1. Diarrheal illnesses JFK pediatric core curriculum MGH Center for Global Health Pediatric Global Health Fellowship Credits: Brett Nelson, MD, MPH

2. Discussion outline Scope of diarrheal illnesses Pathophysiology Differential diagnosis and workup Strategy for management of diarrhea Oral rehydration therapy (ORT) Reduced-osmolarity ORT Home recipes for ORT Obstacles to full implementation

3. Diarrheal illnesses Diarrhea is second leading cause of childhood mortality globally after ARI

4. Scope of diarrheal illnesses In developing countries, children typically have 2-6 diarrheal illnesses each year –~2.2 million children under age 5 die each year as a result of diarrhea (8,000 children/day) –1/20 children die from diarrheal disease before age 5 Other consequences –Impaired nutrition, growth, development, fitness, cognitive, and school performance –Susceptibility to other acute infections

5. Pathophysiology Diarrhea is caused by pathogens that include bacteria, protozoa, and viruses Rapidly drains water and electrolytes from body Recurrent episodes lead to cycle of malnutrition, anemia, and decreased immune function Results in severe loss of energy and protein and ultimately death

6. Differential diagnosis WHO Pocket Book of Hospital Care for Children. Page 111.

7. Workup

8. Assessing degree of dehydration Mild (3-5%)Moderate (6-9%)Severe (≥ 10%) Urine outputNormalDecreasedNone in 12 hours Activity levelIrritableLethargicVery lethargic or unconscious PulseNormalRapidRapid and weak FontanelNormalSunkenVery sunken EyesDecreased tears Sunken, no tearsVery sunken, no tears MouthSlightly dryDryVery dry Skin turgorGoodFairPoor

9. Combined strategy for management of diarrhea Early replacement of fluid losses with appropriate home fluids and oral rehydration therapy (ORT) Continue/increase feeding and breastfeeding Recognize signs of dehydration or other concerning symptoms Antibiotic use only when appropriate Provide zinc x10-14 days –10mg daily for patients 2-5 months old –20mg daily for patients >6 months old

10. Oral rehydration therapy (ORT) Sodium and glucose solution for management of acute diarrhea “Potentially the most important medical advance of this century” 1 1. Water with sugar and salt [editorial]. Lancet 1978;2(8084):300-1.

11. Additional management To include additional management from WHO pocket book page 111- ………

12. Strengths of ORT Broad application: –Simple preparation from readily available ingredients –Locally produced in 60 developing countries –500 million sachets produced each year –Approximately half of all diarrhea cases in developing countries are now treated with ORT Inexpensive: <$0.10/sachet Effective: –ORT alone can successfully treat 90-95% acute diarrheal cases –Since ORT introduction, annual deaths among children with acute diarrhea has fallen from 5 to 2 million deaths –IVFs now only necessary in most severe cases

13. History of ORT First researched in 1940s, fully developed 20 years later by cholera researchers in Bangladesh and India Initially believed that only health professionals in hospitals could mix and administer During 1971 war between India and Pakistan, shown that ORT could be given by non-medical personnel –Death rate 3% in refugee camps with ORT (versus 20- 30% in camps with only IVF) WHO adopted ORT in 1978 as its primary tool for fighting diarrhea

14. Physiology of ORT H20 absorbed by creating osmotic gradient: –Na+ transport coupled to glucose transport on luminal surface in small intestine –Na+ gradient established by actively pumping Na out of cell via Na/K ATPase on basilar surface of cell –H20 subsequently follows Na across intestinal lining

15. Standard versus reduced-osmolarity ORT solutions Standard ORS (mEq/L) Reduced- osmolarity ORS (mEq/L) Glucose11175 Sodium9075 Chloride8065 Potassium20 Citrate10 Osmolarity311245

16. Advantages of reduced-osmolarity ORT Reduced osmolarity of new ORT decreases symptoms –Stool output reduced by ~20% –Incidence of vomiting decreased by ~30% –Also shorter duration of diarrheal symptoms in some studies Decreases need for IVFs by 33% However, has been associated with increased incidence of transient, asymptomatic hyponatremia

17. Home recipes for ORT If ORT sachets aren’t readily available, an effective alternative solution can be made using common household ingredients: –1 liter of clean water (or tea, soups, rice water, fruit juices) –8 level teaspoons of sugar –1 level teaspoon of salt

18. Home recipes for ORT

19. ORT teaching points for parents Wash yours and child’s hands with soap and water before preparing and before feeding solution Mix solution in clean pot Give as much solution as child will take –e.g. 50-100 ml ( 2yo) after each loose stool and between them Continue to provide child with other fluids (e.g. breast milk and juices) If your child vomits, wait ten minutes and give ORS again If child still needs ORS after 24 hours, make a fresh solution ORS does not stop diarrhea –ORS prevents dehydration; diarrhea will stop by itself If diarrhea increases and/or vomiting persists, take child to a health clinic Provide zinc daily x10-14 days

20. Obstacles to implementation While ORT saves an estimated 1 million children annually, there are still approximately 2 million preventable childhood deaths annually from diarrhea ORT requires clean water Doesn’t greatly reduce the diarrhea Not useful in setting of chronic or inflammatory diarrheas Suboptimal acceptance by parents and health care workers –Possibly because too simple? –Over-reliance on anti-diarrheal medications, antibiotics, and IVFs (even though rehydration with IVFs costs 10x more than ORT) Insignificant profit margin in ORT Errors can occur in mixing ORT

21. Conclusions Diarrheal illnesses are a significant cause of morbidity and mortality –2 nd leading cause of childhood mortality Management includes continued feeding, ORT, and zinc supplementation Parents should be instructed in proper preparation and administration of ORT –Simple recipes exist

22. References S.K. Hahn, Y.J. Kim, P. Garner. Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhoea in children: systematic review. BMJ 2001, 323:81-5. Unicef and WHO. Reduced osmolarity oral rehydration salts (ORS) formulation: A report from a meeting of experts jointly organised by UNICEF and WHO. Unicef House, New York, USA, 18 July 2001. USAID. Diarrhoea treatment guidelines including new recommendations for the use of ORS and zinc supplementation for clinic-based healthcare workers. 2005. www.eddcontrol.org/files/Diarrhoea_Treatment_guidelines_USAID.pdf www.eddcontrol.org/files/Diarrhoea_Treatment_guidelines_USAID.pdf WHO. Pocket Book of Hospital Care for Children. http://www.who.int/child_adolescent_health/documents/9241546700/en/index.ht ml http://www.who.int/child_adolescent_health/documents/9241546700/en/index.ht ml WHO. The treatment of diarrhoea: A manual for physicians and other senior health workers. 2005. http://www.eddcontrol.org/files/Treatment_of_Diarrhoea_manual_WHO.pdf http://www.eddcontrol.org/files/Treatment_of_Diarrhoea_manual_WHO.pdf