessment and classification for hydration status
EXAMPLE 4 Sign General condition Eyes Thirst Skin pinch (turgor) No Dehydration (< 5% loss) Well, alert Normal Drinks normally Fast recoil Mildmoderate dehydration Severe (Some dehydration) Dehydration (5-10% loss) (>10% loss) Irritable Lethargic or unconscious Sunken Very sunken Drinks eagerly Drinks poorly or unable to drink Returns slowly Returns very slowly
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Management of Diarrhoeal dehydration
MANAGEMENT No Dehydration (< 5% loss) Replace ongoing losses and prevent diarrhoea from leading to dehydration ORS: 0-23mo:50 -100ml aels 2-10yrs : 100-200ml aels >10yrs : as wanted Mildmoderate dehydration (Some dehydration) (5-10% loss) Severe Dehydration (>10% loss)
Diarrhoea management - Rehydration
Oral: Oral Rehydration Salts Food-based fluids Other fluids
Principle Action
Nutritional
Treat (imminent) shock Correct fluid Deficit and start correcting fluid deficit ORS or IV Rx : IV Rx (Wt X 75) mls in next 4 Infant: hours 30ml/kg in 1st hour, then Review and review or 70ml/kg in next 5hrs (total move left 6 hours) Older Child: 30ml/kg in 1st 30 mins, (aels=after each loose stool) then 70ml/kg in next 2hrs (total 3 hours) Start ORS as soon as patient can drink Encourage easily digestible, energy-rich foods
Messages to the caretaker: Give the child more fluids than usual, to prevent dehydration; Give the child plenty of food, to prevent undernutrition; and Take the child to a health facility if the diarrhoea does not get better, or if signs of dehydration or another serious illness develop.
Oral Rehydration Therapy
95% of episodes of secretory diarrhoea dehydration can be corrected or prevented using only ORS solution (or ORT).
Composition of ORS old vs new
G/600ml Glucose NaCl Tri Sod Citrate KCl Osmolarity
Low Osmolarity ORS
New 8.1 1.56 1.74 0.9 245
Old 12 2.1 1.74 0.9 311
Lower levels of glucose and salt to achieve lower osmolarity (245 mOsm/l) New Improved Benefits Improved efficacy of ORS Decreased the need for intravenous therapy (33%) Decreased stool output by 20% Decrease frequency of vomiting (30%) As safe and effective in children with cholera
No evidence of increased efficacy over non-flavoured in terms of safety, acceptability and correct use Tends to lead to over-consumption Medical Problems with sweeteners: Toxicity and carcinogenicity cyclamic acid cancer (banned in USA) saccharine carcinogenic dulcine toxic and carcinogenic; aspartame unstable at temperatures above 40oC Specified limits of consumption for all these (FDA) Tendency to exceed limits of consumption in high purge situations hence increased Side effects
Contraindications for ORT -1
initial treatment of severe (life-threatening) dehydration, because fluid must be replaced very rapidly (this requires intravenous infusion of water and electrolytes); patients with paralytic ileus or marked abdominal distension; patients who are unable to drink (however, ORS solution can be given to such patients through a nasogastric tube if intravenous treatment is not possible).
Higher pricing ?Allergies: tendency for flavouring agents to induce allergies and other side effects, particularly in infants and small children.
Contraindications for ORT -2
patients with very rapid stool loss, i.e., greater than 15 ml/kg body weight per hour; such patients may be unable to drink fluid at a sufficient rate to replace their losses; patients with severe, repeated vomiting (this is unusual); generally, most of the oral fluid is absorbed despite vomiting, and vomiting stops as dehydration and electrolyte imbalance are corrected; patients with glucose malabsorption (also unusual); in such cases ORS solution causes stool volume to increase markedly and the stool contains large amounts of glucose; dehydration may also worsen.
ETEC, EPEC Ciprofloxacin Campylobacter Erythromycin only when given early V. cholerae Tetracycline, Co-trimoxazole, Furazolidine Cryptosporidium no effective antimicrobial yet
Protocol for Treating Dysenteries
Treatment based on microscopy or culture and sensitivity results - ideal OR Start treatment as shigellosis Change to 2nd line Rx if stools are still bloody after 2 days Treat as amoebiasis if dysentery present after 5th day
Special notes of Shigelosis
About 50% of Shigella diarrhoeas are mild and not bloody Causes 50% or more of all episodes of bloody diarrhoea in young children (<5yrs) Causes most of episodes of clinically severe diarrhoea in young children, severest in < 4 month olds - fatality about 20% Risk of death greatest in infants and malnourished Causes greater adverse effects on nutritional status than other diarrhoeas - anorexia may persist for days to weeks after recovery, serum protein loss through damaged bowel Without approp. treatment diarrhoea may last 2 - 10 day or more May cause rectal prolapse May cause HUS - low Hb, low platelets, renal failure (S. dysenteriae type 1) Complication more frequent when effective antimicrobial treatment started more than day 2 of symptoms.
