Diarrhea in children

2. DIARRHEA DEFINITION
• The normal frequency and consistency of bowel
movements varies with a child's age and diet and
the definition of diarrhea varies accordingly.
• Diarrhea :
• excessive loss of fluids & electrolytes in stool,
Increase in liquidity.
• loose or watery stools, excessively frequent
stools, or stools that are large in volume.
• A more exact definition is excessive daily stool
liquid volume (>10 mL stool/kg body
weight/day).

3. • Frequency — It is normal for young infants to
have up to 3 to 10 stools per day, although this
varies depending upon the child's diet (breast
milk versus formula; breastfed children usually
have more frequent stools). Older infants,
toddlers, and children normally have one to two
bowel movements per day.
• Diarrhea can usually be defined as an increase in
stool frequency to twice the usual number per
day in infants, or three or more loose or watery
stools per day in older children.

4. • Consistency and color — The consistency and color of
a child's stool normally changes with age, which
highlights the importance of knowing what is normal
for your child. Young infants, especially those who are
breastfeeding, usually have soft stools. Their stools
may be yellow, green, or brown, and/or appear to
contain seeds or small curds.
• All children's stools can vary as a result of their diet.
Development of stools that are runny, watery, or
contain mucus is a significant change that should be
monitored. The presence of visible blood or black
stools is never normal and always requires medical
attention.

5. High risk groups
 Young age groups
 Immune deficient individuals
 Measles
 Malnutrition
 Travel to endemic areas
 Lack of breast feeding
 Exposure to unsanitary conditions
 Attendance to child care centers
 Poor maternal education

6. Causes and risk factors
• Microbial,
• Host and
• Environmental
factors interact to
cause GE
Diarrhoea pathogens
Environmental
factorsHost factors

7. Diarrhea Classification
• According to Pathogens.
• According to Duration.
• According to Mechanism of Diarrhea.
• According to clinical types of Diarrhea.

8. DIARRHEA CAUSES
• Infective, non-infective
• The most common cause of acute diarrhea is a
viral infection.
• Other causes include:
• bacterial infections,
• side effects of antibiotics, and
• infections not related to the gastrointestinal (GI)
system.
• In addition, there are many less common causes
of diarrhea.

9. • Acute diarrhea last<14days.
• When episode last >14days it is called chronic
or persistent diarrhea.
Diarrhea according to Duration

10. Mechanisms of diarrhea
• Osmotic: e.g Lactose intolerance
• Secretory: e.g Cholera
• Mixed secretory-osmotic: e.g Rotavirus
• Mucosal inflammation: e.g Invasive bacteria
• Motility disturbance

11. Clinical types of diarrhea
 There are 2 main clinical types of AD
 Each is a reflection of the underlying pathology and altered physiology
Clinical type Description
Nausea,vomiting,fever,abdominal
pain&cramp,diarrhea,tenesmus.
Common pathogens
Acute watery
diarrhoea
This is the most common. It is of recent onset,
commencing usually within 48 hours of presentation. It
is usually self limiting and most episodes subside within
7 days. The main complication is dehydration.
Rotavirus, Vibrio cholera
Acute bloody
diarrhoea
Also referred to as dysentery. This is the passage of
bloody stools. It is as a result of damage to the
intestinal mucosa by an invasive organism. The
complications here are sepsis,
HUS(hemolytic uremic syndrome), malnutrition and
dehydration.
Shigella spp, Entamoeba
histolytica

12. DIARRHEA EVALUATION
• The evaluation of diarrhea in children who do seek
medical evaluation requires a careful review of:
• Medical history, a
• Physical examination, and
• Diagnostic testing.
• The clinician will perform a thorough examination
because there are some infections unrelated to the
bowels (such as an ear infection) that can cause
diarrhea.
• Many tests are available to diagnose the cause of
diarrhea and to determine the severity of dehydration,
although most children will not require testing.

13. Assessment of the child with diarrhoea
History
 Ask the mother or other caretaker about:
 Duration of diarrhoea;
 Presence of blood in the stool;
 Number of watery stools per day;
 Number of episodes of vomiting;
 Presence of fever, cough, or other important
problems (e.g. convulsions, recent measles);
 Pre-illness feeding practices;
 Type and amount of fluids (including breast milk) and
food taken during the illness;
 Drugs or other remedies taken;
 Immunization history.

