Diarrhea resident survival guide (pediatrics)

Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usman Ali Akbar, M.B.B.S.[2]

Synonyms and keywords: Approach to diarrhea in pediatric patients, Approach to infectious causes of diarrhea, Oral Rehydration therapy in children

Diarrhea resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Diarrhea remains one of the leading causes of preventable death in developing countries, especially among children under 5 years of age. Diarrhea is defined as an increase in the number of stools such as more than three bowel movements each day or the presence of loose stools comparative to normal stool consistency. Acute diarrhea is when diarrhea occurs for less than 3 weeks in total and it is chronic when it lasts longer than three weeks. Hydration status plays an important role in the management of pediatric diarrheal illness. The risk of dehydration due to fluid and electrolyte losses is inversely proportional to the child's age hence, the younger the child, the greater is the risk of dehydration. The type of dehydration whether it is isotonic, hypotonic, or hypertonic is usually independent of the responsible agent. Fluid loss due to diarrhea and vomiting can be life-threatening if it is as high as three times the circulating blood volume (80–125–250 mL per kg body weight per day). To keep the blood volume constant, the body usually extracts fluid from the intracellular space which can predispose it to dehydration. Complications and hospitalization due to dehydration can usually be prevented by the early and adequate oral administration of a rehydration solution (glucose-electrolyte solution) and normal food for the child’s age.

Causes

• The causes of diarrhea can range from life-threatening to mild and self-resolving causes:

Life Threatening Causes	Common Causes	Miscellaneous
Cholera Entamoeba histolytica Enterohemorrhagic Escherichia coli (EHEC) Enteroinvasive Escherichia coli (EIEC) Campylobacter spp. Nontyphoidal Salmonella enterica	Rotavirus Enterotoxigenic Escherichia coli (ETEC) Cryptosporidium Shigella spp.	Parenteral causes include infections elsewhere in the body: UTI, Acute otitis media, Sepsis. Inflammatory causes include: IBD, Allergy to cow's milk, Whipple's disease. Malabsorptive causes include: Celiac disease, Lactase deficiency. Endocrine causes include: Hypothyroidism, Addison's disease , Hyperparathyroidism. Neoplastic causes Psychosocial causes

FIRE: Focused Initial Rapid Evaluation

• A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention:

Patient presents with acute diarrhea in emergency

Mild Dehydration

Moderate Dehydration

Severe Dehydration

Home treatment with ORS, patient prescription, and dietary recommendations

Is there any evidence of dehydration or >8 watery stools in 24 hours or >4 episodes of vomiting in 24 hours or <6 months old

Dehydration >9% Shock or Impaired consciousness

Give ORS by spoon or syringe according to age and weight Infants 5—9 kg: 2.0 mL every minute (120 mL/hr) Infants 9—12 kg: 2.5 mL every minute (150 mL/hr) Toddlers 12-15 kg: 3.0 mL every minute (180 mL/hr) If there is no vomiting, then larger volumes at longer intervals: 10-15 mL every 5 or 20-30 mL every 10 minutes Racecadotril in 5 mL of water) <9 kg: 10 mg, 10-15 kg: 20 mg, 16-29 kg: 30 mg

Intensive Care

Complete Diagnostic Approach

• Shown below is an algorithm summarizing the diagnosis of acute diarrhea in children according to the WHO guidelines:

Patient with history of diarrhea

Assessment A child with diarrhea should be assessed for dehydration Bloody diarrhea, persistent diarrhea Malnutrition and serious non-intestinal infections so that an appropriate treatment plan can be implemented.

History Duration and severity of diarrhea Presence of blood in stool Number of watery stools per day Number of episodes of vomiting Diaper rash Presence of fever, cough, or other important problems (e.g. convulsions, recent measles) Pre-illness feeding practices; type and amount of fluids (including breast milk) and food taken during the illness History of Medications History of immunization

Physical Examination Look for the signs and symptoms of dehydration Is the child alert, restless or irritable? Look for the eyes, are they normal or sunken? Look for skin turgor? Does the stool contain red blood? Is the child malnourished? Look for growth chart, weight for length or measure the mid-arm circumference. Measure the temperature of child.

Mild Dehydration There are no specific signs and symptoms

Moderate Dehydration Initially, the signs and symptoms that develop include: - Thirst - Restless or irritable behavior - Decreased skin turgor - Sunken eyes - Sunken fontanelle (in infants)

Severe Dehydration These effects become more pronounced and the patient may develop evidence of hypovolaemic shock including: - Diminished consciousness - Lack of urine output - Cool moist extremities - Rapid and feeble pulse (the radial pulse maybe undetectable) - Low or undetectable blood pressure - Peripheral cyanosis. Death follows soon if rehydration is not started quickly

Treatment

• Shown below is an algorithm summarizing the treatment of acute diarrhea in pediatric patients according to the WHO guidelines:

Patient presents with acute diarrhea in emergency

Mild Dehydration

Moderate Dehydration

Severe Dehydration

Children with no signs of dehydration are given extra fluids and salts to replace losses due to diarrhea. Following fluids can be given in such cases: ORS Salted drinks eg. salted rice water or salted yogurt drink Vegetable or chicken soup with salt Home-based ORS: 3 gm of table salt and 18 gm of common sugar in one liter of water. Plain water should also be given. Commercial carbonated beverages, fruit juices, sweetened tea, coffee, medicinal tea should be avoided.

Oral rehydration therapy for children with moderate dehydration: ORS + Zinc supplementation should be started After 4 hours, reassess the child and decide what treatment needs to be given next as per the Grade of dehydration. Children who continue to have dehydration even after 4 hours should receive ORS by nasogastric tube or RL intravenously (75 ml/kg in 4 hours). If abdominal distension, then oral rehydration should be withheld and only IV rehydration should be given.

*Start IV fluids immediately. If the patient can drink, give ORS by mouth until the drip is set up. Give 100 ml/kg Ringer Lactate solution divided as follows: First, give 30 ml/kg and then give 70 ml/kg in infants (under 12 months) in 1 hour. Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly as follows: After six hours (infants) or three hours (older patients), evaluate the patient using the assessment chart. Then choose the appropriate Treatment Plan (A, B or C) to continue the treatment.

Do's

• Hydrate the child well. Hydration plays a vital role in early recovery and reversal of symptoms of diarrhea.
• Eating properly: Make the child eat properly such as eating a diet consisting of bananas, rice, applesauce, and toast.
• The use of probiotics can help shorten the duration of illness.
• Use antibiotics only when indicated in the case of pediatric diarrheal illness.

Don'ts

• Don't try to make special salt and fluid combinations at home unless your pediatrician instructs you and you have the proper instruments.
• Don't prevent the child from eating if the child is hungry.
• Don't use antibiotics unless prescribed by your pediatrician.
• Don't ignore the symptoms and record temperature and hydration status.