Diarrheal disease in children

Yohannes H( MD, Pediatrician)

 COMPOSITION OF BODY FLUIDS

Total Body Water(TBW)-Varies with age.

 Term infant=75% of body weight.
 At one year=60%
 At puberty males=60%
 At puberty females=50% because of fat
accumulation in females.

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 Compartments of total body
Water

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 Cont…

• Plasma water is affected by:

 Dehydration
 Anemia
 Polycythemia
 HF
 Abnormal plasma osmolality
 Hypoalbuminemia.

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 Electrolyte Composition

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 REGULTATIPN OF OSMOLALITY AND
VOLUME

• The plasma osmolality is tightly regulated and

maintained at 285-295mosmo/kg by
modification of water intake and excretion.
• An elevated plasma osmolality
hypothalamic osmoreceptors
secretion of ADH resorption of water into the
renal medulla increased urinary
concentration and decrement in water excretion.

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 SOURCES OF WATER LOSS

 Urine: 60 %
 Insensible losses: ≈35% (skin and lungs)
 Stool: 5%
• The evaporative losses from the skin do not include
sweat, which would be considered an additional
(sensible) source of water loss.

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 DIARRHEA
• Diarrhea is best defined as excessive loss of fluid
and electrolyte in the stool.
• It’s difficult to quantitate the consistency, so
diarrhea is often defined based on stool
frequency or stool weight alone.
• Normal stool output for westerns is
100-200gm/day for adults and older children and
5-10g/kg/day for infants.

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 Cont…
• Diarrhea
passage of > 3 loose stools/day or
watery stool of any frequency
Diarrhea results from altered intestinal water and
electrolyte transport.

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 Cont…
Diarrhea is a common cause of fluid loss in children
AVERAGE COMPOSITION OF DIARRHEA
 Sodium: 55 mEq/L
 Potassium: 25 mEq/L
 Bicarbonate: 15 mEq/L
AVERAGE COMPOSITION OF GASTRIC FLUID
 Sodium: 60 mEq/L
 Potassium: 10 mEq/L
 Chloride: 90 mEq/L

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 Cont..
• It can be classified as:
– Acute if duration is <2weeks
– Persistent duration 2-4weeks
– Chronic if it lasts >4weeks.

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 EPIDEMIOLOGY

• Diarrhea is the second leading cause of death in

children under 5.
• Accounts for ~525,000 deaths annually.
• Most cases occur in low- and middle-income
countries.

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 Burden of Childhood Diarrhea

• Almost 1 billion episodes of diarrhea per year

• 86% in Africa and South Asia (63% and 23%)
• 39 % decrease in mortality and 10 decrease in
incidence.
• Decreased due to:-
• Rotavirus vaccination,
• Improved case management
• ORS and
• Improved nutritional management
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 Risk Factors

• Poor sanitation
• Lack of clean water
• Unvaccinated
• Immunodeficiency
• Malnutrition (increases the risk of diarrhea and
associated mortality)
• Moderate to severe stunting (increases the odds of
diarrhea-associated mortality)
• Measles
• Lack of EBF and
• Inadequate healthcare access.
 Risk Factors

• Micronutrient deficiency:-
• Vitamin A deficiency accounts for 157,000 deaths from
diarrhea, measles, and malaria.
• Zinc deficiency is estimated to cause 116,000 deaths
from diarrhea and pneumonia

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 Risk factors cont..
• In a study in Ethiopia(Awi Zone.)
• Age of children,
• Source of drinking water,
• Health insurance,
• Place of delivery,
• Family size,
• Water shortage,
• Liquid waste disposal, and
• Vaccination were significantly associated with
diarrhea among under five children.
 ETIOLOGIES
1. Infections
 Bacterial
– V. cholerae
– Salmonella
– Shigella
– Campylobacter
– E. coli (enterotoxigenic, enterohemorrhagic, and
enteroinvasive)
– Yersinia enterocolitica
– C. difficile
– M. tuberculosis
– Aeromonas
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 CONT…
 Viral
– Norovirus
– Rotavirus
– Cytomegalovirus
– Herpes simplex
 Protozoa
– Amebiasis
– Giardiasis
– Cryptosporidium
– Microsporidia
– Cyclospora
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 Etiology of Infectious Diarrhea

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 Cont..
Community acquired – 30-40%
• Virus-Rota and Norovirus
• Bacterial-Campylobacter, nonthyphoidal
salmonella, shigella, EHEC, ETEC,
EIEC,V .cholera.
• Protozoan-Amoeba, giardia, cryptosporidium,
Schistosoma, Strongyloides, Isospora,
blastocystis

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 Cont…
Hospital acquired diarrhea
• Onset of diarrhea 3 days after admission and
not incubating at the time of admission to the
hospital.
• Can be antibiotic associated, or the use of
nonantibiotic medications or use of tube feeds
in the hospitalized patients.
• C.difficile,Salmonella,norvovirus and Rota virus.

