DIARRHOEA

Diarrhoea in Children

Over 1,00,000 children below the age of 11 months die of diarrhoea annually in India which is
the second leading killer of young children globally after pneumonia.

Diarrhoea is the passage of stools with increased frequency, fluidity or volume compared to the
usual for a given individual. It is a response of the bowel to infection, drugs, foods or disease. These
factors can lead to the passage of unformed stools.

Three factors can lead to the passage of unformed stools:

• An increase in intestinal fluid and electrolyte secretion, osmotic or secretory diarrhoea.
• Malabsorption of intra intestinal contents.
•Altered intestinal mobility.

Types.
Three clinical syndromes of diarrhoea have been defined each reflecting a different pathogenesis
and requiring different approaches to treatment.

• Acute watery diarrhoea: It refers to diarrhoea that-begins acutely with passage of loss of
watery stools without visible blood. Vomiting may occur and fever may be present. It subsides
withing 3-7 days. If diarrhoea occurs more than 14 days, it is called persistent diarrhoea. Most
of them are viral aetiology. Persistent diarrhoea may be due to giardiasis.
• Dysentery: It is the term used for diarrhoea with visible blood. Dysentery may also be
associated with fever and tenesmus. Causative organism is shigella.
• Chronic diarrhoea: It is recurrent or long-lasting diarrhoea due to non-infectious causes such
as sensitivity to gluten or inherited metabolic disorders.

Acute diarrhoea during weaning can be due to indigestion. When weaning food has been
introduced early, that is, the infant's digestive system is not ready, or if there is not enough digestive
enzyme secretion, diarrhoea can occur. Poor food hygiene and improperly handled food can cause
infectious diarrhoea. Food intolerance or allergy can also lead to diarrhoea. Most episodes are self-
limiting, but the condition can be fatal to children. Thirty to forty per cent of diarrhoeal episodes are
caused by viruses of which rota virus is the most common one. About 50 per cent are due to bacterial
infections of the gut. Bacteria may cause diarrhoea through the action of toxin and direct invasion of
the intestinal mucosa.
Osmotic diarrhoea is characterised by passage of large, frothy, explosive and acidic stools. Due to
worsening hydration status of the child, there is also a danger of developing hypernatremia in these
cases. High osmolar solutions like carbonated soft drinks or oral rehydration solution (ORS) with high
sugar content can also result in osmotic diarrhoea.

Physiological Disturbances in the Body:

Water constitutes about 75 per cent of body weight at birth and approximately 60 per cent of
child's body weight. Diarrhoea losses come from ECF, Extra Cellular Fluid, and replacement fluids
should be of a similar composition relatively rich in sodium with low potassium.

Loss of water from the body causes a reduction or shrinkage in the volume of extracellular
compartment. Sometimes excessive sodium may also be lost in the stools then, there is a relative
decline in the serum and ECF sodium level (hyponatremia), the osmolality of ECF fall causing
movement of water from the extracellular to intracellular compartment. Skin elasticity is normally
maintained by the presence of water and fat in the tissues. Shrinkage of extracellular fluid in
dehydration impairs the skin elasticity. On pinching, it takes a few seconds for the skin folds to return
to normal. As the extra cellular compartment is depleted, the blood volume is reduced. This results in a
weak thready pulse and a fall in the blood pressure. Extremities appear cold. Because of low
hydrostatic pressure in the renal glomeruli, the filtration of urine is reduced. The quantity and
frequency of urination falls. Stools in diarrhoea contain large amounts of potassium. There will be
abdominal distension and hypotonia of muscles. Since intestinal secretions are alkaline and
considerable bicarbonate is lost in diarrhoeal stools, if the base falls to 12 mMol/l, the breathing
becomes deep and rapid.

Diarrhoea has been shown to have significant impact on nutrition though most nutrients are well
absorbed. Most field studies identify diarrhoea as the major determining factor leading to malnutrition
in developing countries. It is the child with multiple episodes of diarrhoea and particularly chronic
diarrhoea, who suffers most severely from protein energy malnutrition. If diarrhoea becomes unusually
prolonged or is recurrent, the child becomes severely malnourished since he/she also loses nutrients
through stools. The appetite is impaired, and food is often withheld from the child by the mother due
to an erroneous belief that starvation rests the bowel and promotes early recovery from diarrhoea.
Aetiology
There are many causes of diarrhoea in children — diarrhoea is a symptom, not a condition. Conditions
that can cause diarrhoea in children include:
• Chronic constipation
A hard stool can become impacted and stuck in the lower bowel due to constipation. This may
lead to soft stools leaking around the partial blockage, sometimes with no warning, and soiling
the underwear. These episodes of ‘diarrhoea’ are known as encopresis or faecal incontinence.

