Diarrhoea in children

Question 1

Comment on the Diarrheal disease burden

Answer 1

It is a mild to life threatening diseases.
It accounts for 8% of deaths in under 5’s.
It is the leading cause of malnutrition in U5’s.
Diarrheal disease mortality is greater in HIV+ children than in those without.
There are occasional epidemics.
Most diarrheal deaths preventable by simple low cost interventions.
It is part of the top ten causes of childhood mortality in KATH.

Question 2

What is diarrhea? What happens in diarrhea?

Answer 2

Diarrhea is the passage of 3 or more loose watery stools within 24 hours. It is caused by increased stool fluidity and frequency due to increased gut motility, increased gut secretions and decreased gut absorption.
Take into consideration the patient’s usual habit in the history.

Question 3

Give the various mechanisms of diarrhea

Answer 3

There are four mechanisms of diarrhea - invasive, secretory, osmotic and other

Question 4

What are the types of diarrhea?

Answer 4

Acute watery diarrhea - <14 days in duration
Persistent diarrhea - >14 days duration
Severe persistent diarrhea - Persistent diarrhea with signs of dehydration
Dysentry - Bloody diarrhea
Chronic diarrhea

Question 5

What are the features and etiological agents of acute watery diarrhea - most common?

Answer 5

It lasts for <14 days, with not more than 3 days break. Occurs with or without vomiting, no visible blood in stool.

Shigella, Campylobactor Jejuni, E. Coli (ETEC, EPEC), Rotavirus, Norovirus, Cryptosporodium, Vibrio Cholerae 01

Question 6

What are the features and etiological agents of dysentery?

Answer 6

There is visible blood in stool, rapid weight loss, anorexia, intestinal mucosal damage.

Caused by Entamoeba histolytica in young adults, shigella, salmonella, EIEC, Campylobacter jejuni

Question 7

What are the features of persistent diarrhea and its etiological agents?

Answer 7

It starts out as acute watery diarrhea or dysentery but lasts for more than 14 days. There is marked weight loss.

It is caused by Entero-adherence E.coli, Giardia Lamblia, Cryptosporidium, Shigella

Question 8

What is severe persistent diarrhea?

Answer 8

It is persistent diarrhea with signs of dehydration.

Question 9

What should you note about Chronic diarrhea?

Answer 9

It is recurrent diarrhea, not due to an infectious cause (eg. Metabolic disorders)

Question 10

What are the three major pathways to infectious diarrhea?

Answer 10

A sick person without proper sanitation facilities defecates near a water source > this contaminated water is used by farmers to irrigate their crops > the contaminated corps are used to prepare food which is then eaten.

Animals defecate in or near a water source > this water is used for drinking and cooking > the food is ingested, water drank by families

Caregivers change the diapers of a sick baby and contaminate their hands > They touch people, objects and surfaces with their contaminated hands > prepare food with their contaminated hands.

Question 11

What is the viral mechanism for diarrhea?

Answer 11

The virus replicates in the epithelial cell, then there’s villous destruction and shortening, with loss of disaccharidase enzymes. There’s then replacement by immature cells and finally water and electrolyte secretion. Diarrhea persists till the cells mature.

Question 12

What are the various bacterial mechanisms for diarrhea?

Answer 12

Mucosal adhesion, leading to decreased absorption. There’s also mucosa invasion, and toxin secretion.

Question 13

What are the protozoal mechanisms for diarrhea?

Answer 13

Mucosal adhesion - Giardia Lamblia, Cryptosporodium in the ileum. And mucosal invasion - Entamoeba histolytica in the ileum or colon.

Question 14

What is the mechanism for invasive diarrhea and what are some examples of pathogens that cause invasive diarrhea?

Answer 14

The pathogen invades the distal ileum, colon > Inflammation, intestinal mucosal cell destruction > decreased function( increased fluid and nutrient absorption, inflammatory exudate, +/- pain) > diarrhea (dead tissue, mucus, blood, partially digested food).

