Diarrhea gmhc 2012

©2011 MFMER | slide-1

Managing Diarrheain Children

Phil FischerNovember 8, 2012

[email protected]


Who Are We?

A. Non-Clinical Worker

B. Clinical Worker, Not Much Pediatrics

C. Clinical Worker, Lots of Pediatrics


Resources for Learning

Interactive Session

Now!

Slides for Review

GMHC Website or via [email protected]

WHO

www.who.int/mediacentre/factsheets/fs330/en/index.html


Diarrhea


What causes diarrhea?What causes diarrhea?


What causes diarrhea?What causes diarrhea?

1. Germs

2. Lack of hygiene

3. Political problems

4. Witchcraft

5. Guilt

6. Stress


What Causes Diarrhea?

Sure, germs can cause diarrhea.

But, “systems problems” also cause diarrhea.

inadequate sanitation

insecure food supply

incomplete immunization


Why Care About Diarrhea?



1. I don’t like having it.1. I don’t like having it.




2. Kids get sick and die from it.2. Kids get sick and die from it.


Why care about diarrhea?

It’s common!

3 bouts per year in child < 5 yrs oldPLOS Medicine 4:e98, 2007

~2,000,000,000 cases per yearwww.who.int/mediacentre/factsheets/fs330/en/index.html, 2012

It kills!

> 1.5 million deaths per year

PLOS Medicine 4:e98, 2007

It contributes…

… to malnutrition and another 7 million deaths





3. Families suffer because of it.3. Families suffer because of it.





3. Families suffer because of it.3. Families suffer because of it.

4. The world agrees to stop it.4. The world agrees to stop it.


Millennium Development Goals

http://www.un.org/millenniumgoals/


Millennium Development GoalsMillennium Development Goals


A 15 month old presents with diarrhea. Your primary immediate concern is:


A 15 month old presents with diarrhea. Your primary immediate concern is:

A. Hydration

B. Hydration

C. Hydration

D. All of the Above


Dehydration

Early No Signs or Symptoms

Some Thirst

Restless or Irritable

Decreased Skin Elasticity

Sunken Eyes

Severe Symptoms More Severe

Shock

Diminished Consciousness

Lack of Urine

Cool Extremities, Feeble PulseWHO, 2012


For a child with acute gastroenteritis, intravenous fluids are indicated if:

A. Frequent Vomiting

B. Some Dehydration

C. Severe Dehydration

D. All of the Above


For a child with acute gastroenteritis, intravenous fluids are indicated if:

Severe Dehydration

NOT:

Vomiting

Some Dehydration

Pediatrics 97:424, 1996


Rehydration

Early ~100 cc/stool

usual diet

Some 75 cc/kg

oral, 4 hrs

Severe 100 cc/kg

iv initially, 6 hours

30 cc/Kg 1st hourIMCI


Rehydration

Oral versus Intravenous

Equal Weight Gain

Equal Duration of Diarrhea

Equal Hypo/HyperNa+

Shorter Hospitalizations

3% Paralytic Ileus 2% Phlebitis

4% “failures”Hartling, Cochrane 2006


What Oral Rehydration Formula?

3-36 months old, severe malnutrition, cholera

Bangladesh

Rice ORS vs Glucose ORS (+/- added starch)

Less stool 1st 24 hrs (31%, p=.004)

Less ORS needed (26%, p=.002)

Same duration of diarrheaJ Pediatr Gastroenterol Nutr 48:318, 2009


What Oral Rehydration Formula?

Literature review, non-cholera

Reduced osmolarity ORS

41% less need for IV fluids

Less stool output

Less vomitingHahn, Cochrane, 2002


Management of DiarrheaSo Far…

1. Hydration Important

2. Oral Rehydration Usually Better than IV

3. Low Osmolarity ORS Usually Best

4. Special ORS for Severely Malnourished


A 15 month old presents with diarrhea and is now being hydrated. Your next major concern is:


A 15 month old presents with diarrhea and is now being hydrated. Your next major concern is:

A. Nutrition

B. Nutrition

C. Nutrition

D. All of the above


For a dehydrated child with gastroenteritis, regular dietary intake should begin:

A. After the resolution of the diarrhea

B. After the initial rehydration

C. After the resolution of vomiting

D. Immediately at presentation


For a dehydrated child with gastroenteritis, regular dietary intake should begin:

B. After the initial rehydration

Pediatrics 97:424, 1996


Case: A 1 year old has diarrhea. When might antimicrobial therapy help?

