Complications associated with recurrent diarrhea

Recurrent diarrhea is associated with many a number of complications. Out of them dehydration,malnutrition ,failure to thrive, electrolyte imbalances, micro nutrient deficiencies (vitamins & minerals) and severe systemic infections. Here an extensive description is given about these and the relevant management facts are given then and there.

1. Complications associated with Recurrent diarrhea Amila Weerasinghe 21 st Batch Faculty of Medical Sciences University of Sri Jayewardenepura Sri Lanka 14/07/2016

2. Complications associated Dehydration Malnutrition Failure to thrive Electrolyte imbalances Micro nutrient deficiencies (vitamins & minerals) Severe systemic infections.

3. 1. Dehydration During diarrhoea there is an increased loss of water and electrolytes (sodium , chloride, potassium, and bicarbonate) in the liquid stool . Water and electrolytes are also lost through vomit, sweat, urine and breathing .

4. Dehydration occurs when these losses are not replaced adequately and a deficit of water and electrolytes develops.

5. Essential needs in the management Correction of the existing water and electrolyte deficit Replacement of ongoing losses. Provision of normal daily fluid requirement.

6. Correction of the existing water and electrolyte deficit Some dehydration - ORS solution by mouth . However , in cases with severe dehydration, frequent and severe vomiting, or in the presence of complications that prevents successful oral therapy, intra venous therapy is needed.

7. Some dehydration Approximate amount of ORS solution to be given in the first 04 hours Mild to moderate (5-10%) dehydration 75 ml/kg in 4 hours

8. Vomiting does not prevent successful use of ORS solution. Slow administration of ORS solution is useful in children with vomiting.

9. It is a Medical Emergency Severe dehydration

10. Children with severe dehydration need intravenous fluids , as there is a risk of impending shock. Start IV Ringer Lactate fluid immediately . (rapid infusion of 10 -20 mL /kg ) Normal saline could be used if Ringer Lactate solution is not available ,

11. If the patient can drink, ORS should be given while the drip is set up. If intravenous access is impossible , attempt intra osseous administration, give ORS through naso -gastric tube Reassess the patient every 1-2 hours . If hydration is not improving, give the IV drip more rapidly .

12. Management of children who present with severe dehydration and in impending shock Airway, Breathing and Circulation should be assessed and established quickly. Give rapid iv infusion of 10 to 20 ml/Kg body of normal saline or Hartmann solution . Reassess the patient every 1-2 hourly and adjust the fluid therapy

13. Accordingly. If hydration is not improving, give the IV drip more rapidly. When the child can tolerate oral fluids about 5 ml/kg/hour of ORS should be recommenced.

14. Types of dehydration, patients present with Isotonic dehydration Hyponatraemic dehydration Hypernatraemic dehydration

15. Hyponatraemic dehydration Drink large amount of water and hypotonic solutions Greater net loss of sodium than water Fall in plasma sodium Shift of water from extra to intracellular compartments Increase in intracellular volume Cerebral oedema Convultions

16. Hypertonic dehydration Excessive content of sugar (e.g. soft drinks, commercial fruit drinks, too concentrated infant formula) or salt . High insensible water losses. ( High fever or hot/dry environment) Water loss exceeds the relative sodium loss.

17. Plasma sodium concentration increases Extracellular fluid becomes hypertonic Shift of water from intra to extra cellular compartment Signs Depressed fontanelle Reduced tissue elasticity Sunken eyes Cerebral shrinkage Jittery movements Increased muscle tone with hyperreflexia Altered conciousness seizures

18. Hypernatraemic dehydration should be corrected slowly over a period of 12 hours It is not corrected rapidly..

19. Isotonic dehydration Occurs when the out put exceeds the amount of the input. The fluid taken orally is isotonic solutions. Much better than having hypo/hypertonic dehydrations.

20. Replacement of ongoing losses Offer as much fluid as the child wants . Add approximately 50 to 100 ml of ORS or any other fluid for each stool. Depending on the stool volume fluid intake should be increased .

21. Provision of normal daily fluid requirement. Breast feeding should be continued . If on formula milk, continue in the same dilution . Offer as much fluid as possible to drink in addition to ORS solution.

22. Prevention of dehydration Give the child more fluids than usual to prevent dehydration Home based fluids and ORS solutions such as kanjee should be used. Give as much fluid as the child wants. As a guide approximately 50 ml of fluid should be given after each stool. Watch for signs of dehydration.

23. Feeding practices and maintenance of nutrition Encourage the mother to continue breast-feeding Formula feeds need not be diluted Food intake should never be restricted during or following diarrhoea Maintain the intake of energy and other nutrients at as high a level as possible

24. Continued feeding speeds the recovery of normal intestinal function Dietary modifications may be necessary in lactose intolerance and in conditions like post gastroenteritis syndrome.

25. 2. Malnutrition During diarrhoea , decreased food intake , decreased nutrient absorption, and Increased nutrient requirements Children who die from diarrhoea , despite good management of dehydration, are usually malnourished.

26. These often combine to cause weight loss and failure to grow . The child’s nutritional status declines and any pre-existing malnutrition is made worse.