Entamoeba histolytica, EIEC, EHEC, Yersinia enterocolitica, Vibrio parahaemolitica, Shigella, Salmonella, Campylobactor Jejuni

Question 15

What is the mechanisms for secretory diarrhea and what are examples of pathogens that cause secretory diarrhea (acute watery diarrhea?

Answer 15

Pathogen multiplies in the ileum > Toxin production > Toxin attaches to mucosal cell > Toxin causes conversion of ATP to cAMP > cAMP leads to a reduction in the absorption of Na+, increase in the secretion of Cl-. This leads to increased secretion of water, K+ and HCO3 form the tissues into the gut lumen, leading to diarrhea.

Those that secrete enterotoxins: Shigella, Vibrio Cholera, Campylobacter Jejuni, Salmonella, ETEC.

Those that don’t secrete enterotoxins: Rotavirus

Question 16

What is the mechanism for osmotic diarrhea and which agents cause osmotic diarrhea?

Answer 16

There’s presence of osmotically active substances in the gut. These substances cause the movement of fluid from tissues into the gut, leading to diarrhea.

It is caused by purgatives like Epsom salt, improperly prepared ORS/Salt-Sugar solutions, Lactose in lactose intolerant patients, Glucose in Glucose malabsorption patients.

Question 17

Give an overview of the effects of diarrhea

Answer 17

There are two main effects - Dehydration and Nutrient deficit. Dehydration leads to fluid and electrolyte loss, Tissue hypo-perfusuion and multiple organ failure. Nutrient deficit leads to malnutrition, then infection. These can both result in death.

Question 18

What are the effects of dehydration?

Answer 18

Hypovolemia, which leads to cardiovascular collapse and finally multiple organ failure.
Hypoxia which leads to multiple organ failure.
Tissue damage by the release of chemical mediators which amplify the damage done by the hypo-perfusional state.
TNF, Coagulation cascade, Interleukins, Complement, Leukotrienes, Leucocytes, endorphins, platelet activating factors, Lipopolysaccharides.
Abnormal physiology - Plugged capillaries, Abnormal starling’s mechanism, damaged barrier function, abnormal smooth muscle contraction (ileus), blood viscosity changes, AV shunting, altered interstitium, coagulation cascade.

Question 18

What are the effects of dehydration?

Answer 18

Hypovolemia, which leads to cardiovascular collapse and finally multiple organ failure.
Hypoxia which leads to multiple organ failure.
Tissue damage by the release of chemical mediators which amplify the damage done by the hypo-perfusional state.
TNF, Coagulation cascade, Interleukins, Complement, Leukotrienes, Leucocytes, endorphins, platelet activating factors, Lipopolysaccharides.
Abnormal physiology - Plugged capillaries, Abnormal starling’s mechanism, damaged barrier function, abnormal smooth muscle contraction (ileus), blood viscosity changes, AV shunting, altered interstitium, coagulation cascade.

Question 19

What are the other effects of diarrhea?

Answer 19

Acidosis (Base deficit)
Deep, rabid breathing - leading to complementary respiratory alkalosis.
Increased vomiting, Arterial pH < 7.10, Serum bicarbonate < 10.0mmol/L
Not a problem if renal function (perfusion is normal), otherwise acidosis progresses rapidly.

Potassium deficit
Due to large fecal losses (greatest in infants and undernourished children) of K+. Patient presents with general muscle weakness, cardiac arrhythmias and paralytic ileus (especially with the intake of antimotility drugs to treat acute diarrhea like codeine phosphate, co-phenotrope, Loperamide, Kaolin + morphine mixture.

Not a problem if HCO3 and K+ are lost simultaneously. However if the base deficit is corrected first (with Bicarbonate) without correcting K+ hypokalemia could worsen, unless K+ depletion corrected simultaneously.

Question 20

What occurs in isotonic dehydration?

Answer 20

It’s the most common type. Usually occurring from diarrhea and vomiting. Net loss of Na and water is in same proportion as found in ECF. Serum Na - 130-150mEq/L. Serum osmolarity - 275-295 mosmol/L. Hypovolemia can result if there’s substantial loss of ECF.

Question 21

What occurs in hypotonic dehydration?

