9. Diarrheal diseases.pptx

Diarrheal Diseases- Principles of Management Prof. (Dr.) Swapan Chowdhury MBBS; MD (paed); PhD Overview…  Essential concepts    Definition, types Assessment of a child with diarrhea  History  Examination  Assess degree of dehydration  Select treatment plan Management- princi...

Diarrheal Diseases- Principles of Management Prof. (Dr.) Swapan Chowdhury MBBS; MD (paed); PhD Overview…  Essential concepts    Definition, types Assessment of a child with diarrhea  History  Examination  Assess degree of dehydration  Select treatment plan Management- principles of treatment Definition …  What is diarrhea?? Passing of 3 or more loose or semisolid stools per day or any number of blood mixed mucoid stool . New born: Passing of Loose stool with altered frequency as percepted by mother What is not diarrhea?? Frequent passing of normal stools is not diarrhea. Note: Babies who are breastfed often have stools that are soft Types of diarrhea  Acute diarrhea : Sudden onset & <14 days Presentation – dehydration  Persistent diarrhea : Acute diarrhea lasting >14 days Presentation - malnutrition  Chronic diarrhea – recurrent or long lasting diarrhea usually occurring due to a non infectious cause Presentation : Malnutrition  Dysentery : Diarrhea with visible blood and/or mucus, often associated with fever and tenesmus  Presentation - Sepsis, malnutrition Based on Electolyte (Na) status: Iso tonic (isonatremic) /Hypo tonic (Hyponatremic)/ Hypertonic (Hypernatrmic. Etiology Bacterial Viral  Rotavirus   Adenovirus Norwalk virus Protozoa E. Histolytica 5% Giardia   E. coli  Campylobacter  Vibrio cholera 5-10%  Shigella 3-7%  Non typhoidal salmonella  Why is diarrhea dangerous? Dehydration & death Malnutrition Pathophysiology  Increased secretion  Decreased digestion and absorption  Disordered transit Assessment of hydration status Ask, look & feel…!!!! ASK  For how long has the child had diarrhea?  How  Is many liquid stools per day ? there blood in the stool?  Has there been vomiting?  If so, how frequently has the child vomited?  Is the child able to drink? Thirsty?  If so, what type of fluid has been given?  Has the child passed urine?  Breast feeding?If Breast fever , it start before diarrhea or after – Parenteral diarrhea LOOK  What is the child’s general condition?  Is he/she severely malnourished?  Signs of dehydration: Mild: Dry Skin & Mucossa, thirst, urine output, tear Moderate-Severe;   Ant Fontanel  Skin turgor  Sunken eyes  Weak thready pulse and low BP  Cold periphery Presence of pneumonia/ otitis media FEEL When the skin is pinched, does it go back quickly, slowly, or very slowly (longer than 2 seconds)? Skin pinch can be done in abdomen or thigh   Pinching the skin can be misleading in: severely malnourished Obese children Skin turgor is maintained by presence of water or fat in tissue No dehydration Clinical signs General condition Well, alert Eyes Normal Thirst No, drinks normally Skin pinch Goes back quickly Plan A Some dehydration Clinical signs General condition Restless, irritable Eyes Sunken Thirst Thirsty, drinks eagerly Goes back slowly Skin pinch Plan B Severe dehydration Clinical signs General condition Lethargic, unconscious Eyes Sunken Thirst Skin pinch Plan C Not able to drink/ drinks poorly Goes back very slowly Objectives of treatment 1. Prevent dehydration, if there are no signs of dehydration; Treat dehydration, when it is present; 3. Prevent nutritional damage, by 2. feeding during and after diarrhoea 4. Reduce the duration and severity of diarrhoea, by giving supplemental zinc. Plan A Child with NO Dehydration The four rules of treatment Plan A: 1. Give extra fluids, ORS solution or recommended home fluids. 2. Continue feeding, encourage ongoing breastfeeding when applicable. 3. 