Childhood Diarrhea

Junying Qiao
the department of pediatrics
the third affiliatted hospital of zhengzhou uni
versity
 Definition
 An increase in the number of stools

or a decrease in their consistency

 A syndrome that results from

disorders involving digestive ,

absorptive, and secretory

functions
 Definition

6m-2y

Can result in child malnutrition

and disturbance of growth and
development
classification
infectious
etiology
noninfectious

acute ： <2weeks
duration persistent ： 2weeks2month
s
chronic ： >2months
Mild diarrhea
degree
Severe diarrhea
Susceptible factors
 Immature digestive system
 Hypoimmunity

 dysbacteria

 Bottle-feeding infants
Etiology
（Ⅰ） Infectious factors
Enteropathologic infection
a) Viruses rotavirus , norwalk virus , adenovirus
and coronavirus
b) Bacteria salmonella, shigella ， escherichia c
oli （ enteropathogenic E.coli,enterotoxigenic
E.coli ,enteroinvasive E.coli,enterhemorrhagic
E.coli,enteroadherent-aggregative E.coli). and
campylobacter organisms
c) Fungus candida albicans
d) Parasite giardiasis , cryptosporisiosis , amebia
sis, ascariasis
Parenteral infection
 upper respiratory tract infections
 pneumonia
 urinary tract infections
 skin infections
 Tympanitis
 communicable diseases
 Parenteral infection
 Abuse antibiotics
(antibiotics related diarrhea)
(Ⅱ)Noninfectious factors
Dietary diarrhea overfeeding, introd
uction of new foods and unripe food
Symptomatic diarrhea URI , pneumo
nia , urinary tract infections , tympanitis ~~~
Allergic diarrhea milk protein or soy
bean milk
 (Ⅱ)Noninfectious factors
 Lactose enzyme deficiency

 Cold or hot weather and emotional tension

Pathogenesis
 Classification
• Osmotic diarrhea
• Secretory diarrhea
• Infiltrated diarrhea
• Altered motility diarrhea
Mechanisms of noninfectious diarrhea

 Osmotic factors
• osmotic gradients cause water to
passively cross intestinal mucosa in
isotonic proportions
• Unabsorbed solutes create osmotic
gradient that results in movement of
sodium and water in the intestinal lumen
Mechanisms of noninfectious diarrhea

 Diminished absorption or increased

secretion of water and electrolytes

 Altered motility both hypermotility and

hypomotility reduce the amount of substance a
bsorbed by the intestinal mucosa
Mechanisms of infectious diarrhea

 Enterotoxin production

organisms multiplication

enterotoxin mucosa

Secretion of water and electrolytes

Mechanisms of infectious diarrhea

Invasion and destruction of

epithelial cells
• Cause superficial ulcerations of mucosa
• Infection proceeds from the upper to the
lower intestines, producing bloody mucoi
d stools
Mechanisms of infectious diarrhea

Penetration and systemic invasion

Organisms infection elsewhere

mucosa to the systemic circulation

(hyperemic and edematous )
 Clinical
manifestations
classification
infectious
etiology
noninfectious

acute ： <2weeks
duration persistent ： 2weeks2month
s
chronic ： >2months
Mild diarrhea
degree
Severe diarrhea
Acute diarrhea
(A)general Clinical manifestation
 Mild diarrhea
• Dietary factors, parenteral infection or enter
ovirus
• Mainly exhibits GI symptom
• Signs of dehydration and toxicosis are usuall
y absent
• Stools tests only show a few leukocytes and a
great deal of lipocytes
Severe diarrhea
 Serious gastrointestinal symptoms
 Disturbance of fluid ,electrolyte
and acid-base balance
a) Dehydration
b) Metabolic acidosis
c) Hypokalemia
d) Hypocalcemia and hypomagnesemia
(B) characteristics of gastroenteritis
 Autumn diarrhea
 fecal-oral route or respiration
Rotavirus  6~24 months of age
enteritis
 with URI, fever and vomiting
 stool ： large, watery, frequent
 dehydration : mild / moderate
 Self-limited 3-8days
 No specific therapy
  Higher incidence In summer
 The onset is gradual or abrupt
Escherichia  Clinical manifestations are
coli.
enteritis variable: most-green, watery
stools with blood and mucus
 Stools cultivation
 3-7 days
  Candida albicans
 Ususlly associated with abuse of a
Fungal ntibiotics
enteritis  stools ： water ,bubble, mucus a
nd bean clinker
 Sporophyte and mycelium exists i
n stool examination
Prolonged and chronic diarrhea
 Prolonged and chronic diarrhea

 Associated
with malnutrion and inadequat
e management of acute diarrhea

 Itoften occurs in children with bottle-feed

ing and malnutrition
 Prolonged and chronic diarrhea

 The children with malnutrition have susc

eptibility for diarrhea. Moreover, diarrhe
a deteriorates malnutrition and leads to h
ypoimmmunity , secondary infection and
functional abnormity of multi-organs.
 physiological diarrhea
 Commonly appears in infants less than 6
months of age
 Diarrhea after birth, puffiness and eczema
 Grow normally , good appetite, no
malnutrition, no blood in their stool.
 After
increase supplemental food , stools
gradually turn to normal
 Laboratory test
 Blood routine
 Stool examination
 Biochemical examination
 Blood-gas analysis
 Diagnosis
 Clinical manifestation
 physical examination

 laboratory findings

 Stools appearance
 Diagnosis
Notice
 1 Etiological diagnosis
 2 Complication(dehydration disturbance of

electrolyte and acid-base banlance)

