DIARRHOEA IS LEADING CAUSE OF MORTALITY IN INDIA AS WELL AS GLOBALLY .THIS IS NICE PPT BASED ON WHO GUIDELINES,DIARRHOEA IS EASY TO TREAT BUT STILL IT IS IS 2ND MOST COMMON CAUSE OF CHILDHOOD MORTALITY AFTER PNEUMONIA

1. DIARRHOEA
• DR MAHTAB
• MBBS,DCH,DNB
• HIMSR,NEW DELHI

2. CHILD PRESENTING WITH DIARRHOEA
• ACUTE DIARRHOEA- >3 LOOSE STOOL/DAY,NO BLOOD IN STOOL(WHO)
• PASSAGE OF ONE LARGE STOOL WATERY IN YOUNG CHILDREN IS DIARRHOEA;;
FREQUENT PASSAGE OF NORMAL STOOL IS NO DIARRHOEA
• CHOLERA-PROFUSE WATERY DIARRHOEA WITH SEVERE DEHYDRATION DURING CHOLERA
OUTBREAK,POSITIVE STOOL CULTURE FOR VIBRIO CHOLERAE O1 OR O139
• DYSENTRY; BLOOD MIXED WITH THE STOOL
• PERSISTENT DIARRHOEA; DIARRHOEA LASTING ≥ 14 DAYS

3. EPIDIOMOLOGY
SECOND MOST COMMON CAUSE OF DEATH WORLDWIDE IN CHILDREN
1.73BILLION EPISODE ANNUALLY ,AROUND 0.71 MILLION DEATH ANNUALLY
(3-5 billion/annual ,approx. 2 million death/year……ghai)
IN INDIA IT IS ALSO 2ND MOST COMMON CAUSE OF MORTALITY < 5 YR OF AGE AFTER RESPIRATORY TRACT
INFECTION

4. ETIOLOGY
• INTESTINAL INFECTION ( BACTERIAL,VIRAL,PROTOZOAL)
• CERTAIN DRUGS,FOOD ALLERGY,SYSTEMIC INFECTION
(UTI,PNEUMONIA,MENINGITIS) CAN PRESENT AS ACUTE
DIARRHOEA
• ROTAVIRUS AND ENTEROTOXIGENIC E.COLI ACCOUT FOR NEARLY
HALF OF TOTAL DIARRHOEAL EPISODE
INFECTION ACQUIRED THROUGH FECOORAL ROUTE BY INGESTION
OF CONTAMINATED FOOD OR WATER
R/F POOR SANITATION AND PERSONAL HYGIENE,NON AVABILITY OF
SAFE WATER,UNSAFE FOOD PREPARATION,LOW RATE OF BREAST
FEEDING AND IMMUNISATION.

5. CAUSE OF ACUTE DIARRHOEA
• BACTERIAL;
• E.COLI
(ENTEROTOXIGENIC,ENTEROPATHOGENIC,ENTEROHAEMORRHAGIC,ENTEROINVASIVE)
• SHIGELLA :S.SONNEI,S .FLEXNERI,S.BOYDIi,S.DYSENTERIAE
• VIBRIO CHOLERAE; SEROTYPE O1 AND O139
• SALMONELLA; S .TYPHI,S. PARATYPHI
• OTHER; AEROMONAS SPP,BACILLUS CEREUS,CLOSTRIDIUM DIFFICALE,STAPHYLOCCOCUS
AUREUS
• VIRAL; ROTAVIRUS,
HUMAN CALCIVIRUS ;NOROVIRUS SPP,SAPOVIRUS SPP
ENTERIC ADENOVIRUS
OTHERS; ASTEROVIRUS,CORONA VIRUS,CMV
PARASITIC; GIARDIA LAMBIA,CRYPTOSPORODIUM PARVUM, ENTAMOEBA HISTOLYTICA,
CYCLOSPORA CAYETANESIS,ISOSPORA BELLI

