MANAGEMENT OF DIARRHOEA

By Dr Ashka Shah

PRINCIPLES OF MANAGEMENT Oral rehydration therapy Enteral feeding & diet selection Zinc supplements Additional therapies

probioticsantibioticsRececardotril

Signs Classification of dehydration

Treatment

No signs of dehydration

No dehydration Follow Plan A

Two of the following signs

Some dehydration

Follow plan B

•Restless, irritable•Sunken eyes•Tear absent•Dry mouth &tongue•Skin goes slowly•Thirst, drinks eagerly

PLAN OF MANAGEMENT

Signs Classification of

dehydration

Treatment

Two of the following signs

Severe dehydration

Follow plan C

•Unconcious•Floppy•Refusal to feed•Unable to drink•Very sunken eyes•Skin goes back very slowly

PLAN OF MANAGEMENT

PLAN A Cases with No Signs of Dehydration fluid loss is <5% of the body weight, children may

not show any clinical signs of dehydration Correct fluid deficit and ongoing fluid losses Give HAF or ORS Plan A involves counselling the child's mother about

the 3 Rules of Home treatment. GIVE EXTRA FLUID (as much as the child will take) CONTINUE FEEDING WHEN TO RETURN

PLAN-BCases with signs of Some Dehydration

REHYDRATION THERAPY Amount of ORS to be given in first

4 hrsAge < 4 months

4 -12 months

12m- 2 yrs

2-6 yrs

Wt (kg) < 6 6 - < 10 10 - <12 12 - 19

ORS(ml) 200-400 400-700 700-900 900-1400

Glass(No.)

1 - 2 2 - 3 3 – 4 4 - 7

PLAN B Use the child’s age only when we do not know

the weight. The approximate amount of ORS required (in

ml) can also be calculated by multiplying the child’s weight (in kg) × 75

Show the mother how to give ORS solution After 4 hours

Reassess and classify the child for dehydration Select the appropriate plan to continue treatmentBegin feeding the child in clinic

PLAN B After signs of severe dehydration

disappear & child is able to drink, further therapy should be continued with ORS as per plan A or B

Before the mother leaves the hospital two packets of ORS must be given.

PLAN C Cases with signs of Some Dehydration 1% diarrhoea may develop severe dehydration. Children with severe dehydration must be admitted. Child is rehydrated quickly by using I/V infusion. I/V infusions recommended :

R/L solution N/S when R/L is not available 1/2 N/S with 5% dextrose is acceptable

Plain glucose is unsuitable solution

PLAN C Reassess the infant every 15-30 min. until a

strong radial pulse is present. Thereafter, reassess the infant by skin pinch

and level of consciousness at least every 1-hour

Also give ORS (about 5 ml/kg/hour) as soon as the infant can drink: usually after 3-4 hours

Reassess the infant after 6 hours & classify dehydration then choose the appropriate plan (A,B, or C) to continue treatment

PLAN C After signs of severe dehydration

disappear & child is able to drink, further therapy should be continued with ORS as per plan A or B

Before the mother leaves the hospital two packets of ORS must be given.

ORAL REHYDRATION THERAPY It is a balanced mixture of glucose and

electrolytes Almost all deaths from diarrhoea can be

prevented by ORS

MECHANISM OF ACTIONSodium promotes absorption of water from the intestineGlucose promotes the absorption of sodium and water from the intestine

Ingredients Old-ORS New-ORS (WHO-ORS) (Reduced osmolarity ORS)

Sodium (mmol/L) 90 75Potassium (mmol/L) 20 20Chloride (mmol/L) 80 65Citrate (mmol/L) 10 10Glucose (mmol/L) 111 75Osmolarity (mosml/L) 311 245

ORAL REHYDRATION THERAPY

LIMITATION OF ORS Does not reduce the diarrhea stool volume and

duration Parents are concerned to stop the diarrhea but not the

dehydration due to diarrhea It is not or less effective in

ShockAn ileusIntussusceptionCarbohydrate intoleranceSevere emesisHigh stool output

ENTERAL FEEDING AND DIET SELECTION After rehydration completion, food should be

reintroduced Continue oral rehydration to replace ongoing

lossesStart breast feeding as soon as possible

Food with complex carbohydrate is preffered Avoid fatty food or food with simple sugars

(juices, carbonated soda) Energy density should be 1kcal/grm

Energy intake should be 100 kcal/kg/day and protein intake of 2-3 grm/kg/day.

