pediatric infective diarrhoea in developing countries
DESCRIPTION
Brief and relevant information on infective diarrhoea in children The emphasis is on developing countries, but the principles of treatment are the same.TRANSCRIPT
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 11
DIARRHOEA IN INFANTS AND DIARRHOEA IN INFANTS AND YOUNG CHILDRENYOUNG CHILDREN
Dr. Taher Y. Kagalwala M.D., D.C.H.
Hon. Pediatrician
Saifee Hospital, Masina Hospital, Habib HospitalSaboo Siddik Mat. And Gen. Nsg. Home
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 22
Don’t we all want kids to be Don’t we all want kids to be toilet-trained like THIS?toilet-trained like THIS?
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 33
What is diarrhoea?What is diarrhoea?
• It is the passage of liquid or watery stools• Usually, this is more than three times a day.• More important than this is: when there is a
recent change in the consistency, frequency or character of the stools.
• Frequent stools in an exclusively breastfed baby is NOT diarrhoea.
• Teething can cause a few loose stools; diarrhoea lasting more than 24 hours is NOT due to teething.
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 44
Common Etiological CausesCommon Etiological Causes
1. Infectious causes:• Viral – esp. rotavirus, respiratory and
enteroviruses• Bacterial – esp. E. coli (ETEC, EPEC)• Others – fungal, protozoal, helminthic and
miscellaneous2. Non-infectious causes:• Intussusception• Endocrine – hyperthyroidism• Secondary to a remote cause – e.g.
pneumonia
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 55
ClinicalClinical Features - 1Features - 1
1. Symptoms and signs of the primary illness.
2. Symptoms and signs of dehydration.
3. Symptoms and signs of complications and side-effects of treatment.
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 66
ClinicalClinical Features - 2Features - 2
1. Primary Illness:• Bacterial – dysentery and not diarrhoea –
marked by high fever, toxicity, tenesmus and sometimes rectal prolapse while defecating; stool will show mucus, visible or occult blood and at times, frank blood.
• Viral – watery stools with absence of most of the above findings, though there may be mucusy stools. Slight to moderate fever and presence of cough/cold, conjunctivitis and recurrent vomiting are all compatible.
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 77
ClinicalClinical Features – 3aFeatures – 3a
2. Dehydration (1 of 2):
Grade of dehydration/Symptoms
Mild
5 – 7% wt loss
Moderate
7 – 9 % wt loss
Severe
10% or more wt. loss
Fontanelle and eyes
Normal to mildly sunken
Moderately sunken
Severely sunken
Pulses Normal but fast Faster, slight low volume
Thready, peripheral pulses not palpable
Mucous membranes
Moist but sticky Slightly dry Dry
Skin turgor Normal Recoil 1-3 seconds
Recoil > 3 seconds
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 88
ClinicalClinical Features – 3bFeatures – 3b
2. Dehydration (2 of 2)
Grade of dehydration/Symptom
Mild Moderate Severe
Capillary refill time
Normal (< 3 sec)
Normal (< 3 sec)
Delayed 3 or > 3 sec
Urine Output Normal Slightly less (anuria < 4 hours)
Definitely less (anuria > 4 hours)
Mental status Normal but thirsty
Irritable Irritable to lethargic
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 99
Clinical Features - 4Clinical Features - 4
3. Symptoms and signs of complications:
• Hypovolemic shock
• Acute renal failure (pre-renal)
• Venous thrombosis
• Septicemia
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 1010
Case Study - 1Case Study - 1
18 – month old female child from a middle-class family presents with:
• Fever , mild – 4 days• Red eyes, running nose and a mild to mod.
cough – 3 days• Vomiting – 2 days ( frequent, whitish yellow)• Loose motions – yellow, 13 – 15 since the last
24 hours, curdy smell, with mucus• Not passed urine since the last four hours, with
h/o passing concentrated urine earlier too.
