Presentation on diarrheal diseases in children.pptx

Diarrhea

1. Diarrheal Diseases in Children

2. Outline Definition and Classification Epidemiology Etiology Pathophysiology and manifestations Complications Management Prevention

3. Definition and classification Diarrhea Passage of > 3 loose stools/day or watery stool of any frequency or >10ml/kg/day in infants ,in older children >200gm/day o Classification: Acute watery - acute onset, no mucus or blood and lasts less than 14days Persistent - starts acutely , watery and lasts > 14days Severe persistent –persistent diarrhea with any form of dehydration

4. Co n t… Dysentery – blood in the stool ( historical, witnessed, microscopy) It is often associated with fever ,frequent small stool , urgency, abdominal pain and tenesmus. Common clinical features of dysentery include anorexia, rapid weight loss Complications like renal failure and encephalopathy

5. Epidemiology One of the leading causes of morbidity & mortality in children Causes about 2 million deaths annually in children of under five ˷ Common in children of age below 5yrs Peak incidence is during the age of 6-11months? Age of complementary feeding Related with developmental age Declining levels of antibodies acquired from the mother Major route of transmission is feco-oral or ingestion of contaminated food or water

6. Risk factors A. Host factors Inappropriate breast feeding practice no EBF for the 1 st 6months early interruption , bottle feeding Unsanitary food preparations Lack of immunization Young age Measles infection Malnutrition Immunocompromization Vit A and Zinc deficiency

7. Risk factors cont… B. Environmental factors Seasonality Inadequate food intake due to different reasons Poverty and poor living conditions Poor domestic and environmental sanitation especially unsafe water

8. E tiology Non-Infectious Anatomic defects - short bowel syndrome, villus atrophy Malabsorption- disaccharidase deficiency, Celiac disease Food allergy/intolerance Infectious 1. Inflammatory Usually caused by bacteria that invade intestine directly or produce cytotoxins 2. Non-inflammatory through enterotoxin production by some bacteria, villus destruction by viruses or adherence by parasites

9. Infectious etiology A. Bacteria Shigella Salmonella Vibrio cholerae E.coli Campylobacter jejuni Clostridium difficile B. Viruses Rota virus Enteric Adeno virus CMV(in im m uno c o m p r o m i z ed)

10. Etiology cont… C . Parasites G i ardia lamblia Entamoba histolytic a D. Fungi Candida albicans

11. Etiologies of dysentery Shigela spp. Invasive Eschericha coli Campylobacteriosis (Campylobacter jejuni) Amebic dysentery (Entamoeba histolytica) Bilharzial dysentery (Schistosoma japonicum, Schistosoma mansoni) Salmonellosis (Salmonella typhimurium) Typhoid fever (Salmonella typhi) Enteric fever (Salmonella choleraesuis, Salmonella paratyphi)

12. Pathophysiology The basis of all forms of Diahhrea is disturbed intestinal solute transport Movement of water across intestinal membranes is passive and determined by both active & passive fluxes of solutes particularly Na, Cl, and Glucose

13. Mechanisms of diarrheal diseases I. Secretary Through increase in cAMP, CGMP or Calcium Decreased absorption and increased secretion Doesn't stop with fasting E.g. cholera, toxigenic E.coli, VIP II. Osmotic maldigestion, ingestion of unabsorbable solutes It stops with fasting e.g. Lactase deficiency, glucose malabsorption, lactulose

14. Co n t… III. Decreased absorptive surface e.g. Rota virus, short bowel syndrome,Celiac disease IV. Motility disorders e.g. increased motility with decreased transit time ( thyrotoxicosis, irritable bowel syndrome---) or stasis with proliferation of pathogens

15. Clinical manifestations GI– nausea, vomiting, diarrhea, abdominal cramp Systemic– loss of appetite, myalgia, UTI, endocarditis, meningitis Symptoms and signs of dehydration Immune-mediated—extra intestinal manifestations e.g. Reactive arthritis - Salmonella, Shigella, C.jejuni Guillain Barre Syndrome - C.jejuni HUS - E.coli, Shigella

16. C o mpl i c a tions Dehydration & Shock Acute renal failure Malnutrition Sepsis, DIC Metabolic acidosis Paralytic ileus Convulsions and coma (electrolyte disturbance, cerebral thrombosis) Persistent diarrhea

17. D y se n t e r y Diarrhoea presenting with loose frequent stools containing blood. Most are due to Shigella and nearly all require antibiotic treatment. Diagnosis It mainly through its clinical picture. Other findings on examination may include: abdominal pain fever convulsions lethargy dehydration rectal prolapse.

