Diarrhea in children

DIARRHEA DEFINITION
• The normal frequency and consistency of bowel
movements varies with a child's age and diet and
the definition of diarrhea varies accordingly.
• Frequency — 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.

• Consistency and color — The consistency and color of a
child's stool normally changes with age, which highlights
the importance of knowing what is normal for your child.
• 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.

Definition
• Diarrhea 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.
• A more exact definition is excessive daily stool
liquid volume (>10 mL stool/kg body
weight/day).

High risk groups
 Young age groups
 Immune deficient individuals
 Malabsorption.
 Malnutrition
 Travel to endemic areas
 Lack of breast feeding
 Exposure to unsanitary conditions
 Attendance to child care centers
 Poor maternal education

Causes and risk factors
• Microbial,
• Host and
• Environmental
factors interact to
cause GE
Diarrhoea pathogens
Environmental
factors
Host factors

Diarrhea Classification
• According to Pathogens.
• According to Duration.
• According to Mechanism of Diarrhea.
• According to clinical types of Diarrhea.

DIARRHEA CAUSES
• Infective, non-infective
o The most common cause of acute diarrhea is
a viral infection. Other infectious causes
include; Bacterial infections,
o side effects of antibiotics, and
o infections not related to the gastrointestinal
(GI) system.

Clinical types of diarrhea
 There are 2 main clinical types of AD
 Each is a reflection of the underlying pathology and altered physiology
Clinical type Description Common pathogens
Acute watery
diarrhoea
This is the most common. It is of recent onset,
commencing usually within 48 hours of presentation. It
is usually self limiting and most episodes subside within
7 days. The main complication is dehydration.
Rotavirus, Vibrio cholera
Acute bloody
diarrhoea
Also referred to as dysentery. This is the passage of
bloody stools. It is as a result of damage to the
intestinal mucosa by an invasive organism. The
complications here are sepsis,
HUS(hemolytic uremic syndrome), malnutrition and
dehydration.
Shigella spp, Entamoeba
histolytica

• Acute diarrhea last<14days.
• When episode last >14days it is called chronic
or persistent diarrhea.
Diarrhea according to Duration

Mechanisms of diarrhea
• Osmotic: e.g Lactose intolerance
• Secretory: e.g Cholera
• Mixed secretory-osmotic: e.g Rotavirus
• Mucosal inflammation: e.g Invasive bacteria
• Motility disturbance

DIARRHEA EVALUATION
• The evaluation of diarrhea in children who do seek
medical evaluation requires a careful review of:
• Medical history, a
• Physical examination, and
• Diagnostic testing.
• The clinician will perform a thorough examination
because there are some infections unrelated to the
bowels (such as an ear infection) that can cause
diarrhea.
• Many tests are available to diagnose the cause of
diarrhea and to determine the severity of dehydration,
although most children will not require testing.

Assessment of the child with diarrhoea
History
 Ask the mother or other caretaker about:
 Duration of diarrhoea;
 Presence of blood in the stool;
 Number of watery stools per day;
 Number of episodes of vomiting;
 Presence of fever, cough, or other important
problems (e.g. convulsions, recent measles);
 Pre-illness feeding practices;
 Type and amount of fluids (including breast milk) and
food taken during the illness;
 Drugs or other remedies taken;
 Immunization history.

Clinical assessment
Physical examination:
General appearance
Hydration Status
Systemic Examination
Extra intestinal manifestations

NO DEHYDRATION SOME DEHYDRATION SEVERE DEHYDRATION

I. STOOL: MICROSCOPY : low sensitivity & specificity
A. leucocyte (>10/hpf )- Invasive diarrhea
B. RBC ,ova,Trophozoite or cyst.
C. culture & sensitive - persistent diarrhea
II. BLOOD TESTS
A. CBC
B. S. electrolyte
C. BUN & creatinine
III.GUE
IV. Others: celiac disease or colonoscopy .
o A trial of lactose restriction for several days is helpful to
rule out lactose intolerance, or a more specific test, such
as lactose breath hydrogen analysis, can be performed.
Laboratory investigations

Complications & consequences of
watery diarrhea:
o Dehydration.
o electrolyte disturbance.
o Base deficit acidosis.
o Malnutrition
o Persistent diarrhea
o Toxic illus
o Renal Failure.
o Hus(hemolytic uremic syndrome)
o DIC
o Convulsion
o Cerebral damage and cerebral venous thrombosis.

