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Acute diarrhea in children
Acute diarrhea is the second leading cause of death in children worldwide. It is defined as having 3 or more loose or watery stools per day for less than 14 days. The main causes are viral (70-80%), bacterial (10-20%), or protozoal (<10%). The most common viral causes are rotavirus, norovirus, enteric adenovirus, and astrovirus. Symptoms include fever, vomiting, abdominal cramps and watery diarrhea lasting up to a week. Treatment focuses on fluid replacement with oral rehydration solutions and early refeeding. Antibiotics may be used for specific bacterial causes or for severe cases. Zinc supplementation can help reduce the duration and severity of acute
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Acute diarrhea in children
- 1. Acute Diarrhea in children PRESENTED BY: A.PRIYADHARSHINI M.Sc(N), LECTURER, DEPT. OF PAEDIATRIC NURSING, GWALIOR
- 2. Is just alittle case of diarrhea… Second leading causes of all death worldwide Most common cause of morbidity and mortality in children worldwide
- 3. Definition Stool weight in excess of 200 gm/day 3 or more loose or watery stools/day Alteration in normal bowel movement characterized by decreased consistency and increased frequency Less than 14 days in duration
- 4. Epidemiology 1.2-1.9 episodes per person annually in the general population 2.4 episodes per child <3 years old annually 5 episodes per year for children <3 years old and in daycare Seasonal peak in the winter
- 5. Etiology Viral: 70-80% of infectious diarrhea in developed countries Bacterial: 10-20% of infectious diarrhea but responsible for most cases of severe diarrhea Protozoan: less than 10%
- 6. Viral Diarrhea Rotavirus Norovirus (Norwalk-like) Enteric Adenovirus Astrovirus
- 7. Rotavirus Leading cause of hospitalization for diarrhea in children Most prevalent during winter season Fecal-oral transmission: viral shedding can persist for 21 days Acute onset of fever followed by watery diarrhea (10-20 BM/day) and can persist for up to a week
- 8. Norovirus Most common cause of diarrheal outbreaks/epidemics Multiple modes of fecal-oral transmission Acute onset of nausea and vomiting, watery diarrhea with abdominal cramps and can persist for 1-3 days
- 9. Enteric Adenovirus Primarily affects children < 4 years old Fecal-oral transmission Clinical picture similar to rotavirus (fever and watery diarrhea)
- 10. Astrovirus Primarily affects children < 4 years old and immunocompromised Seasonal peak in the winter Fecal-oral transmission: viral shedding can occur for several weeks Fever, nausea and vomiting, abdominal pain, and diarrhea lasting up to a week
- 11. Summary of Viral Diarrhea Most likely cause of infectious diarrhea Rotavirus and Norovirus are most common Symptoms usually include low grade fever, nausea and vomiting, abdominal cramps, and watery diarrhea lasting up to 1 week Viral shedding can occur for weeks after symptoms resolve
- 12. Bacterial Diarrhea Campylobacter Salmonella Shigella Enterohemorrhagic Escherichia coli
- 13. Campylobacter Most common bacterial pathogen Transmitted through ingestion of contaminated food or by direct contact with fecal material Symptoms include diarrhea (+/- blood), abdominal cramps (can be severe), malaise, fever Usually self-limited and does not require antibiotics
- 14. Salmonella Most common in children <4 years old and a peak in the first few months of life Transmitted via ingestion of contaminated food and contact with infected animals Symptoms include fever, diarrhea, and abdominal cramping Antimicrobial therapy can prolong fecal shedding
- 15. Shigella Fecal-oral transmission Symptoms include fever, abdominal cramps, tenesmus, and mucoid stools with or without blood Can lead to serious complications Antimicrobial treatment shortens duration of illness and limits fecal shedding
- 16. E. Coli O157:H7 Transmission via contaminated food and water Symptoms include bloody diarrhea, severe abdominal pain, and sometimes fever Can lead to serious complications Antibiotics have no proven benefit and may increase the risk of complications
- 17. Summary of Bacterial Diarrhea Can affect all age groups Fecal-oral transmission, often through contaminated food Typical symptoms include bloody diarrhea, severe cramping, and malaise Antibiotic treatment not always necessary
- 18. Physical Exam Vitals, vitals, vitals! Abdominal exam Presence of occult blood Signs of dehydration
- 19. Laboratory Evaluation Unnecessary for patients who present within 1 day from onset of diarrhea Warning signs/symptoms: bloody diarrhea, high fever, severe abd pain, dehydration. Fecal leukocytes followed by bacterial culture, ova & parasites, viral antigens CBC, chemistries
