The problem of diarrhea in

young children

Diarrhea control program

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3-4 episodes /child /year 3,200,000 deaths/ year Causes about 30% of infant deaths in the developing countries Contributes to malnutrition Q) what is the relationship between diarrhea and malnutrition Diarrhea Malnutrition

Definition

Diarrhea is newly defined as an increase in the frequency and/or fluidity of the stool relative to the previous habit of the same individual.

WHO classification of diarrhea according to its duration

Acute [ < 14 days as in gastroentritis]  Persistent > or= 14 days  Chronic : if recurrent or long lasting (ex., in lactose intolerance).

Acute versus persistent diarrhea

Characteristics of acute diarrhea versus persistent diarrhea
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Acute diarrhea Sudden onset

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Usually self limited [within 3-5 days] unless child dies from dehydration.

Persistent diarrhea May be sudden or insidious but stool [frequency & characteristics] vary from day to day. May lead to weight loss, permanently impaired growth, or even death.

Acute diarrhea versus persistent diarrhea

Most often caused by pathogenic organisms.

Children 1 to 30 months are more susceptible.

May initially be related to a specific organism but, intestinal damage, malabsorption and other bacteria keep it going. Malnourished children are more susceptible.

Acute diarrhea versus persistent diarrhea

Fever and/ or vomiting may or may not be accompany. May result in rapid dehydration.

Neither fever nor vomiting is common. Dehydration is usually mild but enough to suppress appetite.

Predisposing factors or risk factors for diarrhea
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I- unsanitary environment II- Factors related to the mother; {behavioral factors}. III- Factors related to the host (child) IV- Factors related to the agent.

Behavioral risk factors for diarrhea
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No hand washing Inadequate breast feeding Bottle feeding Eating food left for hours at room temperatures Use of contaminated water either for drinking or in milk preparation Improper refrigeration, boiling or cooking of milk or feeds. Bad weaning practice

Host factors that predisposes to diarrhea
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Malnutrition Age under 5 years susceptibility Immunocomprised child Diseases such as measles, upper repiratory tract infection (otitis media, tonsilitis)

Clinical picture
Mild: self limited, no dehydration,no fever + diarrhea<5 times/ day.  Moderate: with some dehydration.  Severe: Fever, vomiting, diarrhea up to 20 times /day with subsequent dehydration.  Dehydration: sunken eyes– dry mouth— oliguria—acidosis (causes ,rapid respiration, vomiting and anorexia) —depressed anterior fontanel---apathy— mental confusion. skin elasticity

Complication of Acute diarrhea: Metabolic effects of diarrhea

Loss of water dehydration, hypovolemic shock Excess loss of bicarbonates acid base deficit, acidosis Excess loss of potassium K+ depletion

Signs of acidosis

1- deep rapid respiration [ to compensate for by respiratory alkalosis]. (dd from pneumonia) 2vomiting.

3Appetite. (also, in case of protein loss)

When hypokalemia occur?

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When acidosis is corrected without correction of K+. Signs: Muscle weakness Cardiac arrythmia Paralytic ileus especially when associated with antiemetic drugs.

Prevention of diarrhea
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Environmental Sanitation Health education for the mothers about infants feeding (breast feeding, …) Manage host factors {especially scheme of immunization and treat systemic infection} Specific prevention: rota virus vaccine, cholera oral vaccine, E. coli vaccine (not in Egypt)

Control
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Case finding case;: notification , disinfection, Treatment.

Principles of Treatment of acute diarrhea
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Please remember that: 1-Rehydration therapy is The main principle to substitute the lost water and electrolytes and correcting dehydration 2-Diet: Continue feeding. 3-Restrict use of chemotherapeutics. Why? 4- Symptomatic treatment is of fever only. (no antiemetic , no antimotility drugs) 5- treatment of underlying diseases

Composition of oral rehydration solution ORS
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Sodium (90mmol) replace lost sodium K+ (20 mmol) replace lost potassium Bicarbonate (30mm) correct acidosis Glucose (111) Osmolality (320) Isotonic N.B now there is another composition available which contains only 60 mmol of sodium

Fluids for home therapy

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ORS
Water N.b., don’t give water alone; it must be associated with ORS. Why ? because this may cause hypotonic dehydration, with subsequent lethargy and seldom seizures)


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Food-based fluids:
Rice water ---potato Soup, vegetable soup ---Yoghurt Fresh fruit juice. N.B. don’t give concentrated sweetened juices. Why? Because this may cause hypertonic dehydration, with more thirst & seizures Green coconut water

When ORT is not effective ?
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Severe dehydration Severe, vomiting Ileus, abdominal distension Glucose malabsorption {glucose. Is important for sodium reabsorption--glucose-sodium channel.} We use nasogastric tube or IV.

