Adapted IMNCI diarrhoea 2020

Diagnosis and Management of children with diarrhea with reference to IMNCI (Integrated Management of Neonatal and Childhood Illness)

1. A practical approach to the child with
Diarrhoea
Background, Assessment and Management
Prof. Imran Iqbal
Prof of Paediatrics(2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

3. IMNCI
A Strategy for
Outpatient Case Management
of Children
under five years of age

4. Benefits of
IMNCI Case Management Strategy
•Evaluates all the problems the child is having
•Simple guidelines to find relevant symptoms and signs
•Practical algorithms for decision-making
•Gives a provisional diagnosis (Classification)
•Helps in deciding clinical management
•Saves time of Health Care Provider and patient
•Can be practiced by clinical assistants and paramedics
•Can be practiced in remote areas with inadequate facilities

5. Step 1
General Danger Signs
General Danger Signs indicate severe disease
Presence of any one of the General Danger Signs
means that the child needs to be
referred / admitted to the emergency

6. Check for General Danger Signs
•Unable to drink or breastfeed
•Vomiting everything
•Lethargic or unconscious
•Convulsions
•General Danger Signs indicate severity of illness
•Not diagnostic but suggests acuity of situation

7. Step 2
Assess for
Cough or Difficult Breathing

8. Step 3
Assess the Child for
Diarrhoea

9. Assess for Diarrhea
•ASK: Does the child have Diarrhea ?
•IF YES:
•ASK: For how long ? (Diarrhea lasting more than 14 days is persistent diarrhea)
•ASK: Is there blood in the stool ? (Blood in stool indicates dysentery)
•Look and Feel: (Assess Dehydration in the child)
General condition --(lethargicOR restless ORnormal)
Sunken Eyes (ask caretaker as well)
Drinking (poorly OR eagerly ORnormally)
Skin Pinch (very slowlyOR slowlyOR immediately)

10. Diarrhea in Children
Diarrhea is an increasein the:
Fluidity of stools
Volume of stools
Number of stools
relative to the usual habits of child
•More than 3 stools per day (in older children)

11. Clinical Types of Diarrhea
•Acute watery diarrhea
•Dysentery
•Persistent diarrhea80
10
10
Acute Watery
Dysentery
Persistent

12. Epidemiology of Diarrhea in Children
•Diarrhea is a very common illness below two years of age
•Each child suffers from diarrhea once many times in a year
•Child weight may drop by half to one kg with each episode of diarrhea
•After pneumonia, it is the commonest cause of child deaths
•Diarrhea kills because of the dehydration and malnutrition it produces
•Lack of Breastfeeding, unclean top feeds and contaminated food are important
predisposing factors of diarrhea

13. Diarrhea causes Malnutrition and Deaths

14. Common Causes of Diarrhea in Children
•Rotavirus (6 moto 2 yrof age)
•Escherichia coli (EPEC, ETEC, EIEC)
•Vibrio cholera (profuse diarrhea with rice water stools)
•Shigella(dysentery with mucus and visible or microscopic blood in stools)
•Salmonella (fever and watery diarrhea)
•Entameobahistolytica(abdominal pain with mucoid stools or dysentery)

15. Pathophysiology of Diarrhea
•OSMOTIC DIARRHOEA –Rota virus
•SECRETORY DIARRHOEA –E. Coli
•INVASIVE DIARRHOEA –Shigella

16. Small Intestinal Morphology
•Villi:
Covered mainly (90%) by tall
columnar absorptive cells
(enterocytes) having a microvillus
brush border
•Crypts of Lieberkuhn:
Covered mainly by short
columnar secretorycells without
brush border

17. Osmotic Diarrhea by malabsorption of nutrients
(Rotavirus)
•Rota virus destroys absorptive
cells
•Secretary cells from the crypts
replace absorptive cells
•Nutrient Malabsorption and
diarrhea results

18. Secretary Diarrhea by secretion of Electrolytes
(Vibrio cholera and E. Coli)
•Vibrio cholera and E. Coli
Bacteria produce Exotoxins
•Exotoxins stimulate Secretion of
Chloride, Sodium and water
from crypt cells
•Profuse watery diarrhea

19. Invasive diarrhea by destruction of mucosa
(Shigella)
•Toxins cause destruction of
mucosa in colon and distal part
of ileum.
•Mucosal ulcers develop
•Visible (or microscopic) blood
and mucus in stools

20. Symptoms and Signs of Dehydration
•Irritability / Lethargy
•Thirst
•Sunken eyes
•Loss of skin elasticity
•Decreased urine output
•Depressed anterior fontanel (in infants)
•Dry mucus membranes
•Rapid and weak pulse

21. Complications of Diarrhea
•Dehydration and Shock
•Acute Renal Failure
•Convulsions (fever, electrolyte changes)
•Paralytic ileus (hypokalemia, sepsis, anti-motility drugs)
•Nappy rash
•Hypotonia
•Persistent Diarrhea
•Malnutrition

22. Assess for Diarrhoea
•ASK: Does the child have Dirrhoea?
•IF YES:
•ASK: For how long ? (Diarrhea lasting more than 14 days is persistent diarrhea)
•ASK: Is there blood in the stool ? (Blood in stool indicates dysentry)
•Look and Feel: (Assess Dehydration in the child)
General condition --(lethargicOR restless ORnormal)
Sunken Eyes (ask caretaker as well)
Drinking (poorly OR eagerly ORnormally)
Skin Pinch (very slowlyOR slowlyOR immediately)

