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Diarrheal diseases in children

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Acute diarrhea in children
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Diarrheal diseases in children

  1. 1. Diarrheal Diseases in Children Dr .Tazebew T.(MD)
  2. 2. Brainstorming questions 1)How do you define diarrhea in children? 2)How to differentiate small bowel diarrhea from large bowel diarrhea? 3)What are the commonest causes of diarrhea in children ?(bacteria,viruses,protozoa…) 4)What are the management principle of diarrhea in children? 5)Mention some of complications of diarrhea in children?
  3. 3. Outline o Definition and Classification o Epidemiology o Etiology o Pathophysiology and manifestations o Complications o Management o Prevention
  4. 4. Definition and classification • Diarrhea  Passage of > 3 loose stools/day or watery stool of any frequency or >10ml/kg/day in infants ,in older children >200gm/day o Classification: Acute watery - acute onset, no mucus or blood and lasts less than 14days Persistent - starts acutely , watery and lasts > 14days Severe persistent –persistent diarrhea with any form of dehydration
  5. 5. Cont… Dysentery – blood in the stool ( historical, witnessed, microscopy) • It is often associated with fever ,frequent small stool ,urgency, abdominal pain and tenesmus. • Common clinical features of dysentery include anorexia, rapid weight loss • Complications like renal failure and encephalopathy
  6. 6. Epidemiology • One of the leading causes of morbidity & mortality in children • Causes about 2 million deaths annually in children of under five ˷80% of these deaths occur in children in the first 2 years • Common in children of age below 5yrs • Peak incidence is during the age of 6-11months? o Age of complementary feeding o Related with developmental age o Declining levels of antibodies acquired from the mother • Major route of transmission is feco-oral or ingestion of contaminated food or water
  7. 7. Risk factors A. Host factors  Inappropriate breast feeding practice – no EBF for the 1st 6months – early interruption , bottle feeding  Unsanitary food preparations  Lack of immunization  Young age  Measles infection  Malnutrition  Immunocompromization  Vit A and Zinc deficiency
  8. 8. Risk factors cont… B. Environmental factors • Seasonality • Inadequate food intake due to different reasons • Poverty and poor living conditions • Poor domestic and environmental sanitation especially unsafe water
  9. 9. Etiology I. Non-Infectious  Anatomic defects - short bowel syndrome, villus atrophy  Malabsorption- disaccharidase deficiency, Celiac disease  Food allergy/intolerance II. Infectious 1. Inflammatory  Usually caused by bacteria that invade intestine directly or produce cytotoxins 2. Non-inflammatory  through enterotoxin production by some bacteria, villus destruction by viruses or adherence by parasites
  10. 10. Infectious etiology A. Bacteria Shigella Salmonella Vibrio cholerae E.coli Campylobacter jejuni Clostridium difficile B. Viruses  Rota virus  Astro agent  Calici virus  Enteric Adeno virus  CMV(in immunocompromized)
  11. 11. Etiology cont… C. Parasites Gardia lamblia Entamoba histiolytica Strongyloidiasis Isospora belli Cryptosporidium prvum D. Fungi  Candida albicans
  12. 12. Etiologies of dysentery • Shigela spp. • Invasive Eschericha coli • Campylobacteriosis (Campylobacter jejuni) • Amebic dysentery (Entamoeba histolytica) • Bilharzial dysentery (Schistosoma japonicum, Schistosoma mansoni) • Salmonellosis (Salmonella typhimurium) • Typhoid fever (Salmonella typhi) • Enteric fever (Salmonella choleraesuis, Salmonella paratyphi)
  13. 13. Pathophysiology • The basis of all forms of Diahhrea is disturbed intestinal solute transport • Movement of water across intestinal membranes is passive and determined by both active & passive fluxes of solutes particularly Na, Cl, and Glucose
