Treatment of Diarrhea Hitting out Irrational Practices

1. Treatment of Diarrhea�Hitting out Irrational Practices B.R.Thapa Professor & Chief Pediatric Gastroenterology, Hepatology & Nutrition, PGIMER,Chandigarh-160012

2. Quantum of Problem Great public health problem in developing countries II killer disease High Morbidity & Mortality. 70% deaths due to dehydration. ORS brought revolution : Greatest invention of century. 5 Millions - 1.5 millions deaths/ annum now. Main focus on Prolonged/ Persistent diarrhea/CD.

3. Physiological Definition of Diarrhea Loss of fluid and electrolytes via stools is net result of imbalance between secretory and absorptive processes in small & large intestine. Electrolytes have a critical role in the regulation of water absorption and secretion across the intestine.

5. What is not Diarrhea ? Stools of an infant Breast fed Artificially fed Exaggerated gastrocolic reflex Irritable bowel syndrome (IBS) Spurious / factitious diarrhea

6. Age specific incidence for diarrhoea episode per Child per year from 2 reviews of prospective studies in developing areas,1980 - 2000 Incidence of diarrhoea Overall, this impressive decrease in mortality was not associated with a parallel decrease in morbidity due to diarrhoea. The incidence of diarrhoea per age group did not vary much in the last 50 years,especially in the last 20 years. In 1985 3.5 episodes per child per year In 2000 3.2 episodes per child per year Incidence of diarrhoea Overall, this impressive decrease in mortality was not associated with a parallel decrease in morbidity due to diarrhoea. The incidence of diarrhoea per age group did not vary much in the last 50 years,especially in the last 20 years. In 1985 3.5 episodes per child per year In 2000 3.2 episodes per child per year

7. Types of Diarrhea (a) Depending upon duration. Acute diarrhea 3 - 7 days Prolonged or Indeterminate 8 - 14 days Persistent diarrhea > 14 days (b) Depending upon characteristics of stools. Watery diarrhea --- Secretory & Osmotic Bloody diarrhea --- Blood & Mucus (Dysentery) (c) Severity of diarrhea Diarrhea with severe malnutrition Diarrhea with HIV infection Diarrhea with the other immune deficient states.

8. Treatment of Acute Diarrhea Oral Rehydration Therapy Dietary therapy Zinc therapy Antimicrobials Others

9. Oral Rehydration Therapy (ORT) Oral Rehydration Solution (ORS) WHO - ORS = Physiological Basis Other Fluids & Liquid Diets

10. Home Available Fluids Recommended Salt sugar solution Lemon water(Sikanjabi) Rice water / Kanjee Soups Dal water Lassi Coconut water Plain water Not recommended Simple sugar solution Glucose solution Carbonated soft drinks Fruit juices-tinned or fresh Fluids for athletes Gelatin desserts Tea/Coffee

11. Composition of WHO High & Low Osmolality ORS ------------------------------------------------------------------------------------------------------------------------------------ Ingredients / L High Osmolality Low Osmolality Components / Litre_________ Sodium Chloride 3.5 2.6 Na 90 75 Sodium Citrate 2.9 2.9 Citrate 10 10 or Sodium Carbonate 2.5 2.5 H CO3 30 30 Potassium Chloride 1.5 1.5 K 20 20 Glucose 20 13.5 Glucose 111 75 Osmolality 311 245 -------------------------------------------------------------------------------------------------------------------------------------

12. Limitations of WHO High Osm-ORS Does not lower volume, frequency and duration of diarrhea Induces vomiting due to taste, acceptability poor Enhances volume, purge rate & duration of diarrhea due to high osmolality More chances of dehydration � Dehydrating fluid So more oftenly IV fluids required Hypernatremia Good to correct deficit fluids but not good for maintenance therapy

13. Need of Low Osm-ORS Does lower volume, frequency & duration Equally effective in cholera, toxin related & RV diarrhea : Deficit & maintenance therapy No need of IV fluids Good for all ages infancy to adulthood Asymptomatic hyponatremia.

