peditrician

1. DR. RAKES SHAHM.D.(PEDIATRICS)
PANTH CHILDREN HOSPITAL
HATKESHWAR

2. INTRODUCTION Leading cause of childhood morbidity & mortality in
developing countries
 Important cause of malnutrition
 80% of deaths due to diarrhoea occur in the first two
years of life.
 Children <3 years of age in developing countries
experience around three episodes of diarrhoea each year.

3. Definition
 Diarrhoea is the passage of loose or watery stools
at least three times in 24 hour .

4. Epidemiologic features of Diarrhea
 2 billion cases of diarrheal disease every year
 Greatest burden seen in children under the age of 5 years
 About 5000 deaths in children every day
 Incidence and risk of mortality are highest in this age group
 About 78% occur in the South-East Asian & African
regions
 An average of 3 episodes of acute diarrhoea every year

5. Diarrhea in India
 Accounts for 20% of all paediatric deaths in India
 2nd leading cause of child mortality after acute respiratory
infections (30%)
 25.2 % is the Prevalence rate among children under age 5 Yrs
 49.1% : Highest in the age group of 6–11 months
 15.7% : Lowest among children aged 48–59 months
Prevalence of Diarrhoeal Disease, its Seasonal and Age Variation in
Kashmir, India. Int J Health Sci . Jul 2008; 2(2): 126–133.

6. Clinical Types
 Acute watery diarrhoea (including cholera):
 Lasts several hours or days
 Main danger is dehydration
 Weight loss occurs if feeding is not continued;
 Acute bloody diarrhoea:
 Also called dysentery
 Main dangers - damage of the intestinal mucosa,
sepsis and malnutrition
 Other complications : dehydration , HUS

7.  Persistent diarrhoea :
 Lasts 14 days or longer a/w malnutrition
 Main danger - malnutrition & serious non-intestinal
infection
 Other complications : dehydration
 Diarrhoea with severe malnutrition :
 Main dangers - severe systemic infection ,
dehydration,
heart failure and vitamin and mineral deficiency.

8. ETIOLOGY OF ACUTE DIARRHOEA
Viral :
Rota Virus
 Adenovirus
Norwalk Agent
Bacterial :
 V. Cholera
 ETEC, EIEC
 Salmonella
 Shigella
CampylobacterFungal :
 Candida

9. Parasitic Infection :
 Giardia Lamblia
 Cryptosporidium
 Entamoeba Histolytica
Drugs :
 Laxatives
 Sorbitol
 Antacids
 Lactulose
 Theophylline
 Antibiotics
 Quinidine
Diet :
Food Poisoning
Food allergy

10. Pathophysiology of acute diarrhea
 Increased secretion of fluid and electrolytes
 Decreased digestion and absortion of nutrients
 Abnormal transit due to aberrations of intestinal
motility

11. Dehydration
 During diarrhoea there is an increased loss of water
and electrolytes (Na, Cl , K , and HCO3 ) in the liquid
stool.
 Dehydration occurs when these losses are not
replaced adequately and a deficit of water and
electrolytes develops.

12. Diarrheal Disease
Current Management
Bacterial
diarrhea
ORS Zinc Probiotics Antibiotics
Ofloxacin
Ofloxacin +
ImidazleOfloxacin : Not recommended in children
Amoebic infections are to the tune of 5% in children < 5yrs
Limitations of Prescribing antibiotic in Diarrhea / Dysentry
Ofloxacin : Toxicity and risk of cartilage damage
Ofloxacin / Imidazoles : Bitter taste, Palatability, Nausea
5-8 days of lengthy treatment
Recovery time is 4-5 days after treatment
No effect on improvement of stool consistency
Emerging resistance, not recommened in < 8yrs of age
irrational combinations as H1/2 is different quinolones (12hrs)
Metronidazole(8hrs)
Limitation
s

13. Treatment Plan A: home therapy to
prevent dehydration and malnutrition
 Children with no signs of dehydration need extra
fluids and salt to replace their losses of water and
electrolytes due to diarrhoea. If these are not given,
signs of dehydration may develop.

14. four rules of
Treatment Plan A:
 Rule 1: give the child more fluids than usual
 Suitable fluids : two groups:
 Fluids that contain salt :
• ORS solution
• Salted drinks (e.G. Salted rice water or a salted yoghurt drink)
• Vegetable or chicken soup with salt.
 Fluids that do not contain salt, such as:
• Plain water
• Water in which a cereal has been cooked
• Unsalted soup
• Yoghurt drinks without salt
• Green coconut water
• Weak tea (unsweetened)
• Unsweetened fresh fruit juice.