• Lactose intolerance
Lactose intolerance, when the body can’t digest the lactose found in milk, is uncommon in
babies and children. Lactose is the sugar found in the milk produced by all mammals, including
humans. When lactose intolerance does occur, it causes diarrhoea and stomach pain.
Temporary lactose intolerance sometimes occurs after gastroenteritis. If you think your baby or
child is lactose intolerant, see your doctor. Don’t try and modify their diet yourself.

• Inflammatory bowel disease (IBD)

Crohn’s disease and ulcerative colitis are 2 conditions collectively known as inflammatory
bowel disease. The symptoms, including diarrhoea, can flare up and then die down (remit). A
child with IBD may lose weight for no obvious reason.
 • Coeliac disease
Coeliac disease is an autoimmune condition where someone is abnormally sensitive to the
dietary protein gluten. It can cause diarrhoea, bloating, abdominal pain, and weight loss or
slow growth in children.

• Malabsorption
Malabsorption syndrome refers to several disorders that affect someone’s ability to absorb
nutrients from their food. A child with malabsorption may have ongoing diarrhoea and
difficulty gaining weight.

Symptoms
Symptoms can occur a bit differently in each child. They can include:
• Cramping
• Belly (abdominal) pain
• Swelling (bloating)
• Upset stomach (nausea)
• Urgent need to use the bathroom.
• Fever
• Bloody stools
• Loss of body fluids (dehydration)
• Incontinence

The symptoms of diarrhoea may look like other health problems. Severe diarrhoea
may be a sign of a serious disease. Make sure your child sees his or her healthcare provider for a
diagnosis.

Treatment
• The Fluid Management: The key to effective fluid management in childhood diarrhoea is
early replacement of fluid losses, starting with the first sign of liquid stool. Plenty of fluid
should be given to the child early in the illness to prevent dehydration. If renal function is
maintained, profound electrolyte and pH disturbances do not occur.
• Initial Management with any Fluid Available: The child is offered fluids as much quantity as
the child can take orally without vomiting. Coconut water, butter milk, rice kanji with salt,
lemon-sugar-salt beverage, light tea, etc. may be given in unlimited quantity either with a
teaspoon or in small drips from a tumbler. In mild cases, diarrhoea and vomiting are generally
controlled within a short period and dehydration does not develop.

• Oral Rehydration Therapy with Home Made Solution: For one glass of boiled cooled water
one pinch of salt and one tsp sugar can be added, to prepare ORS at home.

• Oral Rehydration Salts solution: If the diarrhoea is prolonged and dehydration becomes
evident, it is desirable to rehydrate the child orally by administering a solution with the
composition approved by the World Health Organisation.
Using zinc alone with oral rehydration salts to treat diarrhoea not only helps children get better
and faster and save lives. This solution provides 90 mEq L of sodium 20 mEq/L of potassium,
80 mEq/L of chloride and 30 mEq/L of bicarbonates. It is administered in mall sips or with a
teaspoon, to prevent rapid passage of stools due to hyperactive gastro-colic reflex. Usually, one
year old infant needs about 1000 ml of ORS in 24 hours. Since children with diarrhoea develop
protein energy malnutrition, the diet should be easily digestible and nutritionally balanced.
Presence of nutrients in the gut promotes absorption of sodium and water and hastens recovery
of the intestinal epithelium because food in the intestine stimulates rapid cell turnover and
renewal of intestinal lining.

• The infant should continue to be breast fed during diarrhoea. Breast milk contains viable
phagocytes and other protective substances such as secretory IgA and specific IgM which
protect against most entero-pathogens except rotavirus infection. Thus, breast milk helps the
infant to recover from an attack of diarrhoea both in terms of the nutrients it supplies, and its
rehydrating effect and it also helps to prevent further infection because it has protective
properties.

• The bowel should not be 'rested' during episodes of diarrhoea but intake of milk and other
lactose containing products should be avoided for a day or two because lactose malabsorption
is often a result of transient lactase deficiency due to entero-pathogens that have damaged the
intestinal lining.
 • Milk should be diluted with equal volume of water and fed along with ORS till the diarrhoea
stops. Mothers should be reassured that although a temporary increase in the frequency of
motions might occur initially, eventual recovery will be faster if the patient continues to be fed.