18. Complications of dysentery Electrolyte imbalances Convulsions Hemolytic uremic syndrome (HUS) Leukemoid reaction Toxic megacolon Protein losing enteropathy Arthritis Perforation

19. A) Isotonic dehydration This is the most type of dehydration Losses of water and Na are in the same proportion There is a balanced deficit of water and Na Serum Na concentration is normal Serum osmolality is normal Hypovolemia occurs as a result of loss of extra cellular fluid

20. B) Hypernatremic dehydration There is loss of water excess of Na It is usually results from ; ingestion of hypertonic fluid that not efficiently absorbed Insufficient intake of water or low –solute drink Ser u m Na c once n t r a tion is e l e v a t ed ( > 1 50 mmol/l) Serum osmolality is elevated (>295m osmol/l ) Thirst is severe and the child is very irritable Sezures may occur (Na >165 mmol /l)

21. C) Hyponatremic dehydration There is loss of Na excess of water It is usually from drinking large amounts of water or hypotonic fluid with low Na or IV infusion 5 % glucose without Na There is deficit of water and Na but the deficit of Na is greater Serum Na concentration is low Serum osmolality is low The child is lethargic , infrequently seizures

22. Hypokalemia Patients with diarrhea often develop K depletion The signs of hypokalemia may include ; General muscular weakness Cardiac arrhythmias Paralytic ileus

23. E v alu a tion Hx type of diarrhea Vomiting (character) Fever Associated illness e.g. cough, rash, UTI Urine out put Abd.pain/distension Hx of seizure Previous Hx of similar ilnes Feeding Hx Developmental Hx Immunization Social & family Hx Antibiotics exposure Any similar illnes in the vicinty

24. Physical exam General examination and V/S Look for signs of: A. water loss Loss of skin turgor Weak/absent pulse Tachycardia Sunken eyes Sunken fontanel Delayed capillary refilling Cold skin Anuria, oliguria mental changes

25. C o n t… Loss of nutrients Hypoglycemia Convulsions, mental changes Loss of bicarbonate Vomiting & retching Deep respiration Decreased myocardial contractility Potassium loss Abdominal distension Paralytic ileus

26. C o n t… Stool microscopy/culture Dysentry, Epidemic (?cholera) Persistent diarrhea Suspected septicemia Immunosupressed child Assess for Dehydration: The 4 important signs in well -nourished child are: 1. Mental status 3. Drinking 2. Eye ball 4. Skin turgor

27. Classification of dehydration: Two signs needed Parameter No dehydration Some dehydrat i on Severe dehydrat i on Men t al status Alert Restless, irritable Lethargic or unconscious Eye ball No sunken eyes sunken eyes sunken eyes Drinking Drinking normally Eager to drink Unable to drink Skin turgor Normal skin turgor Skin pinch returns slowly Skin pinch returns very slowly

28. Skin pinch/skin turgor Pinching the child’s abdomen to test for decreased skin turgor

29. Work up The following investigations directed to diarrhea can be done in hospitals Stool examination (microscopy) Stool Culture &Sensitivity test Serum electrolytes Random blood sugar CBC (Hct, WBC with differential, platelet count) Peripheral RBC morphology RVI screening BUN, creatinine

30. Management of dehydration 1. No DHN – Mx plan A Treat diarrhea at home: Rules of 3 ‘Fs’, 4 Rules Give extra FLUID Continue FEEDING When to come for FOLLOW UP Supplemental Zinc

31. C o n t… Fluid – in addition to the usual fluid intake gi v e ORS: 10ml/kg OR 50-100ml for those below 2yrs 100-200ml for children > 2yrs per bowel motion Other fluids; breast milk, food-based fluids(soup, rice water , yogurt) or clean water Unsuitable fluids: commercial carbonated beverages, commercial fruit juices ,sweetened tea, coffee and some medicinal teas or infusions.

