takvani acute diarrhea junagadh 26 june final 2010 (1)
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Evidence basedMedicine on
Acute DiarrheaDr.H.K.Takvani MD(Ped), FIAP
President NNF GSC 2009-10National Eb Mb. IAP 2002-08
President IAP GSB, 2001President IMA Jamnagar 2008-09
07/04/1023 June, 2010 Takvani 1
Life is short even to take advantage of positive pointsLife is short even to take advantage of positive points
ofof
people around us. Where is the time to see negativepeople around us. Where is the time to see negative
points?points?
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Why to talk on diarrhea?
Prescription Surveys says..
No ORS. IVF where ORS works well or better
No advice on continuing, increasing BF, (unnecessary
stoppage of BF), diet or hygiene
No zinc.
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Why to talk on diarrhea?
Use ofantiemetics
Antibiotics often- Nor-metro,
Oflo-ornida,Inj.Amikacin.
Un-necessaryprobiotics
Racecadotril.07/04/10 Takvani 3
http://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppthttp://../My%20Documents/Downloads/Takvani%20Acute%20Diarrhea%20Junagadh%2026JuneFinal%202010%20(1).ppt -
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IAP ConsensusStatement
Highlights several important
developments.
Aims that benefits of new knowledge
reach affected.
Wants that new products are not
inappropriately used.07/04/10 Takvani 4
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This is what I do since 2004IAP Consensus Statement
Prescribe ORS for all ages.
Continue Breast feeding and diet.
Explain danger signals.
20 mg/10 mg of elemental zinc
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This is what I do since2004
No probiotics, ?placebo, ?pacifier Cautious approach infants
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ORS in diarrhea
ORS for all ages and all types of
diarrhea.
Low osmolarity ORS recommended,WHO
Sodium 75 mmol/L and glucose 75mmol/l, osmolarity 245 mosmol/L
Continue Breast feeding and routine
normal diet and energy dense feeds.07/04/10 Takvani 7
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Why Reduced osmolarityORS?
39% reduction in need for IVF 19% reduction in stool output
29% lower incidence of vomiting
Risk of hyponatremia not significant in
any type of diarrhea.07/04/10 Takvani 8
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Zinc in Diarrhea
Based on studies in India and otherdeveloping countries there issufficient evidence to recommendzinc in the treatment of acute
diarrhea as adjunct to oralrehydration.
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Zinc in Diarrhea
Zinc has an additional modest benefit
Reduces stool volume.
Reduces duration of diarrhea.
Oral rehydration therapy must remain
the main stay of treatment.
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Zinc in Diarrhea
Dose: Elemental Zinc
20 mg/day for 6months and older for 14 days
10 mg/day Between 2-6 months.
Any of zinc salts e.g., sulphate, gluconate or
acetate may be used. back
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Recommendations of the IAP
National Task Force for Use ofProbiotics
The group recommended that basedon analysis of studies there ispresently insufficient evidenceto recommend probiotics in thetreatment of acute diarrhea in oursettings
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Probiotics
Almost all the studies till now weredone in developed countries exceptfor one very small study fromPakistan. It may not be possible to
extrapolate the findings of thesestudies to our setting where thebreast feeding rates are high and the
microbial colonization of the gut is
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Probiotics
The effect of probiotics is strain related
and there is paucity of data to establishthe efficacy of the probiotic species(namely L. acidophilus, Lactic AcidBacteria) available in the Indian market.To recommend a particular species it willhave to be first evaluated in randomizedcontrolled trials in Indian children.
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Recommendations of the IAP
National Task Force for Use ofProbiotics
The earlier studies have documenteda beneficial effect on rotavirusdiarrhea which was present in >75%of cases in studies from the west.Rotavirus constitutes about 15-25%in India.
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Recommendations of the IAP
National Task Force for Use ofProbiotics
The primary outcome analyzed in allthe studies was the duration ofdiarrhea. The more objectiveparameter of stool output was notevaluated.
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Probiotics in diarrheaWhat are Probiotics ??
Nonpathogenic micro-organisms.
Exert a positive influence on the health
or physiology of the host.
They consist of either yeast or
bacteria, Sacc. Bul and Lacto-
bacillus.07/04/10 Takvani 17
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Racecadotril
Not enough evidence:Not enough evidence:
Safety. Efficacy.
There is no data from our settings.
Methodology of studies questionable.
No routine use back
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Acute Diarrhea in the YoungInfant (< 2 mth)
For assessment, recommendations by the
IMNCI which is an adapted version of IMCI for
India, should be followed.
See if child is sick or well child.
Management is different for sick and well.
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Infants who are breastfed and have
no dehydration do not need ORS and
mothers should be advised to
increase breast feeds more often and
for longer duration.07/04/10 Takvani 20
Acute Diarrhea in the YoungInfant (< 2 mth)
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Young infants with dehydration
should be treated as has beenrecommended for other children withdehydration by ORS or IVF as per
grade of dehydration.
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Acute Diarrhea in the YoungInfant (< 2 mth)
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Third generation cephalosporins, intra-venous ceftriaxone and amikacin if thechild is sick looking, ?septicemia.
Where hospitalization is not possible, Oral
Cefixime with Inj. Amikacin may be triedafter explaining the nature of disease andrisk.
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Acute Diarrhea in the YoungInfant (< 2 mth)
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Acute Diarrhea in the YoungInfant (> 2 mth)
For assessment, IMNCI, No, some,sever dehy.
Management is as per grades of dehydration.
In cases of No & some dehydration when orally
acceptable ORS- ZINC- homely available fluids-
increase BF. IVF in Severe Dehydration.
