Acute diarrhea in children

DR.M ABBAS. SUBHANI
MBBS DCH

Diarrhea is one of the commonest problem in all the developing countries. It is estimated that 1/4 to 1/2 disease burden and death toll in preschool children in the developing world is related to diarrhea, There is no doubt that prevalence and death toll is decreasing gradually, still it is a major illness. A preschool child usually suffers 2-7 diarrheal episodes in one year. the peak age of involvement is 2 year.
While dealing children with the complaint of acute diarrhea, consider following aspects

Is it diarrhea? Diarrhea is increased frequency and decreased consistency of the stools.  A recent change in character of stool is more important.

It is not diarrhea Passage of frequently formed stools.  Passage of pasty stools in breast fed infants. Passage of stool during or immediately after feeding due to gastrocolic reflex.  Passage of frequent loose greenish yellow stools on the 3rd and 4th day of life called as transitional stools.
Provided the above mentioned conditions are not associated with dehydration, systemic changes (feeding sleep activity and reactivity patterns) and there is no apparent illness in the child

Ill effects of diarrhea Dehydration, electrolyte imbalance and Malnutrition it may cause death.Impaired intestinal absorption causes loss of nutrients in diarrhea. Increased catabolism due to infection child with diarrhea often loses appetite. Mothers may withhold food during diarrhea, fearing it would aggravate diarrhea.Some of the physicians do not emphasize proper feeding during diarrhea.

Common causes of diarrhea? Almost all acute diarrhea are caused by infection of GIT. Infections other than GIT may also cause diarrhea. In some of the patients the exact cause is not detected and they are managed on the conventional guidelines and recover completely.
 

Is the child dehydrated ? if the child is dehydrated how severe it is?    The decision is based on history and examination.  This classifies the degree of dehydration into mild moderate and severe .

Only less than 10 % develop Hypotonic or Hypertonic dehydration.Around 90 % are isotonic.The plans given below are useful for the majority of dehydrated children( isotonic dehydration ).
 

Child’s weight loss is quite helpful in the assessment of dehydration and need of fluid. It is unfortunate to note that for some children no weight record is available. If a recent accurate weight is available this is the most useful measure to calculate the percentage of weight loss and dehydration. All children with diarrhea must be weighed at the time of their initial presentation to a physician since this weight can be used for comparison over the next few days if the diarrhea is not mild and self-limiting. Delayed capillary refill-time (although affected by temperature and age) should be considered a sign of significant dehydration.

Is it a serious problem? Is it complicated diarrhea ?  All diarrhea patients having following presentations / findings/ associated features  are complicated diarrhea. They should be considered serious problems and at times may be life threatening.
° first half of infancy ° toxic look, swinging fever suggestive of septicemia ° drowsiness / convulsions ° inability to take and retain feeds and fluid ° distension with or without recurrent vomiting and constipation (possibility of paralytic ileus ) ° decreased or absent bowel sounds ° breathlessness ° associated illnesses specially moderate to severe malnutrition, measles, malaria, congenital defects specially cardiac and neurological.
It is desired all the above mentioned patients should be advised admission and managed in the hospitals.

Is there a need for the laboratory  investigations ?
At the primary care level for the majority of the patients there is no need of routine laboratory test as they are not much helpful.
Investigations may be advised selectively (stools mucoid or associated with blood /pus )
Stool test is not of much value as more than 10 leukocytes per HPF are also seen in rotavirus diarrhea. There is no role of stool pH and reducing substances in acute diarrhea as the lactose intolerance in this condition is self-limiting. Trophozoites of giardia and E Histolytica may be rarely demonstrated.
Stool culture and serum electrolytes are not practicable in the majority of primary care settings.

