Acute Diarrhea in children

                                    ACUTE DIARRHEA

 INTRODUCTION

Diarrhoea is not a disease, but is a symptom of a number of illnesses. Children who die from diarrhoea, despite good management of dehydration, are usually malnourished

During diarrhoea, decreased food intake, decreased nutrient absorption, and increased nutrient requirements often

combine to cause weight loss and failure to grow: the child's nutritional status declines and any pre-existing

malnutrition is made worse. In turn, malnutrition contributes to diarrhoea which is more severe and prolonged. This vicious circle can be broken by:

·        continuing to give nutrient rich foods during and after diarrhoea;

·        giving a nutritious diet, appropriate for the child's age, when the child is well.

When these steps are followed, malnutrition can be prevented and the risk of death from a future episode of

diarrhoea is much reduced.—

 It is normal for young infants to have up to 3 to 10 stools per day, although this varies depending upon the child's diet (breast milk versus formula; breastfed children usually have more frequent stools). Older infants, toddlers, and children normally have one to two bowel movements per day.

Diarrhoea can usually be defined as an increase in stool frequency to twice the usual number per day in infants, or three or more loose or watery stools per day in older children.

Young infants, especially those who are breastfeeding, usually have soft stools. Their stools may be yellow, green, or brown, and/or appear to contain seeds or small curds.

All children's stools can vary as a result of their diet. Development of stools that are runny, watery, or contain mucus is a significant change that should be monitored. The presence of visible blood or black stools is never normal and always requires medical attention.

CAUSES

1.     Infections(viral,bacterial,parasitic)

2.     Side effects of antibiotics

3.     Infections not related to the gastrointestinal (GI) system e.g. Acute Otitis Media, ,UTI, ,Acute tonsillitis

Viral infection —  leading cause of diarrhoea in children

 Symptoms: begins 12 hours to 4 days after exposure

 watery diarrhoea, vomiting, fever (temperature higher than 100.4ºF or 38.0ºC), headache, abdominal cramps, lack of appetite, and muscle aches. Resolves within 3 to 7 days.

Treatment: No specific treatment is available for viral causes of diarrhoea.

Best treated with supportive measures (oral rehydration solution, limited diet, and rest). Vomiting is the predominant feature of gastroenteritis caused by Norovirus and medicines to prevent vomiting may be prescribed to assist the child with oral rehydration.

Bacterial infection — Bacterial infection is sometimes hard to distinguish from viral infection.

Symptoms: Persistent high fever (higher than 40ºC or 104ºF) diarrhoea that is bloody or contains mucus.

Treatment: Most children with bacterial infection do not require antibiotics and will improve with time and supportive measures, however, treatment may be necessary in children with bloody diarrhoea (probable shigellosis) or suspected cholera

with severe dehydration.. Anti-protozoal drugs are rarely indicated.

Parasitic infection — .Children aged 1-5 years are most commonly infected. Giardia can cause acute or persistent diarrhoea, sometimes malabsorption, with fatty stools, abdominal pain and bloating. However, the vast majority of infections

are asymptomatic. This

makes it very difficult to

determine when Giardia is

actually the cause of a

diarrhoeal episode. Diarrhoea from parasitic infections is usually persistent diarrhoea-lasting more than 2 weeks.

Antibiotic-associated diarrhoea —  diarrhoea is usually mild and typically does not cause dehydration or weight loss. In most cases, antibiotics should not be stopped and the child's diet does not need to be changed. The diarrhoea usually resolves one to two days after antibiotics are finished.

HOME CARE OF DIARRHEA

Dietary recommendations — Children who are not dehydrated should continue to eat a regular diet and infants who are breastfeeding should continue to do so

§  Most children with diarrhoea tolerate full-strength cow's milk products. It is not necessary to dilute or avoid milk products, except in children with known allergies to cow's milk.

§  Recommended foods include a combination of complex carbohydrates (rice, wheat, potatoes, bread), lean meats, yogurt, fruits, and vegetables. High-fat foods are more difficult to digest and should be avoided.

