Diarrhea in children

Aashish tamang pakhrin

1st year resident
MD,GP & EM
NAMS
CONTENTS
 INTRODUCTION
 EPIDEMIOLOGY
 CAUSES/DIFFERENTIALS
 COMPLICATIONS
 ASSESSMENT
 MANAGEMENT
 PREVENTION
 TAKE HOME MESSAGE
Introduction

 Diarrhea is defined as a change in consistency and frequency of stools, i.e.

liquid or watery stools, that occur > 3 times a day

 Acute watery diarrhea : loose or watery stools at least three times in a

24 hour period.

 Invasive diarrhea : (synonymous with dysentery) gross blood (by history or

inspection) in the stool of <14 days duration, typically accompanied by
fever

 Persistent diarrhea : loose, watery, or bloody stools of ≥14 days

GHAI essentials of pediatrics / UPTODATE 2023

Acute watery
diarrhea

UPTODATE Invasive diarrhea

Epidemiology
 In 2016, more than 5.6 million children under five years of age died
worldwide, of which 8.4% were attributed to diarrhea
 Diarrhea remains the leading cause of morbidity and mortality of children
under five years old in Nepal
 According to the WHO, there were 1193 deaths (4.83% of total deaths) under
five caused by diarrhea in Nepal in 2017 
 The prevalence of diarrhea within two weeks varied geographically across the
country, ranging from 3.7% to 9.0% in different provinces according to the
Nepal Demographic and Health Survey (NDHS) in 2016
 Diarrhea was most common among children age 6-11 months (15%)
 Nearly two-thirds of children under five with diarrhea were taken to a health
facility or providers for treatment or advice
 While 68% of children under five with diarrhea received ORT(oral rehydration
therapy ), 16% received no treatment.
 Only 10% of children under five with diarrhea received ORS and zinc
WHO 2017 REPORT / NDHS 2016
Causes of acute diarrhea/ differentials

 Infectious gastroenteritis :
 Bacterial : Escherichia coli: Enterotoxigenic, enteropathogenlc, enteroinvasive,
enterohemorrhagic types ,
 Shigellosis ( S. dysenteriae ,Shigella flexneri,Shigella boydii and Shigella
sonnei) = major cause of invasive or bloody diarrhea
 Vibrio cholerae serogroups 01 and 0139 Salmonella, Chiefly S. typhi and S.
paratyphi A, B or C , Campylobacter species

 Viral : Rotavirus ( most common cause of watery diarrhea in infants and young)
Human caliciviruses, Norovirus spp, Sapovirus spp, Others: Astroviruses,
coronaviruses, cytomegalovlrus, picornavirus

 Parasitic : Giardia lamblia, Cryptosporidium parvum, Entamoeba histolytica

UPTODATE
 Associated conditions : Systemic infections associated with diarrhea
include :
influenza, measles, dengue fever, human immunodeficiency virus infection,
malaria

 Serious bacterial infections associated with diarrhea include pneumonia,

urinary tract infection, meningitis, and sepsis

 Surgical emergencies such as intussusception or appendicitis also may

present with diarrhea

UPTODATE
 Physiologic : lactose intolerance
 Functional diarrhea: Often associated with excessive sugar or carbohydrate
intake
 Irritable bowel syndrome (diarrhea-predominant)
 Immune-mediated
 Common causes : •Celiac disease
•Inflammatory bowel disease
•Food protein-induced allergic
proctocolitis (eg, due to cow's milk)

 Fat malabsorption: Pancreatic exocrine insufficiency : Cystic fibrosis

 Drugs : Antibiotics (penicillins,cephalosporins,trtracyclines), non-antibiotics
( laxatives,NSAIDs etc)
 Mucosal malabsorption : Short bowel syndrome
 Congenital anomalies associated with bowel obstruction : Chronic
intestinal pseudo-obstruction, Hirschsprung disease, with enterocolitis
Risk Factors

 poor sanitation and personal hygiene

 no availability of safe drinking water
 unsafe food preparation practices
 low rates of breastfeeding
 Low immunization
 Young children
 Malnutrition

