Current Guidelines in

Management of Diarrhoea
Ahmed Laving
Paediatric Gastroenterologist and Lecturer
Dept. of Paediatrics and Child Health
University of Nairobi
 Outline
 Definition of diarrhoea
 Diarrhoea pathophysiology
 Clinical features of shock and dehydration
 Diarrhoea in severely malnourished children
 New WHO guidelines
 Definitions
 Diarrhoea: three or more loose stools per day
 Acute diarrhoea: diarrhoea lasting less than 14
days
 Persistent diarrhoea: diarrhoea lasting more
than 14 days.
 Dysentery: diarrhoea with visible blood in the
stool
 Epidemiology: Diarrhoeal Disease
 Second leading cause of death in children under five
 Account for 9% of all deaths among children under age 5
worldwide in 2015
 over 1400 children dying each day, or about 530,000 children a year
 From 2000 to 2015, total number of deaths from diarrhoea in
children under 5 decreased by >50 per cent – from over 1.2
million to half a million
 In Kenya, deaths due to diarrhoeal diseases reached 23,374 or
6.98% of total deaths (KDHS 2014)

http://data.unicef.org/child-health/diarrhoeal-disease
 Acute Diarrhoea: Pathophysiology
 Villous epithelial damage
 Loss of brush border enzymes
 Immature crypt cells allow net secretion
 Toxins: affect Na/K/ATPase pump

 Net effect: loss of body water, electrolytes,

nutrients
Children more prone to dehydration
 Higher surface to body weight ratio (higher
insensible loss/kg)
 Higher metabolic rate
 Dependent on others for fluids
 Clinical assessment

 History
 Thorough examination

 Weigh the child (?premorbid weight)

 Assess hydration status

 Rehydrate: Plan A, B or C
 Hydration Status
Old Classification Current Classification

Mild: < 5% loss of wt None

Moderate: 5-10% Some dehydration
Severe: > 10% Severe dehydration
Shock
 How severe is the dehydration?

All 4 of:
Cold Hands + temp gradient Y

Pulse: weak/absent Shock

Capillary refill > 3 secs
Sunken eyes, slow skin pinch
(Hb<5gm/dl: Transfuse urgently
20ml/kg)
 How severe is the dehydration?
Cold Hands + temp gradient
Pulse: weak/absent Y
Capillary refill > 3 secs Shock
Sunken eyes, slow skin pinch

Unable to drink or
AVPU<A,
Y Severe
plus:
Dehydration
Sunken Eyes
Skin pinch ≥ 2 secs
 How severe is the dehydration?
Cold Hands + temp gradient
Pulse: weak/absent Y
Capillary refill > 3 secs Shock
Sunken eyes, slow skin pinch

Unable to drink or AVPU <A, plus:

Sunken Eyes Y Severe Dehydration
Skin pinch ≥ 2 secs?

Able to drink plus ≥ 2 of: Y

Some
Sunken Eyes and / or Dehydration
Skin pinch 1 - 2 secs
Restlessness / Irritability
 How severe is the dehydration?
Cold Hands + temp gradient
Pulse: weak/absent
Capillary refill > 3 secs Y
Shock
Sunken eyes, slow skin pinch

Pulse OK but unable to drink plus

Sunken Eyes Y
Skin pinch ≥ 2 secs? Severe Dehydration

Able to drink plus 2 or more of:

Sunken Eyes and / or Y
Skin pinch 1 - 2 secs Some Dehydration
Restlessness / Irritability

Diarrhoea / GE with
fewer than 2 of the Y
No
above signs of Dehydration
dehydration
 Why do we use these signs?
 Shock requires immediate management
 The ability to drink is an important indicator of
severity. If they can drink then use oral or oral + ngt
fluids.
 Sunken Eyes and Skin Pinch are the most reliable
signs of dehydration
 Signs which work poorly include:
 Dry mucous membranes
 Absence of tears
 Poor urine output
 Shock/Severe Dehydration
 Urgent attention
 IV access (3 tries!), Intra-osseous, Nasogastric
(NG)
 Which Fluid?
 Replace deficit, then start maintenance +
remember to replace ongoing losses
 Which Fluid?
Fluid Na K lactate
HCO3
Ringer’ s 131 5 27
Lactate
Normal 154 0 0
saline
Half 61 17 27
Strength
Darrows
Treating Shock / Severe Dehydration
 The greatest concern is the loss of fluid from the circulation.
 To restore circulation the fluid replaced at first needs, ideally, to be like plasma

Sodium, Na+ 140 mmol/l

Potassium, K+ 4.0 mmol/l

 Use of low sodium content fluids

If the fluid deficit is first

Fluid deficit replaced with a low sodium
fluid then body sodium is
diluted.

