What is Diarrhea ?

Types of serious diarrhoea in childrenAcute watery diarrhea- If <14 days ,sever

dehydration Ecoli,cholera ,malnutrition

Persistent diarrhea-If >14 days, 20-30 % death, under nourished and HIV exposed

Dysentery-(atisar) with blood ,with or without mucus 10%-15 % of deaths

Why are children more prone to diarrhoeaProportion of water is more in children ,so

dehydration occur early.Metabolic rate is high and use more water as

compared to adultsKidney can conserve less water ,so loss is

more Sodium loss can be 70-110 m mol/kgChloride and potassium loss is balanced

&same

Assessment of diarrheaDid child vomit? Did child pass urine? What type of liquids did the child get ?Did the child get sufficient food before this

episode ?During diarrhea is child getting food that is

different and is less calorie dense? Look for cough ,fever ,otitis

media ,sepsis ,h/o measles Weight /nutrition

ASSESS:

Degree of Dehydration

DECIDE:

Plan of treatment

Does the child have diarrhea?

If yes, ask:For how long? How many? Has the child been vomiting Is there blood in stool?

LOOK AT THE CHILD’S GENERAL CONDITIONIS THE CHILD◦ Lethargic or Unconscious?◦ Restless or Irritable?

LOOK FOR SUNKEN EYES Look for skin pinch -goes back

promptly/slowly/ very slowly OFFER THE CHILD FLUID TO DRINK –THIRSTY Not able to drink or drinking poorly?

Drinking eagerly, appears thirsty?

Drinking normally?

LOOK

Look at Eyes for Dehydration Shrunken Eyes Normal eyes

Two or more of the following

Degree of dehydration decided on:

•Restless, Irritable

•Sunken Eyes

•Drinks eagerly, Thirsty

•Skin Pinch goes back “slowly”

Some Dehydration Severe Dehydration

•Lethargic or unconscious

•Sunken Eyes

•Not able to drink or drinking poorly

•Skin Pinch goes back “very slowly”

OR NO DEHYDRATION

No Dehydration: PLAN-A

Some Dehydration: PLAN-B

Severe Dehydration: PLAN-C

Treat Diarrhea at Home.

4 Rules of Home Treatment:

GIVE EXTRA FLUID

CONTINUE FEEDING

WHEN TO RETURN [ADVICE TO

MOTHER]

GIVE ORAL ZINC FOR 14 DAYS

PLAN – A

Plan-B is carried out at ORT Corner in

OPD/clinic/ PHC

Treat ‘some’ dehydration with ORS (50-100

ml/kg

If the child wants more, give more

After 4 hours:

Re-assess and classify degree of dehydration.

PLAN – B

PLAN -CSigns of sever dehydration Child not improving after 4 hours

Refer to higher center –give ORS on way /keep warm /BF

When child comes back follow up as other children

Start I. V. Fluid immediately

PLAN – C

Dysentery

Cholera

Severe malnutrition

Associated systemic infection

Antimicrobials should be given during diarrhea only for:

Increase amount of calories during convalescence with

energy dense foods (enrich foods with fats and sugar)

•Feed an extra meal (for at least 2 weeks after diarrhea

stops)

•Give an extra amount

•Use extra rich foods

•Feed with extra patience

•Give extra breastfeeds as often as child wants

Increase amount of calories during convalescence with

energy dense foods (enrich foods with fats and sugar)

•Feed an extra meal (for at least 2 weeks after diarrhea

stops)

•Give an extra amount

•Use extra rich foods

•Feed with extra patience

•Give extra breastfeeds as often as child wants

What Is ORS

PRINICIPLE OF ORSThe sodium-coupled co-transport with

glucose and other carrier organic solutes remains intact, even with viral enteritis associated with epithelial damage .

Ingredient Standard WHO ORS mmol/l

Reduced osmolarity ORS mmol/l (2002)

Glucose 111 75

Na 90 75

K 20 20

Cl 80 65

Citrate 10 10

Osmolarity mOsm/kg

311 245

Limitation of high osmolarity ORS

Does not lower volume, frequency and duration of diarrhoea.

Induces vomiting due to taste, so acceptability poor.

More chances of dehydration, more chances of requiring iv fluid.

Hypernatremia.Good to correct fluid deficit, not good for

maintenance fluid.

LOW OSMOLARITY ORSCompared to WHO standard ORS , hypo-

osmolar ORS is associated with

a) fewer unscheduled intravenous fluid infusions(33%)

b)lower stool volumes (20%), and

c) less vomiting(30%)

Clinical relevance - low osmolarity ORSReduction in need of IV therapy results in

reduced hospitalization and in turn results:

Reduced risk of hospital acquired infections.

Reduced disruption of breastfeeding. Reduced use of needles and interventions Reduced therapy cost. Reduced risk of diarrheal deaths in areas

where IV therapy is not readily available.

Rice-based ORS, Maltodextrin-containing and Amino acid-containing ORS—SUPER ORS

They are not superior to glucose-based ORS for acute non-cholera diarrhea, provided that feeding was promptly resumed after initial rehydration of the child. 

Flavored/Colored ORS Studies showed neither an advantage nor

disadvantage for the flavoured and coloured ORS when compared to the standard ORS with regard to safety, acceptability and correct use.

Concerns about the type of sweetners ,coloring and flavouring agents used.

More expensive

Limitations for ORS

Altered mental status with concern for aspiration

Abdominal ileusUnderlying disorder that limits intestinal

absorption of ORT (e.g, short gut, carbohydrate malabsorption)

PRACTICAL PROBLEMSVomiting: Give less amount more

frequently,wait for 10 minutes and try again.Give food in the form of Kanji,Amylase rich food.

Taste: It is a MEDICINE and the most important medicine in diarrhea. Convince the parents. First drug in your prescription.

If affording, flavoured ORS may help.

ORS IV fluids Once ORT has been initiated, intervention

with intravenous hydration is indicated:

If stool output continues to be excessive, and ORT is unable to adequately rehydrate the child

If there is severe and persistent vomiting, and inadequate intake of ORS

WHO Statement2006: The World Health Organization states

that, “there is no evidence to support the ongoing use of IV therapy for the first-line management of most cases of childhood gastroenteritis.”

Safe & effectiveCan alone successfully rehydrate 95-97% patients with diarrhea,

Reduces hospital case fatality rates by 40 - 50%

Cost savingReduces hospital admission rates by 50% and cost of treatment by 90%

39% reduction in need for unscheduled IV fluids

19% reduction in stool output

29% reduction in vomiting

Hahn et al, 2001; WHO/FCH/CAH 0.1.22, 2001

Should be given to young infants (< 2m) including neonates

if there is dehydration

In exclusively breastfed young infants with no dehydration

encourage exclusive breastfeeding more frequently and for

longer

Low osmolarity ORS is safe and effective for all ages

Advice to parentsStoringHow to give Measuring Home remedies

WHY ZINC?

IZiNCG advocacy statement (http://www.izincg.org/pdf/IZiNCG_Advocacy-PrintingFormat.pdf)

Zinc deficiency is widespread in low and middle income countries like India

Disrupts intestinal mucosa

Reduces brush border enzymes

Increases mucosal permeability

Increases intestinal secretion

Roy 1992, Hoque 2005

Zinc deficiency has direct effects on mucosal functions

20 mg/day (10 mg/day for infants 2-6 mo) of zinc supplementation for 14 days starting as early as possible after onset of diarrhea

WHO/UNICEF Joint statement (2001), IAP 2003, GOI 2007

Recommendations for Use of Zinc in Acute Diarrhea

Preventing and Treating Diarrhea

THANK YOU