DIARRHEA

Yati Soenarto
Child Health Department
Sardjito Teaching Hospital
 EPIDEMIOLOGY
• Worldwide:
leading cause of mortality of children under five:
4.6 million/yr (1982) ® 3.0 million/yr ® 2.5 million/yr (2002)
(Kosek et al, 2003)
• ASIA-WHO SEARO:
Other
ARI
19%
26%
HIV
1%

Perinatal Diarrhea
31% 17%

Measles Malaria
www.who.int.org www.who.int.or
4% 2%
g
 Causes of Mortality of Children in Indonesia

INFANTS UNDER FIVE CHILDREN

Nerve
system
problem Other ARI
3% 17% 23%
Other
Perinatal 35%
Tetanus
36%
3%
Diarrhea
Diarrhea 13%
9% Digestive
tract Typhoid Nerve
Digestive ARI problem system
tract 28% 11%
6% problem
problem
4% 12%

IDHS 2002-2003, HHS 2001

 EPIDEMIOLOGY
45% 40% ORS 2.50%
40%
2.0
35% MORTALITY 2.00%
30% MORBIDITY
25% 23% 1.50%
1.1 1.2
20% 1.1
16% 0.9
14% 1.00% 0.8
15%
10% 8%
0.50%
5%
0% 0.00%
1972 1980 1986 1992 1996 1983 1989 1990 1991 1996 2000
(National household survey, 1996) (National household survey, 2000)

Promotion of ORS and proper feeding to all sectors

Why is diarrhea dangerous?

DIARRHEA à DEATH due to LOST (& LACK) of:

• Water & electrolyte

• Food
 WHAT IS DIARRHEA?
• The passage of unusually loose or watery stools,
usually at least three times in a 24 hour period.

• Frequent passing of formed stool ≠ diarrhea.

(WHO, 2005)
 CLASSIFICATION
1. Based on duration :
• Acute diarrhea
starts suddenly ,may continue for several days.
• Persistent diarrhea
starts like acute diarrhea, lasts for >14 days

(WHO, 2005)
2. Based on pathopysiology :
Osmotic diarrhea
Caused by luminal substances that induced fluid
secretion

Secretory diarrhea
endogenous substances (“secretagogues”) induce
fluid secretion.
Physiology of fluid & electrolyte absorption
 1. Acute diarrhea
• Usually associated with infection of bowel.
• Etiology :

(Szajewska & Mrukowicz, 2005)

Study of enteric pathogens causing acute pediatric diarrheal diseases in Jakarta
& Jogjakarta hospitals, Indonesia, in collaboration with NAMRU2 research, 2005
 Rotavirus : An overview
• RV(+) most common in 6 – 23 months of age
– Breastfeeding protects rotavirus infection
– Support immunization should be given at the first year of
life
• Seasonal pattern occurred year-round
• Dehydration occurred in 90% cases of RV (+) à
potential death à costly
• This finding could be used to support the rationale
use of drugs – convincing health personnel & the
community
 Rotavirus : An Overview
• Strain:
q1970’s:G1,2.3,4 (G3 was the highest)
q 2004: G1,2,4;
q 2007: G1,2,3,4,9 (G9 was the highest).
• Antibiotics, anti-vomiting & anti-diarrhea were
still used in the community for RV diarrhea à
support scientific evidence on irrational use of
drugs
 Seasonal Distribution of Rotavirus
Patients
# Specimen tested (N=2517) % Rotavirus-positive patients (N=1435)
300 100
90
250
75 80
No. of specimen tested

positive patients
70 70 68
66 70
200 62 61
55 56 60

% RV-positive
150 47 50
42
34 36 40
33
100 28
30
20
50
10
0 0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2006 2007
 Age Distribution of Rotavirus
Patients
600 100
97 99 100
88 90
500
positive patients

80

Cumulative incidnece (%)

70
400
60
No. of RV-positive

300 52 50
40
200
30
16 20
100
3 10
0 0
00-02 03-05 06-11 12-23 24-35 36-47 48-59
Age group (month)

Rotavirus-positive patients Cumulative %

 Clinical Presentations
Clinical # RV-positive # RV- OR (95%CI)
presentations Diarrhea Negative
N:1435(%) Diarrhea
N:1089(%)
Vomiting 1219 (85) 718 (66) 2.9 2.4 – 3.5*

Dehydration 1297 (90) 863 (80) 2.4 1.9 – 3.0*

Mucus stool 399 (28) 347 (32) 0.8 0.7 – 0.97*

Bloody stool 24 (2) 62 (6) 0.3 0.2 – 0.5*

Fever 527 (37) 414 (38) 0.9 0.8 – 1.1

*p < 0.05
 2. Persistent Diarrhea
ETIOLOGY

• Global : the most important underlying trigger is an

acute diarrheal episode due to an enteric infection and
the consequences thereof.

