Approach To A Child With Diarrhea

Approach to a child
with Diarrhea
Review of Acute Diarrhea
•DEHYDRATION KILLS!!
Types of diarrhea
• Passage of three or more stools in a day of consistency softer than usual, or

one watery stool is defined as diarrhea. Most diarrheas which cause dehydration
are loose and watery.
• If diarrhea lasts for more than 14 days it is called persistent diarrhea. This
often causes nutritional problems.
• Diarrhea with blood in stools with or without mucous is called dysentery.
Etiology of acute watery diarrhea
Diarrhea
• Infections
• Bacteria: E. Coli (25%), Salmonella (10%), Shigella

(5%), Staph. aureus (food poisoning),
Campylobacter jejuni, Yersinia enterocolitis
• Viruses: Rota virus (40%), Enteric adenovirus
• Parasites: E. Histolytica, G. lamblia, Cryptosporidium
• Fungi: Candida albicans
Etiology of acute watery
diarrhea (contd)
Non infectious causes

• Parenteral causes: otitis media; pneumonia; UTI.
• Dietary factors: overfeeding, starvation;
food allergy/intolerance.
• Drugs: antibiotics
• Case Scenario
Mother brings 8 months old child with complaints of diarrhea from
past 2 days. Baby has not passed urine from past 4 hours. Weight of
baby was 8 kg last week but today weighs 7.5 kg.
• • What will you ask in history?
• • What signs of dehydration would you look for?
• • How would you manage him?
If the child has diarrhea
1) ASK: For how long; Is there blood in the stools
2) LOOK at the child’s general condition: lethargic or unconscious;
restless or irritable
3) LOOK for sunken eyes
4) OFFER the child fluid: child able to drink; drinking
eagerly, poorly, thirsty
5) PINCH the skin of the abdomen: does it go back:

longer than 2 seconds; slowly
Severe Dehydration (>10%)
Two of the following signs:
• Lethargic or unconscious
• Sunken eyes
• Not able to drink or drink poorly
• Skin pinch goes back very slowly
Some Dehydration (5-10%)
• Restless or irritable
• Sunken eyes
• Drinks eagerly, thirsty
• Skin pinch goes back slowly
No Dehydration (<5%)
• 1) Not enough signs to classify as severe or some dehydration

Classification of dehydration
• Lethargic or unconscious
• Sunken eyes SEVERE DEHYDRATION
• Not able to drink or drink poorly
Two of the following signs

• Restless, irritable
• Sunken eyes Some DEHYDRATION
• Drinks eagerly, thirsty
Not enough signs to classify as some or

severe NO DEHYDRATION
dehydration
Severe Dehydration
Plan C
1) Refer URGENTLY to hospital with mother giving sips of ORS on the

way.
2) Advise mother to continue breastfeeding
3) If the child has some dehydration along with another severe

classification or danger sign refer to hospital
4) Rehydrate with Ringers lactate: 100ml/kg intravenously in 4-6 hours
Some Dehydration
PLAN B
1) treat with ORS: 50 –100ml/kg over 4 hours. Recommended

amounts in 4 hours is usually 75ml/kg
2) Show mother how to give ORS
3) After 4 hours reassess the child for dehydration
4) Select appropriate plan to continue treatment
5) Begin feeding the child in the clinic
No Dehydration: PLAN A
Treat at HOME
1) Give extra fluid

2) Teach the mother how to mix and give ORS. Give mom 2 packets of
ORS,
3) Show mother how much fluid to give in addition to the usual intake
4) Continue feeding
5) Give Zinc <6 months 10 mg/day for 2 wks, >6 months
20 mg/day for 2 wks
6) Follow-up
7) Return if danger signs appear
Q. Acute Diarrhea in a child .. contd:
B. Management:
• Look for co-morbids: bacterial infection
elsewhere
• Treat at home, rehydrate orally (50 ml/kg or
0.5 cup/motion)
• Check feeding and continue feeding
• No antibiotics
• Warn about danger signs
• Check immunizations/immunize
• Follow up in 5 days
Key Management points
1) Prevent dehydration if there are no signs of dehydration;
treat dehydration when it is present;
2) Prevent nutritional damage by feeding during and after
diarrhea;
3) Reduce the duration and severity of diarrhoea, and the
occurrence of future episodes, by giving supplemental zinc.
• Non Pharmacological measures:
• • Hygiene care
• • Clean water
• • Safe food preparation
• • Soft diet
• • Immunization
Antibiotics for diarrhea
1) Antimicrobials are reliably helpful only for children with bloody

diarrhea (probable shigellosis), suspected cholera with severe
dehydration, and serious non-intestinal infections such as pneumonia.
2) Anti-protozoal drugs are rarely indicated.
3) "Antidiarrheal" drugs and anti-emetics have no practical benefits for
children with acute or persistent diarrhea
4) Zinc (10-20 mg/day) be given for 10 to 14 days to all children with
diarrhea.
Q. Acute Diarrhea in a child
• Key diagnostic points:
• • 8 month old
• • Vomiting and diarrhea for two days (acute)
• • No blood in the stools (not dysentery)
• • Not passed urine (dehydration)
• • Wt was 8 Kg (appropriate for age??) but has lost
• 0.5 Kg (dehydration 6%)
• A. Signs of dehydration: classify dehydration
• Lethargic, restless, sunken eyes, drinking poorly, skin

• pinch (slowly/>2 secs)
• Assess severity of dehydration (severe dehydration)

Chronic Diarrhea
• History? Failure to thrive, improved with rice, travel , source of water.
Stool is very foul smelling , fatty , difficult to flush, is it alternating with
constipation, developmental milestone, other autoimmune diseases,
IBS, IDA, Vitamin b 12 deficiency. Mouth ulcers..
• Etiology: Giardiasis, Celiac disease, IBD..
• Investigations: Stool R/E, if suspecting typhoid Send blood cultures.
Stool Cultures.
• Treatment: treat the cause, dehydration and vitamin deficiency.

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Approach to a child

• Passage of three or more stools in a day of consistency softer than usual, or

• Bacteria: E. Coli (25%), Salmonella (10%), Shigella

Non infectious causes

5) PINCH the skin of the abdomen: does it go back:

• 1) Not enough signs to classify as severe or some dehydration

Two of the following signs

Not enough signs to classify as some or

1) Refer URGENTLY to hospital with mother giving sips of ORS on the

2) Advise mother to continue breastfeeding

3) If the child has some dehydration along with another severe

1) treat with ORS: 50 –100ml/kg over 4 hours. Recommended

1) Give extra fluid

1) Antimicrobials are reliably helpful only for children with bloody

• A. Signs of dehydration: classify dehydration

• Lethargic, restless, sunken eyes, drinking poorly, skin

• Assess severity of dehydration (severe dehydration)

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