Management of Diarrhea in Pediatrics approved.pptx

Elaborated, updated presentation on diarrhea and its management in children with case scenarios

1. Management of Acute Diarrhea in Developing Countries For Pediatrics Version 3.0 Date 10 March 2021 r

2. Key Facts Diarrhoeal disease is the second leading cause of death in children under five years old. It is both preventable and treatable Each year diarrhoea kills around 525 000 children under five. A significant proportion of diarrhoeal disease can be prevented through safe drinking-water and adequate sanitation and hygiene. Globally, there are nearly 1.7 billion cases of childhood diarrhoeal disease every year. Diarrhoea is a leading cause of malnutrition in children under five years old. Source : https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease

3. Source: Global, regional and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2010. The Lancet, 11 May 2012. 15 countries with largest burden of pneumonia deaths 15 countries with largest burden of diarrhoea deaths 81% of global diarrhoea deaths 13 of the 15 countries with the highest pneumonia mortality are also among the 15 countries with the highest diarrhoea mortality. These 13 countries account for 78% of pneumonia and diarrhoea mortality. Afghanistan Angola Burkina Faso Democratic Republic Congo Ethiopia India Kenya Mali Pakistan Niger Nigeria Sudan-precession Uganda Global Burden of Diarrhea Diarrhoea : second leading cause of under 5 mortality https://www.who.int/en/news-room/fact-sheets/detail/diarrhoeal-disease

4. UNICEF report;Pneumonia and diarrhoea : Tackling the deadliest diseases for the world’s poorest children Pakistan 53,300 children die due to diarrhea each year (PDHS 2013)

5. UNICEF report;Pneumonia and diarrhoea : Tackling the deadliest diseases for the world’s poorest children Malnutrition & mortality

6. Recurrent diarrhea in childhood is associated with malnutrition, which contributes to delays or irreversible deficits in physical and cognitive development ~35% of all deaths, occurring among children aged less than five years in developing countries, could be attributed to malnutrition NNS 2018

7. NNS 2018

8. CASE SCENARIO A A 2 year old male child is brought to the emergency room with history of watery diarrhea for 6 days. On examination he has angular stomatitis and perianal ulcerations. Weight: 7.0 kg MUAC: 10.2cm Peripheries: Hand & feet are cold Pulse: weak & fast Skin pinch: went back slowly Conscious, alert , not lethargic

9. CASE SCENARIO A The doctor in the emergency room gives the child 140 ml of normal saline by rapid IV infusion. The child’s condition has deteriorated… What are the important conditions to identify in this case? Was the doctor’s decision to give IV correct? What are the pathophysiological mechanisms involved

10. CASE SCENARIO B 1 year old boy with poor feeding loose stools and fever for 7 days HISTORY: Child was born with a weight of 2.1 kg to an 18 year old primigravida mother . The child received no breastfeed. He is being feed with half diluted toned milk with bottle. Occasionally he is given pieces of bread that he spits out.

11. CASE SCENARIO B EXAMINATION Length: 64 cm Weight: 5kg Weight for length: -3SD Pallor, Sunken eyes, Wrinkled skin Angular cheilosis Loss of buccal fat pad No edema INVESTIGATION Blood Sugar: 43mg/dl Hb 7.8 g/dl TLC 3,600/ mm 3 DLC: P:45 L:45 E:5 M:5

12. What is Diarrhea? Passage of three or more loose or liquid stools /day (or more frequent passage than is normal for the individual) Classification 1: Acute : <14 days: Infectious: acute watery diarrhea or Invasive (bloody) Diarrhea associated with Extraintestinal infections : Otitis media, UTI, Pneumonia 2: Chronic: > 14 days https://www.who.int/en/news-room/fact-sheets/detail/diarrhoeal-disease https://www.uptodate.com/contents/approach-to-diarrhea-in-children-in-resource-rich-countries?search=approach-to-the-child-with-acute-diarrhea-in-&source=search_result&selectedTitle=2~150&usage_type=defaul Bull World Health Organ. 2003;81(3):197. Epub 2003 May 16. t In resource-limited countries, infants experience a median of six episodes annually

13. Classification Based on Duration Acute Diarrhea Short in duration (less than 2 weeks) Cow’s milk protein Soy milk protein Post infectious gastroenteritis Other food sensitive enteropathies Persistent Diarrhea (2 weeks or more) Intestinal Infections (Bacterial, Viral , Parasitic) Celiac Disease Malnutrition Antibiotic Treatment

14. Acute diarrhea in resource-limited countries are often caused by infectious gastroenteritis The assessment of the child with diarrhea Classification of the type of diarrheal illness Assessment of hydration status Assessment of nutritional status Assessment of co-morbid conditions

15. Watery stools of <14 days duration, with no visible blood constitutes acute watery diarrhea (A) Green watery stool. Green colored stool, often seen in rotavirus gastroenteritis (B) Rice water stool. White colored stool characteristic of severe cholera

16. Global Enterics Multicenter Study (GEMS) Pakistan specific fact sheet

17. MANAGEMENT OF DIARRHEA HYDRATION STATUS NUTRITIONAL STATUS Children with acute diarrhea and malnutrition are at increased risk for fluid overload heart failure serious bacterial infection As a result, such children require an individualized approach to rehydration, nutritional care, and antibiotics.

