Acute diarrhea in children MBBS Lecture
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Transcript of Acute diarrhea in children MBBS Lecture
Acute Diarrhoea
Dr Muhammad Sajjad Sabir MBBS, MCPS ,FCPS(Pediatrics(
Acute Diarrhoea
Definit ionsIncreased frequency and water content of stools than is normal for the individualUsually: ≥ 3 stools per day
(consistency softer than normal --or–one watery stool)stool weight >10g /kgstool weight >200g/day
Diarrhea Acute diarrhea:
Short in duration (less than 2 weeks). Persistent diarrhea:
Starts acutely & lasts more than 2 weeks
Severe Persistent diarrhea: dehydration +ve Dysentery:
Loose stool containing blood
Chronic Diarrhea
Definit ion“Chronic diarrhea is defined as a diarrheal episode that lasts for ≥14 days’’
Common Causes Common Causes of of
Acute DiarrhoeaAcute Diarrhoea
Viral gastroenteritis Infection – highly contagious
Viral gastroenteritis (“stomach flu”)
Rotavirus
Usually cause explosive, watery diarrhoea
Typically last only 48-72hrs
Usually no blood and pus in stool
Bacterial enterocolitis Sign of inflammation – blood or pus in stool,
fever
E. Coli bacteria
•Contaminated food or water
•Usually affect small kids
Bacterial enterocolitis Sign of inflammation – blood or pus in
stool, fever
Salmonella enteritidis bact
•In contaminated raw or undercooked chicken and
eggs
Bacterial enterocolitis Sign of inflammation – blood or pus in
stool, fever
Shigella bacteriaCampylobacter
bacteria
Cryptosporidium
• in contaminated water – can survive
chlorination
Parasites
Giardia lamblia
• in contaminated water
•Usually not associated with inflammation
• Food Poisoning
Staphylococcus aureus
• Produces toxins in food before it is eaten
•Usually food contaminated left unrefrigerated overnight
• Food Poisoning
Clostridium perfringens
• Multiplies in food
•Produces toxins in SI after contaminated food is eaten
Common Causes of Acute Common Causes of Acute Diarrhoea – cont.Diarrhoea – cont.
• Traveller’s Diarrhoea• Drugs / medications
History Duration Frequency Consistency Presence of blood / mucus Fever Feeding Vomiting Abdominal pain
PhysicalExamination
WHO Classification of Dehydration
No dehydration
Some dehydration
Severe dehydration
Severe DehydrationIf any two of the following signs are present, severe dehydration should be diagnosed:
lethargy or unconsciousness sunken eyes skin pinch goes back very slowly(2 seconds or more) not able to drink or drinks poorly
Skin pinch goes back very slowly
(2 seconds or more)
Some DehydrationIf the child has two or more of the
following signs, the child has some dehydration:
restlessness/irritability thirsty and drinks eagerly sunken eyes skin pinch goes back slowly
No Dehydration
Drinks well Eyes -- not sunken Skin pinch goes back rapidly Passing urine normally
Degree of Dehydration
Factors No Dehydration< 3% loss of body weight
Some Dehydration 3-9% loss of body weight
Severe Dehydration >9% loss of body weight
General Condition
Well, alert Restless, thirsty, irri table
Drowsy, cold extremities, lethargic
Eyes Normal Sunken Very sunken, dry
Anterior fontanelle
Normal depressed Very depressed
Tears Present Absent Absent
Mouth /Tongue Moist Sticky Dry
Skin turgor Slightly decrease Decreased Very decreased
Pulse (N=110-120 beat/min)
Slightly increase Rapid, weak Rapid, sometime impalpable
BP (N=90/60 mm Hg)
Normal Deceased Deceased, may be unrecordable
Resp Rate Slightly increased Increased Deep, rapid
Urine output Normal Reduced Markedly reduced
Management
Severe or prolonged episode of diarrhoea
Fever Repeated vomiting, Refusal to drink fluids Severe abdominal pain Diarrhoea with blood or mucus Signs of dehydration
When Treatment is Needed?When Treatment is Needed?
