Diarrhea in children

GOALS
• An overview of:-
Acute diarrhea
Persistent diarrhea
Chronic diarrhea
• Etiology
• Risk factors
• Clinical features
• Diagnosis
• Medical management
• Nursing management
2

ACUTE DIARRHEA
Diarrhea is defined as a change in consistency and frequency
of stools, i.e. liquid or watery stools, that occur >3times a day.
If there is blood in stools – dysentery.
Mostly, acute episodes subside within 7 days.
Globally, 3-5 billion cases annually and 2 million deaths a year.
Accounts for over 20% of all deaths in under five children.
3

ETIOLOGY
• Intestinal infections - most common.
• Certain drugs, food allergy, systemic infections (UTI, otits media) & surgical conditions
(e.g. appendicitis)
• CAUSATIVE AGENTS:-
Bacterial :- E. coli, Shigella, Vibrio cholera, Salmonella, Campylobacter species,
clostridium difficile, Clostridium perfringens, Staphylococcus aureus, etc.
Viral – Rotavirus (leading cause of severe), Enteric adenovirses, Coronaviruses,
cytomegalovirus, picornavirus, etc.
Parasitic – Giardia lamblia, Entamoeba histolytica, Cryptosporidium parvum, Cyclospora
cayetanensis, etc.
4

CONT..
• In India, rotavirus and enterotoxigenic E. coli – nearly half of total cases among
children.
• Rotavirus – vomiting early feature and diarrhea is more severe.
• Cholera – 5-10% cases, stools like rice water, vomiting is common and rapid onset
of severe dehydration within hours.
• Enterotoxin E. coli – 20% of childhood diarrhea.
• Shigella & salmonella species – 3-7%
• Clostridium difficile – suspected in those who have received broad spectrum
antibiotics.
5

RISK FACTORS
• Poor sanitation & personal hygiene
• Nonavailability of safe drinking water
• Unsafe food preparation practices
• Low rates of breastfeeding & immunization
• Young children, <2yr and those with malnutrition – more susceptible
For recurrent episodes :-
• Presence of hypo- or achlorhydria – due to H. pylori infection or therapy with PPIs
• Selective IgA deficiency
• HIV infection & other chronic conditions
6

PATHOGENESIS AND CLINICAL
FINDINGS
• Diarrheal losses come from ECF, which is rich in sodium and low potassium.
• In half cases – Na concentration remains nearly normal
• 40-45% - excessive sodium lost in stools, hyponatremia and fall in ECF
osmolality.
• 5% - Serum Na may be elevated to >150mEq & ECF osmolality increased
• ECF compartment depleted – blood volume reduced = weak, thread pulse, low
blood pressure and cold extremities.
• Hyponatremic and isonatremic dehydration impairs skin elasticity, skin takes
few seconds to return to normal after pinching.
7

CONT..
• Hypernatremic dehydration – soggy, doughy or leathery skin.
• Urine filtration reduced due to low hydrostatic pressure in renal glomeruli. Urine flow –
good indicator of severity.
• If persists more than a few days, serum potassium level falls – more pronounced in
children with severe malnutrition with already depleted potassium = abdominal
distension, paralytic ileus ands muscle hypotonia; and ST depression and flat T waves.
• Alkaline intestinal secretions, bicarbonate loss in stools – Acidosis
• Asymptomatic till base falls to 12mmol/L
8

CLINICAL FEATURES
• thirsty and irritable in early and mild cases. As it continues, more irritable and
pinched look.
• If open, fontanelle depressed.
• Eyes sunken and tongue and inner side of cheeks appear dry.
• Abdomen may distended in hypokalemia
• Child Passes urine at longer intervals.
• Acidosis worsens – breathing deep and rapid (Kussmaul breathing).
• Extreme case – moribund, with weak and thread pulses, low blood pressure and
reduced urine output.
9

ASSESSMENT OF CHILD
Goals :-
• Determine type of diarrhea
• Look for dehydration & other complecatuons
• Assess for malnutrition
• Rule out nondiarrheal illness
• Assess feeding, both pre illness & during illness.
History :-
• Onset of diarrhea, duration & number of stools per day; Blood in stools
• Number of episodes of vomiting
• Presence of fever, cough or other significant symptoms
• Type and amount of fluids (including breast milk) & food taken during illness and pre illness
feeding practices
• Drugs or other local remedies taken
• Immunization history
11

Examination :-
• Assessment of dehydration :-
Look
Condition Well alert Restless, irritable Lethargic or unconscious;
floppy
Eyes Normal Sunken Very sunken & dry
Tears Present Absent Absent
Mouth and tongue Moist Dry Very dry
Thirst Drinks normally Thirsty, drinks eagerly Drinks poorly or not able
to drink
Feel
Skin pinch Goes back quickly Goes back slowly Goes back very slowly
Decide No signs of dehydration 2 or more signs, some
hydration
2 or more signs, sever
hydration
Treatment Plan A Weigh the pt, if poosible
& use Plan B
Weigh the pt & use Plan
urgently
12