6. GOAL OF ASSESSMENT
DETERMINE TYPE OF DIARRHOEA (ACUTE WATERY DIARRHOEA,DYSENTRY,OR PERSISTING DIARRHOEA)
LOOK FOR DEHYDRATION AND OTHER COMPLICATION
ASSESS FOR MALNUTRITION
R/O NON DIARRHOEAL ILLNESS ESPECIALLY SYSTEMIC INFECTION
ASSESS FEEDING BOTH, PREILLNESS AND DURING ILLNESS

7. CHILD PRESENTING WITH DIARRHOEA; HISTORY
FREQUENCY OF STOOL
NO OF DAYS
BLOOD IN STOOL
CHOLERA OUTBREAK IN AREA
RECENT ANTIBIOTIC OR OTHER DRUG T/T
ATTACKS OF CRYING WITH PALLOR IN AN INFANT
PRESENCE OF FEVER,COUGH OR OTHER SIGNIFICANT SYMPTOM (EG CONVULSION ,RECENT MEASLE)
TYPE AND AMOUT OF FOOD TAKEN DURING THE ILLNESS
DRUGS OR OTHER LOCAL REMEDIES TAKEN( INCLUDING OPIODS AND ANTIMOTALITY DRUGS
IMMUNISATION HISTORY

8. EXAMINATION ;LOOK FOR SIGN OF DEHYDRATION
• RESTLESSNESS OR IRRATIBILITY
• LETHARGY AND REDUCE LEVEL OF CONSIOUSNESS
• SUNKEN EYE
• SKIN PINCH RETURNS SLOWLY OR VERY SLOWLY
• THIRSTY/DRINK EAGERLY OR DRINKING POORLY OR NOT ABLE TO DRINK
• SIGN OF SEVERE MALNUTRITION( ANTHROPOMETRY FOR WEIGHT AND HEIGHT
,WASTING,OEDEMA,VITAMIN DEFICIENCY
• ABDOMINAL MASS/DISTENSION
• WT LOSS (<3%/3-9%/>9% NO/SOME /SEVERE DEHYDRATION)
• OTHERS; HEART RATE,QUALITY OF PULSE,TEAR,TONGUE AND MOUTH,CFT,EXTREMITIES,URINE OUTPUT

10. LABORATORY INVESTIGATION
• CBC, S.ELECTROLYTE,RFT ( ASSOCIATED FINDING
PALLOR,ALTERED SENSORIUM,SZ,PARALYTIC ILEUS,OR
• OLIGURIA WHICH SUGGEST ACID BASE
BALANCE,RF,DYSELECTROLYTEMIA
• STOOL MICROSCOPY : IN SELECTED CASES EG
CHOLERA,GIARDIASIS (TROPHOZOITE)
• STOOL CULTURE: IT IS HELPFUL TO ANTIBIOTICS
THERAPY WITH SHIGELLA DYSENTRY WHO DON’T
RESPONDING TO EMPERIC ANTIBIOTICS

11. PRINCIPLES OF MANAGEMENT
• FOUR MAJOR COMPONENT
• 1.REHYDRATION AND MAINTAING HYDRATION
• 2. ENSURING ADEQUATE FEEDING
• 3. ORAL SUPPLIMENT OF ZINC
• 4. EARLY RECOGNIZE OF DANGER SIGN AND TREATMENT OF COMPLICATION

12. ASSESSING DEHYDRATION;CLASSIFICATION OF HYDRATION STATUS
CLASSIFICATION SIGN/SYMPTOM TREATMENT
SEVERE DEHYDRATION TWO OR MORE OF FOLLOWING PLAN C (GIVE IVFLUID)
1.LETHARGY OR UNCONSIOUSNESS
2. SUNKEN EYE
3.UNABLE TO DRINK OR DRINKS POORLY
4. SKIN PICH GOES BACK VERY SLOWLY > 2 SEC
SOME DEHYDRATION TWO OR MORE OF FOLLOWING PLAN B
GIVE FLUID AND FOOD FOR SOME
DEHYDRATION
1.RESTLESSNESS,IRRATIBILTY AFTER REHYDRATION ADVISE FOR
2. SUNKEN EYE TREATMENT
3.DRINK EAGERLY,THIRSTY TELL WHEN TO COME BACK IMME
4. SKIN PICH GOES BACK VERY SLOWLY DIATLY
F/U IN 5 DAY IF NOT IMPROVING

