1. MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN Dr.B.Anjaiah, MD., DCh., Director, RIMS, Ongole

2. INVESTIGATIONS  STOOL- Macroscopy Microscopy- WBC>10/hpf Ova,cysts,throphozoites Hanging drop C/S for shigella & salmonella  BLOOD- CBC Electrolytes, creatinine,BUN C/S

3. MANAGEMENT  PREVENTION  TREATMENT  SUPPORTIVE TREATMENT

4. PREVENTION  HAF  Good liquids without salt -clean water -unsalted rice water -unsalted yoghurt drinks -coconut water -weak tea -unsweatened fresh fruit juice  Good liquids with salt -ORS -Salted soup -salted yoghurt drinks -salted rice water

5. DO NOT GIVE  Soft drinks  Sweetened tea  Sweet fruit juices  coffee

6. TREATMENT  CORNERSTONE of Rx ORT

7.  ORS  Solution made from sugar &salt  Food based solutions  Continued feeding

8. PLAN A (NO DEHYDRATION)  Rule 1 --- Fluids - HAF,SSS  Rule 2 --- Zn supplementation  Rule 3 --- continued feeding  Rule 4 --- return to clinic

9. Rule 1 --- Fluids  WHO Guidelines AGEQUANTITY WITH EACH STOOL <6 mon50 ml(1 cup) 7 mon – 2 yrs50-100 ml 2 yrs- 5 yrs100-200ml Older childAs much as they take

10. ORS is optional in PLAN A

11. Rule 2 --- Zn supplementation  Improves immune function  Improves intestinal permeability  Regulation of intestinal water & electrolyte transport & brush border enzymatic function  Intestinal tissue repair

12. Rule 2 --- Zn supplementation  <6 mon ---- 1/2 tab / day  >6 mon ---- 1 tab / day for 10 – 14 days

13. Rule 3 --- continued feeding  < 6 mon - breast / top fed  Older children – cereals & beans, meat & fish, oil, dairy products & eggs, fruit juices & bananas

14. What is the use of continued feeding?

15. Rule 4 --- return to clinic When the child -passes many stools -very thirsty -sunken eyes -fever -does not eat/drink normally

16. PLAN B (Some dehydration) AGEWeightORSGlass < 4 mon<5 kgs200-400 ml1-2 4-11mon5-8 kgs400-600 ml2-3 12-23 mon8-11 kgs600-800 ml3-4 2-4 yrs11-16 kgs800-1200 ml4-6 5-14 yrs16-30 kgs1200-2200ml6-11 >15 yrs>30 kgs>2200 ml12-20

17.  ORS given at 75 ml / kg over 4 hrs  Continue breast feeding  100-200 ml of water + ORS (in those who are not breastfed)

18.  REASSESS after 4 hrs  Signs of dehydration --- follow NIL - PLAN A PERSISTS - PLAN B SEVERE - PLAN C

19. PLAN C (Severe dehydration) AGE First give 30 ml / kg in Then give 70 ml / kg in < 1 year1 hour 5 hrs > 1 year30 min2 ½ hrs

20. TYPE OF FLUID  BEST ----- RL  IDEAL ----- RL + 5% D  IF RL not available ---- NS

21. INDICATIONS FOR IV FLUIDS  Severe dehydration with/with out shock  Persistent vomiting(>3/hr)  Failure to correct / worsening of dehydration on ORT  High purge rate  Failure of acceptance of ORS in dehydrated child  Abdominal distension  Deranged sensorium

22. GUIDELINES for the total amount of fluids to be replaced in some & severe dehydration Usual fluid Deficit (ml/kg) Deficit fluid replaced (ml/kg) Maintainence fluid required in 8 hrs (ml/kg) Total amount of IV fluids for correction of dehydration to be given in 8 hrs (ml/kg) Some 70-100 50 100 Severe 120-180ml 10050150

23. CONTINUATION OF IVF AFTER CORRECTION OF DEHYDRATION  Children - >3 mon N/4 NS -<3 mon N/6 NS  Maintenance fluids must contain K+ in the con of 20 meq/l

24. TYPE OF FLUID GIVEN AS REHYDRATION THERAPY  Initial fluid of choice-N/2 NS(1 PART OF ISOTONIC SALINE+1 PART 5% DEXTROSE)  Isotonic saline & RL - severe dehydration  ->6y high purge rate

25.  Start ORS -5ml/kg/hr when child able to drink  what to do if IV LINE not accessible?  Reasses after 1-2 hrs

26. COMPLICATIONS  Dehydration  Dyselectrolytaemia  Precipitation of malnutrition  Secondary lactose intolerence  Persistent diarrhoea  HUS  DIC  Cortical vein thrombosis

27. HYPONATRAEMIA Severe-<125meq/l Clinical features Deranged sensorium&convulsions Diminished urine output Correction-N/2 NS (or) RL [Na-125-135] -3N NS [Na-<125]

