Diarrhea in Infants and Children PDF

I Diapers Leoutput Diarrhea and Gastroenteritis always take feeding history September 7th, 2022 Important details about formula feeding that you MUST know. There is no formula milk that can replace breast mil...

I Diapers Leoutput Diarrhea and Gastroenteritis always take feeding history September 7th, 2022 Important details about formula feeding that you MUST know. There is no formula milk that can replace breast milk because of many factors like it contain all the thing the baby needs, there are timely changes according to the need of the baby (daily changes and even hourly changes), it contains normal flora bacteria which will colinize baby’s GIT tract and also it contains IgA to give the baby immunity (protects agains gastroenteritis) and so much more. So always advise to allllllllllll the mothers to breastfed her baby. If she insists formula feeding or having formula as a supplementary feeding, know the following: How many feeding bottles to have? How to clean them? Well, ideally speaking the mother has to have same number of bottles as number of feeding times per day PLUS one. So if she feeds her baby 6 times a day, she needs 7 bottles (and this is technically and financially difficult to achieve. The bottle has to be cleaned after each feeding, mother need put the bottle in boiled water for 15 min but the tip of bottle only 5 minutes. Then you will keep the boiled water in the bottle, close the tip on it, and put it in refrigerator until next day feeding time. T How much does the baby need? How to prepare? You will put one measure (‫ )رقم‬of water in the bottle THEN put one level scoop of milk in it and mix them. 1 ounce or Oz of water = 30 mL, when you put milk in it, contains 20 KCal of energy. Always add milk to the water and NOT water to the milk, because it will make the measurements wrong. All feeding bottles are labelled for this formulation. Baby needs 80-120 KCal / Kg / day (average is 100) 100kcal Ky day E.g a 4 Kg baby needs 320 - 480 KCal / day, we will divide by 20 to get the measures / day, so 16 - 24 measures to be given per day. Now the frequency of feeding really depends on the age but generally for early (3-4) months baby needs to be fed about 8 times a day (feed her baby every 2-3 hours). Yip So divide that result by 8, it will become 2 - 3 measures per time of feeding. And so the mother has to fed her 4 Kg baby 8 times a day each time preparing around 2.5 measure (can be 2, can be 3). If you do a little math, you can make this a little easier. Each Kg needs 4-6 measures per day. ( How do you know the baby is well fed? Bottle I The baby usually gets comfortable after each feeding, does not cry, and the rooting reflex disappears. He/she will sleep around 2 hours after each fed. measure I -> lounce ML 30 20 K Cal Causes of seizue in a patient with diarrhea? Very important: - Dehydration I - Fever (Febrile seizures) - Electrolyte disturbances (hyper/hypo nateremia) Hemay - Hemolytic Uremic Syndrome (can lead to uremic encephalopathy or hypertensive encephalopathy both from renal injury) shigellaToxin Econ - Parentral diarrhea (like a paitent with meningitis can have diarrhea as a symptom of that but also convulsions as a manifestation of meningitis and not diarrhea). Idiarrhea causedby infections that Coronet systemic conditionor housein ite entity Diarrhea->K* ilews distension & vomiting severe - Paralytic -> -dirman adminted bloody - than become dimorman do DRE -> see current jelly stool. -> intussusception, ->  Diarrhea  Definition: Areovers fluidervolumesfor An increase in the fluidity, volume and frequency of stools. -t variable in children, eso breastfeeding ones depends on hydration status, consistency of Steel & Weather Painful or not Acute diarrhea: a  Short in duration (less than 2 weeks). A  Chronic diarrhea: Persistent more than 2 weeks  Mechanisms of Diarrhea  Osmotic  Secretory  Exudative (Inflammatory) Exudation Inflant  Motility disorders mechanisms ofdiarrhea it Mechanisms of Diarrhea  Osmotic withertion Ethel Mdma Defect present: Digestive enzyme deficiencies Ingestion of unabsorbable solute Examples: Viral infection C. Lactase deficiency Sorbitol/magnesium sulfate ( cathartics] Infections Comments: Stop with fasting , ↑ with food No stool WBCs  Mechanisms of Diarrhea  Secretory: diarrhea even when fasting Defect: Increased secretion C Decreased absorption 7 Examples: Cholera cholfe.ca Toxinogenic E.coli ETEC Comments: Persists during fasting ☆ No stool leukocytes  Mechanisms of Diarrhea  Exudative Diarrhea: Defects: Inflammation Decreased colonic reabsorption Increased motility Examples: Bacterial enteritis Comments: x̅ Blood, mucus and WBCs in stool  Mechanisms of Diarrhea  Increased motility: Defect: Decreased transit time Example: Irritable bowel syndrome  Causes of acute diarrhoea in infancy and childhood Non-enteric causes: otitis media. Meningitis, sepsis generally Parenteral diarrhea Non-infectious causes: milk/food allergies, drug side f. effects, malabsorption Infections of the gastrointestinal tract Rotavirus Enteral Diarrhea Infantile gastroenteritis: principal causes Escherichia coli E Coli -enteropathogenic EPEC -enterotoxigenic ETEC time -enteroinvasive EIEC Viruses more common 50-70 % T -rotavirus Valenw -Noroviruses (Norwalk like)  causes integtmen Enterptitt Enteropathogenic Esch coli (EPEC) c - Small intestine affected Local destruction of intestinal epithelial cells - Causes infantile diarrhoea Pediatric Fever, nausea, vomiting, non-bloody stools Self-limiting to Supportive care, no specific antibiotic treatment EPEC Cont’d More than 20 (O) serotypes have been identified in outbreaks of infantile diarrhoea May affect maternity or neonatal units Adherence and colonizing factors appear important in pathogenesis (no toxin) Enterotoxigenic Esch coli - )nfant diarrhoea, Travelers diarrhoea Cause low grade fever, nausea, watery diarrhoea, cramps Small bowel affected waters Heat labile enterotoxin with cholera like effect ↑ secretion  Heat stable toxin ↓ absorption Fluid and electrolyte loss  Inn largeBowl Enteroinvasive Esch coli (EIEC) → Fever, watery diarrhoea, cramps Develops to (bacillary) dysentery, bloody stools Large bowel affected, by invasion and local destruction of epithelial cells Not enteropathogenic serotypes or enterotoxin producers Viral gastroenteritis YU Frequent cause of infantile gastroenteritis Up to 50% of cases caused by rotaviruses in under 3 year olds a Short incubation of 2-4 days 2 4 Presents as acute diarrhoea of mild to moderate severity, may be vomiting More common in winter months FEeqt.tn Diagnosed by detection of rotavirus antigen in stool Supportive care be azincthropistegived  and Other viruses causing infantile gastroenteritis Noroviruses Norwalk like viruses and Sapoviruses are 2 genera of the family Caliciviridae (Small round structured viruses (SRSV)) Astroviruses Adenoviruses Management of infantile gastroenteritis Replacement of fluid and electrolytes Supportive Antibiotics don t alter course of the infection Notindicated May be prevented by breast feeding babies A vaccine under development 1 Rota Vaccine available now weird givewiresto we Infantile gastroenteritis: other infectious causes Salmonella spp: usually food poisoning species, can cause outbreaks on units Note: enteric fever species also can cause this b presentation Styphi - Shigella spp: cause bacillary dysentery Campylobacter jejuni Giardia lamblia hemolytic complicationof oiarrine Uverni syndrome  severe abdominal cramps Enterohemorrhagic E coli HI Blgmm Enterohaemorrhagic Esch coli Haemorrhagic colitis with severe abdominal cramps, watery then bloody diarrhoea Cause Haemolytic Uraemic Syndrome (HUS) Dt ( Typical ) Often caused by E coli 0157 1-17 01570 EMEI Children more affected with renal failure Antibiotics don t alter course ( ↑ ) risk of HUS Haemolytic uraemic syndrome May follow uncomplicated diarrhoeal 0 illness Haemolytic anaemia, acute renal failure, thrombocytopenia Caused by verocytoxin (VTEC) same as S dysenteriae type 1 toxin Identified in microbiology lab as sorbitol non fermenting strains urine output edema TNN Fatigue Pallor briving bleeding Petesia HUS  Most outbreaks due to strain O157:H7 = EHEC = VTEC = STEC  A large outbreak occurred in Scotland 1996 associated with consumption of meat contaminated by organism  Many deaths in elderly people  Source was cattle  Control by good hygiene practices is most Diarrhea severe in extras 22 us Cryptosporidiosis Protozoa A self limiting diarrhoeal illness in children watery Accompanied by nausea and vomiting Acquired by drinking contaminated water containing