CONT..
• Based on the degree of hydration, estimated fluid loss is calculated :-
• Examine features of malnutrition – anthropometry for weight & height, examination
for wasting, edema & signs of vitamin deficiency
• Examine systemic infection – presence of cough, high grade fever, fast breathing &/
or chest indrawing suggests pneumonia; high grade fever with splenomegaly – malaria
• Fungal infections – oral thrush or perianal satellite lesions
Degree of hydration Assessment of fluid loss
No hydration < 50 ml/kg
Some hydration 50-100 ml/kg
Severe hydration >100 ml/kg
13

CONT..
• Mostly managed without laboratory investigations.
• Stool microscopy – cholera (darting motion) & giardiasis (trophozoites)
• Stool culture –useful to decide antibiotic therapy in Shigella dysentery, do not
respond to initial empiric antibiotics.
• Hemogram, blood gas estimation, serum electrolytes, renal function rests – only if
child has pallor, labored breathing, altered sensorium, seizures, paralytic ileus or
oliguria.
14

MEDICAL MANAGEMENT
4 major components:-
• Rehydration & maintaining hydration
• Ensuring adequate feeding
• Oral supplementation of zinc
• Early recognition of danger signs and treatment
of complications.
• Standard WHO ORS – 311mmol/l osmolarity
• Low osmolarity WHO ORS – 245 mmol/l = reduction of stool output, decrease in vomiting
& decrease in the use of unscheduled intravenous fluids without increasing risk of
hyponatremia. Recommended due to this.
• Since 2004, GOI has adopted low osmolarity ORS as the single universal ORS.
15

LOW OSMOLAR ORS COMPOSITION
Constituent g/l
Sodium chloride 2.6
Glucose, anhydrous 13.5
Potassium chloride 1.5
Trisodium citrate,
dihydrate
2.9
Osmole or ion Standard ORS
mmol/l
mmol/l
Sodium 90 75
Chloride 80 65
Glucose. Anhydrous 111 75
Potassium 20 20
citrate 10 10
Total osmolarity 311 245
16

HOME AVAILABLE FLUIDS
• Fluids that contain salt (preferable) – oral rehydration solution, salted drinks
(e.g. salted rice water or salted yogurt drink), vegetable or chicken soup with salt
• Fluids that do not contain salt (acceptable) – plain water, water in which a
cereal has been cooked (e.g. unsalted rice water), unsalted soup, yogurt drinks
without salt, green coconut water, weak unsweetened tea, unsweetened fresh
fruit juice
• Unsuitable home available fluids – commercial carbonated beverages,
commercial fruit juices, sweetened tea
17

TREATMENT PLAN A FOR
NO HYDRATION
• May be treated at home after explanation of feeding and the danger signs to
the mother/caregiver.
• Mother may be given WHO ORS for use at home:-
• Danger signs requiring medical attention – diarrhea beyond 3 days, increased
volume/frequency of stools, repeated vomiting, increasing thirst, refusal to feed,
fever or blood in stools.
Age Amount of ORS or other culturally
appropriate ORT fluids to give after each
loose stool
Amount of ORS to provide
for use at home
<24months 50-100 ml 500 ml/day
2-10 years 100-200 ml 1000ml/day
>10 years Ad lib 2000ml/day
19

TREATMENT PLAN B FOR
SOME DEHYDRATION
• Need to be treated in a health center or hospital.
• Fluid replacement is calculated under the following three headings:-
1. Daily fluid requirements in children :-
Up to 10 Kg = 100 ml/kg
10-20 kg = 50ml/kg
>20 kg = 20ml/kg
For e.g. if a child weighs 15kgj, has daily fluid requirement :- 10×100=1000ml, another 5kg, 5×50=250ml,
total=1250ml.
2. Deficit replacement or rehydration therapy :- 75ml/kg of ORS to be given over 4 hr. if cannot be
taken orally then NG tube can be used.
• If after 4 hr, child still has some dehydration then another treatment with ORS is to be given.
• ORT may be ineffective in children with a high sstool purge rate of >5ml/kg/hr, persistent vomiting >3
per hr, paralytic ileus & incorrect preparation of ORS (very dilute).
20

3. Maintenance fluid therapy to replace losses :-
• Should begin when signs of dehydration disappear, usually within 4hr.
• ORS should be a administered in volumes equal to diarrheal losses, usually to
of 10ml/kg per stool.
• Breast feeding and semisolid food are continued after replacement of deficit.
Age <4mon 4-11mon 12-13mon 2-4yr 5-14yr ≥15yr
Weight <5kg 5-8kg 8-11kg 11-16lg 16-20kg >30kg
ORS, ml 200-400 4000-600 600-800 800-1200 1200-2200 >2200
Number of
glasses
1-2 2-3 3-4 4-6 6-11 12-20
21

