III] - Control of Diarrhea Diseases [CDD]
Diarrhea: passage of liquid or watery stool for at least 3 times during 24 hours, consistency is more important than frequency.Note: breast fed child pass semi-solid stool pasty yellow stool which is not diarrhea.
Two types of diarrhea:Acute, which lasts for less than 14 days?
Persistent, which lasts for 14 days or longer?
Note: bloody diarrhea is called Dysentery which can be broadly categorized into amoebic bacillary with different treatment for each type.
Victims: children U 5 y of age is the major victims it is estimated that U 5 children may develop 1-12 episodes [attacks] of diarrhea per year, this will lead to growth failure other health complication.
Causes: diarrhea is caused by different M.O: viral, bacteria, parasites.
Contributing Factors: to diarrhea are unclear: water, dirty hands of children or mothers during child feeding and food spoilt by high temperature.Diarrhea leads to malnutrition growth retardation under weight, where the degree of growth retardation directly correlates to the duration of the diarrhea 1 day 25gm loss of weight.
Loss of appetite loss food intake
The mother gives the food away from child
Factors leading to growth deficit in a baby with Diarrhea:
Reduced food intake: due to anorexia [loss of appetite] where the child will not eat much, more over the mother withholds feeding the child.
Reduced absorption of nutrients due to rapid gut transient time [GTT] and enteropathy leading to such malabsorption.
Catabolic loss: Vomiting [loss of nutrients], fever leading to energy spenditure.
This malnutrition will lead to immunity reduction leading to more infections and more diarrheas and so on.
We are not scared from diarrhea because its usually self limiting [it is not the killer] but we are afraid from its serious outcome and especially dehydration [the killer], so we have to correct it quickly.
Dehydration:
A deficit in water and electrolytes { Na+, K+ , Cl-, HCO3-], this results from loss from stool, vomiting, urine, fever, sweat and breathing, and the inadequate replacement of this loss.
It is a defense mechanism was the body will increase peristalsis and fluid loss but the amount fluid of a child is limited and this will lead to a fluid electrolyte deficit.
Diarrhea in children is classified into
Diarrhea without dehydration
Diarrhea with some dehydration.
Sever dehydration.
Assessment of diarrhea cases for dehydration:
SignsABC1-ConditionWell, alertRestless, irritable Lethargic unconscious2-EyesNormal SunkenSunken3-ThirstDrinks normallyEager to drink Unable to drink4-Skin pinchGoes back quickly Slowly[1 sec.]Very slowly
[2 or more sec.]These were The main Four signsthen5-ClassificationNo dehydrationSome dehydration
[2 signs at least]Sever dehydration
[ at least 2 signs]6-TreatmentPlan A
[ at home]Plan B
[ in PHC]Plan C
[ Hospital]
Notes:
In the past they used to classify eyes to normal, sunken & very sunken but there is no such thing as very sunken, sometimes genetically the eyes are sunken so look at the mother or the father [look at there eyes] or ask them.
Thirst: eager means that he wants more fluid & follows the spoon or glass with his head.
Skin pinch: expose the abd. & pinch along the long. Axis, this can be easily demonstrated by pinching yourself, your father & your granddad normal, slow, slower due to loss of elasticity.
Note: in a diarrhea case, sometimes we don't have the 4 signs in the same category, but if you find two signs [at least] place in a certain category.
E.g. 1 sign in A & 1 sign in B + 2 signs in C we take C
Treatment Plan
Plan A
The aim: is to dehydration from occurring
Steps:
Give extra fluid: ORS [Oral Rehydration Solution] and home fluids.
Continue feeding of children [breast or another].
Teach the mother.
How to prepare and give ORS [1 liter of water 2 milk bottles or 4 bottles of coke] then we add the schat and give by cup and spoon or by cup directly, to be used within 24 hr of preparation [she must discard what remains after 24 h i.e. throw it away], to give him small cup of tea every time the child passes stool.
Signs of dehydration and danger signs by showing her picture of the main of dehydration and telling her to bring her child immediately to the center if such sign occur.
Plan B
The aim: is to correct dehydration
Steps:
Give ORS in the health center
WT. [kg] 75ml= volume given over a 4 hr period
Assess every hour.
Continue feeding or breast feeding.
Teach mother to prepare and give ORS as in plan A.
Assess every hour.
If the child vomits the ORS, wait for 10 minutes and then restart giving him the solution slowly.
After assessment
If no dehydration ------------go to plan A
If some dehydration -------- go to plan B
If severe dehydration ------- go to plan C
Note:
Puffiness of the face and eyes is a sign of over hydration.
