Management of Acute Diarrhoea in Children

1
Management of Acute Diarrhoea in Children

• Welcome to the module on Management of Acute
  Diarrhoea (AD) in Children!
• Diarrhoeal disease remains a leading cause of
  morbidity and mortality amongst children in low
  and middle income countries.
• Most deaths result from the associated shock,
  dehydration and electrolyte imbalance.
• In malnutrition, the risk of AD, its
  complications and mortality are increased.

A child presenting with AD
For more information about the authors of this
module, click here
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How to use this module

• This module aims to address deficiencies in the
  management of AD and dehydration in children that
  we identified during a clinical audit.
• We suggest that you start with the learning
  objectives and try to keep these in mind as you
  go through the module slide by slide, in order
  and at your own pace.
• Print-out the diarrhoea SDL answer sheet. Write
  your answers to the questions (Q1, Q2 etc.) on
  the sheet as best you can before looking at the
  answers.
• Repeat the module until you have achieved a mark
  of gt20 (gt80).
• You should research any issues that you are
  unsure about. Look in your textbooks, access the
  on-line resources indicated at the end of the
  module and discuss with your peers and teachers.
• Finally, enjoy your learning! We hope that this
  module will be enjoyable to study and complement
  your learning about AD from other sources.

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Learning Outcomes

• By the end of this module, you should be
• competent in the management of acute
• diarrhoea / dehydration.
• In particular you should be able to
• Describe when to use oral and parenteral fluids
  and what solutions to use
• Identify the malnourished child and adjust
  management accordingly
• Describe when antibiotic treatment is indicated
  and the adverse effects of the overuse of
  antibiotics
• Describe the use of zinc in AD

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Definition of AD

• There is a wide range of normal stool patterns in
  children which makes the precise definition of AD
  difficult
• According to the World Health Organization (WHO),
  AD is the passage of loose or watery stools,
  three times or more in a 24 hour period for
  upto14 days
• In the breastfed infant, the diagnosis is based
  on a change in usual stool frequency and
  consistency as reported by the mother
• AD must be differentiated from persistent
  diarrhoea which is of gt14 days duration and may
  begin acutely. Typically, this occurs in
  association with malnutrition and/or HIV
  infection and may be complicated by dehydration
• Takes the shape of the container

Diaper stained with watery stool
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The burden of diarrhoeal disease

• Despite the fact that diarrhoea can be prevented,
  about 2 billion cases of diarrhoea occur globally
  every year in children under 5 years
• About 2 million child deaths occur due to
  diarrhoea every year
• More than 80 of these deaths are in Africa and
  South Asia
• Diarrhoea is the third most common cause of death
  (see diagram)
• In Nigeria, diarrhoea causes 151,700 deaths of
  children under five every year, the second
  highest rate in the world after India
• UNICEF/WHO, Diarrhoea Why children are still
• dying and what can be done, 2009

Causes of death among children under age of five
years UNICEF Progress for children, 2007
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Causes and risk factors for AD

• Microbial, host and environmental factors
  interact to cause AD
• Click on the boxes to find out more

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Host factors

• Biological factors increase susceptibility to AD

• Behavioral factors increase the risk of AD

• Age The incidence of AD peaks at around age 6-11
  months, remains high through 24 months and then
  decreases
• Failure to get immunised against rotavirus
• Failure of measles vaccination measles
  predisposes to diarrhoea by damage to the
  intestinal epithelium and immune suppression
• Malnutrition is associated with an increased
  incidence, severity and duration of diarrhoea

• Not breastfeeding exclusively for 6 months
• Using infant feeding bottles they easily become
  contaminated with diarrhoea pathogens and are
  difficult to clean
• Not washing hands after defecation, handling
  faeces or before handling food

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8
Environmental factors

• These include
• SeasonalityThe incidence of AD has seasonal
  variation in many regions
• In temperate climates, viral diarrhoea peaks
  during winter whereas bacterial diarhoea occurs
  more frequently during the warm season
• In tropical areas, viral and bacterial diarrhoeal
  occur throughout the year with increased
  frequency during drier, cooler months.
• Poor domestic and environmental sanitation
  especially unsafe water
• Poverty