• Bangladesh, 2001 : Persistent Diarrhea occurs in 23%

case of Shigellosis

(Bhutta, 2007)
Pathogens associated with persistent diarrhea

(Bhutta, 2007)
Pathway of Prolonged & Persistent Diarrhea

Bhutta, 2007
 Diarrhea in Clinical Practice
1. History Taking
• Feeding history
• Diarrhea manifestations :
— 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.

WHO Hospital Care for Children, 2006

2. Examinations
Look for:
§ signs of some dehydration or severe dehydration
§ blood in stool
§ signs of severe malnutrition
§ abdominal mass
§ abdominal distension.

WHO Hospital Care for Children, 2006

 3. Laboratory Investigation

• No need for routine stool cultures in children with acute

diarrhea

• Electrolyte levels : in children with features of hypernatremic

dehydration
Hypernatremic dehydration can result from
ingestion of hypertonic liquids or loss of hypotonic
fluid in the stool or urine

WHO Hospital Care for Children, 2006

 Classification of the severity of dehydration in
children with diarrhea
Classification Sign or symptoms Treatment
Severe Two or more of the following signs : Plan C
dehydration • Lethargy/unconsciousness rehydration
• Sunken eyes
• Unable to drink/drinks poorly
• Skin pinch goes back very slowly (> 2
seconds)
Some Two or more of the following signs : Plan B
dehydration • restlessness, irritability rehydration
• sunken eyes
• drinks eagerly, thirsty
• Skin pinch goes back slowly
No Not enough signs to classify as some or Plan A
dehydration severe dehydration rehydration
WHO Hospital Care for Children, 2006
 4 STEPS OF MANAGEMENT

1.ORT USING
ORS
REDUCED
OSMOLARITY

2.CONTINUED,
APPROPRIATE ZINC SUPPLM INCIDENCE &
NUTRITION
SEVERITY ¯

3.PHARMACOLOGIC
ANTIMICROBIAL

4.P-D COMMUNICATION NON--ANTIMICROBIAL

NON
 Reducing concentration:
1. New Lo-ORS -glucose 75 mmol/L
OUTCOME -sodium (NaCl) 75mEq/L
üthe need of IV therapy 33% -overall 245 mOsm/L
üstool output 20%
üvomiting 30%
WHO/UNICEF Joint Statement, 2004

AGE AMOUNT OF ORS AFTER AMOUNT OF ORS TO PROVIDE

EACH LOOSE STOOL FOR USE AT HOME

<12 MONTHS 5O-100 ml 400ml/DAY

1-4 YEARS 100-200 ml 600-800 ml/DAY

> 5 YEARS 200-300 ml 800-1000 ml/DAY
ADULT 300-400 ml 1200-2800 ML/DAY

200 ml: 1 SACCHETE

 Plan A rehydration :
• No need to referral.
• 4 rules of home treatment :
1. Extra fluids.
2. Continue feeding
3. Give zinc supplements.
4. Advise mother when to return

WHO Hospital Care for Children, 2006

 Plan B rehydration :
Amount of ORS given during first 4 hours :
Age Up to 4 months 4-12 months 12 months-2 years 2-5 years
Weight <6 kg 6-<10 kg 10-<12 kg 12-19 kg
In ml 200-400 400-700 700-900 900-1400

After 4 hours :
• Reassess the child & classify for dehydration.
• Select appropriate plan to continue treatment.
• Begin feeding the child in clinic

WHO Hospital Care for Children, 2006

 Plan C rehydration :
• Start IV rehydration immediately. Then continues with
ORS once child can drink.

