Transcript 3.Acute Diarrhoea Management in Children

MANAGEMENT OF ACUTE
DIARRHOEA IN CHILDREN
Dr.B.Anjaiah, MD., DCh.,
Director, RIMS, Ongole
INVESTIGATIONS
 STOOLMacroscopy
Microscopy- WBC>10/hpf
Ova,cysts,throphozoites
Hanging drop
C/S for shigella & salmonella
 BLOODCBC
Electrolytes, creatinine,BUN
C/S
MANAGEMENT
 PREVENTION
 TREATMENT
 SUPPORTIVE TREATMENT
PREVENTION
 HAF
 Good liquids without
salt
-clean water
-unsalted rice water
-unsalted yoghurt
drinks
-coconut water
-weak tea
-unsweatened fresh
fruit juice
 Good liquids with
salt
-ORS
-Salted soup
-salted yoghurt
drinks
-salted rice water
DO NOT GIVE
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Soft drinks
Sweetened tea
Sweet fruit juices
coffee
TREATMENT
 CORNERSTONE of Rx
ORT
ORT
 ORS
 Solution made from sugar &salt
 Food based solutions
 Continued feeding
PLAN A
(NO DEHYDRATION)
 Rule 1 --- Fluids
- HAF,SSS
 Rule 2 --- Zn supplementation
 Rule 3 --- continued feeding
 Rule 4 --- return to clinic
Rule 1 --- Fluids
 WHO Guidelines
AGE
<6 mon
QUANTITY WITH
EACH STOOL
50 ml(1 cup)
7 mon – 2 yrs
50-100 ml
2 yrs- 5 yrs
100-200ml
Older child
As much as they
take
ORS is optional in
PLAN A
Rule 2 --- Zn supplementation
 Improves immune function
 Improves intestinal permeability
 Regulation of intestinal water & electrolyte
transport & brush border enzymatic
function
 Intestinal tissue repair
Rule 2 --- Zn supplementation
 <6 mon ---- 1/2 tab / day
 >6 mon ---- 1 tab / day
for 10 – 14 days
Rule 3 --- continued feeding
 < 6 mon - breast / top fed
 Older children – cereals & beans,
meat & fish , oil, dairy products &
eggs, fruit juices & bananas
What is the use of continued
feeding?
Rule 4 --- return to clinic
When the child
-passes many stools
-very thirsty
-sunken eyes
-fever
-does not eat/drink normally
PLAN B
(Some dehydration)
AGE
Weight
ORS
Glass
< 4 mon
<5 kgs
200-400 ml
1-2
4-11mon
5-8 kgs
400-600 ml
2-3
12-23 mon 8-11 kgs
600-800 ml
3-4
2-4 yrs
11-16 kgs
800-1200 ml 4-6
5-14 yrs
16-30 kgs
1200-2200ml 6-11
>15 yrs
>30 kgs
>2200 ml
12-20
 ORS given at 75 ml / kg over 4 hrs
 Continue breast feeding
 100-200 ml of water + ORS (in those
who are not breastfed)
 REASSESS after 4 hrs
 Signs of dehydration
NIL
PERSISTS
SEVERE
--- follow
- PLAN A
- PLAN B
- PLAN C
PLAN C
(Severe dehydration)
AGE
First give
30 ml / kg in
< 1 year
1 hour
> 1 year
30 min
Then give
70 ml / kg in
5 hrs
2 ½ hrs
TYPE OF FLUID
 BEST
----- RL
 IDEAL ----- RL + 5% D
 IF RL not available ---- NS
INDICATIONS FOR IV FLUIDS
 Severe dehydration with/with out shock
 Persistent vomiting(>3/hr)
 Failure to correct / worsening of dehydration on
ORT
 High purge rate
 Failure of acceptance of ORS in dehydrated child
 Abdominal distension
 Deranged sensorium
GUIDELINES for the total amount
of fluids to be replaced in some &
severe dehydration
Usual fluid
Deficit
(ml/kg)
Deficit
fluid
replaced
(ml/kg)
Maintainence
fluid required
in 8 hrs
(ml/kg)
Total amount of IV
fluids for correction
of dehydration to be
given in 8 hrs
(ml/kg)
Some
70-100
50
50
100
Severe
120-180ml
100
50
150
CONTINUATION OF IVF AFTER
CORRECTION OF DEHYDRATION
 Children - >3 mon N/4 NS
-<3 mon N/6 NS
 Maintenance fluids must contain K+
in the con of 20 meq/l
TYPE OF FLUID GIVEN AS
REHYDRATION THERAPY
 Initial fluid of choice-N/2 NS(1 PART
OF ISOTONIC SALINE+1 PART 5%
DEXTROSE)
 Isotonic saline & RL - severe
dehydration

->6y high purge
rate
 Start ORS -5ml/kg/hr when child able
to drink
 what to do if IV LINE not accessible?