TREATMENT PLAN C FOR
SEVERE DEHYDRATION
• IV fluids should be started immediately using RL with 5% dextrose.
• NS or plain RL – alternative but 5%D alone is not effective
• Total 100ml/kg fluid is given over 6hr in children <12 months & iver 3 hr in children >12
months
• ORS should start if child can take orally.
• If IV fluids cannot be given, NG feeding given at 20ml/kg/hr for 6hr (total 120ml/kg)
• Child should reassessed every 1-2 hr, if repeated vomiting or abdominal distension, oral or
NG fluids given more slowly.
• If no improvement in hydration after 3hr, IV fluids should be started as early as possible.
• Child should be reassessed every 15-30min for pulses & hydration status after first bolus of
100ml/kg of Iv fluid.
22

CONT..
• Persistence of severe dehydration – IV infusion is repeated.
• Hydration is improved but some dehydration is present – IV fluids discontinued;
ORS is administered over 4hr according to Plan B.
• There is no dehydration – IV fluids are discontinued; Rx Plan A followed.
• Child should be observed for at least 6hr before discharge, to confirm that mother is
able to maintain child’s hydration by giving ORS solution.
23

UNIQUE PROBLEMS IN INFANTS
<2MONTHS
• Breastfeeding must continue during rehydration process whenever infant is able to
suck.
• Complications – septicaemia, paralytic ileus and severe electrolyte disturbance.
• Diarrhea should be ideally treated as inpatient by experienced physicians with
appropriate facilities.
• Careful assessment of need of systemic antibiotics and monitoring.
24

NUTRITIONAL MANAGEMENT
• In exclusively breastfed infants, breastfeeding should continue as it helps in better weight
gain & decreases risk of persistent diarrhea.
• Optimally energy dense foods with least bulk, recommended, should be offered in small
quantities, frequently (every 2-3hr).
• Staple foods do not provide optimal calories per unit weight & should be enriched with fat
or oil and sugar, e.g. khichri with oil, mashed banana with milk or curd etc.
• Avoid Foods with high fiber content, e.g. coarse fruits and vegetables.
• In non breastfed infants, cow or buffalo milk can be given undiluted after correction od
dehydration with semisolid foods. Alternatively, milk cereal mixtures, e.g. dalia, sago or
milk-rice mixture, are preferable.
• Routine lactose-free feeding, e.g. soy formula is not required even when reducing
substances are detected in the stools.
• During recovery, an intake of at least 125% of recommended dietary allowances should be
attempted with nutrient dense foods until child achieves a normal nutritional status.
25

ZINC SUPPLEMENTATION
• Intestinal zinc losses during diarrhea aggravate pre-existing zinc deficiency.
• Part of the standard care along with ORS in children with acute diarrhea.
• Helpful in decreasing severity and duration of diarrhea and also risk of persistent
diarrhea.
• Zinc is recommended to be supplemented as sulphate, acetate or gluconate
formulation, at a dose of 20 mg of elemental zinc per day for children >6 months
for a period of 14 days.
26

SYMPTOMATIC TREATMENT
• If vomiting is severe or recurrent and interferes with ORS intake, a single dose of
ondansetron (0.1-0.2 mg/kg/dose) should be given.
• If bowel sounds are absent and abdomen distended – Paralytic ileus - due to
hypokalemia, intake of antimotility agents, necrotizing enterocolitis or septicaemia – oral
intake should be withheld.
• Hypokalemia with paralytic ileus – IV fluids and NG aspiration.
• KCl (30-40mEq/l) IV with parenteral fluids, provided child is passing urine.
• Convulsions due to hypoorhypernatremia, hypoglycaemia, hypokalemia, encephalitis,
meningitis, febrile seizures or cerebral venous or sagittal sinus thrombosis – Rx depends
on etiology.
27

DRUG THERAPY
Antimicrobial – bacillary dysentery, cholera, amebiasis & giardiasis.
Antimotility agents (diphenoxylate hydrochloride ro lomotil ad loperamide or imodium) –
reduce peristalsis, may cause abdominal distension, paralytic ileus, bacterial overgrowth and
sepsis – should not use in children, can be fatal in infants.
Antisecretory agents – e.g Racecadotril – antidiarrheal effects, inhibit intestinal
enkephalinase.
Probiotics – microorganisms that exert beneficial effects on human health when they
colonize bowel.
• Several microorganisms like Lactobacillus rhamnosus, L. plantarum, several strains of
bifidobacteria, Enterococcus Jaecium SF68 and the yeast Saccharomyces boulardii have
some efficacy in reducing the duration of acute diarrhea if started in very early phase of
illness.
• Routine use not recommended.
28

