DIARRHEA
INTRODUCTION
Diarrhea is derived from a Greek word, meaning ‘flowing through’. It
is a common cause of infant deaths worldwide. It is the second leading cause
of death in children under five years of age. The loss of fluids through diarrhea
can cause dehydration, which if not managed promptly may result in deaths of
the child. Diarrhea is both preventable and treatable.
DEFINITION
According to WHO (World Health Organization), “Diarrhea is
defined as ‘passage of 3 or more loose stools per day’ or passing more stools
than normal for the age.
INCIDENCE
Every year there are about 2 billions cases of diarrheal disease
worldwide.
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Children under five years of age, diarrheal disease is the second
leading cause of the death.
In 2015, diarrhea cause more than 1.3 million deaths globally & was
fourth leading cause of death among children younger than five years.
In 2016, diarrhea is a major cause of death in india, contributing to an
average of 15.5% of total deaths (1316 million ) in india from 1990-
2016.
Out of 1.5 million children killed by diarrheal disease in 2017, 80%
were under 2 years of age.
CAUSES
The causes of diarrhea are as follows:
1) Infection :
I) Bacteria :
Shingella, E.coli,
Salmonella, Staphylococcus,
Proteus species
II) Virus :
Influenza virus, Adeno virus,
Entero virus,
Rota virus and Measles virus.
III) Parasites :
Giardia lamblia,
Entamoeba histoiytica,
ameba.
IV) Fungi :
Candida albicans
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2) Drugs :
Intake of antibiotics and iron supplements may lead to diarrhea.
3) Dietary cause :
Food poisoning, food allergies, over eating and eating of stale food can cause
diarrhea in children.
4) Surgical conditions :
Intussusception, polyps,
diverculitis and appendicular abscess can lead to diarrhea.
5) Miscellaneous causes :
Conditions like malabsorption syndrome, abdominal tuberculosis, celiac disease,
ulcerative colitis and irritable bowel syndrome may lead to diarrhea in children.
RISK FACTORS / PREDISPOSING FACTORS
Age
Bottle feeding
Malnutrition
Hygiene
Season
Socio-economic status
Dietary factor
Teething
CLASSIFICATION
1. On the basis of duration
a) Acute diarrhea :
If an episode of diarrhea lasts for less than 14 days, it is known as
acute diarrhea.
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b) Chronic diarrhea :
If diarrhea lasts for 14 days or more, it is known as chronic diarrhea.
2. On the basis of clinical presentation
a) Acute watery diarrhea :
This type lasts for several hours or days and occurs in condition like
cholera.
b) Acute bloody diarrhea :
Diarrhea with blood in stool, with or without mucus is known as
dysentery
3. On the basis of physiology
a) Secretory diarrhea :
It means there is increase in active secretions or an inhibition of
absorption in intestine.
b) Osmotic diarrhea :
It occurs when too much water is drawn from the body into the bowel.
c) Exudative diarrhea :
It includes presence of blood and pus in stool.
d) Motility-related :
It is caused by rapid movement of food through the intestines
(hypermotility).
e) Inflammatory diarrhea :
It occurs when there is damage to the mucosal lining or brush border
which leads to a passive loss of protein rich fluid and decreased ability to
absorb the lost fluid.
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SIGN AND SYMPTOMS
Fever
Anorexia ( loss of appetite)
Irritability
Vomiting
Watery stools
Sunken eyes and cheeks
Sunken fontanelle ( soft spot with inward curve )
No tears
Dry mouth or tongue
General body weakness
Headache
Blood or mucous in stools
DIAGNOSTIC EVALUATION
I) History
a. Number and description of stools passed per day
b. Number and description of stools passed normally
c. Body weight of child prior to illness
d. Presence of fever, abdominal pain, tenesmus or rigidity in abdomen
e. Fluid intake
f. Frequency of urination
II) Physical examination of the child is done to assess the degree of
dehydration.
III) Stool examination : The stool is examined for volume, consistency,
color, PH and presence of blood, mucous, leucocytes.
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IV) Stool culture : If on stool examination it is found to be having low
glucose content with presence of leucocytes, it is sent for culture. Stool culture
helps in identification of the microorganism responsible for causing diarrhea.
V) Blood tests : The following blood tests may be done-
Hematocrit : Infants who are dehydrated have an elevated hematocrit.
Blood urea nitrogen (BUN) : It is elevated,if renal circulation is
impaired due to dehydration.
WBC count may be normal or elevated.
Serum sodium, serum bicarbonate and serum chloride levels are
reduced.
COMPLICATION
Dehydration ( loss of water body salt through diarrhea)
Watery diarrhea
Electrolyte disturbance
Malnutrition
Persistent diarrhea
Toxic illeus
Hematolytic uremic syndrome
Renal failure
Convulsion
MANAGEMENT
The management of children with diarrhea and dehydration focus on :
I) Fluid replacement
II) Administer the prescribed drugs
III) Maintain nutritional status
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I) Fluid Replacement :
Oral rehydration therapy is of prime importance for replacement of lost of
fluid in dehydrated patients. oral rehydration refers to drinking of solution which
contain clean water. Sugar and mineral salts in order to replace the fluid and
electrolytes lots from the body during diarrhea.