23. Signs of Dehydration
Lethargic Thirsty

24. Signs of Dehydration (slow skin pinch)

25. Assess and Classify Dehydration SIGNS No signs of
dehydration
Some (mod.)
dehydration
Severe
dehydration
G
General
condition
well,
alert
restless,
irritable
lethargic,
unconscious
E
Eyes normal sunken sunken
M
Mouth &
Drinking
normal thirsty, drink
eagerly
poor or una-
ble to drink
S
Skin pinch returns rapidly returns slowly very slowly
2 or more signs in 1 column indicate that the
child classification falls in that column
Always start from Red Column

26. Assess and Classify Dehydration

27. Assess and Classify Diarrhea

28. Management of Diarrhea

29. Main Dangers of Diarrhea:
FLUIDS FOOD
DEATH MALNUTRITION
Dehydration

30. Treatment of Dehydration SIGNS
No signs of
dehydration
Some (mod.)
dehydration
Severe
dehydration
G
General
condition
well,
alert
restless,
irritable
lethargic,
unconscious
E
Eyes normal sunken sunken
M
Mouth &
Drinking
normal thirsty, drink
eagerly
poor or una-ble
to drink
S
Skin pinch returns rapidly returns slowly very slowly
Management
of dehydration
Plan A
at Home

Plan B
At OR Center
Plan C
At Hospital

31. Treatment of Severe Dehydration (Plan C)

32. Treatment of Severe Dehydration
(Plan C -IV Fluid Therapy)
•Type of Fluid :for ALLtypes of dehydration
First Choice: Ringer’s lactate,
Second Choice: O.9 % Normal Saline
•Amount:
100 ml / Kg of body weight
•How given:(slow in infants)
•1/3 (30ml/kg): rapidly in1/2-1hour
•2/3 (70ml/kg): slowly in2.5-5 hours

33. Treatment of Some Dehydration
(Plan B)

34. Treatment of Some Dehydration (Plan B)
•Type of Fluid :Low OsmolarORS
•Amounts:
75 ml/ Kg of body weight in 4 hours
•How given:
SLOWLY (1 spoon / 1-2 min) for 4-6 hours
By Cup & spoon, Cup alone, Dropper,
Syringe or by Nasogastric Tube (NGT)

35. Oral Rehydration solution (ORS)
•Sodium Chloride 3.5 gm
•Sodium Citrate 2.9 gm
•Potassium Chloride 1.5 gm
•Glucose 20 gm
•Sodium 90 mmol/l
•Chloride 80 mmol/l
•Citrate 10 mmol/l
•Potassium 20 mmol/l
•Glucose 111 mmol/l
•Osmolarity311 mmol

36. Low OsmolarOral Rehydration solution (LoORS)
•Sodium Chloride 2.6 gm
•Sodium Citrate 2.9 gm
•Potassium Chloride 1.5 gm
•Glucose 13.5 gm
•Sodium 75 mmol/l
•Chloride 65 mmol/l
•Citrate 10 mmol/l
•Potassium 20 mmol/l
•Glucose 75 mmol/l
•Osmolarity245 mmol

37. Treatment of No signs of Dehydration
(Plan A)

38. Treatment of No signs of Dehydration
(Plan A)
•Type of Fluid :Low OsmolarORS,
sugar-salt solution, rice water, lassi, soup
•Amounts:
50 -100 ml (1/2 to 1 cup) after each diarrheal stool
•How given:
SLOWLY (1 spoon / 1-2 min) for 4-6 hours
By Cup & spoon, Cup alone, Dropper,
Syringe or by Nasogastric Tube (NGT)

39. Feeding during & after Diarrhea
•During Diarrhea:
•Continue Mother milk or other milk feeds as before
•Give small frequent semisolid feeds (if more than 6 mo)
•Rice, banana, potato are useful in diarrhea
•After Diarrhea stops:
•Continue feeding the child as usual
•Give one extra meal/day for 3-4 weeks

40. Drugs used in Diarrhea
•Anti-motility drugs should never be used -can lead to paralytic
ileus and sepsis
•Adsorbents (kaolin) are not effective
•Probiotics do not give any advantage
•Antibiotics indicated for blood in stool (ciprofloxacin)
•Zinc recommended for 14 days to help in recovery

41. Persistent Diarrhea
•Usual duration of diarrhea is 5 –10 days
•Diarrhea prolonged to more than 14 days is called Persistent diarrhea
•Persistent Diarrhea is due to failure of recovery of mucosal damage
•Persistent Diarrhea is more common in malnourished children
•Persistent Diarrhea is associated with malabsorption of nutrients
•Persistent Diarrhea is managed by:
giving micronutrients (Vitamin A and Zinc)
providing adequate calories
temporary reduction of un-tolerated ingredients (animal milk feeds)

42. Dysentery
•Dysentery is presence of blood in stool
•Dysentery is caused by Shigella, Compylobacter, and other invasive
organisms
•Some cases have mucus and microscopic blood
•Antibiotic (Ciprofloxacin) should be given
•Other injectable antibiotics (Ceftriaxone) may be needed in resistant
cases

43. Prevention of Diarrhea in Children
•Vaccination –
Rota virus
Measles
•Breastfeeding, avoid animal milk
•Adequate nutrition (semisolid foods from 4-6 months)
•Micronutrients (Vitamins and Minerals)
•Safe drinking water, unpolluted milk, clean food
•Hand washing
•Control of insects and flies in the house