PREVENTION
• Proper nutrition – breastfeeding continuation should be encouraged. Supplementary
feeding with energy-rich food mixtures containing adequate amounts of nutrients
should be introduced by 6 months of age.
• Adequate sanitation – improvement of environment sanitation, clean water supply,
adequate sewage disposal system and protection of food from exposure to bacterial
contamination. 3 C’s :- clean hands, clean container & clean environment..
• Vaccination – vaccine against commonest agent, rotavirus, might be effective.
29

DYSENTERY
• Presence of grossly visible blood in stools and is consequence of infection of the colon by
either bacteria or ameba.
• Bacillary dysentery is more common in children than amebic.
• Bacteria – Shigella species [S. flexneri commonest in developing countries], enterpinvasive
and enterohemorrhagic E.coli, Salmonella and Campylobacter jejuni.
Presentation :-
Bacillary dysentery – fever. Diarrhea (watery to stat with but then shows mucus & blood).
Tenesmus.
• Complications – dehydration, dyselectrolytemia, haemolytic uremic syndrome, convulsions,
toxic megacolon, intestinal perforation, rectal prolapse & very rare, Shigella encephalopathy.
Diagnosis :-
• Stool culture and sensitivity.
31

CONT..
Management :-
Bacillary:-
• Administration of ORS, continuation of oral diet, zinc supplementation and antibiotics.
• Antimicrobial agents, main theraoy for all Shigellosis.
• Ciprofloxacin/fluoroqinolones (15 mg/kg/day in two divided doses for 3 days) has been
recommended by WHO as the first line antibiotic for shigellosis.
• Intravenous ceftriaxone (50-100 mg/kg/ day for 3-5 days) should be the first line of
treatment in a sick child as antimicrobial resistance to fluoroquinolones increased.
• Stable child – ciprofloxacin or oral cefixime may be given, but should monitored for
improvement in 48 hrs. If no improvement, change antibiotics.
• Oral azithromycin (10 mg/kg/ day for 3 days) can be used for shigellosis but the experience
is limited.
Amebic – onset insidious. Tinidazole or metronidazole Drug of choice
32

PERSISTENT DIARRHEA
Episode of diarrhea, of presumed infectious etiology ,
which starts acutely but last more than 14 days.
33

ETIOPATHOGENESIS
• Predominant problem – worsening malnutritional status. Persistent diarrhea is more
common in malnourished children. Apart from malabsorption, malnutrition also results
from inadequate calorie intake due to anorexia, faulty feeding and improper counselling
regarding feeding by doctors.
• Pathogenic E. coli result in malabsorption by causing persistent infection.
• UTI or other infection contribute to failure to thrive and mortality.
• Prolongation of an acute diarrhea may rarely be a manifestation of cow milk protein
allergy. The increased gut permeability in diarrhea predisposes to sensitization to oral
food antigens.
• Use of antibiotics in acute diarrhea suppresses normal gut flora – bacterial overgrowth
with bacteria or fungi – persistent diarrhea & malabsorption.
• Cryptosporidium infection is frequently implicated in persistent diarrhea, even in
immunocompetent children.
34

CLINICAL FEATURES
• Several loose stools daily but remain well hydrated.
• Dehydration develops in some patients due to stool output or when oral intake reduced.
• Growth faltering, worsening malnutrition and death.
• Secondary lactose intolerance when stools are explosive (mixed with gas & passed with
noise) & in presence of perianal excoriation.
• Stool pH low and stool test for reducing substances is positive
35

MANAGEMENT
• Correction of dehydration, electrolytes and hypoglycaemia
• Evaluation for infections using appropriate investigations and their management
• Nutrition therapy.
2/3rd patients can be treated on outpatient basis. Need hospital admission, those
with :-
i. <4months age and not breastfed
ii. Presence of dehydration
iii. Severe malnutrition (weight for height <3SD, mid-upper arm circumference <11.5
cm at 6-60months or bilateral pedal edema)
iv. Presence or suspicion of systemic infection.
36

NUTRITION
• Initially 6-7 feeds are given everyday & a total daily caloric intake of 100 kcal/kg/day ensured,
should be increased gradually over 1-2wks to 150kcal/kg/say to achiever weight gain.
• Nasogastric feeding in children with poor appetite due to presence of serious infection.
• To ensure absorption and decrease stool output, one may attempt to overcome varying
degrees of carbohydrates maldisgestion by using diets with different degrees of
carbohydrates exclusion in form of diet A (lactose reduced), diet B (lactose free) and diet C
(complex carbohydrate free) diets.
• Resumption of regular diet after discharge:-
• Children discharged on totally milk free diet – small quantities of milk as part of mixed diet
after 10 days – no signs of lactose intolerance, then milk gradually increased over next few
days. Age appropriate normal diet can then be resumed over next few wk.
37

