DEHYDRATION IN SAM CHILD

PERSISTANT DIARRHEA

By: Dr. Kuldeep Temani

MANAGEMENT OF DEHYDRATION IN SAM CHILD

Assessment of dehydration in SAM child

• Dehydration tend to be over diagnosed and its severity often overestimated in SAM child.

• usual sign of dehydration like skin pinch, sunken eye ball ,appearance of child is no use in SAM child. because

• Loss of elasticity of skin, and sunken eye may be either due to loss of subcutaneous fat in sam child.

• Irritability, lethargic, unconscious child may be due to hypoglycemia, infection and other complication of SAM.

• Oral mucosa feel dry• Presence of thirst, hypothermia, week pulse

and oliguria, absent tear• Its safe to assume that all SAM child with

watery diarrhea have some dehydration

Sign dehydration in SAM child

MANAGEMENT OF SOME DEHYDRATION IN SAM CHILD

•Recommended solution by WHO is Resomal

•Recommended solution by IAP IS RO-ORS with potassium supplement.

Ingredients of ResomalIngredients Mmol/l

Glucose 125 mmol/lSodium 45 mmol/lPotassium 40 mmol/lChloride 70 mmol/lMagnesium 3 mmol/lZinc .3 mmol/lCopper .045mmol/lcitrate 7 mmol/lTotal osmolarity 290.345 mmol/l

Ingredients of ors solution(mmol/l)

Low osmolarity ors Who-ors(old)

sodium 75 90potassium 20 20chloride 60 80citrate 10 10glucose 75 111Total osmolarity

245 311

• Basis of solution • SAM children are deficient in potassium

and have very high level of sodium, normal ores solution is dangerous for them.

• They need solution which contain less sodium and more potassium.

• These pt. are also deficient in in other minerals like magnesium, copper, zinc, and these minerals are added

ReSoMal

ReSoMal• ReSoMal contains a mixture of salts and minerals to

correct deficiencies of potassium, magnesium, zinc and copper and to address high levels of sodium in children with SAM.

• It is supplied as powder in sachets. Previously, one sachet needed to be reconstituted by adding 2 liters of boiled water to the content of each sachet, producing thereafter 2 liters of rehydration solution.

• The reconstituted solution has to be consumed immediately or used within 24 hours if stored in a refrigerator.

• a quantity of reconstituted ReSoMal was being wasted.

• In order to resolve this problem, discussion was initiated in 2010 between UNICEF Programmed Division, Supply Division, Regional Offices, nutritionists working in in-patient centers and suppliers - and concluded that the sachet sizes should be reduced.

• It was agreed that the optimal volume of the solution should be 1 liter. Hence, it was decided to reduce the sachet sizes by 50 per cent.

• New sachets must be reconstituted by adding 1 liter of boiled, cooled water, which will result in 1 liter of liquid ReSoMal.

ReSoMal

Some dehydration• Dehydration should be corrected slowly over

period of 12 hour.• ReSoMal should be given orally or by nasogastric

tube at 5 ml/kg every 30 minutes for first 2 hours• Then 5-10 ml/kg every hour for next 4-10 hour.• Exact amount depend on how much child want,

volume of stool loss and whether child is vomiting• Ongoing stool losses should be replaced with

approximately 5-10 ml/kg ors after each watery stool

• BF should be continued during the rehydration phase.

• Refeeding must be started with starter f-75 formula within 2-3 hr. of starting rehydration.

• The feed must be given on alternate hours(eg.hours 2, 4, 6) with ors (hr. 1, 3, 5).

• Once rehydration complete feeding must be continued and ongoing losses replaced with ors.

Some dehydration

• Monitor every ½ hourly for first 2 hour and then every hours for next 4-10 hours.

• Monitor pulse rate, respiratory rate ,oral mucosa, urine frequency or volume, and frequency of stool and vomiting.

• Decrease in heart rate and respiratory rate( if initially increased ) and increased in urine output indicate rehydration is proceeding.

• Return of tear, a moist oral mucosa, less shunken eye and fontanelle improved skin turgor also indicate rehydration.

Some dehydration

Some dehydrationSam child Non sam child

recommended fluid ReSoMal Ro-ors

Rout of administration

Oral/NG Oral/NG

Time for correction 12 hours 4 hours

Amount of fluid Very less 5ml/kg every 30 minute

75 ml/kg

For ongoing losses 5-10 ml/kg for each watery stool

10-20 ml/kg for each watery stool

Scenario A Clinical assessment of dehydration

This 2 year old male child was brought to the emergency room with diarrhoea for 6 days. He had angular stomatitis, peri-anal ulceration, weighed 7.0 kg and the MUAC was 10.2 cm.