Plan C
The aim: is to correct dehydration urgently [immediately].
Rout: IV or Naso gastric tube [because we have to act fast].
In IV: give Ringers lactate solution, if it is not available then use normal saline.
Wt. [kg] 100 ml over a period of:
Age30ml/ kg 70 ml/kg < 1 year1 hr5 hr--- 6 hr> 1 year30 min2 and 1/2 hr3 hr
Explanation:
The whole solution is 100%
-So for those under 1 year: give 30% of the solution in the 1st hour and 70% over the next 5-6 hours.
- For those over 1 year: give 30% of the solution in the first 30 minutes, and 70% over the next 3 hours, where rehydration will be achieved in 4-6 hours.
Do not attempt Naso gastric tube because it is not the usual practice in this country.
The next steps:
Reassess every hour, if no improvement, give fluid more rapidly.
If the patient can drink: give ORS in 5 ml/kg/ hr or choose the appropriate plan accordingly:
If rehydrated ------------------ Plan A
If some dehydration ---------- Plan B
Oral Rehydration Solution:
Composition:
Na: 3.5gm, NaHCO3:2.5gm, KCl: 1.5gm, Glucose: 20gm in 1000 ml [1liter] of water.
Note:
Some replace NaHCO3 by 2.9 gm Trisodium Citrate Dihydrate which lessens vomiting and give more suitable taste and more stable.
-Advantages of ORS: Cheap, effective, easy to be given so this is why 95% of the cases are treated by this ORS.
-The water should be boiled and cooled before the powder is added to avoid the loss of bicarbonate.
-In winter, warm it to 400C to increase acceptability and that increase the rate of absorption and decrease the risk of a drop in the body temperature.
- If no ORS is available we use home prepared fluids: household food solutions, rice water, soups, fruit juices, and salt and sugar solutions.
[One teaspoon of salt + one table spoon of sugar].
Fatality rate has decreased a lot after the introduction of the ORS.
Management of Chronic [Persistent] Diarrhea:
If the baby is under 6 months ------- go to hospital
If also dehydrated ------- correct dehydration ------ refer to hospital.
If age > 6 months and not dehydrated teach the mother: If not A or B, then the therapy is mainly dietary:
1-Dilute any animal milk given to the child with an equal volume of water or replace with fermented milk products such as yogurt [for 5 days].
2- Increase energy intake: 6 meals per day of thick cereals and added oils fat + vegetables + white meat.
3- Reassess in 5 days
- If persistent ----------- refer to hospital
- If diarrhea has stopped, teach the mother to use the regular diet, resume the usual animal milk and the regular food and monitor after one month, use growth charts.
Management of blood in stool:
If bacillary dysentery [shigella]: give Co-trimoxazol or trimetheprim.
-If amoebic dysentery: give metroindazol [flagyl].
The management of diarrhea with sever dehydration is very expensive and with bad prognosis.
Reasons for failure of ORS therapy:
High purging rate [e.g. 15 20 times/ day].
Persistent vomiting.Sever dehydration.
Inability to drink [or refusal].
Glucose malabsorption.
Abdominal distention and ileus.
Incorrect preparation or administration or ORS.
*Usually we dont give antibiotic for diarrhea cases except when:
Suspicion for diarrhea due to cholera --------- give tetracyclineBacillary dysentery [shiegella]: Cotrimoxazol, Trimethoprim.
*We give antiparasitic infection drugs when the is evidence of: Ameobiasis & Giardiasis were give metronidazol.
Drugs with no role in RX of childhood diarrhea:
Sulfonamides.Neomycin & Streptomycin.
Clioquinol or other halogenated Oxyquinolines.
Anti motility agents: enterostop
Anti-emetics.
Kaolin and charcoal.
Cardiac stimulants or steroids.
Purgatives.
Indications for IV therapy:
Serve dehydration with or without signs of shock.
Fatigue, coma, unconsciousness.
Persistent vomiting.
Prolonged Liguria.
Any serious complication.
Intervention those are effective and feasible for the control and prevention of diarrhea:
Breast feeding.Improvement of weaning practice.
Hand washing and clean water usage.
Proper disposal of stool of young children.
Use of latrines.
Measles immunization: the common serious complications of measles includes: Diarrhea, Pneumonia and Malnutrition.
Other sides were of:
A lethargic child, a dehydrated child, one with sunken eyes,severe dehydration, skin pinch, rehydration by spoon and cup method.
Primary Health Care Lec: 8