Diets for persistent diarrhea
Diet A (reduced lactose) Diet B (lactose free) Diet C (monosaccharide based)
Constituents
Milk (1/3 katori/50ml)
Puffed rice powder / cooked rice
or sooji (2tsp/6g)
Sugar (1.5 tsp/7g)
Oil (1 tsp/4.5 g)
Water (2/3 katori/100 ml)
Egg white (3tsp/half egg white)
Puffed rice powder/cooked rice
(3tsp/9g)
Glucose (1.5tsp/7g)
Oil (1.5tsp/7g)
Water (3/4 katori/120 ml)
Chicken puree (5tsp/15g) or
Egg white (3tsp/ half egg white)
Glucose (1.5tsp/7g)
Oil (1.5tsp/7g)
Water (1katori/150ml)
Preparation
Mix milk, sugar & rice, add
boiled water & mix well, add oil.
After whipping the egg white,
add rice, glucose & oil & mix
well. Add boiled water & mix
rapidly to avoid clumping.
Boil chicken & make puree after
removing bones. Mix it with
glucose & oil. Add boiled water
to make a smooth flowing feed.
Nutrient content
85 kcal & 2 g protein per 100 g 90kcal & 2.4g protein per 100g 67 kcal & 3 g protein per 100 g
38

SUPPLEMENT VITAMINS AND
MINERALS
• Supplemental multivitamins and minerals at about twice the RDA should be given daily
to all children fro at least 2-4 wks.
• Iron supplements introduced only after diarrhea has ceased.
• Vitamin A & zinc are supplemented, enhance recovery.
• Vitamin A, single oral dose should be given routinely, at 2,00,000 IU for children>12
mon or 1,00,000 IU for 6-12 mon.
• Children weighing less than 8kg – 1,00,000 IU vit A.
• 10-20 mg per day of elemental zinc for at least 2 wks for 6mon – 3yr of age.
• Magnesium – IM at 0.2ml/kg/dose of 50% MgSO4 twice a day for 2-3 days.
• Potassium – 5-6mEq/kg/day orally or as part of IV infusion during initial stabilization
period.
39

ANTIBIOTICS
• A combination of cephalosporin and aminoglycoside can be started empirically and
thereafter changed according to reports of culture/sensitivity.
• UTI is common (10-15%) and should be treated appropriately.
SUCCESSFUL TREATMENT
• Adequate food intake, reduced frequency of diarrheal stools (<2 liquid stools/day for 2
consecutive days) & weight gain.
• All children should be followed regularly after discharge to ensure continued weight gain
& compliance with feeding advice.
PROGNOSIS
• <5% generally have high purge rate, continue to lose weight, don’t tolerate oral feeds and
require referral to specialized paediatric gastroenterology centers.
40

CHRONIC DIARRHEA
Common problem I children
Insidious onset diarrhea of >2wks duration in children &
>4wks in adults.
Not synonymous with persistent diarrghea,
41

APPROACH
• Age of onset :-
Causes of chronic diarrhea according to age of onset (in order of importance)
Age <6 months 6months to 5 yr > 5yr
Cow milk protein allergy
Lymphanfiectasia
UTI
Short bowel syndrome
Immunodeficiency states
Cystic fibrosis
Anatomical defects
Intractable diarrheas of infancy:-
Microvillous inclusion disease
Tufting enteropathy
Autoimmune enteropathy
Glucose galactose malabsorption
Congenital Na/Cl diarrhea
Cow milk protein allergy
Celiac disease
Giardiasis
Toddler diarrhea
Lymphanfiectasia
Short bowel syndrome
Tuberculosis
Inflammatory bowel disease
Immunodeficiency
Bacterial overgrowth
Pancreatic insufficiency
Celiec disease
Giardiasis
Gastrointestinal
Tuberculosis
Inflammatory bowel
disease
Bacterial overgrowth
Lymphanfiectasia
Tropical sprue
Immunoproliferative small
intestinal disease
Pancreatic insufficiency
42

CONT..
• Small or large bowel type of diarrhea :-
Differentiating small bowel from large bowel diarrhea
Features Small bowel diarrhea Large bowel diarrhea
Stool volume Large Small
Blood in stool No Usually present
Rectal symptoms, e.g. urgency,
tenesmus
No Yes
Steatorrhea (greasy stools) Yes No
Carbohydrate and protein
malabsorption
Yes, explosive and yes No and no
Pain (if any) Periumbilical, no reduction after
passage of stool
Hypogastric, reduced after
passage of stool
Color of stool Pale Normal
Smell of stool Unusually offensive Normal
Nutrient deficiency Frequent Can occur due to blood loss
43

