O Lord Our God, may the inpouring of the Holy Spirit

Purify our hearts and make them fruitful

By the sprinkling with the dew of His grace.
We ask this through Our Lord Jesus Christ, Your Son,
Who lives and reigns with You and the Holy Spirit,
One God, forever and ever,
Amen.
OBJECTIVES
At the end of this conference, attendees should be able to:

● Recognize and classify diarrhea in a child

● Identify signs of dehydration in children
● Classify the level of severity of dehydration
● Manage cases of diarrhea with signs of dehydration
Pre-test
APPROACH TO A CHILD
WITH DIARRHEA
BELEN, M.
BUÑO, K
CAABAY, J.
CALDERON, B.
CASAS, A.
CAUTON, J.
CHAN, D.
DIARRHEA
Passage of 3 or more liquid stools in a 24 hour period
Consistency > number of stools

Timing:

• Acute – lasting for a few hours to less than 3 weeks

• Chronic – lasting more than 4 weeks

• Dysentery – small-volume, frequent bloody stools with mucus, tenesmus

and urgency
Does the child have diarrhea?
If YES, ask:
• For how long?
• Is there blood in the stool?

LOOK:
• Child’s general condition lethargic or unconscious? restless and irritable?
• Sunken eyes
• Offer the child fluid not able to drink or drinking poorly? drinking eagerly, thirsty?

FEEL:
• Pinch the skin of abdomen recoil longer than 2 secs?
Classify the diarrhea
SIGNS (Two of the following)
- lethargic or unconscious
- sunken eyes
- not able to drink or drinking poorly
- skin pinch goes back very slowly
SEVERE DEHYDRATION
- restless, irritable
- sunken eyes
- drinks eagerly, thirsty
SOME DEHYDRATION - skin pinch goes back slowly
- not enough signs to classify as some or
severe dehydration
NO DEHYDRATION
MANAGEMENT
If child has no other severe classification:
- Give fluid for severe dehydration (Plan C)
OR
If child also has another severe classification:
- Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
- Advise mother to continue breastfeeding
If child 2 years or older and there is cholera in your area, give antibiotic for cholera
Give fluid, zinc supplements and food for some dehydration (Plan B)
If child also has a severe classification:
- Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way
- Advise mother to continue breastfeeding
Advise mother when to return immediately.
Follow-up in 5days if nor improving.
Give fluid, zinc supplements and food to treat diarrhea at home (Plan A)
Advise mother when to return immediately.
Follow-up in 5days if nor improving.
If diarrhea of 14 days or more
SIGNS MANAGEMENT

Dehydration present Treat dehydration before referral unless the child has another severe
classification.
SEVERE PERSISTENT Refer to hospital.
DIARRHEA

No dehydration. Advise the mother on feeding a child who has persistent diarrhea.
Give multivitamins and minerals (including zinc for 14 days)
PERSISTENT DIARRHEA Follow-up in 5 days.
If with blood in stool,
SIGNS MANAGEMENT

Give ciprofloxacin for 3 days.

DYSENTERY Blood in stool.
Follow-up in 3 days.
DEHYDRATION
Dehydration
Condition that results from excessive loss of body water

Most commonly due to gastroenteritis

In pediatrics, assessing the degree of dehydration is priority

Nelson Textbook of Pediatrics, 20th ed.

Nelson Textbook of Pediatrics, 20th ed.
 Clinical evaluation of dehydration
<5% in an infant
● Essentially normal physical findings
MILD <3% in an older child/
● Able to drink but might refuse
adolescent

5-10% in an infant ● Sympathetic, compensatory responses

MODERATE
3-6% in an older child/ ● Clinically dry
adolescent ● Able to drink, acts thirsty

>10% in an infant
● Ill-looking, drinks poorly or unable to drink
SEVERE >6% in an older child/
● May be entering early signs of shock
adolescent
WHO TREATMENT PLAN
 PLAN A: Treat diarrhea at home
• Counsel the mother on the 4 Rules of Home Treatment
– Give extra fluid
– Give zinc supplements (age 2 months up to 5 years)
– Continue feeding
– Advise when to return
 PLAN A: Treat diarrhea at home
1. Give more fluids than usual (ORS)

Age Amount after each loose stool

Up to 2 years 50-100ml
2 years or more 100-200ml
 PLAN A: Treat diarrhea at home
2. Give Zinc
▪ Tell the mother how much zinc to give

