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Management 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.
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 module
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Click here to move to the next slide

Learning 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: Describe when to use oral and parenteral fluids and what solutions to use Identify the malnourished child and adjust management accordingly Describe when antibiotic treatment is indicated and the adverse effects of the overuse of antibiotics Describe the use of zinc in AD
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Definition 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

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 AD

Microbial, host and environmental factors interact to cause AD Click on the boxes to find out more

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Host factors
Biological factors increase susceptibility to AD
Age: The incidence of AD peaks at around age 6-11 months, remains high through 24 months and then decreases Failure to get immunised against rotavirus Failure of measles vaccination; measles predisposes to diarrhoea by damage to the intestinal epithelium and immune suppression Malnutrition is associated with an increased incidence, severity and duration of diarrhoea
Behavioral factors increase the risk of AD
Not breastfeeding exclusively for 6 months Using infant feeding bottles: they easily become contaminated with diarrhoea pathogens and are difficult to clean Not washing hands after defecation, handling faeces or before handling food
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Environmental factors
These include: Seasonality:The incidence of AD has seasonal variation in many regions In temperate climates, viral diarrhoea peaks during winter whereas bacterial diarhoea occurs more frequently during the warm season In tropical areas, viral and bacterial diarrhoeal occur throughout the year with increased frequency during drier, cooler months. Poor domestic and environmental sanitation especially unsafe water Poverty
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An improved water supply in a peri-urban setting

Common causes of AD

More than 20 viruses, bacteria and parasites have been associated with acute diarhoea Worldwide, rotavirus is the commonest cause of severe dehydrating diarrhoea causing 0.6 million deaths annually, 90% of which occur in developing countries The incidence of specific pathogens varies between developed and developing countries In developed countries, about 40% of AD cases are due to rotavirus and only 10-20% are of bacterial origin while in developing countries, 50-60% are caused by bacteria while 15-25% are due to rotavirus
Other viral agents Enteric adenoviruses Astrovirus Human calciviruses (norovirus and sapovirus)
Bacteria E. coli (EAEC, EPEC, EIEC) Shigella spp Staphylococcus spp Salmonella spp Yersinia enterocolitica Campylobacter jejuni Vibrio cholera
Parasites Entamoeba histolitica Girdia lamblia Cryptosporidium Trichuris trichuria Strongyloides stercoralis
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Clinical 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. The incidence of AD is highest in the age group 6-11 months Acute diarrhoea is of duration less than 14 days Rotavirus is a more common cause of diarrhoea in developing countries than bacterial pathogens Undernutrition is a major risk factor for persistent diarrhoea The largest proportion of deaths from diarrhoea occur in East Asia
a
b
c
d
e
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Answer to Q1a

This statement is True. The incidence of diarrhoea is highest in age group 6-11 months. This is likely to be associated with declining levels of antibodies acquired from the mother, lack of active immunity in the infant and the introduction of complementary foods that may be contaminated with diarrhoeal pathogens.

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Answer to Q1b
This statement is True Diarrhoea that begins acutely and lasts less than 14 days is called acute diarrhoea Diarrhoea lasting longer than 14 days is persistent diarrhoea
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Answer to Q1c

This statement is False Bacterial pathogens cause most cases of diarrhoea in developing countries Bacteria are responsible for 50-60% of cases of AD while rotavirus is responsible for 15-25% cases


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Answer to Q1d

This statement is True. Undernourished children are at higher risk of suffering more frequent, severe and prolonged episodes of diarrhoea

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Answer to Q1e
This statement is False East Asia and Pacific, South Asia and Africa are home to 9%, 38% and 46% respectively of child deaths from diarrhoea The rest of the world contributes only 7%

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Clinical 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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Scenario AAssessment 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!

Emergency Triage Assessment and Treatment (ETAT)

Q2. The first thing to do is ETAT, which involves assessment of “ABC”A: AirwayB: BreathingC: CirculationTemperature of the extremeties Capillary refill time (CRT)Radial pulse: rate, volume Findings in this child:A: Airway – the airway was patent B: Breathing; respiratory rate was 36 breaths/minute and there was no dyspnoeaC: CirculationThe hands felt coldCRT: 5 secondsRadial pulserate: 160/minutevolume: thready Q3. Is this child in shock? Write down you answers and then go to the next slide
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Q3. Yes. In a child with cold hands, either one of the following signs identifies shock: Weak and fast pulse Capillary refill time (CRT): longer than 3 seconds (normal is 1-2 secs) Both signs are present in this child; the child should receive appropriate fluid regimen for shock as follows:

Go to Case Scenario B

*It is critical to reassess and re-classify dehydration before each IV bolus to prevent fluid overload Important! Commence on ORS solution as soon as child can drink
1. Secure intravenous access and draw blood for emergency laboratory investigations
2. Attach Ringers lactate or normal saline and infuse 20ml/kg as rapidly as possible (within 30-60 minutes)
3. Reassess the child after first infusion. If no improvement, repeat 20ml/kg as soon as possible and reassess again
4. This regimen can be repeated up to a maximum of four times during which a provisional diagnosis must have been established *
5. If there is improvement at any stage, give 70ml/kg of Ringers lactate solution or normal saline over - 5 hours in children less than 12 months - 2 1/2 hours (150 mins) in children aged 12 months to 5 years

Scenario 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

Answer: Q4

The diagnosis of severe dehydration is based on two or more of the following clinical signs: Lethargy or unconsciousness Sunken eyes Unable to drink or drinks poorly Skin pinch goes back very slowly (>2 seconds)
Other symptoms and signs of dehydration includes absence of tears, sunken fontanelle in young infants, cold extremities and reduced urinary output Assessment of the degree of dehydration is very important because it determines the appropriate rehydration regimen WHO guidelines for the assessment of dehydration classifies patients into those with no dehydration, some dehydration and severe dehydration
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WHO guideline for the classification of dehydration