14. Role of Diet in Acute Diarrhea Dietary therapy Key role in treatment of diarrhea Gained great importance in recent years. Early refeeding during or after rehydration mandatory Delayed feeding even by one day-slow recovery Fasting deterimental for outcome

15. Advantages of Dietary Therapy Maintains nutrition, helps in absorption Faster recovery Take care of infection and avoids malnutrition Prevents prolongation of diarrhea Corrects malnutrition in mal-nourished children. Extra diet in convalescence / on recovery

16. What are the Diets to be Continued or Given ? Age appropriate diets Breast feeding : Aseptic paint. Artificially fed � milk Whatever child taking earlier Rice, khichri, pulses/ curd/yogurt Small frequent aliquots � Spoon & Katori

17. Foods to be Avoided Fat rich Fruits and fruit juices Junk foods Spicy foods Carbonated fluids Sugar & glucose rich foods

19. Role of Zinc in Acute Diarrhea Acute as well as persistent diarrhea Tremendous loss in stools. Absorption of Zinc intact Deficiency during diarrhea results into lowering of Cell division & maturation. Tissue growth & repair. Maturation of enterocytes. Brush border enzymes. Water & electrolyte absorption. Immune functions.

21. Antimicrobial Therapy in AD No proof that antibiotics effective in reducing the duration of diarrhea Cochrane review of 12 trials � no advantage rather adverse effects more in acute watery diarrhea.

22. Why Antibiotics are not Required in AD? Lack of knowledge of sensitivity of drug against causative agent Risk of development of resistant bacteria Risk of adverse reactions (AAD) Cost of treatment

23. Indications for Antimicrobials ----------------------------------------------------------------------------------------------------Micro - organisms Drugs ---------------------------------------------------------------------------------------------------- Bacteria - Shigella Nalidixic acid, Norfloxaclin Ciprofloxacin Ofloxacin, Cefotaxime, Ceftriaxone - Salmonella typhi Ciprofloxacin, Ofloxacin - Vibrio cholera Cotrimoxazole, Tetracycline,Ciprofloxacin, - Compylobacter jejuni Nalidixic acid, Norfloxacin, Furazolidine - EPEC (PD) Furazolidine, Norfloxacin, Cotrimoxazole Protozoa - Giardia lamblia } Mitronidazole, - Entameba histolytica } Tinidazole, Nitazoxanide, Furazolidine Cryptosporidium parvum Pramomycin, Nitazoxanide ----------------------------------------------------------------------------------------------------

24. Other Special Indications of Antibiotics. Severity of symptoms Host related risk factors * Severely sick child * Neonatal age * Septicemia * Malnutrition * Neurological involvement * HIV Infection * Septic shock State * Other immune deficiency * Invasive diarrhea Socio- environmental indications * Cholera * Nosocomial infection * At risk contacts. * Epidemics

25. Racecadotril Anti-secretory agent. ����� * Effective in treatment of acute diarrhea. ����� * Chronic HIV related diarrhea - Natural way. ����� * Reduction in hypersecretion of water and electohytes. ����� * Reduces diarrhea duration & number of stools significantly. ����� * No effect on motility, microflora of gut, safe and effective. Adverse reactions ��� * Nausea, thirst, vertigo ��� * Constipation, headache and vomiting. ��� * Transient.

26. Probiotics Duration of acute diarrhea decreases by one day in meta-analysis Saccharomyces boulardii : Strong benefit in AAD Shown in meta-analysis of seven studies

27. Diet in Indeterminate Diarrhea(8-14 days) Breast feeds continue Diet A : Low lactose diet Diet B : Lactose free diet, if no response to Diet A. Diet C : Monosaccharide based diet if no response to Diet B.

29. Traditional Practices to be Avoided Antimotility & antispasmodic drugs Stool binding agents Enzyme preparations & steroids Antimicrobial agents in combination Bottle feeding IV fluids to every case Starvation-Nothing like bowel rest These will hamper natural clearance, lower immunity, promote growth of unusual organisms & PEM

30. Practices to be Adopted Breast feeding: Aseptic paint for GIT Cereal supplementation Spoon & katori/ directly from pot Judicious use of antimicrobials Proper hygiene & sanitation Rotavirus vaccine

31. When to refer to higher center Duration of diarrhea more than 7 days Fast deteriorating condition No response to usual therapy Associated complications Severely malnourished child HIV positive

32. � to conclude Low Osm-ORS.. quite effective Zinc therapy ..important component Treat diarrhea with regular diet Limited use of antibiotics : Dysentery