Takvani Acute Diarrhea Junagadh 26 June Final 2010 (1)

8/9/2019 Takvani Acute Diarrhea Junagadh 26 June Final 2010 (1)

1/40

Evidence basedMedicine on

Acute DiarrheaDr.H.K.Takvani MD(Ped), FIAP

President NNF GSC 2009-10National Eb Mb. IAP 2002-08

President IAP GSB, 2001President IMA Jamnagar 2008-09

[email protected]

07/04/1023 June, 2010 Takvani 1

Life is short even to take advantage of positive pointsLife is short even to take advantage of positive points

ofof

people around us. Where is the time to see negativepeople around us. Where is the time to see negative

points?points?


2/40

Why to talk on diarrhea?

Prescription Surveys says..

No ORS. IVF where ORS works well or better

No advice on continuing, increasing BF, (unnecessary

stoppage of BF), diet or hygiene

No zinc.

07/04/10 Takvani 2


3/40

Why to talk on diarrhea?

Use ofantiemetics

Antibiotics often- Nor-metro,

Oflo-ornida,Inj.Amikacin.

Un-necessaryprobiotics

Racecadotril.07/04/10 Takvani 3
http://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppt


4/40

IAP ConsensusStatement

Highlights several important

developments.

Aims that benefits of new knowledge

reach affected.

Wants that new products are not

inappropriately used.07/04/10 Takvani 4


5/40

This is what I do since 2004IAP Consensus Statement

Prescribe ORS for all ages.

Continue Breast feeding and diet.

Explain danger signals.

20 mg/10 mg of elemental zinc

07/04/10 Takvani 5


6/40

This is what I do since2004

No probiotics, ?placebo, ?pacifier Cautious approach infants


7/40

ORS in diarrhea

ORS for all ages and all types of

diarrhea.

Low osmolarity ORS recommended,WHO

Sodium 75 mmol/L and glucose 75mmol/l, osmolarity 245 mosmol/L

Continue Breast feeding and routine

normal diet and energy dense feeds.07/04/10 Takvani 7


8/40

Why Reduced osmolarityORS?

39% reduction in need for IVF 19% reduction in stool output

29% lower incidence of vomiting

Risk of hyponatremia not significant in

any type of diarrhea.07/04/10 Takvani 8


9/40

Zinc in Diarrhea

Based on studies in India and otherdeveloping countries there issufficient evidence to recommendzinc in the treatment of acute

diarrhea as adjunct to oralrehydration.

07/04/10 Takvani 9


10/40

Zinc in Diarrhea

Zinc has an additional modest benefit

Reduces stool volume.

Reduces duration of diarrhea.

Oral rehydration therapy must remain

the main stay of treatment.

07/04/10 Takvani 10


11/40

Zinc in Diarrhea

Dose: Elemental Zinc

20 mg/day for 6months and older for 14 days

10 mg/day Between 2-6 months.

Any of zinc salts e.g., sulphate, gluconate or

acetate may be used. back

07/04/10 Takvani 11


12/40

Recommendations of the IAP

National Task Force for Use ofProbiotics

The group recommended that basedon analysis of studies there ispresently insufficient evidenceto recommend probiotics in thetreatment of acute diarrhea in oursettings


13/40

Probiotics

Almost all the studies till now weredone in developed countries exceptfor one very small study fromPakistan. It may not be possible to

extrapolate the findings of thesestudies to our setting where thebreast feeding rates are high and the

microbial colonization of the gut is


14/40

Probiotics

The effect of probiotics is strain related

and there is paucity of data to establishthe efficacy of the probiotic species(namely L. acidophilus, Lactic AcidBacteria) available in the Indian market.To recommend a particular species it willhave to be first evaluated in randomizedcontrolled trials in Indian children.


15/40



The earlier studies have documenteda beneficial effect on rotavirusdiarrhea which was present in >75%of cases in studies from the west.Rotavirus constitutes about 15-25%in India.


16/40



The primary outcome analyzed in allthe studies was the duration ofdiarrhea. The more objectiveparameter of stool output was notevaluated.