13. No dehydration NOT ENOUGH SIGN TO CLASSIFY AS SOME GIVE FLUID AND FOOD TO TREAT
OR SEVERE DEHYDRATION DIARRHOEA AT HOME
TREATMENT PLAN A
ADVISE MOTHER WHEN TO RETURN
IMMEDIATELY
F/U IN 5 DAYS IF NOT IMPROVING

14. SEVERE DEHYDRATION
• RAPID IV HYDRATION WITH CLOSE MONITORING, F/B ORAL REHYDRATION AND ZINC,IF CHOLERA
OUTBREAK GIVE ANTIBIOTICS AGAINST CHOLERA
• IVFLUID ; ISOTONIC SOLUTIONS ( RL OR NS)
• GIVE 100ML/KG FLUID
• AGE 30ML/KG 70ML/KG
• < 12 M 1 HR 5 HR
• >/12 M 30 MIN 2.5 HR
• Reasess child after 15-30 min if not improving give rapid fluid

15. • ORS SOLUTION SHOULD BE STARTED SIMULTANEOUSLY IF CHILD
AND TAKE ORALLY/ BREAST FEEDING MUST CONTINUE DURING
REHYDRATION PROCESS
• 1.PERSISTENCE OF SEVERE DEHYDRATION;IV INFUSION AS ABOVE
CAN BE REPEATED
• 2. HYDRATION IMPROVED BUT SOME DEHYDRATION PRESENT ;IV
DISCONTINUED,SHIFT TO PLAN B
• 3. THERE IS NO DEHYDRATION ; DISCONTINUE IV FLUID
TREATMENT AS PLAN A

16. SOME DEHYDRATION
• ALL CASES WITH OBVIOUS SIGN OF DEHYDRATION NEED TO BE TREATED IN A HEALTH CENTER OR
HOSPITAL
• FLUID REQUIREMENT IS CALCULATED IN FOLLOWING THREE HEADINGS
• 1. NORMAL DAILY FLUID REQUIREMENT
• 2. REHYDRATION TO CORRECT EXISTING WATER/ELECTROLYTE DEFICIT
• 3.REPLACE ONGOING LOSSES

17. MAINTENANCE VOLUME ;CALORIC CALCULATION
HOLLIDAY-SEGAR METHOD; MOST COMMON METHOD , OFTEN REFD TO “4-2-1 RULE”
• HOLLIDAY SEGAR FORMULA NOT SUITABLE FOR NEONATES < 14 DAY
BODY WT ML/KG/DAY ML/HR
FIRST 10 KG 100 4
SECOND 10 KG 50 2
EACH ADDITIONAL KG 20 1
EG 25 KG FOR FIRST 10KG 1000+500ML FOR NEXT 10 KG+100ML FR NEXT 5 KG MEANS TOTAL 1600ML/DAY
OR 40+20+5 65ML/HR

18. • DEFICIT REPLACEMENT /REHYDRATION THERAPY: 75ML/KG ORS
GIVEN OVER 4 HR
• ORS ORALLY /IF NOT POSSIBLE
GIVE THROUGH NG TUBE
• REASSESS AFTER 4 HR CHILD STILL HAVE SOME DEHYDRATION
THAN REPEAT
• MAINTANENCE FLUID THERAPY TO REPLACE LOSSES; ORS SHOULD
BE ADMINISTERED IN VOLUME EQUAL TO DIARRHOEAL
LOSSESSUSUALLY 10ML/KG PER STOOL, PLAIN WATER CAN BE
OFFERED IN BETWEEN

19. REATMENT PLAN A
• TREAT DIADDHOEA AT HOME
• COUNSIL MOTHER FOUR RULES OF HOME TREATMENT
• 1. GIVE EXTRA FLUID
• 2. GIVE ZINC SUPPLIMENT
• 3 . CONTINUE FEEDING
• 4. KNOW WHEN TO RETURN CLINIC

