Diarrhea Management in the Community

CHILDHOOD DIARRHEA

One in 5* children die of diarrhea or diarrhea related complications every year in India.

Diarrheal illness is the second leading cause of child mortality; among children younger than 5 years, it causes 1.5 to 2 million deaths annually. In developing countries, children experience between three to six episodes of diarrhea annually.

*Predicting the distribution of under-five deaths by cause in countries without adequate vital registration systemsSaul S Morris,1 Robert E Black2 and Lana Tomaskovic3(International Journal of Epidemiology 2003;32:1041–1051)

Magnitude of problem• In India,~380,000 *children die from diarrhea and its

complications every year.• 9.8 million child deaths each year, 2/3 of which are

preventable with low-cost interventions• 2 million child deaths from diarrhea, 88% of Diarrhea

diseases are preventable by easily available interventions.

• Diarrheal diseases are responsible for 18%** of deaths among children under 5 years of age.

• Despite easy and affordable treatment, most patients do not access the recommended treatment.

• Timely use of ORS-Zinc can save over 133,000 lives by 2015***

• *World Health Organization, Global Burden of Disease estimates, 2004 • update. **Causes of Child Deaths - March 26, 2005 The Lancet ***Role of zinc administration in prevention of childhood diarrhea and pneumonia-a meta analysis,Agarwal I R,Sentz J,Miller M A,Paediatrics • 2007,June 119(6)•

Causes of Child Deaths in Low-Income Countries: Diarrhea 18%

Source: WHO, World Health Statistics 2011

What is Diarrhea?

• Any Change in number or consistency of stools in exclusively breast-fed children.

• Passage of 3 or more than 3 loose or watery stools in 24 hours in children over 2 months of age.

• Diarrheal illness may be of the following types- acute watery diarrhea and chronic or persistent diarrhea (lasting for ≥14 days).

• Blood in stools-Dysentery.• Usually seen in children between 2 months and

5 years of age.

When is it NOT Diarrhea?

• Frequent passage of soft, semi-solid stools in an exclusively breast-fed child.

• No change in consistency or number of stools.

Diarrhea and Dehydration

Cause Effect

•Passage of 3 or more than 3 loose or watery stools in 24 hours.•Any Change in number or consistency of stools.•Often associated with vomiting.

•During diarrhea and/vomiting, there is loss of water and electrolytes.•Dehydration occurs when these losses are not replaced adequately and a deficit of water and electrolytes develops.

Consequences of Diarrhoea

The two main dangers: malnutrition and death. Commonest cause of diarrhea related deaths: dehydrationEqually important causes of death are dysentery and prolonged malnourishing diarrheaMalnutrition is associated with nearly two-thirds of diarrhea-related deaths.

Diarrhea & MalnutritionVicious cycle

Absorption Appetite

Voluntary restriction

Immunity Mucosal integrity

Commonpredisposing factors

Losses Catabolism

What are our challenges in the treatment of diarrhea?

• Low ORS use rates

• Use of zinc as an adjunct to ORS

• Inappropriate management of dehydration

• Inadequate emphasis on feeding

• Irrational use of antimicrobials & other

drugs

• Hand washing

CARE SEEKING BEHAVIOUR

Prescription Practices- 10 district survey in India

ORS 47%

Zinc 1.3%

Antibiotics 5.6%

Injections 23.0%

Antidiarrheals 18.2%

Tonic 31.5%

Management Practices for Childhood Diarrhea in India , UNICEF 2009

Two simple rules for effective management of Diarrhea

•ORS

•ZINC

ORSORAL REHYDRATION

SOLUTION

ORS-Benefits• Replaces water and salts lost during

diarrhea.

• Reduces dehydration and need for hospitalization.

• Decrease in severity of diarrhea and vomiting.

• Decrease in duration of illness.

Low osmolarity ORS Composition

Ingredient g/L Dissociates into mmol/L

Glucose, anhydrous

(C6H12O6)

13.5 Glucose 75

Trisodium Citrate,dihydrate

Na3C6H5O7·2H2O

2.9 Sodium 75

Sodium Chloride (NaCl)

2.6 Chloride 65

Potassium Chloride (KCl)

1.5 Potassium 20

TOTAL 20.5 Citrate 10

TOTAL 245

Preparation of ORSThree Important Rules

CLEAN HANDS

CLEAN WATER

CLEAN UTENSILS

Preparation of ORS

WHAT IS ZINC?

What are it’s benefits?

What is Zinc?• Zinc is a micro-nutrient and promotes immunity.• It is an important antioxidant and preserves cellular membrane

integrity.• Promotes the growth and development of the nervous system. • Rich sources of Zinc are foods of animal origin, such as meat and

fish.• Zinc is also present in nuts, seeds, legumes, and whole grain

cereal, but the high phytate content of these foods interferes with its absorption.

• Zinc cannot be stored in the body, and zinc excretion through the gastrointestinal tract is increased during episodes of diarrhea.