GHAI essentials of pediatrics

Complications
Complications Associated causes
Intestinal Complications:
Persistent diarrhea All causes
Recurrent diarrhea (usually Salmonella, Shigella , Yersinia, Campylobacter
immunocompromised persons) Clostridium difficile
Toxic megacolon Entamoeba histolytica
Intestinal perforation Cryptosporidium, Giardia
Rectal prolapse
Extraintestinal Complications:
Dehydration, metabolic abnormalities, All causes
malnutrition, micronutrient deficiency
Bacteremia with systemic spread(endocarditis, Nontyphoidal Salmonella, Shigella, Yersinia,
osteomyelitis, meningitis, pneumonia, Campylobacter
hepatitis, peritonitis etc )
Pseudoappendicitis

Postinfectious complications :
Reactive arthritis
HUS(hemolytic uremic syndrome )
GBS(guillain barre syndrome )
Glomerulonephritis ,myocarditis
Hemolytic anemia
NELSON’S TEXTBOOK OF PEDIATRICS
Salmonella, Shigella, Yersinia
STEC, Shigella dysenteriae 1
Campylobacter
Shigella, Campylobacter, Yersinia
Campylobacter, Yersinia
Assessment of child with diarrhea
 Goals :

 determine the type of diarrhea, i.e. acute watery diarrhea,

dysentery or persistent diarrhea
 look for dehydration and other complications
 assess for malnutrition
 Rule out non-diarrheal illness especially systemic infections
 Assess feeding

GHAI essentials of pediatrics

 History :
 Onset of diarrhea
 duration and number of stools
 Presence of fever, cough,or other symptoms
(e.g.convulsions )
 type and amount of fluids (including breast milk) and
food taken during illness and pre-illness feeding
practices
 drugs and other local remedies taken (including opiods
or antimotility drugs like loperamide that may cause
abdominal distension)
 immunization history
GHAI essentials of pediatrics
Examination :
 The most important assessment is for dehydration

 Look for :
 general condition
 Appearance of Eyes
 Ability to drink
 Skin turgor
 Capillary refill time

 Features of malnutrition

 Systemic infections
GHAI essentials of pediatrics
Laboratory investigations

 Stool microscopy
 Stool culture
 Complete blood count
 Renal function test
 Blood gas studies

GHAI essentials of pediatrics / UPTODATE

 Assessment of dehydration

Look at

General condition Well , alert Restless , irritable lethargic, unconscious

Eyes Normal Sunken Very sunken and dry

Tears Present Absent Absent

Mouth and tongue Moist Dry Very dry

Thirst Drinks normally Thirsty , drinks Drinks poorly or

Not thirsty eagerly unable to drink

Integrated Management of Childhood Illness

Feel

Skin pinch Goes back quickly Goes back slowly Goes back very
slowly

Decide No signs of If the patient has If the patient has

dehydration two or more signs, two or more signs,
there is some there is severe
dehydration dehydration
Treat Use treatment Plan use treatment Plan use treatment Plan
A B C urgently

Integrated Management of Childhood Illness

Integrated Management of Childhood Illness
Principles of Management

 rehydration and maintaining hydration

 ensuring adequate feeding
 oral supplementation of zinc
 early recognition of danger signs and treatment of
complications

GHAI essentials of pediatrics

The cornerstone of acute diarrhea
management is rehydration by using oral
rehydration solutions

Integrated Management of Childhood Illness

Treatment plan A
 Such children may be treated at home after explanation of
feeding and the danger signs to the mother/ caregiver
 The mother may be given WHO ORS for use at home

 Counsel the mother on the 4 Rules of Home Treatment:

1. Give Extra Fluid
2. Give Zinc Supplements (age 2 months up to 5 years)
3. Continue Feeding
4. When to Return

Integrated Management of Childhood Illness

 1. GIVE EXTRA FLUID (as much as the child will take)

TELL THE MOTHER:

 Breastfeed frequently and for longer at each feed.
 If the child is exclusively breastfed, give ORS or clean water
in addition to breast milk.
 If the child is not exclusively breastfed, give one or more of
the following: ORS solution, food-based fluids (such as soup,
rice water, and yoghurt drinks), or clean water
 TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE
MOTHER 2 PACKETS OF ORS TO USE AT HOME
 SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION
TO THE USUAL FLUID INTAKE

Upto 2 years 50-100 ml ORS after each loose stool

2 years and more 100-200 ml ORS after each loose stool
Integrated Management of Childhood Illness
  Tell the mother to:
 Give frequent small sips from a cup.
 If the child vomits, wait 10 minutes. Then continue, but more slowly
Integrated Management of Childhood Illness