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 CONT…
2. Food poisoning
3. Food allergy
4. Medications– Magnesium-containing antacids
– Anti-inflammatory agents (NSAIDs
– Lactulose
– Colchicine
– Prostaglandin analogs (e.g., misoprostol)
– Theophylline
– Acid-reducing agents(histamine H2-RB ,
PPI)
– Antibiotics and Anti-retroviral agents
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 Persistent diarrhea

• Diarrhea lasting for>=14days.

• Infectious etiologies predominate as cause.
• ETIOLOGIES:
• Bacterial- EPEC and EAEC are the most common
while Salmonella and Campylobacter rare causes.
• Viral- Norovirus and Rota virus are responsible in
developed countries.
• Protozoan- Giardia and Cryptosporidium
followed by Entamoeba and Isospora.

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Main causes of persistent diarrhea

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 Pathophysiology of Diarrhea
• Normal physiology-about 8L of fluids reach the
upper small bowel.
• Only about 1L of this fluid reaches the colon,(93%
absorptive efficiency)and out of this <200ml is
excreted in the stool.
• Combined, the efficiency of water absorption in the
small and large intestine is approximately 99% under
normal conditions.
• The colon has the capacity to reabsorb maximum of
3-4l of fluid.

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 Mechanisms
• Disruption of solute transport and water absorption
causes diarrhea.
• Water movement is passive and is determined by both
active and passive flux of solutes, particularly Na, Cl,
and glucose.
• Water is absorbed by three basic mechanisms:
 Neutral sodium chloride (NaCl) absorption,
 Electrogenic sodium absorption, and
 Sodium co-transport.

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 Cont…

• The pathogenesis of most diarrhea can be explained

by:
Secretary
Osmotic
Motility disorder or
Combination (Most common)

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PRIMARY DEFECT STOOL EXAMPLES COMMENT
MECHANI EXAMINATIO
SM N

Secretory • Decreased Watery, Cholera, toxigenic Persists during

absorption, normal E.coli ; carcinoid, fasting;
increased osmolality VIP, neuroblastoma, bile salt
secretion, with ion gap congenital malabsorption
electrolyte <100 chloride diarrhea, can also increase
Transport mOsm/kg Clostridium intestinal water
• enterotoxins difficile , secretion; no
increase in cryptosporidiosis stool
cAMP,cGMP, or (AIDS) leukocytes
increased IC
calcium
concentration
inhibition of
Na-H exchange
and stimulate Cl
secretion in
small intestine
PRIMARY DEFECT STOOL EXAMPLES COMMENT
MECHANISM EXAMINATION

Osmotic Maldigestion, Watery, acidic, and Lactase Stops with fasting;

transport reducing deficiency, increased breath
defects substances; glucose- hydrogen with
ingestion of increased galactose carbohydrate
unabsorbable osmolality with ion malabsorption, malabsorption; no
substances gap >100 mOsm/kg lactulose, stool
laxative abuse leukocytes

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PRIMARY DEFECT STOOL EXAMPLES COMMENT
MECHANISM EXAMINATION

Increased Decreased Loose to normal Irritable bowel Infection can also

Motility transit time appearing stool, syndrome, contribute to
stimulated by thyrotoxicosis, increased
gastrocolic reflex postvagotomy motility
dumping
syndrome

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PRIMARY DEFECT STOOL EXAMPLES COMMENT
MECHANISM EXAMINATION

Decreased Decreased Watery Short bowel Might require

surface area functional syndrome, elemental
(osmotic, capacity celiac diet plus parenteral
motility) disease, alimentation
rotavirus
enteritis

