Dr Anurag ppt2 for acute diarrhea in children .ppt

acute diarrhea in children

1. DRANURAG TAJNE
MBBSDCH
ARIHANT HOSPITAL
NAGPUR
9579510161
APPROACH TO
DIARRHEA

2. OBJECTIVES
INTRODUCTION/ DEFINITION
CAUSES
ETIOPATHOGENESIS
CLINICAL FEATURES AND COMPLICATIONS
DIAGNOSIS
EVALUATION OF DEHYDRATION
TREATMENT
PREVENTION

3. Introduction
Commoncauseofdeathindevelopingcountries
Secondmostcommoncauseofinfantdeaths
worldwide.

4. DIARRHOEA
Diarrhoea defined as excessive loss of fluid and electrolyte in
stool.
For infants stool output >10 ml/kg/24 hr and >200g/24hr for
older children.
When there is an in frequency, volume or liquidity ( Recent
change in consistency) of the bowel movement relative to the
usual habit of each individual
Nelson Textbook of Pediatrics,20th ed

5. DEFINITIONS
•Acute diarrhea
Duration <2 wks, usually of infectious origin
•Prolonged diarrhea
Diarrhea of duration 7-14 days of presumed infectious etiology. It
may be an indicator for children with a high risk of progression to
Persistent diarrhea
•Chronic diarrhea
Diarrhea of more than 2 weeks duration.
•Dysentry
Bloody diarrhea, visible blood and mucus present.
Nelson Textbook of Pediatrics,20th ed

6. Persistent diarrhea
Persistentdiarrhea(PD)isanepisodeofdiarrheaofpresumed
infectiousetiology,whichstartsacutelybutlastsformorethan14
days,andexcludeschronicorrecurrentdiarrhealdisorderssuchas
tropicalsprue,glutensensitiveenteropathyorotherhereditary
disorders[WHO] (INDIANPEDIATRICS,JAN2011)
passageof>=3waterystoolsperdayfor>2weeksinachildwho
eitherfailstogainweightorlosesweight.(ESPGHAN)

7. WHAT IS NOT A DIARRHOEA?
1.Frequent formed stools
2.Pasty stools in breastfed child
3.Stools during or after feeding
4.PSEUDODIARRHOEA:Small volume of stool frequently
(IBS)

9. ETIO-PATHOGENESIS
OSMOTIC DIARRHOEA
LOSS OF MATURE ABSORPTIVE CELLS
INVADE S.I. MUCOSA
VIRAL -MC
ROTA ADENO

10. SECRETORY DIARRHOEA
ULCERATION –SYNTHESIS OF SECRETAGOGUES
ACUTE INFLAMMATION
INVADE LARGE INTESTINE
BACTERIAL -INVASIVE
SHIGELLA, SALMONELLA, YERSINIA, V.PARAHEMOLYTICUS

11. DECREASE ABSORPTIVE SURFACE
CELL INFLAMMATION, CELL DEATH
ELABORATION OF CYTOTOXIN
BACTERIA -CYTOTOXIC
SHIGELLA,EPEC,V.HEMOLYTICUS,C.DIFFICILE

12. ALTERED SALT AND WATER TRANSPORT
ENTEROTOXIN-INCREASE THE CONC. OF INTRACELLULAR
MEDIATORS
COLONISE SMALL INTESTINE
BACTERIA -TOXIGENIC
SHIGELLA,ETEC,VIBRIO

13. DECREASE INTESTINAL ABSORPTIVE SURFACE
FLATTENING OF MICROVILLI
COLONISE & ADHERE SMALL INTESTINE
BACTERIAL ADHERENTS
EPEC,EHEC

14. CLINICAL FEATURES
BLOODY STOOLS –BACTERIAL ETIOLOGY
HUS
ABDOMINAL PAIN –GE
PERITONEAL SIGNS -APPENDICITIS

15. DIAGNOSIS
ATLEAST 3 STOOLS PER 24H
ASSESSING DEHYDRATION
-H/O NORMAL FLUID INTAKE AND OUT PUT
-PHYSICAL EXAMINATION
-PERCENTAGE OF BODY WT LOSS

16. EVALUATING DEHYDRATION
GENERAL CONDITION -MENTAL STATUS*
THIRST*
EXTREMITIES
CAPILLARY REFILL TIME
SKIN TURGOR
BREATHING
HEART RATE
B.P
PULSE QUALITY
EYES*
TEARS*
MUCOUS MEMBRANES*
ANTERIOR FONTANELLE
URINARY OUTPUT

17. SIGNS NONE /MINIMAL
DEHYDRATION(<3
%
LOSS OF BODY WT)
SOME/ MILD
TO
MODERATE(3 -
9% LOSS OF
B.WT)
SEVERE ( >9%
LOSS OF B.WT)