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 1111
Case Study – 2aCase Study – 2a
On examination (1 of 2):
• Average child, 9.5 kg, fever 99.2* F• Crying continuously, eagerly drinks water if
offered by the mother• P 120/min, RR 34/min, nonacidotic, BP not
taken• AF closed, eyes look okay but reduced tears
while crying• Oral mucosa is moist
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 1212
Case Study – 2bCase Study – 2b
On examination (2 of 2):
• CRT 3 seconds
• Skin turgor – slightly prolonged (3 seconds)
• Per abdomen – normal to increased peristalsis. No other findings of note.
• Other systems – normal.
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 1313
Case Study – 3Case Study – 3
• What is the likely diagnosis?• Is the girl dehydrated? How much? Why are
there inconsistencies (mucosae are moist, for example)?
• What investigations are needed? - CBC? - Stool routine? - Serum electrolytes? - Any other?• Will she need hospitalisation?
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 1414
Case Study - 4Case Study - 4
Management (1 of 4):
ORS: Sip by sip, at least 40-50 ml/kg as deficit plus about ¼ to ½ of a 200-ml glass for every medium to large stool passed plus 3 - 5 ml/kg/vomit to replace losses in vomiting.
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 1515
Case Study - 5Case Study - 5
Management (2 of 4):
• The child’s mother should be asked to continue breastfeeding her (if she is doing so); continue nourishing her with khichdi, rice-dal, soft bananas, grated apples, vegetables etc. There is no need to ban any food except food that is too spicy.
• She can be taught how to check the hydration status from time to time (urine output, AF tension, eyeball tension, skin turgor, etc. )
• ORS substitutes may be used only to give “variety” to the child’s intake of liquids. (Buttermilk, rice water, dal soup, etc.)
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 1616
Case Study - 6Case Study - 6
Management (3 of 4):
What is the role of :• Anti-diarrhoeals – norflox +metro, for example• Anti-motility agents – atropine derivatives• Anti-secretory agents - racecadotril • Stool binding mixtures – pectin + kaolin• Starvation• Probiotics – lactobacilli, saccharomyces• Antibiotics – cefixime, gentamicin
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 1717
Case Study - 7Case Study - 7Management (4 of 4):
• When will you refer for hospitalisation?• What home-based fluids are NOT useful?
(coffee, tea, arrowroot kanji)• How often will you see the child?• What supportive medications will be needed?
(anti-emetics, anti-pyretics)• Perianal excoriation and rashes will need topical
antifungal and protective creams.
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 1818
Some recent info on ORSSome recent info on ORS
ORS :• Presence of salt and sugar together facilitate the
reabsorption of water from the gut-lumen along with the salt and sugar.
• We have moved from a sweetish, high osmolar liquid to a salty, high Na+ ORS to ORS’s having probiotics, prebiotics, amino-acids, etc. to the most recent “LOW OSMOLAR ORS” that is approved by the WHO for use all over the world in all age groups for all types of diarrhoeal illness including cholera.
• This new ORS has only 245 mOsm/L as compared to the higher osmolarity of the previous WHO-approved formula.
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 1919
Take-home messagesTake-home messages
• Monsoon diarrhoeas may be bacterial in origin, but winter diarrhoeas are almost always viral.
• Most children with watery diarrhoea do not need metronidazole.
• Most children with typical diarrhoea do not need any investigations.
• ORS is the mainstay of therapy.• IV therapy is only recommended for kids with
uncontrolled vomiting, very frequent diarrhoea, grade II dehydration or more and those with altered sensorium or any other complications.
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 2020
Just one more slide:Just one more slide:
April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 2121
This book is on sale!This book is on sale!
• This comprehensive book on parenting is written for the layman.
• It is priced at Rs. 395/=, but is available to doctors at a special price of Rs. 300/= only.
• It carries detailed information for the care of children from 0 – 18 years.
• Thank you – Dr. Taher