Bala Atisara (Diarrhea in Children)

Presented by
Dr. Reetesh Kumar verma
Lecturer, Department of Kaumarbhritya
Govt. Ayurved College & Hospital
Gwalior (MP)
 BALATISARA
The term Balatisara is first described in
“Harita Samhita”
(H.S. Balaroga Chikitsa -54 page 408)
Definition :
“Guden bahu drava saranam atisaram” (M.N.)
“Atishayena sarayati rechayati atisara” (Sh.s)

Vyutpati: - Ati – Excess

Saran – flowing out

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 NIDANA

 Aatiguru  Atisheetal

 Atisnigdha  Virudha ahara

 Ati ruksha  Adhyashana

 Ati ushna  Vishama bhojanam

 Atidrava  Krimi dosha

(S.Su.U.40/3-4 ,M.N.3/1-3)
 Atistula

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 Balatisara described as a Symptom
Ksheera dosa:

 Paittika ksheera dosa (A.S.,M.N.)

 Sannipataja ksheera dosa (A.H.)
 Vaivarnya ksheera dosa (C.CHI.)

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 Cont. Balatisara described as Symptom ..

Balagrahas: Other causes:

 Negmesha graham  Dantodbhedaja atisara
 Pitra graham (Dentition)
 Putna graham
 Sakuni graham  Mrittika sevanjanya atisara
 Seeta putna graham (Pica)
 Andha putna graham
 Revati graham
 Sushka Revati

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 Balatisara described as a Complication
(Vyadhi janya upadrava)

 Krimiroga Vattika paittikka grahani

 Ksheeraalasaka Paittika arsha

 Talukantaka Visuchika

 Paittika gulma Kumbhakamla

 Pittika jwara Rajyakshma

 Agantuka jwara

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 SAMPRAPTI (C.Chi.19)
(Pathophysiology)
Nidan sevana
(Eitiological Factors)

Aggravated Ap-dhatu
(Osmotic overload / increased chloride secretion)

Pachakagni/Jatharagni dushti & Ap-dhatu mixed with purisha

(Disturbance in body fluid equilibrium & Metabolic derangement)

Carried downwards by aggravated vayu

(Alteration in motility)

Atisara

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 SAMPRAPTI GHATAKA
 Dosha: Vata pradhana

 Dushya: Purisha (fecal matter) &

Ap-dhatu, rasa dhatu

 Srotas: Purishavaha Srotas

 Adhisthana: Pakvasaya

 Sroto dushti: Atipravriti

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 PURVARUPA (Prodomal symptoms)
( K.S. V.25/14)

Deha vaivarnya
Arati (Tiredness)
Mukhglani (Tastelessness)
Anidra (restlessness)
Vatakarma nivriti

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 Types of common atisara described in ancient texts

Charak / Vagbhata Sushruta

Vatika Vatika
Paittika Paittika
Shleshmika Shleshmika
Sannipataja Sannipataja
Shokaja Shokaja
Bhayaja Amaja

 Few other types include :

 Rakta atisara Jwara atisara
 Ama atisara Pakva atisara

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Chikitsa Siddhanta (Principles of management)
 Nidana Parivarjan
 Examine the status of the stool pakva or ama
 Principles For Management Of Ama Atisara
 Langhana, pachana and Laghu Bhojana
 Shodhana therapy is contraindicated except
Ama atisara due to vidagdha ahara
 For digestion of ama dosha - Vacha + ateesa, dhanya
panchaka kwath can be used

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 Treatment acc. to amount of doshas - (Ch. chi. 19/19)

Bahu dosha Virechana by haritaki

Madhyam dosha Pramathya prepared with deepana, paachana
dravya (pippali, nagar, dhanyaka, ajwain, vacha etc.)
Alpa dosha Langhana

Treatment according to dosha predominance

Vattika Deepana, paachana, vatanulomana

Paittika Deepana, paachana, pitta shamaka
Shleshmika Langhana paachana and treatment of amatisara.
Sannipataja Sequence of treatment Vata – Pitta – Kapha or
according to maximum vitiated dosha

