By

GAMAL A. EL. AZAB.,PhD.

 introduction Rehydration Antimicrobial

Adjunctive
etiology management
drugs

pathophysiology malnutrition

Clinical types dehydration

2
Introduction

 Infantile diarrhea is one of the most

common diseases in infants and
toddlers. It is not a definitely disease
but a syndrome caused by infectious
and non infectious factors.

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Introduction

 Clinical manifestations are mainly diarrhea

and vomiting, in severe cases it usually
associated with dehydration and electrolyte
and acid base disturbances.

4
Major causes of death among
children under five in developing
countries, 2014
Sales

Acute respiratory
infection
23% 18% Malaria
5% 10%
HIV/AIDS
15%
25% 4%
Other

Diarrhea

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Nomenclature:
Diarrhea Or Enteritis

 Diarrhea caused by other infectious agents and

unknown pathogens may all be named “enteritis”
and should be defined with the name of the specific
pathogen. Such as enteropathogenic E. Coli.
enteritis, rotavirus enteritis.

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Predisposing age
 Peak incidence occurs in infants under two to three
years of age. Especially under one year, which
account for about half of the patients.

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Prevalent seasons

 Bacterial enteritis is most prevalent

in summer.
 Viral enteritis in autumn and
winter months but they may be
occur all year round.
 Noninfectious diarrhea may occur
at any season.

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Predisposing Factors

Immature
digestive
Rapid
function growth

Disturbed
Poor
enteric
immune
bacterial
function
flora

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Etiology
Non
infective Infective

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Etiology

 Extraintestinal infections acute infectious diseases

may be associate with diarrhea and vomiting.
 Antibiotic-associated diarrhea.

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Pathophysiology
 diarrhea occurs when
intestinal fluid output
overwhelms the
absorptive capacity of
gastrointestinal tract

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Pathophysiology
osmotic secretory Effusive

release of toxins invasive

damage to the that bind to pathogen invades
villous brush specific and multiplys
border of the enterocyte within intestinal
intestine→ receptors mucosa
malabsorption of →release of →inflammatory
intestinal chloride ions into changes
contents. the intestinal →WBC,RBC
lumen. increase in stools.

rotavirus ETEC EIEC

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Clinical types
acute watery
hours or days dehydration
diarrhoea

damage of intestinal
acute bloody also called mucosa,sepsis,
diarrhoea dysentery malnutrition

persistent
14 days or longer malnutrition
diarrhoea
diarrhoea dehydration, and
severe systemic
with severe infection, heart failure
vitamin and mineral
malnutrition deficiency
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Malnutrition
Using midarm circumference to detect
Malnutrition

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Malnutrition

 Diarrhoea is, in reality, as much a nutritional disease

as one of fluid and electrolyte loss.
 Children who die from diarrhoea, despite good
management of dehydration, are usually
malnourished and often severely so.

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Malnutrition

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Malnutrition
 This vicious circle can be broken by:
 continuing to give nutrient rich foods during and after
diarrhoea;
 giving a nutritious diet, appropriate for the child's age,
when the child is well.

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Excessive Loss of Water and Electrolytes

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Dehydration
signs

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Dehydration severity
Hydration 0-5% Dehydration 5-10% 10% or More
Dehydration

(Mild) (Moderate) (Severe)

General Well Restless Lethargic
Fontanel Slight depression depression Deep depression

Eyes Normal Sunken Very sunken

Tears Present Absent Absent
Mouth Moist Dry Very dry
Skin Pinch retracts Pinch retracts Pinch stays folded
immediately slowly
urine present oligouria anuria
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Rehydration
Oral rehydration solutions
(ORS) are specifically
designed fluids that contain
an appropriate amount of
sodium, glucose and other
electrolytes and are of the
appropriate osmolality, to
maximise water absorption
from the gut.

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Rehydration
 They use the principle of glucose-facilitated sodium
transport whereby glucose enhances sodium and secondarily water transport
.
across the mucosa of the upper intestine

 The sodium and glucose concentrations and the

osmolality are of vital importance.