  14. 14. Mechanisms of diarrheal diseases I. Secretary  Through increase in cAMP, CGMP or Calcium  Decreased absorption and increased secretion  Doesn't stop with fasting E.g. cholera, toxigenic E.coli, VIP II. Osmotic  maldigestion, ingestion of unabsorbable solutes  It stops with fasting e.g. Lactase deficiency, glucose malabsorption, lactulose
  15. 15. Cont… III. Decreased absorptive surface e.g. Rota virus, short bowel syndrome,Celiac disease IV. Motility disorders e.g. increased motility with decreased transit time ( thyrotoxicosis, irritable bowel syndrome---) or stasis with proliferation of pathogens
  16. 16. Clinical manifestations GI– nausea, vomiting, diarrhea, abdominal cramp Systemic– loss of appetite, myalgia, UTI, endocarditis, meningitis Symptoms and signs of dehydration Immune-mediated—extra intestinal manifestations e.g.  Reactive arthritis - Salmonella, Shigella, C.jejuni  Guillain Barre Syndrome - C.jejuni  HUS - E.coli, Shigella
  17. 17. Complications • Dehydration & Shock • Acute renal failure • Malnutrition • Sepsis, DIC • Metabolic acidosis • Paralytic ileus • Convulsions and coma (electrolyte disturbance, cerebral thrombosis) • Persistent diarrhea
  18. 18. Dysentery • Diarrhoea presenting with loose frequent stools containing blood. • Most are due to Shigella and nearly all require antibiotic treatment. • Diagnosis  It mainly through its clinical picture. • Other findings on examination may include: ■ abdominal pain ■ fever ■ convulsions ■ lethargy ■ dehydration ■ rectal prolapse.
  19. 19. Complications of dysentery • Electrolyte imbalances • Convulsions • Hemolytic uremic syndrome (HUS) • Leukemoid reaction • Toxic megacolon • Protein losing enteropathy • Arthritis • Perforation
  20. 20. A) Isotonic dehydration  This is the most type of dehydration Losses of water and Na are in the same proportion There is a balanced deficit of water and Na • Serum Na concentration is normal (130-150 m mol / l ) • Serum osmolality is normal (275-295) • Hypovolemia occurs as a result of loss of extra cellular fluid
  21. 21. B) Hypernatremic dehydration  There is loss of water excess of Na It is usually results from ; ingestion of hypertonic fluid that not efficiently absorbed  Insufficient intake of water or low –solute drink • Serum Na concentration is elevated (>150 mmol/l) • Serum osmolality is elevated (>295m osmol/l ) • Thirst is severe and the child is very irritable • Sezures may occur (Na >165 mmol /l)
  22. 22. C) Hyponatremic dehydration  There is loss of Na excess of water • It is usually from drinking large amounts of water or hypotonic fluid with low Na or • IV infusion 5%glucose without Na • There is deficit of water and Na but the deficit of Na is greater • Serum Na concentration is low (<130 mmol /l) • Serum osmolality is low (<275 mosmol /l) • The child is lethargic , infrequently seizures
  23. 23. Hypokalemia  Patients with diarrhea often develop K depletion • The signs of hypokalemia may include ; – General muscular weakness – Cardiac arrhythmias – Paralytic ileus
  24. 24. Evaluation  Hx  type of diarrhea Vomiting (character) Fever Associated illness e.g. cough, rash, UTI Urine out put Abd.pain/distension Hx of seizure Previous Hx of similar ilnes Feeding Hx Developmental Hx Immunization Social & family Hx Antibiotics exposure Any similar illnes in the vicinty
  25. 25. Physical exam • General examination and V/S • Look for signs of: A. water loss Loss of skin turgor Weak/absent pulse Tachycardia Sunken eyes Sunken fontanel Delayed capillary refilling Cold skin Anuria, oliguria mental changes
  26. 26. Cont… B. Loss of nutrients Hypoglycemia Convulsions, mental changes C. Loss of bicarbonate Vomiting & retching Deep respiration Decreased myocardial contractility D. Potassium loss Abdominal distension Paralytic ileus
  27. 27. Cont… • Stool microscopy/culture – Dysentry, Epidemic (?cholera) – Persistent diarrhea – Suspected septicemia – Immunosupressed child Assess for Dehydration:  The 4 important signs in well -nourished child are: 1. Mental status 2. Eye ball 3. Drinking 4. Skin turgor
