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Management of Diarrhea&Dehydration in Children.ppt
- 1. Diarrhoea- a globalproblem 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 1980 1990 2004 Death in million per year non cholera Reduction in cholera Deaths 0.12 million/year
- 2. Cause specific mortality 0 5 10 15 20 25 DiarrhoeaResp Causes Perinatal Deaths in children under 5 years age BULL WHO 2003;81:197-204
- 3. Factors of Mortality Factorsresponsible to increase in morbidity and mortality •Malnutrition •Inadequate safe water •Poor sanitation •Poor hygiene UNICEF:2002
- 4. ORT By mouth By Nasogastrictube IV Fluid to combat dehydartion Severe dehydration- crysalloids Monitoring of serum electrolytes AIM: Rehydrate within 4 h of presentation and Maintain hydration until recovery
- 5. Improved ORS Advantages Reduced Stooloutput Less Vomiting Less need for IV infusions No Hypernatremia or significant hyponatremia BMJ 2001;323:81-85
- 6. Prevention Immunization: OPV, Measles,Vit A supplementation Breast feeding up to 6 months Improving saitation Safe drinking water Rota virus vaccines
- 7. Effect of Zincin Acute Diarrhoea Decreased incidence of subsequent diarrhea and Pneumonia Increases use rates of ORS Decrease antibiotic use rate Decreases mortality
- 8. Management of Diarrhea& Dehydration in Children Lt Col S K Singh Resident DNB Fam Med Dept of Pediatrics
- 9. Case 1 03yrs male child c/o -loose motions x02 days -vomiting x02 days -fever x01 day not passed urine since last 06 hrs No h/o mucus, or blood h/o self-limiting cough/cold 06 days back
- 10. Immunization upto date Nutritional :- breast feed up to 06 months, followed by normal food which being cooked in home
- 11. O/E Irritable &restless Eyes sunken Mucus membrane dry Unable to drink Skin pinch goes back very slowly Temp afebrile H.R 140/min reg, low vol R.R 26/min B.P 90/60 mm of Hg Capillary refill time > 03 sec Wt 11kg
- 12. Chest clinicallyclear CVS NAD P/A soft , bowel sound CNS NAD
- 13. Prov Diag Acutediarrhea with severe dehydration Treated with i.v fluid ORS
- 14. Case 2 18month male child Presented with c/o -Loose motions(6 times) x 02 days -vomiting (4 times) x 02 days -not feeding well x 02 days - activity x 02 days
- 15. O/E Alert cryingat times Not playful anterior fontanel closed minimal tears lips dry
- 16. H.R 110/min reg R.R 25/min B.P 80/60 mm of Hg Skin pinch goes back quickly Wt 10 Kg
- 17. S/E Chest NAD CVS NAD P/A NAD CNS NAD
- 18. Prov Diag Acutediarrhea with mild dehydration Treated with ORS
- 19. Under Five Mortality 20-50% of the 9.7 million child deaths each year… 60.7% of diarrhea deaths 57.3% of malaria deaths 52.3% of pneumonia deaths 44.8% of measles deaths …are attributable to undernutrition
- 20. Definition Diarrhea-Passage ofliquid or watery stool three times a day. Persistent Diarrhea-Liquid stools 3 or more times a day, continuously or intermittently for more than 2 weeks Dysentery-Presence of blood and pus in stool, abdominal cramps and fever.
- 21. 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%
- 22. 06 common diarrheas Rota virus diarrhea E.coli diarrhea Cholera Amoebiasis & Giardiasis Dysentry Toddlers diarrhea
- 23. Rotavirus Leading causeof hospitalization for diarrhea in children Most prevalent during spring sometimes in winter season Fecal-oral transmission: viral shedding can persist for 21 days Acute onset of fever followed by watery diarrhea and can persist for up to a week
- 24. Rota virus diarrhea Age- 06 months-02 yrs Usually preceded by viral fever Effortless diarrhea No Volume Dehydration + No pain abd Fever + Self limiting/no role of antibiotics
- 25. E.Coli Diarrhea Cause-Enteropathogenicstrain such as ETEC,EIEC,EHEC Voluminous watery stool , no blood Abd pain Mild fever Dehydration Does not respond to any antibiotic
- 26. cholera In shock Continuous rice watery Marked dehydration Quinolone , Azithromycin
- 27. Dysentry Caused byshigella Usually fever Stool mixed with blood initially fallowed by only pus and blood Tenesmus No dehydration Naked eye exam of stool imp 3rd gen cephalosporin 4-5 days to recover Sometimes fallowed by rectal prolapse
- 28. Amoebiasis & Giardiasis c/o incomplete evacuation Stool sticky Sometimes blood Mucus No dehydration metronidazole 30mg/kg
- 29. Toddlers diarrhea Intoddlers age Child playful Passes formed stool 6-7 times No mucus/no dehydration
- 30. History and PhysicalExam 3 main goals Estimate the level of dehydration Identify likely causes on the basis of history and clinical findings Determine if additional studies and/or medications are necessary
- 31. History Onset, frequency,quantity, and character of diarrhea Associated symptoms: nausea, vomiting, fever, abdominal pain, tenesmus, malaise Recent oral intake
- 32. Level of Dehydration LOOKAT condition Well alert Restless,irritabl e Lethargic or unconcios Eyes N Sunken Very sunken & dry Tears P A A Mouth & tongue M Dry Very dry Thirst Drinks normally Thirstly drink eagerly Drinks poorly or not able to drink FEEL Skin pinch Goes back quickly Goes back slowly Goes back very slowly Pulse N Rapid Rapid, feeble, sometimes impalpable O/E Respiration N Deep and may be rapid Deep and rapid TREAT Plan A Plan B Plan C
- 33. Dehydration Mild -fluidloss up to 5% Moderate - fluid loss up to 10% Severe - fluid loss up to 15%
- 34. Physical Exam Vitals,vitals, vitals! Abdominal exam Presence of blood in stool Signs of dehydration