CONT..
Systemic causes :-
• Cholestasis due to biliary obstruction or intrahepatic cause
• Pruritus and malabsorption of fat soluble vitamins & calcium.
• Maldigestion due to deficiency of pancreatic enzymes leads to pancreatic diarrhea
in cystic fibrosis, Shwachman-Diamond syndrome or chronic pancreatitis.
• Zollinger-Elison syndrome and secretory tumors like VIPoma, carcinoid or
mastocytosis.
• Sepsis or collagen vascular disorders.
44

CONT..
History :-
• Duration of symptoms; nature, frequency and consistency of stools; & presence of
blood, mucus or visible oil in stools.
• Age of onset; relationship of dietary changes, e.g. introduction of milk or milk products
& wheat or wheat products , with onset of diarrhea; & any specific dietary preferences,
like avoidance of juices
• Family history of atopy, celiec disease Crohn disease or cystic fibrosis
• History of abdominal surgery, drug intake, systemic disease, features of intestinal
obstruction pedal edema, anasarca, recurrent infection at multiple sites, previous blood
transfusion and coexisting medical problems which predispose child to diarrhea.
45

CONT..
Important components of physical examination :-
• Anthropometry
• Signs of dehydration
• Signs of vitamin or mineral deficiencies (e.g. conjunctival xerosis, bitot spots, cheilitis,
rickets etc.)
• Edema, whether symmetric or asymmetric; pitting or non pitting
• Fever and sings of systemic sepsis
• Extragastrointestinal manifestations in eye, skin, joints, oral cvity
• Inspection of perianal area for fissures, anal tags and fistulae
• Oral thrush & scars of recurrent skin infections
• Abdominal distension, localised or generalised tenderness, masses,
hepatosplenomegaly and ascited.
46

CELIAC DISEASE
• Enteropathy caused by permanent sensitivity to gluten in genetically susceptible subjects.
• Most common cause of chronic diarrhea in children over 2yr in north india.
• High risk groups – subjects with type1 DM, down syndrome selective IgA deficiency,
autoimmune thyroid disease, Turner syndrome, Williams syndrome, autoimmune liver
disease and first degree relatives of celiac disease patients.
• Presentation :- small bowel diarrhea, growth failure & anemia. Short stature, delayed
puberty, rickets & osteopenia. Failure to thrive, loss of subcutaneous fat, clubbing, anemia,
rickets & signs of other vitamin deficiencies.
Diagnosis :-
• Serology
• Upper GI endoscopy
• Histology
47

Diagnosis requires the following :-
• Clinical features compatible with diagnosis.
• Positive intestinal biopsy with or without serology.
• Unequivocal response to gluten free diet within 12 wks
of initiation of GFD.
Treatment :-
• Life long GFD & correction of iron, folate & other
vitamin/mineral deficiencies by supplementation.
• Pt should be assess at 3 months for response to GFD.
After initiation of GFD, all symptoms should subside &
weight and height gain should be present.
Celiac disease - Upper gastrointestinal
endoscopy showing scalloping of duodenal
folds (arrow)
48

COW MILK PROTEIN ALLERGY
• Affects2-5% of all children in the West, with highest prevalence during first yr of life.
• In india, Accounts for 13% of all malabsorption cases in children <2yr of age.
• A family history of atopy is common in children with CMPA
• Nearly 50% children outgrow allergy by 1 yr and 95% by 5yr.
• Most common food allergy in small children who are topfed but can also occur
occasionally in breastfed babies due to passage of cow milk antigen in breast milk.
• Immediate reaction, i.e. IgE mediated – occurs within minutes of milk intake.
Characterized by vomiting, pallor, shock like state, urticarial & swelling of lips
• Delayed reaction, i.e. T cell mediated – indolent course & presents mainly with GI
symptoms.
49

Clinical features :-
• Diarrhea with blood and mucus.
• Small bowel, large bowel or mixed type diarrhea based on site & extent of
involvement.
• In Indian study, 40% children presented with bloody diarrhea, 33% watery & 7%
with a mixed type of diarrhea.
• Reflux symptoms and hematemesis
• Respiratory symptoms (20-30%) & atopic manifestations (50-60%)
• Iron deficiency anemia, hypoproteinemia and eosinophilia.
50

Diagnosis :-
• Sigmoidoscopy (aphthous ulcers & nodular
lymphoid hyperplasia)
• Rectal biopsy (plenty of esoniophils)
• Elimination and challenge test – symptoms
subside after milk withdrawal & recur
48 hr of re-exposure to milk.
Cow milk protein allergy – Sigmoidoscopy
showing aphthous ulcer
51