2 months up to 6 months 10 mg elemental Zn

6 months or more 20 mg elemental Zn

▪ Locally available preparations

▪ 27.5mg/2.5mL drops (10mg elemental zinc)
▪ 55mg/5mL syrup (20mg elemental zinc)
 PLAN A: Treat diarrhea at home
3. Continue feeding (exclusive breastfeeding if age less than 6 months)

4. Advice when to return

– Follow up in 5 days if not improving
– When to return immediately?
• Not able to drink or breastfeed
• Becomes sicker
• Develops a fever
• Blood in the stool
• Drinking poorly
Aisis Casas, Jonas Cauton, and Nins Caabay

Plan B and ORS in the Philippines

 PLAN B: Treat some dehydration with ORS
• Determine the amount of ORS to give during
first 4 hours
 PLAN B: Treat some dehydration with ORS
• After 4 hours
– Reassess the child and classify the child for dehydration
– Select the appropriate plan to continue treatment
– Begin feeding the child in clinic
 PLAN B: Treat some dehydration with ORS
• If the mother must leave before completing treatment:
– Show her how to prepare ORS solution at home
– Show her how much ORS to give to finish 4-hour
treatment at home
– Give her instructions how to prepare SSS for use at
home
– Explain the 3 Rules of Home Treatment
Composition of OLD and REFORMULATED
ORS
STANDARD WHO ORS REDUCED OSMOLARITY ORS
(mEq or mmol/L) (mEq or mmol/L)

Glucose 111 75

Sodium 90 75

Chloride 80 65

Potassium 20 20

Citrate 10 10

Osmolarity 311 245

Different Brands of ORS commonly
used in the Philippines
Hydrite Mild Dehydration
Age Group Amount of ORS Solution to
Give After Every Watery
Stool
Children under 2 years ¼ to ½ glass (50 – 100 mL)
Children 2 – 10 years ½ to 1 glass (100 – 200 mL)
Older children and adults As much fluid as they want

tablet sachet Mild to Moderate Dehydration

NaCl 350mg 520mg Age Group Approximate Amount of ORS

Weight (kg) Solution to Give
Within 4 hours
Na 250mg
Up to 4 months Less than 6 1–2 glasses (200–
bicarbonate
400 mL)

Trisodium 290mg 580 mg 4 months – 12 6 – 10 2–3 ½ glasses

months (400–700 mL)
citrate
12 months to 24 10 – <12 3 ½–4 ½ glasses
months (700 –900 mL)
KCl 150mg 300 mg
2 – 5 years 12 – 19 4 ½–7 glasses
(900–1400 mL)
Glucose 2mg 2.7g
Glucolyte Plus
Deficit Therapy: Based on Actual Weight
Infants 100 mL/kg/day
Children and adults 60 mL/kg/day
Preventive / Maintenance Therapy
Under 2 yrs 50 - 100mL (¼ large cup)
Above 2 yrs 100 - 200mL (¼ - 1 large cup)

NaCl 260mg

Trisodium citrate 290mg

KCl 150mg

Dextrose 1.35g
 Pedialyte

Pedialyte Mild 30 Pedialyte – 45

Electrolyte Per L Electrolyte Per L
Sodium 30 mEq Sodium 45 mEq
Chloride 30 mEq Chloride 35 mEq
Lactate 28 mEq Citrate 30 mEq
Potassium 20 mEq Potassium 20 mEq
Calcium 4 mEq Dextrose 25 g
Magnesium 4 mEq
 Pedialyte

Pedialyte – 75 Pedialyte – 90
Electrolyte Per L Electrolyte Per L
Sodium 75 mEq Sodium 90 mEq
Chloride 65 mEq Chloride 80 mEq
Citrate 30 mEq Citrate 30 mEq
Potassium 20 mEq Potassium 20 mEq
Dextrose 25 g Dextrose 25 g
Dehydrosol
NaCl 0.65g

Trisodium citrate 0.725g

dihydrate

KCl 0.375g

Anhydrous glucose 3.375g

Dehydrosol
Electrolyte Per L
Sodium 75 mmol
Chloride 65 mmol
Citrate 10 mmol
Potassium 20 mmol
Glucose 75 mmol
 PLAN C: Treat for severe dehydration
quickly
Start IV fluid immediately
Simultaneous oral replacement with ORS-75 if tolerated
Give 100 ml/kg LRS (if unavailable D5W + NaCl/NSS), divided as
follows:
 PLAN C: Treat for severe dehydration
quickly
• Reassess the child every 1-2 hours. If hydration status is not
improving, give IV drip more rapidly
• Also give ORS (approx. 5 ml/kg/hr) as soon as the child can
drink
–Infants: 3-4 hours
–Children: 1-2 hours