17/40

Probiotics in diarrheaWhat are Probiotics ??

Nonpathogenic micro-organisms.

Exert a positive influence on the health

or physiology of the host.

They consist of either yeast or

bacteria, Sacc. Bul and Lacto-

bacillus.07/04/10 Takvani 17


18/40

Racecadotril

Not enough evidence:Not enough evidence:

Safety. Efficacy.

There is no data from our settings.

Methodology of studies questionable.

No routine use back

07/04/10 Takvani 18


19/40

Acute Diarrhea in the YoungInfant (< 2 mth)

For assessment, recommendations by the

IMNCI which is an adapted version of IMCI for

India, should be followed.

See if child is sick or well child.

Management is different for sick and well.

07/04/10 Takvani 19


20/40

Infants who are breastfed and have

no dehydration do not need ORS and

mothers should be advised to

increase breast feeds more often and

for longer duration.07/04/10 Takvani 20



21/40

Young infants with dehydration

should be treated as has beenrecommended for other children withdehydration by ORS or IVF as per

grade of dehydration.

07/04/10 Takvani 21



22/40

Third generation cephalosporins, intra-venous ceftriaxone and amikacin if thechild is sick looking, ?septicemia.

Where hospitalization is not possible, Oral

Cefixime with Inj. Amikacin may be triedafter explaining the nature of disease andrisk.

07/04/10 Takvani 22



23/40

Acute Diarrhea in the YoungInfant (> 2 mth)

For assessment, IMNCI, No, some,sever dehy.

Management is as per grades of dehydration.

In cases of No & some dehydration when orally

acceptable ORS- ZINC- homely available fluids-

increase BF. IVF in Severe Dehydration.

07/04/10 Takvani 23

acceptable unacceptable


24/40

07/04/10Takvani

24

h

ome ly

av

aila

blef

luid

s acceptable unacceptable

Plain water coffee

cocconut water aerated cold drinks

plain buttermilk fruit juice(with sugar

milk Lassi(with sugar)

thin dal

fruit juice(withoutsugar)

Lassi(without sugar) NEXT


25/40

Antibiotic in AcuteDiarrhoeaIndicated only for :

Acute bloody diarrhea with grossblood

Shigella positive culture,

Cholera,

Associated systemic infection

Severe malnutrition. (Septicemia)07/04/10 Takvani 25


26/40

Antibiotic in AcuteDysentery Indiscriminate use of antibiotics

Increasing incidence of resistance.

Cotrimoxazole is the first line drug for

acute bloody diarrhea.

High resistance of shigella to

cotrimoxazole07/04/10 Takvani 26


27/40

Antibiotic in AcuteDysentery If resistance rates to cotrimoxazole exceed 30%

Cefixime 20mg/kg/day 5-7 days should be used

instead of quinolones looking to safety and medico

legal aspects.

No response to cefixime in 3 days Ceftriaxone100mg/kg/day till blood disappears ->cefixime.

07/04/10 Takvani 27


28/40

Antibiotic in AcuteDysentery

Antibiotics are notnot indicated if

No visible blood in stools

Pus cells on stool microscopy becauseof poor specificity of the test.

Routine stool examination or stoolcultures have no useful role. (except toshow that antibiotics are not required-

personal)07/04/10 Takvani 28


29/40


Entamoeba histolytica and helminths rarely

ever cause acute diarrhea in children.

Metronidazole and antihelminthics therefore

have no role in the routine management of

acute bloody diarrhea.

07/04/10 Takvani 29


30/40


Metronidazole/Tinidazole should beused when cases of acute dysenteryfail to respond to second line drugsfor dysentery such as cefixime or

when a stool examination hasconfirmed trophozoites ofEntamoebahystolitica.

07/04/10 Takvani 30


31/40

Antibiotics in AcuteDysentery

Aminoglycosides like gentamicin andamikacin have a poor spectrum of

activity against shigella species and

therefore they are ineffective in the

management of acute bloody07/04/10 Takvani 31


32/40

Antiemetics in AcuteDiarrhea

Vomiting, common associated symptom.