An improved water supply in a peri-urban setting
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Common causes of AD

• More than 20 viruses, bacteria and parasites have
  been associated with acute diarhoea
• Worldwide, rotavirus is the commonest cause of
  severe dehydrating diarrhoea causing 0.6 million
  deaths annually, 90 of which occur in developing
  countries
• The incidence of specific pathogens varies
  between developed and developing countries
• In developed countries, about 40 of AD cases are
  due to rotavirus and only 10-20 are of bacterial
  origin while in developing countries, 50-60 are
  caused by bacteria while 15-25 are due to
  rotavirus

• Other viral agents
• Enteric adenoviruses
• Astrovirus
• Human calciviruses (norovirus and sapovirus)

• Bacteria
• E. coli (EAEC, EPEC, EIEC)
• Shigella spp
• Staphylococcus spp
• Salmonella spp
• Yersinia enterocolitica
• Campylobacter jejuni
• Vibrio cholera

• Parasites
• Entamoeba histolitica
• Girdia lamblia
• Cryptosporidium
• Trichuris trichuria
• Strongyloides stercoralis

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Clinical types of AD

• 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, E. coli, 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, malnutrition and dehydration. Shigella spp, Entamoeba histolytica
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Q1Write T or F on the answer sheet. When you
have completed all 5 questions, click on each box
and mark your answers.

• The incidence of AD is highest in the age group
  6-11 months
• Acute diarrhoea is of duration less than 14 days
• Rotavirus is a more common cause of diarrhoea in
  developing countries than bacterial pathogens
• Undernutrition is a major risk factor for
  persistent diarrhoea
• The largest proportion of deaths from diarrhoea
  occur in East Asia

a
b
c
d
e
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Answer to Q1a

• This statement is True.
• The incidence of diarrhoea is highest in age
  group 6-11 months. This is likely to be
  associated with declining levels of antibodies
  acquired from the mother, lack of active immunity
  in the infant and the introduction of
  complementary foods that may be contaminated with
  diarrhoeal pathogens.

ü
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Answer to Q1b

• This statement is True
• Diarrhoea that begins acutely and lasts less than
  14 days is called acute diarrhoea
• Diarrhoea lasting longer than 14 days is
  persistent diarrhoea

ü
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Answer to Q1c
û

• This statement is False
• Bacterial pathogens cause most cases of diarrhoea
  in developing countries
• Bacteria are responsible for 50-60 of cases of
  AD while rotavirus is responsible for 15-25
  cases

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Answer to Q1d
ü

• This statement is True.
• Undernourished children are at higher risk of
  suffering more frequent, severe and prolonged
  episodes of diarrhoea

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Answer to Q1e
û

• This statement is False
• East Asia and Pacific, South Asia and Africa are
  home to 9, 38 and 46 respectively of child
  deaths from diarrhoea
• The rest of the world contributes only 7

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Clinical scenarios

• You will now work through a series of cases of AD
• You will learn how to assess and manage children
  according to the latest WHO guidelines
• Start with scenario A. Try to answer the
  questions yourself before clicking on the answers

http//www.who.int/maternal_child_adolescent/docum
ents/9241546700/en/index.html
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Scenario AAssessment and management of shock

• This 2 year old child was
• rushed into the emergency
• room. She had AD and had
• become very unwell.