- 20. Treatment Fluid replacement – Fluids or Oral Rehydration Solutions (ORS) – Parenteral rehydration Early refeeding Symptomatic Treatment – Oral bismuth – Loperamide Antibiotics
- 21. Fluid Replacement ORS: Infalyte, Pedialyte, Naturalyte and Rehydralyte Must be used or thrown out 24 hours after opening/mixing
- 22. AAP Guidelines Diarrhea with no dehydration – normal diet and supplemental ORS with each diarrheal episode. Diarrhea with some dehydration – seek medical care, give ORS in the doctor's office, and cont. ORS and normal diet at home. Moderate - severe dehydration – consider intravenous hydration, especially if patient is also vomiting
- 23. Early Refeeding Luminal contents help promote growth of new enterocytes and facilitate mucosal repair Can shorten duration of the disease Lactose restriction is not necessary except in severe disease
- 24. Symptomatic Treatment Only in patients who are afebrile and have nonbloody diarrhea Loperamide – inhibits peristalsis and has antisecretory properties Bismuth subsalicylate – may help with nausea, vomiting, and abdominal pain, as well as shorten duration of illness
- 25. Antibiotics antibiotic therapy generally not beneficial and can be harmful Those with more than eight stools/day, diarrhea >1 wk, volume depletion, immunosuppresion, or warning signs Fluoroquinolone or Azithromyzin
- 26. Specific Antibiotic Therapy Viral – of course not! Campylobacter – only if severe Salmonella – can prolong fecal shedding, only prescribe if severe Shigella – proven beneficial E. Coli O157:H7 – can be harmful
- 27. Zinc Supplementation in AD ! Responsible for > 200 enzymes in body. ! Improves the immune function & absorption. ! Supplementation in AD and PD helpful in 20-30% reduction in diarrhea. ! 42% lower rate of treatment failure or death. – Dosages – o Infants 10mg daily x 2 weeks. – o Older children 20mg daily x 2 weeks. – o Persistent diarrhea x 4 weeks
- 28. Home Available Fluids Recommended Salt sugar solution Lemon water(Sikanjabi) Rice water / Kanjee Soups Dal water Lassi Coconut water Plain water
- 29. Not recommended Simplesugar solution Glucose solution Carbonated soft drinks Fruit juices-tinned or fresh Fluids for athletes Gelatin desserts Tea/Coffee
- 30. Nursing management: Restoring fluid and electrolyte balance by ORS and IV therapy. Prevention of spread of infection by good hand washing practices, hygienic disposal of stools, care of diapers, general cleanliness and universal precautions.
- 31. Preventing skin breakdown by frequent change of diaper, keeping the perineal area dry and clean Providing adequate nutritional intake by appropriate dietary management Reducing fear and anxiety by explanation, reassurance, answering questions and providing necessary informations.
- 32. Giving health education for prevention of diarrhea, home management of diarrheal diseases, importance of ORS, dietary management etc..
- 33. References Dennehy P.H., Acute Diarrheal Disease in Children: Epidemiology, Prevention, and Treatment. Infect Dis Clin North A 2005;(19) 3: Wanke C.A., Approach to the patient with acute diarrhea. Up To Date (updated Jan. 4, 2005) www.uptodate.com/ Blacklow N.R., Epidemiology of viral gastroennteritis in adults. Up To Date (updated March 3, 2005) www.uptodate.com/ Thielman N.M., (2004) Acute Infectious Diarrhea. N Engl J Med 2004;350:38-47. Burkhart D.M., Management of Acute Gastroenteritis in Children. Am Fam Physician. 1999 Dec;60(9):2555-63
Editor's Notes
- #3 Diarrhea is the second most frequent illness encountered by American families.
- #8 Rotavirus is the leading cause of viral gastroenteritis worldwide. Virtually every child develops rotavirus gastroenteritis by three years of age. Reinfections are common, but symptoms are typically less severe or asymptomatic. The virus is transmitted principally be the fecal-oral route. Individuals handling diapers of infected chilrden can easily spread the infection if they do not wash their hands carefully. The virus can also survive on hard surfaces like toys and countertops for a limited amount of time. A very small inoculum is considered contagious.
- #9 Norovirus is the major cause of epidemic viral gastroenteritis. Norovirus outbreaks affect all ages. More than 90% of young adults are seropositive, however, immunity is not long lasting and reinfections are common. Outbreaks are most common at restaurants or catered meals, in hospitals and nursing homes, in schools, daycares, and camps, and on cruise ships. Transmission is fecal-oral through consumption of contaminated food, person to person contact, and contact with contaminated objects. Norovirus is highly contagious. It can even be transmitted through the aerosolization of vomit.