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 Dysentery
• Dysentery is diarrhea presenting with loose frequent
stools containing blood.
• Most episodes are due to Shigella and nearly all
require antibiotic treatment.
• Others(amebiasis , salmonella, EHEC, EIEC ,
yersinia, campylobacter …….)
• Don.t forget intussusception

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 Pathogenesis of Infectious Diarrhea

• Enteropathogens that are infectious in small inocula

(Shigella, STEC, norovirus, rotavirus, G. intestinalis,
Cryptosporidium spp., C. difficile, E. histolytica ) are
readily transmitted by person-to-person contact via the
fecal-oral route.
• Pathogens with larger infectious doses, such as cholera,
NTS, ETEC, and Campylobacter , generally require food
or water vehicles.

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 Pathogenesis of Infectious Diarrhea

• Pathogens that produce preformed toxins (S. aureus, B.

cereus emetic toxin) have shorter incubation periods (1-6
hr)
• Compared with 8-16 hr for those that must elaborate
enterotoxins in situ (e.g., C. perfringens and B. cereus
enterotoxin ).

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 Pathogenesis of Infectious Diarrhea
• Viral AGE causes a Cytolytic infection of the small
intestinal villus tips resulting in
• Decreased absorption of water,
• Disaccharide malabsorption,
• Inflammation, and
• Cytokine activation.

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 Pathogenesis of Infectious Diarrhea

• The rotavirus protein NSP4 acts as a viral enterotoxin

that produces secretory diarrhea.
• Rotavirus also activates the enteric nervous system
causing decreased gastric emptying and increased
intestinal mobility.
• Genetic susceptibility to both rotavirus and norovirus
infection that is mediated by histo-blood group(O blood
group) antigens on the epithelial cell surface and in
mucus secretions(FUT 2&3 genes)

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 Clinical Evaluation of Diarrhea

• Take detail history and do through P/E

• Assess the degree of dehydration and acidosis
• Obtain appropriate contact, travel, or exposure
history.
• Clinically determine the etiology of diarrhea for
institution of prompt antibiotic therapy, if indicated.

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 Patient Evaluation-History

• Type of • Abd.pain/distension
diarrhea(watery or • Hx of seizure
bloody) • Previous Hx of DD
• Vomiting (character) • Feeding Hx
• Fever • Developmental Hx
• Associated illness e.g. • Immunization
cough, rash, UTI
• Social & family Hx
• Urine out put

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 Physical Examination

General examination and  Delayed capillary

V/S refilling
A. water loss  Cold skin
 Loss of skin turgor  Anuria, oliguria
 Weak/absent pulse  Mental status changes
 Tachycardia B. Loss of nutrients
 Sunken eyes
Hypoglycemia
 Sunken fontanelle
Convulsions, mental status
changes

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C. Loss of bicarbonate
 Vomiting & retching
 Deep respiration
 Decreased myocardial contractility
D. Potassium loss
 Abdominal distension
 Paralytic ileus

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Determine the degree of dehydration and
treatment plan
Steps:
• Determine the degree of dehydration
• Select a plan to prevent or treat dehydration
• Estimate the fluid deficit
• Diagnose other important problems

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Assess for Dehydration:
 The 4 important signs in well -nourished child are:
1. Mental status
2. Eye ball
3. Eagerness to drink
4. Skin turgor

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 table

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 Differential Diagnosis

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 Differential Diagnosis cont...

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 Indications for medical evaluation of children
with acute diarrhea
• Age <3 months or Weight <8 kg
• History of premature birth, chronic medical conditions, or
concurrent illness
• Fever >=38 C for infants <3 months or >=39C for children
3-36months
• Visible blood in the stool
• High output diarrhea
• Persistent emesis
• Signs of dehydration as reported by caregiver
• Mental status changes
• Inadequate response to or caregiver unable to administer
ORT
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 Laboratory Evaluation-Stool exam

• The most commonly used method is direct microscopy of

stool
• This approach is time consuming and lacks sensitivity, in
part because shedding can be intermittent.
• Analyzing 3 specimens from separate days is optimal
• Molecular methods (NAAT)

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 Laboratory Evaluation-Stool exam

• Stool specimens could be examined for mucus, blood,

neutrophils, parasites and bacteria.
• The finding of more than 5 leukocytes per high-power
field suggests an infection with a classical bacterial
enteropathogen;
• Patients infected with STEC and E. histolytica usually
have negative tests.
• Norovirus is real-time reverse transcription quantitative
polymerase chain reaction (RT-qPCR)

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 Laboratory Evaluation-Culture

• Stool cultures for detection of bacterial agents are costly

and time consuming,
• So requests should be restricted to patients with:-
– Have moderate or severe disease,
– Immunocompromised,
– In outbreaks with suspected hemolytic-uremic
syndrome, or have a highly suggestive epidemiologic
history.