Q2. How would you proceed? Write down your
answer before moving to the next slide!
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Emergency Triage Assessment and Treatment (ETAT)

• Q2. The first thing to do is ETAT,
• which involves assessment of ABC
• A Airway
• B Breathing
• C Circulation
• Temperature of the extremeties
• Capillary refill time (CRT)
• Radial pulse rate, volume

• Findings in this child
• A Airway the airway was patent
• B Breathing respiratory rate was 36
  breaths/minute and there was no dyspnoea
• C Circulation
• The hands felt cold
• CRT 5 seconds
• Radial pulse
• rate 160/minute
• volume thready

Q3. Is this child in shock? Write down you
answers and then go to the next slide
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• Q3. Yes. In a child with cold hands, either one
  of the following signs identifies shock
• Weak and fast pulse
• Capillary refill time (CRT) longer than 3
  seconds (normal is 1-2 secs)
• Both signs are present in this child the child
  should receive appropriate fluid
• regimen for shock as follows

1. Secure intravenous access and draw blood for
emergency laboratory investigations
2. Attach Ringers lactate or normal saline and
infuse 20ml/kg as rapidly as possible (within
30-60 minutes)
3. Reassess the child after first infusion. If no
improvement, repeat 20ml/kg as soon as possible
and reassess again
4. This regimen can be repeated up to a maximum
of four times during which a provisional
diagnosis must have been established
5. If there is improvement at any stage, give
70ml/kg of Ringers lactate solution or normal
saline over - 5 hours in children less than 12
months - 2 1/2 hours (150 mins) in children aged
12 months to 5 years

• It is critical to reassess and re-classify
  dehydration before each IV bolus to prevent fluid
  overload
• Important! Commence on ORS solution as soon as
  child can drink

Go to Case Scenario B
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Scenario B Clinical assessment of
dehydration

• This 2 year old child presented
• with AD. She did not have features
• of shock or SAM but was assessed to have severe
  dehydration.

Q4. List the 4 clinical signs recommended for
classifying a child as severely dehydrated Write
down your answers and then go to the next slide
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Answer Q4

• The diagnosis of severe dehydration is based on
  two or more of the following clinical signs
• Lethargy or unconsciousness
• Sunken eyes
• Unable to drink or drinks poorly
• Skin pinch goes back very slowly (gt2 seconds)

• Other symptoms and signs of dehydration includes
  absence of tears, sunken fontanelle in young
  infants, cold extremities and reduced urinary
  output
• Assessment of the degree of dehydration is very
  important because it determines the appropriate
  rehydration regimen
• WHO guidelines for the assessment of dehydration
  classifies patients into those with no
  dehydration, some dehydration and severe
  dehydration

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WHO guideline for the classification of
dehydration
Parameters No dehydration Some dehydration Severe dehydration
Appearance Well, alert Restless, irritable Lethargic,or unconscious floppy
Eyes Normal Sunken Very sunken
Thirst Drinks nomally, not thirsty Thirsty, drinks eagerly Drinks poorly or not able to drink
Skin pinch Goes back quickly (lt1 second) Goes back slowly (1 second) Goes back very slowly (2 seconds)
There are other established guidelines. Click
here to see details
In the management of a 2 year old with severe
dehydration Q5 what is the appropriate route for
fluid administration? Q6 what is the most
approriate fluid to give? Q7 what volume of
fluid and over how long? Write down your answer
and then go to the next slide
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Other guidelines used to assess dehydration due
to AD

• National Institute for Health and Clinical
  Excellence guidelines (NICE/UK)
• ESPGHAN guidelines
• These classify patients into
• minimal or no dehydration
• mild to moderate dehydration
• severe dehydration
• AAP guideline classifies patients as mild (3-5),
  moderate (6-9) and severe (gt10) dehydration
• Various scoring systems (Fortini et al., Gorelick
  et al.) proposed for assessment of child with
  dehydration, but there is limited evidence to
  support their use particularly in developing
  countries

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Treatment of severe dehydration

• Q5 Children with severe dehydration require
  rapid IV rehydration followed by oral rehydration
  therapy
• Q6 For IV rehydration, Ringers lactate (also
  called Hartmanns solution) is recommended. If
  not available, normal saline can be used
• Q7 Give 100ml/kg of fluid as shown below
• aRepeat if the radial pulse is still very weak or
  not detectable

