Pediatric Infective Diarrhoea in Developing countries

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June 7, 2022 June 7, 2022 Dr.Kagalwala/Diarr Dr.Kagalwala/Diarr 1 DIARRHOEA IN INFANTS AND DIARRHOEA IN INFANTS AND YOUNG CHILDREN YOUNG CHILDREN Dr. Taher Y. Kagalwala M.D., D.C.H. Hon. Pediatrician Saifee Hospital, Masina Hospital, Habib Hospital Saboo Siddik Mat. And Gen. Nsg. Home

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Brief and relevant information on infective diarrhoea in children The emphasis is on developing countries, but the principles of treatment are the same.

Transcript of Pediatric Infective Diarrhoea in Developing countries

Page 1: Pediatric Infective Diarrhoea in Developing countries

April 10, 2023April 10, 2023 Dr.Kagalwala/DiarrDr.Kagalwala/Diarr 11

DIARRHOEA IN INFANTS AND DIARRHOEA IN INFANTS AND YOUNG CHILDRENYOUNG CHILDREN

Dr. Taher Y. Kagalwala M.D., D.C.H.

Hon. Pediatrician

Saifee Hospital, Masina Hospital, Habib HospitalSaboo Siddik Mat. And Gen. Nsg. Home

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Don’t we all want kids to be Don’t we all want kids to be toilet-trained like THIS?toilet-trained like THIS?

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What is diarrhoea?What is diarrhoea?

• It is the passage of liquid or watery stools• Usually, this is more than three times a day.• More important than this is: when there is a

recent change in the consistency, frequency or character of the stools.

• Frequent stools in an exclusively breastfed baby is NOT diarrhoea.

• Teething can cause a few loose stools; diarrhoea lasting more than 24 hours is NOT due to teething.

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Common Etiological CausesCommon Etiological Causes

1. Infectious causes:• Viral – esp. rotavirus, respiratory and

enteroviruses• Bacterial – esp. E. coli (ETEC, EPEC)• Others – fungal, protozoal, helminthic and

miscellaneous2. Non-infectious causes:• Intussusception• Endocrine – hyperthyroidism• Secondary to a remote cause – e.g.

pneumonia

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ClinicalClinical Features - 1Features - 1

1. Symptoms and signs of the primary illness.

2. Symptoms and signs of dehydration.

3. Symptoms and signs of complications and side-effects of treatment.

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ClinicalClinical Features - 2Features - 2

1. Primary Illness:• Bacterial – dysentery and not diarrhoea –

marked by high fever, toxicity, tenesmus and sometimes rectal prolapse while defecating; stool will show mucus, visible or occult blood and at times, frank blood.

• Viral – watery stools with absence of most of the above findings, though there may be mucusy stools. Slight to moderate fever and presence of cough/cold, conjunctivitis and recurrent vomiting are all compatible.

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ClinicalClinical Features – 3aFeatures – 3a

2. Dehydration (1 of 2):

Grade of dehydration/Symptoms

Mild

5 – 7% wt loss

Moderate

7 – 9 % wt loss

Severe

10% or more wt. loss

Fontanelle and eyes

Normal to mildly sunken

Moderately sunken

Severely sunken

Pulses Normal but fast Faster, slight low volume

Thready, peripheral pulses not palpable

Mucous membranes

Moist but sticky Slightly dry Dry

Skin turgor Normal Recoil 1-3 seconds

Recoil > 3 seconds

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ClinicalClinical Features – 3bFeatures – 3b

2. Dehydration (2 of 2)

Grade of dehydration/Symptom

Mild Moderate Severe

Capillary refill time

Normal (< 3 sec)

Normal (< 3 sec)

Delayed 3 or > 3 sec

Urine Output Normal Slightly less (anuria < 4 hours)

Definitely less (anuria > 4 hours)

Mental status Normal but thirsty

Irritable Irritable to lethargic

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Clinical Features - 4Clinical Features - 4

3. Symptoms and signs of complications:

• Hypovolemic shock

• Acute renal failure (pre-renal)

• Venous thrombosis

• Septicemia

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Case Study - 1Case Study - 1

18 – month old female child from a middle-class family presents with:

• Fever , mild – 4 days• Red eyes, running nose and a mild to mod.

cough – 3 days• Vomiting – 2 days ( frequent, whitish yellow)• Loose motions – yellow, 13 – 15 since the last

24 hours, curdy smell, with mucus• Not passed urine since the last four hours, with

h/o passing concentrated urine earlier too.

