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Management of Acute Diarrhoea in Children. Welcome to the module on Management of Acute Diarrhoea (AD) in Children! Diarrhoea l disease remains a leadin g cause of morbidity and mortality amongst children in l ow and middle income countries.

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management of acute diarrhoea in children
Management of Acute Diarrhoea in Children

Welcome to the module on Management of Acute Diarrhoea (AD) in Children!

Diarrhoeal disease remains a leading cause of morbidity and mortalityamongst children in lowand middle income countries.

Most deathsresult from the associated shock, dehydrationand electrolyte imbalance.

In malnutrition, the risk of AD, its complications and mortality are increased.

A child presenting with AD

For more information about the

authors of this module, click here

Next

how to use this module
How to use this module
  • This module aims to address deficiencies in the management of AD and dehydration in children that we identified during a clinical audit.
  • We suggest that you start with the learning objectives and try to keep these in mind as you go through the module slide by slide, in order and at your own pace.
  • Print-out the diarrhoea SDL answer sheet. Write your answers to the questions (Q1, Q2 etc.) on the sheet as best you can before looking at the answers.
  • Repeat the module until you have achieved a mark of >20 (>80%).
  • You should research any issues that you are unsure about. Look in your textbooks, access the on-line resources indicated at the end of the module and discuss with your peers and teachers.
  • Finally, enjoy your learning! We hope that this module will be enjoyable to study and complement your learning about AD from other sources.

Next

Click here to move to the next slide

learning outcomes
Learning Outcomes

By the end of this module, you should be

competent in the management of acute

diarrhoea / dehydration.

In particular you should be able to:

  • Describe when to use oral and parenteral fluids and what solutions to use
  • Identify the malnourished child and adjust management accordingly
  • Describe when antibiotic treatment is indicated and the adverse effects of the overuse of antibiotics
  • Describe the use of zinc in AD

Next

definition of ad
Definition of AD
  • There is a wide range of normal stool patterns in children which makesthe precise definition of AD difficult
  • According to the World Health Organization (WHO), AD is the passage of loose* or watery stools, three times or more in a 24 hour period for upto14 days
  • In the breastfed infant, the diagnosis is based on a change in usual stool frequency and consistency as reported by the mother
  • AD must be differentiated from persistent diarrhoea which is of >14 days durationand may begin acutely.Typically, this occurs in association with malnutrition and/orHIV infection and may be complicated by dehydration

*Takes the shape of the container

Diaper stained with watery stool

Next

the burden of diarrhoeal disease
The burden of diarrhoeal disease
  • Despite the fact that diarrhoea can be prevented, about 2 billion cases of diarrhoea occur globally every year in children under 5 years
  • About 2 million child deaths occur due to diarrhoeaevery year
  • More than 80% of these deaths are in Africa and South Asia
  • Diarrhoea is the third most common cause of death (see diagram)
  • In Nigeria, diarrhoeacauses 151,700 deaths of children under five every year,* the second highest rate in the world after India

* UNICEF/WHO, Diarrhoea: Why children are still

dying and what can be done, 2009

Causes of death among children under age of five years

UNICEF: Progress for children, 2007

Next

causes and risk factors for ad
Causes and risk factors for AD
  • Microbial, host and environmental factors interact to cause AD
  • Click on the boxes to find out more

Next

clinical types of ad
Clinical types of AD
  • There are 2 main clinical types of AD
  • Each is a reflection of the underlying pathology and altered physiology

Next

slide8
Q1Write “T” or “F” on the answer sheet. When you have completed all 5 questions, click on each box and mark your answers.
  • The incidence of AD is highest in the age group 6-11 months
  • Acute diarrhoea is of duration less than 14 days
  • Rotavirus is a more common cause of diarrhoea in developing countries than bacterial pathogens
  • Undernutrition is a major risk factor for persistent diarrhoea
  • The largest proportion of deaths from diarrhoea occur in East Asia

a

b

c

d

e

Next

clinical scenarios
Clinical scenarios
  • You will now work through a series of cases of AD
  • You will learn how to assess and manage children according to the latest WHO guidelines
  • Start with scenario A. Try to answer the questions yourself before clicking on the answers

http://www.who.int/maternal_child_adolescent/documents/9241546700/en/index.html

Next

scenario a assessment and management of shock
This 2 year old child was

rushed into the emergency

room. She had AD and had

become very unwell.

Scenario AAssessment and management of shock

Q2. How would youproceed?

Write down your answer before moving to the next slide!

Next

scenario b clinical assessment of dehydration
This 2 year old child presented

with AD. She did not have features

of shock or SAM but was assessed to have severe dehydration.

