Diarrhoea in Children

DIARRHOEA IN
CHILDREN
Dr Resham Rana
MDGP & EM (1st year Resident)
Introduction
• Diarrhoea is one of the important cause of deaths in
children under 5 years of age. Each year about 10%
under 5 children die from diarrhoea.
• WHO defined diarrhoea as passage of 3 or more loose

or liquid stools per day (or more frequent passage than
is normal for the individual).
• Frequent passage of formed stool is not diarrhoea, nor

is the passing of loose, pasty stools by breastfeed
• Types
1. Acute diarrhoea
2. Persistent diarrhoea
3. Dysentrery
ACUTE DIARRHOEA
When diarrhoea persist for less than 14 days.
Sometimes patient may have vomiting and low grade fever.
Etiology
•Intestinal infection- most common
•Certain drugs, food allergy, systemic infections (UTI, otitis media) and surgical
conditions (appendicitis or Hirschsprung disease)
Causative agents
Bacterial : E. coli, Shigella, Vibrio cholerae, Salmonella, Campylobacter species
Viral: Rotavirus (leading cause), Enteric adenovirus, Astrovirus, coronavirus,
cytomegalovirus, picornavirus
Parasitic- Giardia lamblia, Entamoeba histolytica, Cryptosporidium parvum,
Cyclospora cayetanensis, Isospora belli
Clinical assessment
History: ask the mother or the other caretaker about
•presence of blood in the stool
•duration of diarrhoea
•Number of watery stools per day
•Number of episodes of vomiting
•Presence of fever, cough, or other important problems (eg convulsions, recent
measles)
•Pre-illness feeding practices (exclusive breast feeding below six
•months)
•Type and amount of fluids, food taken during illness
•Drugs or other remidies taken (including opioids or antimotility drugs like
loperamide that may cause abdominal distension)
•Immunization history
• recent contact with someone with acute watery diarrhoea and/or vomiting and
exposure to a known source of enteric infection (possibly contaminated water or
food)
Physical examination:
1. Look for these signs:
• General condition: is the child alert; restless or irritable, lethargic
or unconscious?
• Are the eyes normal or sunken?
• When water or ORS is offered to drink, is it taken normally or
refused, taken eagerly or unable to drink ongoing to lethargy or
coma?
2. Feel the child to access:

• Skin tugor- when the skin over the abdomen is pinched and
released, does it flatten immediately, slowly or very slowly (> 2
sec)?
• Pulse volume: weak/ feeble or absent
• Feel for the extremities: warm, cool
Treatment :
The essential elements of treatment are :-
• Rehydration
• Zinc supplementation
• Continue feeding
A. Rehydration
1. Plan C
• Choice of fluid : Ringer’s lactate. If not available Normal Saline.
• Amount of fluid: 100 ml/kg
• Route of rehydration: intravenous (IV)
• Duration of rehydration
Age of child as per age of child
First give 30 ml/kg Then give 70 ml/kg
over over
< 12 months 1 hour 5 hours
>12 months ½ hour 2 ½ hours
• Monitoring
Recess the child every 15-30 minutes until a strong radial pulse is present. When full amount
of IV fluid has been given, reassess the child’s hydration status fully and decide accordingly:-
• If signs of severe dehydration still present : repeat IV fluid as outlined in Plan C
• If signs of some dehydration: Discontinue IV fluid and give ORS for 4 hours as in plan B
• If no signs of dehydration: advise mother to give ORS after each stool as in Plan A
2. Plan B
• Choice of fluid : Oral rehydration solution

• Amount of fluid : 75ml/kg
• Route of rehydration: oral
• Duration of rehydration: 4 hours
• Monitoring
Reassess child’s hydration status after 4 hours of oral rehydration and decide
accordingly-
• If no signs of dehydration: advise mother to give ORS after each stool as in Plan A
• If signs of some dehydration: Rehydrate with ORS for another 4 hours as in plan B
• If signs of severe dehydration still present : rehydrate with IV fluid as outlined in
Plan C
3. Plan A
• Choice of fluid : Oral rehydration solution

• Amount of fluid after each stool
 Less than 2 years: 50-100 ml (500 ml/day)
 2 years and above: 100-200 ml (1000 ml/day)
• After rehydration advise mother-