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acceptable unacceptable
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h
ome ly
av
aila
blef
luid
s acceptable unacceptable
Plain water coffee
cocconut water aerated cold drinks
plain buttermilk fruit juice(with sugar
milk Lassi(with sugar)
thin dal
fruit juice(withoutsugar)
Lassi(without sugar) NEXT
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Antibiotic in AcuteDiarrhoeaIndicated only for :
Acute bloody diarrhea with grossblood
Shigella positive culture,
Cholera,
Associated systemic infection
Severe malnutrition. (Septicemia)07/04/10 Takvani 25
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Antibiotic in AcuteDysentery Indiscriminate use of antibiotics
Increasing incidence of resistance.
Cotrimoxazole is the first line drug for
acute bloody diarrhea.
High resistance of shigella to
cotrimoxazole07/04/10 Takvani 26
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Antibiotic in AcuteDysentery If resistance rates to cotrimoxazole exceed 30%
Cefixime 20mg/kg/day 5-7 days should be used
instead of quinolones looking to safety and medico
legal aspects.
No response to cefixime in 3 days Ceftriaxone100mg/kg/day till blood disappears ->cefixime.
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Antibiotic in AcuteDysentery
Antibiotics are notnot indicated if
No visible blood in stools
Pus cells on stool microscopy becauseof poor specificity of the test.
Routine stool examination or stoolcultures have no useful role. (except toshow that antibiotics are not required-
personal)07/04/10 Takvani 28
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Antibiotic in AcuteDysentery
Entamoeba histolytica and helminths rarely
ever cause acute diarrhea in children.
Metronidazole and antihelminthics therefore
have no role in the routine management of
acute bloody diarrhea.
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Antibiotic in AcuteDysentery
Metronidazole/Tinidazole should beused when cases of acute dysenteryfail to respond to second line drugsfor dysentery such as cefixime or
when a stool examination hasconfirmed trophozoites ofEntamoebahystolitica.
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Antibiotics in AcuteDysentery
Aminoglycosides like gentamicin andamikacin have a poor spectrum of
activity against shigella species and
therefore they are ineffective in the
management of acute bloody07/04/10 Takvani 31
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Antiemetics in AcuteDiarrhea
Vomiting, common associated symptom.
Distressing to the parent, antiemetics. Overdose due to haste/improper
preparation like domperidone 10mg/1mlinstead of 1mg/1ml in sone (Domstal Baby
and Motinorn) and round the clockprescrition like TDS leads to side effects.
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Antiemetics in AcuteDiarrhea Low osmolarity ORS reduces
vomiting. Stop for 10 minutes and than restart
giving ORS in small sips.
Most can be managed by frequentsmall sips (5-10 ml) of ORS with sipsof simple water and breast feeding inbetween without force feeding ORS.
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Antiemetics in AcuteDiarrhea
Antiemetics should be reserved for
children in whom the vomiting is
severe, recurrent and interferes withORS intake (more than 3 per hour).
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Antiemetics in AcuteDiarrhea
A single dose of domperidone/?
ondansetron in children with severevomiting.
Continued use is not recommended.
Dose of 0.1-0.3 mg/kg/dose.
Single dose only
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Antiemetics in AcuteDiarrhea In view of serious side effects
metoclopramide is not recommended. Personal experience: Single dose of
Inj.Metoclopramide 0.2mg/kg stopsvomiting and improves ORS intakeand avoids IV fluids in many caseswithout a single case of side effect.Not validated by IAP. back
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I conclude .This is what I do since 2004
Prescribe ORS for all ages.
Continue Breast feeding and diet.
Explain danger signals.
20 mg/10 mg of elemental zinc
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I conclude.
No probiotics, ?placebo, ?pacifier
Causious approach infants
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If interested IndianPediatrics statement
Consensus statement of IAP National Task Force: Status report on manShinjini Bhatnagar,Nita Bhandari, U.C. Mouli , M.K. Bhan. IndianPediatrics : Apr 2004;41:335 - 348
StatementNational seminar on importance of zinc in human healthMs. RekhaSinha. Indian Pediatrics : Dec 2004;41:1213 - 1217
EditorialThe role of zinc in child health in developing countries: Taking the scieZulfiqar A. Bhutta. Indian Pediatrics : May 2004;41:429 - 433
Brief Reports
Outcome of Nutritional Rehabilitation with and without ZincSupplementationK.E. Elizabeth, P. Sreedevi and S. Noel Narayanan.Indian Pediatrics : Jun 2000;37:650 655
Management of Acute Diarrhea: From Evidence to PolicyShinjiniBhatnagar, Seema Alam* and Piyush Gupta*
National Co-ordinator, and *Joint National Co-ordinators, IAP-UNICEFProgram on Evidence-based Management of Diarrhea.http://indianpediatrics.net/mar2010/mar-215-217.htm
07/04/10 Takvani 39
http://indianpediatrics.net/apr2004/apr-335-348.htmhttp://indianpediatrics.net/dec2004/dec-1213-1217.htmhttp://indianpediatrics.net/may2004/may-429-433.htmhttp://indianpediatrics.net/june2000/june-650-655.htmhttp://indianpediatrics.net/june2000/june-650-655.htmhttp://indianpediatrics.net/mar2010/mar-215-217.htmhttp://indianpediatrics.net/mar2010/mar-215-217.htmhttp://indianpediatrics.net/june2000/june-650-655.htmhttp://indianpediatrics.net/june2000/june-650-655.htmhttp://indianpediatrics.net/may2004/may-429-433.htmhttp://indianpediatrics.net/dec2004/dec-1213-1217.htmhttp://indianpediatrics.net/apr2004/apr-335-348.htm -
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Dr.H.K.Takvani MD (Pediatrics), FIAPChildren Hospital and Neonatal Care Centre
Valkeshwari NagariIndira Marg
JAMNAGAR-361008, Gujarat, India
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