cysts of Crypto parvum Its very resistant to chlorination Source is infected cattle A more severe illness occurs in immunocompromised (AIDS) Diagnosed by finding cysts in stool acid fast or PCR or Ag No specific treatment Gastrointestinal infections associated with travel (common) Enterotoxigenic Esch coli Travellers diarrhoea _ Salmonella and Campylobacter spp (food poisoning) Shigella spp ( Bacillary dysentery) 152 SEC TION II ` MICROBIOLOGY—PARASITOLOGY MICROBIOLOGY ` MICROBIOLOGY—PARASITOLOGY  Giardia lamblia (giardiasis) Protozoa—gastrointestinal infections ORGANISM DISEASE TRANSMISSION DIAGNOSIS TREATMENT Giardia lamblia Giardiasis—bloating, flatulence, Cysts in water Multinucleated Metronidazole foul-smelling, nonbloody, trophozoites A or fatty diarrhea (often seen in Steatorrhea cysts B in stool, Tian campers/hikers)—think fat-rich antigen detection, Ghirardelli chocolates for fatty PCR stools of Giardia Entamoeba Amebiasis—bloody diarrhea Cysts in water Serology, antigen Metronidazole; histolytica (dysentery), liver abscess testing, PCR, and/ paromomycin or (“anchovy paste” exudate), RUQ or trophozoites iodoquinol for pain; histology of colon biopsy (with engulfed asymptomatic cyst shows flask-shaped ulcers C RBCs D in the passers cytoplasm) or cysts with up to 4 nuclei in stool E ; Entamoeba Eats Erythrocytes 0 10 Cryptosporidium Severe diarrhea in AIDS Oocysts in water Oocysts on acid-fast Prevention (by Mild disease (watery diarrhea) in stain F , antigen filtering city immunocompetent hosts detection, PCR water supplies); Cryptosporidiosis nitazoxanide in immunocompetent hosts A B C D E F Travellers’ diarrhoea Commonly associated with travel especially to South America, Far East, Middle East etc. Diarrhoea with constitutional upset Ideally diagnosis made by microbiological tests Severe diarrhoea with 6 or more stools per day consider therapy Selective prophylaxis Giardiasis I Caused by Giardia lamblia Protozoon pathogen Cosmopolitan found all over the world. Is water Acquired by ingestion of cysts in contaminated food or water (resists chlorination) 2 These develop into trophozoites in duodenum Symptoms of cramping abdo pain, flatulence, of diarrhoea Steatorrhea , Giardiasis: Diagnosis and management Find cysts or rarely trophozoites in stool Need to perform a stool concentration iiiiiai.mn Look at several samples Occasionally need duodenal aspirate or small bowel biopsy Metronidazole is antimicrobial of choice  Shigellf Bacillary dysentery (SHIGELLOSIS) Shigella sonnei is the most common species in developed countries O Causes a mild intestinal illness, with fever, malaise, self-limiting diarrhoea Requires low infecting dose acquired by direct contact Short incubation period E Is locally invasive in large bowel Isolate organism on selective culture media Shigellosis cont’d  Other 3 species S flexneri, S boydii, S dysenteriae usually acquired abroad  S dysenteriae causes severe illness which in developing countries can be fatal  Produces an enterotoxin 8  For this form of disease antibiotic therapy necessary SMX Ceftriaxone TMP or - , Uncommon causes Amoebic dysentery protozoan liver also Causative organism: Entamoeba histolytica affected Mainly found in Indian sub Continent, Africa (but Worldwide distribution) Acquired from eating food contaminated with cysts Causes ulceration of the colon Variation in severity of symptoms but can be severe diarrhoea with blood and mucus in stool - Amoebic dysentery Can progress to cause perforation of large bowel and peritonitis Also, liver involvement with hepatitis or liver - abscess Diagnosis made by finding amoebic trophozoites in warm stool Serology positive in liver infection V15 for abscess (immunofluorescence test for antibody) nnot activeagainst pha Treatment with metronidazole (emetine in non responders) ↳ for infants also diuloxanrde → cyst Casymptomutrc Passer carrier ) for adult cyst Passers so we we if 2 years  Just Cholera  A severe diarrhoeal illness with production of rice - water stools -  Vomiting and nausea may accompany  Leads to dehydration, prostration, electrolyte loss, circulatory and renal failure short time within  Due to toxigenic V cholerae of 3 types, classic, El Tor, and O139 if you find 1 case in clinic → there are 200 more cases bez it is waterborne need Tangent illness diciplinary