5

WELCOMEWELCOME

ALLALL

Dr Mohammad Nurul Huq

7

ARI

54%

Diarrhoea

85%

Malaria

79%

Measles

89%

Percentage of deaths occurring among:

Global Burden of Diseases Borne by U-5 Children Year 2000

8

Diarrhea Key FactsDiarrhea Key Facts Globally: 1.7 billion cases/y. Globally: 1.7 billion cases/y. 2 attacks/child/y2 attacks/child/y 2nd2nd largest U-5 killer largest U-5 killer (0.76mn/y:2013)(0.76mn/y:2013);; was was No.1No.1 (5mn)(5mn) Most deaths from dehydrationMost deaths from dehydration It is preventable and treatable.It is preventable and treatable. Safe water and sanitation Safe water and sanitation

can largely prevent itcan largely prevent it BangladeshBangladesh: : 250k deaths/y250k deaths/y A leading c/of malnutrition in U-5A leading c/of malnutrition in U-5

Mortality rate is falling fast (Mortality rate is falling fast (ORT)ORT)

9

Diarrhea Death is FallingDiarrhea Death is Falling

Successful ORTSuccessful ORT Breastfeeding, no bottle, no formulaBreastfeeding, no bottle, no formula Safe water and food, health educationSafe water and food, health education Hand washing, improved sanitationHand washing, improved sanitation ImmunizationImmunization HPVAC, ZnHPVAC, Zn Fall in MnFall in Mn AwarenessAwareness

HPVAC: high potency Vitamin A capsule. Zn: zincHPVAC: high potency Vitamin A capsule. Zn: zinc

10

30 Years of ORS30 Years of ORS

Absorption of salt plus water is enhanced with Absorption of salt plus water is enhanced with glucose, glucose, amino a. amino a. discovery of ORS and later rice discovery of ORS and later rice ORSORS

WHO:WHO:““ORT is the most rewarding scientific achievement ORT is the most rewarding scientific achievement

of 20th century”of 20th century”

11

Definition of DiarrheaDefinition of Diarrhea Passage of 3 loose stools/24h. Loose stool: one that

takes up the shape of the container

Exception!! Exception!!

EBFEBF babies babies pass pass manymany loose/unformed motions/d loose/unformed motions/d They do They do not not develop dehydration and thrive well!develop dehydration and thrive well! We call these We call these BM stoolsBM stools!!

With its With its other unique qualities BM other unique qualities BM also has ORS like actionalso has ORS like action

12Breast milk stools

13

Diarrhea Harms ..Diarrhea Harms ..

DehydrationDehydration DyselectrolytemiasDyselectrolytemias MalnutritionMalnutrition VADXVADX AnemiaAnemia More infx More infx Growth failureGrowth failure

VADX: Vitamin A deficiency and xerophthalmia. Infx.: infectionVADX: Vitamin A deficiency and xerophthalmia. Infx.: infection

14

Diarrhea Causes Diarrhea Causes MalnutritionMalnutrition Food intake Food intake by 1/3 ( by 1/3 (appetite poor, NVD)appetite poor, NVD) Starvation therapy Starvation therapy (‘rest to bowel’)(‘rest to bowel’) Faulty feeds, food fadsFaulty feeds, food fads MalabsorptionMalabsorption VADX VADX Infx Infx More nutrients to cope with diarrheaMore nutrients to cope with diarrhea

Mn. makes D. worse. Mn.Mn. makes D. worse. Mn. longer, severer D. longer, severer D.The cycle can be broken by good nutritionThe cycle can be broken by good nutrition

Stress on feeding in D.! Stress on feeding in D.! D: diarrheaD: diarrhea

15

Diarrhea Kills ..Diarrhea Kills ..ShockShock, ARF, ARF Dyselectrolytemia Dyselectrolytemia (hypokalemia)(hypokalemia) Severe malnutritionSevere malnutrition Associated infx. (pneumonia)Associated infx. (pneumonia) HUS (E coli)HUS (E coli) GBS (C jejunae)GBS (C jejunae)

How dehydration kills HypovolemiaHypovolemiaFor each 1% dehydration body function falls by 5%For each 1% dehydration body function falls by 5%20% dehydration is lethal20% dehydration is lethal