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Case Study – 2aCase Study – 2a

On examination (1 of 2):

• Average child, 9.5 kg, fever 99.2* F• Crying continuously, eagerly drinks water if

offered by the mother• P 120/min, RR 34/min, nonacidotic, BP not

taken• AF closed, eyes look okay but reduced tears

while crying• Oral mucosa is moist

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Case Study – 2bCase Study – 2b

On examination (2 of 2):

• CRT 3 seconds

• Skin turgor – slightly prolonged (3 seconds)

• Per abdomen – normal to increased peristalsis. No other findings of note.

• Other systems – normal.

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Case Study – 3Case Study – 3

• What is the likely diagnosis?• Is the girl dehydrated? How much? Why are

there inconsistencies (mucosae are moist, for example)?

• What investigations are needed? - CBC? - Stool routine? - Serum electrolytes? - Any other?• Will she need hospitalisation?

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Case Study - 4Case Study - 4

Management (1 of 4):

ORS: Sip by sip, at least 40-50 ml/kg as deficit plus about ¼ to ½ of a 200-ml glass for every medium to large stool passed plus 3 - 5 ml/kg/vomit to replace losses in vomiting.

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Case Study - 5Case Study - 5

Management (2 of 4):

• The child’s mother should be asked to continue breastfeeding her (if she is doing so); continue nourishing her with khichdi, rice-dal, soft bananas, grated apples, vegetables etc. There is no need to ban any food except food that is too spicy.

• She can be taught how to check the hydration status from time to time (urine output, AF tension, eyeball tension, skin turgor, etc. )

• ORS substitutes may be used only to give “variety” to the child’s intake of liquids. (Buttermilk, rice water, dal soup, etc.)

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Case Study - 6Case Study - 6

Management (3 of 4):

What is the role of :• Anti-diarrhoeals – norflox +metro, for example• Anti-motility agents – atropine derivatives• Anti-secretory agents - racecadotril • Stool binding mixtures – pectin + kaolin• Starvation• Probiotics – lactobacilli, saccharomyces• Antibiotics – cefixime, gentamicin

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Case Study - 7Case Study - 7Management (4 of 4):

• When will you refer for hospitalisation?• What home-based fluids are NOT useful?

(coffee, tea, arrowroot kanji)• How often will you see the child?• What supportive medications will be needed?

(anti-emetics, anti-pyretics)• Perianal excoriation and rashes will need topical

antifungal and protective creams.

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Some recent info on ORSSome recent info on ORS

ORS :• Presence of salt and sugar together facilitate the

reabsorption of water from the gut-lumen along with the salt and sugar.

• We have moved from a sweetish, high osmolar liquid to a salty, high Na+ ORS to ORS’s having probiotics, prebiotics, amino-acids, etc. to the most recent “LOW OSMOLAR ORS” that is approved by the WHO for use all over the world in all age groups for all types of diarrhoeal illness including cholera.

• This new ORS has only 245 mOsm/L as compared to the higher osmolarity of the previous WHO-approved formula.

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Take-home messagesTake-home messages

• Monsoon diarrhoeas may be bacterial in origin, but winter diarrhoeas are almost always viral.

• Most children with watery diarrhoea do not need metronidazole.

• Most children with typical diarrhoea do not need any investigations.

• ORS is the mainstay of therapy.• IV therapy is only recommended for kids with

uncontrolled vomiting, very frequent diarrhoea, grade II dehydration or more and those with altered sensorium or any other complications.

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Just one more slide:Just one more slide:

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This book is on sale!This book is on sale!

• This comprehensive book on parenting is written for the layman.

• It is priced at Rs. 395/=, but is available to doctors at a special price of Rs. 300/= only.

• It carries detailed information for the care of children from 0 – 18 years.

• Thank you – Dr. Taher