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Rehydration
 When assessing dehydration it is important to
consider:

Degree of Maintenance Ongoing

dehydration fluid losses
(deficit) requirements

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Rehydration
 Minimal or no dehydration
 Rehydration therapy - Not applicable
 Replacement of ongoing losses
 Less than 10 kg body weight - 60-120 mL oral rehydration
solution for each diarrhea stool or vomiting episode
 More than 10 kg body weight - 120-140 mL oral rehydration
solution for each diarrhea stool or vomiting episode

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Rehydration
 Mild-to-moderate dehydration
 Rehydration therapy - Oral rehydration solution (50-
100 ml/kg over 3-4 h)
 Replacement of losses
 Less than 10 kg body weight - 60-120 mL oral rehydration
solution for each diarrhea stool or vomiting episode
 More than 10 kg body weight - 120-140 mL oral rehydration
solution for each diarrhea stool or vomiting episode

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Rehydration
 Severe dehydration
 Rehydration therapy - Intravenous lactated Ringer solution
or normal saline (20 mL/kg until perfusion and mental
status improve), followed by 100 mL/kg oral rehydration
solution over 4 hours
 Replacement of losses
 Less than 10 kg body weight - 60-120 mL oral rehydration solution
for each diarrhea stool or vomiting episode
 More than 10 kg body weight - 120-140 mL oral rehydration
solution for each diarrhea stool or vomiting episode
 If unable to drink, administer through nasogastric tube or
intravenously administer 5% dextrose (one fourth normal saline) with
20 mEq/L potassium chloride

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Rehydration
 At completion of hydration,
resumption of feeding is strongly
recommended.
 children with gastroenteritis
should be returned to a normal
diet as rapidly as possible.
 Early feeding reduces illness
duration and improves nutritional
outcome.

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New trends ORS
 New research suggests that polymer-
based ORS, made from complex
carbohydrates such as rice, wheat,
or maize, may reduce stool output
and length of diarrhea compared with
glucose-based ORS.

 With these solutions, carbohydrates are slowly

digested in the small intestine, releasing glucose to
facilitate sodium uptake without adding a significant
osmotic load to bowel contents

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Antimicrobial
 Since the majority of cases of acute
gastroenteritis in developed and
developing countries are due to viruses,
 antibiotics are generally not indicated
 antibiotics may prolong the carrier state
(Salmonella infection) antibiotics suppress the
“protective effect” of endogenous flora + resistance
 may increase the risk of developing
hemolyticuremic syndrome
(enterohemorrhagic Escherichia coli
infection).
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Antimicrobial

 In patients with positive stool assays or high clinical

suspicion for C.difficile infection, the offending
antibiotic should be stopped immediately.

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Antimicrobial when?
 The diseases for which antimicrobials
should be given
 Cases of bloody diarrhoea (dysentery).
 Suspected cases of cholera with
severe dehydration.
 Laboratory proven, symptomatic
infection with Giardia duodenalis

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Antimicrobial when?
 All severely malnourished children should
receive broad spectrum antimicrobial treatment,
e.g. gentamicin and ampicillin.

 When diarrhoea is associated with another acute

infection (e.g. Pneumonia, UTI), that infection
also requires specific antimicrobial therapy.

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Cause Antibiotic(s) of choice Alternative(s)

Cholera Tetracycline Erythromycin

Children: 12.5 mg/kg Children: 12.5 mg/kg
4 times a day x 3 days 4 times a day x 3 days

Shigella dysentery Ciprofloxacin Ceftriaxone

Children: 15 mg/kg Children: 50-100 mg/kg
2 times a day x 3 days once a day IM x 2 to 5 day

Amoebiasis Metronidazole Nitazoxanide oral

Children: 10 mg/kg suspension (age 1-3 y: 100 mg
3 times a day x 5 days (10 PO q12h for 3 days; age 4-11 y: 200 mg

days for severe disease) is as

PO q12h for 3 days)
effective as metronidazole
and has the added benefit
of treating other intestinal
parasites, such as
Giardiasis Metronidazole
Cryptosporidium
Children: 5 mg/kg
3 times a day x 5 days
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Antimicrobial 

 Streptomycin
 Neomycin → destruction of microvilli 3days
 Halogenated hydroxyquinolines→ neurotoxic
 Nonabsorbable sulfonamides and other sulfa
containig drugs. → allergic reaction.

