6. Diarrhea In Children Sam..........pptx

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1. Diarrhea In Children

2. Definition: WHO definition: Passage of 3 or more loose or watery stools per day A loose stool being one that would take the shape of a container Based on out put >10 g/kg/24 hr. for infants and young children, >200 g/24 hr. in older children .

3. Other definition: Any deviation from child's usual pattern regardless of actual number of stools or their water content (passage of blood or mucus) AGE : Infections of the gastrointestinal tract caused by bacterial, viral, or parasitic pathogens

4. Types of diarrhea Base On Duration 1-Acute diarrhea Short duration(less than 14 days ) Frequent episodes of acute diarrhea can result in Nutritional Compromise Predispose To Persistent Diarrhea 2.Persistent diarrhea Lasting 14 days or longer & is infectious in origin . Is episodes that began acutely but last for ≥14 days. Account for 3-20% of all diarrheal episodes in children <5 yr of age 50 % of all diarrhea-related deaths 5/2/2023 4

5. 3.Chronic diarrhea Lasting for more than 4wks 4.Dysentery —Blood in stool (seen or reported )

6. Base On Mechanisms of Diarrhea Secretory Osmotic Exudative (Inflammatory) Motility disorder( or ) 5/2/2023 6

7. I .Secretory diarrhea Impaired absorption of sodium by the villi Increased secretion of chloride in the crypt cells The net result is fluid secretion, which leads to the loss of water and salts from the body as watery stools; May be due to toxigenic bacteria ( E.coli , vibrio,)or rotavirus

8. II.Osmotic diarrhea O ccur when a poorly absorbed, osmotically active substance is ingested. Or Small bowel absorption disorder due to enzyme deficiency (lactose with lactase deficiency )

9. III. Motility disorder Increased motility: Defect: Decreased transit time Example : Thyrotoxicosis

10. Decreased motility: Defect: Stasis (bacterial overgrowth)

11. III. Inflammation   The inflammatory process causes Destruction of villous cells and/or dysfunction of the transporters, leading to loss of fluids and electrolytes. Exudation of mucus, protein, and blood into the gut lumen.

12. PRIMARY MECHANISM DEFECT STOOL EXAMINATION EXAMPLES COMMENT Secretory Decreased absorption, increased secretion, electrolyte transport Watery, normal osmolality with ion gap <100 mOsm /kg Cholera, toxigenic Escherichia coli; carcinoid, VIP, neuroblastoma, congenital chloride diarrhea, Clostridium difficile, cryptosporidiosis (AIDS) Persists during fasting; bile salt malabsorption can also increase intestinal water secretion; no stool leukocytes Osmotic Maldigestion , transport defects ingestion of unabsorbable substances Watery, acidic, and reducing substances; increased osmolality with ion gap >100 mOsm /kg Lactase deficiency, glucose- galactose malabsorption, lactulose, laxative abuse Stops with fasting; increased breath hydrogen with carbohydrate malabsorption; no stool leukocytes Increased motility Decreased transit time Loose to normal-appearing stool, stimulated by gastrocolic reflex Irritable bowel syndrome, thyrotoxicosis , postvagotomy dumping syndrome Infection can also contribute to increased motility Decreased motility Defect in neuromuscular unit(s) stasis (bacterial overgrowth) Loose to normal-appearing stool Pseudo-obstruction, blind loop Possible bacterial overgrowth Decreased surface area (osmotic, motility) Decreased functional capacity Watery Short bowel syndrome, celiac disease, rotavirus enteritis Might require elemental diet plus parenteral alimentation Mucosal invasion Inflammation, decreased colonic reabsorption, increased motility Blood and increased WBCs in stool Salmonella, Shigella, infection; amebiasis ; Yersinia, Campylobacter infections Dysentery evident in blood, mucus, and WBCs MECHANISMS OF DIARRHEA 5/2/2023

13. Epidemiology Diarrheal diseases are one of the leading causes of morbidity and mortality in children worldwide The majority of affected children are Under 5 .