Answer 21

Occurs when there’s ingestion of large amounts of distilled water, other hypotonic fluids (like 0.45% Normal saline), 5% dextrose infusion.
Deficit of water and sodium but the deficit of sodium is greater.

Low serum sodium - < 130mEq/L
Low serum osmolarity - < 275 mOsmol/L

Early appearance of signs of dehydration. Patients may be lethargic, and occasionally have seizures.

Question 22

What occurs in hypertonic dehydration?

Answer 22

There’s ingestion of hypertonic fluids such as Salt sugar solutions. high solute fluids, or insufficient water intake.

High serum osmolarity >295 mOsmol/L
High serum Na: >150mEq/L
There’s deficit of Na and water, but water deficit is greater.

Patient presents with severe thirst out of proportion to apparent dehydration, irritability. Signs of dehydration appear at greater degrees of dehydration.

Seizures at Serum Na of >165 mOsmol/L
Blood volume sustained longer

Question 23

What are the principles of diarrhea management?

Answer 23

Rehydration - based on assessment of patient’s hydration status
Treat shock
Correct deficit - quickly
Maintain ongoing losses (to prevent further dehydration)

Other Specific therapy - drugs
Supplemental zinc

Nutritional support

Question 24

What are the signs of dehydration?

Answer 24

Key Signs Thirst Altered sensorium Skin Pinch: Diminished Skin turgor Sunken eyes Others Dry mouth and tongue Absence of Tears on crying Late Signs Low BP Fast pulse rate Sunken Fontanelle

Question 25

How is the Skin Pinch: Test for Skin Turgor done?

Answer 25

Pinch in the longitudinal plane Pinched between thumb and bent forefinger Classification of skin pinches Normal / Fast recoil - It goes back immediately Slow recoil - Fold is visible for <2 seconds Very slow recoil - Fold is visible for >2 seconds

Question 26

Give the WHO Assessment and classification for hydration status

Answer 26

No dehydration (<5% loss) General Condition: Well, alert Eyes: Normal Thirst: Drinks normally Skin Pinch (Turgor): Fast recoil Mild to Moderate ("Some") Dehydration (5-10% loss) General Condition: Irritable Eyes: Sunken Thirst: Drinks eagerly Skin Pinch (Turgor): Slow recoil Severe Dehydration (>10% Loss) General Condition: Lethargic or Unconscious Eyes: Very Sunken Thirst: Poor Drinking or Unable to Drink Skin Pinch (Turgor): Very slow recoil Read from right to left (Bottom to Top). Need 2 or more signs per category to decide.

Question 27

Management of Diarrheal Dehydration

Answer 27

No Dehydration (<5% Loss) Replace ongoing losses and prevent diarrhea from leading to dehydration. 0-23 months: 50-100ml aels 2 - 10 yrs: 100 - 200ml aels >10 years: As wanted Mild to Moderate Dehydration ("Some", 5- 10% Loss) Correct fluid deficits ORS Wt x 75ml in the next 4 hours Review then review or move left Replace ongoing losses Severe Dehydration (>10% Loss) IV Rx Treat imminent shock, and start correcting fluid deficits Infants: 30ml/kg for first hour, then 70 ml/kg in next 5 hours. Total of 6 hours Older children: 30 ml/kg in first 30 minutes, then 70ml/kg in next 2.5 hours. Total of 3 hours. Replace ongoing losses with ORS as soon as patient can drink. Encourage easily digestible, energy rich foods

Question 28

How is Rehydration carried out in diarrhea management?

Answer 28

Oral: Oral Rehydration salts Food-based fluids Other fluids If vomiting is <3x/hour, ORS has 3 times the normal fluid absorption rate IV Rx: Ringer's Lactate (5:4:1 - 5% Dextrose in Ringer's Lactate and Darrows solution)

Question 29

What are the three basic rules for treating Diarrhea at home?

Answer 29

To the caretaker: More fluids than usual - To prevent dehydration More food intake, to prevent undernutrition Review at the health facility - If diarrhea does not get better, if symptoms of dehydration or another serious illness develops.

Question 30

What should you note about Oral Rehydration Therapy?

Answer 30

95% of episodes of secretory diarrhea dehydration can be corrected or prevented using only ORS solution.