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Vaccines
 Rotarix(rota virus vaccine)
was efficacious in a large
study, which reported that
Rotarix protected patients
with severe rotavirus
gastroenteritis and
decreased the rate of severe
diarrhea or gastroenteritis of
any cause.

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Zinc
 The World Health Organization (WHO)
recommends zinc supplementation (10-20
mg/day for 10-14 days) for all children younger
than 5 years with acute gastroenteritis

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Probiotics
 Probiotics are live microbial feeding
supplements commonly used in the
treatment and prevention of acute
diarrhea.
 Mechanisms of action
 Synthesis of antimicrobial
substances,
 Competition with pathogens for
nutrients,
 Modification of toxins,
 Stimulation of nonspecific immune
responses to pathogens.

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Adsorbents
 (e.g. kaolin, attapulgite, smectite, activated charcoal,
cholestyramine).
 These drugs are promoted for the treatment of
diarrhoea on the basis of their ability to bind and
inactivate bacterial toxins or other substances that
cause diarrhoea, and their claim to "protect" the
intestinal mucosa.
 None, however, has proven practical value in the
routine treatment of acute diarrhoea in children.

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Bismuth subsalicylate.
 When given every four hours, it is reported to
decrease stool output in children with acute
diarrhoea by about 30%.
 Salicylate ??

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Antimotility drugs
 (e.g. loperamide hydrochloride, diphenoxylate with
atropine, tincture of opium, camphorated tincture
of opium, paregoric, codeine).
 These opiate or opiate like drugs and other
inhibitors of intestinal motility may reduce the
frequency of stool passage in adults.
 However, they do not appreciably decrease the
volume of stool in young children.

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Antimotility drugs
 They can cause severe paralytic ileus, which can
be fatal.
 Prolong infection by delaying elimination of the
causative organisms.
 Sedation may occur at usual therapeutic doses
and fatal CNS toxicity has been reported for
some agents.
 None of these agents should be given to infants or
children with diarrhoea.

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Antiemetics.
 These include drugs such as prochlorperazine and
chlorpromazine, which cause sedation that can
interfere with ORT.
 For this reason antiemetics should never be given to
children with diarrhoea. Moreover, vomiting stops
when a child is rehydrated.

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Cardiac stimulants.
 Shock in acute diarrhoeal disease is caused by
dehydration and hypovolaemia.
 Correct treatment is rapid IV infusion of a balanced
electrolyte solution.
 The use of cardiac stimulants and vasoactive drugs
(e.g.adrenaline, nicotinamide) is never indicated.

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Blood or plasma.
 Blood, plasma or synthetic plasma expanders are
never indicated for children with dehydration due to
diarrhoea.
 These children require the replacement of lost water
and electrolytes.
 These treatments are used,however, for patients
with hypovolaemia due to
septic shock.

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Table 2. Summary of new evidence on the management of acute gastroenteritis
in children
Remains central to the management of children with AGE. Efforts to improve the taste and/or
Oral efficacy of ORS continue, and some interventions are promising.
rehydration
While standard (over 24 h) nasogastric rehydration is still being used, new evidence confirms that
Nasogastric rapid (over 4 h) nasogastric rehydration is also effective.
rehydration
New evidence is available regarding rapid or ultrarapid and large-volume vs. standard-volume
Intravenous rehydration. As the new evidence is not consistent, until more data are available, the administration
rehydration of 20 ml/kg is appropriate.

Ondansetron reduces the risk of vomiting in young children with AGE, but there is no evidence to
support the use of other antiemetics. The FDA recommends electrocardiogram monitoring of the QT
Antiemetics interval in patients receiving ondansetron.