Scenario BClinical assessment of dehydration

Q4. List the 4 clinical signs recommended for classifying a child as severely dehydrated

Write down your answers and then go to the next slide

Next

scenario c clinical assessment of dehydration
Scenario C Clinical assessment of dehydration

A mother brought her 2 year old male child to the hospital because of AD. On examination, he was irritable and his skin pinch goes back slowly (1 second)

Q8: Write down your assessment of this child’s hydration status

Q9: List 2 other key clinical signs consistent with this degree of dehydration

Write down your answer and then go to the next slide

Next

scenario d a child with bloody diarrhoea
Scenario D A child with bloody diarrhoea

A child was brought to the emergency room because of bloody diarrhoea of 3 days duration with associated vomiting and fever.

When examined, there were no signs of dehydration or SAM.

Q11: What it is the most likely diagnosis in this child?

Q12: How will you treat?

Write down your answers and then move to the next slide

Next

answers scenario d
Answers: Scenario D

Q11:

  • This child has acute bloody diarrhoea also called dysentery
  • Most episodes are due to Shigella spp
  • The diagnostic signs of dysentery are frequent loose stools with visible red blood
  • Other findings in the history or on examination may include
    • Abdominal pain
    • Fever
    • Convulsions
    • Lethargy
    • Dehydration
    • Rectal prolapse

Q12:

All children with severe dysentery require antibiotic treatment for 5 days

    • Give an oal antibiotic to which most strains of shigella in your localiity are sensitive
    • Examples of antibiotics to which shigella strains can be sensitive are ciprofloxacin and other fluoroquinolones

Also manage any dehydration

Ensure breastfeeding is continued for childen still breastfeeding and normal diet for older childen

Follow-up the child

Go to Case Scenario E

scenario e clinical assessment of dehydration
Scenario E Clinical assessment of dehydration

This 2 year old male child was brought to the

Children’s emergency room with diarrhoea for 6 days. He had angular stomatitis, peri-anal ulceration, weighed 7.0 kg and the MUAC was 10.2 cm.

His hands were cold, pulse weak and fast and skin pinch went back very slowly. However, he appeared to be fully conscious and was not lethargic.

The resident doctor gave 140ml of normal saline by rapid IV infusion but his condition deteriorated.

Q13: What important condition needs to be recognised in this child?

Q14: Was the doctor’s management correct?

Q15: List 2 pathophysiological mechanisms in this condition that affect fluid management.

Next

answer scenario e fluid management in children with sam
Answer: scenario E - Fluid management in children with SAM

Q13: The child has severe acute malnutrition: SAM

Q14: No.Dehydration is difficult to diagnose in SAM and it is often over diagnosed. The doctor’s choice of IV normal saline, amount of fluid and rapidity of given IV fluid were all incorrect and may have caused the child’s deterioration

Q15: The pathophysiological mechanisms that affect fluid management are:

  • Although plasma sodium may be very low, total body sodium is often increased due to
    • increased sodium inside cells
    • additional sodium in extracellular fluid if there is nutritional oedema
    • reduced excretion of sodium by the kidneys
  • Cardiac function is impaired in SAM

This explains why treatment with IV fluids can result in death from sodium overload and heart failure.

  • The correct management is reduced sodium oral rehydration fluid (ORF; e.g. ReSoMal) given by mouth or naso-gastric tube if necessary. The volume and rate of ORF are much less for malnourished than well-nourished children (see next slide)

IV fluids should be used only to treat shock in children with SAM who are also lethargic or have lost consciousness!

Next

end of clinical scenarios
End of clinical scenarios

The next few slides are on how to assess nutritional status, indications for laboratory investigations, rational use of antibiotics and usage of zinc

Next

assessment of nutritional status
Assessment of nutritional status
  • Assessment of nutritional status is important in children with diarhoeal disease to identify those with severe acute malnutrition (SAM)
  • This is because abnormal physiological processes in SAM markedly affect the distribution of sodium and therefore directly affect clinical management
  • In patients with SAM, although plasma sodium may be very low, total body sodium is often increased due to:
    • increased sodium inside cells as a result of decrease activity of sodium pumps
    • additional sodium in extracellular fluid if there is nutritional oedema
    • reduced excretion of sodium by the kidneys

A West African child with kwashiokor

Next

methods of nutritional assessment
Methods of nutritional assessment

Nutritional assessment can be done by:

  • Looking for visible signs of severe wasting such as muscle wasting and reducedsubcutaneous fat
  • Looking for other signs of malnutrition: angular stomatitis, conjuctival and palmar pallor, sparse and brittle hair, hypo- and hyperpigmentationof the skin
  • Looking for nutritional oedema (pitting oedema of both feet)
  • Use of anthropometry such as Weight-for-Height z-score (WHZ; < -3.0) or Mid-Upper Arm Circumference (MUAC < 11.5cm in children aged 6-60 months)