First, give 30 ml/kg in Then, give 70 ml/kg in

< 12 months old 1 hour* 5 hours

>12 months old 30 minutes* 2 ½ hours
*Repeat again if radial pulse is still weak/undetectable

WHO Hospital Care for Children, 2006

2. Continued feeding
Improper beliefs
& lack of
knowledge

“Resting of
bowels”

Malnutrition

Brown, 2003
Ø CONTINUE BREAST FEEDING
Ø IF NO BF, CONTINUE THE PREVIOUS MILK.
<6MONTHS: FREQUENT SMALL FEEDING
Ø 6MONTHS/ >:
- PORRIDGE + NUTS, VEGETABLES,MEAT/FISH
+1-2 TEESPOON OIL
- FRESH FRUIT/BANANA (POTASIUM)
- FRESH FOOD; COOKED AND SOFT FOOD
- STIMULATE TO EAT, AT LEAT 6 TIMES
- DIARRHEA STOP: CONTINUE FEEDING + EXTRA
MEAL/DAY->2 WEEKS (WHO, 1997)
Breast feeding shortens the duration of acute
diarrhea, rotaviral diarrhea, and persistent
diarrhea (cit. WHO, 1997)

Early breast feeding (within the first 3 days of

life) reduces the risk of diarrhea in the first 6
months of life à due to the effects of human
colostrum (Clemens et al, 1999)
Micronutrients

• Zinc Supplementation
Zn the risk of continued diarrhea 23% children with acute
diarrhea (Sazawal et al., 1995)
Zn duration of disease (14%) and stool output (28%) in children
(Tomkins et al., 1997)

WHO/UNICEF recommendations (2004):

Infant – 6 month old : 10 mg/day (10-14 days)
Children older : 20 mg/day (10-14 days)
3. Pharmacologic

1. Antimicrobial drugs

Antimicrobial agents should not be used routinely.

• should be preceded by appropriate stool cultures
or pathogen detection tests.
• only few indications for empiric use , e.g.
suspected or confirmed shigellosis or cholera,
selected cases of inflammatory diarrhea, travelers’
diarrhea and diarrhea due to parasites).

(Szajewska & Mrukowicz, 2005)

3. Pharmacologic

2. Non-antimicrobial drugs
• Anti-diarrhoeal drugs and anti-emetics
have no practical benefits for children with acute or
persistent diarrhea.

• Antimotility drugs
potentially life-threatening adverse effects, including
lethargy, ileus, respiratory depression, & coma

(Szajewska & Mrukowicz, 2005)

4. COMMUNICATION

Definition (Pearson & Nelson, 2000):

The process of understanding
and sharing meaning.
Notes:
§ Communicare (Latin word): to share
§ A process : dynamic, ongoing, always
changing, continuous
 HEALTH PROFESSIONALS
NON-HEALTH
(Physician,PH,nurse,mid-
PROFESSIONALS
wife, dentist, pharmacist)
(administrative, finance)

HOSPITAL (others)
How to serve the community How to make money
(colleagues/team members) (competitors)

PATIENTS
 Communication Skills
• Listen to caregiver.
• Speak in easy to understand words.
• Help & encourage caregiver à don’t criticize
• Use teaching methods that encourage
caregiver’s participation.
 Fluids to replace loss

Components of
communication in Mixing & Giving ORS
treating diarrhea
Returning to health
provider
 Fluids
• Criteria: • Water
– Safe to give in large
amount • Soups, etc.
– Easy to prepare • Salt&sugar solution
– Acceptable
• New Lo-ORS
– Effective [in replacing
loss of fluid]

Notes:
-Importance of giving in sufficient amount
-Expiration date
-Age and feeding status
-Appropriate feeding
 Giving ORS
ØCHILD < 2 YEARS: GIVE 1 TEASPOON EVERY 1-
2 min.
ØOLDER CHILD: USE GLASS – GIVE SEVERAL
ØIF VOMIT: WITH 10 MINUTESà LESS FLUID (1
SPOON EVERY 1-2 MINUTES)
ØIF DIARRHEA STILL OCCURS; NO MORE ORS:
GIVE ALTERNATIVE FLUIDS OR VISIT HEALTH
PROVIDER
 When to Return ?

1. Very frequent passing of stool

2. Frequent vomiting
3. Increasing thirst
4. Not being able to feed and drink as
usual
 DYSENTERY

• Diarrhea with stools containing blood.