18. NUTRITIONAL MANAGEMENT: Without malnutrition Encourage sufficient feeding both during and after the diarrheal illness episode to prevent development of malnutrition chronic enteropathy Continue breast feeding If not breastfed continue formula feed + ORS Encourage solid foods immediately after initial dehydration is corrected INFANTS OLDER CHILDREN delaying the initiation of a nutrient rich diet may increase the risk of malnutrition.

19. Nutrition During Diarrheal Episode foods high in energy content and micronutrients at frequent intervals (at least six meals a day) After diarrhea resolves at least one extra meal per day should be continued for a minimum of two weeks, or until the patient regains normal weight-for-height

20. Nutritional status   - In diarrhea Should be assessed for malnutrition according to WHO standards Acute diarrhea and malnutrition at increased risk for developing fluid overload and heart failure during rehydration Risk of serious bacterial infection is also increased. Such children require an individualized approach to rehydration, nutritional care and antibiotics http://www.uptodate.com/contents/approach-to-the-child-with-acute-diarrhea-in-resource-limited-countries/abstract/27

21. Methods of Nutritional Assessment Look for visible signs: muscle wasting, reduced subcutaneous fat Others signs of malnutrition: angular stomatitis, pallor, sparse/brittle hair, hypo/hyper pigmented skin Nutritional edema Anthropometric measures: z-score MUAC

22. Severe Acute Malnutrition Moderate Acute Malnutrition Normal

23. Approach in Normal Child Treatment consists of correcting fluid and electrolyte losses, administering appropriate nutrition, and managing associated comorbid conditions FLUID THERAPY: Replacement & Maintenance Therapy The replacement phase is continued until all signs and symptoms of diarrhea are absent and the patient has urinated; ideally this is achieved during the first four hours of therapy. Maintenance therapy counters ongoing losses of water and electrolytes; this phase is continued until all symptoms resolve. Parenteral fluid resuscitation with an isotonic solution ( eg , normal saline) should be initiated promptly in children with moderate to severe dehydration or circulatory compromise Most children with diarrhea will not require intravenous hydration. Treatment with oral rehydration solutions should be encouraged as the first line therapy for both rehydration and maintenance therapy in patients who have mild to moderate dehydration and can drink http://www.uptodate.com/contents/approach-to-the-child-with-acute-diarrhea-in-resource-limited-countries/abstract/27

24. Approach in Normal Child Antibiotics should not be used for children with acute bloody diarrhea unless a specific pathogen has been isolated. Antibiotic therapy may be a risk factor for the development of hemolytic uremic syndrome in patients with bloody diarrhea The practice of withholding food for > 4 hours is inappropriate — normal feeding should be continued for those with no signs of dehydration, and food should be started immediately after correction of some (moderate) and severe dehydration, which usually takes 2–4 hours. Breastfed infants and children should continue receiving food, even during the rehydration phase. Infants that are not breastfed should be encouraged to continue to take undiluted formula at least every three hours, in addition to ORS. As long as diarrhea persists, foods high in energy content and micronutrients should be offered at frequent intervals (at least six meals a day). After diarrhea resolves, at least one extra meal per day should be continued for a minimum of two weeks, or until the patient regains normal weight-for-height http://www.uptodate.com/contents/approach-to-the-child-with-acute-diarrhea-in-resource-limited-countries/abstract/27

25. Approach to Severely Malnourished Child The mortality of children with diarrhea and severe malnutrition 50 – 60 percent Important clinical signs of dehydration may be masked (kwashiorkor and sepsis) Approach to rehydration should be conservative( risk of fluid overload ) All patients with severe malnutrition and diarrhea should be started on empiric broad spectrum antibiotics immediately, as well as appropriate nutritional therapy Intravenous fluids only in patients with overt shock The WHO recommends the use of reduced osmolality ORS in malnourished children Lancet. 1999;353(9168):1919 WHO THE TREATMENT OF DIARRHOEA :A manual for physicians and other senior health workers .

