Diarrhea in children DrAzad A Haleem AL.Mezori U ‘Duhok niversity Of Faculty of Medical Science School Of Medicine 20ie SEDIARRHEA DEFINITION The normal frequency and consistency of bowel movements varies with a child's age and diet and the definition of diarrhea varies accordingly. Diarrhea ; excessive loss of fluids & electrolytes in stool, Increase in liquidity. loose or watery stools, excessively frequent stools, or stools that are large in volume. Amore exact definition is excessive daily stool liquid volume (>10 mL stool/kg body weight/day).Frequency — It is normal for young infants to have up to 3 to 10 stools per day, although this varies depending upon the child's diet (breast milk versus formula; breastfed children usually have more frequent stools). Older infants, toddlers, and children normally have one to two bowel movements per day. Diarrhea can usually be defined as an increase in stool frequency to twice the usual number per day in infants, or three or more loose or watery stools per day in older children.* Consistency and color — The consistency and color of a child's stool normally changes with age, which highlights the importance of knowing what is normal for your child. Young infants, especially those who are breastfeeding, usually have soft stools. Their stools may be yellow, green, or brown, and/or appear to contain seeds or small curds. * All children's stools can vary as a result of their diet. Development of stools that are runny, watery, or contain mucus is a significant change that should be monitored. The presence of visible blood or black stools is never normal and always requires medical attention.alten cde ups v Young age groups ¥ Immune deficient individuals v Measles Y Malnutrition ¥ Travel to endemic areas v Lack of breast feeding v Exposure to unsanitary conditions v Attendance to child care centers v Poor maternal educationCauses and risk factors * Microbial, + Host and + Environmental factors interact to cause GE f \ Environmental Diarrhoea pathogensDiarrhea Classification * According to Pathogens. * According to Duration. * According to Mechanism of Diarrhea. * According to clinical types of Diarrhea.DIARRHEA CAUSES infective, non-infective The most common cause of acute diarrhea is a viral infection. Other causes include: bacterial infections, side effects of antibiotics, and infections not related to the gastrointestinal (GI) system. In addition, there are many less common causes of diarrhea.Diarrhea according to Duration * Acute diarrhea last<14days. * When episode last >14days it is called chronic or persistent diarrhea.Mechanisms of diarrhea * Osmotic: e.g Lactose intolerance * Secretory: e.g Cholera * Mixed secretory-osmotic: e.g Rotavirus * Mucosal inflammation: e.g Invasive bacteria * Motility disturbanceClinical types of diarrhea Q There are 2 main clinical types of AD Q Each is a reflection of the underlying pathology and altered physiology teeter pees Counc ea DOU en uC Re oe a a Le ue This is the most commen, Itis of recent onset. Rotavirus, Vibrio cholera diarrhoea commencing usually within 48 hours of presentation. It ‘is usually self limiting and mast episodes subside within 7 days. The main complication is detydration. ‘Acute bloody ‘Also referted to as dysentery. This is the passage of Shigella spp, Entamoeba aiaphben bloody stools, It is as @ result of damage to the histolytica intestinal mucosa by an invasive organism. The ‘complications here are sepsis, HUSthemolytic uremic syndrome), malnutrition and dehydration,PAN AW ABOU e) The evaluation of diarrhea in children who do seek medical evaluation requires a careful review of: Medical history, a Physical examination, and Diagnostic testing. The clinician will perform a thorough examination because there are some infections unrelated to the bowels (such as an ear infection) that can cause diarrhea. Many tests are available to diagnose the cause of diarrhea and to determine the severity of dehydration, although most children will not require testing.Assessment of the child with diarrhoea Ohistory = Ask the mother or other caretaker about: ¥ Duration of diarrhoea; Y Presence of blood in the stool; ¥ Number of watery stools per day; ~ Number of episodes of vomiting; ¥ Presence of fever, cough, or other important problems (e.g. convulsions, recent measles); Y Pre-illness feeding practices; ¥ Type and amount of fluids (including breast milk) and food taken during the illness; ¥ Drugs or other remedies taken; ¥ Immunization history.Clinical assessment OPhysical examination: ¥ General appearance v Hydration Status v Systemic Examination ¥ Extra intestinal manifestationsDegree of dehydration NO DEHYDRATION SOME DEHYDRATION — SEVERE DEHYDRATION Symptoms _| (<39% less of body weight) | (3-946 loss of body weight) | (>9% loss ofiody weight) Mental status Well; alert Normal, fatigued or restless, | Apathetic, lethargic, unconscious initable Thirst Drinks normally; mightrefuse | Thirsty; eager to drink Drinks poorly; unable to drink liquids Heart rate Normal | Normal to increased Tachycardic; bradycardic in severe | cases Quality of pulses | Normal Normal to decreased | Weak, thready, or impalpable Breathing Normal Normal; fast deep Eyes Nommal