• Young children who have frequent episodes of diarrhea and have diets low in animal products and high in phytate-rich foods are most at risk of Zinc deficiency.

ZINC- Benefits• Zinc reduces the fluid and salt loss in stools by

improving mucosal permeability. • Accelerated regeneration of mucosa• Increased levels of brush-border enzymes• Enhanced cellular immunity • Higher levels of secretory antibodies• Zinc improves absorption of ORS.• Reduces the severity and duration of illness.• Reduces need for antibiotics.• Reduces the chances of complications.• Full dose for 14 days protects against diarrhea and

pneumonia for next 3 months.• Acts as a general tonic-improves appetite and

promotes growth.

Research Studies on efficacy of Zinc

• A study conducted by an international team of scientists working in Bangladesh and led by researchers from the Johns Hopkins Bloomberg School of Public Health.

• The researchers treated 8,070 children with diarrhea

living in areas of Bangladesh.

• Groups of children were randomized by region to receive zinc in addition to standard treatments and compared to children who did not receive zinc.

• The children in the zinc areas received 20 mg elemental zinc daily for 14 days during each episode of diarrhea in addition to ORS therapy.

Research Studies-Contd.

• The researchers found the incidence of diarrhea was significantly less and non-injury deaths were 50 percent less in children who received zinc compared to those who did not.

• In addition, it was found that oral rehydration solution therapy (ORS) use, which is one of the standard treatments for diarrheal disease, increased by 20 percent among the children who received zinc. Antibiotic use decreased by 60 percent among the same group. These findings are published in the November 9, 2002, of the British Medical Journal.

Recommendations for Use of Zinc in

Acute Diarrhea• WHO/UNICEF Joint Statement (2001)• Endorsed by Indian Academy of

Pediatrics (2003)• Endorsed by Government of India

(2006)• Zinc has been included in the WHO

and India Essential Medicines List for the treatment of diarrhoea

• Zinc tablets included in Kit-A

Evidence of Efficacy of ZINC

• 15% faster recovery during the episode of diarrhea*.• 16 % decrease in duration of diarrhea*.• 24% decrease in frequency of episodes lasting more

than 7 days*.• 9-23% decrease in frequency of stools*.• Up to 31% reduction in stool output during the episode

of diarrhea**.• 42% reduction in treatment failure or death in persistent

diarrhea*ACUTE CHILDHOOD DIARRHEA: A REVIEW OF RECENT ADVANCES IN THE STANDARD MANAGEMENTSeema Alam, Rajeev Khanna, Uzma FirdausPediatric Gastroenterology Section, Department of Pediatrics, JNMC, AMU, Aligarh**Zinc with ORT reduces the stool output and duration of diarrhea in hospitalized children -a randomized controlled trial;S Bhatnagar et al, Dept of Paediatrics at AIIMS and Kasturba Hospital ,New Delhi***Zinc Investigators’ Collaborative Group. AJCN 2000.

Long Term Effects of Zinc

• Zinc supplementation for 10-14 has longer term effects on childhood illnesses in the 2-3 months after treatment

• 34% reduction in prevalence of diarrhoea

• 26% reduction in incidence of pneumonia

Zinc Investigators’ Collaborative Group. Pediatrics. 1999.

Cost Effectiveness of ORS and Zinc Supplementation

• Decreases the duration and severity of the episode

• Decreases the need for expensive hospitalization

• Decreases the use of unnecessary antibiotics and other drugs

• Further cost-benefit analyses are underway

Robberstad, Strand, Sommerfelt, and Black. Bull WHO 2004.Baqui, Black, Arifeen. J Health Pop Nutr. 2004.

Current total costs of treating a case of diarrhea higher than the

cost of Zinc treatment

Location of treatment

Reported total costs of treating a case of diarrhea, for differing levels of perceived severityMild Moderate Severe

At home <Rs. 50 Rs. 50-100

Private clinic

Rs.100-200 Rs. 300-500 Rs.500-1500

ORS sachets are sold for Rs 5-7 in the private sector ($0.10-$0.14). Zinc treatment for 10-14 day regimen costs ~Rs.28-33 in the private sector ($0.56-$0.66)Source: Formative research in preparation for promotion of zinc treatment for childhood diarrhea: Cross-country comparison of diarrhea treatment practices and implications for programs; June 2004

Dosage of Zinc

• Available as ZINC Tablets.

• Given for 14 days for full benefits.

• 20 milligrams per day for children older than six months.

• 10 mg per day in those younger than six months.

Administration of ZINC

Age Tablet Preparation Duration

Less than 2 months

Not required

2 months – 6 months

½ tablet

(10 mg)

Dissolved in 1 tsp of breast

milk

14 days

6 months- 5 years

1 tablet

(20 mg)

Dissolved in 1 tsp of breast

milk/ORS/clean drinking water

14 days

Objective of Treatment

• Prevent dehydration, if no signs of dehydration are present.

• Treat dehydration, if present.

• Reduce duration and severity of illness.

• Prevent nutritional damage.

