1. Chapter 5 Diarrhoea Case I

2. Case study: Sarah
Sarah, 9 months old, was brought to the hospital with 5 day history of watery stools. She was restless and irritable.

3. What are the stages in the management of Sarah?

4. Stages in the management of a sick child (Ref. Chart 1, p. xxii)
Triage
Emergency treatment
History and examination
Laboratory investigations, if required
Main diagnosis and other diagnoses
Treatment
Supportive care
Monitoring
Discharge planning
Follow-up

5. Have you noticed any emergency or priority signs?
Temperature: 36,80C, pulse: 130/min, RR: 40/min, capillary refill time: below 2 seconds, weight: 8 kg, sunken eyes, normal skin turgor

6. Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing
Severe respiratory distress
Central cyanosis
Signs of shock
Coma
Convulsions
Severe dehydration
Priority signs (Ref. p. 6)
Tiny baby
Temperature
Trauma
Pallor
Poisoning
Pain (severe)
Respiratory distress
Restless, irritable
Referral
Malnutrition
Oedema of both feet
Burns

7. History
Sarah had been well 5 days ago, but then she began to have loose watery stools 8-10 times a day. There was no blood or pus in the stool.
Past medical history: previously well, no significant past history
Immunization: completed according to Expanded Programme on Immunization schedule, measles due
Social history: lives with her mother and sister, 4 years old
Medications: none
Allergies: not known

8. Examination
Sarah was crying continuously, she only stopped briefly when her mother put her to her breast. When she was offered ORS she drank eagerly.
Vital signs: temperature: 36.8 °C, pulse: 130/min, RR: 40/min
Weight: 8 kg
Eyes: sunken
Skin: normal skin turgor (skin pinch goes back immediately)
Chest: air entry was good bilaterally and there were no added sounds
Cardiovascular: both heart sounds were audible and there was no murmur
Abdomen: bowel sounds were active and there was no organomegaly
Neurology: restless and irritable; no neck stiffness and no other focal signs

9. Differential diagnoses
List possible causes of the illness
Main diagnosis
Secondary diagnoses
Use references to confirm (Ref. p. 127)

10. Differential diagnoses (continued)
Acute (watery) diarrhoea
Cholera
Dysentery
Persistent diarrhoea
Diarrhoea with severe malnutrition
Diarrhoea associated with recent antibiotic use
Intussusception

11. Additional questions on history
Diarrhoea
frequency of stools
number of days
blood in stools
Local reports of cholera outbreak
Recent antibiotic or other drug treatment
Attacks of crying with pallor in an infant

12. Further examination based on differential diagnoses
Look for:
Signs of dehydration such as: restlessness, irritability, lethargy, sunken eyes, skin pinch returns slowly
Blood in stool
Severe malnutrition
Abdominal mass
Abdominal distension

13. Further examination based on differential diagnoses
Sunken eyes
(Ref. p. 127)

14. Classification of the severity of dehydration in children with diarrhoea
Rapid assessment of hydration status and classification of severity of dehydration in children with diarrhoea:
Classification
Signs or symptoms
Severe
dehydration
Two or more of the following signs:
lethargy/unconsciousness
sunken eyes
unable to drink or drinking poorly
skin pinch goes back very slowly (>2 seconds)
Some
restlessness, irritability
drinks eagerly, thirsty
skin pinch goes back slowly No
Not enough signs to classify as some or severe dehydration
(Ref. Table 12, p. 128)

15. Please summarize the signs of dehydration you noticed in Sarah

16. Classification of the severity of dehydration in children with diarrhoea
Signs or symptoms
Severe
dehydration
Two or more of the following signs:
lethargy/unconsciousness
sunken eyes
unable to drink or drinking poorly
skin pinch goes back very slowly (>2
seconds)
Some
restlessness, irritability
drinks eagerly, thirsty
skin pinch goes back slowly No
Not enough signs to classify as some or severe dehydration
(Ref. Table 12, p. 128)

17. What investigations would you like to do to make your diagnosis ?

18. At this stage no additional investigations are necessary

19. Diagnosis Summary of findings:
 Examination: restlessness, irritability, sunken eyes, drinks eagerly, thirsty
Acute diarrhoea with some dehydration

20. How would you treat Sarah?

21. Treatment Plan B (Ref. Chart 14, p. 135)
In the first 4 hours give 75 ml per kg of ORS as shown in table below
Show the mother how to give the child ORS solution, a teaspoonful every 1-2 minutes if the child is under 2 years; frequent sips from a cup for an older child

22. Treatment (continued)
After 4 hours:
- Reassess the child and check the signs of dehydration
- Select the appropriate plan to continue (discharge if necessary to Treatment Plan A or C)
- Begin feeding the child in clinic
If the mother must leave before completing treatment:
- Show her how to prepare ORS at home
- Give her enough ORS packets to complete rehydration
- Explain the 4 Rules of Home Treatment:
Give extra fluid
Give zinc supplements
Continue feeding
When to return

23. Treatment (drugs)
Antibiotic treatment is rarely necessary (Ref. p. 126)
Only for:
Dysentery (mostly Shigella)
Cholera
Neonates with diarrhoea and fever
Anti-diarrhoeal agents
Never necessary and often harmful!

24. What supportive care and monitoring are required?

25. Supportive Care
Check regularly to see if there are problems (Ref. p )
If the child vomits, wait 10 minutes, then, resume giving ORS solution more slowly
If the child's eyelids become puff, stop ORS solution and give plain water or breast milk
Advise breastfeeding mothers to continue to breastfeed whenever the child wants
Infection control: hand washing in clinic and hospital

26. Monitoring The child should be checked by nurses frequently
Use a Monitoring chart (Ref. p. 320, 413)
Pay special attention to signs of dehydration such as:
lethargy/unconsciousness
sunken eyes
unable to drink or drinking poorly
skin pinch goes back slowly or very slowly (>2
seconds)
restlessness, irritability
drinks eagerly, thirsty

27. Summary Sarah was rehydrated with oral rehydration solution.
She was discharged on the same day when she was alert, able to drink and eat.
Before discharge home Sarah was given zinc supplements.
At the time of discharge her mother was given advice on how to give extra fluid, to continue feeding and when to return.
She was also given a Mother’s card containing this information and two packets of oral rehydration solution.