Evidence from one study in Europe, where zinc deficiency is rare, confirms no benefit from the use
Zinc of zinc.

Data, mainly from outside of Europe, have reconfirmed that racecadotril may be an effective
Racecadotril adjunctive therapy to oral rehydration.

Data, mainly from outside of Europe, have reconfirmed that smectite may be an effective adjunctive
Smectite therapy to oral rehydration.

Certain probiotics, such as Lactobacillus GG or S. boulardii, are useful. It is likely that many more
probiotics are effective; the current lack of clear evidence of efficacy does not mean that future
clinical research will not establish significant health benefits for other probiotics (single or in
Probiotics combination). The same applies to synbiotics
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J.M. is a 15 month old, 8.5kg female was admitted to Tanta
Univeristy Hospital complaining of diarrhea and vomitting.

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Subjective
 Problem list:
 Diarrhea: (frequency : 6 times/day - increased fluidity-
offensive odor – no blood in stool)
 Vomiting (vomit after eating or drinking)
 Loss of apetit
 No fever
 She had these symptoms since two weeks,
 she took metronidazole ,smecta with no response.

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Objectives
 Signs :
 Slightly sunken eyes
 Skin pinch retract slowly
 Sticky toung
 Normal tears
 Urine present
 Which indicates mild dehydration

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Objectives
CBC
Hb 12.4 g/dl 10.0-13.5

3.7 Million/cmm 3.70 – 5.30

RBCs count
Platet count 229,000 /cmm 150,000-400,000

Total WBCs 9100 /cmm 6000-11000

Neutrophils 25% 15 - 45%

Lymphocytes 60% 45 - 76%

Monocytes 8.9% 2 - 8%

Esinophils 1 1- 6 %
0
Basophils 0-1%
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Objectives
Liver profile
Billirubin total 0.90 mg/dl 0.00 -1.00

Bilirubin indirect 0.7 mg/dl Up to 0.75

Bilirubin direct 0.2 mg/dl Up to 0.25

AST 25 U/L <35

ALT 18 U/L <37

Albumin 3.3 g/dL 3.5 – 5.0

Total protien 6 g/dL 6 -8

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Objectives
Renal
Serum 0.7 Mg/dl 0.2-1.2
creatinine
BUN 10 Mg/dl <40

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Objectives
Stool analysis
Color Brown
Cosistency Soft
Blood Nil
Mucus Nil
Worms Nil
Pus cells 2-4
Red cells 1-2
Ova Nil
protozoa Nil
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Assesment
 Persistant diarrhia with mild dehydration and
malnutrition.
 Given iv saline to correct dehydration.

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Assesment
Day 1
 Cefotax (ceftriaxon) IV 400
mg /12hr .
 ORS powder dissolved in 200
ml , given 100 ml po after each
diarrhea stool or vomit episode.
 Cholestrane (cholestyramin) 1
gm/12hr po.
 Amrizole( metronidazole)
2.5ml /12hr po.
 Gentamicin 80mg/12hr po.
 ……

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Assesment
Day 1 (cont.) Day 2-5
 Zinc syp 10mg/12hr  The same treatment
 Potassium syp 80mg/8hr po.  No vomitting
 Motinorm (domperidone) susp  Stop cortigen and zantac
2.5 mg/8hr before feeding
 Cetal (paracetamol) syp
150mg/8hr
 Cortigen (vit B6+ adrenal
cortical 50 u) amp
 Zantac (ranitidine 50mg) amp

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Plan
 Cefotax  Zinc syp 10mg/12hr
 ORS powder dissolved in  Potassium syp 80mg/8hr
200 ml , given 100 ml po po.
after each diarrhea stool  Motinorm
or vomit episode.
 Cetal (paracetamol) syp
 Cholestrane 150mg/8hr
(cholestyramin) 1
gm/12hr po.
 Amrizole( metronidazole)
2.5ml /12hr po.
 Gentamicin 80mg/12hr
po.
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