26. Management In Severe Malnutrition Fluid management in children with severe malnutrition and dehydration without shock Rehydrated slowly, either orally or by nasogastric tube, using oral rehydration solution for malnourished children (5–10 mL/kg/h up to a maximum of 12 h). Either ReSoMal or half-strength standard WHO low- osmolarity oral rehydration solution should be given, with added potassium and glucose, unless the child has cholera or profuse watery diarrhea. In children with cholera or profuse watery diarrhea : standard WHO low- osmolarity oral rehydration solution that is normally made, i.e. not further diluted

27. Management In Severe Malnutrition Rate: 5 mL/kg ReSoMal every 30 min for the first 2 h. Then, if the child is still dehydrated, 5–10 mL/kg/h ReSoMal should be given in alternate hours with F-75, up to a maximum of 10 h; signs of improved hydration status and over-hydration should be checked every half hour for the first 2 h, then hourly; Observe signs of rehydration: pulse rate respiratory rate urine frequency stool/vomit frequency Signs of excess fluid (over-hydration) are increasing respiratory rate and pulse rate, increasing edema and puffy eyelids. If these signs occur, stop fluids immediately and reassess after one hour. zinc (10–20 mg per day) should be given to all children as soon as the duration and severity of the episodes of diarrhea start to reduce, thereby reducing the risk of dehydration. By continuing supplemental zinc for 10–14 days, this will also reduce the risk of new episodes of diarrhea in the following 2–3 months.

28. Managment In Severe Malnutrition Fluid management of children with severe acute malnutrition (SAM) and shock Children with SAM and signs of shock or severe dehydration and who cannot be rehydrated orally or by nasogastric tube should be treated with intravenous fluids, either: half-strength Darrow’s solution with 5% dextrose, or Ringer’s lactate solution with 5% dextrose. If neither is available, 0.45% saline + 5% dextrose should be used. RATE: 15 mL/kg/h it is important that the child is carefully monitored every 5–10 min for signs of over-hydration and signs of congestive heart failure if a child with SAM presenting with shock does not improve after 1 h of intravenous therapy, a blood transfusion (10 mL/kg slowly over at least 3 h) should be given; children with SAM should be given blood if they present with severe anemia, i.e. Hb <4 g/ dL or <6 g/ dL if with signs of respiratory distress; the general principles of resuscitation, in particular providing oxygen and improving breathing all children with SAM with signs of shock with lethargy or unconsciousness should be treated for septic shock.

29. Nutritional Management The goal of nutritional management for patients without malnutrition is to encourage sufficient feeding both during and after the diarrheal illness episode to prevent development of malnutrition Development of chronic enteropathy Infants with diarrhea should be encouraged to breastfeed as much as possible. 1 1: http://www.uptodate.com/contents/approach-to-the-child-with-acute-diarrhea-in-resource-limited-countries/abstract/27

30. Nutritional Management Specialized feeding protocols for SAM : Feedings should supply not more than 80 to 100 kcal/kg of energy and about 1 g protein/kg. The rationale for this regimen is to avoid overloading the body's depleted enzyme systems. The final phase begins when appetite has been restored, and high-energy feedings with reasonable amounts of protein can be given without risk Zinc , Vitamin A supplementation 2 2: ZA Bhutta etal ” Malnutrition and Diarrhea: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology , and Nutrition” Journal of Pediatric Gastroenterology & Nutrition: August 2002 - Volume 35 - Issue - pp S173-S179 1: http://www.uptodate.com/contents/approach-to-the-child-with-acute-diarrhea-in-resource-limited-countries/abstract/27

31. CASE Scenarios Death in malnourished children with diarrhea commonly occurs during the first 48 hours after hospital admission and has been attributed to faulty case-management ZA Bhutta etal ” Malnutrition and Diarrhea: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology , and Nutrition” Journal of Pediatric Gastroenterology & Nutrition: August 2002 - Volume 35 - Issue - pp S173-S179

32. CASE SCENARIO A The child has Severe Acute Malnutrition ( SAM ) Dehydration is difficult to diagnose in SAM and often over diagnosed . The doctor’s choice of IV fluid was wrong and let to worsening of his condition Pathophysiology: Although plasma sodium may be very low, but the total body sodium is often increased due to: Increased sodium inside the cell Additional sodium in ECF if there is nutritional edema Reduced excretion of sodium by the kidneys

33. CASE SCENARIO B DIAGNOSIS: SEVERE MALNUTRITION ACUTE DIAHRREA

34. CASE SCENARIO B : MANAGEMENT Rehydration Broad Spectrum Antibiotics Vitamin A 200,000 IU orally zinc (10–20 mg per day)