Muscle wasting and loss of subcutaneous fat in a West African child with marasmus

Next

muac recommended for nutritional assessment in dehydration
MUAC: recommended for nutritional assessment in dehydration
  • MUAC is widely used in community screening of malnutrition because it is easy to perform, accurate and quick
  • MUAC is measured using Shakir’s strip or an inelastic tape measure placed on the upper arm midway between acromion process and olecranon
  • Dehydration reduces weight; MUAC was less affected by dehydration than WFLz score in a recent study*
  • Mid-Upper Arm Circumference (MUAC):
  • <115mm: SAM
  • 110 - 124mm: Moderate Acute Malnutrition (MAM) 
  • 125 - 135mm: risk of acute malnutrition
  • >135mm: child well nourished
  • www.motherchildnutrition.org/

*http://www.nutritionj.com/content/10/1/92

Next

laboratory investigations
Laboratory investigations

AD is usually self-limiting and investigations to identify the infectious agent are

not required

  • Indications for stool microscopy, culture and sensitivity
  • Blood and mucus in the stool
  • High fever
  • Suspected septicaemic illness
  • Diagnosis of AD is uncertain
  • Indications for measurement of Urea and Electrolytes
  • Severe dehydration or shock
  • Children on IV fluid
  • Children with severe malnutrition
  • Suspected cases of hypernatreamic dehydration

Next

rational use of antibiotics
Rational use of antibiotics
  • Even though bacterial pathogens are the commonest cause of AD in developing countries, there should be cautious and rational use of antibiotics to discourage development of microbial resistance, avoid side effects and reduce cost
  • Antibiotics should be used for:
    • Severe invasive bacterial diarrhoea eg Shigellosis
    • Cholera
    • Girdiasis
    • Suspected or proven sepsis
    • Immunocompromised children

Antibiotics are contraindicated in:

  • E. coli 0157: H7 because they increase the risk of Haemolytic Uraemic syndrome (HUS)
  • Uncomplicated salmonella enteritis because they prolong bacteria shedding

Next

zinc and diarrhoea
Zinc and diarrhoea
  • Zinc deficiency is common in developing countries and zinc is lost during diarrhoea
  • Zinc deficiency is associated with impaired electrolyte and water absorption, decreased brush border enzyme activity and impaired cellular and humoral immunity
  • Treatment with zinc reduces the duration and severity of AD and also reduces the frequency of further episodes during the subsequent 2-3 months
  • WHO recommends that children from developing countries with diarrhoea be given zinc for 10-14 days
    • 10mg daily for children <6 months
    • 20 mg daily for children >6 months

Next

how can we prevent diarrhoeal disease
How can we prevent diarrhoeal disease?

This involves intervention at two levels:

  • Primary prevention (to reduce disease transmission)
    • Rotavirus and measles vaccines
    • Handwashing with soap
    • Providing adequate and safe drinking water
    • Environmental sanitation
  • Secondary prevention (to reduce disease severity)
    • Promote breastfeeding
    • Vitamin A supplementation
    • Treatment of episodes of AD with zinc

Next

end of module
End of module
  • Well done! You have completed this module
  • Make sure that you repeat the module until you have a good score in the assessment
  • It is vital that you now apply the knowledge you have gained from this module into your management of children with AD
  • Please do let us know if you think that there are any ways that this module could be changed as a learning resource that is effective in improving practice
  • Please e-mail any comments to Dr. Senbanjo at [email protected]

Authors and acknowledgements

authors acknowledgement
Authors/Acknowledgement

Authors:

Dr. Idowu Senbanjo, Lecturer/Consultant

Paediatrician, Department of Paediatrics and

Child Health, Lagos State University College of

Medicine, Ikeja, Lagos, Nigeria.

Dr. Chinlye Ch‘ng, Consultant

Gastroenterologist/Hepatologist, Abertawe

Bro Morgannwg University Health Board,

Singleton Hospital, Swansea, UK.

Prof. Steve Allen, Professor of Paediatrics and

International Health, RCPCH International

Officer and David Baum Fellow, The

College of Medicine, Swansea University, UK.

Acknowledgement

We would like to acknowledge the British

Society of Gastroenterology for awarding

an educational grant which supported Dr. Senbanjo in developing this module.

Permissions

Please note that consent was obtained

from parents/carers to use the images in this module for teaching purposes only. The images should not be used for any other purpose.

We are very interested to receive feedback regarding any aspect of this module, especially if it helps us to improve it as a learning resource. Please e-mail any comments to Dr. Senbanjo at [email protected]

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