Diarrheal Diseases

in children
Dr. Abdulfetah Ibrahim (GP)
November 2023 G.C
Outline

• Definition
• Epidemiology
• Etiology
• Diagnosis
• Treatment
• Prevention
Definition
Diarrhea is best defined as excessive loss of fluid and
electrolyte in the stool.
WHO defines a case as the passage of three or more loose or
watery stools per day.

Acute diarrhea is defined as sudden onset of excessively loose

stools of >10 mL/kg/day in infants and >200 g/24 hr in older
children, which lasts <14 days.
When the episode lasts >14 days, it is called persistent diarrhea
Disorders that interfere with absorption in the small bowel tend to
produce voluminous diarrhea, whereas disorders compromising
colonic absorption produce lower-volume diarrhea.

Dysentery - (small-volume, frequent bloody stools with mucus,

tenesmus, and urgency) is the predominant symptom of colitis
Mechanisms
• Secretory diarrhea
• When the intestinal epithelial cell solute transport system is in an
active state of secretion.
• Occurs when the absorption of sodium by the villi is impaired
while the secretion of chloride in the crypt cells continues or is
increased
• Often caused by a secretagogue, such as cholera toxin, binding to a
receptor on the surface epithelium of the bowel and thereby
stimulating intracellular accumulation of (cAMP) or (cGMP).
• Is usually of large volume
• It persists with fasting
• Osmotic diarrhea
• Diarrhea can occur when a poorly absorbed, osmotically active
substance is ingested
• The solute may be one that is normally not well absorbed
(magnesium, phosphate, lactulose, sorbitol) or
• one that is not well absorbed because of a disorder of the small
bowel (lactose with lactase deficiency or glucose with rotavirus
infection)
• usually of lesser volume
• stops with fasting
• Motility disorders
- fast or slow transit
- not usually large volume
Epidemiology
• One of the leading causes of morbidity & mortality in children(20%
cause of death in U5)
• Causes 3-5million deaths annually in children of under five
• Common in children of age below 5yrs
• Peak incidence is during the age of 6-11months
• Age of complementary feeding
• Related with developmental age
• Major route of transmission is feco-oral
Prevalence and outcome of the three main types of diarrhea

Type of diarrhea % of cases of % of deathsdue to % of deaths preventable by

diarrhea diarrhea standard case management

Acute watery 80 50 100

Dysentery 10 15 80

persistent 10 35 80

Total 100 100 90

Risk factors
Behavioral (maternal) risk factors
• Failing to exclusively breast feed for 1st 6 months
• Bottle feeding
• Storing food at room temperature
• Drinking contaminated water
• Failing to wash hands after defecation, after disposing of feces or before
handling food
• Improper disposal faeces
Host factors
• Malnutrition, higher with micronutrient malnutrition Vit. A deficiency, zinc
deficiency
• Measles
Causes
• Life-threatening conditions
- Intussusception
- Hemolytic uremic syndrome
- Pseudomembranous colitis
- Appendicitis
- Toxic megacolon
- Congenital secretory diarrheas
Common causes
The common causes of diarrhea are infections with viruses
bacteria, and parasites.

Diarrhea due to a systemic infection other than gastrointestinal(

otitis media, UTI)

Diarrhea associated with antibiotic administration, and

Over feeding
Types
Acute Watery Diarrhea
• Begins acutely and lasts less than 14 days
• Causes dehydration
• Etiologies
• Rota virus
• E. coli
• Shigella
• C. jejuni
• Cryptosporidium
• Cholera
• Salmonella
• G. lamblia
Dysentery
• Is diarrhea with visible blood in the stool
• Up to 10% of all diarrheal episodes in under five children
• It is severe in infants and those with malnutrition
• Etiologies:
• Shigella
• C. jejuni
• E. coli
• Salmonella
• E. histolytica
• Manifestations include
• Fever, Abdominal cramp, tenesmus
Cont…
Complication - due to shigella
• Dehydration
• Intestinal perforation
• Toxic megacolon
• Rectal prolapse
• Convulsions (with or without a high fever)
• Septicemia
• Hemolytic-uremic syndrome
• Prolonged hyponatremia
• Severe malnutrition
Persistent diarrhea
• Begins acutely and lasts at least 14 days
• Up to 20% of episodes of diarrhea become persistent
• Is associated with extensive changes in bowel
mucosa and reduced absorption of nutrients
• Weight loss is frequent
• Etiologies:
• E. coli, shigella, salmonella, cryptosporidium

