MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN Dr.B.Anjaiah, MD., DCh., Director, RIMS, Ongole.
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Transcript of MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN Dr.B.Anjaiah, MD., DCh., Director, RIMS, Ongole.
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MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN
Dr.B.Anjaiah, MD., DCh.,Director, RIMS, Ongole
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INVESTIGATIONS STOOL- Macroscopy Microscopy- WBC>10/hpf Ova,cysts,throphozoites Hanging drop C/S for shigella & salmonella
BLOOD- CBC Electrolytes, creatinine,BUN C/S
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MANAGEMENT PREVENTION
TREATMENT
SUPPORTIVE TREATMENT
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PREVENTION HAF Good liquids without
salt -clean water -unsalted rice water -unsalted yoghurt
drinks -coconut water -weak tea -unsweatened fresh
fruit juice
Good liquids with salt
-ORS -Salted soup -salted yoghurt
drinks -salted rice water
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DO NOT GIVE Soft drinks Sweetened tea Sweet fruit juices coffee
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TREATMENT CORNERSTONE of Rx
ORT
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ORT ORS
Solution made from sugar &salt
Food based solutions
Continued feeding
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PLAN A (NO DEHYDRATION)
Rule 1 --- Fluids - HAF,SSS
Rule 2 --- Zn supplementation
Rule 3 --- continued feeding
Rule 4 --- return to clinic
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Rule 1 --- Fluids WHO Guidelines
AGE QUANTITY WITH EACH STOOL
<6 mon 50 ml(1 cup)7 mon – 2 yrs 50-100 ml2 yrs- 5 yrs 100-200mlOlder child As much as they
take
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ORS is optional in
PLAN A
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Rule 2 --- Zn supplementation Improves immune function
Improves intestinal permeability
Regulation of intestinal water & electrolyte transport & brush border enzymatic function
Intestinal tissue repair
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Rule 2 --- Zn supplementation
<6 mon ---- 1/2 tab / day
>6 mon ---- 1 tab / day
for 10 – 14 days
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Rule 3 --- continued feeding < 6 mon - breast / top fed
Older children – cereals & beans, meat & fish , oil, dairy products & eggs, fruit juices & bananas
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What is the use of continued feeding?
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Rule 4 --- return to clinicWhen the child -passes many stools -very thirsty -sunken eyes -fever -does not eat/drink normally
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PLAN B (Some dehydration)
AGE Weight ORS Glass< 4 mon <5 kgs 200-400 ml 1-24-11mon 5-8 kgs 400-600 ml 2-312-23 mon 8-11 kgs 600-800 ml 3-42-4 yrs 11-16 kgs 800-1200 ml 4-65-14 yrs 16-30 kgs 1200-2200ml 6-11>15 yrs >30 kgs >2200 ml 12-20
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ORS given at 75 ml / kg over 4 hrs Continue breast feeding 100-200 ml of water + ORS (in those
who are not breastfed)
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REASSESS after 4 hrs
Signs of dehydration --- follow NIL - PLAN A PERSISTS - PLAN B SEVERE - PLAN C
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PLAN C (Severe dehydration) AGE First give
30 ml / kg in Then give70 ml / kg in
< 1 year 1 hour 5 hrs
> 1 year 30 min 2 ½ hrs
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TYPE OF FLUID BEST ----- RL
IDEAL ----- RL + 5% D
IF RL not available ---- NS
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INDICATIONS FOR IV FLUIDS Severe dehydration with/with out shock Persistent vomiting(>3/hr) Failure to correct / worsening of dehydration on
ORT High purge rate Failure of acceptance of ORS in dehydrated child Abdominal distension Deranged sensorium
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GUIDELINES for the total amount of fluids to be replaced in some & severe dehydration
Usual fluid Deficit(ml/kg)
Deficit fluid replaced(ml/kg)
Maintainence fluid required in 8 hrs(ml/kg)
Total amount of IV fluids for correction of dehydration to be given in 8 hrs (ml/kg)
Some 70-100 50 50 100
Severe 120-180ml 100 50 150
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CONTINUATION OF IVF AFTER CORRECTION OF DEHYDRATION Children - >3 mon N/4 NS -<3 mon N/6 NS
Maintenance fluids must contain K+ in the con of 20 meq/l
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TYPE OF FLUID GIVEN AS REHYDRATION THERAPY Initial fluid of choice-N/2 NS(1 PART
OF ISOTONIC SALINE+1 PART 5% DEXTROSE)
Isotonic saline & RL - severe dehydration
->6y high purge rate
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Start ORS -5ml/kg/hr when child able to drink
what to do if IV LINE not accessible?
