Transcript Diarrhea is one of the major causes of infant morbidity and mortality worldwide.

Diarrhea
is one of the major causes of
infant morbidity and mortality
worldwide.
Every year approximately 500
million episodes of diarrhea
are registered.
Approximately 4 million children
below 5 years of age die per
year from diarrheal diseases
(every 6 seconds – one child)



Infection is the major cause of acute diarrhea.
So, very often synonym to it is acute
gastroenteritis.
In developing countries, an estimated overall
incidence of acute gastroenteritis ranges from
6 to 12 episodes of diarrhea per year in
children under 5 years of age compared to
1.3 to 2.3 episodes in developed countries.
The economic burden of acute gastroenteritis
is enormous. In the US alone, gastroenteritis
accounts for more than 220,000 hospital
admissions per year in children under 5 years
of age (10 % of all hospitalizations in this age
group), resulting in an estimated direct annual
cost of $2 billion.
It is well accepted that diarrhea of
infancy is associated with malnutrition
and is primarily a nutritional disease.
 Thus, the main objective of treatment is
immediate and adequate nutritional
support.
 Appropriate nutrient supply during the
acute stage can also prevent
progression to the protracted diarrhea of
infancy.

Nutritional treatment
in children with
diarrhea
By Nataliya Haliyash, MD, BSN
Diarrhea
is increase in the number of stools
and/or a decrease in their
consistency as a result of
malabsorption or alterations of water
and electrolyte transport by the
alimentary tract.
Diarrhea may be acute or chronic.
Grades of diarrhea



Mild diarrhea – 4 to 7 loose stools each day
as a rule without other evidence of illness
Moderate diarrhea – 8 to 15 loose or watery
stooles daily with elevated temperature,
vomiting, irritability, mild dehydration
Severe diarrhea – numerous (>15) to
continuous stools, evident signs of moderate
to severe dehydration, drawn, flaccid
expression, high pitched cry, irritable or
lethargic or even comatose.
Acute gastroenteritis
is characterized by the passage of ≥3
loose or watery stools in an 24 hour
period, or the passage of one or more
bloody stools, with or without vomiting,
nausea, fever, and abdominal pain.
Acute gastroenteritis usually refers to an
illness lasting no longer than 10-14 days.
Etiology of acute diarrhea
Viral agents
Human rotavirus
Small round viruses:
Norwalk
Taunton
Snow Mountain
Astrovirus
Wollan
Enteric adenoviruses
Coronaviruses
Bacterial pathogens
Escherichia coli
Campylobacter
Salmonella
Shigella
Vibrio cholera
Yersinia enterocolitica
Clostridium difficile
Parasitic pathogens
Protozoa:
Giardia lamblia
Cryptosporidium
Entamoeba histolytica
Balantidium coli
Helmintic pathogens
Nematodes:
Ancylostoma duodenale
Strongyloides stercoralis
Necator americanus
Trichuris trichiura
Trematodes:
Schistosoma
Cestodes:
Taenia solium
Taenia saginata
Diphyllobothrium latum
Pathogenesis of Acute Diarrhea


1.
2.
3.
4.
5.
Diarrhea results when the net intestinal
fecal loss of fluid and salt exceeds the
absorbed amount.
There are 5 pathogenic forms of diarrhea:
Toxigenic diarrhea
Osmotic diarrhea
Secretory diarrhea
Invasive diarrhea
Motility disorders
Toxigenic diarrhea





Toxins from bacteria, like enterotoxigenic E.coli
or Vibrio cholerae, bind to specific receptors:
labile toxin (LT) raises the level of cyclic
guanosine monophosphate (cGMP) in the
intestinal mucosa,
stable toxin (ST) increases the adenasine
3‫׳‬:5‫׳‬-cyclic monophosphate (cAMP)
This leads to blocking the absorption of Na and
Clˉ ions into the villous enterocytes.
LT induce the secretion of Clˉ and HCO3ˉ ions
by crypt cells.
Osmotic diarrhea
Characterized by a positive osmotic gap
of the stool
 Clinically, osmotic diarrhea is
distinguished by the fact that the
diarrhea diminishes when the patient
fasts or stops eating the poorly ingested
solute.

Differential diagnosis of
osmotic and secretory diarrhea
Stools
Osmotic diarrhea
Secretory diarrhea
Electrolytes
Na<70 mEq/l
Na>70 mEq/l
Osmolality
>(Na + K)2
=(Na + K)2
pH
<5
>6
Reducing
substances
Positive
Negative
Volume
< 200 ml/day
> 200 ml/day
Secretory diarrhea



There is no positive osmotic gap and the
stool osmolality is equal to the ionic
constituents:
(Na + K)2 = stool osmolality
Food ingestion does not usually affect the
stool volume
The stool is watery without blood or pus and
is characterized by very high volume and ion
output
Invasive diarrhea
Is caused by direct mucosal damage by
the invasive organism
 It is similar to colitis and is usually
associated with blood and mucous.

