1. Diarrhea Dr. Adnan Hamawandi Professor of Pediatrics

2. Treatment of diarrhea Rehydration therapy Goals 1. Correct existing fluid deficit. 2. Replace further fluid losses.

3. Treatment of diarrhea Sever dehydration : The treatment of choice is Intravenous fluid. Ringer’s lactate is the preferred solution. Normal saline or half normal saline in glucose may be used. Infants should receive IV fluid at a rate of 30ml./kg in the first hour followed by 70ml./kg in the next 5 hours, thus providing 100ml./kg in 6 hours.

4. Treatment of diarrhea Older children should be given 30ml./kg within 30 minutes followed by 70ml./kg in the next 2 and half hours, thus providing 100ml./kg in 3 hours. After the first 30ml/kg has been given a strong radial pulse should be readily palpable If it is very weak and rapid a second infusion of 30ml./kg should be given in the same rate; however, this is rarely necessary.

5. Treatment of diarrhea Small amounts of ORS( 5ml/kg) should also be given by mouth as soon as the patient is able to drink to provide additional potassium and bicarbonate. This is usually possible after 3 – 4 hours for infants and 1 – 2 hours for older children.

6. Treatment of diarrhea At the end of planned rehydration period (usually 3 – 6 hours), the patient hydration state should be reassessed carefully. If signs of sever dehydration are still present rehdration should be continued by IV route, If there are signs of some dehydration shift to treatment of some dehydration.

7. Treatment of diarrhea Some dehydration: Can be treated in the ORT corner where mothers can help with treatment and learn how to continue it at home. Oral rehydration solution 75 ml./kg has to be given in the first four hours. It should be given by a cup and spoon. A teaspoonful every 1 – 2 minutes for infants and frequent sips from a cup for an older child.

8. Treatment of diarrhea If the child vomits, wait 10 minutes and then continue giving ORS but more slowly. If the child eyelids become puffy stop ORS and give plain water or breast milk until the puffiness is gone. After 4 hours carefully reassess the child’s hydration status; If the child has No signs of dehydration, the child can continue treatment at home by ORS and feeding.

9. Treatment of diarrhea If there are signs of some dehydration continue giving the estimated volume of ORS again until the signs of dehydration disappear. If the child is passing watery stools frequently and the signs of sever dehydration appear ORT should be temporarily stopped and the child rehydrated intravenously.

10. Treatment of diarrhea Treatment of diarrhea at home: Is appropriate when the child have no signs of dehydration. Three important rules has to be explained to the mother:- 1. Give the child more fluid than usual to prevent dehydration. The recommended home fluids include ORS, food based fluids ( soups, rice water, and yoghurt), and water.

11. Treatment of diarrhea Amount of ORS to be given after each loose stool is 50 – 100 ml. in children less than 2 years of age and 100 – 200 ml. in older child. Continue giving these fluids until diarrhea stops.

13. Treatment of diarrhea 2. Give the child plenty of food to prevent malnutrition. Continue to breast feed frequently and if the child is not breast fed give the usual milk. If the child is 6 months or older - give cereal or another starchy food mixed with pulses, vegetables and meat or fish. Add 1-2 teaspoonful vegetable oil to each serving

14. Treatment of diarrhea -Give fresh fruit juice or mashed banana to provide potassium. -Encourage the child to eat. Give food at least 6 times/day. -Give the same foods after diarrhea stops and give an extra meal each day for 2 weeks.

15. Treatment of diarrhea 3. Take the child to the health center if he does not get better in three days or develops - Many watery stools. - Repeated vomiting. - Marked thirst. - Eating or drinking poorly. - Blood in stools. - Fever.

16. Treatment of diarrhea Nutritional therapy Feeding should be continued during all types of diarrhea to the greatest extent possible and should be increased during convalescence so as to avoid malnutrition.

17. Treatment of diarrhea Antimicrobial therapy Should not be used routinely. Most episodes including sever diarrhea and diarrhea with fever do not benefit from such treatment. The exceptions are :- 1. Dysentery 2. suspected cholera.

18. Treatment of diarrhea 3. Persistent diarrhea when trophozoite or cyst of Giardia or trophozoite of E. histolytica are seen in the feces or intestinal fluids, or when pathogenic enteric bacteria are identified by stool culture.

19. Treatment of diarrhea Antidiarrheal and antiemetic Antimotility agents (Diphenoxylate, Codeine, Loperamide) adsorbants(Charcoal, Pectin, Kaolin) and antiemetics including Chlorpromazine and Promethazine should NOT be used in the treatment of diarrhea in children less than 5 years of age as non of these drugs has any proved practical benefits and some may have serious side effects.

20. Role of Zinc in treatment of acute diarrhea in children. Zinc treatment is a simple, inexpensive, and critical new tool for treating diarrheal episodes among children in the developing world. This important micronutrient becomes depleted during diarrhea, but recent studies suggest that replenishing zinc with a10- to 14-day course of treatment can reduce the duration and severity of diarrheal episodes and may also prevent future episodes for up to three months. WHO and UNICEF specifically recommend daily 20 mg zinc supplements for 10 days for children with acute diarrhea and 10 mg per day for infants under six months old.

21. Role of Probiotics in the management of diarrhea in children Specific probiotic strains can contribute to both the prophylaxis and therapeutic management of acute infectious diarrhea in children decreasing its incidence and duration. They favorably affect the host by local and/or immune modulation pathways. 1. In the gut, the probiotic agents compete with pathogens for nutrients and prevent their adherence to the mucosa. 2. They produce bacteriocins that acts as local antibiotic; and they induce the synthesis of human B- defensin 2 an antimicrobial peptide. 3. they produce lactic and acetic acid that can inhibit pathogen growth by lowering luminal PH. 4. Probiotics may improve integrity of the mucosal barrier function by stimulating mucin production.