Reasses after 1-2 hrs
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COMPLICATIONS Dehydration Dyselectrolytaemia Precipitation of malnutrition Secondary lactose intolerence Persistent diarrhoea HUS DIC Cortical vein thrombosis
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HYPONATRAEMIASevere-<125meq/lClinical featuresDeranged sensorium&convulsionsDiminished urine outputCorrection-N/2 NS (or) RL [Na-125-135] -3N NS [Na-<125]
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Amount of Na required=Na deficit x 0.6 x wt
Half of it corrected as 3N over ½-1hr
Remaining corrected as RL (or) N/2 NS slowly
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HYPERNATRAEMIA
Etiology Clinical features Usual signs of dehydration are absent Management If in shock-20-30ml/kg RL Confirm hypernatraemia Give N/3 NS in maintenance amounts
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METABOLIC ACIDOSIS Etiology Clinical features-deep fast breathing with plasma
HCO3 <15 meq/lit
Management Amount of NaHCO3= HCO3 deficit x 0.6 x wt (OR) 3ml/kg of 7.5% NaHCO3 diluted 6 times 5% Dextrose [total of 20ml/kg] over 30-60 min
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HYPOKALEMIA Serum K- <3 Meq/l Clinical features Management- ORS -K rich food Oral potassium supplementation -2meq/kg/d in PEM
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WHO Formulagm/ lit component Mmol/lit
NaCl 3.5 Na 90
KCl 1.5 K 20
Tri sodium citrate
2.9 Cl 80
Glucose 20 Citrate 10
water 1Lit Glucose 111
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Various measures to reduce Na Lower Na content in ORS
Alternating breast milk and ORS(2:1)
Diluting ORS in 1.5 lit of water
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Limitations of ORS Does not decrease the volume frequency severity of diarrhoea
Does not stop diarrhoea
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IMPROVED ORS Should reduce amount & rate of
purging
Should stop diarrhoea
Should provide nutritional support (SUPER ORS)
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FORMULATIONS Amino acid Glycine / L-alanine / L-
glutamine added to glucose ORS Decreasing conc. Of glucose & sodium Cooked cereal powder esp. rice to
replace glucose Combining glucose polymers & AA’s to
replace glucose Polymers like maltodextrine to replace
glucose
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CEREAL baesed ORS 50 gm/lit of cooked rice added to salt
ADVANTAGES?
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REDUCED OSMOLARITY ORS Principle?
Gms/lit Mmol/litNaCl 2.6 Na 75Glucose 13.5 Cl 65KCl 1.5 Glucose 75Tri Na cit 2.9 K 20
Citrate 10Osm 245
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Amylase resistant starch in ORS Add 50 gm/lit of starch to standard
glucose ORS
Increases absorption efficiency
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ReSoMalComponent Standard ORS ReSoMalGlucose 111 mmol/lit 125mmol/litNa 90 45K 20 40Cl 80 70Citrate 10 7Mg - 3Zn - 0.3Cu - 0.045Osmolarity 311 300
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DRUG THERAPY SHIGELLA Cotrimoxazole(5d)
CHOLERA Tetracycline/ Doxy(3-5d) (1dose)
AEROMONAS cotrimoxazole
ETEC & EPEC -do-
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Campylobacter Erythromycin(5-7d)
Clostridium difficile Vancomycin/metronidazole
Salmonella Ampicillin/Cefotaxime(5-7d)
Giardiasis Metronidazole(5d)
Amoebiasis Metronidazole(7-10d)
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RACECADORTIL Mode of action Comparing with Loperamide
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MULTIVITAMINS Vit A- on day 1,2 and 14
Folic acid- 5 mg on day 1 then 1mg/d for 2 wks
Other vitamins and trace elements double the maintanance dose
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MICRONUTRIENTS Potassium-5-6 meq/kg/d for few days 2-3 meq/kg/d orally for 2wks MgSO4-0.2ml/kg Zinc-10 mg for 2wks Copper-0.3 mg/kg/d Iron
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PROBIOTICS IN DIARRHOEA Viable microbial supplements / live
microorganisms given to confer beneficial health effects on the growth of the host
Lactobacillus acidophilus/ L.casei Bifidobacterium Streptococcus thermophilius Saccharomyces
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PREBIOTICS IN DIARRHOEA Food ingredients or part of bacteria
largely undergraded in small bowel and can beneficially affect the host by stimulating colonic bacteria
Lactulose alfa disaccharide Fructo-oligosaccharide In some vegetables and fruits
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USES OF PRE/PROBIOTICS Establishes normal microbial flora
Enhancement of immunity Nutritioal benefits-vit B Production -improved digestibility -body growth
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MECHANISMS OF ACTION Competing for receptor sites Growth inhibition Immune modulation Production of short chain fatty acids Modification of toxin receptors Disaccharidases Decreases permeability
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DIARROEA IN PEM Clinical features MANAGEMENT Mild to moderate-ORS 70-100 ml/kg over 6-12 hrs Severe – N/2 NS+5%D 30ml/kg – 2hr -N/6 NS+5%D 10ml/kg- 10hr -N/6 NS+5%D 5ml/kg/hr –12hrMAINTENANCE FLUIDS-N/6 NS in 5% D -75-100 ml/kg/d
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NUTRITION IN PEM The goal – 150-200 kcal -3-4g protein -6-8 feeds Micronutrients & multi vitamins
Trace elements
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