15.  Unsuitable fluids
 Drinkssweetened with sugar, which can cause
osmotic diarrhoea and hypernatraemia.
 Some examples are:
• Commercial carbonated beverages
• Commercial fruit juices
• Sweetened tea.
 With stimulant, diuretic or purgative effects, for
example:
• Coffee
• Some medicinal teas or infusions.

16.  How much fluid to give
 The general rule is: give as much fluid as the child or adult
wants until diarrhoea stops.
 • Children under 2 years of age: 50-100 ml (a quarter to
half a large cup) of fluid;
 • Children aged 2 up to 10 years: 100-200 ml (a half to one
large cup);
 • Older children and adults: as much fluid as they want.

17.  Rule 2: Give supplemental zinc (10 - 20 mg) to
the child, every day for 10 to 14 days
 Dose : infant – 0.5 mg/kg/day
<6 mth – 10 mg/day
>6 mth – 20 mg/day
 Preparations : zinconia 20mg/5ml
zincovit 10mg/5ml

18.  Rule 3: Continue to feed the child, to prevent
malnutrition
 Food should never be withheld
 Breastfeeding should always be continued.
 Aim - give as much nutrient rich food as the child
will accept.

19.  Rule 4: take the child to a health worker if
there are warningsigns of dehydration or
other problems
 • Starts to pass many watery stools;
 • Has repeated vomiting;
 • Becomes very thirsty;
 • Is eating or drinking poorly;
 • Develops a fever;
 • Has blood in the stool; or
 • The child does not get better in three days.

20. ROLE OF
ANTIBIOTICS

21. Bacteria Antibiotic
Salmonella typhi,
Salmonella paratyphi
Ampicillin,† chloramphenicol,† TMP-SMZ, cefotaxime,
ciprofloxacin‡
Nontyphoidal
Salmonella
Usually none (if ≥ 3 months old); ampicillin,
cefotaxime, ciprofloxacin‡
Shigella ( Dysentery ) Children: Third-generation cephalosporin, TMP-SMZ
Nalidixic acid
Adults: fluoroquinolones‡
Escherichia coli
Enterotoxigenic Usually none if endemic; TMP-SMZ or ciprofloxacin for
traveler's diarrhea
Enteroinvasive TMP-SMZ, ampicillin if susceptible
Enteropathogenic TMP-SMZ or an aminoglycoside
Enterohemorrhagic Usually none
Enteroaggregative TMP-SMZ or an aminoglycoside
Campylobacter jejuni Mild disease needs no treatment; erythromycin or
azithromycin for diarrhea; aminoglycoside,

22. Bacteria Antibiotic
Yersinia enterocolitica None for uncomplicated diarrhea;
TMP-SMZ; gentamicin or
cefotaxime for extraintestinal
disease
Vibrio cholerae Tetracycline, doxycycline, TMP-
SMZ
Clostridium difficile Oral metronidazole,§ oral
vancomycin
Entamoeba histolytica Metronidazole§ followed by
iodoquinol to treat luminal
infection
Giardia lamblia Metronidazole,§ quinacrine,
furazolidone, others
Cryptosporidium parvum None; azithromycin or
paromomycin and octreotide in

23. Complications
1) DEHYDRATION
2) DYSELECTROLYTAEMIA
3) PPT. OF MALNUTRITION
4) PERSISTENT DIARRHOEA
5) TOXIC ILEUS
6) HUS
7) DIC
8) CORTICAL VIEN THROMBOSIS.

24. ORAL REHYDRATON SOLUTION
 ORS -special combination of dry salts that, when
properly mixed with clean water, can help rehydrate
the body when a lot of fluid has been lost due to
diarrhoea.
 Basis of ORS – Glucose linked absorption of sodium
remains intact irrespective of etiology of diarrhoea.