• Fermented milk (buttermilk) with a culture of streptococcus haemophilus and lactobacillus

bulgaricus has a beneficial effect. It discourages growth of pathogenic bacteria.

Age < 4 months 4-11 12-23 2-4 years 5-14 years

Wt.kg <5 5-8 8-11 11-16 16-30
ORS ml 200-400 400-600 600-800 800-1200 1200-2000
Measure, glass 1-2 2-3 3-4 6-4 6-11
Note: More ORS can be given in case the child requires. For infants under 6 months who are
not breastfed additional 100-200 ml of clean water can be given during this period.

Composition of WHO oral rehydration salt solution

Components Amount g/litre
Glucose 20
Sodium chloride 3.5
Sodium bicarbonate 2.5
Trisodium citrate 2.9
Potassium chloride 1.5

Dietary Guidelines

• Rice based solutions, potato, millet, maize and other cereal flours reduce the number and
volume of stools. There is no danger of producing osmotic diarrhoea as when given sugar.
Dextrin are larger molecules than sucrose or glucose and have less osmotic effect weight for
weight and less likely to cause osmolar diarrhoea. The cereal provides some potassium and a
little protein; amino acids have a synergetic effect with carbohydrate in promoting the
absorption of water and salt.

• For older infants, milled cereals are preferred to whole cereals. A well-cooked gruel of rice and
lentil is usually well tolerated. Mashed bananas are also good. The diet should be iso- osmolar.
These foods should be started within 4 to 6 hours of starting the treatment.
 • Sugary soft drinks, fruit juices and tea are not suitable for use because they contain high
osmolytes due to carbohydrate concentration which may exacerbate diarrhoea.

• Most children tolerate small quantities of fats and oils which are rich source of energy, and the
diarrhoea does not get worse Solid foods should be offered as soon as the child is able to eat.

• Caffeine should be avoided.

• Fibre, fruits and vegetables are avoided.

• Precooked ready to mix cereal pulse mixture prepared from roasted and powdered rice black
gram in the ratio 1:2 can be given.

• Parents must also be educated regarding storage of water and foods in clean utensils, instance
of breast feeding, using only freshly prepared weaning foods and thorough washing of hands
with soap before handling foods.

• Usage of ORT

• Continued feeding and avoiding inappropriate antibiotics are all that are needed to prevent
chronic diarrhoea. Vitamin A, folic acid and zinc supplementation are also beneficial. Zinc
treatment for diarrhoea could reduce the risk of death. Daily intake of at least 25% normal
caloric intake should be attempted until the cold reaches pre illness weight.

Dietary Management: -
The objectives of dietary management in Chronic diarrhoea are: -
• To meet the nutritional requirements
• To replenish water and Electrolyte losses
• To provide Extra nutrients to compensate fat for losses.

PRINCIPLE OF THE DIET: -

High calorie, High protein, low fat, high Carbohydrates, low fibre, vitaminised and mineralised, high
fluid and Electrolyte soft diet.
ENERGY
Energy requirements are increased by 10- 20% to meet the losses during diarrhoea as well as
overcome weakness and loss of weight.
PROTEIN: -
A high protein intake is essential to build up body tissue and replace the which has occurred. It is
advisable to increase protein intake by as much as 50%.
CARBOHYDRATES: -
The intake of carbohydrates should be increased to meet the high energy requirement. However, the
fibre intake is kept to minimum [1-2g/day) to give rest to the intestines.
FATS: -
Due to increased motility of the intestine fats are not completely digested and therefore their intake
needs to be restricted. At the same time, some amount of fat is essential to meet the increased energy
needs. Emulsified fats like butter and whole milk may be given as they are easy to digest.
Medium chains triglycerides [MCTs) are better utilized since these are directly absorbed into the
lymphatic system.
MINERALS: -
During a diarrhoeal episode, the absorption of calcium and iron in the intestines is lowered as they
form insoluble salts with free fatty acids. Therefore, the care should be taken to include calcium and
iron rich foods in the diet.
VITAMINS: -
Greater amounts of B group vitamins to be provided to compensate for the losses that occur due to
diarrhoea. The absorption of fat-soluble vitamins like vitamin A is important and therefore sufficient
amount should be provided in the diet.

FOODS ALLOWED FOODS AVOIDED

Cereals, Pulses, Low fibre foods, Fruits, High fibre foods(wheat), fatty foods, junk foods,
Vegetables, Milk and milk products (if bakery items, mutton, caffeine.
tolerated), Chicken, Fluids and electrolytes in
high amounts, MCTs