Drug with little or no role in diarrhoea case Management
Sulfonamides Neomycin and Streptomycin Antimolitity agents Antiemetics Kaolin and charcoal Cardiac stimulants Purgatives
Zinc for the Treatment of Diarrhoea
Research Findings
Safety Profile of Zinc
RDA: Essential micronutrient 4-5mg in infants 13-19 in adult men Toxicity achieved in excess of 150mg/day over long time or >1g/dose gastric distress and signs of food poisoning; Anaemia from decreased iron absorption
15% reduction in duration of acute diarrhoea 24% reduction in duration of persistent diarrhoea 42% reduction in treatment failure or death in persistent diarrhoea Zinc Investigators Collaborative Group. AJCN 2000.
Dose of zinc: 20 mg/d (range 5-45 mg/d) (Syrup: 20 mg of elemental Zn/5 ml, or Tablets: 20 mg Zn as Zn sulphate, gluconate or acetate)
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Additional Preventive Aspects of Zinc Treatment
Global Diarrhoea Management Policy
May 2004, WHO and UNICEF sign a joint policy for the treatment of diarrhoea in children Management should include: Liberal use of low-osmolarity Oral Rehydration Salts Solution and home fluids to correct or prevent dehydration Zinc supplementation for 10-14 days to shorten duration and severity of diarrhoea Continued feeding including breastfeeding WHO/UNICEF. Joint statement on the clinical management of acute diarrhoea. 2004.
Zinc supplementation for 10-14 has longer term effects on childhood illnesses in the 2-3 months after treatment 34% reduction in prevalence of diarrhoea 26% reduction in incidence of pneumonia
Super ORS solutions Antisecretory drugs Antidiarrhoeal immunisation
PREVENTION OF DIARRHOEA Hand Washing (not rotavirus) Food Hygiene Safe disposal of Excreta Good Nutrition Immunization Rotavirus Cholera Measles
Diarrhoea and Child Mortality
88% of diarrhoea deaths are preventable with widespread prevention and treatment interventions, including: Breastfeeding Vitamin A supplementation Treatment of pneumonia Treatment of diarrhoea with ORS, zinc supplementation, home fluids, and continued feeding
CONCLUSIONS Irrespective of aetiology and mechanism, REHYDRATION is the mainstay of treatment for all forms of acute watery diarrhoea Success of treatment depends on early rehydration Diarrhoeal disease mortality can be controlled in a very costeffectively way with ORS Very few drugs are useful in the management of acute watery diarrhoeas It is important to feed during an episode of diarrhoea
Black, Morris, Bryce. Lancet 2003. Jones, Steketee, Black et al. Lancet 2003.
Introduction of low osmolarity ORS and zinc in the management of diarrhoeal dehydration in Ghana should further reduce mortality and complications. Prevention: Good hygiene, Good nutrition, Rotavirus Immunization of infants
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References Cunliffe NA, et al. WHO, 1998. (rotavirus diarrhoea) Reduced osmolarity oral rehydration salts (ORS) formulation Report from a meeting of experts jointly organised by UNICEF and WHO. WHO/CAH/01.22 http://www.who.int/childadolescenthealth/New_Publications/CHILD_HEALTH/Expert_consultati on.htm Bhutta ZA, Bird SM, Black RE, Brown KH,Gardner JM, Hidayat A et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials. Am J Clin Nutr 2000;72:1516-22.
Exercise:11 mo old male; Wt 15kg
P/C:Fever, Profuse Vomiting & diarrhoea -1/7 Cries at stool, normal stool colour. O/E: Temp=38.5oC, Irritable, Sunken eyes, not pale, Periph pulses palpable with good volume, Pulse rate 100 bps; refuses drink, Abdomen rather full, non tender; Skin recoil slow Bowel sounds normal pitch, about 4 clusters per minute All other systems - normal
QU: Possible diagnoses/?Impressions
Discuss management What if stools become pinkish the following day
