Diarrhoea in children

Dr. K.A.W.Karunasekera Department of Paediatrics Faculty of Medicine University of Kelaniya

Clinical impact
A major cause of childhood morbidity and mortality 3 million die each year in the world 80% deaths occur < 2 years of age Most die due to severe dehydration Repeated attacks cause malnutrition

Definition
Passage of 3 or more liquid motions /day Acute diarrhoea usually for 7 days Persistent diarrhoea (3-10%) >14 days Watery (AGE) Acute diarrhoea Invasive diarrhoea Bloody (Dysentery)

Aetiology - AGE
Viruses: rotavirus , adenovirus, calicivirus, Astor & measles viruses Bacteria: Vibrio cholarae, ETEC, Campylobacter jejuni, Shigella, EPEC Parasitic: Cryptosporidium, giardia Mixed infection with 2 or more up to 20%

Aetiology- invasive diarrhoea

Bacteria:Shigella spp. Shiga toxins EIEC, EHEC, Campylobacter jejuni, Yersinia enterocolitica, non-typhoidal salmonella Parasites: Entamoeba histolytica

Site of pathology
Small intestine: secretory diarrhoeal pathogens e.g. rotavirus, vibrio, ETEC Large intestine: invasive diarroeal pathogens e.g. Shigella spp. Recto sigmoid and progress up, Entamoeba caecum and adjacent colon Both small and large bowel e.g. C. jejuni

Rotavirus
The commonest pathogen for AGE between 6-24 months of age More common during dry season, and during monsoons Neonatal and adult infections are mild Faeco-oral transmission Patchy damage to the epithelium causes blunting of villi watery D

Rotavirus contd.
Results in transient lactase deficiency Intestine regenerates in 2-3 days, longer in malnourished IP 2-3 days Abrupt onset vomiting and D Severity vary mild to severe Lasts up to a week, improves in 2-3 days Low grade fever

Rotavirus - management
Stool macroscopy, microscopy Management of dehydration Continuation of BF Continuation of solid food No AB No antidiarrhoeal agents Extra meal for 2-3 weeks to catch-up Wt.

Vibrio cholerae
The most important cause for severe dehydration Outbreaks occur in Sri Lanka from time to time Common age is 2-9 years A large infective dose is required Organisms adhere to the intestine, X and produce enterotoxin D

Cholera contd.
2 biotypes: El tor & classical 2 serotypes: Ogava & Inaba Enterotoxins secrete water, Na & Cl in to small intestine Exchange of K with Na and HCO3 with Cl in large intestine Hence net loss of water, Na, K, Cl, Hco3

Cholera contd.
IP hours to few days Mild to severe disease Rice water stool Muscle cramps Notifiable disease to regional epidemiologist by telephone

Cholera management
Stool culture Management of dehydration Continuation of food Notification Antibiotics furazolidone, chloramphenicol

Shigella spp.
S. dysenteriae has 15 serotypes. responsible for epidemics. Type 1 is the most severe form S. flexneri - responsible for endemic disease S. boydii S. sonnei Infective dose is very small (10 organisms)

Shigella spp.
Faeco-oral transmission Shigella can survive in gastric juice Shiga toxin an endotoxin, which has a cytotoxic property fluid secrete in to small intestine

Shigellosis
Common under 5 years Uncommon under 6 months as there is no specific enterocyte receptors IP 2-3 days Severity varies from very mild to fulminating disease Prominent systemic symptoms

Shigellosis contd.
High fever, anorexia, headache, malaise Frequent passage of small volume stool mixed with blood and mucous & less amount of stool particles Intense cramps in LIF, tenesmus, tender abdomen Rectal prolapse in malnourished

Shigellosis- management
Stool macroscopy and microscopy Stool culture & ABST Management of dehydration Dietary management: loss of protein is high. Thus continue feeding during acute illness and extra meal during convalescence. Near normal energy intake can be ensured by small, but frequent feeding.

Shigellosis management contd.

