Chapter 5

Diarrhoea Case I

Case study: Sarah

Sarah, 9 months old, was brought to the hospital with 5 day history of watery stools. She was restless and irritable.

What are the stages in the management of Sarah?

Stages in the management of a sick child

1. Triage

(Ref. Chart 1, p. xxii)

Emergency treatment, if required

2.
3. 4. 5. 6. 7.

History and examination

Laboratory investigations, if required

Differential diagnoses
Main diagnosis

Treatment Supportive care Monitoring Plan discharge

Follow-up, if required

Have you noticed any emergency or priority signs?

Temperature: 36,80C, pulse: 130/min, RR: 40/min, capillary refill time: below 2 seconds, weight: 8 kg, sunken eyes, normal skin turgor

Triage
Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable Referral Malnutrition Oedema of both feet Burns

History
Sarah had been well 5 days ago, but then she began to have loose watery stools 8-10 times a day. There was no blood or pus in the stool. Past medical history: previously well, no significant past history Immunization: completed according to Expanded Programme on Immunization schedule, measles due Social history: lives with her mother and sister, 4 years old Medications: none Allergies: not known

Examination
Sarah was crying continuously, she only stopped briefly when her mother put her to her breast. When she was offered ORS she drank eagerly.

Vital signs: temperature: 36.8 C, pulse: 130/min, RR: 40/min Weight: 8 kg Eyes: sunken Skin: normal skin turgor (skin pinch goes back immediately) Chest: air entry was good bilaterally and there were no added sounds Cardiovascular: both heart sounds were audible and there was no murmur Abdomen: bowel sounds were active and there was no organomegaly Neurology: restless and irritable; no neck stiffness and no other focal signs

Differential diagnoses
List possible causes of the illness Main diagnosis Secondary diagnoses Use references to confirm (Ref. p. 127)

Differential diagnoses (continued)

Acute (watery) diarrhoea Cholera Dysentery Persistent diarrhoea Diarrhoea with severe malnutrition Diarrhoea associated with recent antibiotic use Intussusception

Additional questions on history

Diarrhoea
frequency of stools number of days blood in stools

Local reports of cholera outbreak Recent antibiotic or other drug treatment Attacks of crying with pallor in an infant

Further examination based on differential diagnoses

Look for: Signs of dehydration such as: restlessness, irritability, lethargy, sunken eyes, skin pinch returns slowly Blood in stool Severe malnutrition Abdominal mass Abdominal distension

Further examination based on differential diagnoses

Sunken eyes

(Ref. p. 127)

Classification of the severity of dehydration in children with diarrhoea

Rapid assessment of hydration status and classification of severity of dehydration in children with diarrhoea:
Classification Signs or symptoms

Severe dehydration

Two or more of the following signs: lethargy/unconsciousness sunken eyes unable to drink or drinking poorly skin pinch goes back very slowly (>2 seconds) Two or more of the following signs: restlessness, irritability sunken eyes drinks eagerly, thirsty skin pinch goes back slowly

Some dehydration

No dehydration

Not enough signs to classify as some or severe dehydration

(Ref. Table 12, p. 128)

Please summarize the signs of dehydration you noticed in Sarah

Classification of the severity of dehydration in children with diarrhoea

Classification Severe dehydration Signs or symptoms Two or more of the following signs: lethargy/unconsciousness sunken eyes unable to drink or drinking poorly skin pinch goes back very slowly (>2 seconds) Two or more of the following signs: restlessness, irritability sunken eyes drinks eagerly, thirsty skin pinch goes back slowly Not enough signs to classify as some or severe dehydration

Some dehydration

No dehydration

(Ref. Table 12, p. 128)

What investigations would you like to do to make your diagnosis ?

At this stage no additional investigations are necessary

Diagnosis
Summary of findings: Examination: restlessness, irritability, sunken eyes, drinks eagerly, thirsty Acute diarrhoea with some dehydration

How would you treat Sarah?

Treatment Plan B
(Ref. Chart 14, p. 135) In the first 4 hours give 75 ml per kg of ORS as shown in table below

Show the mother how to give the child ORS solution, a teaspoonful every 1-2 minutes if the child is under 2 years; frequent sips from a cup for an older child

Treatment (continued)
After 4 hours:
- Reassess the child and check the signs of dehydration - Select the appropriate plan to continue (discharge if necessary to Treatment Plan A or C) - Begin feeding the child in clinic

If the mother must leave before completing treatment:

- Show her how to prepare ORS at home - Give her enough ORS packets to complete rehydration - Explain the 4 Rules of Home Treatment: 1.Give extra fluid 2.Give zinc supplements 3.Continue feeding 4.When to return

Treatment (drugs)
Antibiotic treatment is rarely necessary (Ref. p. 126) Only for: Dysentery (mostly Shigella) Cholera Neonates with diarrhoea and fever Anti-diarrhoeal agents Never necessary and often harmful!

What supportive care and monitoring are required?

Supportive Care
Check regularly to see if there are problems (Ref. p. 132-136 )
If the child vomits, wait 10 minutes, then, resume giving ORS solution more slowly If the child's eyelids become puff, stop ORS solution and give plain water or breast milk

Advise breastfeeding mothers to continue to breastfeed whenever the child wants Infection control: hand washing in clinic and hospital

Monitoring
The child should be checked by nurses frequently

Use a Monitoring chart (Ref. p. 320, 413) Pay special attention to signs of dehydration such as: lethargy/unconsciousness sunken eyes unable to drink or drinking poorly skin pinch goes back slowly or very slowly (>2 seconds) restlessness, irritability drinks eagerly, thirsty

Summary
Sarah was rehydrated with oral rehydration solution.

She was discharged on the same day when she was alert, able to drink and eat.
Before discharge home Sarah was given zinc supplements. At the time of discharge her mother was given advice on how to give extra fluid, to continue feeding and when to return. She was also given a Mothers card containing this information and two packets of oral rehydration solution.