Severe persistent diarrhea

• Is persistent diarrhea with dehydration (some or
severe)
Types based on etiology
• Viral: rota virus, enteric adenovirus, norwalk agent
• Bacterial: E. coli, shigella, salmonella, v. cholera
• Protozoal: cryptosporidium, G. lamblia, E.
histolytica
• Helminthic: s. stercoralis

• Rota virus is most common cause of severe life

threatening diarrhea in under two year children
 Causative agents of acute diarrhea
Viral Bacterial parasites

Rota virus Campaylobactor jejuni Giardia

Enteric adenovirus Closteridum defficil and E. histolitica

perfringens
CMV E.coli cryptosporidium

HSV Shigella and salmonella Isospora belli

Vibro cholera strongloidosis

Staph.aureus Trichuris trichuria

Yersina enterocolitica
Consequences
• Dehydration: Is the major cause of death from acute
diarrhea
• Shock
• Metabolic acidosis / Base deficit acidosis due to loss
of large amount of bicarbonate in the stool
• Hypokalemia: due to large loss of potassium in the
stool
• Paralytic ileus
• Malnutrion
Complications of dysentery
• Intestinal perforation
• Toxic mega-colon
• Sepsis
• Malnutrition
• Hemolytic Uremic syndrome – characterized by:
• Anemia
• Thrombocytopenia
• Uremia / ARF
• Convulsion with / with or without fever
Patient Evaluation
History
P/E

Stool microscopy/culture
Dysentry
Epidemic (?cholera)
Assess for Dehydration

The 4 important signs in well -nourished child are:

1. Mental status
2. Eye ball
3. Drinking Ability
4. Skin turgor
Assessing and classifying
dehydration
Severe dehydration
Two of the following signs
• Lethargy / unconscious
• Sunken eye ball
• Not able to drink
• Skin pinch goes back very slowly

Additional (weight loss >10%, weak /feeble pulse)

 Some dehydration

Two of the following signs

• Irritable / restless
• Sunken eye ball
• Eager to drink
• Skin pinch goes back slowly

Additional (weight loss 5 –10%, dry tongue and buccal mucosa)

No dehydration

• If there is no enough sign to classify as some or

severe dehydration
• Weight loss of <5%
Assessment of dehydration in
malnutrition
• Reliable clues for dehydration in malnourished children
• Hx of recent watery diarrhea
• Thirst
• Sunken eyes (Recent )
• Weak or absent radial pulse
• Cold hands and feet
• Urine flow decreased
• Not Reliable
• Mental status
• Mouth, tongue and buccal mucosa
• Skin pinch
• Rehydration
• Rehydrate orally whenever possible
• IV only when there are definite signs of shock
Laboratory Diagnosis
• Presence of fecal leukocytes 20 or more and RBC per high power field
of stool microscopy suggests invasive diarrhea (possibly shigellosis).
• Stool microscopy also reveals parasitic and helminthic infections.
• Dark field microscopy is a rapid diagnostic test for Vibrio.
• Stool cultures are available for detecting bacteria including Vibrio
cholera, Salmonella, Shigella, and others.
• Antigen tests are done for different serotypes of E. coli.
Principles of Mgt of diarrheal
diseases
No DHN
• Treat diarrhea at home using 4 rules
1. Give extra fluid
• ORS after each loose stool
• 50- 100 ml if <2 years of age
• 100 – 200 ml if >2 years
2. Continue feeding
3. Advise when to return immediately
4. Zinc supplementation
• 10 mg po/day for 10 days if <6 month of age
• 20 mg po/day for 10 -14 days if >6 month
• Reduces severity of diarhea and episodes of diarrhea
• Reduces incidence of diarrhea in the coming 2–3months
Some DHN
• Give ORS 75ml/kg over four hours
• If child wants more than calculated, give more
• Reassess after 4 hours and classify for DHN
• Select the appropriate plan to continue
Severe DHN
• Give 100ml/kg RL or NS as follows