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 Useful drugs
Single Drugs
Name Useful part Pharmacological Action
BILVA Root, bark, leaf & fruit Grahi (B.P ,S.su.46 ,C.su.25)
KUTJA Bark, seed Atisara jitta (B.P.)
Samgrahi (c.su.25)
AJWAIN Fruit Deepana (B.P. )
Amahara
JAYAPHALA Beeja (seed) ,Kosha (Javitri) Atisara shamana
DADIMA Phala , Phala twaka Varchovibandhanam
Deepaniya (S.Su.46)
Grahi (C.Su.27)

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 Herbal combinations
• Balchaturbhadra churna evam avaleha
• Dadima chatusam
• Lavanga chatusam
• Raspipari
• BalKutjavleha
• Dhatakyadi churna
• Changeri gritam
• Karpura rasa
• Gangadhara churna

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 USEFUL PATENT PREPARATION
Diarex - (Himalaya ) – Tablet & Syrup
Ing. - Kutaja, guduchi, bilva, dadima, shankhbhasma, musta
Dose - ½ to 1 tab daily
Diasyn - (J& J) - Tablet & Syrup
Ing. - Holarrhena antidysentrica, Aegle marmelos, silicate of
almunia,& oxide of iron, Terminalia chebula, Berberis aristata
Dose - ½ tab every four hour
Entostal tablet - (Solumiks)
Ing. - Kutaja, shyonaka, daruharidra, markandika, bilva, vidanga,
bhringraja, shalmali, shunthi, kutki,rasaparpati.
Dose - 1 tab thrice daily
Powder Lomotral – contains Kutaja, Dhanyaka etc.
Prepared in One liter of water

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 PATHYA
 Laghu Ahara

 Takra, yavagu, food with honey

 Yavagu, vilepi, khada (bilva + tila+ malai of curd+ ghee), yusha,

mamsarasa aoudana prepared with deepana samgrahaka dravya.

 Shaka – jeevanti, yavani, ksheerini, bathua, suvarchala etc

 Yava, munga, urada, shali chavala,tila, bilva (unriped)

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 DIET SCHEDULE
Infants :
 Breastfeeding as per demand
 Formula feeding
Child :
.
Plain,Starchy Rice, Potatoes, Pasta, Crackers, Toast
Foods
Cereal Without added sugar, either cold or hot
Soups With Rice, Noodles, Vegetables, and/or Meat
Cooked Vegetables without butter
Fresh Fruits e.g. Bananas
Applesauce Unsweetened
Avoided foods Canned Fruits/Fruit Juice Soft Drinks, Ice
Cream Sherbet, Pudding, Fried or Fatty Foods

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 ORIGIN and DEFINITION
Diarrhea (Greek word):
 Dia:- Flow / through.
 Rhoea:- Excessive, irritable laxity of bowel.

Diarrhea is loose, watery and frequent stool, it is an

intestinal disorder characterized by abnormal fluidity
and frequency of fecal evacuation.
Defined by :
 Frequency – more than 3
 Consistency - loose
 Volume – more than 10g/kg/day

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 CAUSES
 Infectious causes
Bacterial:-
 Escheria coli.
 Vibrio cholerae
 Campylobacter
 Salmonella
 Shigella – mainly responsible for dyssentry
Viral:-
 Rota virus
 Enteric virus
 Adeno virus
 Norwalk virus
 Cytomegalovirus
Parasitic:-
 Giardia lambia,
 Entamoeba histolytica
 Cryptosporidium

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 Causes Cont.
Food intolerance/ malabsorption:-
 Artificial sweeteners
 Lactose intolerance. (5-10% of infants)
Reaction to medicines:-
 Antibiotics
 Blood pressure medicines
 Antacids containing (magnesium) etc.
Intestinal disease:-
 Inflammatory bowel disease,
 Colitis
 Crohn’s disease
 Celiac disease
Others:-
 Introduction of new food or formulas
 Teething
 Change in water

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 NORMAL INTESTINAL FLUID BALANCE
 Absorption of water and electrolytes occur by the villi &
secretion by the crypts of the bowel epithelium
throughout the intestine. (two-directional flow)
 Normally
Fluid absorption > fluid secretion
 > 90% of the fluid entering the small intestine is
absorbed, remaining reaches to the large intestine and
absorbed.
 100 to 200 ml. of water is being excreted each day in
formed stools.