- #10 Adenoviruses are responsible for only a small amount of viral gastroenteritis. It predominantly affects very young children. Transmission is fecal-oral through person to person contact but much less contagious than rotavirus or noroviruses
- #11 Astrovirus is a common cause of diarrhea in daycare centers and a common cause of nosocomial disease. It can also cause illness in the immunocomromised, especially AIDS patients and elderly institutionalized patients. Transmission is person to person via the fecal-oral route. There are no commercially available diagnostic tests for astrovirus in the U.S.
- #14 Campylobacter is the most common bacteria isolated in foodborne diarrheal illness. Improperly cooked poultry, untreated water, and unpasteurized milk are the most common culprits. Transmission occurs by ingestion of contaminated food or by direct contact with fecal material from infected animals or people. Many farm animals and pets (esp. kittens and puppies) harbor the bacteria. Most patients recover in less than 1 week but 20% relapse or have a prolonged illness. Treatment usually shortens the duration of bacterial shedding in the stool.
- #15 The major vehicles of transmission are foods of animal origin, including poultry, beef, fish, eggs, and dairy products. Salmonella attack rates are highest among people younger than 4 years old with a peak during the first months of life. Antimicrobial treatment can prolong viral shedding but is recommended for those at increased risk of invasive disease or complications, including infants <3m/o, those with chronic GI disease, or who are immunosuppressed. Complications include bacteremia, osteomyletis, and meningitis.
- #16 Shigella affects people of all ages. Predominant modes of transmission include person-person contact, contact with contaminated objects, ingestion of contaminated food and water, and sexual contact. Most infections are self-limited and do not require antibiotics, however, antimicrobial therapy is effective in shortening the duration of diarrhea and eradicating the organism from feces. Rare complications include bacteremia, toxic megacolon and perforation, and toxic encephalopathy.
- #17 There are at least 5 types of diarrhea-producing E. Coli, but the only kind that commonly causes diarrhea in the U.S is enterohemmorhagic E. Coli o157:H7. Transmission is from ingestion of contaminated food, especially undercooked ground beef, dirty water and produce, and unpasteurized milk. The most common complication of EH E. Coli infection is HUS, defined as the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acte real dysfunction.. HUS occurs in ~8% of children with EH E. Coli and usually presents about 2 weeks after the onset of diarrhea. TTP occurs in adults and is the same disease as postdiarrheal HUS in children. Patients with bloody stools suggestive of hemorrhagic colits should have a CBC and chem. 7 checked to evaluate for HUS or TTP. If there is no laboratory abnormality 3 days after resolution of the diarrhea, the risk of developing HUS is low.
- #22 Treatment with oral rehydration solution is simple and enables the management of uncomplicated cases of diarrhea at home, regardless of etiologic agent
- #23 Minimal Dehydration – 10ml of fluids should be administered per kg of body weight for each episode of diarrhea OR children less than 10kg should be administered 2-4 oz for each episode of diarrhea and those weighing >10kg should be administered 4-8 oz. Mild-Moderate Dehydration – administer 50-100 of ORS per kg of body weight to replace fluid deficit with additional ORS to replace ongoing losses. Start 1 tsp at a time and gradually increase the amount as tolerated. Severe Dehydration – administer intravenous fluids
- #24 Regardless of the fluid used, an age-appropriate diet should also be given. Infants should be offered more frequent breast or bottle feedings. Luminal contents are a known growth factor for enterocytes and help facilitate mucosal repair after injury. Introducing a regular diet withing a few hours of rehydration has been shown to shorten the duration of the disease and has not been associated with increased morbidy
- #25 Nearly 400 over-the-counter products are promoted in the U.S. for their antidiarrheal properties but only a few have been proven to be effective in RCTs. The two most common are loperamide (Imodium) and bismuth subsalicylate (Pepto Bismal). Loperamide (Imodium) inhibits intestinal peristalsis and has anitsecretory properties. It does not penetrate the CNS and has no substantial potential for addiction. It should be avoided in those with bloody or suspected inflammatory diarrhea because it can prolong fever in those with shigella, cause toxic megacolon in those with C. diff, and HUS in those with Shiga toxin-producing E. coli. Bismuth subsalicylate (Pepto Bismal) – can alleviate nausea and vomiting as well as decrease the duration of illness of viral diarrhea
- #26 Because most diarrheal illnesses are self-limited or viral, and nearly half last less than 1-2 days, microbiologic investigation is usually unnecessary for patients who present within 24 hours after the onset of diarrhea, unless such patients are dehydrated or febrile or have blood or pus in their stool.