1. DIARRHEA and DEHYDRATION

2. Sources: Excerpts from:
“Integrated Approach to the Management of Childhood Illnesses” from the WHO - Integrated Management of Childhood Illness (IMCI) Manuals and Courses
“Management Protocols of Infectious and Tropical Diseases” of the Research Institute for Tropical Medicine, DOH

3. DIARRHEA Defined by WHO as change in consistency of stools
Del Mundo, 4th ed, p.698
Acute Diarrhea
loose bowel movement
lasting <14 days

4. DIARRHEA 2ND leading cause of death globally
(WHO, Tropical Disease, 1990 ASM News)
In the Philippines (1998 data)
#1 cause of morbidity for all ages
2nd leading cause of child mortality
An important cause of malnutrition

5. DEHYDRATION Causes many diarrheal deaths
If not severe, can be safely & effectively treated using oral rehydration
Oral Rehydration Salts
combination of glucose & several salts
absorbed in the small intestines even during copious diarrhea

6. PRINCIPLES OF MANAGEMENT
Prompt replacement of fluids & electrolytes
Maintenance of nutrition
Use of anti-microbials only for those with bloody diarrhea, suspected cholera or serious non-intestinal infections & avoidance of anti-diarrheal agent
Patients or caretakers should be taught about feeding & hygiene practices that reduce diarrhea morbidity. Emphasize prevention & follow-up.

7. ASSESS & CLASSIFY DIARRHEA
History
Physical Examination
Select a plan to prevent or treat dehydration
Management of acute diarrhea
Management of acute bloody diarrhea
Management of persistent diarrhea
Prevention of diarrhea

8. HISTORY presence of blood in stool duration of diarrhea
presence of fever, cough, convulsions, recent measles
pre-illness feeding practices
type & amount of fluids (including breast milk) & food taken during the illness
drugs or other remedies taken (herbal)
immunization history

9. Physical Examination Check for signs & symptoms of dehydration
1.1. LOOK for:
- general condition
- eyes and tears
- mouth and tongue
- thirst
1.2. FEEL the child:
- skin turgor

10. Physical Examination Check for signs of other important problems:
- does the stool contain red blood?
- take the temperature

11. Prevent of Treat Dehydration
Choose the treatment plan that corresponds with the patient’s degree of dehydration
No Signs of Dehydration – follow Treatment Plan A at home to prevent dehydration & malnutrition
Some Dehydration – follow Treatment Plan B to treat dehydration
Severe Dehydration – follow Treatment Plan C to treat dehydration urgently

12. Management of Acute Diarrhea
Treatment Plan A
Rule 1: Give the child more fluids than usual to prevent dehydration
What fluids to give
Any fluid that normally contains salt
Plain clean water
Other fluids
How much fluids to give
General Rule:
As much fluid as patient wants until diarrhea stops

13. Management of Acute Diarrhea
Treatment Plan A
Home ORS: Mix the ff in a liter of water:
- 1 level tsp of table salt + 8 level tsp of table sugar
- Give at least 2 bananas
How much fluids to give after each loose stool:
Children < 2 yrs: 50 – 100 mL of fluid
Children 2 – 10 yrs: 100 – 200 mL
Older children & adults: as much fluid as they want

14. Management of Acute Diarrhea
Treatment Plan A
Rule 2: Continue to feed the child to prevent malnutrition
Continue feeding during diarrhea
Increase feeding afterwards
Do not withhold food
Do not dilute usual food
Continue breastfeeding
AIM: GIVE AS MUCH NUTRIENT-RICH FOOD AS THE CHILD WILL ACCEPT

15. Management of Acute Diarrhea
Treatment Plan A
What foods to give
Milk
Breast milk – as often & as long as child wants
Milk formula – every 3 hrs, if possible by cup
Infants < 4 months: on mixed feeding should receive increased breastfeeding. If possible, breastfeed exclusively
Other foods
Those recommended for child’s age
Locally appropriate energy & nutrient rich food

16. Management of Acute Diarrhea
Treatment Plan A
Rule 3: Take the child to a health worker if there are signs of dehydration or other problems:
Starts to pass many watery stools
Has repeated vomiting
Becomes very thirsty
Is eating or drinking poorly
Develops a fever
Has blood in the stools or
Child does not get better in 3 days

17. Management of Acute Diarrhea
Treatment Plan B
Patients with Some Dehydration should receive oral rehydration therapy (ORT) with ORS solution in a health facility following treatment plan B
Adults can consume up to 750mL/hr while still dehydrated
Children can consume up to 20mL/kg BW/hr

18. Management of Acute Diarrhea
Treatment Plan C
For patients with SEVERE dehydration
Patients should be brought to the hospital so that IV fluids can be started immediately
Usual fluid given is Lactated Ringer’s solution
If not available, Normal Saline solution may be used

19. Management of Acute Bloody Diarrhea
Patient should be referred immediately to the hospital
Especially if also with severe malnutrition
If not, assess patient, give appropriate fluids to prevent or treat dehydration and give food

20. Management of Persistent Diarrhea
Objective of treatment:
Restore weight gain
Restore normal intestinal function
Treatment consists of:
Appropriate fluids to prevent or treat dehydration
Antimicrobials to treat diagnosed infections
A nutritious diet that does not worsen the diarrhea
Supplementary vitamins and minerals

21. PREVENTION & CONTROL Breastfeeding Improved weaning practices
Use of safe water
Proper hand-washing / hand hygiene
Use of latrine and safe disposal of stools
Measles immunization