28.  Amount of Na required=Na deficit x 0.6 x wt  Half of it corrected as 3N over ½-1hr  Remaining corrected as RL (or) N/2 NS slowly

29. HYPERNATRAEMIA  Etiology  Clinical features  Usual signs of dehydration are absent  Management  If in shock-20-30ml/kg RL  Confirm hypernatraemia  Give N/3 NS in maintenance amounts

30. METABOLIC ACIDOSIS Etiology  Clinical features-deep fast breathing with plasma HCO3 <15 meq/lit Management  Amount of NaHCO3= HCO3 deficit x 0.6 x wt (OR) 3ml/kg of 7.5% NaHCO3 diluted 6 times 5% Dextrose [total of 20ml/kg] over 30-60 min

31. HYPOKALEMIA  Serum K- <3 Meq/l  Clinical features  Management- ORS  -K rich food  Oral potassium supplementation  -2meq/kg/d in PEM

33. WHO Formula gm/ litcomponentMmol/lit NaCl3.5Na90 KCl1.5K20 Tri sodium citrate 2.9Cl80 Glucose20Citrate10 water1LitGlucose111

34. Various measures to reduce Na  Lower Na content in ORS  Alternating breast milk and ORS(2:1)  Diluting ORS in 1.5 lit of water

35. Limitations of ORS  Does not decrease the volume frequency severity of diarrhoea Does not stop diarrhoea

36. IMPROVED ORS  Should reduce amount & rate of purging  Should stop diarrhoea  Should provide nutritional support (SUPER ORS)

37. FORMULATIONS  Amino acid Glycine / L-alanine / L- glutamine added to glucose ORS  Decreasing conc. Of glucose & sodium  Cooked cereal powder esp. rice to replace glucose  Combining glucose polymers & AA’s to replace glucose  Polymers like maltodextrine to replace glucose

38. CEREAL baesed ORS  50 gm/lit of cooked rice added to salt  ADVANTAGES?

39. REDUCED OSMOLARITY ORS  Principle? Gms/litMmol/lit NaCl2.6Na75 Glucose13.5Cl65 KCl1.5Glucose75 Tri Na cit2.9K20 Citrate10 Osm245

40. Amylase resistant starch in ORS  Add 50 gm/lit of starch to standard glucose ORS  Increases absorption efficiency

41. ReSoMal ComponentStandard ORSReSoMal Glucose111 mmol/lit125mmol/lit Na9045 K2040 Cl8070 Citrate107 Mg-3 Zn-0.3 Cu-0.045 Osmolarity311300

42. DRUG THERAPY SHIGELLACotrimoxazole(5d) CHOLERATetracycline/ Doxy (3-5d) (1dose) AEROMONAScotrimoxazole ETEC & EPEC-do-

43. CampylobacterErythromycin(5-7d) Clostridium difficileVancomycin/ metronidazole SalmonellaAmpicillin/ Cefotaxime(5-7d) GiardiasisMetronidazole(5d) AmoebiasisMetronidazole(7-10d)

44. RACECADORTIL  Mode of action  Comparing with Loperamide

45. MULTIVITAMINS  Vit A- on day 1,2 and 14  Folic acid- 5 mg on day 1 then 1mg/d for 2 wks  Other vitamins and trace elements double the maintanance dose

46. MICRONUTRIENTS  Potassium-5-6 meq/kg/d for few days 2-3 meq/kg/d orally for 2wks  MgSO4-0.2ml/kg  Zinc-10 mg for 2wks  Copper-0.3 mg/kg/d  Iron

47. PROBIOTICS IN DIARRHOEA  Viable microbial supplements / live microorganisms given to confer beneficial health effects on the growth of the host  Lactobacillus acidophilus/ L.casei  Bifidobacterium  Streptococcus thermophilius  Saccharomyces

48. PREBIOTICS IN DIARRHOEA  Food ingredients or part of bacteria largely undergraded in small bowel and can beneficially affect the host by stimulating colonic bacteria  Lactulose alfa disaccharide  Fructo-oligosaccharide  In some vegetables and fruits

49. USES OF PRE/PROBIOTICS  Establishes normal microbial flora  Enhancement of immunity  Nutritioal benefits-vit B Production -improved digestibility -body growth

50. MECHANISMS OF ACTION  Competing for receptor sites  Growth inhibition  Immune modulation  Production of short chain fatty acids  Modification of toxin receptors  Disaccharidases  Decreases permeability

51. DIARROEA IN PEM  Clinical features  MANAGEMENT  Mild to moderate-ORS 70-100 ml/kg over 6-12 hrs Severe – N/2 NS+5%D 30ml/kg – 2hr -N/6 NS+5%D 10ml/kg- 10hr -N/6 NS+5%D 5ml/kg/hr –12hr MAINTENANCE FLUIDS-N/6 NS in 5% D -75-100 ml/kg/d

52. NUTRITION IN PEM  The goal – 150-200 kcal -3-4g protein -6-8 feeds  Micronutrients & multi vitamins  Trace elements