  28. 28. Classification of dehydration: Two signs needed Parameter No dehydration Some dehydration Severe dehydration Mental status Alert Restless, irritable Lethargic or unconscious Eye ball No sunken eyes sunken eyes sunken eyes Drinking Drinking normally Eager to drink Unable to drink Skin turgor Normal skin turgor Skin pinch returns slowly Skin pinch returns very slowly
  29. 29. Skin pinch/skin turgor Pinching the child’s abdomen to test for decreased skin turgor
  30. 30. Work up • The following investigations directed to diarrhea can be done in hospitals  Stool examination (microscopy)  Stool Culture &Sensitivity test  Serum electrolytes  Random blood sugar  CBC (Hct, WBC with differential, platelet count)  Peripheral RBC morphology  RVI screening  BUN, creatinine
  31. 31. Management of dehydration 1. No DHN– Mx plan A  Treat diarrhea at home:  Rules of 3 ‘Fs’, 4 Rules 1. Give extra FLUID 2. Continue FEEDING 3. When to come for FOLLOW UP 4. Supplemental Zinc
  32. 32. Cont… • Fluid – in addition to the usual fluid intake give ORS: 10ml/kg OR 50-100ml for those below 2yrs per bowel 100-200ml for children > 2yrs motion  Other fluids; breast milk, food-based fluids(soup, rice water , yogurt) or clean water • Unsuitable fluids: commercial carbonated beverages, commercial fruit juices ,sweetened tea, coffee and some medicinal teas or infusions.
  33. 33. Cont… • Feeding- frequent breast feeding -cow’s milk or formula - continue other foods if he started • Return/follow up-see him in 2days  come back immediately if the child becomes sick(unable to drink, repeated vomiting, sicker ,fever, dysentery)
  34. 34. Cont… B. Some DHN– plan B, loss is estimated to be 5%-10% of body weight Treat with ORS: Volume is 75ml/kg Give over 4hrs Continue breast feeding If vomiting, wait for 10minutes After 4hrs, reassess and classify DHN
  35. 35. ORS inappropriate for • Paralytic ileus • Frequent emesis • Abdominal distension • Patients who are in shock • Initial treatment of Severe dehydration because fluid must be replaced very rapidly • Patients who are unable to drink
  36. 36. Cont… C. Severe DHN- • Treatment plan C-loss estimated to be ≥10% of body weight • Start IV immediately • Ringer’s lactate or NS • Volume is 100ml/kg
  37. 37. Mx of severe dehydration Infants (below 12months of age) 1st give 30ml/kg over 1hour (repeat if no response *) Then give 70ml/kg over 5hrs Children>12mont hs of age Over 30minutes (repeat if no response *) Over two and half hours
  38. 38. Case presentation • The following example describes how to treat a child with SEVERE DEHYDRATION according to Plan C. • A six-month old (9 kg) girl, Eleni, had diarrhoea with SEVERE DEHYDRATION. • She was not in shock and did not have severe malnutrition. • She was not able to drink. The health worker decided to treat the infant with IV fluid according to Plan C
  39. 39. • The health worker gave Eleni 270 ml (30 ml x 9 kg) of Ringer’s lactate by IV during the first hour. • Over the following five hours, he gave her 630 ml of IV fluid (70 ml x 9 kg), approximately 125 ml per hour. • The health worker assessed the infant’s hydration status every 1-2 hours (that is, he assessed for dehydration). • Her hydration status was improving, so the health worker continued giving Eleni the fluid at a steady rate
  40. 40. • After 4 hours of IV treatment, Eleni was able to drink. • The health worker continued giving her IV fluid and began giving her approximately 45 ml of ORS solution to drink per hour.
  41. 41. • After Eleni had been on IV fluid for 6 hours, the health worker reassessed her dehydration. She had improved and was reclassified as SOME DEHYDRATION. • The health worker chose Plan B to continue treatment. The health worker stopped the IV fluid. • He began giving Eleni ORS solution as indicated in Plan B.