Age First, give 30ml/kg in Then, give 70ml/kg in
lt 12 months old 1 houra 5 hours
12 months old 30 minutesa 2 1/2 hours
Go to Case Scenario C
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Scenario C Clinical assessment of
dehydration

• A mother brought her 2 year old male child to the
  hospital because of AD. On examination, he was
  irritable and his skin pinch goes back slowly (1
  second)

• Q8 Write down your assessment of this childs
  hydration status
• Q9 List 2 other key clinical signs consistent
  with this degree of dehydration
• Write down your answer and then go to the next
  slide

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Answers Scenario C

• Q8 This child has some dehydration
• Q9 The key signs consistent with some
  dehydration are any 2 or more of the following
• Restlessness/irritability
• Thirsty and drinks eagerly
• Sunken eyes
• Skin pinch goes back slowly (1 second)

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Q10Write T or F on the answer sheet. When
you have completed both questions, click on the
box and mark your answers.

• In the management of some dehydration, decide on
  whether each of the following statements is true
  or false. Then click on the square to see the
  answer.
• 10a. Rehydration with IV fluid and thereafter
  commenced on ORS
• 10b. Treatment with ORS is appropriate

a
b
Go to Case Scenario D
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Answer Q10a
û

• This statement is False. The appropriate
  treatment is use of oral rehydration fluid. IV
  infusion is only recommended for children with
  shock or severe dehydration. Even when a child
  with some dehydration can not tolerate oral
  fluids, it is advisable to give oral fluids
  through a nasogastric tube.

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Answer Q10b
ü
This statement is True. WHO/UNICEF recommends the
new improved oral rehydration solution which has
reduced concentration of sodium and glucose
(LO-ORS). LO-ORS reduces the risk of
hypertonicity, reduces stool output, shortens the
duration of diarrhoea and reduces the need for
intravenous fluids.

• Give the child 75ml/kg of ORS in the first 4
  hours
• Show the mother how to give ORS solution, a
  teaspoonful every 1-2 minutes for child under 2
  years
• If the child vomits, wait 10 minutes, then resume
  giving ORS solution more slowly
• Monitor the child to be sure child is taking ORS
  solution
• Check childs eyelids if they become puffy, stop
  ORS solution
• Reassess the child after 4 hours, checking for
  signs of dehydration
• Teach the mother how to prepare ORS solution at
  home
• Advise on breastfeeding, for those still
  breastfeeding, and adequate feeding
• If no dehydration, teach the mother the rules of
  home treatment

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Scenario D A child with bloody
diarrhoea

• A child was brought to the emergency room because
  of bloody diarrhoea of 3 days duration with
  associated vomiting and fever.
• When examined, there were no signs of dehydration
  or SAM.

• Q11 What it is the most likely diagnosis in
  this child?
• Q12 How will you treat?
• Write down your answers and then move to the next
  slide

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Answers Scenario D

• Q11
• This child has acute bloody diarrhoea also
  called dysentery
• Most episodes are due to Shigella spp
• The diagnostic signs of dysentery are frequent
  loose stools with visible red blood
• Other findings in the history or on examination
  may include
• Abdominal pain
• Fever
• Convulsions
• Lethargy
• Dehydration
• Rectal prolapse
• Q12
• All children with severe dysentery require
  antibiotic treatment for 5 days
• Give an oal antibiotic to which most strains
  of shigella in your localiity are sensitive
• Examples of antibiotics to which shigella
  strains can be sensitive are ciprofloxacin and
  other fluoroquinolones
• Also manage any dehydration
• Ensure breastfeeding is continued for childen
  still breastfeeding and normal diet for older
  childen
• Follow-up the child

Go to Case Scenario E
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Scenario E Clinical assessment
of dehydration

• This 2 year old male child was brought to the
• Childrens emergency room with diarrhoea for 6
  days. He had angular stomatitis, peri-anal
  ulceration, weighed 7.0 kg and the MUAC was 10.2
  cm.
• His hands were cold, pulse weak and fast and skin
  pinch went back very slowly. However, he appeared
  to be fully conscious and was not lethargic.