Question 30

What should you not about Oral Rehydration Therapy?

Answer 30

95% of episodes of secretory diarrhea dehydration can be corrected or prevented using only ORS solution.

Question 30

What should you not about Oral Rehydration Therapy?

Answer 30

95% of episodes of secretory diarrhea dehydration can be corrected or prevented using only ORS solution.

Question 31

What is the composition of ORS?

Answer 31

G/600ml Tri sodium citrate - 1.74, Glucose - 8.1, KCL - 0.9, NaCl - 1.56, Osmolarity (245 - Low)

Question 32

How is Low Osmolarity ORS formulated? What are the benefits of Low Osmolarity ORS?

Answer 32

The concentrations of Glucose and KCL are lowered in order to achieve Low osmolarity ORS There is improved efficacy of ORS, Decreased need for intravenous therapy - 33%, Decreased stool production - 20%, Decreased in vomiting frequency - 20% and its safe and effective for children with Cholera.

Question 33

What's the deal with Flavored ORS preparations?

Answer 33

There is no evidence of increased efficacy over non-flavored counterpart in terms of safety, acceptableness and correct use. Tends to lead to over consumption. Medical Problems with Sweeteners: Toxicity and Carcinogenicity: Cyclamic acid - Carcinogenic (banned in USA), Dulcine - Toxic and carcinogenic, Saccharine - Carcinogenic. Aspartame is unstable at temperatures above 40 degrees Celsius. There are specified limits of consumption for all of these by the FDA There's a tendency to exceed limits of consumption in high purge situations thius increasing toxic side effects. Increased price Allergies: There's a tendency of the flavoring agents to induce allergies and other side effects, esp. in infants and small children

Question 34

What are the contraindications for ORT?

Answer 34

Initial treatment of severe life threatening dehydration which requires rapid replacement of fluid. It requires Giving Intravenous infusion of water and electrolytes. Patients with paralytic ileus or marked abdominal distension Patients who can't drink ( Although these patients can be given ORS through a nasogastric tube if IV treatment isn't possible. In patients with very rapid stool loss - greater than 15ml/kg body weight/hr, drinking of ORS won't be at a sufficient rate to replace losses In patients with severe frequent vomiting - unusual - oral fluids can be absorbed despite the vomiting, and vomiting resolves once dehydration and fluid and electrolyte imbalance is corrected. In patients with Glucose malabsorption, intake of ORS causes marked increase in stool volume and increased concentration of glucose in stool. This can worsen dehydration.

Question 35

What are the special limitations of use of ORS?

Answer 35

Severely malnourished children - ReSoMal Breastfeeding Infants

Question 36

What choice of IV fluids alongside their compositions are used in treating diarrhea?

Answer 36

Ringer's Lactate - Na - 130, Cl - 109, K - 4, Ca - 3, Lactate/Acetate - 28 Normal Saline - Na - 154, Cl - 154 Full-strength Darrow's - Na - 121, Cl - 103, K - 35, Lactate/Acetate - 53 Half-Strength Darrow's - Na - 61, Cl - 52, K - 18, Lactate/acetate - 27 ORS - Na - 90, Cl - 80, K, Citrate - 10, Glucose - 111 5:4:1 - Na, Cl - 99, K - 13.5, Lactate/Acetate

Question 37

What is the function of zinc in the treatment of Diarrhea?

Answer 37

It reduced the duration of diarrhea (acute and persistent), the severity of diarrhea, treatment failure or death in persistent diarrhea, incidence of pneumonia, prevalence of diarrheaand the risk of dehydration when given at onset. 10-14 days of zinc supplementation fully replenishes zinc lost during diarrhea and reduces the risk of having new diarrhea episodes in 2-3 months after treatment.

Question 38

What is the dosage of zinc given in diarrhea? When does Zn toxicity occur?

Answer 38

For a child <6months, 10mg/kg/day. For a child >6months, 20mg/kg/day is given. In the syrup form, 20mg of elemental Zn is given/5ml or Tablets: 20mg Zn as Zn sulphate, acetate or gluconate. When an excess of 150mg/dy of Zn is given over a long time, or >1g/dose is given. This leads to gastric distress and food poisoning, anemia from decreased iron absorption.

