The problem of diarrhea in

young children

Diarrhea control
program
 3-4 episodes /child /year
 3,200,000 deaths/ year
 Causes about 30% of infant deaths
in the developing countries
 Contributes to malnutrition
 Q) what is the relationship
between diarrhea and malnutrition
 Diarrhea Malnutrition
Definition
 Diarrhea is newly defined as an
increase in the frequency and/or
fluidity of the stool relative to the
previous habit of the same
individual.
WHO classification of
diarrhea according to its
duration
 Acute [ < 14 days as in
gastroentritis]
 Persistent > or= 14 days

 Chronic : if recurrent or

long lasting (ex., in

lactose intolerance).
Acute versus persistent
diarrhea
 Characteristics of acute
diarrhea versus persistent
diarrhea
 Acute diarrhea  Persistent diarrhea
 Sudden onset  May be sudden or
insidious but stool
[frequency &
characteristics] vary
from day to day.
 Usually self limited  May lead to weight
[within 3-5 days] loss, permanently
unless child dies impaired growth, or
from dehydration. even death.
 Acute diarrhea versus
persistent diarrhea
 Most often caused  May initially be
by pathogenic related to a specific
organisms. organism but,
intestinal damage,
malabsorption and
other bacteria keep
it going.
 Children 1 to 30
 Malnourished
months are more children are more
susceptible.
susceptible.
 Acute diarrhea versus
persistent diarrhea
 Fever and/ or  Neither fever nor
vomiting may or vomiting is
may not be common.
accompany.
 May result in  Dehydration is
rapid usually mild but
dehydration. enough to
suppress
appetite.
Predisposing factors or risk
factors for diarrhea
 I- unsanitary environment
 II- Factors related to the mother;
{behavioral factors}.
 III- Factors related to the host
(child)
 IV- Factors related to the agent.
Behavioral risk factors for
diarrhea
 No hand washing
 Inadequate breast feeding
 Bottle feeding
 Eating food left for hours at room temperatures
 Use of contaminated water either for drinking or
in milk preparation
 Improper refrigeration, boiling or cooking of milk
or feeds.
 Bad weaning practice
Host factors that
predisposes to diarrhea
 Malnutrition
 Age under 5 years
susceptibility
 Immunocomprised child
 Diseases such as measles, upper
repiratory tract infection (otitis media,
tonsilitis)
Clinical picture
 Mild: self limited, no dehydration,no fever
+ diarrhea<5 times/ day.
 Moderate: with some dehydration.

 Severe: Fever, vomiting, diarrhea up to 20

times /day with subsequent dehydration.

 Dehydration: sunken eyes– dry mouth—

oliguria—acidosis (causes ,rapid

respiration, vomiting and anorexia)
—depressed anterior fontanel---apathy—
mental confusion. skin elasticity
 Complication of Acute
diarrhea:
Metabolic effects of diarrhea
 Loss of water dehydration, hypovolemic
shock
 Excess loss of bicarbonates

acid base deficit, acidosis

 Excess loss of potassium K+ depletion
Signs of acidosis
 1- deep rapid respiration [ to
compensate for by respiratory
alkalosis]. (dd from pneumonia)

 2- vomiting.

 3- Appetite. (also, in case of

protein loss)
When hypokalemia occur?
 When acidosis is corrected without
correction of K+.
 Signs:
 Muscle weakness
 Cardiac arrythmia
 Paralytic ileus especially when
associated with antiemetic drugs.
Prevention of diarrhea
 Environmental Sanitation
 Health education for the mothers about
infants feeding (breast feeding, …)
 Manage host factors {especially scheme of
immunization and treat systemic infection}
 Specific prevention: rota virus vaccine, cholera
oral vaccine, E. coli vaccine (not in Egypt)
Control
 Case finding
 case;: notification , disinfection,
Treatment.
 Principles of Treatment of
acute diarrhea

 Please remember that:

 1-Rehydration therapy is The main principle to
substitute the lost water and electrolytes and
correcting dehydration
 2-Diet: Continue feeding.
 3-Restrict use of chemotherapeutics. Why?
 4- Symptomatic treatment is of fever only.
 (no antiemetic , no antimotility drugs)
 5- treatment of underlying diseases
 Composition of oral
rehydration solution ORS
 Sodium (90mmol) replace lost sodium
 K+ (20 mmol) replace lost potassium
 Bicarbonate (30mm) correct acidosis
 Glucose (111)
 Osmolality (320) Isotonic

 N.B now there is another composition available

which contains only 60 mmol of sodium
 Fluids for home therapy
 ORS
 Water
 N.b., don’t give water alone; it must be associated
with ORS. Why ?
 because this may cause hypotonic dehydration, with
subsequent lethargy and seldom seizures)
 Food-based fluids:
 Rice water ---potato Soup, vegetable soup ---Yoghurt
 Fresh fruit juice.
 N.B. don’t give concentrated sweetened juices.
Why? Because this may cause hypertonic
dehydration, with more thirst & seizures
 Green coconut water
When ORT is not
effective ?
 Severe dehydration
 Severe, vomiting
 Ileus, abdominal distension
 Glucose malabsorption {glucose. Is
important for sodium reabsorption---
glucose-sodium channel.}
 We use nasogastric tube or IV.
In the diarrhea control program
we must Assess the diarrhea
patient to detect:
 Onset Acute or Persistent diarrhea
 Dehydration and its degree
 Dysentery

 ---------------------------------------
 Then continue assessment as planed in IMCI.
 (Malnutrition)
 (Other infections such as pneumonia, and
malaria, measles).
 fever
*assess for
dehydratio
n
 Only two signs (in red and pink)

[No D.] [Some D.] [Severe D.]