How to replace the lost fluid ? (orally or IV fluid). What to replace and how much ?
Replacement of fluid by IV route is required for minority of patients. They are
Drowsy and unarousable children, children not able to drink or retain fluid, severely dehydrated children or any of the presentation suggestive of complicated dehydration mentioned above
for severe dehydration 20ml/kg ringer lactate in 1 hour if the child does not pass urine give the same amount in another hour if the child does not pass urine after 40 ml /kg ringer manage as acute renal failure
for moderate dehydration 150-200ml/kg/day (24 hours)                                                             half of the total 24 hour requirement in first 8 hours as Darrows solution or normal saline in dextrose or ringer   half of the total 24 hour requirement next 16 hours as 1/3 (0.3N) saline in dextrose or 1/5 (0.18N)saline in dextrose

Physicians should keep IV fluid bottles, drip sets, infusion chambers, butterflies or IV cannulas  splints at their clinics and in their emergy bags. This saves time. Loss of time in the purchase may sometimes lead to loss of life.
All other dehydrated patients can be rehydrated effectively by ORT

What is ORAL REHYDRATION THERAPY (ORT) ?
It is the cornerstone of management of diarrhea. The term ORT includes
WHO ORS solution- It has reduced the diarrhea related deaths significantly
Home made salt sugar solution
Food based solutions
Culturally acceptable fluids in presence of continued feeding.
Why to use WHO ORS?
Osmolarity is best suited. Its glucose concentration achieves optimum sodium and water absorption.
75 ml per kg body weight ORS in 1st 4 hrs and then reassess.
in addition to, it after the passage of each stool give 1/2-1 cup fluid

If the WHO ORS is not available the salt can be prepared at home by 1 teaspoonful of common salt, 8 teaspoonful of common sugar dissolved in 4 glasses of water. If available add a little lemon to it.

Use of antibiotics and other drugs in diarrhea?
Saying that antibiotics should not be used for diarrhea and vomiting (gastro-enteritis) is true but misunderstood by some physicians. It forbids only the injudicious and routine use of antibiotics in gastro-enteritis not the judicious and selective use.
Antibiotics can be used if the child is very young, septicemia is suspected, there is clinical or laboratory evidence of infection requiring chemotherapy(e.g pneumonia), child is severely malnourished or immuno-deficient or has congenital defects specially cardiac or neurological, there is mucous, pus, and / or blood in the stools, or stool microscopy /culture suggests treatable infection.
Which antibiotics?
malnourished -ampicillin+gentayicine Shigella - trimethoprim+sulfa - nalidixic acid -- ceftriaxone- ciprofloxacin
Cholera - trimethoprim+sulfa          chloramphenicol and tetracycline may also be used

For the majority of the patients with invasive diarrhea trimethoprim+sulfa alone or with furazolidone is effective. Metronidozole should better be avoided below 2 years. Antibiotics that may be effective include (in order of increasing cost): ampicillin, nalidixic acid, ciprofloxacin (3 day course, better be avoided in children below 12 year of age ) and intramuscular ceftriaxone(third generation cephalosporins ).

• Antimotility, antiemetic, digestive enzymes and binding drugs  are not to be used routinely.
• If plain water is used for rehydration, it may precipitate hyponatremia
• Please do not use mineral water along with ORS and IV fluids. It may precipitate hypernatremia
• Use of too sweetened fruit juice may cause osmotic diarrhea.
• Please do not use potassium by parental route before the passage of urine
• Please do not use aminoglycosides (e.g. gentamycine) before the passage of urine or reduce the dose
• Use the drug according to the age of the child (chloramphenicol is not to be given to newborns, tetracycline is not advised below 8 years

What is the dietary management in diarrhea?
Children should continue to be fed during acute diarrhea because feeding prevents or minimizes the deterioration of nutritional status.
In acute diarrhea breast-feeding should be continued with ORS uninterrupted even during dehydration.
Give  banana, rice , curd, dal water (pulses water)
In non-breast fed infants, cow or buffalo milk can be given undiluted after correction of dehydration together with semisolid foods. Milk should not be diluted with water. Alternatively milk cereal mixtures can be used.
Routine lactose free feeding is not required in acute diarrhea. Lactose malabsorption needing dietary modification is very uncommon in acute diarrhea.
During recovery, caloric intake of at least 125% of normal should be attempted with energy dense foods till nutritional status is normal as measured for age.

Before the discharge please make sure

• dehydration has been corrected (there is no clinical evidence of dehydration)
• the child is fully conscious taking and retaining fluid orally
• there is no evidence of complicated diarrhea
• the child has passed urine
• the mother has learnt the identification of dehydration, preparation and use of ORS