Motility disorders
Hypermotility can cause diarrhea by
reduction of contact time between
intestinal mucosa and its contents,
despite normal absorption function of
the cell
 Hypomotility can be primary, as in
idiopathic intestinal pseudo-obstruction
syndrome, or secondary to neuronal
disorders.

Clinical characteristics of infectious
gastroenteritis in depence on
enteropathologic cause.
Organism
Rotavirus
Incubation
period:2-3 d.
Norwalk-like
viruses
Inc.period:
1-2 days
Characteristics
Comments
Abrupt onset
Fever (≥ 38°C)
for 48 hh
Associated upper
resp.tract infection
Fever
Loss of appetite
Nausea/vomiting
Abdominal pain
Malaise
Incidence higher in
cool weather
6- to 24-month-old
infants are more
vulnerable

Source of
infection: drinking
water, food
Affects all ages
Self-limited
Pathogenic
Escherichia coli
Incubation
period: highly
variable
Salmonella
groups
(nontyphoidae)
– gramnegative, nonencapsulated,
nonsporulating
Incubation
period: 6 hh-21
day
Diarrhea with moistgreen, watery stool with
mucus; becomes explosive
Vomiting may be present
from onset
Abdominal distension
Fever, intoxication
Rapid onset
Variable symptoms – mild
to severe
Nausea, vomiting, and
colicky abdominal pain
followed by diarrhea,
occasionally with blood
and mucus
Infants may be afebrile
and nontoxic

•Incidence
higher
in summer
•Usually
interpersonal
transmission, but
may transmit via
inanimate objects
•Highest
incidence
in children
younger than 9
years, especially
infants
•Transmission –
via contaminated
food and drink,
more commonly
poultry and eggs
Shigella groups
– gramnegative,
nonmotile,
anaerobic bacilli
Incubation
period: 1-7 days

Onset usually abrupt
Fever (to 40.5°C) and
cramping abdominal pain
initially
Febrile convulsions in 10
% cases
Headache, neck rigidity,
delirium
Transmitted
directly or
indirectly
from infected
persons
Vibrio cholerae
groups
Inc.period: 1-3
days
Sudden onset of profuse,
watery diarrhea without
cramping, tenesmus, or anal
irritation
Stools are intermittemt at
first, then almost continuous
Stools are whitish, almost
clear, with flecks of mucus –
Rare in
infants
Mortality is
high
Transmitted
via
contaminated
food or water
Food poisoning:
Staphylococcus
Incub.period:
4-6 hours
Nausea,vomiting
•Transfered
via
Severe abdominal contaminated food –
inadequately cooked:
cramps
custards, mayonnaise,
Profuse diarrhea
cream-filled desserts
Shock may occur
•Self-limited (24-72
in severe cases
hours)
May be a mild
•Exellent prognosis
fever
Botulism
Clostridium
botulinum
Incub.period:
12 hr – 3 days
Nausea,vomiting
Transfered via
contaminated food
Variable severity –
mild symptoms to
rapidly fatal within a
few hours
Antitoxin
administration
Diarrhea
CNS
symptoms
with curare-like
effect
Dry mouth,
dysphagia
Diagnosis



Diagnosis is based on:
the history, physical exam, and laboratory
studies focused on evaluating the child's
hydration status and identifying the causative
agent.
The history should include the following data:
– • Recent exposure to infectious agents
– • Travel history
– • Exposure to contaminated food and water
supplies
– • Exposure to turtles
– • Attendance at a day-care center
If no systemic manifestations are
present:
Diagnostic laboratory tests are not
indicated.
 Stool cultures should be performed for:

– children with a fever lasting more than 24
hours,
– blood or mucus in the stool,
– a family or household member with similar
symptoms,
– or a positive stool white blood cell stain.
Treatment
The main treatment aims are:
 To prevent dehydration – restoration
and maintenance of adequate hydration
and electrolyte balance.
 Nutritional support, adequate to prevent
protracted diarrhea and malnutrition.
DEHYDRATION
Dehydration is a critical condition that
results from an extracellular fluid loss.
 Since a large portion of a child's body
fluid is located in extracellular spaces, a
child is more susceptible to dehydration
states than an adult.
 Dehydration that is not corrected will
lead to hypovolemic shock and death.