 Continue giving extra fluid until the diarrhea stops

2. GIVE ZINC (age 2 months up to 5 years)
 TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab)
 SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS
 Infants- dissolve tablet in a small amount of expressed breast
milk, ORS or clean water in a cup.
 Olderchildren - tablets can be chewed or dissolved in a small
amount of water.
2 months up to 6 months 1/2 tablet daily for 14 days

6 months or more 1 tablet daily for 14 days

3. CONTINUE FEEDING (exclusive breastfeeding if age less than 6
months)
4. WHEN TO RETURN : Danger signs requiring medical attention are
those of :
 continuing diarrhea beyond 3 days,
 increased volume/frequency of stools,
 repeated vomiting,
 increasing thirst,
 refusal to feed, fever or blood in stools

Integrated Management of Childhood Illness

FLUIDS FOR PATIENTS WITH NO SIGNS OF
DEHYDRATION

Uptodate
Treatment plan B

 All cases with obvious signs of dehydration need

to be treated in a health center or hospital

 oral fluid therapy must be commenced promptly

and continued during transport

Integrated Management of Childhood Illness

 1) DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST 4
HOURS
WEIGHT <6 kg 6-10 kg 10-12 kg 12 -19 kg

AGE*
Up to 4 4-12 months 12 months to 2 2years -5 years
months years
in ML 200-450 450-800 800-960 960-1600

*Use the child's age only when you do not know the weight.
The approximate amount of ORS required (in ml) can also be calculated by multiplying
the child's weight (in kg) times 75
If the child wants more ORS than shown, give more.
For infants under 6 months who are not breastfed, also give 100 - 200 ml clean water
during this period if you use standard ORS. This is not needed if you use new low
osmolarity ORS.

Integrated Management of Childhood Illness

2) SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.
 Give frequent small sips from a cup.
 If the child vomits, wait 10 minutes. Then continue,
but more slowly.
 Continue breastfeeding whenever the child wants.

3) 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

Integrated Management of Childhood Illness

4) 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 enough ORS packets to complete rehydration
 Also give her 2 packets as recommended in Plan A
 Explain the 4 Rules of Home Treatment :
I. GIVE EXTRA FLUID
II. GIVE ZINC (age 2 months up to 5 years)
III. CONTINUE FEEDING (exclusive breastfeeding if age less than 6 months)
IV. WHEN TO RETURN

Integrated Management of Childhood Illness

Composition of commonly used fluids

Uptodate
Treatment plan C
 Intravenous fluids should be started immediately
 A total of 100 mL/kg of fluid is given, over 6 hours in
children 12 months and over 3 hours in children >12
months as shown below

Age 30ml/kg 70ml/kg

<12 month 1 hour 5 hour
>12 month 30 minutes 2.5 hour

Integrated Management of Childhood Illness

 Can you give
intravenous (IV) fluid
immediately? YES
NO
Is IV treatment
available nearby
(within 30 minutes)?
YES
NO
Are you trained to use
a naso-gastric (NG)
tube for rehydration
YES Reassess the child every 1-2 hours while waiting for transfer:
No
Refer URGENTLY to
hospital for IV or NG
Start IV fluid immediately. If the child can drink, give ORS by mouth
while the drip is set up. Give 100 ml/kg Ringer's Lactate Solution (or, if
not available, normal saline), divided as follows :
Reassess the child every 1-2 hours. If hydration status is not improving,
give the IV drip more rapidly.
Also give ORS (about 5 ml/kg/hour) as soon as the child can drink:
usually after 3-4 hours (infants) or 1-2 hours (children).
Reassess an infant after 6 hours and a child after 3 hours. Classify
dehydration. Then choose the appropriate plan (A, B, or C) to continue
treatment
Refer URGENTLY to hospital for IV treatment. If the child can
drink, provide the mother with ORS solution and show her
how to give frequent sips during the trip or give ORS by naso-
gastric tube
Start rehydration by tube (or mouth) with ORS solution: give
20 ml/kg/hour for 6 hours (total of 120 ml/kg).
If repeated vomiting or abdominal distension, give the fluid
more slowly. If hydration status is not improving after 3
hours, send the child for IV therapy
Unique problems in infants below 2
months of age:
 Breastfeeding must continue during the rehydration
process, whenever the infant is able to suck
 Complications like septicemia, paralytic ileus and severe
electrolyte disturbance are more likely in young infants
with diarrhea than at later ages
 Diarrhea in these infants should be ideally treated as
inpatient,
 This allows for careful assessment of need of systemic
antibiotics and monitoring