The resident doctor gave 140ml of normal saline
by rapid IV infusion but his condition
deteriorated.
Q13 What important condition needs to be
recognised in this child? Q14 Was the doctors
management correct? Q15 List 2
pathophysiological mechanisms in this condition
that affect fluid management.
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Answer scenario E - Fluid management in children
with SAM

• Q13 The child has severe acute malnutrition SAM
• Q14 No. Dehydration is difficult to diagnose in
  SAM and it is often over diagnosed. The doctors
  choice of IV normal saline, amount of fluid and
  rapidity of given IV fluid were all incorrect and
  may have caused the childs deterioration
• Q15 The pathophysiological mechanisms that
  affect fluid management are
• Although plasma sodium may be very low, total
  body sodium is often increased due to
• increased sodium inside cells
• additional sodium in extracellular fluid if there
  is nutritional oedema
• reduced excretion of sodium by the kidneys
• Cardiac function is impaired in SAM
• This explains why treatment with IV fluids can
  result in death from sodium overload and heart
  failure.
• The correct management is reduced sodium oral
  rehydration fluid (ORF e.g. ReSoMal) given by
  mouth or naso-gastric tube if necessary. The
  volume and rate of ORF are much less for
  malnourished than well-nourished children (see
  next slide)
• IV fluids should be used only to treat shock in
  children with SAM who are also lethargic or have
  lost consciousness!

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Fluid management in children with SAM

• For childen with SAM, diarrhoea, signs of shock,
  lethargy or unconscious, WHO recommends
• Insert an IV line and draw blood for emergency
  laboratory investigations
• Give IV fluid 15ml/kg over 1 hour
• The IV fluid of choice (in order of preference)
  according to availability are
• Ringers lactate with 5 dextrose
• Half-nomal saline with 5 dextrose
• Half-strength Darows solution with 5 dextrose
• Ringers lactate

Note the differences in management in SAM and
well nourished children
Monitor pulse and breathing rate at the start and
every 5-10 minutes If there is improvement
(pulse and respiratoy rate fall), repeat IV fluid
15ml/kg over 1 hour Then switch to oral or
nasogastric rehydration with Resomal 100ml/kg for
10 hours
If the child deteriorates during the IV
rehydration (breathing increases by 5 breath/min
or pulse by 15 beats/min), stop the infusion
because IV fluid can worsen the childs condition
End of clinical scenarios
36
End of clinical scenarios
The next few slides are on how to assess
nutritional status, indications for laboratory
investigations, rational use of antibiotics and
usage of zinc
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Assessment of nutritional status

• Assessment of nutritional status is important in
  children with diarhoeal disease to identify those
  with severe acute malnutrition (SAM)
• This is because abnormal physiological processes
  in SAM markedly affect the distribution of sodium
  and therefore directly affect clinical management
• In patients with SAM, although plasma sodium may
  be very low, total body sodium is often increased
  due to
• increased sodium inside cells as a result of
  decrease activity of sodium pumps
• additional sodium in extracellular fluid if there
  is nutritional oedema
• reduced excretion of sodium by the kidneys
•  

A West African child with kwashiokor
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Methods of nutritional assessment

• Nutritional assessment can be done by
• Looking for visible signs of severe wasting such
  as muscle wasting and reduced subcutaneous fat
• Looking for other signs of malnutrition angular
  stomatitis, conjuctival and palmar pallor, sparse
  and brittle hair, hypo- and hyperpigmentation of
  the skin
• Looking for nutritional oedema (pitting oedema of
  both feet)
• Use of anthropometry such as Weight-for-Height
  z-score (WHZ lt -3.0) or Mid-Upper Arm
  Circumference (MUAC lt 11.5cm in children aged
  6-60 months)

Muscle wasting and loss of subcutaneous fat in a
West African child with marasmus
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MUAC recommended for nutritional assessment in
dehydration