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 Stool Culture

• Stool specimens need to be transported and plated quickly

• Transported in special transport media.
• If the child has not passed a stool and antibiotics will be
administered, a rectal swab should be collected promptly.

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 Stool Anion Gap

• The stool osmolar gap is calculated as 290 mOsm/kg (or

measured stool osmolality) minus [2 × (stool Na + stool
K)].
• If the osmolar gap is above 100 mOsm/kg,
– Derived from ingested or nonabsorbed osmotically
active solutes or nonmeasured ions.
• In contrast, A low gap (<50 mOsm/kg) is typically
observed in secretory diarrhea.

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 Laboratory Evaluation-Serum Electrolyte
• Most episodes of diarrheal dehydration are isonatremic and do
not warrant serum electrolyte measurements.
• Electrolyte measurements are most useful in children with:-
• Severe dehydration,
• When IV fluids are administered,
• When there is a history of frequent watery stools, yet the
skin pinch feels doughy without delayed recoil, which
suggests hypernatremia, or
• When inappropriate rehydration fluids have been
administered at home.

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 Laboratory Evaluation-Serum Electrolyte

• Congenital chloride diarrhea(SLC26A3 gene defect)

check stool chloride(>90mmol/L), serum electrolytes

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 Lab in HUS Suspects

• A suspicion for HUS prompts a:-

• Complete blood count with review of the
peripheral smear,
• Platelets,
• Serum electrolytes, and
• Renal function tests.

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 Blood Culture

• Indications include:-
• Infants and children with fever and/or blood in
the stool who are younger than 3 mo,
• Immunocompromised, or
• Have hemolytic anemia or other risk factors.

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 Endoscopy and Biopsy

• If diarrhea persists with no cause identified, endoscopic

evaluation may be indicated.
• Biopsy specimens help in diagnosing inflammatory
bowel disease or identifying infecting agents that may
mimic it.

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 Endoscopy cont..

• Capsule endoscopy can be done when the patient

weighs more than 10 kg ;
• The new SmartPill measures pressure, pH, and
temperature as it moves through the GI tract, assessing
motility

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 Treatment
The broad principles of management of acute
gastroenteritis in children include
• Rehydration therapy,
• Feeding and diet selection,
• Zinc supplementation, and
• Additional therapies

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 CONT..
For classification of DHN, presence of 2 signs is needed
a. No DHN– Mx plan A
 Treat diarrhea at home:
 Rules of 3 ‘Fs’
1. Give extra FLUID
2. Continue FEEDING
3. When to come for FOLLOW UP

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 CONT..
• Fluid – in addition to the usual fluid intake
give ORS: 10ml/kg
OR
50-100ml for those below 2yrs per bowel

100-200ml for children > 2yrs motion

Other fluids; breast milk, food-based fluids(soup, rice

water, yogurt) or clean water

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 CONT..
• Feeding - frequent breast feeding
- cow’s milk or formula
- continue other foods if he started
• Return/follow up-see him in 2days
- come back immediately if the child becomes
sick(unable to drink, sicker, fever, dysentery)

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 CONT..
b. Some DHN– plan B, loss is estimated to be 5%
(average)
Treat with ORS:
Volume is 75ml/kg
Give over 4hrs
Continue breast feeding
If vomiting, wait for 10minutes
After 4hrs, reassess and classify DHN
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 CONT..

c. Severe DHN-
Treatment plan C, loss estimated to be 10% of
body weight
Start IV immediately
Ringer’s lactate or NS
Volume is 100ml/kg

Infants (below 1st give Then give

12months of age) 30ml/kg over 70ml/kg over 5hrs
1hour
Children>12month Over 30minutes Over two and half
s of age hours

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 Management of Persistent Diarrhea

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 Diet Management in Persistent Diarrhea

• First diet: A starch-based, reduced milk

concentration (low lactose) diet

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 Diet Management in Persistent Diarrhea