Question 39

What are the specific diarrhea therapy given to children?

Answer 39

Amoebiasis & Giardiasis - Metro Campylobacter - Erythromycin only when given early. Shigellosis - Cipro, Nalidixic acid, Ceftriaxone as per Cult & Sens ETEC & EPEC - Cipro Vibrio Cholerae - (cases with severe dehydration only) <12 years - Erythromycin 12.5mg/kg qds x3 & Zn daily x10/7 Older Children/Adults: Tetra 12.5mg/kg qds x3 or Doxy 300mg stat (to reduce volume of stools, duration of vibrio excretion) Cryptosporidium - None yet

Question 40

What is the protocol for treating Dysenteries?

Answer 40

Ideally - take a stool culture & sensitivity/ do a microscopy, then treat based on results. Otherwise, treat as shigellosis. If stools are bloody after than 2 days, switch to second line treatment. If dysentery is present after day 5 treat as amoebiasis

Question 41

What can you note about Shigellosis?

Answer 41

50% of shigella diarrheas are mild and not bloody.. Causes 50% or more of bloody diarrhea in young children <5years. May lead to HUS - low Hb, low platelets, renal failure (S. dysenteriae type 1) May cause rectal prolapse. Leads to a lot of adverse effects on nutrition than other diarrheas - anorexia (persists for days to weeks after recovery), serum protein loss through damaged bowel. Greatest risk of death in infants and malnourished. Natural history is 2-10 days or more. The cause of most episodes of clinically severe diarrhea in young children - most severe in <4 months old with 20% fatality. If effective antimicrobial treatment is delayed to mre than day 2, the complications are more frequent.

Question 42

What can you note about Rotavirus diarrhea?

Answer 42

It is the most common cause of severe diarrhea in young children. >1/3rd of all hospitalizations of children <5 is due to rota diarrhea. A primary infection is associated with severe dehydration, fever, profuse watery diarrhea, vomiting. Infects children ages 2-3 years First infections are symptomatic and re-infections are common. Occurs year round with peaks between the dry months - December to March.

Question 43

Give the drugs that have little or no role in diarrhea case management.

Answer 43

Sulfonamides, Neomycin, Streptomycin, anti-motlitity drugs, Kalin & charcoal, purgatives, cardiac stimulants, antiemetics

Question 44

What is the Global Diarrheal Management Policy?

Answer 44

Management should include - Liberal use of Low osmolarity ORS and home fluids to correct or prevent dehydration. Zinc supplementation for 10-14 days to shorted the duration and severity of diarrhea. Continued feeding including breastfeeding.

Question 45

What is included in the Future Specific treatment for Diarrhea?

Answer 45

Super ORS solutions - Using resistant starch Anti-Secretory drugs - Enkephalinase inhibitors - Racecadotril Non- absorbable locally active antimicrobials - Rifaximin Anti-diarrheal immunization

Question 46

How can diarrhea be prevented?

Answer 46

Hand washing - not against Rotavirus) Good nutrition Food hygiene Safe disposal of excreta Immunization - Rotavirus, Norovirus, Measles, Cholera

Question 47

Describe the Protect, prevent and Treat Framework - Prevents 88% of diarrhea deaths

Answer 47

The main aim is to reduce Pneumonia and Diarrhea morbidity and mortality. Protect children by establishing good health practices from birth - exclusive breastfeeding for 6 months (promote & support), adequate complementary feeding, vitamin A supplementation. Prevent children from becoming ill from Diarrhea and Pneumonia - Reduce air pollution at home, Hand washing with soap, Safe drinking water and sanitation, Vaccines - Pertussis, Measles, PCV, Hib, Rotavirus, HIV prevention, Co-trimoxazole prophylaxis for HIV infected and exposed children Treat all children ill with pneumonia or diarrhea - Supplies on deck - Zinc, Low-osmolarity, ORS, Oxygen (where indicated), Antibiotics. Improve care seeking and referral. Continued feeding including breastfeeding, Care management at the health facility and community level