Milk should not be diluted with water during any phase of acute diarrhoea.

Milk can also be given as milk cereal mixture e.g. dalia, milk-rice mixture.

This technique reduces the lactose load & preserving energy density.

ENTERAL FEEDING AND DIET SELECTION

ENTERAL FEEDING AND DIET SELECTION To make foods-energy dense some of

preparation are:- - Khichri with oil - Rice with curd & sugar- Mashed banana with milk or curd - Mashed potatoes with oil.

ZINC SUPPLEMENTS 10 mg/kg in infants <6 months and 20

mg/kg in >6 months of age. Benefits of zinc therapy

Reduced duration and severityprevent recurrencereduction of inappropriate use of

antibiotics

ANTIBIOTICS IN DIARRHOEA Indication

Suspected cholera with severe dehydration Bloody diarrhoea Associated non gastrointestinal infection Severely malnurished or

immunocompromised child Specific infection

PROBIOTICS It means bacteria associated with beneficial effects

for humans and animals. Can inhibit the growth and adhesion of a range of

entero-pathogens Indicated in

- Treatment and prevention of acute diarrhoea caused by rotavirus in children - Antibiotic associated diarrhoea

Probiotic strains - Lactobacillus rhamnosus GG and Bifidobacterium

lactis BB-12

POTENTIAL USES OF PROBIOTICS -diarrhoea -Helicobacter pylori infection -Inflammatory bowel disease -Cancers -To increase Immunity -Allergy -Heart disease -Urogenital tract infections

PROBIOTICS

ADDITIONAL THERAPY Antiemetics like ondansetron can be

useful during rehydration therapy. Racecadotril an enkephalinase

inhibitor is found useful to reduce stool output

Exclusive Breast Feeding Bottle feeding should be avoided Improved personal hygiene and sanitation

Wash Hand Eat clean Food Drink clean water

Immunization e.g. Measles, Rota virus Vit. A - Prophylactic doses Better Nutrition Improved case management

PREVENTION OF DIARRHOEA

ROTA VIRUS VACCINATION Rotashield vaccine -1999 Withdrawn because of its association with

intussuscption Two new oral, live attenuated rotavirus vaccines were

licensed in 2006 with very good safety and efficacy The first dose administered between ages 6-10 weeks

. subsequent doses at intervals 4-10 weeks. Vaccination should not be initiated before 6weeks and

after 12 weeks of age. All doses should be administered before 32 weeks.

ROTA VIRUS VACCINATIONRota Rix vaccine Rota Teq vaccine

Oral, live attenuated

Oral, live attenuated, pentavalent vaccine.

Contains 5 live reassortant rotaviruses

2 dose schedule 3 dose schedule

1st dose - 2 month of age at 2 month of age

2nd dose- 4 month 4 month of age…………………………

. 6 month of age

NATIONAL DIARRHOEAL DISEASE CONTROL PROGRAMME

National ORT Programme was incepted in 1985- 86 From 1992-93 the programme has become a part

of CSSM Programme. CSSM programme become a part of RCH

programme in 1997 In RCH Programme, policy of IMCI was adopted Strategy of IMCI was to address all children and not

only sick children IMCI focused on life threatening illnesses-

diarrhoea, Pneumonia, Measles, Malaria etc.

IMNCI Since 2003 - DDCP included in IMNCI

which includes Neonates of 0-7 days Incorporating national guidelines on diarrhoea, ARI ,Malaria, Anaemia, Vit. A supplementation & Immunizations

STRATEGIES OF IMNCI Ensure standard case management of diarrhoea

by training of medical and other health personnel.

Promote standard case management practices among private practitioners through IMA and IAP.

Improve maternal knowledge on home management and recognition of danger signs of diarrhoea for immediate medical care.

CASE MANAGEMENT STRATEGYCLASSIFICATION:

PINK : Child needs referral ( Inpatient care)

YELLOW : Child needs specific treatment, provide

it at home (e.g. Antibiotics, ORS)

GREEN : Child needs no medicine, give home care

LIMITATIONS OF IMNCI Outpatient Facility Based

Community activities not given adequate focus

Vertical initiatives in Non IMNCI districts sorely lacking