When this exceeds its limited absorptive capacity,

diarrhoea occurs.

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 MECHANISMS OF WATERY DIARRHOEA

 Secretion
 Osmotic imbalance

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 SYMPTOMS
Cramping pain
Bloating
Nausea
An urgent need to use bathroom
May have fever, blood in stool

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 WARNING SIGNS
 Abdominal pain Urinates less frequent.
(wets fewer diapers less
 Blood in the stool than 6/day )

Frequent diarrhea.
 Frequent vomiting
Extreme thirsty no tear when crying.
 Loss of appetite
Lethargy.
 High fever
Excessive sleepiness.
 Dry sticky mouth
Sunken eyes.
 Weight loss

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 TYPES OF DIARRHEA
Acute watery diarrhea Acute bloody diarrhea/dysentery
 Not associated with Blood in stools.
blood or mucus Generally associated with
 Lasts for less than 14 more complications, intestinal
days damage, sepsis, malnutrition
 May be associated with etc.
fever and vomiting. Lasts longer and has a
higher risk of death.

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 Cont.TYPES

Persistent diarrhea:
( > 2 weeks)
Risk factors:
 Low birth weight
 Absence of breast-feeding
 Concurrent medical illness
 Malnutrition
 Blood or mucus in stools

Diarrhea with severe malnutrition

Marasmus or kwashiorkor

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APPROACH TO A CHILD WITH DIARRHEA
1. 3 or more stools/day lasting for > 1 week with no other
symptoms.

2. Temp. greater than100.4°F for > 48 hrs. 8 or

more stools/day over 48 hrs. with no
improvement after changes in diet.

3. Signs of dehydration, severe and constant

abdominal pain or cramps, blood in stools,
> 1 stool/hr.

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 DIAGNOSIS OF DIARRHEA
 Medical history and physical examination.

 Stool culture.

 Blood tests.

 Sigmoidoscopy.

 Colonoscopy.

 Imaging tests.

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 CONSEQUENCES

1. Metabolic acidosis
2. Potassium depletion
3. Malnutrition
4. Dehydration
5. Death

Diarrhea and fever as risk factors for anemia among children in

developing countries (J Infect Dis. 2007 Jul 11,PUBMED)

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 MANAGEMENT OF DIARRHEA
Aims:
 Prevent dehydration.
 Treat dehydration.
 Feed the child.
 Treatment comprises of:
 Oral rehydration therapy (ORT).
 Continued feeding during and after diarrhea.
 Selective use of intravenous fluids.
 Selective use of anti microbials & other drugs.

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 Dehydration:
 The acute loss of water and electrolytes from the
body in liquid stool, causes dehydration.

It can lead to :

 Decreased blood volume (hypovolaemia),

 Cardiovascular collapse,
 Death (if not treated promptly)

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 Assesment of Dehydration (WHO criteria)

Treatment Plan A Wg. the child Plan B Wg. The child Plan C

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ORAL REHYDRATION THERAPY (ORT)
ORT includes :
 ORS solution.

 Solution made from sugar and salt.

 Food based solution. e.g.

 Rice water with salt
 Lassi with salt
 Plain water, lemon water, coconut water
 soups, Dal water
 Thin Rice kanji

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 Constituents of WHO ORS are:
Concentrations of ingredients in reduced osmolarity Concentrations of ingredients
ORS in normal ORS/liter
Ingredient g/L mmol/L g/l mmol/L
sodium chloride (NaCl) 2.6 45 3.5 90
Chloride ion 65 80
glucose, anhydrous (C6H12O6) 13.5 75 20 110
potassium chloride (KCl) 1.5 20 1.5 20
trisodium citrate, dihydrate 2.9 10 2.9 10
Total osmolarity 245 310

*Rice-based ORS as a solution that would help stop diarrhoea

J Diarrhoeal Dis Res. 1997 Jun;15(2):47-52. pubmed

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 Treatment Plan A
 Used in Diarrhea with no signs of dehydration
 More fluids than normal should be given.
e.g. rice water, coconut water. Vegetable soups etc.