4. Give zinc supplementation for 10/14 days Advise the mother on when to return to the health facility. Rule 1 Guidelines for replacement of fluid in Plan A Age < 6 months After each loose stool, offer ¼ cup = 50 ml 7 mo – 2 years ½ cup = 100 ml 2-5 years 1 cup = 200 ml Older children As much as the child can take Do not Give Commercial carbonated drinks Sweetened tea Sweetened fruit drinks Can cause osmotic diarrhea/ hypernatremia Coffee Some local medicinal teas or infusions Stimulant / purgative action What fluids?  ORS-  If if available. ORS is not available at home -give the recommended home available fluid such as soup, butter milk or rice water. ORS ORAL REHYDRATION SOLUTION Physiological basis for ORS  Glucose dependent sodium and water absorption  Osmolarity is lower than blood WHO recommended Low Osmolarity ORS Component Concentration (mmol/L)  Sodium 75  Chloride 65  Potassium  Citrate 10  Glucose 75  Osmolarity 20 245 ORS - Benefits  Replaces salts and water lost during diarrhea  Reduces dehydration and need for hospitalization  Decrease in severity of diarrhea and vomiting  Decrease in duration of illness When to stop?  ORS or recommended home-fluids should be given until the diarrhea stops How effective is ORT?  95-97% of cases in some dehydration Rule 2 Continue feeding What foods? What to avoid? How much? Hygiene Rule 3 Zinc supplementation  Zinc – micronutrient ,antioxidant, promotes immunity and preserves cellular membrane integrity  Zinc decreases the length and severity of the diarrhea  Zinc will help the child fight off new episodes of diarrhea in the next 2-3 months following treatment  Zinc  How improves appetite and growth much? Children less than 6 months – 10 mg Children 6 months and older- 20 mg Duration- 10-14 days Danger signs  Pass too many watery stools  Has repeated vomiting  Becomes very thirsty  Is eating or drinking poorly  Develops fever  Has blood in the stool  Does not get better in three days Plan B Rehydration with ORS under supervision in a health care facility  Give  If 75 ml/ kg of ORS over 4 hours child wants/tolerate more - give more Reassess after 4 hours  If still dehydrated – give ORS as above  If rehydrated- shift to Plan A  If not successful- treat as severe dehydration – go to Plan C  If over hydrated=Oedematous (puffy) eyelids.  Stop ORS  give breastmilk or plain water  do not give a diuretic Plan C  Primary objective: Quickly rehydrate the child with IV fluid therapy in a hospital  Preferred solution: Ringer Lactate solution [ Alternatively normal saline]  Volume: 100 ml/kg over 6 hours in infants and over 3 hours in older children Deficit fluid therapy for severe dehydration Plan C Volume of Ringer lactate solution 100 ml/kg Infants < 1 yr Older child 30 ml/kg body weight within first 1 hour 30 ml/kg body weight within first ½ hour 70 ml/ kg body weight over next 5 hours 70 ml/ kg body weight over next 2 ½ hours Later reassess hydration status and choose appropriate plan A,B or C Do not overlook daily mantainance fluid & ongoing loss What else apart from fluids..? Antisecretory drugs in diarrhoea  Racecadrotil : There is presently not enough evidence on either safety or efficacy Antimicrobials 1. Antibiotic therapy reserved only for acute dysentery and suspected cholera 2. Associated non GI infections like pneumonia, meningitis, urinary tract infection 3. In severe malnutrition it is assumed that there is underlying infection for which broad spectrum parenteral antibiotics are given Anti motility drugs  Opiate analogues like diphenoxylate HCl (Lomotil) and loperamide reduce gut peristalsis  Course of illness gets prolonged  Paralytic ileus, bacterial over growth NOT RECOMMENDED Probiotics  Microorgansims that exert beneficial effects when they colonise the bowel  Examples  Lactobacillus strains  Saccharomyces  Bifidobacteria Prevention of diarrhea  Exclusive breastfeeding for 6 months  Safe drinking water  Hand washing  Food safety  Sanitary disposal of wastes THANK YOU