Types of dehydration
1.
2.
3.
hypotonic,
isotonic,
hypertonic
Conditions causing dehydration









Vomiting
Diarrhea
Burns
Hemorrhage
Nasogastric suctioning and drainage loss
NPO status or inadequate fluid/food intake
due to
illness
Overuse of diuretics or enemas
Adrenal insufficiency
Clinical Manifestations
Depend on the degree of dehydration.
 Weight loss
 Rapid-thready pulse
 Hypotension
 Decreased peripheral circulation
 Decreased urinary output
 Increased specific gravity
 decreased skin turgor
 dry mucous membranes
 absence of tears
 a sunken fontanel in infants.
Clinical Manifestations Associated
with Degree of Dehydration
Nursing Diagnoses
Nursing diagnoses appropriate for a child with
dehydration may include:
1. Deficient fluid volume related to excessive
fluid volume loss or inadequate fluid intake.
2. Risk for injury (fall) related to orthostatic
(postural) hypotension.
3 . Deficient knowledge (caregiver) related to
lack of exposure to information about
preventing/detecting dehydration.

Outcome Identification
1. The child will receive sufficient fluids to
replace losses.
2. The child will exhibit signs of adequate
hydration.
3. The child will not fall or sustain other injuries
while hypotensive or lethargic.
4. Caregivers will demonstrate understanding of
conditions that can lead to dehydration and of
the early signs and symptoms.
Planning/Implementation

Nursing interventions include:
– administration of IV fluids,
– assessment of daily weight, vital signs, and
maintenance of accurate intake and output
records.
– Injury due to falls can be prevented by making
sure that the side rails of the bed are raised,
assessing level of consciousness, and monitoring
the serum sodium level.
– An elevation in serum sodium will cause the brain
cells to dehydrate and result in a loss of
consciousness if not corrected quickly.
Treatment
What about antimicrobial therapy?
In about 30 % of patients no specific
agent can be found
 Most of the isolated pathogenic
organisms are viral
 The majority of the bacterial pathogens
are self-limited
 In some cases, antimicrobial therapy
prolongs the infection duration
 Antibiotic therapy has no effect on fluid
transport nor on nutritional support

When should antibiotics be used?
In young infants
 In immunocompromised patients
 When a systemic bacteremia is
suspected.
 In case of specific persisting infection
caused by Yersinia, Campylobacter, and
Giardia

Rehydration
In the majority of cases of acute
diarrhea with mild or moderate
dehydration, this aim can be achieved
with oral rehydration solutions (ORS)
 Severe dehydration requires immediate
admission to hospital and intravenous
replacement of fluid and electrolytes.

The rationale for the use of ORS
1.
2.
During diarrhea, the normal
mechanism for water and sodium
absorption is impaired, so, the
replacement of water or saline fluids
alone will only lead to more diarrhea.
The sodium-glucose-coupled transport
generally remains intact. This
mechanism stimulates water transport
by solvent drag.
The basic components of ORS
Glucose
 Electrolytes
in an isotonic solution.

In the World Health Organization formula
the glucose concentration is 2 %.
WHO recommendations for a
sodium concentration
90 mEq/l, essentially for treatment of
cholera
 30-60 mEq/l for countries, where
cholera is not a concern and the stool
sodium concentration in diarrheal illness
is much lower
 30-40 mmol/l for neonates up to 2 mo
whose kidneys have less capacity to
excrete excess amounts of fluid and salt

Rehydration Fluids

The World Health Organization recommends
the following electrolyte concentrations for
rehydration fluids:
–
–
–
–
–

20 g glucose/L,
90 mEq sodium/L,
80 mEq chloride/L,
20 mEq potassium/L,
and 30 mEq bicarbonate/L.
Encourage caregivers to look at product
labels and make sure that the rehydration
fluid they are choosing has the above
electrolyte concentrations.
Composition of oral electrolyte
solutions (in mEq/l)
Na+
K+
Clˉ
Other anion
CHO(%)
WHO solution
90
20
80
30
2
Gastrolyte
90
20
80
30
2
Pedialyte
45
20
35
30
2.5
Rehydralyte
75
20
65
30
2.5
infalyte
50
20
40
30
2
Composition of
“clear liquid” solutions
Na+
K+
CHO(%)
Pepsi Cola
1-2
0.1
10.9
Coca Cola
1-2
0.1
10
Root beer
6
0.6
10.6
Super-ORS