Symptomatic therapy for fever AB for 5 days: furazolidone, nalidixic acid 15 mg/kg 6 hrly, pivmecillinam 15 mg/kg 6 hrly, aminoglycosides, 3rd gene. Cephalosporines Antispasmodic or constipating agents have no role & it may worsen severity of the disease Notification

Entamoeba histolytica
Causes dysentery Extra-intestinal manifestations can occur Diagnosis by direct visualization of tropozoites Metronidazole

E.coli
5 types: EIEC, EHEC, EPEC, ETEC,EAEC Faeco-oral transmission ETEC causes travelers diarrhoea Clinical features of EIEC similar to Shigella

Campylobacter
Peak occurs in infancy Infects through infected animals, their faeces, food or water Causes AGE or dysentery (1/3)

Non-typhoidal salmonellae
Uncommon in developing countries Through contaminated animal products Causes watery D, vomiting and cramps

Complications of diarrhoea
Dehydration, hypovolaemic shock & ARF Electrolyte imbalance: Na low or high, hypokalaemia, met. Acidosis, low Mg Septicaemia and shock with invasive D, DIC Hypoglycaemia, common with shigellosis

Complications contd.
PEM: diarrhoeal disease and PEM make a vicious cycle Haemolytic uraemic syndrome Abnormal CNS status e.g. convulsions, encephalitis Intestinal such as rectal prolapse, bleeding due to stress ulcers, perforation & peritonitis, paralytic ileus, persistent D, NEC

HUS
Microangiopathic anaemia, low platelets & ARF S.dysenteriae type 1 & E.coli 0157:H 7 Bi-phasic illness Crenated RBCs, neutrophilia, low plt. Symptomatic management

Fluid management in diarrhoea

Principles: Correction of dehydration Replacement of on-going loses Continuation of normal requirement

Important questions to be asked

Duration of illness Quantity & frequency of stool Presence of blood or mucous Frequency of vomiting Degree of thirst When did the child pass urine last? Is the urine darker than usual?

Questions to be asked contd.

Presence of fever or convulsions Presence of other illness Pre-illness and during illness feeding Contact H/O diarrhoea Any medication given

Then assess the degree of dehydration (see transparencies for assessment and management of dehydration)

Home management
Rules of home management: Rehydration with appropriate fluids Continue feeding Recognition of referral signs to a doctor

Rehydration at home
Suitable fluids: ORS, rice kanji, king/young coconut water, puffed rice water, plain water, weak plain tea. (best if prepared with salt) Substantially reduces the requirement of hospital admission and severe dehydration

Continuation of feeding
This helps early recovery and prevents malnutrition Continue BF Continue formula if the child is on (if the indication to start formula is correct) Solid/semi-solid food 5-6 times, small frequent feeds are better tolerated One additional meal for 2-3 weeks

Warning signs for referral

Many watery stool Repeated vomiting Marked thirst Eating or drinking poorly Fever Blood in the stool Reduced UOP

Indications for admission

Severe dehydration Persistent vomiting High rate of purging Inability or refusal to drink Ill child with complications Blood and mucous in stool

Rehydration solutions
Oral rehydration solution (ORS Jeevani) Used from 1971 onwards Composition of a packet Nacl 3.5 g, Na-citrate 2.9 g, Kcl 1.5 g & glucose 20 g.

ORS molar concentration mmol/L

Na 90, Cl 80, citrate 10, K 20, glucose 111 Physiological basis of ORT: Glucose & other carrier-mediated absorption is intact even in severe D. Citrate and K are absorbed independently of glucose during D. Citrate absorption appears to increase Na & Cl absorption.

Advantage of ORT over IV

> 95% of some dehydration can be treated Less cost Does not need much training Easily available Over-hydration is less likely Mothers are actively participated in management

Reasons for failure of ORT

High rate purging Persistent vomiting Severe dehydration Inability or refusal to drink Glucose malabsorption Incorrect preparation Abdominal distension or ileus

Suitable intravenous fluids

Hartman (Na 130, K 4, Cl 109, Lactate 28) N.saline (Na 154, Cl 154)