Dr.p.

natarajan

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• The passing of 3 or more watery or loose stools in a 24-hour
period. Normally, a young infant has approximately 5
mL/kg/day of stool output

• Acute diarrhea is defined as sudden onset of excessively loose

stools of >10 mL/kg/day in infants and >200 g/24 hr in older
children, which lasts <14 days.

• When the episode lasts >14 days, it is called chronic or

persistent diarrhea

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 Four types: Acute watery
Persistent
Dysentery
Diarrhea in a malnourished
child

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 Acute watery diarrhoea (including cholera):

 Lasts several hours or days:

 Dehydration,

 Acute bloody diarrhoea, (dysentery)

 Damage of the intestinal mucosa,

 Sepsis and

 Malnutrition

 Persistent diarrhoea, >14 days or longer:

 Malnutrition

 Diarrhoea with severe malnutrition

 severe systemic infection,

 Dehydration,

 high mortality 4
 4.6 million U5 children die of diarrheal diseases.

 19% of all deaths among children ages 0-4.

 85% occur in the first year of life.

 At least 3 episodes per year

 Diarrhea and malnutrition set a vicious cycle

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 Diarrhoeal diseases
(post-neonatal)
17% Other

diseases and
Acute
injuries
respiratory
13%
infections

19%
Malaria
More than half of under
five deaths associated 8%
with malnutrition

Measles

4%

Neonatal
HIV/AIDS
causes
3%
36%

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Bacterial, Viral, and
Parasitic Agents
 Rotavirus Giardia

 Enterotoxigenic E. Coli

 Shigellae

 Salmonellae Rotavirus
 Vibrio Cholerae

 Campylobacter jejuni

 Cryptosporidium E.Coli

 Protozoans

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 Feco oral transmission
Finger, Flea, Food, Fluid & Fomite

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 Rota virus, Shigella
and E.coli : Person to person

 Cholera : Food and water

 Salmonella and
camphylobacter : Food poison

 Clostridium difficile : Antibody associated

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 Toxin

 Invasion

 Osmotic

 Increased motility

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 Rota virus:
 Activates intracellular signal
transduction
 Inhibits Na, Cl coupled
transport
 Eflux of Cl
 E.Coli:
 Activates adenylate cyclase
 Increases intracellular cAMP
 Pumps out Na and Cl
 Shigella:
 Invasion, mucosal
destruction and exudation
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 EnteroToxicgenic EC:
 fimbrial adherence ; toxin
mediated chloride shift
 Entero Pathogenic EC:
 Adherence and effacement;
cell injury
 Entero Invasive EC:
 Shigella toxin; invasion cell
necrosis
 Entero Hemorrhagic EC:
 Hemolytic uremic syndrome
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 Osmotic :
 Eg: Lactose intolerance;
unabsorbed food produce
osmotic pressure to water
into lumen

 Motility disorder:
 Eg: Irritable bowel
syndrome

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 Age
 Measles
 Malnutrition
 Breast feeding
 Formula feeding
 Vit.A deficiency
 Zinc deficiency
 Race – lactase deficiency in caucasians
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The Five Human Races, Ethiopian. American. Caucasian. Mongolian. Esquimaux.

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  Failure to breast-feed exclusively for the first 4-6
months of life

 Using infant bottles

 Unsafe water

 Improper hand washing

 Open air defecation

Claeson, M., & Merson, M. 1990. Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9: 345-355.
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17
1. component of enzymes like :
carbonic unhydrase, alcohol dehydrogenase,
alkaline Phosphatase, carboxy peptidase,
superoxide dismutase etc.
2. Essential for insulin storage and secretion by b cells.
3. it is required for maintaining Vit A level in serum.
4. It is required for wound healing by unknown mechanism.
5. Gusten is a zinc containing protein and is important for taste
sensation.
6. Zinc plays important roles in growth and development, the
immune response, neurological function, and reproduction.
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 Improved absorption of water and electrolytes
by the intestine,

 Faster regeneration of gut epithelium,

 Increased levels of enterocyte brush border

enzymes,

 Enhanced immune response,

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 Prevent dehydration, if there are no signs of
dehydration;
 Treat dehydration, when it is present;
 Prevent nutritional damage, by feeding during and
after diarrhoea;
 Reduce the duration and severity of diarrhoea, and
the occurrence of future episodes, by giving
supplemental zinc.
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 No dehydration <5% <50 ml/kg