 Reasses after 1-2 hrs
COMPLICATIONS
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Dehydration
Dyselectrolytaemia
Precipitation of malnutrition
Secondary lactose intolerence
Persistent diarrhoea
HUS
DIC
Cortical vein thrombosis
HYPONATRAEMIA
Severe-<125meq/l
Clinical features
Deranged sensorium&convulsions
Diminished urine output
Correction-N/2 NS (or) RL [Na-125-135]
-3N NS [Na-<125]
 Amount of Na required=Na deficit x
0.6 x wt
 Half of it corrected as 3N over ½-1hr
 Remaining corrected as RL (or) N/2
NS slowly
HYPERNATRAEMIA
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Etiology
Clinical features
Usual signs of dehydration are absent
Management
If in shock-20-30ml/kg RL
Confirm hypernatraemia
Give N/3 NS in maintenance amounts
METABOLIC ACIDOSIS
Etiology
 Clinical features-deep fast breathing with plasma
HCO3 <15 meq/lit
Management
 Amount of NaHCO3=
HCO3 deficit x 0.6 x wt
(OR)
3ml/kg of 7.5% NaHCO3 diluted
6 times 5% Dextrose [total of
20ml/kg] over 30-60 min
HYPOKALEMIA
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Serum K- <3 Meq/l
Clinical features
Management- ORS
-K rich food
Oral potassium supplementation
-2meq/kg/d in PEM
WHO Formula
gm/ lit
component Mmol/lit
NaCl
3.5
Na
90
KCl
1.5
K
20
Tri sodium 2.9
citrate
Glucose
20
Cl
80
Citrate
10
water
Glucose
111
1Lit
Various measures to reduce Na
 Lower Na content in ORS
 Alternating breast milk and ORS(2:1)
 Diluting ORS in 1.5 lit of water
Limitations of ORS
 Does not decrease the
volume
frequency
severity of diarrhoea
Does not stop diarrhoea
IMPROVED
ORS
 Should reduce amount & rate of
purging
 Should stop diarrhoea
 Should provide nutritional support
(SUPER ORS)
FORMULATIONS
 Amino acid Glycine / L-alanine / Lglutamine added to glucose ORS
 Decreasing conc. Of glucose & sodium
 Cooked cereal powder esp. rice to
replace glucose
 Combining glucose polymers & AA’s
to replace glucose
 Polymers like maltodextrine to
replace glucose
CEREAL baesed ORS
 50 gm/lit of cooked rice added to salt
 ADVANTAGES?
REDUCED OSMOLARITY ORS
 Principle?
Gms/lit
Mmol/lit
NaCl
2.6
Na
75
Glucose
13.5
Cl
65
KCl
1.5
Glucose
75
Tri Na cit
2.9
K
20
Citrate
10
Osm
245
Amylase resistant starch in ORS
 Add 50 gm/lit of starch to standard
glucose ORS
 Increases absorption efficiency
ReSoMal
Component
Glucose
Na
K
Cl
Citrate
Mg
Zn
Cu
Osmolarity
Standard ORS
111 mmol/lit
90
20
80
10
311
ReSoMal
125mmol/lit
45
40
70
7
3
0.3
0.045
300
DRUG THERAPY
SHIGELLA
Cotrimoxazole(5d)
CHOLERA
Tetracycline/ Doxy
(3-5d)
(1dose)
AEROMONAS
cotrimoxazole
ETEC & EPEC
-do-
Campylobacter
Erythromycin(5-7d)
Clostridium difficile
Giardiasis
Vancomycin/
metronidazole
Ampicillin/
Cefotaxime(5-7d)
Metronidazole(5d)
Amoebiasis
Metronidazole(7-10d)
Salmonella
RACECADORTIL
 Mode of action
 Comparing with Loperamide
MULTIVITAMINS
 Vit A- on day 1,2 and 14
 Folic acid- 5 mg on day 1 then 1mg/d
for 2 wks
 Other vitamins and trace elements
double the maintanance dose
MICRONUTRIENTS
 Potassium-5-6 meq/kg/d for few days
2-3 meq/kg/d orally for 2wks
 MgSO4-0.2ml/kg
 Zinc-10 mg for 2wks
 Copper-0.3 mg/kg/d
 Iron
PROBIOTICS IN DIARRHOEA
 Viable microbial supplements / live
microorganisms given to confer
beneficial health effects on the
growth of the host
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Lactobacillus acidophilus/ L.casei
Bifidobacterium
Streptococcus thermophilius
Saccharomyces
PREBIOTICS IN DIARRHOEA
 Food ingredients or part of bacteria
largely undergraded in small bowel
and can beneficially affect the host by
stimulating colonic bacteria
 Lactulose alfa disaccharide
 Fructo-oligosaccharide
 In some vegetables and fruits
USES OF PRE/PROBIOTICS
 Establishes normal microbial flora
 Enhancement of immunity
 Nutritioal benefits-vit B Production
-improved digestibility
-body growth
MECHANISMS OF ACTION
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Competing for receptor sites
Growth inhibition
Immune modulation
Production of short chain fatty acids
Modification of toxin receptors
Disaccharidases
Decreases permeability
DIARROEA IN PEM
 Clinical features
 MANAGEMENT
 Mild to moderate-ORS 70-100 ml/kg
over 6-12 hrs
Severe – N/2 NS+5%D 30ml/kg – 2hr
-N/6 NS+5%D 10ml/kg- 10hr
-N/6 NS+5%D 5ml/kg/hr –12hr
MAINTENANCE FLUIDS-N/6 NS in 5% D
-75-100 ml/kg/d
NUTRITION IN PEM
 The goal – 150-200 kcal
-3-4g protein
-6-8 feeds
 Micronutrients & multi vitamins
 Trace elements