Extra intestinal manifestations
&complications
 Reactive arthritis :Salmonella ,shigella , Yersinia,
C.difficile campylobacter.
 Guillain-Barre Syndrome: campylobacter.
 Glomerulonephritis:Shigella , campylobacter ,Yersinia
 IgA nephropathy :campylobacter
 Erythema nodosum: Yersinia ,campylobacter, salmonella
 Hemolytic anemia : Yersinia ,campylobacter
 HUS(hemolytic uremic syndrome): shigella , E. coli
 Systemic infections e:g:
UTI,Pneumonia,osteomylitis,meningitis …(parantral
diarrhea).

Management
Treating dehydration is the corner stone in managing
diarrhea.(Oral rehydration therapy)/IVF.
Feeding: Continue Breast feeding and routine normal diet
and energy dense feeds.
Hand washing after defecation & before meal alone can
reduce 40% of water & excreta related disease
Drug therapy has very little place
o Antibiotic.
o Zinc
o Probiotics
o antidiarrheal medications.
Follow-up to ensure recovery

Treatment : home therapy to prevent
dehydration and malnutrition
Children with no signs of dehydration need
extra fluids and salt to replace their losses of
water and electrolytes due to diarrhoea. If
these are not given, signs of dehydration
may develop

Composition of standard and reduced osmolarity
ORS solutions
Standard ORS
solution
Reduced ORS
solution
(mEq or mmol/l) (mEq or mmol/l)
Glucose 111 75
Sodium 90 75
Chloride 80 65
Potassium 20 20
Citrate 10 10
Osmolarity 311 245

The advantages of this new reduced osmolarity ORS
solution
• It reduces stool output or stool volume by
about 25% when compared to the original
WHO-UNICEF ORS solution
• It reduces vomiting by almost 30%
• It reduces the need for unscheduled IV
therapy by more than 30%.

warning signs
Take the child to a health worker if there are
warning signs of dehydration or other problems
• The child does not get better in three days.
• Starts to pass many watery stools;
• Has repeated vomiting;
• Becomes very thirsty; lethargy, poor urine output
• Is eating or drinking poorly;
• Develops high fever;
• Has blood in the stool;

Indications for IV therapy:
1. Depressed level of consciousness.
2. Moderate dehydration when there is no
improvement after the firs 4 hours of
treatment with ORS.
3. Severe dehydration
4. Uncontrolled vomiting, poor urine out put
5. Patients unable to drink from extreme
fatigue, stupor, or coma
6. Patients with Abdominal distention.

Zinc in Diarrhea
• Zinc deficiency is common in developing countries and zinc is lost during
diarrhea
• Zinc deficiency is associated with impaired electrolyte and water
absorption, decreased brush border enzyme activity and impaired cellular
and humeral immunity .
• Treatment with zinc reduces the duration and severity of AD and also
reduces the frequency of further episodes during the subsequent 2-3 months
• WHO recommends that children from developing countries with
diarrhea be given zinc for 10-14 days
10mg daily for children <6 months
20 mg daily for children >6 months

• Probiotics have been defined by the joint
FAO/WHO Working Group (Food and Agriculture
Organisation/World Health Organisation) as “live
microorganisms that when administered in
adequate amount confer a health benefit on the
host”.
• Some research shows that the bacteria strains most
likely to help are Lactobacillus reuteri, Lactobacillus
rhamnosus, and the probiotic yeast Saccharomyces
boulardii, although other strains might be useful.
Probiotics in the Treatment of
Diarrhea

Probiotics in the Treatment of
Diarrhea
Mechanisms:
1. Protect the intestine by competing with
pathogens for attachment.
2. Strengthening tight junctions between
enterocytes
3. Enhancing the mucosal immune response to
pathogens.

Antibiotic in Acute Diarrhoea
Indicated only for :
• Acute bloody diarrhea with gross blood
• Severe invasive bacterial diarrhea e:g Shigella
• Cholera,
• Associated systemic infection
• Severe malnutrition.
• Giardiasis ,Entamoeba hitolytica
• Suspected or proven sepsis
• Immuno compromised children
Antibiotics are contraindicated in:
E. coli 0157: H7 because they increase the risk of Haemolytic Uraemic syndrome (HUS)
Uncomplicated salmonella enteritis because they prolong bacteria shedding

Antidiarrheal Medication
Classes
• There are three common groups
of antidiarrheal medications:
• Adsorbents: kaolin and pectin ,
Methylcellulose, Bismuth
• Antimotility agents: Codiene,
Diphenoxylate & Loperamide &
anticholinergics.
• Antisecretory drugs: Racecadotril,
anticholinergics, Bismuth & Octeriotide.