 Some dehydration 5-10% 50-100 ml/kg

 Severe dehydration >10% >100 ml/kg

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Parameter No dehydration Mild/some Severe

General condition Alert Irritable Lethargy

Skin turgor Good recoil Slow recoil Tenting

Eye signs Moist Dry Very dry

Tears + Less tears No tears
Not sunken Mildly sunken Deeply sunken
Urine output Normal Reduced Absent

Thirst No thirst Increased Absent

Pulse Normal Increased Rapid thready

AF Normal Sunken More sunken

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1. Poor feeding
2. Cyanosis
3. Abdominal distension
4. Loss of consciousness
5. Convulsions

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 90% no dehydration; self limiting

 9 %: some dehydration

 1 %: severe dehydration

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 Home care/Home available fluid (HAF)

 Oral Rehydration solution

 Zinc supplementation

 Nutritional support

 Probiotics

 Antibiotics

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 Continue breast feeding
 Give extra HA fluids
 Juices

 Buttermilk

 Rice water; coconut water

 Rice, cereal, dhal kanji

 Give more food

 ORS if available
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 Standard Reduced
Glucose (mmol/L) 111 75
Sodium (mmol/L) 90 75
Potassium (mmol/L) 20 20

Chloride (mmol/L) 80 65
Citrate (mmol/L) 10 10
Osmolarity (mmol/L) 311 245

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 No dehydration
 children under 2 years of age: 50-100 ml / per
episode
 children aged 2 up to 10 years: 100-200 ml/ per
episode
 older children : as much fluid as they want.
 Some dehydration:
 75 to 100 ml/kg in 4 hours
 Continue as in “ no dehydration”

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 Zinc:
 10 mg for <6m 20 mg for >6 m for 14 days
 Probiotics:
 Produce microbial lactase
 Competes with pathogenic bacteria
 Increase immune effect
 Provide acidity
 Protects cancer and allergy?
 Drugs:
 No benefits
 Co-trimoxazole in Cholera
 Nitazoxanide for Giardia ? Rota virus
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 Vomiting:
 Ondensitran 2 mg stratum

 Racecodotril:
 Enkephalinaze inhibitor

 Anti secretory

 Under evaluation

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 Treat shock:
 < 12 mo: 30 ml / kg NACL/RL in 1 hour

 >12 mo: 30 ml / kg NACL/RL in 30 minutes

 Treat dehydration:
 < 12 mo: 70 ml/kg GNS/RL for next 5 hours

 >12 mo: 70 ml/kg GNS/RL for next 2 ½ hours

 Maintenance:
 PMS 100 ml/kg/24 hrs
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1. Hyponatremia:
<130 m.eq/l: 3% Nacl for rapid correction
2. Hypernatremia:
>150 m.eq /l: ORS
3. Hypokalemia:
<3 m.eq/l: Iv potassium
4. Hyperkalemia:
> 6 meq/l: ORS
5. Acidosis: correct by IV soda bicarb
6. Alkalosis: ORS 33
 Shock kidney- ARF

 Intra cerebral thrombosis

 Hemolytic Uremic syndrome

 Hypoglycemia

 Paralytic ileus

 PEM

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 Electrolytes

 Stool microscopy

 Stool culture

 Stool Reducing substance

 CBC

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 Breast Feeding
 Improved weaning
practices
 Proper use of water
 Hand washing
 Disposing feces
properly
 Effectiveness of
measles vaccination

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 “Super-ORS”
 Rotavirus vaccine

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1. It increases shelf life,
2. Improves taste,
3. Cheaper,
4. No soiling of pockets.
5. Bircarbonate is hygroscopic and absorbs moisture
and get spoiled on storage

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1. Does not decrease stool volume
2. Does not decrease frequency
3. Does not decrease severity
4. Does not stop diarrhoea
5. Potential risk of hypernatremia in children with non
cholera diarrhoea
6. May provide too much Sodium to edematous children

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1. Reduction in need for IV therapy (35% in meta
analysis)

2. Significant reduction in vomiting (30%)

3. Reduction in stool output (20%)

4. Reduction in duration of diarrhoea

5. No risk of hyponatremia

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