• Reduce the occurrence of future episodes.

WHO-UNICEF recommended policies

• Caregivers/ mothers should start treatment with new low osmolarity ORS solution immediately upon onset of diarrhea in a child.

• Zinc supplementation with 20 mg per day of zinc supplementation for 14 days (10 mg per day for infants under six months old).

• Emphasize continued feeding or increased breastfeeding during, and increased feeding after, the diarrheal episode.

• Emphasize handwashing.

Zinc LossWater + Electrolytes Loss

Lessen absorption capacityDecreases Immunity

Dehydration

Faster Recovery of Intestine Mucosa Increase in absorption capacity

Increase in immunityRehydration

ORS Zinc Tablets

Diarrhea

Management of Diarrhea and Dehydration

ASK How long?

How many?

Is the child passing urine?

3-7 days

Yes, freely

7-14 days

Yes, but in decreased quantity

More than 14 days

Blood in stool

Greatly reduced urine output

No Dehydration Some Dehydration

Severe Dehydration

SEE Condition Well , Alert Restless , Irritable

Lethargic, unconscious

Eyes Normal Sunken Sunken

Thirst Drinks normally, Not thirsty

Thirsty, drinks eagerly

Drinks poorly or not able to drink

Skin pinch Goes back quickly

Goes back slowly bit in less than 2 seconds

Goes back very slowly, in more than 2 seconds

Fluid deficit <5 % of body wt or 50 ml./ kg

body wt

5-10% of body wt or 50-100 ml / kg

body wt

>10% of body wt or 100 ml / kg

body wt

DO PLAN A PLAN B PLAN C

Assessment of a child with Diarrhea

PLAN A Home therapy to prevent dehydration and malnutrition Children with no signs of dehydration need extra fluid and salt to replace their losses of

water and electrolytes due to diarrhea.

Fluids to be givenORS      

Salted drinks e.g. salted rice water, salted yoghurt drink ,green coconut water.    Home based ORS.

Plain water should also be given. Commercial fizzy drinks, fruit juices, sweetened tea, coffee, medicinal tea should be

avoided.

How much to give?

    Give as much fluid as the child wants until diarrhea stops.  Children < 2 years of age : 50-100 ml of fluid.  Children 2 years - 10 years : 100-200 ml.

   Older children and adults : As much as they want.

Zinc supplement Give 10 / 20 mg (depending on age of the child) every day for 14 days.

What feeds to give?

Breastfeeding should always be continued. The infant's usual diet should be continued during diarrhea and increased afterwards.

.Emphasize washing of Hands

PLAN B

For children with some dehydration• Approximate amount of ORS required (in ml) can be calculated by multiplying

the patient's weight in kg by 75.• More can be given, if required.• Breast feeding should be continued. • No other foods are to be given during the initial period.• After 4 hours, the child should be given some food every 3-4 hours.• After 4 hours, reassess the child and decide what treatment to be given next as

per level of dehydration.• Referred for IV rehydration if dehydration persists.

AGE <4 months

4-11

months

12-23 months

2-4 years 5-15 years >15 years

WEIGHT

<5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9 kg 30 kg or more

ML 200-400 ml

400-600 ml

600-800 ml

800-1200 ml

1200-2400 ml

2400-4000 ml

CUPS(200 ml)

2 3 5 7 12 20

Signs of Dehydration

PLAN C

For children with severe dehydration

• Refer the patient.

• Preferred treatment is rapid intravenous rehydration.

Skin pinch test for dehydration

Why are drugs prescribed in Diarrhea?

•Lack of Knowledge•Lack of confidence in ORS

and Zinc•Families demand drugs and

Injections•Consultation/ Dispensing

fees

Irrational use of drugs• Increases the cost of therapy• Diverts attention from main therapy- ORS, feeding and Zinc• Side-effects - antibiotic induced diarrhea• Complications- Simple infection converted into a life- threatening infection due to - - Abdominal distension, - Paralytic ileus - Respiratory depression - Septicemia - Pseudomembranous entero-colitis• Drug resistance

Antibiotics, Adsorbents and Anti-motility drugs are NOT indicated in the routine treatment of acute childhood diarrhea.

Danger Signs

Refer immediately if-• Does not improve within 3 days.• Increase in the number of stools.• Develops very watery or bloody stools.• Severe vomiting.• Marked reduction in urine output.• Develops high grade fever.• Decrease in alertness or consciousness.

Prevention of diarrhea

• Exclusive breast feeding for 6 months

• Complementary feeding at 6 months

• Hand washing

• Safe drinking water

• Environmental sanitation and safe disposal of excreta

• Measles vaccination

CONCLUSION• A substantial reduction in the diarrhea burden will require

greater emphasis on the following actions:• Reinstate diarrhea prevention and treatment as a cornerstone

of community-based primary health care. • Reach every child with effective interventions.• Ensure wide availability of low-osmolarity ORS.• Ensure wide availability and use of zinc.

THERE IS NO BETTER TIME THAN NOW

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