Adsorbents
• Adsorbents: it work by coating the walls of the GI
tract.
• Firstly, it can adsorb bacterial toxins, bacteria,
viruses.
• Secondly, due to its multilayer structure and its high
plastic viscosity, it possesses powerful coating
properties. The preserved integrity of the mucus layer
can render the intestinal epithelium.
• Thirdly, it may affect intestinal permeability and
electrolyte flux, perhaps as a consequence of its
protective effect on the gastrointestinal epithelium.
• Finally, it appears to have a protective effect against
intestinal inflammation.

• kaolin and pectin:
o Kaolin: is hydrated magnesium allumenium
silicate.
o Pectin: indigestive carbohydrate droved from
apples.
o kaolin-pectin must not be given to young children (under 3
years of age)
• Gelatin Tannate: affords mechanical protection of the
gut through the formation of a protein-based film that lines
the gut walls. it reduces local inflammation & there are
antibacterial properties of tannins through inhibiting the
growth of pathogens.
• Bismuth, Cholestyramine.
Adsorbents

Antimotility
• Antimotility agents, which help to
treat diarrhea by slowing peristalsis.
• There are two categories of antimotility
medication: anticholinergics and opiate-
like medication.

• Anticholinergics: Hyoscyamine is an anticholinergic that
works on the smooth muscle of the GI tract to inhibit
propulsive motility and decreases GIT secretion.
• contraindications include glaucoma, myasthenia gravis,
paralytic ileus, and intestinal obstruction.
• opiate-like medication: Loperamide has an opioid-like
chemical structure but causes fewer CNS effects. It works by
decreasing the flow of fluids and electrolytes into the bowel
and by slowing down the movement of the bowel to decrease
the number of bowel movements.
• contraindications Loperamide should not be given to a child
younger than two years of age because of the risk of serious
breathing and heart problems

• Loperamide is a synthetic opiate agonist activating
the μ receptors in the myenteric plexus of the large
intestine.
• The physiological consequence of this is to enhance
phasic colonic segmentation and inhibit peristalsis,
thus increasing intestinal transit time.
• In addition, muscarinic acetylcholine receptors on
secretory epithelial cells in the gut wall mediate
stimulation of secretion of water and electrolytes into
the intestinal lumen by parasympathetic activity.
Inhibition by loperamide of acetylcholine release will
thus also have an antisecretory activity .

• Although loperamide is widely used in adult patients and has
shown some efficacy in paediatric studies, its use in children
has been discouraged by the WHO and the American
Academy of Pediatrics due to concerns over its efficacy and
safety in young children.
• The practice guidelines produced by these organisations state
that loperamide should not be used in children under twelve
years of age.
• The drug is not approved for use in children in most countries,
although in the United States, loperamide is approved by the
FDA for use in children above the age of two.
• Loperamide should never be given if an inflammatory
disease is suspected (visible blood in stools, dysentery, or
acute colitis).

Antisecretory
• Racecadotril is indicated for the symptomatic
treatment of acute diarrhoea in both adults and
children.
• Racecadotril is a prodrug that is rapidly absorbed
from the gut and hydrolysed in the plasma to its active
metabolite thiorphan.
• Like loperamide, racecadotril interacts with the opioid
neurotransmitter system in the gut wall.
• Unlike loperamide, this drug does not act at the level
of the opiate receptor but rather as an inhibitor of the
enzyme neutral endopeptidase , which is responsible
for the degradation of the endogenous opioid peptides
Met- and Leu-enkephalin.

• Enkephalins interact preferentially with
the δ opiate receptors that are found in
high density on secretory epithelial cells.
• Activation of these receptors leads to
reduced secretion of water and
electrolytes mediated by a decrease in
cellular cAMP.
• By inhibiting the breakdown of
enkephalins, thiorphan facilitates this
antisecretory activity.

• The effectiveness and safety of racecadotril used
as an adjunct to ORS for treating acute
gastroenteritis in children were reviewed through
the meta-analysis conducted by in 2007.
• The analysis demonstrated clinically relevant
benefits of racecadotril with respect to reducing
diarrhoea duration , stool output , and stool
number.
• In terms of safety, no adverse events specifically
associated with racecadotril have been identified
in the published clinical trials.

How can we prevent diarrhoeal
disease?
This involves intervention at two levels:
Primary prevention (to reduce disease transmission)
Rotavirus and measles vaccines
Hand washing with soap
Providing adequate and safe drinking water
Environmental sanitation
Secondary prevention (to reduce disease severity)
Promote breastfeeding
Vitamin A supplementation
Treatment with zinc

Diarrhea in children

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Diarrhea in children