Laboratory Investigation Blood CP Serum Electrolytes Urea & Creatinine Stool R/E
mucus, blood, and leukocytes G. lamblia and E. histolytica
Culture blood stool: cholera, shigella, campylobacter
Management of
Severe Dehydration
Severe Dehydration Start IV fluid immediately If the child can drink, give ORS by
mouth Give 100 ml/kg Ringer’s lactate (or, if not available, Normal Saline) If in shock 20ml N/Saline Bolus*
* Repeat once if radial pulse sti l l very weak/undetectable
AGE First give 30 ml/kg in:
Then give70 ml/kg in:
Infants (< 12 months)
1 hour* 5 hours
Children(12 mo to 5 yrs)
30 minutes* 2 ½ hours
Diarrhoea Treatment Plan C:
* Repeat once if radial pulse sti l l very weak/undetectable
Administration of IV f luid (100 ml) to a severely dehydrated child
Monitoring Reassess the child every 15–30 minutes
until a strong radial pulse is present. If hydration is not improving, give the IV
solution more rapidly Sunken eyes recover more slowly than
other signs and are less useful for monitoring
When the full amount of IV fluid has been given, reassess the child’s hydration status
Management of
Some Dehydration
Diarrhoea Treatment Plan B:Treat some dehydration with ORS
DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4 HOURS
ORS required ( in
ml)=weight (in kg) X 75
Diarrhoea Treatment Plan B:
— If the child wants more ORS give more
— Infants under 6 months who are not breastfed, also give 100–200 ml clean water during this period
TEACH THE MOTHER HOW TO MIX ORS HOW TO GIVE ORS
GIVE THE MOTHER 2 PACKETS OF ORS TO USE AT HOME
Diarrhoea Treatment Plan B:
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE:
Up to 2 years 50 to 100 ml after each loose stool
2 years or more 100 to 200 ml after each loose stool
Diarrhoea Treatment Plan B:
Diarrhoea Treatment Plan B:
SHOW THE MOTHER HOW TO GIVE ORS
— Give frequent small sips from a CUP
— If the child vomits: Wait 10 minutes Then continue ORS , but more slowly
— Continue breastfeeding whenever the child wants
Diarrhoea Treatment Plan B:
Explain 3 Rules of Home Treatment 1. GIVE EXTRA FLUID 2. CONTINUE FEEDING 3. WHEN TO RETURN
WHEN TO RETURNIf child develops any of the following signs:
— drinking poorly or unable to drink or breastfeed
— becomes more sick — develops a fever — has blood in the stool
Managementof
Child with No Dehydration
If there is no dehydration, teach the mother thethree rules of home treatment: (i) give extra fluid (ii) continue feeding (iii) return if the child develops any of
following signs:— drinking poorly or unable to drink or breastfeed— becomes more sick— develops a fever— has blood in the stool.
Diarrhoea Treatment Plan A :
TELL THE MOTHER: — Breastfeed frequently and for longer at
each feed — If exclusively breastfed, give ORS or
clean water in addition to breast milk — If not exclusively breastfed, give one or
more of the following: ORS solution Food-based f luids (such as soup, r ice water,
yoghurt drinks) Clean water
Diarrhoea Treatment Plan A :
Role of Antibiotics
Indicated when Fever Blood/mucus in stool Severe or prolonged episode of diarrhoea Severe abdominal pain Amoebiasis Giardiasis
Oral Co-trimoxazol Naladixic acid Cefixime
Injectable Ampiciline Cirofloxacine Ceftriaxone
Metronidazolonly when Amoebiasis Giardiasis
Role of Antibiotics
Role of Zinc 25% reduction in duration of
diarrhoea episode
30% reduction in stool volume
Decreases morbidity & mortality
Prevents recurrent diarrhoea
Zinc supplementation is efficacious in reducing severity and duration of diarrhoea
dose of Zn 2 RDAs per day for 10-14 days 10 mg per day < 6 months age 20 mg per day > six months age
Role of Zinc
Role of ProbioticsProbiotic – Live microorganisms
(bacteria or yeasts) which, when administered in adequate amounts, confer a health benefit on the host
Examples Saccharomyces boulardii (Enflore) Lactobacilli Enterococci Bifidobacteria
Mechanism of action of Probiotics competit ion for nutrit ion destruction of receptor site for toxin producing protease aid host with both the digestion and absorption of
nutrients Produce abundant lactate--lowering pH of intestine ,
l imit ing the growth of certain enteropathogens (eg Salmonella
colonise intestinal epithelia---depriving pathogens of attachment sites
increasing macrophage activity enhancing the production of immunoglobulins (eg
IgA) destroy the invading organism
Potential Advantages of Probiotics
Multiple Mechanisms of Action Resistance is Infrequent Use May Reduce Exposure to Antibiotics Delivery of Microbial Enzymes Well Tolerated Benefit to Risk Ratio is Favorable
How to prepare ORS at home
Thanks….
But it’s not the end !!!
Prevention
Wash your hands frequently, especially after using the toilet, changing diapers
Wash your hands before and after preparing food
Wash diarrhea-soiled clothing in detergent and chlorine bleach
Never drink unpasteurized milk or untreated water
Proper hygiene
access to clean water safe sanitation hygiene education exclusive breast-feeding improved weaning practices immunizing all children; especially measles keeping food and water clean washing hands with soap (the baby's as well)
before touching food sanitary disposal of stools
Prevention
Points to Remember Gastroenterit is is acute self-l imited
i l lness Diarrhea and vomiting in infancy and
childhood is usually due to viral gastroenterit is
Fluid replacement with ORS is mainstay of management
Breast feeding should be continued, but formula feeding should cease unti l recovery.
Antibiotics usually not required Antidiarrhoeal and antiemetics
agents are contraindicated zinc supplementation should be
given as an adjunct Use Probiotics
Points to Remember
Thank You for Being Patient Ti l l the End
SOLUTION
glucose (g/L)
Na (mmol/L)
K(mmol/L)
Cl (mmol/L)
BASE (mmol/L)
OSMOLARITY
(mOsm/L)
Low osmolali ty
ORS13.5 75 20 65 10 245
WHO (2002) 13.5 75 20 65 30 245
WHO (1975) 20 90 20 80 10 311
Pedialyte 25 45 20 35 30 250
COMPOSITION OF COMMERCIAL ORS AND COMMONLY CONSUMED BEVERAGES