  42. 42. DHN management follow up sheet d a t e Time B p P R RR T0 CNS WT UOP Skin pinch Capillary refill - - - _ _ _ Wt and mental status are the most important sign of improvement in the absence of fluid overload where as improvement from sunken eyeball takes time .
  43. 43. ORS The formula for ORS recommended by WHO/ UNICEF contains Reduced osmolarity ORS Grams / litre Reduced Osmolarity ORS mmols/litre Sodium chloride 2.6 Sodium 75 Glucose, anhydrous 13.5 Chloride 65 Potassium chloride 1.5 Glucose, anhydrous 75 Trisodium citrate, dihydrate 1.9 Potassium 20 Citrate 10 Total osmolarity 245
  44. 44. Zinc supplementation • Zinc deficiency is common in developing countries and zinc is lost during diarrhoea and associated with: – impaired electrolyte and water absorption – decreased brush border enzyme activity – impaired cellular and humoral immunity • Zinc supplementation – reduce duration and severity of diarrhea – increased use of ORS and reduction in the inappropriate use of antimicrobials – Reduce recurrence with in 2-3 months – It helps for epithilization – 10 mg/day for infants <6 mo of age and 20 mg/day for those >6 mo for 10 days
  45. 45. Vitamin A Usually given for patients with diarrhea who had a)measles infection b) malnutrition Vitamin A(dosing)  50,000 IU for children less than 6 months  100,000 IU for 6 – 12 months and  200,000 IU for those older than 12 months
  46. 46. • Anti diarrhoeal drugs and anti-emetics should not be given to young children with acute or persistent diarrhoea or dysentery • They do not prevent dehydration or improve nutritional status • Some have dangerous, sometimes fatal, side- effects.
  47. 47. • ondansetron is an effective and less-toxic antiemetic agent . • Because persistent vomiting can limit oral rehydration therapy, a single sublingual dose ondansetron (4 mg 4-11 yr and • 8mg for children older than 11 yr [generally 0.2 mg/kg]) may be given. • However, most children do not require specific antiemetic therapy; • careful oral rehydration therapy is usually sufficient
  48. 48. Antibiotics should not be used for children with acute bloody diarrhea unless a specific pathogen has been isolated.  Antibiotic therapy may be a risk factor for the development of hemolytic uremic syndrome in patients with bloody diarrhea due to E. Coli O157:H7, which may be indistinguishable from bloody diarrhea seen with other non E Coli bacterial etiologies
  49. 49. Antibiotics? • Dysentery • Suspected cholera • Suspected or proven sepsis • Associated non-gastrointestinal infections like pneumonia, meningitis, UTI • Associated malnutrition
  50. 50. Antimicrobial agents Type of diarrhea Antimicrobial agents Shigellosis Cotrimoxazole Ciprofloxacin Ceftriaxone Cholera Tetracycline or Doxycycline (adults and older children) Erythromycine Ciprofloxaciline Amebiasis Metronidazole /tinidazole
  51. 51. Prevention This involves intervention at two levels: • Primary prevention (to reduce disease transmission) – Rotavirus and measles vaccines – Hand washing with soap – Providing adequate and safe drinking water – Environmental sanitation • Secondary prevention (to reduce disease severity) – Promote breastfeeding – Vitamin A supplementation – Treatment of episodes of AD with zinc  summarized by the “ 5F” diagram (as it involve: Feces, Food/Fluid , Flies, fomites (utensils) and Finger)
  52. 52. Take home message • Diarrhea is one of leading cause of under 5 mortality • Classification of DHN as NO, SOME and SEVERE is important for management • Antibiotics ,antiemetics and antimotilty agents shouldn't not be given routinely.
  53. 53. Home assignment 1)A one-year old girl has a two-day history of diarrhea and vomiting. Her weight is 6.5 kg. She is restless and irritable. Her airway and breathing are OK. AVPU=voice. Skin pinch lasts 4 seconds. Her eyes are sunken and the mother confirms this fact. How do you manage her?
  54. 54. AMESEGNALEHU!!!