They should be well cooked, and mashed or ground to make them

§  easy to digest; fermented foods are also easy to digest

§  potassium rich foods

§  Apple, pear, and cherry juice, and other beverages with high sugar content should be avoided

Monitoring for dehydration 

Finding	Mild (3-5 percent)	Moderate (6-9 percent)	Severe (≥10 percent)
Pulse	Full, normal rate	Rapid	Rapid and weak
Systolic pressure	Normal	Normal to low	Very low
Respirations	Normal	Deep, rate may be increased	Deep, rapid rate
Oral tissues	Tacky or slightly dry	Dry	Parched
Infant fontanelle (soft spot in skull)	Normal	Sunken	Markedly sunken
Eyes	Normal	Sunken	Markedly sunken
Skin	Normal	Cool	Cool, mottled, blue-tinged hands/feet
Urine output	Mildly reduced	Markedly reduced	Absent
Systemic signs	Increased thirst	Listlessness, irritability	Grunting, lethargy, coma

Oral rehydration therapy — ORT does not cure diarrhea, but it does help to treat the dehydration that often accompanies it.

A child who refuses to drink or vomits immediately after drinking ORT should be monitored closely for worsening dehydration. Children who are not dehydrated may drink ORS after every episode of vomiting to prevent dehydration.

Medications — Medications such as antibiotics and antidiarrheal agents are generally not necessary and could be harmful for infants or children with diarrhoea. Rarely, antibiotics may be used in cases of bacterial infection when a specific cause of diarrhoea has been found  Inappropriate use of antibiotics will not improve diarrhoea. Furthermore, antibiotics can cause side effects and lead to development of antibiotic resistance.

Give supplemental zinc (10 - 20 mg) to the child, every day for 10 to 14 days. The duration and severity of the episode as well as the risk of dehydration will be

reduced. By continuing zinc supplementation for 10 to 14 days, the zinc lost during diarrhoea is fully replaced and

the risk of the child having new episodes of diarrhoea in the following 2 to 3 months is reduced.

Antidiarrheal agents (including Imodium, Pepto-Bismol, and Kaopectate) are not recommended for infants or children, since the benefits do not outweigh the risks. One risk of using an antidiarrheal agent is that it could mask worsening symptoms and delay treatment.

Antiemetics. These include drugs such as prochlorperazine and chlorpromazine, which cause sedation that can

interfere with ORT. For this reason antiemetics should never be given to children with diarrhoea. Moreover,

vomiting stops when a child is rehydrated

Probiotics — There are "healthy" bacteria (called probiotics) that may help reduce the duration of diarrhoea (by about 12 to 30 hours). Some of these are available.. While it is not unreasonable to use them, their overall benefit is small and they can be expensive.

Preventing spread — Parents with children who have diarrhoea should be cautious to avoid spreading infection to themselves, their family, and friends. Care with hand washing, diapering, and keeping sick children out of school or day care until the diarrhoea is gone are a few ways to limit the number of people exposed to the infection.

Hygiene measures — Hand washing is an essential and very effective way to prevent the spread of infection. Hands should ideally be wet with water and plain or antimicrobial soap, and rubbed together for 15 to 30 seconds. Special attention should be paid to the fingernails, between the fingers, and the wrists. Hands should be rinsed thoroughly and dried with a single-use towel.

Alcohol-based hand rubs are a good alternative for disinfecting hands if a sink is not available, however, alcohol-based hand rubs do not prevent all types of diarrhoea (eg, Norovirus, Clostridium difficile).

Hands should be cleaned after changing a diaper or touching any soiled item. They should also be washed before and after preparing food and eating, after going to the bathroom, after handling garbage or dirty laundry, after touching animals or pets, and after blowing the nose or sneezing.

WHEN TO SEEK HELP FOR DIA

list of signs and symptoms that are worrisome and require immediate medical attention:

§  Bloody diarrhoea

§  If an infant refuses to eat or drink anything for more than a few hours

§  Moderate to severe dehydration

§  Abdominal pain that comes and goes or is severe

§  Behaviour changes, including lethargy or decreased responsiveness

SOURCE

·        UPTODATE: Acute Diarrhoea in children

(http://www.uptodate.com/contents/acute-diarrhea-in-children-beyond-the-basics)

·        http://whqlibdoc.who.int/publications/2005/9241593180.pdf