A. If the child is vomiting

B. If the family is stressed

C. If the family is rich

D. If the diarrhea is bloody


Acute Diarrhea (Overseas)

Bloody ? >> Potential Rx

Fever >> Bacterial >> Antibiotic

(Shigellosis)

No Fever >> Parasitic >> Metronidazole

(Amebiasis)

IF bloody diarrhea

AND

IF in an area with industrialized cattle(with risk of E coli O157:H7 and HUS)

THEN consider stool testing prior to Rx

E coli O157:H7 + Antibiotics >> More HUSNew Engl J Med 342:1930, 2000

Acute Diarrhea (in “resourced” area)



A 1 year old has diarrhea. You’ve handled hydration. No antimicrobial therapy is indicated. What else might help?

A. Vitamin A

B. Zinc

C. Loperamide

D. Ondansetron

E. Lactobacillus


Vitamin A to Treat Diarrhea

Literature review, 5 studies

3 studies – no impact

1 study – shorter duration in non-breastfeeders

1 study – more “cures” at 5 days if ShigellaMittra, Pediatr Rev 29:349, 2008

Walker, Clin Infect Dis 45:S73, 2007


Zinc to Treat Diarrhea

Literature review, 15 studies

Less likelihood (15%) to persist with diarrhea

39% less stool if zinc used

51% less death if zinc used

Some increased vomiting with zincWalker, Clin Infect Dis 45:S73, 2007

Larsen, J Health Pop Nutr 26:356, 2008

Lazzerini, Cochrane, 2008


Zinc and Acute Diarrhea

1. It works in developing countries.

- decreased stool output

- decreased duration of disease

2. Use it (in areas with presumed zinc deficiency).

3. Dose: 20 mg/day x 10-14 days if > 6 mo

10 mg/day x 10-14 days if < 6 mo (??)Curr Opin Clin Nutr Metab Care 11:711, 2008

Aliment Pharmacol Ther 28:713, 2008

Cochrane Database Syst Rev. 2012 Jun 13;6:CD005436


Loperamide to Treat Diarrhea

Meta-analysis

34% fewer with diarrhea after 1st day

shorter duration of diarrhea and fewer stools

1% serious adverse events, all < 3 yrs old

AVOID IN YOUNG CHILDRENLi, PLOS Medicine 4:495, 2007


Ondansetron to Treat Diarrhea

Randomized trial, 107 children, mean age 5 yrs

All received IV fluids

More (70% vs 51%, p=.04) quit vomiting

“Fewer” (26% vs 30%, p>.05) required hospitalization

Reeves, Pediatrics 109:e62, 2002

Cochrane Database Syst Rev 9:CD005506, 2011

Perhaps useful in some settings. BMJ Open July 2012


Probiotics to Treat Diarrhea

High-dose (1010-1012CFU) Lactobacillus GG helpfulBasu, J Clin Gastroenterol 43:208, 2009

Lactobacillus GG (6x106CFU) not effectiveBasu, J Paediatr Child Health 43:837, 2007

Probiotic “Bifilac” usefulNarayanappa, Indian J Pediatr 75:709, 2008

So…

Continue studying – formulations, populations


A 1 year old has diarrhea. You’ve handled hydration. What else might help?

A. Vitamin A

B. Zinc

C. Loperamide

D. Ondansetron

E. Lactobacillus


What About Chronic Diarrhea?

Giardia >> metronidazole

5 mg/kg x3/day x 5 d

Cryptosporidium >> nitazoxanide

?? HIV, TB, IBD


A 1 year old has acute diarrhea. What should we do?

1. Hydrate!

2. Regular diet when no longer dehydrated.

3. Antibiotic if bloody.

4. Zinc if in developing country.

5. “Don’t let it happen again!”


Prevention of Diarrhea

1. Fix the system >> good nutrition

2. Fix the system >> good sanitation

3. Fix the system >> good vaccination


Vitamin A to Prevent Diarrhea

Literature review, meta-analysis, 1966 – 2000

9 studies

Vitamin A NOT protective against morbidity

Grotto, J Pediatr 142:297, 2003


Hand Hygiene to Prevent Diarrhea

Australian Aboriginal Populations

Education and Handwashing >> 53% Less Diarrhea

McDonald, BMC Pub Health, 8:153, 2008


Diarrhea - “Bottom” Lines

If acute diarrhea

>> hydrate, usually orally

>> nourish, soon

If acute bloody diarrhea

>> antibiotic if febrile

>> metronidazole if afebrile

If acute diarrhea in developing country

>> zinc

If you really care >> prevent!

Diarrhea gmhc 2012

Health & Medicine

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