16

Predisposing Factors for D. Predisposing Factors for D. Not Not breastbreast feeding feeding FormulaFormula feeds feeds Using feeding Using feeding bottlebottle Not Not washingwashing hands hands Unsafe foods, drinks, waste disposalUnsafe foods, drinks, waste disposal No immunization, malnutritionNo immunization, malnutrition MeaslesMeasles VADX, Zn deficiencyVADX, Zn deficiency ImmunodeficiencyImmunodeficiency

17

Complications Complications

DehydrationDehydration Shock, ARF, acidosis Shock, ARF, acidosis HypokalemiaHypokalemia HyponatremiaHyponatremia HypochloremiaHypochloremia HypocalcemiaHypocalcemia

Hypoglycemia, fitHypoglycemia, fit HypothermiaHypothermia Food intoleranceFood intolerance GBS, HUS, anemiaGBS, HUS, anemia MalnutritionMalnutrition VADXVADX

18

HUS: HUS: Schistocytes (broken RBCs)

19

Types of Ac. DiarrheaTypes of Ac. Diarrhea

33 clinical clinical typestypes Ac. Ac. waterywatery D D (AWD) 75% (AWD) 75% lasts several hours to dayslasts several hours to days Ac. Ac. invasiveinvasive D D (AID) 15% or (AID) 15% or ac. bloody D (dysentery)ac. bloody D (dysentery) PersistentPersistent D D (PD) 10%(PD) 10% lasts 14d or more lasts 14d or more

20

Ac. Watery Diarrhea Ac. Watery Diarrhea

CommonestCommonest Large motions: rapid dehydrationLarge motions: rapid dehydration 45% of diarrheal deaths45% of diarrheal deaths No invasion No invasion Duration ~7 daysDuration ~7 days

21

Cl. Features of AWDCl. Features of AWD

Usually Usually starts as a starts as a viral syndrome*viral syndrome* Loose/watery stoolsLoose/watery stools NV NV ++ Fever Fever +/-+/- Abdominal pain Abdominal pain

*Viral syndrome: cold, cough, flushing, red eyes, malaise, bodyache, etc.

22

Causes of AWDCauses of AWD

RotavirusRotavirus ETECETEC EPEC EPEC V. choleraeV. cholerae

No pathogen detectable in 5%No pathogen detectable in 5%

GiardiaGiardia Nontyph. salmonellaNontyph. salmonella CryptosporidiumCryptosporidium A. hydrophilaA. hydrophila

23

Rota VirusRota Virus

33% of all D.33% of all D. 60% of all D. <2yoa60% of all D. <2yoa 20k deaths in Bangladesh20k deaths in Bangladesh Starts as upper respiratory catarrhStarts as upper respiratory catarrh Yellowish/greenish watery stools with flakes of fecesYellowish/greenish watery stools with flakes of feces Rapid dehydration Rapid dehydration Vaccine preventable: v. effectiveVaccine preventable: v. effective

24

25

V cholerae

26

27

28

Remember AWD..Remember AWD..CommonestCommonest Rapid severe dehydrationRapid severe dehydration Rx only by ORTRx only by ORT No ABT (antibiotic therapy)* Self- limitingNo ABT (antibiotic therapy)* Self- limitingWrong Rx may lead to PDWrong Rx may lead to PD Increased fluid and continued feeding is v. imp.Increased fluid and continued feeding is v. imp.

*ABT recommended in cholera*ABT recommended in cholera

29

Ac. Inv. Diarrhea (Dysentery)Ac. Inv. Diarrhea (Dysentery)

FeaturesFeatures InvasionInvasion InflammationInflammation System upsetSystem upset Characteristic stoolsCharacteristic stools

Dysentery: Dysentery: loose stools mixed with mucus and blood; AP and loose stools mixed with mucus and blood; AP and tenesmus (urge to purge with little output: irritation of internal anal tenesmus (urge to purge with little output: irritation of internal anal

sphincter)sphincter)

30

InvasionInvasion : : inflammation, spreadinflammation, spread Inflammation Inflammation : : congestion, edema, congestion, edema, mucusmucus, ,

ulcer, ulcer, bleedbleed, , AP, AP, tenesmustenesmus, , distensiondistension

Sys. UpsetSys. Upset : : HGF, HA, NV, toxicity, HGF, HA, NV, toxicity, prostrationprostration

