1. Challenges in Treating the Child with Diarrhea Dr Soumalay Family Medicine Specialist CME Pakse, Laos PDR, October 15-17, 2012

2. Objectives 1) Using case studies, understand the causes of acute and chronic diarrhea 2) Discuss the challenges of management of acute dehydration 3) Understand strategies for monitoring and preventing diarrhea in the community

3. Case #1 Samsay is a 12- month old child. His aunt, who is his caregiver, brings him to your clinic because he has diarrhea.

4. Discussion question What do you do first and why?

5. FIRST Examine the child quickly to be sure he is not severely dehydrated or in shock. If he is, he must be treated quickly before asking other history

6. Discussion Question The child is sleeping in his aunt’s arms What important questions will you ask?

7. Questions Diarrhea –timing, frequency, onset, watery, pus, blood Associated symptoms-fever, vomiting, URTI, appetite, abdominal pain, irritability, Assess dehydration-frequency of urine, intake- what fluid, how much? Triggers-contacts with diarrhea, water source, medications(antibiotics)

8. Questions PMHx- previous episodes of diarrhea Other illnesses Birth history and weight Nutritional history SHx-why does he live with his aunt? Immunization

9. Facts Non-bloody diarrhea Started five days ago No fever Vomits 2x per day He drinks diluted cow’s milk. His mother died three months ago with a chronic illness.

10. Facts Two previous hospitalizations: Pneumonia-9 days in hospital, age 2 months Diarrhea-two weeks in hospital, age 8 months

11. Physical Examination What are the important things to look for?

12. Physical Exam Hydration status-mild, medium or severe dehydration? Growth parameters Abdominal exam

13. Dehydration Level of Consciousness Tears, mucus membranes Fontanelle Skin pinch Pulse rate, strength, capillary refill, RR, BP Thirst Urine output

14. Mild Dehydration 5% in less than 1 year; 3 % if older than 1 year Mental status normal* Thirsty* Mucous Membranes moist or a bit tacky Capillary refill 2-3 sec N or slightly increased pulse Slightly decreased urine output Normal skin pinch time*

15. Moderate Dehydration 10% 1 year Irritable, restless* Sunken eyes* Skin pinch goes back slowly* Drinks eagerly, thirsty* Tacky/dry mucous membranes Capillary refill 3-4 sec Increased heart rate Decreased urine output Perfusion +/- mottled,

16. Severe Dehydration 15% 1 year Lethargic or unconscious* Poor perfusion, mottled skin, sunken eyes* Skin pinch goes back very slowly*>2seconds Not able to drink or drinking poorly* Dry, parched mucous membranes Capillary refill >4sec HR >> Urine output greatly reduced

17. Physical exam Ht:68cm, Wt 6.9 kg, HC 45cm, MUAC 11.6cm RR40, HR110, BP 85/50 Mouthy tacky. White adhesive material on buccal mucosa. Noisy respirations with transmitted sounds but no wheezes or crackles. HS normal, pulses normal, skin hangs on legs Abdomen protuberant, BS active, Liver 3cm BCM, spleen 4cm

18. What is the Differential Diagnosis?

19. Malabsorption or secretory diarrhea Viral- rotavirus, enteroviruses Giardia, other parasites cholera cryptosporidium, cryptococcus, Enterotoxic E.coli

20. Less likely Invasive bacteria less likely-no blood, fever Shigella, salmonella, campylobacter, yersinia, enterinvasive e.coli, entamoeba histolytica, c. difficile

21. What is Samsay’s problem list?

22. Problem list Acute gastroenteritis-likely viral Oral thrush Malnutrition with stunting and wasting Mild dehydration 5% Possible immunosuppression Orphan

23. How would you treat this child?

24. Treatment ORS

25. Therapy of Gastroenteritis (New) Two phases: 1. Rehydration: fluid deficit is replaced quickly over 3-4 hours 2. Maintenance: Regular diet is resumed and maintenance and replacement fluids are provided.

26. Rapid Rehydration 1.Intravenous fluid is given as normal saline or Ringer ’ s lactate 50-100ml/kg over 3-4 hours 2.ORS is given by NG 50-100 ml/kg over 3-4 hours 3.ORS, 50-100ml/kg is given in small aliquots of 5-15 ml q5 minutes, increasing as tolerated until the total is ingested

27. Oral Rehydration, no NG Can be started at home Can be started in the ER waiting room Can be given by parents If patient vomits it can be resumed after an interval of 30 minutes Vomiting more than 3 times is an indication for IV therapy

28. Parent Instructions Give parents a predetermined amount of ORS with written and verbal instructions to give small amounts every five minutes over one hour. Amount is determined by multiplying the child ’ s wt by 50-100 ml/kg depending on the degree of dehydration

29. Calculation of ORS Mild Dehydration: 50 ml/kg Wt=10 kg Amount =500 ml Give parents 125 ml each hour for 4 hours

30. Calculation of ORS Moderate dehydration in 3 yo : Wt= 15 kg ORS = 75ml/kg Amount = 1125 ml Give parents 250-300 ml every hour for 4 hours

31. Maintenance Phase Resume normal diet Resume age appropriate diet Resume full strength formula Resume breast feeding Replace diarrheal stool or vomitus with ORS

32. Calculation of ORS Phase 2 <10 kg body wt: 60-120 ml ORS per episode of diarrhea or vomiting >10 kg of body wt: 120-240 ml of ORS per episode of diarrhea of vomiting

33. Oral Rehydration Solutions ORSNa+K+Cl-BaseOsmCHO WHO7520653024513.5 PedLy4520353025025 AJ0.44445N/A730120

34. Rehydration Solutions ORSNa+K+Cl-BaseOsmCHO PedLy4520353025025 Rehyd7520653030525 Cola1.6N/AN/A13.4650112

35. Monitoring and prevention of diarrhea Hand washing Isolate patient Latrines Boiled water Pets in home

36. What about the HIV? Education campaign Condom use STI clinics Prenatal testing and use of antivirals

37. What about the malnutrition? For another talk!! Education Early identification Frequent weights