- 35. Treatment Fluid replacement Fluids or Oral Rehydration Solutions (ORS) Parenteral rehydration Early refeeding
- 36. IAP Guidelines Diarrheawith no dehydration – normal diet and supplemental ORS with each diarrheal episode. Diarrhea with mild dehydration – seek medical care, give ORS under doctors supervision and normal diet. Moderate - severe dehydration – consider intravenous hydration, especially if patient is also vomiting
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- 38. How to calculatefluid Deficit Mild -50ml/kg/day Moderate -100ml/kg/day Severe -150ml/kg/day
- 39. Maintenance If wt3-10 kg 100ml/kg/day If wt 10-20 kg 1000ml+50ml/kg/ beyond 10 kg If wt >20kg 1500ml +20ml/kg beyond 20 kg Concurrent 20-40ml /kg/stool
- 40. Principle Of totalcalculation only 75% is given to prevent overhydration Of total calculation 50% is given in 1st 08 hours, remaining in another 16 hours As soon as child passes urine add KCL @ 1ml/100ml of fluid If child is on iv fluid must assess the child hourly
- 41. If child isin shock –give iv 20ml/kg rapid in 1-2 hours so that pulse become palpable if not palpable another bolus
- 42. To calculate thefluid req for T/T of child with severe dehydration, Wt 11 kg Deficit 150x11 =1650ml Maintenance 1000+50 =1050ml Total =2700ml of 75%=2025ml
- 43. Early Refeeding Luminalcontents help promote growth of new enterocytes and facilitate mucosal repair Can shorten duration of the disease
- 44. In Summary Extremelycommon Most is viral in origin and self-limited A good H&P is crucial Warning signs include high fever, severe abd. pain, dehydration, and bloody stool Fluid replacement is most important Antibiotics are usually not necessary
- 45. Principles of treatment Prevention of dehydration – early replacement of fluids with appropriate home fluids and ORS solution (ORT) Continue feeding (or increase breastfeeding) Zinc in doses of 20 mg per day for 10-14 days (for children 6 months or older); 10 mg (for 2-5 months of age) Recognition of signs of dehydration or other symptoms (blood in stools) Antibiotic use only when appropriate (bloody diarrhea or shigellosis) Abstain from using antidiarrheal drugs
- 46. Effect of Zincin Diarrhea 20 mg of zinc for 10-14 days during and after diarrhea: Shortens duration Decreases severity of episode Prevents episode in following 2-3 months Indicated for diarrhea regardless duration or type (acute or persistent; bloody or watery)
- 47. What is newin ORS? Standard formulation of ORS Sodium 90 meq/L Glucose 111meq/L Osmolarity of 311 mmol/L New formulation of ORS Sodium 75 meq/L Glucose 75meq/L Osmolarity 245 mmol/L Reduction of levels of glucose and salt shortens duration of diarrhea Reduced osmolarity decreases stool output Improved effectiveness for children with acute, non-cholera diarrhea
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Editor's Notes
- #1 Diarrhoea remians a global prolific kiler of children less than 5 years age. In 1980, it accounted for about 4-6 million deaths every year. A decade later the death toll deecreased to 3.3 milion per yar. This happened because WHO was coordinating implementation of ORT worldwide. More recent estimate suggests deaths being closer to 1.5 million per year in under five children.
- #2 If you ee cause specofoc mortality, one would find that doarrhoea is exceeded only by respiratory causes (18%) and perinatal causes (23%).Morbidity of diarrheal illnesses in developing world is quite grave. Usually it is 6-7 episodes per child per year in developing countries than 1-2 episodes per child per year in developed countries.
- #3 25% children in developing countries are still malnourished. 1.1 billion people do not have access to safe drinking water and 2.4 billion are without proper sanitation facility.
- #4 ORT whether given by mouth or by naso gastric tube are equally effective and as better as giving intravenous fuids. But in cases of severe dehydration where intake by mouth or byadministration by naso gastric tube is doubt ful start IV and give crystalloids to prevent shock. Institute ORT as early as possible.
- #5 The International study grop on reduced osmalrity ORS observed in a muticentric study that reduced osmlairity ORS has beneficial effects on the clinical course of acute non cholra diarrhoea in chidlren in developing countries.. The incience of hyponatremis <125 mEq/L is much less. Only one study in Bangladesh has observed incidence of hyponatremia to be 8.8%
- #23 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.
- #31 The patient’s history can be useful in identifying the pathogens associated with acute diarrhea and may help guide therapy. The clinical history should assess the onset, frequency, quantity, and character of vomiting and diarrhea. It is important to know if the patient has been in contact with anyone with similar symptoms, has taken antibiotics recently, or has any comorbid medical conditions. Ask about recent oral intake including unpasteurized or undercooked foods. You should also be on the lookout for warning symptoms like high fever, severe abdominal pain, and bloody or mucousy stool. And finally, try to assess hydration status.
- #36 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
- #37 Treatment with oral rehydration solution is simple and enables the management of uncomplicated cases of diarrhea at home, regardless of etiologic agent
- #43 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