Distressing to the parent, antiemetics. Overdose due to haste/improper

preparation like domperidone 10mg/1mlinstead of 1mg/1ml in sone (Domstal Baby

and Motinorn) and round the clockprescrition like TDS leads to side effects.

07/04/10 Takvani 32


33/40

Antiemetics in AcuteDiarrhea Low osmolarity ORS reduces

vomiting. Stop for 10 minutes and than restart

giving ORS in small sips.

Most can be managed by frequentsmall sips (5-10 ml) of ORS with sipsof simple water and breast feeding inbetween without force feeding ORS.

07/04/10 Takvani 33


34/40


Antiemetics should be reserved for

children in whom the vomiting is

severe, recurrent and interferes withORS intake (more than 3 per hour).

07/04/10 Takvani 34


35/40


A single dose of domperidone/?

ondansetron in children with severevomiting.

Continued use is not recommended.

Dose of 0.1-0.3 mg/kg/dose.

Single dose only

07/04/10 Takvani 35


36/40

Antiemetics in AcuteDiarrhea In view of serious side effects

metoclopramide is not recommended. Personal experience: Single dose of

Inj.Metoclopramide 0.2mg/kg stopsvomiting and improves ORS intakeand avoids IV fluids in many caseswithout a single case of side effect.Not validated by IAP. back

07/04/10 Takvani 36


37/40

I conclude .This is what I do since 2004

Prescribe ORS for all ages.

Continue Breast feeding and diet.

Explain danger signals.

20 mg/10 mg of elemental zinc

07/04/10 Takvani 37


38/40

I conclude.

No probiotics, ?placebo, ?pacifier

Causious approach infants


39/40

If interested IndianPediatrics statement

Consensus statement of IAP National Task Force: Status report on manShinjini Bhatnagar,Nita Bhandari, U.C. Mouli , M.K. Bhan. IndianPediatrics : Apr 2004;41:335 - 348

StatementNational seminar on importance of zinc in human healthMs. RekhaSinha. Indian Pediatrics : Dec 2004;41:1213 - 1217

EditorialThe role of zinc in child health in developing countries: Taking the scieZulfiqar A. Bhutta. Indian Pediatrics : May 2004;41:429 - 433

Brief Reports

Outcome of Nutritional Rehabilitation with and without ZincSupplementationK.E. Elizabeth, P. Sreedevi and S. Noel Narayanan.Indian Pediatrics : Jun 2000;37:650 655

Management of Acute Diarrhea: From Evidence to PolicyShinjiniBhatnagar, Seema Alam* and Piyush Gupta*

National Co-ordinator, and *Joint National Co-ordinators, IAP-UNICEFProgram on Evidence-based Management of Diarrhea.http://indianpediatrics.net/mar2010/mar-215-217.htm

07/04/10 Takvani 39
http://indianpediatrics.net/apr2004/apr-335-348.htmhttp://indianpediatrics.net/dec2004/dec-1213-1217.htmhttp://indianpediatrics.net/may2004/may-429-433.htmhttp://indianpediatrics.net/june2000/june-650-655.htmhttp://indianpediatrics.net/june2000/june-650-655.htmhttp://indianpediatrics.net/mar2010/mar-215-217.htmhttp://indianpediatrics.net/mar2010/mar-215-217.htmhttp://indianpediatrics.net/june2000/june-650-655.htmhttp://indianpediatrics.net/june2000/june-650-655.htmhttp://indianpediatrics.net/may2004/may-429-433.htmhttp://indianpediatrics.net/dec2004/dec-1213-1217.htmhttp://indianpediatrics.net/apr2004/apr-335-348.htm


40/40

07/04/10 T k i 40

[email protected]

Dr.H.K.Takvani MD (Pediatrics), FIAPChildren Hospital and Neonatal Care Centre

Valkeshwari NagariIndira Marg

JAMNAGAR-361008, Gujarat, India

Friends. Please Share your views

Takvani Acute Diarrhea Junagadh 26 June Final 2010 (1)

Documents

Transcript of Takvani Acute Diarrhea Junagadh 26 June Final 2010 (1)