Slightly sunken | Deeply sunken Tears Present Decreased Absent | Mouth and tongue | Moist Dry | Parched Skin fold Instant recoil Recoil in <2 seconds Recoil in >2 seconds | Capillary rfl Normal Prolonged Protonged; minimal Extremities Warm Cool Cold; mottled; cyanotic Urine output Nommal to decreased Decreased Minimal 4.Laboratory investigations 1) STOOL: MICROSCOPY : low sensitivity & specificity a) leucocyte (>10/hpf )- Invasive diarrhea b) RBC ,ova,Trophozoite or cyst. c) culture & sensitive - persistent diarrhea Il) BLOOD TESTS a) CBC b) S. electrolyte c) BUN & creatinine MI)GUE IV) Others: Tests for specific diagnoses : should he sent \ when appropriate, Toni as ae antibo dy tests or cl Ic Isease or col onoscopy for atdays UC Atria 3 actose restriction or several days is helpful to ule e out actose into! erance, or a more specifi ic test, suc actose breath hydrogen analysis, can be performed.> Treating dehydration is the corner stone in managing diarrhea.(Oral rehydration therapy) > Feeding: Continue Breast feeding and routine normal diet and energy dense feeds. > Hand washing after defecation & before meal alone can reduce 40% of water & excreta related disease > Drug therapy has very little place Antibiotic Antisecretory Antimotility. » Follow-up to ensure recoveryTreatment : home therapy to prevent dehydration and malnutrition Children with no signs of dehydration need extra fluids and salt to replace their losses of water and electrolytes due to diarrhoea. If these are not given, signs of dehydration may developComposition of standard and reduced osmolarity ORS solutions Standard ORS Reduced ORS solution solution (mEq or mmol/l) (mEq or mmol/l) Glucose 111 7s Sodium 90 75 Chloride 80 65 Potassium 20 20 Citrate 10 10 Osmolarity 311 245The advantages of this new reduced osmolarity ORS ET) ite) * It reduces stool output or stool volume by about 25% when compared to the original WHO-UNICEF ORS solution * It reduces vomiting by almost 30% * It reduces the need for unscheduled IV therapy by more than 30%.Management | Bes Plain water coffee coconut water aerated cold drinks plain buttermilk fruit juice(with sugar milk Lassi(with sugar) thin dal fruit juice(without sugar) Lassi(without sugar)| warning signs Take the child to a health worker if there are warning signs of dehydration or other problems * The child does not get better in three days. * Starts to pass many watery stools; ¢ Has repeated vomiting; ¢ Becomes very thirsty; lethargy, poor urine output ¢ Is eating or drinking poorly; * Develops high fever; * Has blood in the stool;Indications for IV therapy: 1. Depressed level of consciousness. 2. Moderate dehydration when there is no improvement after the firs 4 hours of treatment with ORS. 3. Severe dehydration Uncontrolled vomiting, poor urine out put 5. Patients unable to drink from extreme fatigue, stupor, or coma 6. Patients with Abdominal distention.Composition of IV solutions: Composition of IV solutions: Baste etal Dr 1S iE Ca | Lactate NS (0.9% Nach En: ses Ve NS (0.45 NaC) DENT er ven) Bitola oa eteie-te aZinc in Diarrhea Zinc deficiency is common in developing countries and zine is lost during diarrhea Zinc deficiency is associated with impaired electrolyte and water absorption, decreased brush border enzyme activity and impaired cellular and humeral immunity . Treatment with zinc reduces the duration and severity of AD and also reduces the frequency of further episodes during the subsequent 2-3 months WHO recommends that children from developing countries with diarrhea be given zinc for 10-14 days 10mg daily for children <6 months 20 mg daily for children >6 monthsProbiotics in the Treatment of TET) Mechanisms: 1. Protect the intestine by competing with pathogens for attachment. 2. Strengthening tight junctions between enterocytes 3. Enhancing the mucosal immune response to pathogens.Indicated only for : * Acute bloody diarrhea with gross blood * Severe invasive bacterial diarrhea e:g Shigella * Cholera, * Associated systemic infection * Severe malnutrition. * Giardiasis ,Entamoeba hitolytica * Suspected or proven sepsis * Immuno compromised children rome (HUS)oooo0oo0aqo 0 00 00 Dehydration. electrolyte disturbance. Base deficit acidosis. Malnutrition Persistent diarrhea Toxic illus Renal Failure. Hus(hemolytic uremic syndrome) DIC Convulsion Cerebral damage and cerebral venous thrombosis.ie Ceca itd &complications Reactive arthritis :Salmonella ,shigella , Yersinia, C.difficile campylobacter. Guillain-Barre Syndrome: campylobacter. Glomerulonephritis:Shigella , campylobacter Yersinia IgA nephropathy :campylobacter Erythema nodosum: Yersinia ,campylobacter, salmonella Hemolytic anemia : Yersinia ,campylobacter HUS(hemolytic uremic syndrome): shigella , E. coli Focal infections e:g: UTI,Pneumonia,osteomylitis, meningitis ...(parantral diarrhea).How can we prevent diarrhoeal disease? This involves intervention at two levels: Primary prevention (to reduce disease transmission) Rotavirus and measles vaccines Hand washing with soap Providing adequate and safe drinking water Environmental sanitation Secondary prevention (to reduce disease severity) Promote breastfeeding Vitamin A supplementation Treatment with zincFat AC)