20. • 1. GIVE EXTRA FLUID;
• BREAST FEEDING FREQUENTLY,AND LONGER TIME EACH FEED,GIVE ORS/CLEAN WATER IN ADDITION TO
BF, WHEN DIARRHOEA STOP RESUME TO EXCLUSIVE BF
• NON BREAST FEED CHILD; GIVE ONE OR MORE OF FOLLOWING
• ORS,
• FOOD BASED FLUID EG SOUP/RICE WATER/YOGHART DRINK
• OR COCONUT WATER/UNSWEETENED FRUIT JUICE
• CLEAN WATER
< 2YR 50-100ML AFTER EACH LOOSE STOOL 500ML/DAYS
2-10 YR 100-200ML AFTER EACH STOOL 1000ML/DAYS
>10 YR 2000ML/DAYS

21. ZINC SUPPLIMENT
• IMP MICRONUTRIENT FOR OVERALL HEALTH AND DEVELOPMENT BUT LOST IN GREATER QUANTITIES
DURING DIARRHOEA
• REPLACEMENT HELP IN CHILD RECOVERY,REDUCES DURATION AND SEVERITY OF EPISODE,LOWER
INCIDENCE FOLLOWING 2-3 MONTHS
• <6MONTH 10MG/DAY FOR 10-14 DAYS
• >6MONTH 20MG/DAY FOR 10-14 DAYS

22. • SYMPTOMATIC TREATMENT;
• IF VOMATING IS SEVERE OR RECURRENT SINGLE DOSE OF
ONDASETRON .1-.2MG/KG
• ABDOMINAL DISTENTION ;NO SPECIFIC TREAMENT BS +NT/IF
ABSENT PARALYTIC ILEUS CAN
OCCUR(HYPOKALENIA/SEPTICEMIA/NEC )ORAL INTAKE WITHHOLD
• CONVULSION MN A/P ETIOLOGY

23. FOLLOW UP
• MOTHER TO RETURN IMMEDIATELY TO CLINIC IF CHILD
• 1. BECOME SICKER
• 2. UNABLE TO DRINK OR BREAST FEED
• 3.DRINKS POORLY
• 4. DEVELOP FEVER OR HAS BLOOD IN STOOL
• 5 IF CHILD STILL NOT IMPROVING ADVISE MOTHER TO RETURN FOR F/U AFTER 5 DAYS

24. ADDITIONAL THERAPY
• PROBIOTIC NON PATHOGENIC BACTERIA FOR PREVENTION AND THERAPY OF DIARRHOEA HAS BEEN SUCCESSFUL IN
SOME SETTING ,ENHANCE HOST PROTECTIVE IMMUNITY,ORGANISM LIKE LACTOBACILLUS ,BIFIDOBACTERIUM
• SACCHAROMYCES BOULARDII IS EFFECTIVE IN ANTIBIOTICS-ASSOCIATED AND C.DIFFICALE DIARRHOEA
• LACTOBACILLUS RHAMNOSUS GG IS ASSOCIATED WITH REDUCED DIARRHEAL DURATION AND SEVERITY
• REDUCTION IS MORE EVIDENT IN CASE OF CHILDHOOD ROTA VIRUS DIARRHEA
• ANTIMOTALITY DRUG EG LOMOTIL AND LOPERAMIDE OR IMODIUM SHOULD NOT BE USED
• antibiotics is not used routinely give you suspect
• Cholera, parenteral diarrhoea, and dysentry