Administration of ORS:-
Oral rehydration solution can be used to prevent development of dehydration
and in many cases is a life saver. Homemade solution that can be used for oral
rehydration are salted rice water, salted pulses (daal) water ,salted yogurt drinks ( lassi
, chachh), vegetable.
At home , ORS can be prepared by mixing in 1 liter water , three finger
pinch salt (3 grams) and two tablespoons sugar (18 grams ).this solution should be
given to the child after every loose stool.
WHO & UNICEF recommended & distributed ORS packets as a drug for
treatment of clinical dehydration. the new ORS has lesser glucose and salt
concentration which reduces the possible adverse effects of hypertonicity. the
contents of readymade ORS packets are to be dissolved in one liter of clean drinking
water.
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II) Administers the prescribed drugs
1. Antibiotics:
Antibiotics are used only in cases with bacterial or protozoal diarrhea. These
cases usually present with blood or mucous in stool and high fever.
2. Binding agents:
Binding agent like bismuth compounds (pepto-bismol), pectin and kaolin do
not reduce fluid and electrolyte loss.
3. Anti-motility agents:
Anti motility agents (like loperamide) are effective in reducing the duration of
diarrhea. Codeine is used in the treatment of diarrhea to slow down peristalsis.
4. Anti-secretory agents:
Eg, aspirin, chlorpromazine, adrenergic blockers etc.
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5. Rota virus vaccine:
6. Bovine virus vaccine:
III) Maintain nutritional status
The child should be fed during acute diarrhea because feeding prevents
deterioration of nutritional status.
Breast feeding should be continued along with ORS.
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Soft energy rich food should be given to the child like khichdi, soft cooked
rice with milk or curd and sugar, mashed banana, mashed potato etc.
Avoid food with high fiber content and spicy foods which may irritate the
bowel mucosa.
Zinc supplementation benefits children suffering from diarrhea.
PREVENTION
1) Sanitation
a) Provision of improved water supply.
b) Improved excreta disposal.
c) Improved domestic & food hygiene
1. Hand washing.
- Hand washing is one of the most effective ways of preventing the
spread of viruses & bacteria that can cause diarrhea.
- You should always wash your hand thoroughly after using the toilet,
changing nappies &before meals.
It should be before preparing food.
Before eating.
Before feeding child.
And after defecation.
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2. Use plenty of water for hygiene
3. Hand washing should be promoted
2) Personal hygiene
1. Oral hygiene
2. Bathing
3. Cutting of nails
4. Washing of hand before meals & after defecation
3) Breastfeeding
Exclusive breastfeeding : only breast milk is given no other food or drink
not even water is given.an infant should be exclusively breastfed for first
6 months of life .breast milk contains several anti-infective factors,
which protect the baby from enteral infections.
Feeding bottles & rubber teats, which are particularly difficult to clean,
are often breast feeding grounds for germ should be avoided.
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4) Weaning
literal meaning of the term weaning is taking the infant away from the
breast and nourishment by other means it starts around the age of 6
months.
Common weaning foods are :-
1. Khichdi
2. Dalia
3. Mashed potato & banana
4. Jaggery
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5. Soft cooked rice with milk or curd and sugar.
5) Immunization
Immunization against measles is a potential intervention for diarrhea
control when administered at the recommended age, the measles vaccine
can prevent up to 25 % of diarrhea deaths in children under 5 years of
age. A vaccine for rotavirus is available free for babies in New Zealand.
Rotavirus is a common cause of diarrhea in infants & young children.
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6) Zinc supplementation
After appropriate treatment of diarrhea zinc supplementation can prevent
the occurrence of diarrhea for following 2-3 months.
1. Reduces stool volume.
2. Reduces duration of diarrhea.
3. Zinc has an additional modest benefit.
WHO recommends that children from developing countries with diarrhea
be given zinc for 10-14 days.
1. 10 mg daily for children < 6 months.
2. 20 mg daily for children > 6 months.
Food should be kept covered to protect it from dust and flies.
Wash fruits & vegetables before consuming.
Eat freshly cooked food.
Children should be made to wash their hands before eating food and after
going to the toilet.
Never use open spaces for passing stool sanitary latrine facilities should be
available in every household.
PREVENTION OF DEHYDRATION
Know the physical condition of the child.
Drink plenty of fluids every day, especially when the weather is hot.
Eating food with higher water content.
eg. Fruits & vegetables
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Drinking extra fluids when feeling unwell due to a short term illness.
eg. Cold, Influenza
HOME REMEDIES FOR DIARHHEA
Drink water for diarrhea drink enough water & stay hydrated.
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Eat starchy foods for diarrhea.
Eat yogurt for diarrhea.
Use apples for diarrhea.
Use bananas for diarrhea.
Use cooked rice with yogurt for diarrhea.
Drink chamomile (Babune ka phal) tea.
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