 Diagnosis
Judge Etiology from stool routine
 1 No or little leukocyte
virus, noninvasive bacteria ,parasite 　 infec
tion or dietary factor.
 2 many leukocyte or with red blood cell

invasive bacteria .
Therapy
 Therapy principles
• Dietary adjustment
• Prevent and correct dehydration
• Reasonable treatment
• Enhance nursing
• Prevent complication
 ①adjustment of dietary

 The foods should be continued

 Adjusted to meet physiological

needs and supply consumes in
order to shorten the duration of
recovery
②Correction of disturbance
 Dehydration

 Mild and moderate diarrhea

—— ORS

 Moderate and severe dehydration

—— intravenous rehydration
ORs(oral rehydration salts)
(The world health organization recommended)

 Composition:
– sodium chloride 3.5g
– Bicarbonate sodium 2.5g
– Potassium chloride 1.5g
– glucose 20.0g
– And water 1000ml to dissolve

 2/3 isotonic
 The concentration of potassium is 0.15%
 The goal is to maintain or restore the
normal volume and composition of body
and normalize optimize cell and organ
function.
 The therapy has three phases

• Cumulated losing volume

• Losing continuing

• Physiological need
 A. Volume

Degree
Cumulated physiological need,
Total volume
losing volume losing continuing

100 ～ 120 m
Mild 30 ～ 50ml/kg
l/kg

Moder 120 ～ 150 m 50 ～ 100ml/k

80 ～ 100ml/kg
a-te l/kg g

150 ～ 180 m 100 ～ 120 ml/

Severe
l/kg kg
 B. Quality

Dehydrant categor Cumulated physiological need,

y losing volume losing continuing

Hypotonic 3:4:2

Isosmotic 3:2:1 1/3 ～ 1/4

Sodium solution
1/3 Sodium
Hyperosmotic
solution
 C. Speed

physiological
Cumulated
Total volume need, losing
losing volume
continuing

24 h 8 ～ 12 h 12 ～ 16 h

8 ～ 10ml / kg /
－ 5ml / kg /h
h
 D. Shock volume expansion

Volume Solution Speed

2:1 or
20ml/kg 30 ～ 60min
1.4 ％ NaHCO3

Total volume ≤ 300ml

 Intravenous rehydration
 Principle
1 first rapidly secondly slowly
2 first sodium secondly glucose
3 Supply potassium after urination
4 Supply calcium and magnesium when tetany and c
onvulsion
Intravenous rehydration

 Fluid therapy in the first day

 1 Volume of fluid
 2 Composition of fluid
 3 Rapidity of therapy
A Initial phase B Repletion phase C Stabilization

 4 Correction of metabolic acidosis 、 hypokal

emia 、 Hypocalcemia and hypomagnesemia
Treatment of metabolic acidosis

Mild or moderate metabolic acidosis metabolic

acidosis: No special treatment

Severe metabolic acidosis ： 5%NaHCO3 1ml/kg

[HCO3-] level can increase about 1 mmol.
Treatment of hypokalemia not
iced
 Daily dosage of supplemental potassium is
3~4mmol/kg(200~300mg/kg)
 Concentration less than 0.3% by IV
 Transfusion duration more than 8 hours daily
 Avoiding IV push
 Supplement lasting 4 to 6 days
 Normal renal function (Supply kalium after urination urina
tion 6 hours of preadmission)
Treatment of Hypocalcemia and hy
pomagnesemia
　— 10% calcium gluconate5-10ml 　 dis
solved 　 10% glucose solution10-20ml in
travenous IV slowly ，平均 1ml/min 。
----25%magnesium sulfate 0.1mg/Kg eac
h time injection intromusculari in deep p
art ， once every 6h 。
Intravenous rehydration

 The second day

 1 Volume
 2 Solution
 3 Speed
 4 Correction of metabolic acidosis and hyp
okalemia
§ Supply what losed
 Drug therapy
 1 Control infection
 2 Micecological therapy
 3 Intestinal mucosa protective agent (protecta
nt)
 4 Avoid using antidiarrheal
 Control of infection
Etiologic treatment
 Virus infection
dietary therapy
supportive therapy
self-limited
 Bacteria ,fungus and parasite
specific antimicrobial therapy
 Control of infection
 Dietary 、 Virus and noninvasive bacteria diarrhea----
Need no antibiotics
 Invasive bacteria diarrhea---- Need antibiotics
 G+ coccus----penicillin, vancocin 万古霉素 ,
 rifampin 利福平
 G- bacillus---- 头孢曲松 ceftriaxone, 　 ofloxacin 氧氟
沙星　庆大霉素 cidomycin
 Fungus ---- 氟康唑 fluconazol 　
 Micoecological therapy
 Aim ： help recove the normal bacteria populatio
n in intestinal lumen, prohibit the pathogen perma
nent planting and invasion, control the diarrhea.
 Drug : 双歧杆菌 bacillus bifidus 　 bacillus acid
i-lactici 乳酸杆菌　粪链球菌 fecal streptococci,
　　需氧芽孢杆菌 aerobic spore-bearing bacilli,
　
Such as jinshuangqi mamiai
 Intestinal mucosa protective drug
can absorb the pathogen and toxin ， maintain
the absorb and secetory function of enterocyte
， prevent the attack of pathogen (montmorill
onite powder) 蒙脱石散．
 Avoid using antidiarrheal 　洛哌丁醇　　 i
nhibit gasenterokinesia, increase bacteria multi
plication and toxin absorption ， it is dangerio
u to infectious diarrhea.
 Treatment of prolonged and chron
ic diarrhea
1.Look fof cause positively
2. Disturbance of fluid ,electrolyte and acid-
base balance
3Dietary adjustment
4.Drug Supply microelement and vitamin ；
cautiously using antibiotics ； use micoecolo
gical therapy and intestinal mucosa protecti
ve drug
5.Chinese medicin
Prevention