Diarrhea

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Diarrhea

• Dr. Adnan Hamawandi
• Professor of Pediatrics

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Treatment of diarrhea

• Rehydration therapy
• Goals
• 1. Correct existing fluid deficit.
• 2. Replace further fluid losses.

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Treatment of diarrhea

• Sever dehydration The treatment of choice is
  Intravenous fluid.
• Ringers lactate is the preferred solution.
  Normal saline or half normal saline in glucose
  may be used.
• Infants should receive IV fluid at a rate of
  30ml./kg in the first hour followed by 70ml./kg
  in the next 5 hours, thus providing 100ml./kg in
  6 hours.

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Treatment of diarrhea

• Older children should be given 30ml./kg within
  30 minutes followed by 70ml./kg in the next 2 and
  half hours, thus providing 100ml./kg in 3 hours.
• After the first 30ml/kg has been given a strong
  radial pulse should be readily palpable If it is
  very weak and rapid a second infusion of 30ml./kg
  should be given in the same rate however, this
  is rarely necessary.

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Treatment of diarrhea

• Small amounts of ORS( 5ml/kg) should also be
  given by mouth as soon as the patient is able to
  drink to provide additional potassium and
  bicarbonate. This is usually possible after 3 4
  hours for infants and 1 2 hours for older
  children.

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Treatment of diarrhea

• At the end of planned rehydration period (usually
  3 6 hours), the patient hydration state should
  be reassessed carefully.
• If signs of sever dehydration are still
  present rehdration should be continued by IV
  route,
• If there are signs of some dehydration shift
  to treatment of some dehydration.

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Treatment of diarrhea

• Some dehydration
• Can be treated in the ORT corner where mothers
  can help with treatment and learn how to continue
  it at home.
• Oral rehydration solution 75 ml./kg has to be
  given in the first four hours. It should be given
  by a cup and spoon. A teaspoonful every 1 2
  minutes for infants and frequent sips from a cup
  for an older child.

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Treatment of diarrhea

• If the child vomits, wait 10 minutes and then
  continue giving ORS but more slowly.
• If the child eyelids become puffy stop ORS and
  give plain water or breast milk until the
  puffiness is gone.
• After 4 hours carefully reassess the childs
  hydration status If the child has No signs of
  dehydration, the child can continue treatment at
  home by ORS and feeding.

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Treatment of diarrhea

• If there are signs of some dehydration
  continue giving the estimated volume of ORS again
  until the signs of dehydration disappear. If the
  child is passing watery stools frequently and the
  signs of sever dehydration appear ORT should be
  temporarily stopped and the child rehydrated
  intravenously.

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Treatment of diarrhea

• Treatment of diarrhea at home
• Is appropriate when the child have no signs
  of dehydration. Three important rules has to be
  explained to the mother-
• 1. Give the child more fluid than usual to
  prevent dehydration. The recommended home fluids
  include ORS, food based fluids
• ( soups, rice water, and yoghurt), and water.

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Treatment of diarrhea

• Amount of ORS to be given after each loose
  stool is 50 100 ml. in children less than 2
  years of age and 100 200 ml. in older child.
• Continue giving these fluids until diarrhea
  stops.

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Treatment of diarrhea

• 2. Give the child plenty of food to prevent
  malnutrition.
• Continue to breast feed frequently and if the
  child is not breast fed give the usual milk.
• If the child is 6 months or older
• - give cereal or another starchy food mixed
  with pulses, vegetables and meat or fish. Add 1-2
  teaspoonful vegetable oil to each serving

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Treatment of diarrhea

• -Give fresh fruit juice or mashed banana to
  provide potassium.
• -Encourage the child to eat. Give food at least
  6 times/day.
• -Give the same foods after diarrhea stops and
  give an extra meal each day for 2 weeks.

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Treatment of diarrhea

• 3. Take the child to the health center if he does
  not get better in three days or develops
• Many watery stools.
• Repeated vomiting.
• Marked thirst.
• Eating or drinking poorly.
• Blood in stools.
• Fever.

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Treatment of diarrhea

• Nutritional therapy
• Feeding should be continued during all types
  of diarrhea to the greatest extent possible and
  should be increased during convalescence so as to
  avoid malnutrition.

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Treatment of diarrhea

• Antimicrobial therapy
• Should not be used routinely . Most episodes
  including sever diarrhea and diarrhea with fever
  do not benefit from such treatment.
• The exceptions are -
• 1. Dysentery
• 2. suspected cholera.

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Treatment of diarrhea

• 3. Persistent diarrhea when trophozoite or
  cyst of Giardia or trophozoite of E. histolytica
  are seen in the feces or intestinal fluids, or
  when pathogenic enteric bacteria are identified
  by stool culture.

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Treatment of diarrhea

• Antidiarrheal and antiemetic
  Antimotility agents (Diphenoxylate,
  Codeine,
• Loperamide) adsorbants(Charcoal, Pectin,
  Kaolin) and antiemetics including Chlorpromazine
  and Promethazine should NOT be used in the
  treatment of diarrhea in children less than 5
  years of age as non of these drugs has any proved
  practical benefits and some may have serious side
  effects.

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Role of Zinc in treatment of acute diarrhea in
children.

• Zinc treatment is a simple,
  inexpensive, and critical new tool for treating
  diarrheal episodes among children in the
  developing world. This important micronutrient
  becomes depleted during diarrhea, but recent
  studies suggest that replenishing zinc with a10-
  to 14-day course of treatment can reduce the
  duration and severity of diarrheal episodes and
  may also prevent future episodes for up to three
  months.
• WHO and UNICEF specifically recommend
  daily 20 mg zinc supplements for 10 days for
  children with acute diarrhea and 10 mg per day
  for infants under six months old.

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Role of Probiotics in the management of diarrhea
in children

• Specific probiotic strains can contribute
  to both the prophylaxis and therapeutic
  management of acute infectious diarrhea in
  children decreasing its incidence and duration.
  They favorably affect the host by local and/or
  immune modulation pathways.
• 1. In the gut, the probiotic agents compete
  with pathogens for nutrients and prevent their
  adherence to the mucosa.
• 2. They produce bacteriocins that acts as
  local antibiotic and they induce the synthesis
  of human B- defensin 2 an antimicrobial peptide.
• 3. they produce lactic and acetic acid that
  can inhibit pathogen growth by lowering luminal
  PH.
• 4. Probiotics may improve integrity of the
  mucosal barrier function by stimulating mucin
  production.