1. HAFIZ USMAN WARRAICH Roll#17-C Diarrhea and Dehydration Dr Shreedhar Paudel 25/03/2009

2. Diarrhea Passage of loose stools in increased frequency If mother says her baby is having diarrhea then the baby is having diarrhea Diarrhea may be – Acute – Chronic – Persistent

3. Diarrhea.. Diarrhea might be – Secretory – Osmotic It might be: --Infective --Non-infective

4. Diarrhea … Secretory diarrhea --there is an increase in the active secretion, or there is an inhibition of absorption --little or no structural damage --most common cause is a cholera toxin that stimulates the secretion of anions, especially chloride ions.cholera toxinanionschloride

5. Osmotic diarrhea “Osmotic diarrhea occurs when too much water is drawn into the bowels” (Lactose intolerance, malabsorption)

6. Diarrhea… Acute diarrhea --a common cause of death in developing countriesdeveloping countries --second most common cause of infant deaths worldwideinfant deaths --loss of fluids through diarrhea can cause severe dehydration which is one cause of death in diarrhea sufferersfluidsdehydration --Along with water, dangerous amounts of important salts, electrolytes, and other nutrients are lostwatersaltselectrolytesnutrients

7. Acute Diarrhea Important causes of infective diarrhea in developing countries – Rotavirus – E. coli – Campylobacter jejuni – Shigella – Protozoal parasites—5-15% of cases – No pathogen found—20-30% of cases

8. Acute diarrhea.. Non-infective causes – Malabsorption – Specific food intolerance – Indigestion – Lactose intolerance – Antibiotics – Inflammatory bowel disease – Milk protein allergy

9. Assessing the patient with diarrhea Brief history and examination of the child--- Objectives: -To detect dehydration - To diagnose dysentery - To diagnose persistent diarrhea - To evaluate nutritional status - To diagnose concurrent illnesses - To find immunization status of measles

10. Clinical assessment should lead to - A plan for treating or preventing dehydration - A plan for treating dysentery, if present - A plan for treating persistent diarrhea, if present - Recommendations for feeding during and after diarrhea - A plan for follow-up

11. Treatment of Diarrhea Home treatment is essential part – Mothers should begin it before they seek medical care – Mothers should be taught how to continue the treatment of her child at home

12. At the time of discharge of the baby Mothers should be able to – Prepare and give appropriate fluids for ORT – Feed a child with diarrhea correctly – Recognize when a child should be taken to a health worker

13. Assessing the patient for dehydration AB C 1.Look at: Condition Eyes Thirst Well alert Normal Drinks normally Restless, irritable Sunken Thirsty, drinks eagerly Lethargic or unconscious Very sunken Drinks poorly/not able to drink 2.Feel: Skin pinch Goes back quickly Goes back slowly Goes back very slowly(>2 secs)

14. Assessing the patient for dehydration ABC 3. DecideThe patient has no signs of dehydration If 2 or more signs present— some dehydration If 2 or more signs present- severe dehydration 4. TreatUse treatment plan A Weigh the baby and use treatment plan B Weigh the baby and use treatment plan C urgently

15. TREATMENT PLAN A ( to treat diarrhea at home) Three rules of treatment plan A 1. Give the child more fluids than usual to prevent dehydration 2. Give the child plenty of food to prevent malnutrition 3. Take the child to the health worker if the child does not get better in 3 days or becomes worse

16. Treatment plan A First rule – Use recommended home fluids Oral rehydration solution Food based fluids( soup, rice water…) Plain water – Give as much fluid as the child takes – Continue giving fluids until the diarrhea stops

17. Treatment plan A… Second rule – Continue breast feeding frequently – Give usual milk if no breast feeding – If the baby has already started weaning Encourage the child to eat Offer food at least 6 times a day Give freshly prepared foods Provide mixture of foods—balanced diet

18. Treatment plan A…. Third rule – Watch for the following features Many watery stools Repeated vomiting Marked thirst Eating or drinking poorly Fever Blood in stool

19. Treatment plan [A] How much ORS to give after each loose stool AgeAmount of ORS to give after each loose stool Amount of ORS to provide for use at home Less than 2 yrs50-100 ml500 ml/ day 2-10 yrs100-200 ml1000 ml/ day More than 10 yrsAs much as wanted2000 ml/ day

20. Treatment plan B ( treatment of patients with some dehydration) Usually do not need to be admitted Treated in ORT corner of the oral rehydration area Mothers should stay with their children – To help with treatment – To learn how to continue it at home

21. Treatment plan [B].. Approximate amount of ORS to give,in the first 4 hrs AgeWeight in KGFluids in ml Less than 4 monthsLess than 5200- 400 4-11 months5- 8400- 600 12-23 months8- 10600- 800 2-4 yrs11- 16800- 1200 5-14 yrs16- 301200- 2200 15 yrs or older30 or more2200- 4000

22. Treatment plan B… The approximate amount of ORS required can be calculated by multiplying pt. wt in kg with 75 ml After 4 hours – Reassess the child using the assessment chart – Then select plan A, for no signs of dehydration – Plan B, for some signs of dehydration – Plan C, for severe signs of dehydration

23. TREATMENT PLAN C… Treatment of patients with severe dehydration Admit the patient Start IV fluids immediately If you can’t open IV line– rehydrate the patient by using naso-gastric tube If patient can take orally start ORS If you can’t open IV line and also unable to insert NG tube—refer the patient for IV or NG treatment

24. Treatment plan C…. Start IV fluids immediately While the drip is set up give ORS if the child can take orally Give 100 ml/kg RL or NS divided as follows: AgeFirst give 30 ml/kg inThen give 70 ml/kg in Infants1 hour *5 hours More than 1 year 30 minutes *2.30 hours

25. Treatment plan C…. * Repeat once if radial pulse is still very weak or not detectable Reassess the patient every 1-2 hrs If not improving, give the IV drip more rapidly Also give ORS as soon as the patient can drink – 5 ml/kg/hr

26. Treatment plan C…. Reassess the patient using the chart – After 6 hours in infants – After 3 hours in older children Then choose the appropriate treatment plan to continue the treatment