14. Mode of transmission - F aecal -oral route, - Person to person 5/2/2023 14

15. Risk factors 1. Socioeconomic factors Poverty Overcrowding Poor sanitation Contamination of water Inadequate food hygiene Low maternal education 5/2/2023 15

16. 2 .Behavioral Factors Failure to breast-feed exclusively for the first 6 months of life Failure to continue breast-feeding until one year of age Using infant bottles Storing food at room temperature Contaminated drinking water Failure to wash hands Failure to dispose of feces hygienically 5/2/2023 16

17. 3 . Host factors Malnutrition Measles immunodeficiency or immunosuppression ( AIDS) Age group during the first 2 years of life. 5/2/2023 17

18. Cause Infants and young children Older children and adolescents 1.GI Infections* Viruses * Rotavirus Bacteria* Enterotoxigenic E. coli Shigella Campylobacter jejuni Vibrio cholerae Salmonella (non-typhoid) Enteropathogenic E. coli Parasites Cryptospondium, giardia lamblia, E.hystolitica Viruses * Bacteria * Parasites Etiology of Diarrhea

19. Cause Infants and young children Older children and adolescents 2. Non-GI infections Otitis media* Urinary tract infections* Other systemic infections Systemic infections 3.Dietary disturbances Overfeeding * Food allergy * Starvation stools * weaning Starvation stools * Food poisoning 4.Anatomic abnormalities Intussusception Hirschsprung disease  (± toxic megacolon) Partial bowel obstruction Blind loop syndrome Intestinal lymphangiectasis Short gut syndrome Appendicitis Partial obstruction Blind loop syndrome Etiology conti ……

20. Etiolgy cont… 5. IBD   Ulcerative colitis  (± toxic megacolon ) Crohn's disease  (± toxic megacolon ) 6. Malabsorption or increased secretion Cystic fibrosis Celiac disease Disaccharidase deficiency Acrodermatitis enteropathica Celiac disease Disaccharidase deficiency Acrodermatitis enteropathica Secretory neoplasms 7.Immunodeficiency Severe combined immunodeficiencies and other genetic disorders Human immunodeficiency virus infection (HIV) Human immunodeficiency virus infection (HIV) 8.Endocrinopathy Congenital adrenal hyperplasia Hyperthyroidism Hypoparathyroidism 9. Miscellaneous Antibiotic-associated diarrhea* Pseudomembranous colitis Toxins Hemolytic uremic syndrome * Neonatal drug (opiate) withdrawal * Antibiotic-associated diarrhea * Pseudomembranous colitis Toxins Irritable bowel syndrome Psychogenic disturbances *Common cause , red is life threatning Rotavirus infections is the most common identifiable viral cause of gastroenteritis in all children

21. Evaluation of diarrhea History GI Manifestation: Most common manifestations are abdominal cramp , diarrhea and vomiting Although nausea and vomiting are nonspecific symptoms, they indicate infection in the upper intestine. 5/2/2023 21

22. Dehydration Malnutrition Anemia Hypoglycemia Sepsis Metabolic acidosis Manifestation of Cx 5/2/2023 22

23. Systemic and extra intestinal manifestations Fever Reactive arthritis GBS GN HUS Risk Factors C ontact with a person who traveled to a diarrhea-endemic area, Recent travel of patient U se of antimicrobial agents. 5/2/2023 23

24. Laboratory investigation Stool examination Stool microscopy Stool cultures Stool osmolality Immunoassay for viral identification from stool Stool AFS Blood (serology , culture, CBC ,electrolytes…) 5/2/2023 24

25. Treatment Principles of management Rehydration therapy, Enteral feeding Diet selection Zinc supplementation Treat complication 5/2/2023 25

26. Dehydration and shock   5/2/2023 26

27. Assessment of Dehydration 1. AAP guideline classifie s as mild (3-5%), moderate (6-9%) and severe ( > 10% ) dehydration