These low sodium fluids are

much less good at restoring
the circulation and can
cause hyponatraemia
Existing fluid

leading to convulsions
Na+, 140 mmol/l
Intra-osseus line
Use IO or bone marrow needle 15-18G, or 16-21G
hypodermic needle if IO not available
Identify landmarks then use sterile gloves and sterilize site
Site – Middle of antero-medial (flat) surface of tibia at
junction of upper and middle thirds – and introduce
vertically (900)- advance slowly with rotating movement
Stop advancing when there is a ‘sudden give’ – then
aspirate with 5mls needle
Slowly inject 3mls N/Saline looking for any leakage
under the skin – if OK attach iv fluid giving set and apply
dressings and strap down
Give fluids as needed – a 20mls/50mls syringe will be
needed for boluses
Watch for leg/calf muscle swelling
Replace IO access with iv within 8 hours
 Treatment of hypovolaemic
shock
Airway & Breathing (oxygen) effectively
Shock identified
managed

Establish iv / io access

Signs persist

20 mls / kg bolus of fluid Re-assess clinical signs

(<15 mins) of shock
Fluid therapy for severe dehydration
(not in shock)
AGE Phase 1- 30ml/kg Phase 2
70ml/kg
INFANT (<12 1 hour 5 hours
months)
CHILD (12-60 30 minutes 2 ½ hours
months)
Treat for
hypoglycaemia
 Follow-up: severe dehydration
 Reassess hourly and at 3 or 6 hours depending
on age, and reclassify as severe, some or no
dehydration
 Manage as per the new classification
 Start ORS 5ml/kg soon as child can drink
 If IV access not possible, give ORS by NG at
100ml/kg for 6 hrs and reassess every hour
 Some dehydration
 Best treated with ORS
 Volume 75ml/kg over 4 hours
 Continue breastfeeding and encourage feeding if >6 months old

Counsel the mother:

 How to prepare the ORS
 If child vomits, wait 10 minutes and continue at a slower rate:

a teaspoon every 1-2 min

 Reassess child after 4 hours: Reclassify hydration status and
treat appropriately
 Start Zinc supplements
ORS in practice.

300 mls 200 mls

 ORS Formulations

Na K Cl HCO3 Glu Osm

Old ORS 90 20 80 10 111 311

New ORS 75 20 65 10 75 245

 Vomiting and feeding?
 Vomiting is NOT a contra-
indication to oral rehydration
 Careful counseling about, slow,
steady administration of ORS is
helpful.
 Breast feeding and other forms of
feeding can and should continue
during diarrhoea and oral
rehydration.
 There is no evidence of benefit
from using half-strength feeds or
gradual re-introduction of
feeding.
 No dehydration
 Prevent dehydration by preventing on-going
losses: give 10ml/kg of ORS after every loose
stool
 Give zinc supplement for 14 days
 Continue breastfeeding and encourage feeding
if >6 months old
 Advice mother on when to return
 Zinc and Diarrhoea
 Reduces stool volumes (18-53%) and duration
(25%) of ongoing diarrhoea
 Lowers the incidence of diarrhea in the
following 2-3 months by 18-20%
 10mg for an infant below 6 months for 14 days
 20 mg for a child older than 6 months for 14
days
Baqui et al. BMJ 2002
Zinc Investigators’ s Group. Am J Clin Nut 2000
 Antibiotics and Diarrhoeal Illness
 Majority of diarrhoea episodes are caused by
viruses

 Antibiotics NOT recommended routinely for

acute childhood diarrhoeal illness

 Antibiotics for: dysentery, cholera, some bacterial

GE
Robins-Browne, R. M., H. M. Coovadia, et al. (1983). "Treatment of acute nonspecific
gastroenteritis of infants and young children with erythromycin." Am J Trop Med Hyg 32(4):
886-90.
 Anti-Emetic in Diarrhoeal Illness
 Promethazine, metoclopramide and prochlorperazine
 Extrapyramidal reactions
 Promethazine :- respiratory depression children <2yrs
 NOT recommended for children
 Ondansetron
 reduced the number of episodes of vomiting but increased the
incidence of diarrhoea
 Reduced need of IVI compared to placebo (24% vs. 55%)
 Alhashimi, D., H. Alhashimi, et al. (2006). "Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents."
Cochrane Database Syst Rev(4): CD005506.
 Ramsook, C., I. Sahagun-Carreon, et al. (2002). "A randomized clinical trial comparing oral ondansetron with placebo in children with vomiting
from acute gastroenteritis." Ann Emerg Med 39(4): 397-403.
 Carey, MJ., Aitken, ME. Diverse effects of antiemetics in children. NZ Med J 1994;107:452
 Anti-Diarrhoeal in GE
 Loperamide (v placebo)
 reduced intestinal luminal motility
 But significant side effects including: lethargy, paralytic
ileus, toxic megacolon, CNS depression
 delays transit time therefore prolong course of bacterial
diarrhoea
 no effect on hospital stay and stool output in 2 other trials
 NOT RECOMMENDED for routine use

Elliott E, Dalby-Payne J. Gastroenteritis in children. Clin Evid 2006;15:1-7.

