management of acute diarrhoea in children dr.b.anjaiah, md., dch., director, rims, ongole
DESCRIPTION
MANAGEMENT PREVENTION TREATMENT SUPPORTIVE TREATMENTTRANSCRIPT
MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN
Dr.B.Anjaiah, MD., DCh.,Director, RIMS, Ongole
INVESTIGATIONS STOOL- Macroscopy Microscopy- WBC>10/hpf Ova,cysts,throphozoites Hanging drop C/S for shigella & salmonella
BLOOD- CBC 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 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 QUANTITY WITH EACH STOOL
<6 mon 50 ml(1 cup)7 mon – 2 yrs 50-100 ml2 yrs- 5 yrs 100-200mlOlder 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 clinicWhen 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 1-24-11mon 5-8 kgs 400-600 ml 2-312-23 mon 8-11 kgs 600-800 ml 3-42-4 yrs 11-16 kgs 800-1200 ml 4-65-14 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 --- follow NIL - PLAN A PERSISTS - PLAN B SEVERE - PLAN C
PLAN C (Severe dehydration) AGE First give
30 ml / kg in Then give70 ml / kg in
< 1 year 1 hour 5 hrs
> 1 year 30 min 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 Dehydration Dyselectrolytaemia Precipitation of malnutrition Secondary lactose intolerence Persistent diarrhoea HUS DIC Cortical vein thrombosis
HYPONATRAEMIASevere-<125meq/lClinical featuresDeranged sensorium&convulsionsDiminished urine outputCorrection-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
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 Serum K- <3 Meq/l Clinical features Management- ORS -K rich food Oral potassium supplementation -2meq/kg/d in PEM
WHO Formulagm/ lit component Mmol/lit
NaCl 3.5 Na 90
KCl 1.5 K 20
Tri sodium citrate
2.9 Cl 80
Glucose 20 Citrate 10
water 1Lit Glucose 111
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 / L-
glutamine 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/litNaCl 2.6 Na 75Glucose 13.5 Cl 65KCl 1.5 Glucose 75Tri Na cit 2.9 K 20
Citrate 10Osm 245
Amylase resistant starch in ORS Add 50 gm/lit of starch to standard
glucose ORS
Increases absorption efficiency
ReSoMalComponent Standard ORS ReSoMalGlucose 111 mmol/lit 125mmol/litNa 90 45K 20 40Cl 80 70Citrate 10 7Mg - 3Zn - 0.3Cu - 0.045Osmolarity 311 300
DRUG THERAPY SHIGELLA Cotrimoxazole(5d)
CHOLERA Tetracycline/ Doxy(3-5d) (1dose)
AEROMONAS cotrimoxazole
ETEC & EPEC -do-
Campylobacter Erythromycin(5-7d)
Clostridium difficile Vancomycin/metronidazole
Salmonella Ampicillin/Cefotaxime(5-7d)
Giardiasis Metronidazole(5d)
Amoebiasis Metronidazole(7-10d)
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
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 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 –12hrMAINTENANCE 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