25. TYPES OF ORS FORMULATIONS
 Glucose based ORS
 Rice based ORS
 Low osmolarity ORS
 Home available ORS
 Mineral based ORS(zinc)

26. 15th Aug. 2013
US FDA Announcement - Fluroquinolones

28. NORMAL BACTERIAL FLORA OF THE
GI TRACT
 Aerobic and anaerobic bacteria, yeast and fungi live into the GI tract
which has more than 400 m2 of surface area.
 There are more than 2000 species of commensal bacterial organisms
within our bodies, the vast majority in the gut.
 The several species of microorganisms in the adult human gut are
known as the microbiota which may contain nearly 100 times the
number of genes contained within the human genome.
 The genome of these collective organisms is called the microbiome.
 The longitudinal distribution of intestinal microorganisms increases in
density progressing from the small bowel to colon.
Therapeutical use of probiotic formulations in clinical practice. Clinical Nutrition 29 (2010) 701e725

29. Therapeutical use of probiotic formulations in clinical practice. Clinical Nutrition 29 (2010) 701e725

30. GI flora components
Therapeutical use of probiotic formulations in clinical practice. Clinical Nutrition 29 (2010) 701e725

31. Mechanisms of probiotic/host interaction.
World Gastroenterology Organisation Practice Guideline Probiotics and prebiotics.
www.worldgastroenterology.org/.../guidelines/19_probiotics_prebiotics

32. Probiotics
 Probiotics are “live microorganisms, which when administered in
adequate amounts, confer a health benefit on the host.
 Probiotics are generally recommended to help strengthen host
system and assist in recovery from certain diseases.
 There are several challenges in choosing the appropriate
probiotic; including the wide diversity of probiotic strains,
quality control of commercially-available probiotic products and
the degree of evidence-based trials for each disease and
probiotic.
McFarland LV. Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. World J Gastroenterol
2010 May 14; 16 (18):2202-2222

33. Probiotics
 The ability of an organism to be an effective probiotic has been
found to be strain-specific and microbial organisms are defined
by their genus, species and strain.
 Probiotic products are available in various forms: capsules of
freeze-dried or lyophilized cultures, heat-dried culture
supernatants mixed in dairy food or other foods.
McFarland LV. Systematicv review and meta-analysis of Saccharomyces boulardii in adult patients. World J
Gastroenterol 2010 May 14; 16 (18):2202-2222

35. Saccharomyces boulardii
 Saccharomyces boulardii was discovered by a French microbiologist, Henri
Boulard in 1920 when he was in Indo-China searching for new strains of
yeast that could be used in fermenting processes.
 Saccharomyces boulardii (S. boulardii) is a yeast isolated from the skin of
Lychees grown in Indo-china and belongs to the same species as
Saccharomyces cerevisiae (S. cerevisiae), although it definitively has
different taxonomy, physiological, metabolic and genetic characteristics.
 It is a non-pathogenic thermotolerant yeast that grows optimally at 370C.
 It is a live yeast that is available as a lyophilized preparation for adults as a
250 mg capsule.
Prajapati P, Patel M, Krishnamurthy R. Saccharomyces boulardii- a probiotic of choice. CIBTech Journal of
Biotechnology. 2013 Vol. 2 (2) April-June, pp.1-6

36. Properties of S boulardii
 Organisms need to survive at body temperature, be resistant to stomach
acids and bile acids, and exist in the competitive milieu of the intestinal
tract to show their effect.
 Probiotic strains of Saccharomyces have been shown to have these abilities.
 Although the optimal temperature for most strains of Saccharomyces range
from 22-30 c, S. boulardii survives best at 37 c, giving it a unique advantage
of being one of the few yeasts that do best at human body temperatures.
 These studies indicate that S. boulardii is a safe and effective
biotherapeutic agent for the treatment of gastrointestinal disease.
Prajapati P, Patel M, Krishnamurthy R. Saccharomyces boulardii- a probiotic of choice.
CIBTech Journal of Biotechnology. 2013 Vol. 2 (2) April-June, pp.1-6

37. Pharmacokinetics
 S. boulardii, when given orally, achieves steady-state concentrations
within three days and is cleared within 3-5 d after it is discontinued.
 Blehaut et al gave eight healthy volunteers S Boulardii (oral dose of 5
X109) for six days and followed them for time to clearance.
 They determined that S boulardii has a half life of 6 hours, fecal steady
state concentration (2 × 107/g) were reached by day 3 and the yeast was
cleared after four days after administration.
 Elmer et al found that some types of fiber (psyllium) increased S
boulardii levels by 22%, while other type of fiber (pectin) showed no
effect.
McFarland LV. Systematicv review and meta-analysis of Saccharomyces boulardii in adult patients. World J
Gastroenterol 2010 May 14; 16 (18):2202-2222