Treatment :-
• All animal milk/milk products have to be removed from diet.
• Soy or extensively hydrolysed formula can be used as alternatives.
• Soy – more palatable and cheap but not recommended in infants <6months.
• 10-15% of CMPA have concomitant soy allergy, necessitating use fo extensively
hydrolysed formulae.
• Majority of children may not tolerate extensively hydrolysed formulae and need
amino acid formulas.
• Parental education regarding diet and calcium supplementation is essential.
52

INTESTINAL LYMPHANGIECTASIA
• Characterized by ectasia of bowel lymphatic system, which on rupture causes
leakage of lymph in the bowel.
Presentation :-
• Peripheral edema which could be bilateral & pitting due to hypoalbuminemia or
asymmetrical and non pitting due to lymphedematous limb.
• Diarrhea, abdominal distension & abdominal pain.
• Abdominal and/ or thoracic chylous effusions may be associated.
• Presence of hypoalbuminemia, low immunoglobulins, hypocalcemia and
lymphopenia is characteristic of lymphangiectasia
53

Diagnosis :-
• Barium meal follow-through shows thickening of
jejuna! folds with nodular lucencies in mucosa.
• On UGI endoscopy after fat loading with 2 gm/kg of
butter at bedtime scattered white plaques or chyle like
substance covering the mucosa may be seen.
• Duodenal biopsy reveals dilated lacteals in villi and lamina propria.
Treatment :-
• low fat, high protein diet with MCT oil, calcium and fat soluble vitamin supplementation.
• IV albumin is required for symptomatic management and total parenteral nutrition (TPN) is
reserved for management of chylous effusions.
• Resection may be considered if the lesion is localized to a small segment of intestine.
Upper gastrointestinal
endoscopy showing white
deposits;
54

IMMUNODEFICIENCY
• Congenital and acquired both can cause chronic diarrhea.
Risk factors :- History of recurrent infections at multiple sites and wasting.
• common immunodeficiency conditions presenting with diarrhea include Ig A
deficiency, SCID, CVID, CGD.
• Diarrhea is either due to enteric infections like giardia, cryptosporidium, CMV, etc. or
due to bacterial overgrowth.
Diagnosis - measuring serum immunoglobulins, T cell counts and functions,
phagocytic function.
Treatment - administration of antimicrobials for bacterial overgrowth and
opportunistic infections and therapy for underlying cause (IV immunoglobulins, y
interferon or bone marrow transplantation).
55

ACQUIRED IMMUNODEFICIENCY
SYNDROME (AIDS)
• Chronic diarrhea is common feature in children.
• AIDS enteropathy is characterized by chronic diarrhea and marked weight loss in absence of
enteric pathogens.
• Presence of oral thrush, lymphadenopathy hepatosplenomegaly and parotiditis (10-20%
cases) gives clue to the diagnosis.
• Common infections :-
• Viral. Cytomegalovirus, herpes simplex, adenovirus, norovirus
• Bacterial. Salmonella, Shigella, Mycobacterium avium complex (MAC), Campylobacter jejuni,
Clostridium difficile
• Fungi. Candidiasis, histoplasmosis, cryptococcosis
• Protozoa. Microsporidium, Isospora belli, Cryptosporidium, Entamoeba histolytica, Giardia
lamblia, Cyclospora, Blastocystis hominis
56

Diagnosis :-
• Multiple stool examinations are required to identify the causative etiology by using
special stains and PCR techniques.
• Colonic/terminal ileum biopsy and duodenal fluid examination - diagnosing
opportunistic infections.
Treatment :-
• specific antimicrobials along with HAART (highly active anti-retroviral therapy).
57

DRUG INDUCED DIARRHEA
• Altered GI motility, mucosal injury and/ or change in intestinal microflora are the
main etiologic factors.
• Antibiotics can cause loose watery stools by altered bacterial flora or bloody stools
secondary to Clostridium difficile overgrowth and pseudomembranous colitis (PMC)
• PMC - stool for toxin assay sigmoidoscopy is required for confirmation.
• Metronidazole or oral vancomycin is the drug of choice for PMC.
58

INFLAMMATORY BOWEL DISEASE
• Chronic inflammatory disease of GI tract
• Two main types – Crohn disease & ulcerative colitis
• Indeterminate colitis – 10% cases, findings are non specific & subjects cannot be classified
into two above groups.
• 25% of all IBD presents in pediatric age group.
• Average age of presentation in childrens – 10-11 yr.
• Risk factor – genetics, upto 30% patients may have family member with IBD.
Clinical features :-
• Ulcerative colitis – diarrhea & rectal bleeding
• Crohn disease – abdominal pain, diarrhea & growth failure. Classical triad, i.e. pain, diarrhea
& weight loss seen in only 25% cases. Fever fatigue & anorexia – 25-50% cases.
• Absence of blood in stools & non specific complaints – delays diagnosis.
59