StoolsStools : : Dysenteric: frequent (>6/d), Dysenteric: frequent (>6/d),

plenty plenty pus cellspus cells, , RBCRBC, ,

macrophagesmacrophages, ,

epithelial cellsepithelial cells

31

Colitis in Ac. Inv. Diarrhea Colitis in Ac. Inv. Diarrhea

32Rectal prolapse

33CT of Amebic L. Abscess (F, RUQ Pain and Pleuritic Pain)

34

C/of Ac. Invasive Diarrhea C/of Ac. Invasive Diarrhea

Shigella (60%)Shigella (60%) Salmonella (some strains)Salmonella (some strains) EIEC, otherEIEC, other E coli E coli CampylobacterCampylobacter HelicobacterHelicobacter E. histolyticaE. histolytica

35Intracellular Shigella

36EM: Salmonella

37Motile E. histolytica Trophozoite in Stool Showing Ingested RBCs

38E coli, flagella

E coliE coli Diarrhea (Including HUS). Diarrhea (Including HUS). EMEM of of E coli E coli O157:H7 showing O157:H7 showing

flagellaflagella

39

Remember AID may cause:Remember AID may cause:

Complications: HUS (E. coli), GBS (Campylobacter)Complications: HUS (E. coli), GBS (Campylobacter) Malnutrition Malnutrition AnemiaAnemia Persistent diarrheaPersistent diarrhea DeathDeath

40

Persistent DiarrheaPersistent Diarrhea

30-50% of deaths in diarrhea! 30-50% of deaths in diarrhea! Almost unknown in EBFB Almost unknown in EBFB Starts as AWD/AID; but predisposingStarts as AWD/AID; but predisposing

factors prolong it factors prolong it >> 1414dd Child is malnourished, develops VADXChild is malnourished, develops VADX Often with serious non-GIT infx.Often with serious non-GIT infx.

EBFB: exclusively breastfed babies

41

Predisposing Factors for PDPredisposing Factors for PD

Not breastfeedingNot breastfeeding Bottle feedingBottle feeding Unjustified ABTUnjustified ABT MalnutritionMalnutrition VADX VADX

ImmunodeficiencyImmunodeficiency Starvation therapy Starvation therapy Food intoleranceFood intolerance

Preventing these can avert PDPreventing these can avert PD

42

I do all, without a mom!

43

Effects of PDEffects of PD

A A seriousserious condition condition!!

Dehydration Dehydration Rapid wt. loss, malnutritionRapid wt. loss, malnutrition Malabsorption: Nutrient deficiencies, Malabsorption: Nutrient deficiencies, VADXVADX

44

Causes of PD Causes of PD

No single microbial causeNo single microbial cause

Some Some maymay play a role: play a role: CryptosporidiumCryptosporidium Enteroaggregative Enteroaggregative E. coliE. coli ShigellaShigella

45

Chronic vs. PDChronic vs. PD

Don’t confuse chr. D with PDDon’t confuse chr. D with PD

Chr. diarrhea is:Chr. diarrhea is: insidiousinsidious long lasting/recurrentlong lasting/recurrent usuallyusually non-infx. causes (eg thyrotoxicosis) non-infx. causes (eg thyrotoxicosis)

46

History. History. Volume of Volume of urineurine (never forget)(never forget)Looking at the stoolLooking at the stoolPhysical ExamPhysical Exam S/S/of dehydrationof dehydration and malnutrition and malnutrition

Assessing DiarrheaAssessing Diarrhea

47

HistoryHistory

Duration and onsetDuration and onset Stool:Stool: times, vol., form, times, vol., form,

color, blood +/-mucuscolor, blood +/-mucus AP, feverAP, fever

Distension Distension TenesmusTenesmus NV, appetite, activityNV, appetite, activity Urine vol. Urine vol.