28. 2.Types of dehydration Isotonic dehydration Normal serum Na concentration, b/n 130-150 Balanced loss of Na and water Most common type Hypertonic dehydration Serum Na >150mmol/l More water loss Osmolarity > 295 Hypotonic dehydration More Na loss than water

29. Types of dehydration….

30. 3.WHO Classification

31. Routes of administration ORT, oral rehydration therapy ORS via spoon, cup, dropper, syringe, naso -gastric tube Home fluids Breast feeding IV route R/L, N/ S With specific indication

32. Oral Rehydration Solution (ORS): Effective in all types & all degrees of dehydration. Can prevent dehydration if given early in the disease. Cheap, easy to administer; can be given by mother at home. No chance of over hydration or electrolyte overdose.

33. IV Fluids Ringer's Lactate Solution - preferred It supplies an adequate concentration of sodium and S ufficient lactate (which is metabolized to bicarbonate) for the correction of acidosis C oncentration of potassium is low and It can be used in all ages, for any etiology of diarrhoea . .

34. Ringer's Lactate Solution with 5% dextrose has the added advantage ,it prevent hypoglycemia . it is preferred to Ringer's Lactate Solution without dextrose. Normal saline (0.9% NaCl ) -acceptable is often available. It does not contain a base to correct acidosis and does not replace potassium losses

35. Treatment of DHN I-No dehydration Treatment plan A (Rx at home) give the child more fluids than usual Continue feeding See again any time if no improvement ORS: Age < 2years  100ml after each loose stool Age 2 –10  100-200 ml after each loose stool Older children – as much as they tolerate 5/2/2023 35

36. II- Some dehydration Treatment plan B ( ORS by mouth or NGT, 75ml/kg over 4 hrs. Tell the mother to continue breast feeding Teach how to give the ORS and follow frequently Given sufficient ORS packets and correct advice Reassess and classify at the end 5/2/2023 36

37. III. Severe DHN(Plan C) AGE First give Then give 30 ml/kg 70 ml/kg Infants (<12 mo ) : 1 hr * 5 hrs Children 30 mins* 2 1/2 hrs (12 mon- 5 yrs ) * Repeat once if radial pulse is still very weak or not detectable. 5/2/2023 37

38. cont… Reassess the child every 15–30 minutes. If hydration status is not improving, give the IV drip more rapidly. ➤ Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3–4 hours (infants) or 1–2 hours (children). ■ Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration Then choose the appropriate plan (A, B, or C) to continue treatment 5/2/2023 38

39. Shock if there are signs of: D epressed level of consciousness or weakness W eak or absent peripheral pulses P rolonged capillary refill time of > 3 second T achycardia of > 120 bpm Rapid venous access, either an intravenous or intraosseous line Bolus of 20 ml/kg of Ringers lactate or normal saline .

40. 5/2/2023 40

41. Composition and types of ORS

42. Management of Diarrhea with severe malnutrition Management of dehydration :  Admit to hospital. Rehydration is per oral. Oral rehydration should be done slowly giving 70-100 ml/kg over 12 hours starting by giving about 10 ml/kg/hour during the 1st 2 hours with ReSOMAL . Feeding: Breast feeding should be continued . Initial diet: From admission till child's appetite returns to normal. Diet contains 75 kcal/100 ml. Vitamins, minerals and salts Antimicrobials All severely malnourished children should receive broad spectrum antibiotics for infections.

