Childhood Diarrhea: Junying Qiao The Department of Pediatrics The Third Affiliatted Hospital of Zhengzhou Uni Versity

Childhood Diarrhea
Junying Qiao
the department of pediatrics
the third affiliatted hospital of zhengzhou uni
versity
Definition
 An increase in the number of stools
or a decrease in their consistency
 A syndrome that results from
disorders involving digestive ,
absorptive, and secretory
functions
Definition
6m-2y
Can result in child malnutrition

and disturbance of growth and
development
classification
infectious
etiology
noninfectious
acute ： <2weeks
duration persistent ： 2weeks2month
s
chronic ： >2months
Mild diarrhea
degree
Severe diarrhea
Susceptible factors
 Immature digestive system
 Hypoimmunity
 dysbacteria
 Bottle-feeding infants
Etiology
（Ⅰ） Infectious factors
Enteropathologic infection
a) Viruses rotavirus , norwalk virus , adenovirus
and coronavirus
b) Bacteria salmonella, shigella ， escherichia c
oli （ enteropathogenic E.coli,enterotoxigenic
E.coli ,enteroinvasive E.coli,enterhemorrhagic
E.coli,enteroadherent-aggregative E.coli). and
campylobacter organisms
c) Fungus candida albicans
d) Parasite giardiasis , cryptosporisiosis , amebia
sis, ascariasis
Parenteral infection
 upper respiratory tract infections
 pneumonia
 urinary tract infections
 skin infections
 Tympanitis
 communicable diseases
Parenteral infection
 Abuse antibiotics
(antibiotics related diarrhea)
(Ⅱ)Noninfectious factors
Dietary diarrhea overfeeding, introd
uction of new foods and unripe food
Symptomatic diarrhea URI , pneumo
nia , urinary tract infections , tympanitis ~~~
Allergic diarrhea milk protein or soy
bean milk
(Ⅱ)Noninfectious factors
 Lactose enzyme deficiency
 Cold or hot weather and emotional tension

Pathogenesis
Classification
• Osmotic diarrhea
• Secretory diarrhea
• Infiltrated diarrhea
• Altered motility diarrhea
Mechanisms of noninfectious diarrhea
 Osmotic factors
• osmotic gradients cause water to
passively cross intestinal mucosa in
isotonic proportions
• Unabsorbed solutes create osmotic
gradient that results in movement of
sodium and water in the intestinal lumen
Mechanisms of noninfectious diarrhea
 Diminished absorption or increased

secretion of water and electrolytes
 Altered motility both hypermotility and

hypomotility reduce the amount of substance a
bsorbed by the intestinal mucosa
Mechanisms of infectious diarrhea
 Enterotoxin production
organisms multiplication
enterotoxin mucosa
Secretion of water and electrolytes

Invasion and destruction of

epithelial cells
• Cause superficial ulcerations of mucosa
• Infection proceeds from the upper to the
lower intestines, producing bloody mucoi
d stools
Penetration and systemic invasion
Organisms infection elsewhere
mucosa to the systemic circulation

(hyperemic and edematous )
Clinical
manifestations
classification
infectious
etiology
noninfectious
acute ： <2weeks
duration persistent ： 2weeks2month
s
chronic ： >2months
Mild diarrhea
degree
Severe diarrhea
Acute diarrhea
(A)general Clinical manifestation
 Mild diarrhea
• Dietary factors, parenteral infection or enter
ovirus
• Mainly exhibits GI symptom
• Signs of dehydration and toxicosis are usuall
y absent
• Stools tests only show a few leukocytes and a
great deal of lipocytes
Severe diarrhea
 Serious gastrointestinal symptoms
 Disturbance of fluid ,electrolyte
and acid-base balance
a) Dehydration
b) Metabolic acidosis
c) Hypokalemia
d) Hypocalcemia and hypomagnesemia
(B) characteristics of gastroenteritis
 Autumn diarrhea
 fecal-oral route or respiration
Rotavirus  6~24 months of age
enteritis
 with URI, fever and vomiting
 stool ： large, watery, frequent
 dehydration : mild / moderate
 Self-limited 3-8days
 No specific therapy
 Higher incidence In summer
 The onset is gradual or abrupt
Escherichia  Clinical manifestations are
coli.
enteritis variable: most-green, watery
stools with blood and mucus
 Stools cultivation
 3-7 days
 Candida albicans
 Ususlly associated with abuse of a
Fungal ntibiotics
enteritis  stools ： water ,bubble, mucus a
nd bean clinker
 Sporophyte and mycelium exists i
n stool examination
Prolonged and chronic diarrhea
 Associated
with malnutrion and inadequat
e management of acute diarrhea
 Itoften occurs in children with bottle-feed