48

IMCI IMCI

Management of Management of

Diarrhoea Diarrhoea

49

History takingHistory taking1. General Danger Signs1. General Danger Signs2. Main Symptoms2. Main Symptoms

a. Cougha. Cough

b. b. DiarrheaDiarrhea

c. Feverc. Fever

d. Ear Problemsd. Ear Problems

3. Nutritional Status3. Nutritional Status4. Immunization Status4. Immunization Status5. Other Problems5. Other Problems IMCI record form

50

DANGERSIGNS

CONVULSIONS

INABILITY TO DRINKOR BREASTFEED

VOMITING

LETHARGYUNCONSCIOUSNESS

51

4 Signs to 4 Signs to classifyclassify::

General conditionGeneral condition Sunken eyesSunken eyes ThirstThirst Skin pinch Skin pinch

Assessing DehydrationAssessing Dehydration

52

Child’s general condition

Lethargic or unconscious (also a GDS) or Restless (a child who cannot be consoled) or Well and alert

53Consoled

54

Sunken eyes:

– Dehydration– Visible wasting– Old age

Though less reliable it is still useful

55Signs of Dehydration Signs of Dehydration

56

Thirst: 3 stages Thirst: 3 stages

Not able to drink or drinks poorlyNot able to drink or drinks poorly weak, drinks with help, swallows only if fluid is weak, drinks with help, swallows only if fluid is put in mouthput in mouth

Drinking eagerly, thirstyDrinking eagerly, thirsty wants to drink morewants to drink more

Drinks normallyDrinks normally

57

Drinks eagerly

58

Skin Pinch Skin Pinch

Middle of umbilicus and flankMiddle of umbilicus and flank Pinch all layers with thumb + index in long axis for Pinch all layers with thumb + index in long axis for

1 sec and release suddenly:1 sec and release suddenly:– goes back goes back very slowlyvery slowly (>2 sec) (>2 sec)– sslowlylowly– or or immediatelyimmediately

59

60

61

Exception!Exception!

Marasmic and elderly: pinch Marasmic and elderly: pinch goes back slowlygoes back slowly Obesity/edema: Obesity/edema: goes back immediatelygoes back immediately though though

dehydrated!dehydrated!

Though Though lessless reliable it is useful reliable it is useful

62

63

Any 2 signs:Any 2 signs:• Lethargic or unconsciousLethargic or unconscious• Sunken eyesSunken eyes• Unable to drink/drink poorlyUnable to drink/drink poorly• Skin pinch returns v. slowly Skin pinch returns v. slowly

SevereSevere dehydrationdehydration(Rx plan A)(Rx plan A)

Any 2 signs:Any 2 signs:• Restless, irritableRestless, irritable• Sunken eyesSunken eyes• Drinks eagerly, thirstyDrinks eagerly, thirsty• Skin pinch returns slowly Skin pinch returns slowly

SomeSomedehydrationdehydration(Rx plan B)(Rx plan B)

Not enough signs to classify as Not enough signs to classify as above above

NoNo dehydrationdehydration(Rx plan C)(Rx plan C)

64

No No dehydrationdehydration

Plan APlan A

SomeSome dehydrationdehydration

Plan BPlan B

Severe Severe dehydrationdehydration

Plan CPlan C

Look: Look: Gen. Con. Gen. Con.

EyesEyesThirst Thirst

Well, alertWell, alert

Not sunkenNot sunkenDrinks wellDrinks well

Restless, irritableRestless, irritable

SunkenSunkenThirsty, drinks Thirsty, drinks eagerlyeagerly

Lethargic/comaLethargic/coma

Sunken Sunken Drinks poorly or Drinks poorly or not able to not able to

Feel: Feel: Skin pinchSkin pinch Goes back Goes back

quicklyquicklyGoes back Goes back slowlyslowly

Very slowlyVery slowly

Classifying DehydrationClassifying Dehydration

65

Principles of Rx Principles of Rx

Only rehydration in most casesOnly rehydration in most cases Correct existing deficitCorrect existing deficit Replace further lossReplace further loss IVF in severe dehydration IVF in severe dehydration FeedingFeeding, specially BM continued, specially BM continued AntimicrobialsAntimicrobials if warrantedif warranted

66

SSevere ....:evere ....: immediate replacement with IVF, NGT immediate replacement with IVF, NGT or ORT or ORT (Plan C)(Plan C)

Some ......: Some ......: ORTC/at homeORTC/at home (Plan B)(Plan B) No .....: No .....: at home at home (Plan A)(Plan A)