38. Stability of S boulardii
 Probiotic product manufacturing may affect its shelf-life. Probiotics
may be available as lyophilized or heat-dried preparations.
 Lyophilized preparations of S boulardii are stable over one year at room
temperature, as long as it is protected from moisture.
 Daily administration of lyophilized S. boulardii at standard doses
results in detectable levels of live yeast throughout the GI tract.
 S. boulardii does not attach to the mucosa of the intestine
Prajapati P, Patel M, Krishnamurthy R. Saccharomyces boulardii- a probiotic of choice. CIBTech
Journal of Biotechnology. 2013 Vol. 2 (2) April-June, pp.1-6

40. Anti-Microbial Action – Direct Anti-
Toxin Effect
 The anti-toxin action elicited by S boulardii is mainly due to small
peptides produced by the yeast.
 A 54kDa serine protease is able to inhibit enterotoxin and cytotoxic
activities of C. difficile by degradation of toxin A and B and receptors
sites of toxin A on the enterocyte cell surface.
 S. boulardii has several different types of mechanisms of action. which
may be classified into three main areas: luminal action, trophic action
and mucosal-anti-inflammatory signaling effects.
 S. boulardii may interfere with pathogenic toxins, preserve cellular
physiology, interfere with pathogen attachment, interact with normal
microbiota or assist in reestablishing short chain fatty acid levels.
Prajapati P, Patel M, Krishnamurthy R. Saccharomyces boulardii- a probiotic of choice. CIBTech
Journal of Biotechnology. 2013 Vol. 2 (2) April-June, pp.1-6

41. Inhibition of Growth and Invasion
of Pathogen
 In vitro, S boulardii directly inhibits the growth of several pathogens
(Candida albicans, E. coli, Shigella, Pseudomonas aeruginosa,
Staphylococcus aureus, Entamoeba hystolitica), and cell invasion by
Salmonella typhimurium.
 This mode of action is most likely important for the prevention and
therapy of infectious diseases but also for the treatment of (chronic)
inflammation of the digestive tract or parts thereof.
 In addition, this probiotic action could be important for the
eradication of neoplastic host cells.
Prajapati P, Patel M, Krishnamurthy R. Saccharomyces boulardii- a probiotic of choice. CIBTech Journal of
Biotechnology. 2013 Vol. 2 (2) April-June, pp.1-6

42. Trophic and Immune System Effects
 S boulardii can reduce mucositis, restore fluid transport pathways,
stimulate protein and energy production or act through trophic effect
by releasing spermine and spermidine or other brush border enzymes
that aid in the maturation of enterocytes.
 S boulardii may also regulate immune responses, either acting as an
immune stimulant or by reducing pro-inflammatory responses.
 S. boulardii may cause an increase in secretory IgA levels in the
intestine. It has also been found associated with higher levels of serum
IgG to C. difficile toxins A and B.
McFarland LV. Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. World J
Gastroenterol 2010 May 14; 16 (18):2202-2222

43. Trophic and Immune System Effects
 S. boulardii may also interfere with NF-κB-mediated signal
transduction pathways, which stimulate pro-inflammatory
cytokine production.
 S. boulardii has also been shown to cause the trapping of T
helper cells into mesenteric lymph nodes, thereby reducing
inflammation.
McFarland LV. Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. World J Gastroenterol
2010 May 14; 16 (18):2202-2222

44. Mechanism of Action
McFarland LV. Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. World J
Gastroenterol 2010 May 14; 16 (18):2202-2222

45. The normal microbiota and probiotics interact with the
host in metabolic activities and immune function and
prevent colonization of opportunistic and pathogenic
microorganisms
World Gastroenterology Organisation Practice Guideline Probiotics and prebiotics.
www.worldgastroenterology.org/.../guidelines/19_probiotics_prebiotics

46. Commercially used probiotic strains.
Therapeutical use of probiotic formulations in clinical practice. Clinical Nutrition 29 (2010) 701e725

47. Bifidobacteria benefits on human health.
Therapeutical use of probiotic formulations in clinical practice. Clinical Nutrition 29 (2010) 701e725

48. Main therapeutic and nutritional effects of Lactobacilli.
Therapeutical use of probiotic formulations in clinical practice. Clinical Nutrition 29 (2010) 701e725