25. DYSENTRY
• FREQUENT LOOSE STOOL MIXED WITH BLOOD
• ETIOLOGY; BACTERIA OR AMOEBA BACILLARY (SHIGELLA
SPP,ENTEROINVASIVE/ENTEROHAEMORRHAGIC E.COLI/SALMONELLA/CAMPYLOBACTERBJEJUNI
• MOST COMMONLY DUE TO SHIGELLA NEED ANTIBIOTICS UNTREATED MAY LED TO LIFE THREATENING
COMPLICATION INCLUDING INTESTINAL PERFORATION,TOXIC MEGACOLON,AND HEMOLYTIC UREMIC
SYNDROME
• C/F FREQUENT LOOSE STOOL MIXED WITH BLOOD MAY INCLUDE ABDOMINAL
PAIN,FEVER,CONVULSION,LETHARGY,DEHYDRATION,RECTAL PROLAPS/

26. TREATMENT
• MOST CHILDREN CAN BE TREATED AT HOME
• ADMIT IN HOSPITAL; YOUNGER INFANTS <2MONTH, SEVERELY ILL PT LOOK
LETHARGIC,ABDOMINAL DISTENTION,TENDERNESS OR
CONVULSION,CHILD WITH ANY OTHER CONDITION REQUIRE HOSPITAL
TREATMENT
• GIVE ORAL ANTIBIOTICS (5 DAYS) TO WHICH MOST LOCAL STRAINS
SENSITIVE
• GIVE CIPROFLOXACIN 15MG/KG TWICE A DAYS IF ANTIBIOTIC SENSITIVITY
IS UNKNOWN
• GIVE CEFTRIXONE 50-80MG/KG FOR 3 DAYS TO SEVERELY ILL PT OR AS
SECOND LINE TREATMENT
• IF NO IMPROVEMENT AFTER 2 FULL SHIFT TO SECOND LINE
ANTIBIOTICS,IF TWO ANTIBIOTICS WHICH IS USUALLY EFFECTIVE AGAINST
SHIGELLA AFTER 2 DAYS OF TREATMENT WITH NO SIGN OF CLINICAL
IMPROVEMENT CHECK FOR OTHER CONDITION
• IF AMOEBIOSIS IS POSSIBLE GIVE METRONIDAZOLE 10MG/KG THRICE A
DAY FOR 5 DAYS

27. CHOLERA
VIBRIO CHOLERAE GRAM NEGATIVE,COMMA SHAPED BACILLUS, SUB
DIVIDED BY SOMATIC O ANTIGEN EG SEROGROUP 01,SEROTYPE O 139
i.P IS 1-3 DAYS (FEW HOURS – 5 DAYS)
SUSPECT CHOLERA IN CHILDREN > 2 YR OLD HAVING WATERY DIARRHOEA
AND SIGN SEVERE DEHYDRATION OR SHOCK ,IF CHOLERA IS PRESENT IN
AREA
• ASSESS AND TREAT DEHYDRATION+ GIVE ORAL ANTIBIOTICS TO WHICH
STRAIN OF V.CHOLERAE IS SENSITIVE.+ZINC SUPPLIMENT AS SOON AS
VOMIT STOP.
• MOST CASES ARE MILD OR INAPPARENT
• 20% DEVELOP SEVERE DEHYDRATION CAN RAPIDLY LEAD TO DEATH.

28. • C/F ACUTE WATERY DIARRHOEA AND VOMATING ,SOME PT HAVE COMPLAIN OF PRODROME OF
ANOREXIA AND ABDOMINAL DISCOMFORT
• DIARRHOEA CAN PROGRESS TO PROFUSE RICE WATER STOOL(SUSPENDED FLECKS OF MUCUS)WITH
FISHY SMELL….. HALLMARK OF DISEASE
• LABORATORY FINDING ELECTROLYTE IMBALANCE EG NA AND CL NORMAL/DECREASED,METABOLIC
ACIDOSIS,HYPOGLYCEMIA
• DIAGNOSIS; SUSPECTED IN WATERY DIARRHOEA WITH SEVERE DEHYDRATION RESIDING IN CHOLERA
BENDEMIC AREA OR WHO HAVE RECENTLY TRAVELED TO AN AREA KNOWN TO HAVE CHOLERA
• DIARRHOEA BY OTHER ETIOLOGY EH ENTEROTOXIGENIC E.COLI,ROTA VIRUS DIARRHOEA DIFFICULT TO
DISTINGUISH CLINICALLY
• TREAT DEHYDRATION AS SOON AS POSSIBLE