His hands were cold, pulse weak and fast and skin pinch went back very slowly. The resident doctor gave 140ml of normal saline by rapid IV infusion but his condition deteriorated.

Questions

• Q1: What important condition needs to be recognised in this child?

• Q2: Was the doctor’s management correct?

• Q3: List 2 pathophysiological mechanisms in this condition that affect fluid management.

Answer 1

• The child has severe acute malnutrition: SAM with shock

ANSWER 2• The doctor’s choice of IV normal saline,

amount of fluid and rapidity of given IV fluid were all incorrect and may have caused the child’s deterioration.

• The IV fluid of choice (in order of preference) according to availability are:–Ringers lactate with 5% dextrose–Half-nomal saline with 5% dextrose–Half-strength Darows solution with 5%

dextrose–Ringers lactate

• Amount of fluid–Give IV fluid 15ml/kg over 1 hour

• Monitor pulse and breathing rate at the start and every 5-10 minutes

• If there is improvement (pulse and respiratory rate fall), repeat IV fluid 15ml/kg over 1 hour

• Then switch to oral or nasogastric rehydration with Resomal 5-10 ml/kg/hr

ANSWER 2

ANSWER 3• The pathophysiological mechanisms that affect fluid

management are:

1. Although plasma sodium may be very low, total body sodium is often increased due to – increased sodium inside cells– additional sodium in extracellular fluid if there is

nutritional oedema– reduced excretion of sodium by the kidneys

2. Cardiac function is impaired in SAMThis explains why treatment with IV fluids can result

in death from sodium overload and heart failure.

CONCLUSION

• The correct management is reduced sodium oral rehydration fluid (ORF; e.g. ReSoMal) given by mouth or naso-gastric tube if necessary.

• The volume and rate of ORF are much less for malnourished than well nourished children (see next slide)

• IV fluids should be used only to treat shock in children with SAM who are lethargic or have lost consciousness!

How can we prevent diarrhoeal disease?

This involves intervention at two levels:• Primary prevention (to reduce disease transmission)

– Rotavirus and measles vaccines– Handwashing with soap– Providing adequate and safe drinking water– Environmental sanitation

• Secondary prevention (to reduce disease severity)– Promote breastfeeding– Vitamin A supplementation– Treatment of episodes of AD with zinc

Next

Persistent diarrhea

Definition•Diarrhea that starts as an acute episode and last at least 14 days is sad to be persistant

Etiology• Persistent infection• PEM• Malabsorption of carbohydrate and

fat due to combination of malnutrition and enteric infection

• Infrequently, dietary protein intolerance

Complication• Malnutrition and

worsening of malnutrition• dehydration

INVESTIGATION• Following ix recommended in each pt of PD 1. Examination of stool

macroscopic, , consistency, presence of mucus and blood

2. microscopic-pus cell, RBC, parasites, ova, cyst, trophozoites of E.histolytica, G.lamblia

3. Stool culture for salmonella shigella4. Stool for reducing sugar carbohydrate

intolerance5. Stool ph. carbohydrate intolerance

Management• Indication of hospitalization

1. Presences of dehydration2. Severe malnutrition3. Suspicion systemic infection4. Age less than 6 month and not

breastfeed

• Assessment and correction of dehydration

• Dietary management• Additional drug• Antimicrobial therapy

Management #

Dietary management• Diet A (reduced lactose diet)• Diet B (lactose free diet with

reduced starch)• Diet C (monosaccharide based

diet)

Diet A• Basis of diet A1. In PD due to persistent infection or reinfection of same and

different microorganism2. And due to malnutrition there is damaged to small bowel

epithelium. Brush border of small bowel epithelium contain disaccharides.

3. In the absence of these enzyme disaccharide are not hydrolyzed in simple sugar and reach unchanged in to the lower gut where these draw water from gut wall throw osmosis.

4. Unabsorbed sugar fermented by gut bacteria leading to production H2, methane, co2,these gas cause abdominal distention and frothy character of stool.

Diet A1. Infant age less than 6 month• Encourage exclusive breast feeding• Reestablish lactation• If only animal milk must be given,

replace it with curd and lactose free milk formula(give with a cup and spoon)

• If required, cooked rice can be mixed with milk/curd/lactose free formula

Diet A #• Limit daily intake of milk 50-60 ml/kg• Lactose not more than 2 gm/kg day• To reduced lactose concentration in

animal milk do not dilute it reduced energy density critically.