 Avoid - Aerated cola drinks, sweetened commercial fruit

drinks, and large amounts of glucose (it may cause
osmotic diarrhea ).

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 PLAN A contd…

Age Amount of ORS/ORT Amount of ORS to

after each stool provide for at home

less than 24 months 50 -100ml 500ml/day

2-10 years 100-200ml 100ml/day

10 years and above as much as wanted 2000ml/day

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 TREATMENT PLAN B
Child with some dehydration:
 Treated with ORT, even children who are vomiting.
 Breast feed & ORS (every 1-2min)
 If the child vomits, wait for 10 mins. & then continue ORS.
 If the child becomes puffy, stop ORS and give plain water and ORS.
Component of plan B are:
 Rehydration therapy / Deficit replacement :75ml/kg of ORS in the
first 4 hours
 Maintenance therapy: volume equal to diarrhea losses /app. 10-20 ml/kg
of each liquid stool offer plain water in b/w
 Provision of normal fluid requirement.

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 TREATMENT PLAN C
Child with severe dehydration
 I.V. fluids : Ringer Lactate with 5 % dextrose or 0.9% Normal
Saline
 Dextrose containing fluids should not be used .
Reassess the patient after 6 hrs (infant) or 3 hrs (Child) for the
hydration status and choose plan A, B or C for further treatment.
 If the child can drink give ORS orally, as 5 ml/kg /hr as
soon as the child can drink.
Reassess every 15 to 30 minutes & if hydration doesn't
improve, infusion more rapidly.
 If intravenous access cannot be obtained in time give ORS via
nasogastric tube ( 20 ml/kg/hr)

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 Treatment Plan C contd..

I.V. fluid therapy in severe dehydration

Age First Than

<12 months 30ml/kg in 70 ml/kg in

1 hour 5 hours
12 months -5 years 30 minutes 2 ½ hours

I.V. fluids restore rapidly blood volume and correct shock

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 DRUG Therapy in Diarrhea

 Binding agents : Pectin, kaolin or Bismuth salts

are useful
 Anti motility agents : e.g. Ophoid derivatives -
Lopramide, Diphenoxylate, atropin, Tincture of
opium.
 Anti Secretory Agents : Racecadotril
 Probiotics : Lactobacillus rhamnosus
 Zinc : 10 mg/day for children less than 6 months
20 mg/day for children more than 6 months

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 Antibiotic therapy *
1.Cholera
 Tetracycline 12.5 mg/kg/dose
 Furazolidone 1.25 mg/kg/dose (QID for 3 days)
2.Shigella /dysentery
 Nalidixic acid 15 mg/kg/ QID
 Ampicillin 25 mg/kg/dose (QID for 5 days)
3.Amebiasis
 Metronidazole 10 mg/kg/dose
4.Giardiasis
 Metronidazole 5 mg/kg/dose TID

*Should be used in Shigella infection or in case of bacterial infection with severe

sepsis or underlying debilitating disease.

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 PREVENTION & INTERVENTIONS

 Improving access to clean water and safe

sanitation
 Promoting hygiene education.
 Exclusive breast-feeding
 Improved weaning practices
 Immunize all children

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 Conti. PREVENTION & INTERVENTIONS

 Washing hands with soap (the baby's as well)

before touching food
 Sanitary disposal of stools
 Health education about how infections spread.
 Consulting a health worker if there are signs of
dehydration or other problems.
 Prophylactic zinc supplementation has been
shown to reduce diarrhea in many developing
countries.( PLoS ONE. 2007 Jun 27;2:e541)

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