29. • MICROBIOLOGIC ISOLATION OF V.CHOLERA IS GOLD STANDARD
FOR DIAGNOSIS SPECIMENS STOOL,VOMITUS,RECTAL SWABS
TRANSPORTED ON CARY-BLAIR MEDIA AND THAN SELECTIVE
MEDIA THIOSULFATE CITRATE-BILE SALT SUCROSE AGAR
• STOOL EXAMINATION ; LEUKOCYTES,ERYTHROCYTES,DARK FIELD
MICROSCOPY MAY USED FR RAPID IDENTIFICATION OF TYPICAL
DARTING MOVEMENT
• MOLECULAR IDENTIFICATION WITH THE USE OF PCR AND DNA
PROBES IS AVALIEBLE

30. TREATMENT
• REHYDRATION IS MAIN STAY OF THERAPY( TIMELY AND EFFECTIVE MANAGEMENT IDECREASE
MORTALITY)
• MILD TO MODERATE DEHYDRATION SHOULD BE TREATED WITH ORS ( RICE BASED ORS PREFERRED)
• SEVERELY DEHYDRATED PT NEED IV FLUID RL
• ANTIBIOTICS SHOULD BE GIVEN IN MODERATE TO SEVERE DEHYDRATION,SINGLE DOSE
ANTIBIOTICS(DOXYCYCLINE,CIPROFLOXACIN,AZITHROMYCIN)HAS INCREASE COMPLIANCE
• RECOMMENDED ANTIBIOTICS IN CHOLERA;
• WHO ADULTS DOXYCYCLINE 300MG SINGLE DOSE/ OR TETRACYCLINE 500MG 4 TIMES A DAY FOR
• 3 DAYS
• ALTERNATE; ERYTHROMYCIN 250MG 4 TIME A DAYS FOR 3 DAYS
•
• CHILDREN TETRACYCLINE 12.5MG/KG/DOSE 4 TIME A DAY FOR 3 DAYS( MAX 500MG/DOSE)
• ALTERNATE ERYTHROMYCIN 12.5MG/KG/DOSE 4 TIME A DAYS FOR 3 DAY(MAX 250MG/DOSE)

31. • PAHO (PAN AMERICA HEALTH ASSOCIATION)
• ADULT DOXYCYCLINE 300MG PO SINGLE DOSE
• ALTERNATE CIPROFLOXACIN 1 GM PO STAT
• OR AZITHROMYCIN 1 GM PO SINGLE DOSE
• CHILDREN ERYTHROMYCIN 12.5MG/KG/DOSE 4 TIME A DAYS FOR 3 DAYS
• OR AZITHROMYCIN 20MG/KG AS A SINGLE DOSE
• ALTERNATE CIPROFLOXACIN 20MG/KG SINGLE DOSE
• OR DOXYCYCLINE 2-4 MG/KG PO SINGLE DOSE

34. PREVENTION
• 1. PROPER NUTRITION;EXCLUSIVE BREAST FEEDING UPTO 6M TNAN APPROPRIATE COMPLEMENTARY
FEEDING(ENERGY MIXED FOOD MIXTURE
• 2. ADEQUATE SANITATION; IMPROVEMENT OF ENVIRNMENTAL SANITATION,CLEAN WATER
SUPPLY,ADEQUATE WATER DISPOSAL SYSTEM,PROTECTION OF FOOD FROM BACTERIAL
CONTAMINATION
3. VACCINATION : EG ROTAVIRUS VACCINE /CHOLERA VACCINE
KEY MESSAGES THREE Cs (CLEAN HAND,CLEAN CONTAINER,AND CLEAN ENVIRONMENT)

35. THANKS HIMSR
SOURCE:NELSON 20TH EDITION,GHAI ESSENTIAL PEDIATRICS 8TH EDITION;WHO GUIDELINE FOR
MANAGEMENT OF COMMON CHILDHOOD ILLNESSESS