Parameters
No dehydration
Some dehydration
Severe dehydration
Appearance
Well, alert
Restless, irritable
Lethargic,or unconscious; floppy
Eyes
Normal
Sunken
Very sunken
Thirst
Drinks nomally, not thirsty
Thirsty, drinks eagerly
Drinks poorly or not able to drink
Skin pinch
Goes back quickly (<1 second)
Goes back slowly (1 second)
Goes back very slowly (≥2 seconds) In the management of a 2 year old with severe dehydration Q5: what is the appropriate route for fluid administration? Q6: what is the most approriate fluid to give? Q7: what volume of fluid and over how long? Write down your answer and then go to the next slide
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There are other established guidelines. Click here to see details

Other guidelines used to assess dehydration due to AD

National Institute for Health and Clinical Excellence guidelines (NICE/UK) ESPGHAN guidelines These classify patients into minimal or no dehydration mild to moderate dehydration severe dehydration AAP guideline classifies patients as mild (3-5%), moderate (6-9%) and severe (>10%) dehydration Various scoring systems (Fortini et al., Gorelick et al.) proposed for assessment of child with dehydration, but there is limited evidence to support their use particularly in developing countries
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Treatment of severe dehydration

Q5: Children with severe dehydration require rapid IV rehydration followed by oral rehydration therapyQ6: For IV rehydration, Ringer’s lactate (also called Hartmann’s solution) is recommended. If not available, normal saline can be usedQ7: Give 100ml/kg of fluid as shown below: aRepeat if the radial pulse is still very weak or not detectable Age
First, give 30ml/kg in:
Then, give 70ml/kg in:
< 12 months old
1 houra
5 hours
≥12 months old 30 minutesa
2 1/2 hours
Go to Case Scenario C

Scenario 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 Next

Answers: Scenario C

Q8: This child has some dehydration Q9: The key signs consistent with some dehydration are any 2 or more of the following: Restlessness/irritability Thirsty and drinks eagerly Sunken eyes Skin pinch goes back slowly (1 second)
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In the management of some dehydration, decide on whether each of the following statements is true or false. Then click on the square to see the answer. 10a. Rehydration with IV fluid and thereafter commenced on ORS 10b. Treatment with ORS is appropriate

a
b
Q10Write “T” or “F” on the answer sheet. When you have completed both questions, click on the box and mark your answers. Go to Case Scenario D

Answer: Q10a

This statement is False. The appropriate treatment is use of oral rehydration fluid. IV infusion is only recommended for children with shock or severe dehydration. Even when a child with some dehydration can not tolerate oral fluids, it is advisable to give oral fluids through a nasogastric tube.
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Answer: Q10b

Give the child 75ml/kg of ORS in the first 4 hoursShow the mother how to give ORS solution, a teaspoonful every 1-2 minutes for child under 2 yearsIf the child vomits, wait 10 minutes, then resume giving ORS solution more slowlyMonitor the child to be sure child is taking ORS solutionCheck child’s eyelids; if they become puffy, stop ORS solution Reassess the child after 4 hours, checking for signs of dehydrationTeach the mother how to prepare ORS solution at homeAdvise on breastfeeding, for those still breastfeeding, and adequate feedingIf no dehydration, teach the mother the rules of home treatment This statement is True. WHO/UNICEF recommends the new improved oral rehydration solution which has reduced concentration of sodium and glucose (LO-ORS). LO-ORS reduces the risk of hypertonicity, reduces stool output, shortens the duration of diarrhoea and reduces the need for intravenous fluids.

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Scenario 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 D

Q11: 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 prolapse Q12: 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 fluoroquinolones Also manage any dehydration Ensure breastfeeding is continued for childen still breastfeeding and normal diet for older childen Follow-up the child
Go to Case Scenario E

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. Next
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

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 deteriorationQ15: 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 cellsadditional sodium in extracellular fluid if there is nutritional oedemareduced excretion of sodium by the kidneysCardiac 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! Next



For childen with SAM, diarrhoea, signs of shock, lethargy or unconscious, WHO recommends: Insert an IV line and draw blood for emergency laboratory investigations Give IV fluid 15ml/kg over 1 hour The IV fluid of choice (in order of preference) according to availability are: Ringers lactate with 5% dextrose Half-nomal saline with 5% dextrose Half-strength Darows solution with 5% dextrose Ringers lactate
Fluid management in children with SAM
End of clinical scenarios
Note the differences in management in SAM and well nourished children
If the child deteriorates during the IV rehydration (breathing increases by 5 breath/min or pulse by 15 beats/min), stop the infusion because IV fluid can worsen the child’s condition Monitor pulse and breathing rate at the start and every 5-10 minutes If there is improvement (pulse and respiratoy rate fall), repeat IV fluid 15ml/kg over 1 hour Then switch to oral or nasogastric rehydration with Resomal 100ml/kg for 10 hours

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

A West African child with kwashiokor
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Methods of nutritional assessment

Nutritional 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 dehydration

MUAC is widely used in community screening of malnutrition because it is easy to perform, accurate and quickMUAC 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*
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Laboratory investigations

AD is usually self-limiting and investigations to identify the infectious agent are not required Indications for stool microscopy, culture and sensitivity Blood and mucus in the stool High fever Suspected septicaemic illness Diagnosis of AD is uncertain 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 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 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?

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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