• MUAC is widely used in community screening of
  malnutrition because it is easy to perform,
  accurate and quick
• MUAC is measured using Shakirs strip or an
  inelastic tape measure placed on the upper arm
  midway between acromion process and olecranon
• Dehydration reduces weight MUAC was less
  affected by dehydration than WFLz score in a
  recent study

• Mid-Upper Arm Circumference (MUAC)
• lt115mm SAM  
• 110 - 124mm Moderate Acute Malnutrition (MAM) 
• 125 - 135mm risk of acute malnutrition
• gt135mm child well nourished
• www.motherchildnutrition.org/

http//www.nutritionj.com/content/10/1/92
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Laboratory investigations

• AD is usually self-limiting and investigations to
  identify the infectious agent are
• not required
• Indications for stool microscopy, culture and
  sensitivity
• Blood and mucus in the stool
• High fever
• Suspected septicaemic illness
• Diagnosis of AD is uncertain
• Indications for measurement of Urea and
  Electrolytes
• Severe dehydration or shock
• Children on IV fluid
• Children with severe malnutrition
• Suspected cases of hypernatreamic dehydration

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Rational use of antibiotics

• Even though bacterial pathogens are the commonest
  cause of AD in developing countries, there should
  be cautious and rational use of antibiotics to
  discourage development of microbial resistance,
  avoid side effects and reduce cost
• Antibiotics should be used for
• Severe invasive bacterial diarrhoea eg
  Shigellosis
• Cholera
• Girdiasis
• Suspected or proven sepsis
• Immunocompromised 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

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Zinc and diarrhoea

• Zinc deficiency is common in developing countries
  and zinc is lost during diarrhoea
• Zinc deficiency is associated with impaired
  electrolyte and water absorption, decreased brush
  border enzyme activity and impaired cellular and
  humoral 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 diarrhoea be given zinc for 10-14
  days
• 10mg daily for children lt6 months
• 20 mg daily for children gt6 months

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How can we prevent diarrhoeal disease?

• This involves intervention at two levels
• Primary prevention (to reduce disease
  transmission)
• Rotavirus and measles vaccines
• Handwashing with soap
• Providing adequate and safe drinking water
• Environmental sanitation
• Secondary prevention (to reduce disease severity)
• Promote breastfeeding
• Vitamin A supplementation
• Treatment of episodes of AD with zinc

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End of module

• Well done! You have completed this module
• Make sure that you repeat the module until you
  have a good score in the assessment
• It is vital that you now apply the knowledge you
  have gained from this module into your management
  of children with AD
• Please do let us know if you think that there are
  any ways that this module could be changed as a
  learning resource that is effective in improving
  practice
• Please e-mail any comments to Dr. Senbanjo at
  senbanjo001_at_yahoo.com

Authors and acknowledgements
45
Authors/Acknowledgement

• Authors
• Dr. Idowu Senbanjo, Lecturer/Consultant
• Paediatrician, Department of Paediatrics and
• Child Health, Lagos State University College of
• Medicine, Ikeja, Lagos, Nigeria.
• Dr. Chinlye Chng, Consultant
• Gastroenterologist/Hepatologist, Abertawe
• Bro Morgannwg University Health Board,
• Singleton Hospital, Swansea, UK.
• Prof. Steve Allen, Professor of Paediatrics and
• International Health, RCPCH International
• Officer and David Baum Fellow, The
• College of Medicine, Swansea University, UK.

• Acknowledgement
• We would like to acknowledge the British
• Society of Gastroenterology for awarding
• an educational grant which supported Dr. Senbanjo
  in developing this module.
• Permissions
• Please note that consent was obtained
• from parents/carers to use the images in this
  module for teaching purposes only. The images
  should not be used for any other purpose.

We are very interested to receive feedback
regarding any aspect of this module, especially
if it helps us to improve it as a learning
resource. Please e-mail any comments to Dr.
Senbanjo at senbanjo001_at_yahoo.com
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