Rehydration PlanRehydration Plan

67

Rx PlanRx Plan

AA Rx at Rx at home home Teach Teach IF/CF IF/CF **

BB

ORS in 4h: 70 ml/kgORS in 4h: 70 ml/kg <4 mo 200- 400ml<4 mo 200- 400ml4-12 mo 400- 600ml4-12 mo 400- 600ml1-2y 600- 800ml1-2y 600- 800ml2-4y 800-1200ml2-4y 800-1200ml5-14y 1200-2200ml5-14y 1200-2200ml

Reassess after 4 h: select Reassess after 4 h: select plan A, B, or Cplan A, B, or C

CC

Start IVF @ 100ml/kgStart IVF @ 100ml/kg 50% in first 2h 50% in first 2h

50% next 3-4h50% next 3-4h Replace further loss; Replace further loss;

ORT if can drinkORT if can drink

Assess pulse, BP, UOPAssess pulse, BP, UOP frequently and review Rx frequently and review Rx

planplan** IF/CF: increased fluid and continued feeding IF/CF: increased fluid and continued feeding

68Some dehydration

69

Feeding in Diarrhea Feeding in Diarrhea

Growth slows during diarrhea but children catch up Growth slows during diarrhea but children catch up later later Give an extra meal for 2wGive an extra meal for 2w Continue Continue BM+ORTBM+ORT, family foods, family foods Severe malnutrition: feed during ORT, rehydrate slowlySevere malnutrition: feed during ORT, rehydrate slowly

70

Any dehydrationAny dehydration SevereSevere PD PD

No dehydrationNo dehydration Persistent diarrheaPersistent diarrhea

Classification of PDClassification of PD

71

Severe PD: Severe PD: hospitalise hospitalise

FeedingFeeding is most important: is most important:

– tempo. tempo. animal milk animal milk

– energy, protein, vitamins, mineralsenergy, protein, vitamins, minerals

– avoidavoid aggravating aggravating foodsfoods

– enough enough food during convalescencefood during convalescence

No routine ABTNo routine ABT

Treatment of PDTreatment of PD

72

Remember! PD meansRemember! PD means

MalabsorptionMalabsorption Weight loss, malnutrition, VADX Weight loss, malnutrition, VADX Hidden infxHidden infx Death!Death!

73

Dysentery SyndromeDysentery Syndrome

Basically IDBasically IDBloody mucoid stools, F, cramps, tenesmus. High MMBloody mucoid stools, F, cramps, tenesmus. High MMStool CS is rarely possibleStool CS is rarely possibleMore severe in malnourished, not breast-fed, or bottle fed More severe in malnourished, not breast-fed, or bottle fed babies. babies. frequent and severe in measles frequent and severe in measles likely to become PDlikely to become PD

MM: morbidity and mortalityMM: morbidity and mortality

74

Classification of DysenteryClassification of Dysentery

Classify Classify dysenterydysentery if blood is in stool if blood is in stool 15% diarrheas in U-5y are dysentery15% diarrheas in U-5y are dysentery 15% of diarrheal deaths15% of diarrheal deaths

Blood in the stool Dysentery

Other Causes of Bloody StoolsOther Causes of Bloody Stools

Rectal polyp, anal fissureRectal polyp, anal fissure Meckel diverticulumMeckel diverticulum Diverticulosis/diverticulitisDiverticulosis/diverticulitis Cow’s milk protein intoleranceCow’s milk protein intolerance AV malformationAV malformation Hemorrhagic diseaseHemorrhagic disease

75

76

3 Types of Dehydration3 Types of Dehydration

Serum Na

Isotonic 130-150mmol/lHypertonic >160 mmol/l

(hypernatremic)Hypotonic <130 mmol/l

(hyponatremic)

77

Isotonic: Isotonic: commonestcommonest

Fluid lost in DV is isotonicFluid lost in DV is isotonic Plasma osmolality 275-295mOsmol/lPlasma osmolality 275-295mOsmol/l Serum Na is Serum Na is 130-150 mmol/ l 130-150 mmol/ l