• Diet for persistent diarrhoea, second diet: A no-

milk (lactose-free) diet with reduced cereal
(starch)

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 Zinc Supplementation

• Reduce all-cause mortality by 46% and

• Hospital admission by 23%.
• Leads to increased use of ORS and
• Reduction in the inappropriate use of antimicrobials.
• Reduces reccurence of diarrhea for 2-3 months
• All children older than 6 mo of age with acute diarrhea (20
mg/day) for 10-14 days
• Promotes both enterocyte growth and ion absorption, means
healing of GI and promotes immunity
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 Ondansetron

• Reduces the incidence of emesis, thus permitting more

effective oral rehydration
• Well-established in emergency management of AGE ,
• Reduces intravenous fluid requirements and
hospitalization
• Preparations: syrup,IM/IV, tablet
• Dose 0.15mg/Kg ,PRN or TID

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 Antibiotic Therapy

• Judicious antibiotic therapy for suspected or proven

bacterial infections can reduce the duration and severity
of illness and prevent complications.
• Several factors justify limited use.
• First, most episodes of AGE are self-limited among
otherwise healthy children.
• Second, the increasing prevalence of antibiotic resistance
has prompted restricted use of these drugs.

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 Antibiotic Therapy cont..

• Third, antibiotics may worsen outcome, because some

studies have shown that antibiotic therapy of STEC
infection increases the risk of HUS and prolongs
excretion of STS without improving clinical outcome.
• Therefore antibiotics are used primarily
• To treat severe infections,
• Prevent complications in high-risk hosts, or
• To limit the spread of infection.

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 Antibiotic Therapy

• First line Cotrimoxazole(Bacteria,Isosporia &

Cryptosporidium),Azithromycin
• Second line Cefixime
• Metronidazole (Amebiasis ,Gardiaisis, C. difficile)
• Doxycycline for cholera (age above 8 years and high
dose azithomycin stat or ciprofloxacin for < 8 years )

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 The Era of Prebiotics/Probiotics

• Prebiotics are non-digestible food components that

promote the growth and activity of beneficial gut bacteria
• Example; breast milk(human milk
oligosaccharides(HMOs))
• Oats, banana, onions, garlic etc...

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 The Era of Prebiotics/Probiotics

• Probiotics are live microorganisms that improve or

restoring the gut microbiota
• Eg.; Breast milk contains Bifidobacterium and
Lactobacillus
• Yoghurt
• Saccharomyces boulardii(normagut) is effective in
antibiotic-associated diarrhea and in C. difficile diarrhea,
• There is some evidence that it might prevent diarrhea in
daycare centers
• Reduces incidence of NEC
• 08/15/2025
Reduces duration of AGE by 25 hours
 Complications
• The major complications are dehydration, electrolyte, or
acid-base derangements, which can be life-threatening
• Malnutrition(macro and micro)
• HUS(5–10% of patients infected with STEC.)
• Intestinal Perforation(Amoeba, Shigella, C.Deficille)
• Intussusception(viral AGE)
• Toxic Megacolon, Bactremia and sepsis
• Pseudoappendicitis(Yersinia)
• Reactive arthritis
• Guillain-Barré syndrome(Campylobacter jejuni)
• UTI
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 Prevention

• Exclusive breastfeeding for the first 6 months prevents

12% of all deaths of children younger than 5 yr of age.
• Vitamin A supplementation reduces all-cause childhood
mortality by 25% and diarrhea-specific mortality by
30%.
• Rotavirus vaccine (40-60% effectivety) but drastically
decreases severity
• Measles vaccine
• Cholera and Typhoid vaccines available but not routine

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 Prevention cont..

• Hand washing with soap can reduce the risk of diarrhea

by 48%,
• Safe excreta disposal can reduce the risk of diarrhea by
36% and
• 17% reduction is estimated as a result of improvements
in water quality.

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 References
• WHO
• AAP
• Nelson 22nd Edition
• Uptodate
• 1-Adam Birhan, N., Workineh, A.Y., Meraf, Z. et al.
Prevalence of diarrhea and its associated factors
among children under five years in Awi Zone,
Northwest Ethiopia. BMC Pediatr 24, 701 (2024).
https://doi.org/10.1186/s12887-024-05191-2
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 THANK YOU

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