• Milk can be mixed with cereals• Start feeding as soon as the child can eat• Offer 6-7 feed per day

• Total energy intake of 110 kcal/kg to begin with increase energy intake steadily up to 150 kcal/kg over next two week

Diet A #

Advantage of diet A• Well tolerated• Highly palatable• Consumed in large quantity• Provide adequate calories, good

quality proteins and micronutrient• Results in faster weight gain

Diet A #Ingredients measures Weight/volumeMilk 1/3katori 50 mlSugar 1 ½ tsp 7 gmOil 1 tsp 4.5 gmPowder puff rice* 2 tsp 6.0 gmWater 2/3 katori 100 mlCalories/100gm 85 kcalProteins/100gm 2.0gm

• Puffed rice can be substitute by cooked rice and sooji

• Preparation• Mix milk, sugar, rice together. add

boil water and mix well. add oil, the feed can now be given to the child

Diet A #

Diet B

Lactose free diet with reduced starch

Diet B• Basis for diet B• some children do not respond well to initial low

lactose diet. they have impaired digestion of starch and other disaccharides other than lactose.

• therefor not only milk is eliminated but starch is reduced and partially substitute by glucose.

• Substituting only part of the cereal with glucose increase the digestibility but at the same time does not cause very high osmolarity

Diet B #• Milk free diet (Lactose free)• Carbohydrates provided as a

mixtures cereals and glucose• Milk protein is replaced by chicken,

egg, and protein hydrolysate

Diet B #ingredients measures Weight/volumeEgg white 10 tsp ½ egg whitegulcose 1 ½ tsp 7 gmOil 1 ½ tsp 7 gmPowder puff rice* 3 tsp 9.0 gmWater ¾ katori 120 mlCalories/100gm 90 kcalProteins/100gm 2.4 gm

Diet C

Monosaccharide based diet

Diet c• Basis for diet C• Over all 80-85% pt. with severe persistent diarrhea

will recover with sustained wt. gain on the initial diet A or the second diet B.

• Some pt. may not tolerate moderate intake of cereal in diet B

• These children are given the third diet C.• Diet C contain only glucose and a protein source as

egg white or chicken or protein hydrolysates.• Energy density is increased by adding oil to the diet

Diet C #ingredients measures Weight/volume

Egg white or chicken puree

10 tsp ½ egg white or 15 gm

glucose 1 ½ tsp 7 gm

Oil 1 ½ tsp 7 gm

Water 1 katori 150 ml

Calories/100gm 67 kcal

Proteins/100gm 3 gm

preparation• Boil chicken, remove bones and

make chicken puree.• Mix chicken puree with glucose and

oil.• Add boiled water to make a smooth

flowing feed

Supplemental vitamins and minerals

• About twice the RDA should be given to all children for at least 2-4 week.

• Iron supplements should be given only after diarrhea ceased.

• Provide Vitamin A(as a single large dose) and zinc ,these have been show effect recovery from persistent diarrhea.

• is• and minerals

Vitamin A• >12 months 2,00,000 iu orally• 6-12 months 1,00,000 iu orally• Children less than 8 kg irrespective of

there age should be given 1,00,000 iu orally

zinc• <6 months 10 mg/day• > 6 months 20 mg/day

Other recommendation

• Magnesium sulphate 50% : 0.2ml/kg/dose twice a day for 2-3 days

• Potassium 5-6 meq/kg/day orally or i.v. as a part of initial stabilization period.

Indication for change from the initial diet A to diet B or diet B to diet C

• In the absence of initial or hospital acquired infection, the diet should be changed when treatment failure, defined as

1. A marked increased in stool frequency usually more than 10 watery stool/day any time after initiating treatment.

2. Return of sign of dehydration any time after initiating treatment.

3. Failure to established weight gain by day 7.4. Unless sign of treatment failure occur earlier each

diet should be given for minimum period of 7 days

Resumption of regular diet after discharge

• Children discharge on diet B should be given small quantities of milk as apart of mixed diet after 10 days.

• If they have no sign suggestive of lactose intolerance (diarrhea, vomiting, abdominal pain, abdominal distention, excessive flatulence)

• milk can be gradually increased over next few days

• A normal diet appropriate for age can be resumed over next week.

Recommendation for antimicrobial therapy

• High fever• Presence of blood and mucus in stool• Associated systemic infection• Severe malnutrition• Severe abdominal pain • Recent use of antibiotics or hospitalized

patients• Immunocompromised patients, including

(HIV)

THANKS