The patientThe patientProportionately dehydrated Proportionately dehydrated

78

HypertonicHypertonic

Rehydration by hypertonic fluidRehydration by hypertonic fluid Serum Na is Serum Na is >160 mmol/l>160 mmol/l Osmolality is >295mOsmol/lOsmolality is >295mOsmol/l

The patient isThe patient is sseverely dry, thirsty, irritable, bounding pulse everely dry, thirsty, irritable, bounding pulse fits at Na >165mmol/lfits at Na >165mmol/l

79

HypotonicHypotonic

Rehydrated with hypotonic fluidRehydrated with hypotonic fluid Serum Na Serum Na <130 mmol/l<130 mmol/l OsmolalityOsmolality <275mOsmol/l<275mOsmol/l

The patient isThe patient is Lethargic, feeble pulseLethargic, feeble pulse May have fitsMay have fits

80

OLD ORS

New ORS (WHO): All ingredients except K + and alkali

are reduced: 27.9 20.5 g It is hypo-osmolar: 311 245mmol/L

New New Old Old

NaClNaCl 2.6 g/l2.6 g/l 3.5 g/l3.5 g/lGlucoseGlucose 13.513.5 2020KClKCl 1.51.5 1.51.5Trisodium citrateTrisodium citrate 2.92.9 2.92.9TotalTotal 20.520.5 27.927.9 Osmolarity Osmolarity mmol/Lmmol/L mmol/Lmmol/LNaNa 7575 9090ClCl 6565 8080GlucoseGlucose 7575 111111KK 2020 2020BaseBase 1010 1010

TotalTotal 245245 311311

Old and New ORS Old and New ORS (1L)(1L)

83

Old vs. New ORS Old vs. New ORS

OldOld

HypertonicHypertonic More vomitingMore vomiting More stoolsMore stools IVFIVF

New New

IsotonicIsotonic -20%-20% -30% -30% -33%-33%

84

Rice based ORSRice based ORS

WaterWater 500ml 500ml Rice powder Rice powder 30-40g 30-40g NaCl NaCl 2.5g 2.5g

Boil for 5-7 minBoil for 5-7 minRice ORS is equally effectiveRice ORS is equally effective

85

Home Made SSS Home Made SSS (salt sugar solution)(salt sugar solution)

Water 500 ml Table salt 3 finger pinch Sugar/molasses 4 finger grip

3 finger pinch

4 finger grip

86

Use of ORSUse of ORS

Only for diarrhea or V+D Not for vomiting alone Never as soft drink nor tonic or water Do not use in excess

Rice ORS is not a food

87

ORS may be IneffectiveORS may be Ineffective

Severe dehydration, vomitingSevere dehydration, vomiting Lethargic, unconsciousLethargic, unconscious Rapid loss of water Rapid loss of water Sugar malabsorption (large stools, reducing substance)Sugar malabsorption (large stools, reducing substance)

88

89

WHO: WHO: increased fluidsincreased fluids (ORS or home-made SSS plus (ORS or home-made SSS plus

continued feedingcontinued feeding (IF/CF) (IF/CF)

It is the key program to control diarrhea dehydrationIt is the key program to control diarrhea dehydration

Sugar-salt soln. (SSS)Sugar-salt soln. (SSS)

Oral Rehydration Therapy (ORT)?Oral Rehydration Therapy (ORT)?

90

ORT CornerORT Corner

OPD room for ORTOPD room for ORT Trained person, ORS and toolsTrained person, ORS and tools For For ‘No- and Some- dehydration’‘No- and Some- dehydration’ 4 - hr stay 4 - hr stay reassessed reassessed Training and counseling mothersTraining and counseling mothers

91

92

Antimicrobials in DiarrheasAntimicrobials in Diarrheas

Not used routinely, mostly Not used routinely, mostly NONENONE Kills commensalsKills commensals Secondary/superinfectionSecondary/superinfection Expensive, toxic, allergicExpensive, toxic, allergic

93

Indications of ABTIndications of ABT

ShigellosisShigellosis Inv. Inv. ssalmonellosisalmonellosis CholeraCholera GiardiasisGiardiasis E. histolyticaE. histolytica C jejuniC jejuni Y enterocoliticaY enterocolitica

94

Do not use:

Loperamide, diphenoxylate:Loperamide, diphenoxylate: not effective: SoB and not effective: SoB and severe distensionsevere distension

Antispasmodics:Antispasmodics: inhibit peristalsis inhibit peristalsis Kaolin, pectin, charcoal, attapulgite:Kaolin, pectin, charcoal, attapulgite: consistency, but consistency, but

no no fluid loss. They can fluid loss. They can action of other drugs action of other drugs

95

ZINC IN DIARRHEA ZINC IN DIARRHEA (ICCDR’B)(ICCDR’B)

Significant role in the MDG #4Significant role in the MDG #4

Globally, 400k lives could be saved:Globally, 400k lives could be saved:

severity, duration, recurrence, admissionseverity, duration, recurrence, admission

positive impact on pneumoniapositive impact on pneumonia

Entire U-5 of Bangladesh is targeted:Entire U-5 of Bangladesh is targeted:

It could save 75k lives/yIt could save 75k lives/y

96

Why Zinc Rx. In Bangladesh?Why Zinc Rx. In Bangladesh?

It is rich in protein foods: poor have It is rich in protein foods: poor have Zn Zn Soil is poor in ZnSoil is poor in Zn U-5 are the most vulnerableU-5 are the most vulnerable Evidence of benefit existsEvidence of benefit exists Essential for growth, immunityEssential for growth, immunity Supplement till ideal foods for all attainedSupplement till ideal foods for all attained

97

Prevention of DiarrheaPrevention of Diarrhea

EBF, no bottle nor formula EBF, no bottle nor formula Hand washingHand washing Safe food, waterSafe food, water Safe eatingSafe eating Disposal of excretaDisposal of excreta

ImmunizationImmunization HPVAC HPVAC Safe complementary feeds Safe complementary feeds No overcrowdingNo overcrowding

All are virtually low-cost interventionsAll are virtually low-cost interventions

98

99

Vaccines for DiarrheaVaccines for Diarrhea

Cholera (Dukoral)Cholera (Dukoral) Rota virusRota virus ETEC (Dukoral)ETEC (Dukoral) Typhoid Typhoid MeaslesMeasles

100

MESSAGEMESSAGE

ORT ORT diarrheal MR by 70% diarrheal MR by 70% No ABT in most diarrheasNo ABT in most diarrheas Feeding is v. important Feeding is v. important Prevention is low-costPrevention is low-cost Zn has a roleZn has a role Vitamin A in prolonged diarrheaVitamin A in prolonged diarrhea

HUSHUSdestroys RBCs. It is the commonest c/of ARF in children. destroys RBCs. It is the commonest c/of ARF in children.

Although it can cause serious complications, most Although it can cause serious complications, most children recoverchildren recover

Healthy RBC are smooth and round. In HUS, toxins Healthy RBC are smooth and round. In HUS, toxins destroy RBC and render them misshapen (schistocyte): destroy RBC and render them misshapen (schistocyte): may clog the tiny BV in the kidneysmay clog the tiny BV in the kidneys

101

102Healthy RBCs (left) are smooth and round. In HUS, toxins

destroy them (right). These misshapen cells may clog the tiny BV in the kidneys.

Causes of HUSCauses of HUS E. coliE. coli toxins toxins destroy RBCsdestroy RBCs It is found in contaminated meat, dairies, and juice. It is found in contaminated meat, dairies, and juice.

Swimming pools or lakes can be contaminatedSwimming pools or lakes can be contaminated Most E coli AGE recover fully and do not develop HUSMost E coli AGE recover fully and do not develop HUS

103

CF of HUSCF of HUS The child is pale, tired, irritable. May have small bruises, The child is pale, tired, irritable. May have small bruises,

epistaxis, haematuria. SS may not develop till a weekepistaxis, haematuria. SS may not develop till a week ARF (>50%). Damaged RBCs, acid hematin clog the tiny BV ARF (>50%). Damaged RBCs, acid hematin clog the tiny BV

in the kidneys. CF of AGN may appear. UOP falls. HTN in the kidneys. CF of AGN may appear. UOP falls. HTN Anuria for 12h should attend EDAnuria for 12h should attend ED

DiagnosisDiagnosis H/o and PE. Dx is confirmed by PBF study to see if the RBC H/o and PE. Dx is confirmed by PBF study to see if the RBC

are misshapenare misshapen

CF: cl. features. ED: emergency dept.CF: cl. features. ED: emergency dept.

