Management of Acute Diarrhoea in ChildrenManagement 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 mortality amongst children in low and middle income countries.

Most deaths result from the associated shock, dehydration and electrolyte imbalance.

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

For more information about the authors of this module, click here

A child presenting with AD

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• 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.

How to use this moduleHow to use this module

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Learning OutcomesLearning 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:

1.Describe when to use oral and parenteral fluids and what solutions to use2.Identify the malnourished child and adjust management accordingly3.Describe when antibiotic treatment is indicated and the adverse effects of the overuse of antibiotics4.Describe the use of zinc in AD

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Definition of ADDefinition of AD• There is a wide range of normal stool

patterns in children which makes the 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 duration and may begin acutely. Typically, this occurs in association with malnutrition and/or HIV infection and may be complicated by dehydration

*Takes the shape of the container

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Diaper stained with watery stool

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 diarrhoea every 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, diarrhoea causes 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

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Causes and risk factors for ADCauses and risk factors for AD

• Microbial, host and environmental factors interact to cause AD

• Click on the boxes to find out more

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Clinical types of ADClinical types of AD• There are 2 main clinical types of AD

• Each is a reflection of the underlying pathology and altered physiology

Clinical type Description Common pathogens

Acute watery diarrhoea

This is the most common. It is of recent onset, commencing usually within 48 hours of presentation. It is usually self limiting and most episodes subside within 7 days. The main complication is dehydration.

Rotavirus, E. coli, Vibrio cholera

Acute bloody diarrhoea

Also referred to as dysentery. This is the passage of bloody stools. It is as a result of damage to the intestinal mucosa by an invasive organism. The complications here are sepsis, malnutrition and dehydration.

Shigella spp, Entamoeba histolytica

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Q1Write “T” or “F” on the answer sheet. When you have completed all 5 questions, click on each box and mark your answers.

Q1Write “T” or “F” on the answer sheet. When you have completed all 5 questions, click on each box and mark your answers.

a) The incidence of AD is highest in the age group 6-11

months

b) Acute diarrhoea is of duration less than 14 days

c) Rotavirus is a more common cause of diarrhoea in

developing countries than bacterial pathogens

d) Undernutrition is a major risk factor for persistent

diarrhoea

e) The largest proportion of deaths from diarrhoea occur in

East Asia

a

b

c

d

e

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Clinical scenariosClinical 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

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

Scenario A

Assessment and management of shockScenario 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.

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Q2. How would you proceed?

Write down your answer before moving to the next slide!

Scenario B

Clinical assessment of dehydrationScenario 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.

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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

Scenario C

Clinical assessment of dehydrationScenario 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 statusQ9: List 2 other key clinical signs consistent with this degree of

dehydration

Write down your answer and then go to the next slide

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Scenario D A child with bloody diarrhoeaScenario 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

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Answers: Scenario DAnswers: Scenario DQ11:• 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 prolapseQ12: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

fluoroquinolonesAlso manage any dehydrationEnsure breastfeeding is continued for childen still breastfeeding and normal diet for older childenFollow-up the child

Go to Case Scenario EGo 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.

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.NextNext

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

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: SAMQ14: 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 SAMThis 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!

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End of clinical scenarios

End of clinical scenarios

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

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

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Methods of nutritional assessmentMethods of nutritional assessmentNutritional assessment can be done by:• Looking for visible signs of severe

wasting such as muscle wasting and reduced subcutaneous fat

• Looking for other signs of malnutrition: angular stomatitis, conjuctival and palmar pallor, sparse and brittle hair, hypo- and hyperpigmentation of 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)

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Muscle wasting and loss of subcutaneous fat in a West African

child with marasmus

MUAC: recommended for nutritional assessment in dehydrationMUAC: 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/

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

Laboratory investigationsLaboratory investigationsAD is usually self-limiting and investigations to identify the infectious agent are not required

A. Indications for stool microscopy, culture and sensitivity

• Blood and mucus in the stool• High fever• Suspected septicaemic illness• Diagnosis of AD is uncertain

B. Indications for measurement of Urea and Electrolytes

• Severe dehydration or shock• Children on IV fluid• Children with severe malnutrition • Suspected cases of hypernatreamic dehydration

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Rational use of antibioticsRational 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

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Zinc and diarrhoeaZinc 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

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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

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End of moduleEnd 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 senbanjo001@yahoo.com

Authors and acknowledgements

Authors and acknowledgements

Authors/AcknowledgementAuthors/AcknowledgementAuthors: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.

AcknowledgementWe would like to acknowledge the British Society of Gastroenterology for awarding an educational grant which supported Dr.

Senbanjo in developing this module.

PermissionsPlease 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 senbanjo001@yahoo.com

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