 To continue home treatment
 To continue feeding at home
 Counsel when to return immediately
B. Zinc supplementation
Age Dose Duration
< 6 months 10 mg/day 14 days
> 6 months 20 mg/day 14 days
C. Continue feeding
Age Foods
< 6 months Breast feeding
> 6 months Breast feeding + freshly
prepared energy dense
complementary foods, fresh
fruit juice etc
PERSISTENT DIARRHOEA
Diarrhoea that begins acutely and lasts for >= 14
days. It should not be confused with chronic diarrhoea
which has prolonged duration but an insidious onset
and includes condition causing malabsorption.
Clinical assessment
• Assessment like that of acute diarrhoea
• Evidence of dehydration
• Evidence of any non intestinal infection e.g. pneumonia,
sepsis, UTIs, oral thrush, otitis media etc.
• Associated malnutrition
Treatment of Persistent Diarrhoea
A. Rehydration : plan A, B or C
B. Feeding : recommended special diets-
• Initial diet A (reduced lactose)
• Second diet B (lactose free diet with reduced starch)
• Third diet C (monosachharide based)
C. Micronutrients and vitamin supplimentations:-

Folate, zinc, vitamin A, iron, copper, magnesium
D. Antimicrobial therapy
• Amoebiasis/ giardiasis: metronidazole 30 mg/kg/dose 8 hourly for 10 days
• Shigella: ciprofloxacin, pivmecillinam and nalidixic acid
• Cholera
 Tetracycline 12.5 mg/kg 6 hourly for 3 days
 Doxycycline 2-5 mg/kg/day 12 hourly for 3 days
 Cotrimoxazole 10 mg/kg/day 12 hourly for 3 days
E. Treatment of non intestinal infection eg pneumonia, sepsis, oral thrush, otitis media if
any
DYSENTERY
• Passage of frequent loose stools containing
blood. In addition patients may have fever,
abdominal cramps, tenesmus and pallor.
Organisms:
o Shigella spp, Salmonella spp,
o EIEC,EHEC,
o Campylobacter spp
o Entamoeba histolytica, etc
Treatment of Dysentery
-
 Antibiotics
1. Bacillary dysentery
• ciprofloxacin 15 mg/kg/dose BD for 5-7 days or
• cefixime 10 mg/kg/day BD for 5-7 days or
• azithromycin 10 mg/kg/day OD for 5 days
2. Amoebic dysentery
• metronidazole 10 mg/kg/dose TDS for 5-7 days
 Diet: usual family diet

 Rehydration: plan A,B or C
 Zinc supplementation as outlined before
 Others like paracetamol for fever etc
• Diagnosis
Based on the c/f and relevant investigations.
• Investigations
 Stool for R/M/E - to look for RBC, pus cells and
macrophage
 Stool for C/S – to identify organism and drug
sensitivity
 Blood for TC/DC, Hb , PBF – to assess anemia,
neutrophilic leukocytosis
 ABG- metabolic acidosis
 To evaluate complications eg. Creatinine- may be
Complications
• Electrolyte imbalance eg. Hypokalemia, metabolic acidosis,

hypo/hypernatremia
• Paralytic ileus
• Acute renal failure
• Growth failure/ malnutrition
• Guillain- Barre from C. Jejuni
In addition, dysentery can lead to-

• Rectal prolapse
• Convulsions
• Haemolytic uraemic syndrome (HUS)
PREVENTION OF DIARRHOEA
• Promotion of exclusive breast feeding

• Improved complementary feeding practices
• Promotion of personal and domestic hygiene
• Improved water and sanitary facilities
• Improved case management of diarrhoea
• Immunization of measles and rotavirus vaccine
References
• Ghai Essential Pediatrics
• Nelson text book of Pediatrics
• WHO manual - the treatment of diarrhoea
• WHO – pocket book of hospital care for
children
Thank you

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DIARRHOEA IN

• WHO defined diarrhoea as passage of 3 or more loose

• Frequent passage of formed stool is not diarrhoea, nor

2. Feel the child to access:

• Choice of fluid : Oral rehydration solution

• Choice of fluid : Oral rehydration solution

• After rehydration advise mother-

C. Micronutrients and vitamin supplimentations:-

 Diet: usual family diet

• Electrolyte imbalance eg. Hypokalemia, metabolic acidosis,

In addition, dysentery can lead to-

• Promotion of exclusive breast feeding

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