104

RxRx Maintaining FEB to ease SS and prevent further problemsMaintaining FEB to ease SS and prevent further problems BT may be neededBT may be needed In severe cases: dialysisIn severe cases: dialysis Some children may develop CKDSome children may develop CKD Limiting protein in diet and treating HTN with ACEI helps Limiting protein in diet and treating HTN with ACEI helps

delay/prevent the onset of CKDdelay/prevent the onset of CKD Most children recover completelyMost children recover completely

105

PreventionPrevention Food hygiene especially for meats; avoiding unclean Food hygiene especially for meats; avoiding unclean

swimming areas are the best waysswimming areas are the best ways

Points to PonderPoints to Ponder HUS is the commonest c/of short-term-ARF in children. HUS is the commonest c/of short-term-ARF in children.

Most children recoverMost children recover Most cases of HUS follow an AGE by Most cases of HUS follow an AGE by E. coliE. coli Maintaining FEB eases SS and prevents further problemsMaintaining FEB eases SS and prevents further problems A child may need BTA child may need BT Only the most severe cases require dialysisOnly the most severe cases require dialysis

106

107

MCQMCQ

Diarrhea is the biggest child killerDiarrhea is the biggest child killer Ac. ID causes more dehydration than AWDAc. ID causes more dehydration than AWD Shigella is the commonest c/of Ac. IDShigella is the commonest c/of Ac. ID

Diarrhea can cause ARFDiarrhea can cause ARF Glucose in ORS is meant for providing nutritionGlucose in ORS is meant for providing nutrition C jejuni can cause GBS C jejuni can cause GBS

108

MCQMCQ

Most diarrheas do not need ABTMost diarrheas do not need ABT Cholera is an example of ac. invasive DCholera is an example of ac. invasive D In EBF babies diarrhea is virtually nilIn EBF babies diarrhea is virtually nil

Persistent D is synonymous with chr. DPersistent D is synonymous with chr. D Giardia causes ac. invasive DGiardia causes ac. invasive D Breast milk stools can cause dehydrationBreast milk stools can cause dehydration

109

MCQMCQ

Persistent D with mild dehydr. is classified as severe PDPersistent D with mild dehydr. is classified as severe PD Zinc Rx reduces diarrheal mortalityZinc Rx reduces diarrheal mortality Breast milk is discontinued if there is lactose intoleranceBreast milk is discontinued if there is lactose intolerance Vitamin A is supplemented in prolonged diarrheaVitamin A is supplemented in prolonged diarrhea Diarrhea prevention interventions are expensiveDiarrhea prevention interventions are expensive

110

OSPEOSPE A 3 mo old formula fed child had mild runny nose and A 3 mo old formula fed child had mild runny nose and

cough for 1 d. It was f/by passage of frequent loose cough for 1 d. It was f/by passage of frequent loose watery motions containing flakes of feces. watery motions containing flakes of feces. – What is the most probable Dx?What is the most probable Dx?

He was lethargic and could not drink. He had sunken He was lethargic and could not drink. He had sunken eyes and skin pinch went back v. slowlyeyes and skin pinch went back v. slowly– Classify his dehydration according to IMCIClassify his dehydration according to IMCI– How do you treat this child?How do you treat this child?

111

A 2y old child had ac. HGF with V and AP immediately A 2y old child had ac. HGF with V and AP immediately f/by frequent loose mucoid and bloody stools. He had f/by frequent loose mucoid and bloody stools. He had tenesmus.tenesmus.– What is the most probable Dx?What is the most probable Dx?– How can you confirm it?How can you confirm it?

He was restless with sunken eyes but drank eagerly; skin He was restless with sunken eyes but drank eagerly; skin pinch went back slowly.pinch went back slowly.– Classify his dehydration according to IMCIClassify his dehydration according to IMCI– How do treat it?How do treat it?– What ABT do you suggest?What ABT do you suggest?

OSPEOSPE

112

114

Next Lec.Next Lec.

Infant FeedingInfant Feeding

116

THANK YOUTHANK YOU