35. CASE SCENARIO B : MANAGEMENT Prevention: To prevent dehydration when a child has continuing watery diarrhea: replace approximate volume of stool losses with ReSoMal . As a guide give 50-100 ml after each watery stool. if the child is breastfed, encourage to continue

36. What do we forget? Children presenting with a single episode of MSD had a nearly 8.5-fold increase in risk of death over a two-month follow-up period compared to control children without MSD. 61% of deaths occurred more than one week after children were diagnosed with MSD, when children may no longer be receiving care . GEMS Study: The Lancet, Volume 382, Issue 9888, Pages 209 - 222, 20 July 2013

37. NUTRITIONAL MANAGEMENT: ZINC Zinc Supplementation Reduces severity and duration of diarrhea reduces the incidence of subsequent episodes of diarrhea The supplements are given at a dose of 20 mg/day for children, 10 mg/day for infants younger than 6 months old, for 10 to 14 days Promotes immunity, resistance to infection Especially important for cells with rapid turnover – Immune system – Intestinal mucosa WHO recommends zinc supplementation for infants and children with acute diarrhea in resource-limited countries

38. NUTRITIONAL MANAGEMENT: VITAMIN A Children with diarrhea in resource-limited countries are at high risk of  vitamin A  deficiency and should receive high dose supplementation with vitamin A. Patients with signs of xerophthalmia, severe malnutrition, or a history of measles should receive a three dose series of repeated treatments for vitamin A deficiency https://www.uptodate.com/contents/approach-to-the-child-with-acute-diarrhea-in-resource-limited-countries https://www.uptodate.com/contents/overview-of-vitamin-a?topicRef=13956&source=see_link

39. Antibiotics are not indicated for most children with acute watery diarrhea; suspected cholera is an important exception in which antibiotic therapy is useful

40. NUTRITIONAL MANAGEMENT: LACTOSE Secondary lactose intolerance in acute infectious diarrhea at-risk infant ( eg , younger than 3 months or malnourished ) who develops infectious diarrhea, lactose intolerance may be a significant factor that will influence the evolution of the illness. Giardiasis, cryptosporidiosis, and other parasites that infect the proximal small intestine often lead to lactose malabsorption from direct injury to the epithelial cells 1 Transient lactose intolerance secondary to infective diarrhea is common in developing countries…” Lactose Intolerance in Infants, Children, and Adolescents pediatrics.aappublications.org › content › pediatrics › 1279.full.pdf Gupta R, Gupta S; Indian J Med Sci ; 1993 Jan; 47(I):1-7

41. Mal-absorption of nutrients leading to weight loss or slow weight gain Higher intraluminal osmolality leading to loose stools In the case of acute diarrhea when the mucosa is severely injured, one third of lactase activity is left ( Lebenthal 1980)

42. ESPGHAN specifies that in severe cases, lower osmolality formulae should be considered

43. Why Low Lactose? Low in lactose to address lactase deficiency secondary to diarrhea Low osmolality to prevent loose stools Limits acceleration of loose stool due to low osmolality therefore allowing faster recovery of mucosa Reduces the risk of nutritional deficiencies and malnutrition

44. Role of Probiotics in Acute Diarrhea Bacteriotherapy with Lactobacillus reuteri in rotavirus gastroenteritis L. reuteri effectively colonized the gastrointestinal tract after administration and significantly shortened the duration of watery diarrhea associated with rotavirus* Safety and Possible Anti-diarrheal Effect of the Probiotic Lactobacillus reuteri after Oral Administration to Neonates It is safe to administer L. reuteri at doses up to 10 9 CFU/day to newborn infants** * Pediatr Infect Dis J 1997; 16:1103-7 ** Clin Nutr . 2001; 20 ( suppl 3):63 (no 216) (Poster at ESPEN Congress, Munich 2001)

45. Additional Therapies No additional therapies have well established benefits and some are potentially harmful Children with acute diarrhea should NOT receive ant- imotility agents or antiemetics Antimotility agents ( loperamide , diphenoxylate -atropine, and tincture of opium) prolong some bacterial infections and may cause fatal paralytic ileus in children Antiemetics (chlorpromazine, prochlorperazine , promethazine , and metoclopramide ) have sedating effects that can interfere with rehydration and may cause extrapyramidal reactions and respiratory depression

46. Thank You Breast Feeding the best for Babies

47. 25 times less Lactose content to address transient lactose intolerance 20% lower osmolality than standard formula to prevent acceleration of loose stools and helps in faster recovery of mucosa Zinc that strengthens immune defences Neucleotides that are known for their trophic effect on intestinal epithelium L. Reuteri