32. Co n t… Feeding- frequent breast feeding -cow’s milk or formula - continue other foods if he started Return/follow up- see him in 2days come back immediately if the child becomes sick ( unable to drink, repeated vomiting, sicker , fever, dysentery )

33. C o n t… B. Some DHN – plan B, loss is estimated to be 5%-10% of body weight Treat with ORS: Volume is 75ml/kg Give over 4hrs Continue breast feeding If vomiting, wait for 10minutes After 4hrs, reassess and classify DHN

34. ORS inappropriate for Paralytic ileus Frequent emesis Abdominal distension Patients who are in shock Initial treatment of Severe dehydration be c ause f l ui d mu s t b e r eplaced v e r y r apidly Patients who are unable to drink

35. C o n t… C. Severe DHN- Treatment plan C-loss estimated to be ≥10% of body weight Start IV immediately Ringer’s lactate or NS Volume is 100ml/kg

36. Mx of severe dehydration Infants (below 12months of age) 1 st give 30ml/kg over 1hour (repeat if no response *) Then give 70ml/kg over 5hrs Chi l dr e n > 12 m ont hs of age Over 30minutes (repeat if no response *) Over two and half hours

37. O R S Th e f ormul a f o r O R S r e c ommend e d b y WHO/ U N ICEF c o n t ains Reduced osmolarity ORS Grams / litre Reduced Osmolarity ORS mmols/litre Sodium chloride 2.6 Sodium 75 Glucose, an h y d r ou S 13.5 Chloride 65 P o t as s ium chloride 1.5 Glucose, an h y d r ous 75 Trisodium citrate, dihydrate 1.9 Potassium 20 Citrate 10 Total osmolarity 245

38. Zinc supplementation Zinc deficiency is common in developing countries and zinc is lost during diarrhoea and associated with: impaired electrolyte and water absorption decreased brush border enzyme activity impaired cellular and humoral immunity Zinc supplementation reduce duration and severity of diarrhea increased use of ORS and reduction in the inappropriate use of antimicrobials Reduce recurrence with in 2-3 months It helps for epithilization 10 mg/day for infants <6 mo of age and 20 mg/day for those >6 mo for 10 days

39. Vitamin A Usually given for patients with diarrhea who had measles infection malnutrition Vitamin A(dosing) 50,000 IU for children less than 6 months 100,000 IU for 6 – 12 months and 200,000 IU for those older than 12 months

40. Anti diarrhoeal drugs and anti-emetics should not be given to young children with acute or persistent diarrhoea or dysentery They do not prevent dehydration or improve nutritional status Some have dangerous, sometimes fatal, side- effects.

41. ondansetron is an effective and less-toxic antiemetic agent . Because persistent vomiting can limit oral rehydration therapy, a single sublingual dose ondansetron (4 mg 4-11 yr and 8mg for children older than 11 yr [generally 0.2 mg/kg]) may be given. However, most children do not require specific antiemetic therapy; careful oral rehydration therapy is usually sufficient

42. 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 due to E. Coli O157:H7, which may be indistinguishable from bloody diarrhea seen with other non E Coli bacterial etiologies

43. Antibiotics? Dysentery Suspected cholera Suspected or proven sepsis Associated non-gastrointestinal infections like pneumonia, meningitis, UTI Associated malnutrition

44. Antimicrobial agents Type of diarrhea Antimicrobial agents Shigellosis Cotr i m o x a z ole Ciprofloxacin Ceftriaxone Cholera Tetracycline or Doxycycline (adults and older children) Erythromycine Ciprofloxaciline Amebiasis Metronidazole /tinidazole

45. P r e v e n tion This involves intervention at two levels: Primary prevention (to reduce disease transmission) Rotavirus and measles vaccines Hand washing with soap Providing adequate and safe drinking water Environmental sanitation Secondary prevention (to reduce disease severity) Promote breastfeeding Vitamin A supplementation Treatment of episodes of AD with zinc summarized by the “ 5F” diagram (as it involve: Feces, Food/Fluid , Flies, fomites (utensils) and Finger)

46. Take home message Diarrhea is one of leading cause of under 5 mortality Classification of DHN as NO, SOME and SEVERE is important for management Antibiotics ,antiemetics and antimotilty agents shouldn't not be given routinely.