GHAI essentials of pediatrics

Nutritional Management of Diarrhea

 In exclusively breastfed infants, breastfeeding should

continue as it helps in better weight gain and decreases
the risk of persistent diarrhea
 Optimally energy dense foods with the least bulk,
recommended for routine feeding in the household, should
be offered in small quantities but frequently (every 2-3
hours)
 Staple foods do not provide optimal calories per unit weight
and these should be enriched with fat or oil and sugar, e.g.
khichri with oil, rice with milk or curd and sugar, mashed
banana with milk or curd, mashed potatoes with oil and
lentil
GHAI essentials of pediatrics
 Foods with high fiber content, e .g. coarse fruits and
vegetables should be avoided
 In non-breastfed infants, cow or buffalo milk can be given
undiluted after correction of dehydration together with
semisolid foods. Milk should not be diluted with water during
any phase of acute diarrhea. Alternatively, milk cereal
mixtures, e.g. dalia, sago or milk-rice mixture, are
preferable
 During recovery, an intake of at least 125% of recommended
dietary allowances should be attempted with nutrient dense
foods; this should continue until the child reaches pre-illness
weight and ideally until the child achieves a normal
nutritional status

GHAI essentials of pediatrics

Zinc Supplementation

 Intestinal zinc losses during diarrhea aggravate pre-

existing zinc deficiency
 Zinc supplementation is now part of the standard care
along with ORS in children with acute diarrhea
 It is helpful in decreasing severity and duration of diarrhea
and also risk of persistent diarrhea
 Zinc is recommended to be supplemented as sulfate,
acetate or gluconate formulation, at a dose of 20 mg of
elemental zinc per day for children >6 months for a period
of 14 days, 10 mg once daily for 2 months – 6 months

GHAI essentials of pediatrics /UPTODATE /IMCI

Symptomatic Treatment
 Vomiting : if severe give ondansetron (0.1-0.2 mg/kg/dose)
 Abdominal distention : if suspected paralytic ileus , which may
be due to hypokalemia, intake of anti-motility drugs, necrotizing
enterocolitis or septicemia , Nasogastric aspiration with iv fluids
given
 Potassium chloride (20-40 mEq/L) should be administered intravenously
with parenteral fluids provided the child is passing urine
 Convulsions : maybe due to hypo- or hypernatremia;
hypoglycemia, hypokalemia , encephalitis, meningitis, febrile
seizures
 The management depends on the etiology
GHAI essentials of pediatrics / UPTODATE
Drug Therapy
 Most episodes of diarrhea are self-limiting and do not
require any drug therapy except in a few situations
 Antibiotics are not recommended for routine treatment
 In acute diarrhea, antimicrobials are indicated in bacillary
dysentery, cholera, amebiasis and giardiasis
 Escherichia coli are normal gut flora and their growth on
stool culture is not an indication for antibiotics
 Diarrhea maybe manifestation of sepsis in a child , suspect
sepsis in a child with : (i) poor sucking; (ii) abdominal
distension; (iii) fever or hypothermia; (iv) fast breathing;
and (v) significant lethargy or inactivity in well-nourished,
well-hydrated infants
 such babies should be screened and given adequate days
of age appropriate systemic antibiotics for sepsis
 Antimotility agents : reduce peristalsis or gut motility and
should not be used in children with acute diarrhea
 Reduction of gut motility allows more time for the
harmful bacteria to multiply. These drugs may cause
distension of abdomen, paralytic ileus, bacterial
overgrowth and sepsis and can be dangerous, even
fatal, in infants
 Antisecretory agents : not enough data on it’s efficacy

 Probiotics: the routine use of probiotics m patients with

acute diarrhea is not recommended
 It has been shown to have some efficacy in reducing
duration of acute diarrhea if started in early phase of
illness, it’s efficacy is strain and concentration ( dose )
dependent
GHAI essentials of pediatrics/UPTODATE
Prevention of Diarrhea

 Proper nutrition

 Adequate sanitation : Three Cs; clean hands, clean

container and clean environment are the key messages

 Vaccination

GHAI essentials of pediatrics / UPTODATE

Take home message

 Assessment begins with assessing clinical condition of patient then

determining type of diarrhea , detailed history taking and physical
examination
 Assess severity of dehydration and treat accordingly
 ORS/fluid therapy is the cornerstone of management
 Routine lab investigations not performed unless clinically relevant
 Routine use of drugs including antibiotics not recommended
 Health education for prevention is important part of management
THANK YOU