14. Clinical assessment
Physical examination:
General appearance
Hydration Status
Systemic Examination
Extra intestinal manifestations

15. NO DEHYDRATION SOME DEHYDRATION SEVERE DEHYDRATION

16. I) STOOL: MICROSCOPY : low sensitivity & specificity
a) leucocyte (>10/hpf )- Invasive diarrhea
b) RBC ,ova,Trophozoite or cyst.
c) culture & sensitive - persistent diarrhea
II) BLOOD TESTS
a) CBC
b) S. electrolyte
c) BUN & creatinine
III)GUE
IV) Others: Tests for specific diagnoses should be sent when
appropriate, such as serum antibody tests for celiac
disease or colonoscopy for suspected UC. A trial of
lactose restriction for several days is helpful to rule out
lactose intolerance, or a more specific test, such as
lactose breath hydrogen analysis, can be performed.
Laboratory investigations

17. Management
Treating dehydration is the corner stone in managing
diarrhea.(Oral rehydration therapy)
Feeding: Continue Breast feeding and routine normal
diet and energy dense feeds.
Hand washing after defecation & before meal alone
can reduce 40% of water & excreta related disease
Drug therapy has very little place
Antibiotic
Antisecretory
Antimotility.
Follow-up to ensure recovery

18. Treatment : home therapy to prevent
dehydration and malnutrition
Children with no signs of dehydration need
extra fluids and salt to replace their losses of
water and electrolytes due to diarrhoea. If
these are not given, signs of dehydration
may develop

19. Composition of standard and reduced osmolarity
ORS solutions
Standard ORS
solution
Reduced ORS
solution
(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

20. The advantages of this new reduced osmolarity ORS
solution
• It reduces stool output or stool volume by
about 25% when compared to the original
WHO-UNICEF ORS solution
• It reduces vomiting by almost 30%
• It reduces the need for unscheduled IV
therapy by more than 30%.

21. Management

22. warning signs
Take the child to a health worker if there are
warning signs of dehydration or other problems
• The child does not get better in three days.
• Starts to pass many watery stools;
• Has repeated vomiting;
• Becomes very thirsty; lethargy, poor urine output
• Is eating or drinking poorly;
• Develops high fever;
• Has blood in the stool;

23. Indications for IV therapy:
1. Depressed level of consciousness.
2. Moderate dehydration when there is no
improvement after the firs 4 hours of
treatment with ORS.
3. Severe dehydration
4. Uncontrolled vomiting, poor urine out put
5. Patients unable to drink from extreme
fatigue, stupor, or coma
6. Patients with Abdominal distention.

24. Composition of IV solutions:

25. Zinc in Diarrhea
• Zinc deficiency is common in developing countries and zinc is lost during
diarrhea
• Zinc deficiency is associated with impaired electrolyte and water
absorption, decreased brush border enzyme activity and impaired cellular
and humeral immunity .
• Treatment with zinc reduces the duration and severity of AD and also
reduces the frequency of further episodes during the subsequent 2-3 months
• WHO recommends that children from developing countries with
diarrhea be given zinc for 10-14 days
10mg daily for children <6 months
20 mg daily for children >6 months

26. Probiotics in the Treatment of
Diarrhea
Mechanisms:
1. Protect the intestine by competing with
pathogens for attachment.
2. Strengthening tight junctions between
enterocytes
3. Enhancing the mucosal immune
response to pathogens.

27. Antibiotic in Acute Diarrhoea
Indicated only for :
• Acute bloody diarrhea with gross blood
• Severe invasive bacterial diarrhea e:g Shigella
• Cholera,
• Associated systemic infection
• Severe malnutrition.
• Giardiasis ,Entamoeba hitolytica
• Suspected or proven sepsis
• Immuno compromised children
Antibiotics are contraindicated in:
E. coli 0157: H7 because they increase the risk of Haemolytic Uraemic syndrome (HUS)
Uncomplicated salmonella enteritis because they prolong bacteria shedding

28. Complications & consequences of
watery diarrhea:
o Dehydration.
o electrolyte disturbance.
o Base deficit acidosis.
o Malnutrition
o Persistent diarrhea
o Toxic illus
o Renal Failure.
o Hus(hemolytic uremic syndrome)
o DIC
o Convulsion
o Cerebral damage and cerebral venous thrombosis.

29. Extraintestinal manifestations
&complications
– Reactive arthritis :Salmonella ,shigella , Yersinia, C.difficile
campylobacter.
– Guillain-Barre Syndrome: campylobacter.
– Glomerulonephritis:Shigella , campylobacter ,Yersinia
– IgA nephropathy :campylobacter
– Erythema nodosum: Yersinia ,campylobacter, salmonella
– Hemolytic anemia : Yersinia ,campylobacter
– HUS(hemolytic uremic syndrome): shigella , E. coli
– Focal infections e:g:
UTI,Pneumonia,osteomylitis,meningitis …(parantral
diarrhea).

30. How can we prevent diarrhoeal
disease?
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 with zinc