27. Wasting (indicates acute malnutrition): Moderate wasting – weight/height SD <-2 to -3 Severe wasting – weight/height SD <-3 Stunting (indicates chronic malnutrition): Moderate stunting – height or length SD <-2 to -3 Severe stunting – height or length SD <-3

28. Moderate malnutrition – moderate wasting or stunting Severe malnutrition – severe wasting , severe stunting , OR edematous malnutrition

29. So this may lead to PROTEIN-ENERGY MALNUTRITION   ( marasmus , kwashiorkor) Other than this micronutrient deficiencies can occur. (vitamins and minerals)

30. It is the most common form of PEM It is characterized by the wasting of muscle mass and the depletion of body fat stores. It is caused by inadequate intake of all nutrients , but especially dietary energy sources (total calories ) Marasmus

31. Kwashiorkor It is characterized by marked muscle atrophy normal or increased body fat. Pure kwashiorkor is characterized by inadequate protein intake in the presence of fair to good energy intake . Anorexia is almost universal

32. 3. Failure to thrive Inadequate weight gain when plotted in a centile chart Mild failure – fall across 2 centile lines within 6 months ( -2SD and -3SD ) Severe failure – fall across 3 centile lines within 6 months ( less than -3SD)

33. Occurs mainly due to problems with Inadequate intake ( Non organic/ environmental, organic – chronic illnesses ) Inadequate retention ( diarroea , vomiting) Malabsorption ( coeliac disease, cowsmilk protein intolerance)

34. Recommended food items to include in a meal of a diarroea child Lime juice - Fluid + P ottasium Yoghurt – Probiotics Kanjee – Fluid + Energy Cream cracker biscuit – Energy Bananas ( Anamalu / Ambun ) – Energy + Fibre + Protein

35. 4. Electrolyte imbalances Hypertonic / hypotonic dehydration To avoid use isotonic solutions for rehydration (standard WHO ORS solution, 0.9% normal saline, hartmans solution) With severe malnutrition sodium retention reduced potasium and magnesium levels

36. Improved ORS formulation The need for unscheduled supplemental intravenous therapy in children was reduced by 33%. Stool output was reduced by about 20 % Incidence of vomiting was reduced by about 30 %.

37. The new formula could safely be used in the prevention of dehydration. As well as in the treatment of dehydration.

38. Instructions for mothers regarding ORS Read the instructions clearly given in the packet. Sachets available for 1L and 200ml of water. Don’t add sugar, salt or anything After prepared use within 24 hours and discard the remaining. Give as demanded by the child.

39. But if the child is severley malnourished then the standard WHO ORS is not given for rehydration. ( hypernatraemia,hypokalaemia , hypomagnesimia ) Becouse it contains high sodium and low pottasium levels. ReSoMal rehydration fluid is given.

40. ReSoMal contains G lucose (125 mmol /L), So dium (45 mmol /L), P otassium (40 mmol /L), M agnesium (3 mmol /L ), Z inc (0.3 mmol /L), Copper  (0.045 mmol /L).

41. 5. Micronutrient deficiencies Essential fatty acid deficiencies ( linoleic and linolenic acid ) Fat soluble vitamin deficiencies (A,D,E.K) Water soluble vitamin deficiencies ( folate , B1,B2,B3,B6,B12,C) Minerals ( iron, zinc, copper, selenium, iodine, Calcium, phosphate, and magnesium )

42. Essential fatty acid deficiencies ( linoleic and linolenic acid) S caly dermatitis Alopecia Thrombocytopenia . Effect on growth , and cognitive and visual function in infants

43. Vit D

44. Folate Megaloblastic anaemia

45. Thiamine Vit B1

46. Vit B2

47. Vit B3 - Niacin

48. Vit C – Scurvey

49. Iron

50. Zn supplimentation Z inc supplementation ( 10-20 mg per day until cessation of diarrhoea ) Reduces the severity and duration of diarrhoea in children less than 5 years S hort course supplementation with zinc ( 10-20 mg per day for 10 to 14 days . Reduces the incidence of diarrhoea for 2 to 3 months

51. Probiotics Derived from food sources, especially cultured milk products. Suppression of growth or epithelial binding / invasion by pathogenic bacteria . Improvement of intestinal barrier function Modulation of the immune system Modulation of pain perception

52. What are the downsides to taking probiotics ?   Probiotics are not regulated by the Food and Drug Administration (the FDA) the way standard medicines are. That means that the companies that package probiotics don't have to prove that the ingredients listed on the label are actually in the bottle.

53. BIFILAC  TM Capsules №20 Ingredients of the preparation : Each capsule contains: Probiotic composite 100,0 mg (lactobacillus acidophillus - 500 mln . CFU, bifidobacterium bifidum - 300 mln . CFU, enterococcus faecum - 200 mln . CFU) Vitamin С Echinacea extract

54. 6. Severe systemic infections. The severely malnourished child is at high risk for infection. Because of diminished immune defenses , and is typically exposed to infection because of inadequate sanitation and food preservation . Dehydration is also common in these children because of acute or persistent diarrhea.

55. Important Anti diarrhoeal and anti spasmodic drugs are never indicated for the treatment of acute diarrhoea in children . If the child continues to vomit non-sedative anti emetics ( Ondansetrone ) could be used .