18. CLINICAL DEHYDRATION SCORE

19. No Dehydration: PLAN-A
Some Dehydration: PLAN-B
Severe Dehydration: PLAN-C
Plan of Treatment

20. Treat Diarrhea at Home.
4 Rules of Home Treatment:
GIVE EXTRA FLUID
CONTINUE FEEDING
WHEN TO RETURN [ADVICE TO MOTHER]
GIVE ORAL ZINC FOR 14 DAYS
PLAN –A

21. TELL THE MOTHER:
Breastfeed frequently and for longer at each feed
If exclusively breastfeed give ORS for replacement of stool
losses
If not exclusively breastfed, give one or more of the following:
ORS, food-based fluid (such as soup, rice water,
coconut water and yogurt drinks), or clean water.
TEACH THE MOTHER HOW TO MIX AND GIVE
O.R.S
AMOUNT OF FLUID TO GIVE IN ADDITION TO THE
USUAL FLUID INTAKE:
Up to 2 years: 50 to 100 ml after each loose stool.
2 years or more: 100 to 200 ml after each loose stool.
Give extra fluid

22. Continue usual feeding, which the child was
taking before becoming sick 3-4 times
(6 times)
Up to 6 months of age:
Exclusive Breast feeding
6 months to 12 months of age:
add Complementary Feeding
12 months and above:
Family Food
Continue feeding

23. Advise mother to return immediately if the
child has any of these signs:
Not able to drink or breastfeed or drinks poorly
Becomes sicker
Develops a fever
Blood in stool
[IF IT WAS NOT THERE EARLIER]
When to Return
[Advice to mother]

24. Plan-B is carried out at ORT Corner in
OPD/clinic/ PHC
Treat ‘some’ dehydration with ORS (50-100
ml/kg
Give 75 ml/kg of ORS in first 4 hours
If the child wants more, give more
After 4 hours:
Re-assess and classify degree of dehydration.
PLAN –B

25. PLAN -C
Signs of sever dehydration
Child not improving after 4 hours
Refer to higher center –give ORS on way /keep
warm /BF
When child comes back follow up as other children

26. Start I. V. Fluid immediately
Give 100 ml/kg of Ringer’s Lactate
Age First give
30ml/kg in
Then give
70 ml/kg in
Under 12 months 1 hour 5 hours
12 months and
older
½ hour 2½ hour
PLAN –C

27. Use intravenous or intraosseusroute
Ringers Lactate with 5% dextrose or ½ normal saline with 5% dextrose
at 15 ml/kg/hour for the first hour
* do not use 5% dextrose alone
Fluid therapy in severe dehydration
Continue monitoring every 5-10 min.
Assess after 1 hour
If no improvement or worsening If improvement(pulse slows/faster
capillary refill /increase in blood pressure)
Consider septic shock Consider severe dehydration with shock
Repeat Ringers Lactate 15 ml/kg over 1 h
Switch to ORS 5-10ml/kg/hr orally or by
nasogastric tube for up to 10 hrs

28. What Is ORS

29. Safe & effective
Can alone successfully rehydrate 95-97% patients with
diarrhea,
Reduces hospital case fatality rates by 40 -50%
Cost saving
Reduces hospital admission rates by 50% and cost of
treatment by 90%
BUT
WHO-ORS:“potentially the most important medical advance of this
century”’ The Lancet

30. > 50% Goa, Himachal, Meghalaya, Tripura,
Manipur
> 40% West Bengal, J&K, Mizo, Chhattisgarh
>20% Bihar, Orissa, Uttaranchal, Punjab, Gujarat,
MP, Southern States
< 20% Rajasthan, UP,Assam, Jharkhand,
Nagaland
Recent NFHS 3 data
ORS use rates are dismally low in some regions

31. STANDARD ORS SOLUTION LOW
OSMOLARITY ORS
(MEQOR MMOL/L)
GLUCOSE 111 75
SODIUM 90 75
CHLORIDE 80 65
POTASSIUM 20 20
CITRATE 10 10
OSMOLARITY 311 245
Composition of standard and low osmolarity
ORS solutions

32. LAB.EVALUATION AND IMAGING
STOOL CULTURE-salmonella
shigella
yersinia
campylobacter
pathogenic E.coli-serotyping
RAPID STOOL TEST: for inflammatory markers
Hematological tests: white blood cell band count >100/mm
3.
C-reactive protein cut point of >12
milligrams/dl
Biochemical tests: BUN
Ser.bicarbonate <17 mEq/L
GRBS
USG

34. TREATMENT
ANTIEMETIC-Ondansetron0.5mg/kg/dose
NO ANTIMOTILITY MEDICATION :
Diarrhea may function as an evolved expulsion
defense mechanism
Can cause HUS in EHEC infection.
ADSORBANTS AND ANTISECRETORY AGENTS:
Bismuth –inc.salicylate levels
PROBIOTICS -LactobacillusGGand
Saccharomyces boulardii
ANTIBIOTICS FOR A/C GE

35. PREVENTION
Good Hygiene
Vaccines
Prevent global warming
Global warming αfood borne infections
αcontamination of water
ENRICH –( December 2011Bulletin from IAP )