Control of Diarrheal Diseases

Control of Diarrheal Diseases (CDD)Acute Respiratory Infections(ARI)

Assistant ProfessorDr. Batool Ali Ghalib YassinDepartment of Family & Community MedicineCollege of Medicine – University of Baghdad2015 - 2016 *

Objectives

By the end of this lecture you will be able to: Define and classify diarrhea Identify the level of dehydration according to the CDD program adopted by WHO Follow the guidelines of managing a child with diarrhea
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Objectives

Appraise the important of ARI program on childhood morbidities & mortalities Follow the guidelines of managing a child with ARI, Sore Throat and Ear Problems. Classify the ARI cases according to age, severity ,signs & symptoms. List the steps of management according to ARI case management chart.
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Control of Diarrhoeal diseases (CDD)

Diarrhoea: Passage of liquid or watery stool for at least 3 times during 24 hours. Consistency is more important than frequency.
Breast fed infants usually pass semi-solid, pasty and yellow stools. Sometimes, they pass stool after each breast feed. This is not diarrhoea.
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Clinical type of diarrhea

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Control of Diarrhoeal diseases (CDD)
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* Causative Agents; Viruses, Bacteria & Protozoa

Control of Diarrhoeal Diseases (CDD)
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Dehydration

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* Assessment of Diarrhoea cases for dehydration

Classification
Sign
C
B
A
Lethargic, Unconscious
Restless, Irritable
Well, Alert
General Condition
Sunken* Absent Very Dry
Sunken * Absent Dry
Normal Normal Moist
Eyes Tears Mouth & Tongue
Unable to drink
Eager to drink
Drinks normally
Thirst
Goes Back Very Slowly (2 or more sec)
Goes Back Very Slowly (1 sec)
Goes Back Quickly
Skin pinch
Severe Dehydration
Some dehydration
No Dehydration
Classification
Plan C (Hospital)
Plan B (PHC)
Plan A (Home)
Treatment

* Assessment of Diarrhoea cases for dehydration

Treatment plan
Estimated fluid deficit
Loss in body weight
Degree of Dehydration
A
< 50 ml/kg
< 5 %
No signs of dehydration
B
50-100 ml/kg
5-10 %
Some dehydration
C
>100ml/kg
>10 %
Severe dehydration
In a diarrhoea case, sometimes we don’t have the 4 signs in the same category. Two signs in the category, are enough to classify the case. E.g. 1 sign in A & 1 sign in B + 2 signs in C, so we classify as C.

Assess Degree of Dehydration

No dehydration
Some dehydration
Severe dehydration
Plan A
Plan B
Plan C
Aim: To prevent dehydration
Give extra fluid: ORS &/or home fluids
Continue Breastfeeding or feeding
Aim: to correct dehydration
ORS in Clinic 75 ml/Kg body weight over a 4 hr period
Assess hourly Continue Breastfeeding or feeding
Aim :to correct dehydration urgently
Give Ringer’s lactate OR normal saline by IV or Naso-Gastric tube 100 ml/kg Over 6 hrs for infants Over 3 hrs for older children
Teach the mother How to prepare fluid Recognize danger signs
Give 100-200 ml of clean water. (for Bottle fed)
Teach the mother How to prepare fluid Recognize danger signs
Reassess After 4 hours
Reassess hourly & after Completing treatment
If the patient can drink, give ORS in 5ml/kg body weight/hr
Do not attempt NG rout if not well trained

* Important Notes

During treatment with plan B; the child may develop puffiness of the face & eyes which is a sign of over hydration. In that case; Stop ORS, Give fluids that doesn't contain much salt, Give the fluid slowly & send the child for home treatment when puffiness has gone. Role of Breast feeding throughout an episode of diarrhoea: Reduce the severity & duration Reduce the risk of dehydration Reduce the risk of diarrhoea worsening nutritional status.

* Oral Rehydration Solution

Composition: Sodium chloride: 3.5 gm, NaHCO3: 2.5 gm, KCl: 1.5 gm, Glucose: 20 gm, In 1000ml (1litre) of water. Some replace NaHCO3 by 2 gm Tri-sodium Citrate Di-hydrate which lessens vomiting, is tastier and more stable in humid and hot areas. Advantages of ORS: Cheap, effective and easy to give at home by the mother. This is why 95% of the cases are treated by ORS, as children will not develop dehydration, when they get diarrhoea. Preparation of ORS: The water should be boiled and cooled before the powder is added to avoid the loss of bicarbonate, and changes of concentration. In winter, warm the solution to 40oC to increase acceptability, increase the rate of absorption, decrease vomiting & decrease the risk of a drop in the body temperature when large volumes are consumed. If no ORS is available we use home prepared fluids or household food solutions, rice water, soups , fruit juices salt and sugar solution (one teaspoon of salt + one table spoon of sugar). Diarrhoea case fatality rate has decreased a lot after the introduction of the ORS, due to the prevention of dehydration.

Management of Chronic (Persistent) Diarrhoea

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Management of Blood in Stool

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* Drugs not to be used for diarrhoea

Anti-bacterials: Most cases are viral. Antibacterials are only used when there is lab evidence of bacterial infections (mainly cholera and bacillary dysentery). They will eventually lead to secondary infection due to the inhibition of the growth of the normal flora. Anti-protozoal: Used only when there is lab evidence of amoebic dysentery or giardiasis. Mycostatin: Monilia is a normal inhabitant of the GIT. Mycostatin is only given when there is oral thrush or anal moniliasis. Anti-motility agents and anti-spasmodics: As they may cause paralytic ileus in children. Pectocaolines: Will coat the GIT, allow colonization of the GIT bacteria with bacteria and lead to persistent diarrhoea. Anti-emetics: May cause CNS symptoms.

Acute Respiratory Infections (ARI)

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Acute Respiratory Infections (ARI)
* On average, a child living in an urban area gets 5-8 attacks of ARI/year, & each attack lasts for 7-9 days (35-72 days of illness/year)

The Standard Case Management of ARI Cases

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The Standard Case Management of ARI Cases

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The Standard Case Management of ARI Cases

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* Standard Case Management of Ear Problems

Management
Classification
Assessment
Antibiotics for 5 days Dry the ear by wicking Reassess in five days Treat fever and pain with paracetamol
Acute Ear Infection


< 2 wks
Ask: a. Does the child have ear pain? Yes
b. Does the child have pus draining from the ear? If yes, for how long?
Dry ear by wicking Treat fever and pain with paracetamol If case does not improve, refer
Chronic Ear Infection
> 2 wks
Antibiotics for 5 days Dry the ear by wicking Reassess in five days Treat fever and pain with paracetamol
Acute Ear Infection
Yes
Look : for pus draining from the ear, and a red immobile ear drum.
Refer urgently to hospital Give pre-referral antibiotic Treat fever and pain with paracetamol
Mastoiditis
Yes
Feel: for a tender swelling behind the ear.

* Standard Case Management of Sore Throat

Management
Classifi-cation
Assessment
Ask: a. Does the child have a sore throat?
Refer urgently to hospital 2. Give pre-referral antibiotic 3.Treat fever and pain with paracetamol
Throat abscess
No
b. Is the child able to drink?
Soft food and drink Treat fever and pain with paracetamol
Viral Sore Throat
Yes, but with pain
Benzathin penicillin or amoxicillin Give a safe soothing remedy Treat fever and pain with paracetamol
Streptococcal Sore Throat
Yes
Look for exudates on the throat.
Yes
Feel the front of the neck for lymph nodes.