ing and malnutrition
 The children with malnutrition have susc

eptibility for diarrhea. Moreover, diarrhe
a deteriorates malnutrition and leads to h
ypoimmmunity , secondary infection and
functional abnormity of multi-organs.
physiological diarrhea
 Commonly appears in infants less than 6
months of age
 Diarrhea after birth, puffiness and eczema
 Grow normally , good appetite, no
malnutrition, no blood in their stool.
 After
increase supplemental food , stools
gradually turn to normal
Laboratory test
 Blood routine
 Stool examination
 Biochemical examination
 Blood-gas analysis
Diagnosis
 Clinical manifestation
 physical examination
 laboratory findings
 Stools appearance
Diagnosis
Notice
 1 Etiological diagnosis
 2 Complication(dehydration disturbance of
electrolyte and acid-base banlance)

Diagnosis
Judge Etiology from stool routine
 1 No or little leukocyte
virus, noninvasive bacteria ,parasite 　 infec
tion or dietary factor.
 2 many leukocyte or with red blood cell
invasive bacteria .
Therapy
Therapy principles
• Dietary adjustment
• Prevent and correct dehydration
• Reasonable treatment
• Enhance nursing
• Prevent complication
①adjustment of dietary
 The foods should be continued
 Adjusted to meet physiological

needs and supply consumes in
order to shorten the duration of
recovery
②Correction of disturbance
Dehydration
 Mild and moderate diarrhea

—— ORS
 Moderate and severe dehydration

—— intravenous rehydration
ORs(oral rehydration salts)
(The world health organization recommended)
 Composition:
– sodium chloride 3.5g
– Bicarbonate sodium 2.5g
– Potassium chloride 1.5g
– glucose 20.0g
– And water 1000ml to dissolve
 2/3 isotonic
 The concentration of potassium is 0.15%
 The goal is to maintain or restore the
normal volume and composition of body
and normalize optimize cell and organ
function.
The therapy has three phases
• Cumulated losing volume
• Losing continuing
• Physiological need
A. Volume
Degree
Cumulated physiological need,
Total volume
losing volume losing continuing
100 ～ 120 m
Mild 30 ～ 50ml/kg
l/kg
Moder 120 ～ 150 m 50 ～ 100ml/k

80 ～ 100ml/kg
a-te l/kg g
150 ～ 180 m 100 ～ 120 ml/

Severe
l/kg kg
B. Quality
Dehydrant categor Cumulated physiological need,

y losing volume losing continuing
Hypotonic 3:4:2
Isosmotic 3:2:1 1/3 ～ 1/4

Sodium solution
1/3 Sodium
Hyperosmotic
solution
C. Speed
physiological
Cumulated
Total volume need, losing
losing volume
continuing
24 h 8 ～ 12 h 12 ～ 16 h
8 ～ 10ml / kg /
－ 5ml / kg /h
h
D. Shock volume expansion
Volume Solution Speed
2:1 or
20ml/kg 30 ～ 60min
1.4 ％ NaHCO3
Total volume ≤ 300ml

Intravenous rehydration
 Principle
1 first rapidly secondly slowly
2 first sodium secondly glucose
3 Supply potassium after urination
4 Supply calcium and magnesium when tetany and c
onvulsion
 Fluid therapy in the first day