In the diarrhea control program we must Assess the diarrhea patient to detect:
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Onset Acute or Persistent diarrhea Dehydration and its degree Dysentery --------------------------------------Then continue assessment as planed in IMCI. (Malnutrition) (Other infections such as pneumonia, and malaria, measles). fever

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*assess for dehydratio n

Only two signs (in red and pink)
[No D.] [Some D.] [Severe D.]

Condition

Thirst

Skin pinch

About 2 seconds.

>2 sec.

Degree of dehydration and % of fluid deficit
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Assessment No signs of dehydration Some dehydration Severe dehydration

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Fluid deficit * 0 – 4% 5 – 10% > 10 %

* % of body weight

Plans of Treatment

Select a treatment plan

Assessment Treatment Severe dehydration Plan C

Objective Referred to hospital & Rehydrate urgently with IV fluids Rehydrate at health center with ORS Treat at home to prevent dehydration


Some dehydration No signs of dehydration

Plan B Plan A

Treatment Plan A at home
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Give more fluids: A- Give ORS, Dose, {200 ml/kg/day} B- Use plain water, breast milk, or low salt drinks during the course of diarrhea Continue breast feeding or use same milk formula and concentration or Give more food than usual to prevent malnutrition

Plan A
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If the child is ≥ 6 months,: Feeding:give cereal or starchy food mixed with beans, or vegetables or meat. Add 1-2 teaspoonful of oil. Give fresh fruit juice or mashed banana to supply potassium. Give at least 6 feeds / 24 hours. Identify warning signs of dehydration to the mother to come back to the doctor Follow up in 5 days if not improving.

Treatment Plan b at health center or rehydration unit

ORS required for the child { 75ml/ kg}  2-The child is given this amount during 4 hours that he stays in the center. No breast feeding or other in the first 4 hours,  3- Initially one teaspoonful is given every 510 minutes to avoid vomiting. Then increase gradually.  4- Weight every 1- 2hours.

1- First the doctor estimate the amount of

Plan B

5-Educate the mother to prepare
ORS.

6- Observe and monitor body weight
gain and improved signs of dehydration

7-The mother is instructed to
continue treatment at home as in plan A. (200ml/kg/day).And follow up in 5 days

When do we need nasogastric administration of ORS?
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Repeated vomiting {We give Iv.fluid in case of continuos vomiting} When the baby refuses ORS The baby is too sleepy The mother is so exhausted Lack of facilities during transmission to hospital in severe dehydration

In plan b you must refer to hospital immediately if:
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There is a general dangerous sign: Convulsions Or an indication of plan C Such as Lethargy or unconscious, not able to drink

Treatment plan C in hospital

1- Start IV fluids immediately before


transmission. 2- If shock is present: Give Ringer’s lactate solution {20ml/kg} in the first ½ hour. If no response, give plasma or blood transfusion {10-20 ml/kg} in ½ hour. Airway clearance, warmth, oxygen and lower limbs elevation to manage shock.

Plan C
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If not shocked or after correction of shock Start rehydration with polyelectrolyte solution {same composition as ORS} Dose: 100 ml/kg within the next 6 hours Reassess the baby after the 6 hours then choose plan A, B, or C to continue treatment.

Oral fluids and breast feeding should be initiated as soon as the patient can drink and be given with IV fluids untill all deficits in fluids are restored. Discontinue IV.

Thank you

Why antibiotics are not recommended as a first line therapy

1-most childhood diarrhea are caused by viral agents [25-40% of cases in Egypt are due to rota virus]. 2-Many other cases are caused by parasites like Giardia and amoeba [not affected by antibiotics] 3-the use of many antibiotics may lead to secondary enteritis and persistent diarrhea because they destroy the flora of the intestine.

continue

4- Sensitivity studies show that most other cases are caused by bacteria which are resistant to the most frequently used antibiotics. 5-Using antibiotics when not indicated may reduce its effectiveness when needed [due to resistance].

continue
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D- Symptomatic treatment: For fever. Don’t give anti-emetics. Why? 1-Because correction of acidosis can stop vomiting. 2-It causes sedation and or precipitate paralytic ilieus.

Continue symptomatic tt

Don’t give anti-motility drugs. Why?

1- it keeps the toxins and pathogens inside the intestine. 2- It can cause ileus or respiratory failure.

Continue control

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E- treatment of underlying diseases: Malnutrition Systemic infection Parasitic infestation

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