43. Children with severe Malnutrition ReSoMal (Rehydration solution for the malnutrition) Contents: Glucose = 125mmol/l Citrate = 7 mmol/l Na = 45mmol/l Mg = 3mmol/l K=40mmol/l Zn 0.3mmol/l Cl= 70mmol/l Cu= 0.045mmol/l ORS-too high Na &too low K Dilute 1 packet of ORS with 2 liters of water and add 50 gm of sugar and 40ml of mineral mix.(K, CU, Zn, Mg) 5/2/2023 43

44. Management of Acute bloody diarrhea (dysentery) S hould be referred immediately to hospital. P revent or treat dehydration and feeding should be continued antibiotic such as Ciprofloxacin (15 mg/kg/dose bd for 3 days or alternately Ceftriaxone (50 mg-100 mg/kg OD IM for 2 to 5 days).Should be given to treat shigellosis as shigella causes most episodes of bloody diarrhea in children. If there is no improvement after two days, antimicrobial should be changed. Treatment for amoebiasis should be given if stool shows trophozoites of histolytica or treatment for shigella fails in spite of 2 different antimicrobials. 

45. Management of persistent diarrhea O bjective of treatment is to restore weight gain and normal intestinal function. Treatment consists of appropriate fluids to prevent or treat dehydration, a nutritious diet that does not cause diarrhea to worsen, supplementary vitamins and minerals, including zinc for 10-14 days and antimicrobial to treat diagnosed infections. 

46. Feeding recommendations Continue breast feeding in those children on breast feeds If yoghurt is available, give it in place of any animal milk usually taken by the child or else give lactose free milk formula Mix the milk with the child's cereal. Give frequent small meals at least 6 times a day Reduce lactose diet Lactose free with reduced starch diet: This is meant for children who do not improve with reduced lactose diet.

47. Indication for admission Severe dehydration with/without shock Altered neurological status Intractable vomiting or ORS failure Caregivers that cannot provide adequate care at home Young age, < 6 months with dehydration Children with associated chronic illness

48. Indication for IV fluid Shock Severe dehydration, especially if depressed level of consciousness Paralytic ileus Moderate dehydration with vomiting all fluid Children with profuse watery stools unable to keep up with fluid losses

49. Anti-microbial therapy Indications depend on clinical condition and causative organism Salmonella : Infants< 3months, typhoid fever, bacteremia , disseminated disease with local suppuration. Severe invasive bacterial diarrhoea eg Shigellosis Vibrio cholera : all cases Aeromonas : dysentery like, prolonged diarrhea. C. difficile : moderate to severe disease. E.coli . **Contra indicated in case of E. coliO157:H7 considering risk of HUS Girdiasis Suspected or proven sepsis Immunocompromised children

50. Zinc supplementation Zinc deficiency is common and zinc is lost during diarrhea Zinc deficiency is associated with impaired electrolyte and water absorption, decreased brush border enzyme activity and impaired cellular and humoral immunity Treatment with zinc reduces the Duration and severity of AD Reduces frequency of further episodes during the subsequent 2-3 months WHO recommends that children with diarrhoea be given zinc for 10-14 days 1 0mg daily for children <6 months 20 mg daily for children > 6 months

51. Diarrhea and Nutrition Breast milk C omplete food: it provides all the nutrients and water C omposition of breastmilk is always ideal for the infant, not diluted or concentrated H as immunological properties that protect the infant from infection, especially diarrhea; these are not present in animal milk or formula. Breastfeeding is clean: it is not contaminated with bacteria that can cause diarrhea. For "bonding" of the mother to her infant Milk intolerance is very rare in infants who take only breastmilk.

52. Complementary foods S hould normally be started after 4-6 months of age Good feeding practices involve selecting nutritious foods and using hygienic practices S oft mashed foods (e.g. cereals), when possible, eggs, meat, fish and fruit should be given Safe water Reduces risk of diarrhoea by using safe and clean water Collect water from the cleanest available source. Latrines should be located more than 10 meters away Keep animals away from protected water sources .

53. Prevention Primary prevention (to reduce disease transmission) Rotavirus and measles vaccines G ood personal and food hygiene; Providing adequate and safe drinking water Environmental sanitation H ealth education about how infections spread

54. Secondary prevention (to reduce disease severity) Promote breastfeeding exclusive breastfeeding for the first six months of life; Vitamin A supplementation Treatment of episodes of AD with zinc

55. Thank You