• Reassess degree of dehydration

–After 6 hours: infant
–After 3 hours: child

• Choose the appropriate plan (A,B, or C) to continue treatment

 PLAN C: Treat for severe dehydration
quickly
• Refer URGENTLY to hospital for IV treatment

• If the child can drink, provide the mother with ORS solution
and show how to give frequent sips during the trip.
IN-HOSPITAL MANAGEMENT OF
DEHYDRATION
 Maintenance
• Holliday-Segar method
• 1st 10 kg x 100 ml/kg
• 2nd 10 kg x 50 ml/kg
• Succeeding x 20 ml/kg
 Deficit Therapy
• Deficit
<2 y.o. >2 y.o.
< 15 kg > 15 kg
Mild 5% or 50ml/kg 3% or 30ml/kg

Moderate 10% or 100ml/kg 6% or 60ml/kg

Severe 15% or 150ml/kg 9% or 90ml/kg

 Total Fluid Requirement
• Maintenance + Deficit
• Resuscitative fluids are subtracted from total
• Difference is then given over 24 hours
 Monitor Response to Therapy
• Initial resuscitation and rehydration is complete with
resolution of intravascular volume depletion
– HR, RR, and BP
• Monitor weight and fluid output and input
• WOF: clinical signs of congestion (i.e. edema, crackles
on auscultation)
Audience Participation

Role-play/ORS sampling
 CASE
•AC, a 2 year old male was brought to your clinic due to a 4
day history of loose, watery, non-mucoid, non-bloody
stools.
•On PE: awake, alert, not in distress. HR 87 RR 28 T 36.8.
Eyeballs not sunken, moist lips & oral mucosa. Symmetrical
chest expansion, no retractions, clear breath sounds.
Abdomen globular, soft, nontender. Warm extremities, full
pulses. Skin pinch goes back slowly.
 GUIDE QUESTIONS
1. How would you classify the patient’s
dehydration based on IMCI?
2. How will you manage the patient?
3. When would you advise the mother to
return?
 MANAGEMENT
The four rules of home treatment
are:

1. Give extra fluid

2. Give zinc supplements

3. Continue feeding

4. Return immediately if the child

develops danger signs, drinks
poorly, or has blood in stool
 PLAN A: Treat diarrhea at home
1. Give more fluids than usual (ORS)

Age Amount after each loose stool

Up to 2 years 50-100ml
2 years or more 100-200ml
 PLAN A: Treat diarrhea at home
2. Give Zinc
▪ Tell the mother how much zinc to give

2 months up to 6 months 10 mg elemental Zn

6 months or more 20 mg elemental Zn

▪ Locally available preparations

▪ 27.5mg/2.5mL drops (10mg elemental zinc)
▪ 55mg/5mL syrup (20mg elemental zinc)
 PLAN A: Treat diarrhea at home
3. Continue feeding (exclusive breastfeeding if age less than 6 months)

4. Advice when to return

– Follow up in 5 days if not improving
– When to return immediately?
• Not able to drink or breastfeed
• Becomes sicker
• Develops a fever
• Blood in the stool
• Drinking poorly
 Case
A 3 y.o., 14kg came in the ER.
On PE, he had chapped lips, slightly sunken
fontanels, slightly sunken eyeballs, cold
extremities and CRT 4 seconds.
 GUIDE QUESTIONS
1. Compute for the fluid maintenance and
deficit.
 Fluid Maintenance
• Holliday-Segar method
• 1st 10 kg x 100 ml/kg
• 2nd 10 kg x 50 ml/kg
• Succeeding x 20 ml/kg
• Patient (14kg)
• 10 kg x 100 mL/kg = 1000 mL
• 4 kg x 50 mL/kg = 200 mL
• 1200 mL
 Deficit Therapy
• Deficit
<2 y.o. >2 y.o.
< 15 kg > 15 kg
Mild 5% or 50ml/kg 3% or 30ml/kg

Moderate 10% or 100ml/kg 6% or 60ml/kg

Severe 15% or 150ml/kg 9% or 90ml/kg

Nelson Textbook of Pediatrics, 20th ed.
 Fluid Deficit
• Patient (3 yo; 14kg; Severe dehydration)
• 150 mL/kg x 14 kg
• 2100 mL
THANK YOU!