Li, ST, Grossman, DC, Cummings, P. Loperamide therapy for acute diarrhea in children: Systematic Review and Meta-Analysis. PLoS
Med 2007; 4:e98
Bergstrom, T., K. Alestig, et al. (1986). "Symptomatic treatment of acute infectious diarrhoea: loperamide versus placebo in a double-
blind trial." J Infect 12(1): 35-8.(1984).
"Loperamide in acute diarrhoea in childhood: results of a double blind, placebo controlled multicentre clinical trial. Diarrhoeal Diseases
Study Group (UK)." Br Med J (Clin Res Ed) 289(6454): 1263-7.
 Probiotics
Pros Cons
 Reduced mean duration of  Usually not regulated
diarrhoea by 24.7 hrs
 Reduced stool frequency on
 Great variability
day 2 by 1 episode  No determined optimal type,
dosage and regime
 Reduced risk of diarrhoea
lasting >4 days by 59%

Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for treating acute infectious diarrhoea.
Cochrane Database of Systematic Reviews 2010, Issue 11 .
 Prevention
 Hygiene especially hand washing has been

shown to reduce spread of infection

 Vaccine e.g. rotavirus vaccine is efficacious in

preventing diarrhea by rotavirus and all-cause

diarrhea
◦ Decrease severity and hospital admission

Soares-Weiser K, Goldberg E, Tamimi G, Leibovici L, Pitan F. Rotavirus vaccine for preventing

diarrhoea. Cochrane Database of Systematic Reviews 2004, issue 1. Art. No: CD002848:DOI:
10.1002/14651858. CD002848.pub2.
Questions?
 Dehydration and Severe
Malnutrition
 Assessment difficult:
Loss of skin elasticity (skin pinch over breast bone)
Sunken eyes due to loss of subcutaneous tissue
Dry mouth – salivary gland function suboptimal
 Choice of oral rehydration fluid
fluid should have low sodium, high potassium, high
glucose
 Choice of intravenous fluid
Volume and flow rate
 Case fatality rate is high especially if not well managed

Tahmeed et al. Ind J Paeds 1998

 Fluid management in Severe
Malnutrition with diarrhoea
 Shock: AVPU<A, plus absent, or weak pulse
plus prolonged capillary refilling (>3s) plus
cold periphery with temperature gradient
 20 mls/kg in 2 hrs of Ringers with 5% dextrose
- add 50mls 50% dextrose to 450mls Ringers
(or 5%Dextrose/HSD if Ringers not available)
 If severe anaemia, start urgent blood transfusion
(not Ringers)
 Fluid management in Severe
Malnutrition with diarrhoea
 If not shocked or after treating shock
If unable to give oral/ngt fluid due to poor medical condition,
continue with iv fluids at maintenance regimen of 4mls/kg/hr
 If able to introduce oral or ng fluids / feeds:
For 2 hours: Give Resomal at 10mls/kg/hour
Then: Introduce first feed with F75 and alternate Resomal
with F75 each hour at 7.5mls/kg/hr for 10 hours
Can increase /decrease hourly fluid as tolerated to 5 – 10
mls/kg/hr
 At 12 hours switch to 3 hourly oral/ngt feeds with F75
 ReSoMal – modified ORS
 ReSoMal: Rehydration Solution for
Malnutrition
 Preparation of ReSoMal from ORS
1. Add two pkts of ORS in 2 litres of water (instead of 1
litre)
2. Add 50gm ( 10 rounded 5mls teaspoon of sugar)
3. Add 3 vials of the 10 ml vial of 15% KCL
(20mmol/10ml) in the 2 liters
 Oral Rehydration in Severe
Malnutrition
All concentrations are in
mmol/l Lactate*
Na
+
K+
(HCO3-)
Glucose

WHO / UNICEF
90 20 10 111
ORS

Rehydration Solution
for Malnutrition – 45 40 5 ~ 200
ReSoMal*.
 Replace on-going losses
 Should be done once the rehydration therapy is
over
 ReSoMal 10ml/kg for every watery stool

 Continue feeding
 Vitamin A, multivitamins, zinc
supplementation
 Antibiotics etc