Condition

Thirst

Skin
pinch About 2 seconds. >2 sec.
Degree of dehydration and
% of fluid deficit
 Assessment  Fluid deficit *
 No signs of dehydration  0 – 4%

 Some dehydration  5 – 10%

 Severe dehydration  > 10 %

 * % of body weight
Plans of Treatment
 Select a treatment plan
 Assessment  Objective
Treatment
 Referred to hospital &
 Severe dehydration Plan C Rehydrate urgently
with IV fluids

 Some dehydration Plan B

 Rehydrate at health
center with ORS
 No signs of dehydration Plan A  Treat at home to
prevent dehydration
 Treatment Plan A at home
 Give more fluids:
 A- Give ORS, Dose, {200 ml/kg/day}
 B- Use plain water, breast milk, or low salt
drinks during the course of diarrhea
 Continue breast feeding or use same milk
formula and concentration or Give more
food than usual to prevent malnutrition
 Plan A
 If the child is ≥ 6 months,:
 Feeding:give cereal or starchy food
mixed with beans, or vegetables or
meat. Add 1-2 teaspoonful of oil.
 Give fresh fruit juice or mashed banana
to supply potassium.
 Give at least 6 feeds / 24 hours.
 Identify warning signs of dehydration to the
mother to come back to the doctor
 Follow up in 5 days if not improving.
 Treatment Plan b at health
center or rehydration unit
 1- First the doctor estimate the amount of
ORS required for the child { 75ml/ kg}
 2-The child is given this amount during

4 hours that he stays in the center.

No breast feeding or other in the first 4 hours,
 3- Initially one teaspoonful is given every 5-
10 minutes to avoid vomiting. Then increase
gradually.
 4- Weight every 1- 2hours.
Plan B
 5-Educate the mother to prepare
ORS.
 6- Observe and monitor body weight
gain and improved signs of
dehydration
 7-The mother is instructed to
continue treatment at home as in
plan A. (200ml/kg/day).And follow up
in 5 days
 When do we need
nasogastric administration of
ORS?

 Repeated vomiting
 {We give Iv.fluid in case of continuos
vomiting}
 When the baby refuses ORS
 The baby is too sleepy
 The mother is so exhausted
 Lack of facilities during transmission to
hospital in severe dehydration
In plan b you must refer to
hospital immediately if:
 There is a general dangerous sign:
 Convulsions
 Or an indication of plan C

 Such as Lethargy or unconscious,

not able to drink
 Treatment plan C
in hospital
 1- Start IV fluids immediately before
transmission.
 2- If shock is present:
 Give Ringer’s lactate solution
{20ml/kg} in the first ½ hour.
 If no response, give plasma or blood
transfusion {10-20 ml/kg} in ½ hour.
 Airway clearance, warmth, oxygen and
lower limbs elevation to manage shock.
 Plan C
 If not shocked or after correction of shock
 Start rehydration with polyelectrolyte solution
{same composition as ORS}
 Dose: 100 ml/kg within the next 6 hours
 Reassess the baby after the 6 hours then choose
plan A, B, or C to continue treatment.
 Oral fluids and breast feeding
should be initiated as soon as the
patient can drink and be given
with IV fluids untill all deficits in
fluids are restored. Discontinue IV.
Thank you
 Why antibiotics are not
recommended as a first line
therapy
 1-most childhood diarrhea are caused by
viral agents [25-40% of cases in Egypt are
due to rota virus].
 2-Many other cases are caused by parasites
like Giardia and amoeba [not affected by
antibiotics]
 3-the use of many antibiotics may lead to
secondary enteritis and persistent
diarrhea because they destroy the flora of
the intestine.
continue
 4- Sensitivity studies show that
most other cases are caused by
bacteria which are resistant to the
most frequently used antibiotics.
 5-Using antibiotics when not
indicated may reduce its
effectiveness when needed [due to
resistance].
continue
 D- Symptomatic treatment:
 For fever.
 Don’t give anti-emetics. Why?

 1-Because correction of acidosis can

stop vomiting.
 2-It causes sedation and or precipitate
paralytic ilieus.
Continue symptomatic tt
 Don’t give anti-motility drugs. Why?

 1- it keeps the toxins and pathogens

inside the intestine.
 2- It can cause ileus or respiratory
failure.
Continue control
 E- treatment of underlying
diseases:
 Malnutrition
 Systemic infection
 Parasitic infestation