Recent studies demonstrate the advantage of
short glucose polymers as the carbohydrate
source in ORS
Traditionally it is widely used rice water + 3-5
% sugar syrup.
Or carrot decoction: 500 g of cleansed carrot
boil in 1 l of water during 1 hour, then mash it
to homogenous mass and add boiled water
up to 1 l. Boil for 10 min. Add 3 tsf of lemon
juice. Give 1-2 teaspoon every 5-10 min up to
400 ml/day.
Fluid needs for rehydration
(in ml/kg)
Grade of
dehydration
Weight
defficit, %
0-12 mo
1-5 yrs
6-10 yrs
I
(mild)
1-5
130-150
100-125
75-100
6-10
170-200
130-170
100-110
>10
200-230
175-200
100-150
II
(moderate)
III
(severe)
Calculating fluid loss
from weight loss:
Fluid lost can be calculated according to
weight lost.
 One kilogram of body weight equals 1 L
of water.
 Therefore, each kilogram of weight lost
is equal to 1,000 ml of fluid lost.

It is important to know the last weight of
the child before the beginning of
diarrhea
 The total amount of rehydration fluid is
counted per factual weight
 The total amount of rehydration fluid is
divided per 2 days: ⅔ - on the 1st day, ⅓
- on the 2nd day.

For example:
The child with body weight 6 kg have lost 10 %
from last weighing due to diarrhea.
So, we have to prescribe 600 ml of fluid for
rehydration: 400 ml on the 1st day, 200 ml on
the 2nd day.
Additionally,
 for perspiration 50 ml/kg (506=300 ml)
 For diuresis 40 ml/kg (406=240 ml)
 For vomiting and stool losses 60-120 ml/kg
(606=360 ml)
So, the total fluid amount on the 1st day is
400+300+240+360 = 1300 ml (215 ml/kg)
The total fluid amount on the 2nd day is
200+300+240+360 = 1100 ml (185 ml/kg)

50 % of this amount is given as oral
electrolyte solutions
 50 % as herbal teas, herbal decoctions
(Hamomilla, Rosa canina, Fenhel)
 Raisins water is prepared:
Put 7-9 raisins into just boiled water (250
ml). Keep it covered for 15-20 min.
Cool. Give it to child.

Nutritional therapy
In this question opinions differ: “bowel
rest” versus “early feeding” is still
controversial.
 Generally, formula feeding should be
introduced gradually by starting with
dilute mixtures.




In practice, refeeding can start gradually after
24 hr of only fluid intake, i.e.,”bowel rest”.
An exception is made for nursing infants, who
should continue their regular feeding.
Children already on solid foods are easier to
handle. Food with a high content of
disaccharides and monosaccharides (fruits,
sweets) should be withheld in the
convalescent period. Foods with starch
carbohydrates (cereal, rice, noodles,
bananas, potatoes, carrot) should be
encouraged.



•
•
It is important to give often small food-intakes
(up to 8-10 times per day)
Administration of pancreatini (0.2 3-4 times
per day immideately after food) or
panzynormi (⅓ tab. 2 times per day for infants
under 6 mo) for 3-7 days is effective.
Enterosorbent drugs are given 1.5 hr after
and 1 hr before any food or drug intake from
the onset of diarrhea:
Enterodes : dissolve 5 g in 100 ml of 5 %
glucose and give 5-10 ml/kg 2-3 times/day for
3-5-7 days
Enterosgel : 1g/kg
Probiotics
For infants under 6 mo:
 Bifidumbacterin – 2-3 doses 3 t/day for
3 weeks
 Lactobacterin – 2-3 doses 2 t/day for 3
weeks
 L.acidophilus – 5 doses once daily 1-3
weeks
 For children older 6 mo:
 Coli-bacterin – 2-5 doses 2 t/day for 3-4
weeks

Treatment of severe (>10%)
dehydration:
Treat as an emergency.
 Begin IV therapy (40 ml/kg/hr) until child
improves;
 then offer 50-100 ml/kg ORS.
 Obtain and monitor electrolyte levels.
 Reassess frequently.
 Provide ORS when alert.

Adding Potassium to Intravenous
Solutions





Be sure that the child is able to void (1 -2 ml/kg/hr)
before adding potassium to the IV.
Children who are dehydrated are oliguric and can
become anuric. An anuric child will not be able to
excrete electrolytes that are in the IV solution;
therefore, if potassium is added to the IV, it would
result in an elevated serum potassium. An elevated
serum potassium can cause cardiac irritability and
ventricular fibrillation.
Always check the dose and dosage calculations prior
to giving. Never give more than 40 mEq/L at a rate
not to exceed 1 mEq/kg/hr.
After adding potassium to an IV bag, shake it to make
sure the potassium is equally distributed.
Never give potassium by IV push.
Thank you for attention