control a → a multi team to spread of it 1 boilwater 2 resembles resterous 4 breastfeeding  7 d 5 Cholera secretory  Typically water borne  Short incubation period  Vibrio attaches to small intestinal epithelium and produces an enterotoxin which causes increased cyclic AMP production with outpouring of fluid and electrolytes (similar to heat labile of ) toxin f- TEC  Treat by rehydration and antibiotics Erythromycin Doxycycline for elderly or  Prevent by good sanitation, heat drinking water, oral vaccine Other infections of intestinal tract  Enteric fever (typhoid and paratyphoid) caused by Salmonella enterica serotypes Typhi/paratyphi  Yersinia enterocolitica gastroenteritis water  Aeromonas hydrophila (aqautic organism)  Plesiomonas shigelloides colitis  Pseudomembranous colitis (C difficile)  Complications of Diarrhea  Dehydration www.E  Metabolic Acidosis Loss of 1-165 , if severe → shock > hectic acidosis  Gastrointestinal complications : Perforation , 2° Lactase deficiency  Nutritional complications can't eat or absorb  Complications of Diarrhea Metabolic Acidosis  Reduced serum bicarbonate  Reduced arterial PH  Compensating respiratory alkalosis  Complications of Diarrhea Gastrointestinal complications  Secondary carbohydrate malabsorption [ Lactase deficiency )  Protein intolerance Lactose intolerance  Persistent diarrhea  Management  Non-specific , supportive  Oral Rehydration Solution (ORS): Effective in all types & all degrees of dehydration. Can prevent dehydration if given early in the disease. Cheap, easy to administer; can be given by mother at home. No chance of overhydration or electrolyte overdose.  Methods of administration: spoon, cup, dropper, syringe, naso-gastric tube -  ORS Composition  Sodium Chloride N  Tri-Sodium Citrate (bicarbonate) Bia  Potassium Chloride  Glucose  Notes: DO therefore Gastroenteritis is acute self-limited illness. Diarrhea and vomiting in infancy and childhood is usually due to viral gastroenteritis. Fluid replacement with ORS is the mainstay of management. Breast feeding should be continued. Antibiotics and antiemetics agents are contraindicated. OdIWW Loperumide is absolutely contraindicated if 95%.  Testing for gliadin antibodies is no longer recommended because of the low sensitivity and specificity for celiac disease. ELISA  The tTG antibody test is less costly because it uses an enzyme-linked immunosorbent assay; it is the recommended single serologic test for celiac disease screening in the primary care setting.  When the prevalence is low, as in the general U.S. population, the risk of a false-positive result is high even with an accurate test. PPV 49.7%, NPV 99.9%  Confirmatory testing, including small bowel biopsy, is advised. SMALL BOWEL BIOPSY  Required to confirm the diagnosis of celiac disease for most patients.  Should also be considered in patients with negative serologic test results who are at high risk or in whom the physician strongly suspects celiac disease.  Mucosal changes may vary from partial to total villous atrophy, or may be characterized by subtle crypt lengthening or increased epithelial lymphocytes.  To avoid false-negative results on endoscopic biopsy, most authorities recommend obtaining at least four tissue samples, which increases the sensitivity of the test. Normal small intestine Normal villi Celiac Disease Villous atrophy COMORBIDITIES  Osteoporosis  Thyroid dysfunction  Deficiencies in folic acid, vitamin B12, fat-soluble vitamins, and iron Malabsorption  Increased mortality due to increased risk of malignancy  Non-Hodgkin's lymphoma (3-6x more likely)  Oropharyngeal, esophageal, and small intestinal adenocarcinoma.  Cow milk intolerance immune-mediated mucosal injury ❏ can be associated with anemia, hypoalbuminemia, edema ❏ up to 50% of children intolerant to cow’s milk may be intolerant to soy protein ❏ often in atopic individuals ❏ 2 scenarios e enterocolitis – vomiting, diarrhea, anemia, hematochezia enteropathy – chronic diarrhea, hypoalbuminemia ❏ treatment: casein hydrosylate formula ❏ Inflammatory Bowel Disease (IBD) Other ❏ specific enzyme deficiencies ❏ liver disease, biliary atresia ❏ a-ß-lipoproteinemia ❏ short gut toxic or immunologic reaction ❏ blind loop syndrome ❏ Giardia lamblia 2. PANCREATIC INSUFFICIENCY Cystic Fibrosis (CF) Schwachman-Diamond Syndrome