• Extraintestinal manifestations –
arthralgia/arthritis in 15-17% cases.
Uveitis, erythema nodosum & sclerosing
cholangitis.
Disease distribution :-
• Ulcerative colitis – distal colitis (proctitis/proctosigmoiditis), left side colitis (up to splenic
flexure) and pancolitis (majority).
• Crohn disease – 50-70% have ileocolonic disease, with isolated colonic involvement in 10-
20% & small bowel in 10-15% patients. Upper GI involved in 30-40% and perianal disease in
20-25% cases.
• Crohn disease – inflammatory, fistulising or structuring disease.
60

DIFFERENCE B/W ULCERATIVE COLITIS
AND CROHN DISEASE
61

Diagnosis :-
• Detailed clinical, family & treatment history.
• Complete examination with growth charting,
perianal and rectal examination for fistulae, tags
and fissures is essential.
• Hemogram, ESR, C reactive protein, total
serum albumin and stool for occult blood –
screening and confirming IBD.
• Upper GI endoscopy with biopsy, colonoscopy
with ileal intubation and biopsy is essential for
cases.
• Small bowel evaluation with BMFT, CT
enteroclysis or MR enterography – for classifying
and to determine disease extent.
Deep, linear,
serpigenous
ulcers on
colonoscopy in
Crohn disease
Confluent
superficial
ulcerations with
friability on
colonoscopy in
ulcerative
colitis
62

Treatment :- to control inflammation, improve growth and ensure a good quality of
life with least toxic therapeutic regimen.
• 5 aminosalicylates, steroid & immunomodulators (6-mercaptopurine, azathioprine,
methotrexate and monoclonal antibodies against tumor necrosis factor, t.e. infliximab)
• Proper nutrition with caloric supplementation (120% of RDA) necessary for children.
• Calcium and vitamin D supplementation.
• Counselling of the patient and family.
Surgery – in ulcerative colitis with severe acute colitis refractory to medical disease
• Indications – uncontrolled haemorrhage, perforation, toxic megacolon, abscesses &
obstruction.
63

ABDOMINAL TUBERCULOSIS
• The gastrointestinal tract, peritoneum, lymph nodes and/ or solid viscera can be
involved in it.
• peritoneal involvement is of two types: wet (or ascitic)and dry ( or plastic) type. On the
other hand, the intestinal involvement may be ulcerative, hypertrophic or ulcero-
hypertrophic type.
Clinical presentation :-
• chronic diarrhea, features of subacute intestinal obstruction (abdominal pain,
distension, vomiting, obstipation), ascites, lump in abdomen an/or systemic
manifestations (fever, malaise, anorexia and weight loss).
64

Diagnosis :-
• Fine needle aspiration cytology for lymph nodes,
ascetic fluid endoscopic biopsies – presence of
acid fast bacilli on Ziehl-Neelson staining, PCR or
culture.
• Endoscopic, peritoneal or liver biopsies – presence
of tubercular granuloma wih caseation.
• CT abdomen shows enlarged lymph nodes with central necrosis.
Treatment :-
• Antitubercular drugs – mainstay for Rx.
• Surgery – if bowel perforation, obstruction or massive haemorrhage.
CT scan showing multiple enlarged lymph
nodes with central necrosis in para-aortic
& mesenteric region.
65

NURSING DIAGNOSIS
• Fluid volume deficit related to diarrhea.
• Risk for cross-infection related to infective loose motion.
• Potential to altered skin integrity related to frequent passage of stools.
• Altered nutritional status, less than body requirement related to malabsorption and
poor oral intake.
• Fear and anziety related to illness and hospital procedures.
• Knowledge deficit related to causes of diarrhea & its prevention.
66

NURSING MANAGEMENT
• Restoring fluid and electrolyte balance by ORS and IV therapy, intake and output
recording and checking of vital signs.
• Prevention of spread of infection by good hand washing practices, hygienic disposal of
stools, care of diapers, general cleanliness and universal precautions.
• Preventing skin breakdown by frequent change of diaper, keeping the perineal area dry
and clean, avoiding scratching and rubbing of irritated skin and use of protective barrier
cream.
• Providing adequate nutritional intake by appropriate dietary management.
• Reducing fear and anxiety by explanation, reassurance, answering questions and
providing necessary information.
• Giving health education for prevention of diarrhea, home management of diarrheal
diseases, importance of ORS, dietary management etc..
67

PREVENTION
• Improvement of food hygiene and environmental hygiene.
• Safe water, adequate sewage disposal, hand washing practices, clean utensils, avoidance of
exposures of food to dust and dirt, fly control, washing of fruits and vegetables.
• Avoid bottle feeding.
• Boiling or filtering to be practiced for safe drinking water.
• Prevention of LBW and
prematurity, exclusive
breast feeding, appropriate
weaning practices,
Balanced diet, immunization
are significant aspects of
Child care.
68

Diarrhea in children

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