Diarrhoea is usually defined as the passage of three or more loose or watery stools in a 24 hr period, according to WHO. Diarrhoea is three types as follows: Acute watery diarrhoea, Persistent diarrhea and Dysentery. It is one of the leading cause of malnutrition, illness and death among children in developing countries like Bangladesh, Pakistan, India, African countries etc. Fortunately the treatment of diarrhea is simple and easy. Hardly requires costly treatment. Loose stool of diarrhea being one that would take the shape of a container. Exclusively breast fed infant normally pass several soft, semi-solid stools each day, for them, it is practical to define diarrhea as an increase in stool frequency or liquidity that is considered abnormal by the mother. Children’s are usually admitted in hospitals for acute watery diarrhea. In my previous article, I have posted the list of Most Commons Patients admitted in Pediatrics Ward. Acute Watery diarrhea is the major cause. Diarrhea sometimes presents with dehydration. If the diarrhea is severe and persisting for many days, the baby will be dehydrated. Vomiting is also common with AWD. It causes more damage to the babies.
Acute watery diarrhoea:
This term refers to diarrhoea starts acutely, lasts less than 14 days ( most episodes last less than 7 days), & involves the passage of frequent loose or watery stools without visible blood. Acute watery diarrhoea causes dehydration which may kill the patient. The cause of death in diarrhea is acute dehydration. If blood is present in the stool, it is called dysentery. The infectious agents that cause diarrhoea are usually spread by the faecal-oral route.
The most important causes of acute watery diarrhoea in young children in developing countries are rotavirus, enterotoxigenic Escherichia coli, Shigella, Campylobacter jejuni, and Cryptosporidium. The causes are listed below in details:
• Bacillus cereus
• Staphylococcal enterotoxin
• Clostridial spp. Enterotoxin
2 .Infective food poisoning
• Rotavirus gastroenteritis
• Verocytotoxigenic E coli
• Other E coli
• Clostridium difficile
• Amoebic dysentery
4 .Systemic illness
• Meningococcal sepsis
• Acute diverticulitis
• IBD (Ulcerative colitis, Crohn’s disease)
• Bowel malignancy
• Overflow from constipation.
2. Metabolic upset
• Vasoactive intestinal peptide release.
• Carcinoid syndrome
3. Drugs & toxin
• Cytotoxic agents
• Plant toxins
• Heavy metals
• Ciguatera fish poisoning.
Clinical features of Diarrhoea and Dehydration
The diagnosis is written as Acute Watery diarrhea with no/some/severe sign of dehydration. The treatment is different for each category. Antimicrobial is not required for most of the patients. And it is not practiced in our hospital.
Severe dehydration: Two of the following signs
- Lethargic or unconscious
- Sunken eye
- Not able to drink or drinking poorly
- Skin pinch goes back very slowly.
Some dehydration: Two of the following signs
- Restless, irritable
- Sunken eye
- Drink eagerly, thirsty
- Skin pinch goes back slowly.
No dehydration: Not enough signs to classify as some or severe dehydration.
Treatment of acute watery diarrhoea:
The causative agents is not routinely identified in a laboratory . Specific etiological diagnosis is not also required for treatment. The treatment of patients with diarrhoea based on the major features of the disease and an understanding of the underlying pathogenetic mechanisms. The main principle of treatment of diarrhea is to maintain the fluid and electrolyte balance. Feeding should be continued. If the baby was previously breast feeding, it should be continued. Antimicrobials and antiparasitic agents should not be used routinely. Although dysentery, suspected cholera with severe dehydration, persistent diarrhoea requires Antimicrobials and antiparasitic agents. In area where Cholera cannot be excluded for patient more than 2 years old with severe dehydration, antibiotics are recommended.
The requirements of fluid is calculated by the age and weight of the baby. Oral rehydration salts (ORS) is given after each purgation.
Oral Rehydration Therapy (ORT): Fluids requirements of diarrhea patients:
No Sign: 50ml/kg body weight
Some sign: 75ml/Kg body weight
Severe dehydration: 100ml/Kg body weight
For AWD With No Sign of Dehydration: (Treatment Plan A)
Before age 2 years: 10-20 tsf of ORS after each purgation.
After age 2 years: 20-40 Tea Spoon Full (tsf) of ORS after each purgation.
If the baby presents with Some sign of dehydration (Treatment Plan B), additional fluid is required. For example, if the weight of the baby is 6kg, the total fluid required in 4 hours is 6*75= 450 ml. It is given in 4 hours. The mother should be instructed to feed the baby as follows:
450 ml in 4 hours, so 112 ml in 1 hour/60 minutes. 1 tsf contains 5ml fluid. So 3-4 tsf in each 10 min or 7 tsf in each 20 min. The baby is assessed after 4 hours. If some sign of dehydration still persists, the treatment is repeated, otherwise treatment of no sign is started.
In case of AWD with Severe Dehydration (Treatment Plan C), IV infusion of Cholera saline is indicated ASAP. The fluid required is 100 ml/Kg body weight. Close monitoring of the vital parameters is required. After the full fluid is given, reassess the patient again.
|Age||1st Give 30ml/Kg Body Weight||Then at 70ml/Kg Body Weight|
|<1 Year||Within 1 Hour||5 Hours|
|>1 Year||Half Hours||Two and Half Hours|
Complication of acute watery diarrhoea:
- Electrolyte disturbance Hypernatremia, Hyponatremia, Hypokalemia, Hypoglycemia.
- Convulsion-Febrile, Shigella encephalopathy, electrolyte disturbance.
- Abdominal distention.
- Paralytic ileus.
- Intussusception (Dysentery).
- Vit A deficiency.
How to Prevent Diarrhoea:
- Feed only breast milk for the first 6 months of life. Continue breast-feed for at least the first 2 years of life.
- Avoid the use of infant feeding bottles.
- Improving practices related to the preparation and storage of weaning foods (to minimize microbial contamination and growth).
- Use clean water for drinking.
- Wash hands (after defecation or disposing of faeces, and before preparing food or eating);
- Safely dispose faeces, including those of infants. Use sanitary latrines.
- Immunization, especially measles.
Q: A 4 years old baby presented to you with loose motion & vomiting several times for 3 days. On examination he is lethargic & skin pinch goes back very slowly. Others are normal .what is your diagnosis & how will you manage this case?
Ans: As the patient presented with loose motion & vomiting several times for 3 days. He is lethargic & on examination his skin pinch goes back very slowly, so my clinical diagnosis – it is a case of acute watery diarrhoea with severe dehydration.
Useful Resources for Diarrhea & Dehydration:
Pediatric Dehydration http://emedicine.medscape.com/
Is Your Baby Dehydrated? www.parents.com/
Diagnosis and Management of Dehydration in Children www.aafp.org