Age 30 ml/kg 70 ml/kg

< 12 months 1 hour 5 hours

> 12 months 30 minute 2 and half hours

Severe DHN
• Repeat the IV fluid once if radial pulse is very weak
or not palpable
• Reassess the child every 1 – 2 hour. And
• If hydration status of the child is not improving
give IV drip more rapidly
• Give ORS 5ml/kg/hour as soon as the child can
drink
• Reassess an infant after 6 hours & a child after 3
hours and decide
Severe DHN
• If IV fluid is not available, start rehydration by NG
tube or mouth with ORS 120ml/kg over 6hours

• Reassess the child every 1 – 2 hour and

• If there is repeated vomiting or abdominal distention,
give the ORS more slowly
• If hydration status is not improving after 3 hours, refer
the child for IV treatment
Zinc Supplementation
• Reduce duration and severity of diarrhea
• Prevents recurrence.
• Promotes ion absorption, restores epithelial proliferation, and
stimulates immune response.
• Reduce mortality by 46% and hospital admission by 23%
Antibiotics
• Are not indicated in acute watery diarrhea
Dysentery
• Cotrimoxazole is 1st line
Cholera
• Tetracycline is 1st line
• Cotrimoxazole – 2nd line
Protozoa
• Metronidazole 25-50mg/kg/day in 3 divided doses
Management of Dysentery
• Antibiotics for 5 days (Choice depends on local sensitivity)
• Treat dehydration
• Feeding
• Continue breast feeding
• Give small nutrient rich meals at least 6x/day
• Give extra meal each day for 2 weeks
• Follow up
• See child after 2 days if:
• Under one year of age
• Initially dehydrated
• Still blood in the stool
• Not getting better
• If no improvement or has deteriorated, give 2nd line antibiotics for shigella (If no
response still, suspect amebiasis)
Nutrition
During diarrhea there is:
• Increased nutrient requirement
• Reduced food intake
• Reduced absorption of nutrient

• To prevent growth faltering / malnutrition, good nutrition should be

maintained both during & after episode of diarrhea
Persistent diarrhea
• If the child is breast feeding, give more frequently
• If taking other milk /> 6month/
• Replace the milk with increased breast milk frequency
• Replace with fermented milk products like yoghurt
• Replace half of the milk with nutrient rich semisolid food
• Give vitamin A
Nutritional therapy
• Proper feeding is the most important aspect of treatment for most
children
• Continue breast-feeding
• Replace half the usual amount of animal milk with nutrient-rich semisolid
food
• Replace with a fermented milk product, such as yoghurt.
• Avoid foods that are hyperosmolar (sweet drinks by the addition of sucrose,
such as soft drinks or commercial fruit drinks)
• Provide supplementary vitamins and minerals, in particular folate, vitamin B,
vitamin A, zinc and iron, if possible.
Follow up
• Advise mother to return immediately if the child
• Is not able to drink or breast feed
• Becomes sicker
• Develops a fever
• Has Blood in stool
• Advise mother to return in five days if the child is
not improving
Prevention of diarrhea
Diarrhea can be prevented by pursuing multisectoral
efforts by:
• Optimal Breast feeding
• Improving nutritional status (by improving the
nutritional value of weaning foods and giving
children more food) - Improved weaning practice
• Use of clean water
• Hand washing, use of latrine, safe waste disposal
• Immunization: rota vaccine, measles….
• Improved case management of diarrhea
THANK YOU !!!