• Mostly caused by Shigella (bacillary
dysentery), thus, nearly all require
antibiotic.
1. Bacillary Dysentery

Introduction :
. Incidence : approx. 165 million/year, 163 million in
developing countries
• Mortality à 1,3 million.
• Highest prevalence : children aged of 1-4 year.
• Shigella infection is a major public health problem
in developing countries where sanitation is poor.
• Humans are the only natural reservoir.
Bacillary Dysentery
• Etiology :
Shigella sp.
Shigellosis is spread 4 groups : S. Dysentriae (grup A),
S. flexneri, (grup B), S. boydii (grup C) & S. sonnei (
Grup D).
• Transmission : fecal-oral transmission.
• Infectivity dose (ID) ® extremely low.
S.dysenteriae : 10 bacilli, S. sonnei or S. flexneri :100-
200 bacilli.
Bacillary Dysentery
• CLINICAL MANIFESTATIONS :

– Sudden onset of severe abdominal cramping,

high-grade fever, emesis, anorexia, large-volume
watery diarrhea.
– Abdominal pain, tenesmus, urgency, fecal
incontinence, and small-volume mucoid diarrhea
with frank blood may subsequently occur.
– Rectal prolapse may be occurs
 Bacillary Dysentery
TREATMENT :
• Oral antibiotic (for 5 days) that sensitive for
Shigella : Ciprofloxacin (10-15 mg/kg per dose,
given twice per day, p.o)

• Co-trimoxazole & ampicillin : not effective

anymore

WHO Hospital Care for Children, 2006

2. Amebic Dysentery
q Agentà Entamoeba hystolitica
q 2 form à
q Trophozoite àfragile, metabolically active:
potentially pathogenic form
q Cyst à hardy, infective, environmentally
resistant
q Mode of Transmission:
fecal-oral, by ingestion of cysts. Contaminated
food/water/person to person spread/sexual (e.g.:
oral-anal contact)
Life cycle of E. Hystolitica
Amebic Dysentery
CLINICAL MANIFESTATIONS :
Acute dysentery with fever, chills & bloody diarrhea, mild
abdominal discomfort cramps, tenesmus, bloody/mucous,
alternating with flatulence, loose stool or
constipation/remission

LABORATORY DIAGNOSIS
Microscopic ®Trophozoite or cysts in: stool, aspirates,
tissue or tissue scrapings.
• Differentiation of pathogenic E.histolytica from
nonpathogenic E.dispar : immunologic differences-based &
isoenzymes patterns & PCR
• Serologic tests : available as adjuncts for extraintestinal
amoebiasis Van Hal, et al., 2007
 Treatment of amoebiasis
Asymptomatic carriage (treat with luminal amoebicide ONLY)

Oral paromomycin* 500 mg three times daily for 7 days

Invasive disease (treat with tissue amoebicide and luminal

amoebicide)

Oral metronidazole 750–800 mg three times daily for 6–10 days

OR

Oral tinidazole 2 g once daily for 2–3 days (up to 10 days) and oral
paromomycin* 500 mg three times daily for 7 days

Van Hal, et al., 2007

CHOLERA
 CHOLERA
• Etiology : Vibrio cholerae
• V. cholerae à highly infectious, leading cause to
waterborne disease in the worldwide
• Mortality : 120.000 mortality/year (WHO, 2002)
• 1997à global CFR 4.3%, in Africa up to 20%.
• Pandemicà El Tor Biotype of V. cholerae , serogrup
O1à in South East Asia (1961)
• 1992à a new virulent V. Cholerae O139
 CHOLERA

• Route of infection : fecal-oral.

• Related to sanitation & hygiene problems. Usually
occurs in area with destroyed infrastructure facilities
due to natural disaster, war, etc..
• Very short period of incubation (2 hrs – 5 days) ®
potentially causes outbreaks
• Clinical manifestation :
Severe form & sudden onset of acute watery
diarrhea
(WHO, 2002)
 CHOLERA
Management :
• Managed as child with some or severe dehydration.
• Careful monitoring of dehydration is required.
• 80% case can be treated adequately by administration of
ORS. In severe dehydration : use IV rehydration
• Prescribe oral antimicrobials effective against local
strains of V. cholerae as soon as vomiting stops.
• Prescribe zinc supplementation as soon as vomiting stops
• Cholera vaccine?

WHO , 2007
 Cholera Vaccine
WC/rBS CVD103-HgR
q killed vaccine q live attenuated
q save for pregnant & V.cholerae
breast –feeding mother q Protective rate : 60-
q Protective rate :85- 100%
90%, after 3 years : 50% q well-tolerated by young
infant
Thank You