Acute diarrhea

Duration is less than 2 weeks

Definition: Increase frequency or water content of stool
It is responsible for 18% of all childhood deaths
Causes of diarrhea:
 Microorganism
 Feeding error
 Parental
 Toxins
 Drugs
Microorganism:
 E. coli
 Giardia lamblia  Rota virus
 Cholera
 Entameba histolytica  Adenovirus
 Bacillus
 Trichinella spiralis  Parvovirus
 Brucella
 Toxoplasma gondii  Calicivirus
 Shigella
 Cyclospora  Astrovirus
 Salmonella
 Cryptosporidium  Hepatitis A virus
 Campalylobacter
 Angiostrongylus
 Clostredium botulinum
 Staphylococcus aureus

Toxins: Feeding error: Parental:

 Tin  Wrong start  Urinary tract infection
 Zinc  Wrong weaning  Pneumonia
 Nitrite  Food allergy  Tonsillitis
 Copper  Overfeeding  Otitis
 Arsenic  Starvation
 Fluoride
 Thallium
 Mercury
Drugs:
 Cadmium Predisposing factors for diarrhea:
 Antibiotics
 Mushroom  Antifungal  Environmental contamination
 Shellfish toxins  Exposure to enteropathogens
Types of diarrhea:  lack of exclusive breast-
 Osmotic feeding
 Secretory  Immune deficiency
 Motility-related  Malnutrition
 Inflammatory  Young age
WHO clinical classification of diarrhea:  Measles
 Acute watery diarrhea   Vit.A
 Acute bloody diarrhea  Zinc
 Chronic diarrhea
Complications:
Acute diarrhea: Persistent diarrhea > 14 days:
 Electrolyte disturbances  Malnutrition
 Persistent diarrhea  Bacteremia
 Dehydration  Infections
 Septicemia
 ATN
 HUS

Management of diarrhea:
 Prevention of dehydration
 Replacement of loss Indication of antibiotic:
 Continue feeding  Severe dehydration
 Probiotics  Bloody diarrhea
 Zinc  High fever
Degree of dehydration:
 Mild : lost 5% of TBF
 Moderate: lost 10% of TBF
 Severe: lost 15% of TBF
WHO classification of degree of dehydration:

Severe Moderate Mild

Lethargic Irritable Normal
Sunken eyes Sunken eyes
Unable to drink Thirsty or drink eagerly Thirsty
Skin pinch goes back very Skin pinch goes back very No enough signs to classify
slowly > 2 sec slowly > 2 sec as severe or moderate

Assessment of degree of dehydration:

Severe Moderate Mild

Infant 15% 10% 5%
Adolescent 9% 6% 3%
Infants/young Drowsy, limp, cold, sweaty, Thirsty or drink eagerly Thirsty,
children cyanosed+/- comatose alert,
restless
Older children Usually conscious (but at Skin pinch goes back Thirsty,
reduced level), very slowly > 2 sec alert
apprehensive; cold, sweaty,
cyanotic extremities;
wrinkled skin on fingers and
toes; muscle cramps
Treatment of dehydration:
 ORS for mild& moderate dehydration
 ORS for replacement of ongoing loss
 IVF for severe dehydration
 IVF for frequent vomiting
Oral rehydration therapy:
ORS: Oral rehydration solution
Pedialyte: More KCL
Re-So-Mal: Rehydration solution for malnutrition
Other home rehydration fluids:
 Home ORS: 5 table spoons sugar
1/2 table spoon salt
1 liter water
+/-banana or papaya or orange juice
 Rice water+ Salt+ lemon
 Cereals+ Yoghurt+ Water
 Carrot juice
 Light tea
 Banana
Replacement of ongoing loss by ORS:
 Alternative water& ORS for bottle feed babies
 One by one for breast feed babies
 Stop if periorbital edema
 Stop if diarrhea stop
Indication of IVF:
 Severe dehydration
 Uncontrollable vomiting
 Gastric or intestinal distention.
 Unable to drink because of extreme fatigue, stupor, or coma.
Indication of antibiotic therapy:
 Bloody diarrhea
 Fecal leukocytes
 Hemolytic-uremic syndrome
 Immunosuppressed children
After C/S:
 TMP 10 mg/kg/d and 50 mg/kg/d of SMX bid × 5 d
 Ampicillin PO, IV 50–100 mg/kg/d qid × 7 d
 Ciprofloxacin PO 20–30 mg/kg/d bid × 7–10 d
 Azithromycin PO, 5–10 mg/kg/d qid × 5 d
 Metronidazole PO 30–40 mg/kg/d tid × 7 d
Additional therapy:
 Antimotility agents (loperamide) are contraindicated in children with dysentery and probably
have no role in the management of acute watery diarrhea in otherwise healthy children.
 Antiemetic agents (Phenothiazine) are of little value and are associated with potentially serious
side effects.
 Ondasterone a single sublingual dose of an oral dissolvable tablet
 Prevention:
 Promotion Of Exclusive Breast-feeding.
 Improved Complementary Feeding Practices.
 Rotavirus Immunization.
 Improved Water And Sanitary Facilities.
 Promotion Of Personal And Domestic Hygiene.
 Improved Case Management Of Diarrhea.
WHO method for correction of no dehydration plan A:
 Extra-fluid
 Continue feeding
 ORS after each loss:
10 ml / motion & 5 ml / vomitus
WHO method for correction of some dehydration plan B:
 ORS:
 75 ml/kg/ 4 hours
 Reassessment of dehydration
 Resume feeding once patient is able
Or RL same amount if patient developed distension or frequent vomiting
WHO method for correction of severe dehydration plan C:
RL 100 ml/kg Infants Children
Shock 30 ml/kg Over 1 hour Over 30 min
Deficit 70 ml/kg Over 5 hours Over 2.5 hours

Enteral feeding:
 Once rehydration is completed, food should be reintroduced while oral rehydration can be
continued to replace ongoing losses from emesis or stools and for maintenance.
 Breast-feeding or nondiluted regular formula should be resumed as soon as possible.
 Foods with complex carbohydrates (rice, wheat, potatoes, bread, and cereals), lean meats,
yogurt, fruits, and vegetables are also tolerated.
 Fatty foods or foods high in simple sugars (juices, carbonated sodas) should be avoided
Other drugs:
Probiotic:
 Normal flora orally to enhance GIT immunity against other foreign organisms
 Lactobacillus
 Bacteroides
Zinc orally:
 < 6 months 10 mg/day for 10-14 days
 > 6 months 20 mg/day for 10-14 days

Types of dehydration:
Hyponatremic dehydration: S. Na < 125 mEq/L
It is due to plan water intake
Signs of dehydration mainly in skin
The patient is lethargic, brain edema, herniation& death
Hypernatremic dehydration: S. Na > 145mEq/L
Due to lack of fluid intake
Signs of dehydration mainly in tongue
The patient is irritable, Rapid correction will lead to cerebral edema, brain herniation and death
Isonatremic dehydration:
Loss of both fluid& electrolytes
Signs of dehydration all over the body
IVF Rehydration:
 A child with thready pulse should be corrected for shock therapy
 A child who has GIT losses should have these losses replaced with replacement solution
 The child should also receive an appropriate maintenance fluid
Method of fluid therapy for GIT loss:
Replace intravascular loss:
20 ml/kg normal saline or ringer lactate over 20 min
Repeat as needed.
Rapid volume repletion:
20 ml/kg normal saline over 2 hours
Replace intracellular loss:
Deficit+ maintenance
Subtract ( isotonic fluid from total)
Administer ½ Saline+ 5% Dextrose+ 20 mEq/L Potassium
Replace ongoing loss:
ORS or IVF: 10 ml/kg/motion& 5 ml/kg/vomiting
Monitoring therapy:
Vital signs:
HR, BP, RR
Input& output:
Fluid balance, UOP& bowel motion
Physical examination:
Clinical signs of dehydration& weight