 1 Volume of fluid
 2 Composition of fluid
 3 Rapidity of therapy
A Initial phase B Repletion phase C Stabilization
 4 Correction of metabolic acidosis 、 hypokal

emia 、 Hypocalcemia and hypomagnesemia
Treatment of metabolic acidosis
Mild or moderate metabolic acidosis metabolic

acidosis: No special treatment
Severe metabolic acidosis ： 5%NaHCO3 1ml/kg

[HCO3-] level can increase about 1 mmol.
Treatment of hypokalemia not
iced
 Daily dosage of supplemental potassium is
3~4mmol/kg(200~300mg/kg)
 Concentration less than 0.3% by IV
 Transfusion duration more than 8 hours daily
 Avoiding IV push
 Supplement lasting 4 to 6 days
 Normal renal function (Supply kalium after urination urina
tion 6 hours of preadmission)
Treatment of Hypocalcemia and hy
pomagnesemia
　— 10% calcium gluconate5-10ml 　 dis
solved 　 10% glucose solution10-20ml in
travenous IV slowly ，平均 1ml/min 。
----25%magnesium sulfate 0.1mg/Kg eac
h time injection intromusculari in deep p
art ， once every 6h 。
 The second day

 1 Volume
 2 Solution
 3 Speed
 4 Correction of metabolic acidosis and hyp
okalemia
§ Supply what losed
Drug therapy
 1 Control infection
 2 Micecological therapy
 3 Intestinal mucosa protective agent (protecta
nt)
 4 Avoid using antidiarrheal
Control of infection
Etiologic treatment
 Virus infection
dietary therapy
supportive therapy
self-limited
 Bacteria ,fungus and parasite
specific antimicrobial therapy
Control of infection
 Dietary 、 Virus and noninvasive bacteria diarrhea----
Need no antibiotics
 Invasive bacteria diarrhea---- Need antibiotics
 G+ coccus----penicillin, vancocin 万古霉素 ,
 rifampin 利福平
 G- bacillus---- 头孢曲松 ceftriaxone, 　 ofloxacin 氧氟
沙星　庆大霉素 cidomycin
 Fungus ---- 氟康唑 fluconazol 　
Micoecological therapy
 Aim ： help recove the normal bacteria populatio
n in intestinal lumen, prohibit the pathogen perma
nent planting and invasion, control the diarrhea.
 Drug : 双歧杆菌 bacillus bifidus 　 bacillus acid
i-lactici 乳酸杆菌　粪链球菌 fecal streptococci,
　　需氧芽孢杆菌 aerobic spore-bearing bacilli,
　
Such as jinshuangqi mamiai
 Intestinal mucosa protective drug
can absorb the pathogen and toxin ， maintain
the absorb and secetory function of enterocyte
， prevent the attack of pathogen (montmorill
onite powder) 蒙脱石散．
 Avoid using antidiarrheal 　洛哌丁醇　　 i
nhibit gasenterokinesia, increase bacteria multi
plication and toxin absorption ， it is dangerio
u to infectious diarrhea.
Treatment of prolonged and chron
ic diarrhea
1.Look fof cause positively
2. Disturbance of fluid ,electrolyte and acid-
base balance
3Dietary adjustment
4.Drug Supply microelement and vitamin ；
cautiously using antibiotics ； use micoecolo
gical therapy and intestinal mucosa protecti
ve drug
5.Chinese medicin
Prevention

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Childhood Diarrhea

or a decrease in their consistency

 A syndrome that results from

disorders involving digestive ,

absorptive, and secretory

Can result in child malnutrition

 Cold or hot weather and emotional tension

 Diminished absorption or increased

 Altered motility both hypermotility and

Secretion of water and electrolytes

Invasion and destruction of

Penetration and systemic invasion

Organisms infection elsewhere

mucosa to the systemic circulation

 Itoften occurs in children with bottle-feed

 The children with malnutrition have susc

electrolyte and acid-base banlance)

 The foods should be continued

 Adjusted to meet physiological

 Mild and moderate diarrhea

 Moderate and severe dehydration

• Cumulated losing volume

Moder 120 ～ 150 m 50 ～ 100ml/k

150 ～ 180 m 100 ～ 120 ml/

Dehydrant categor Cumulated physiological need,

Isosmotic 3:2:1 1/3 ～ 1/4

Volume Solution Speed

Total volume ≤ 300ml

 Fluid therapy in the first day

 4 Correction of metabolic acidosis 、 hypokal

Mild or moderate metabolic acidosis metabolic

Severe metabolic acidosis ： 5%NaHCO3 1ml/kg

 The second day

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