1. 19 FEB 2011 Mejino, Carmelou Melgarejo, Ivy Mendoza, Alvin Mendoza, Diana

2. OUTLINE  Definition of Diarrhea  Assessment of Child with Diarrhea  Discussion of IMCI Guidelines on Diarrhea

3. DEFINITION: DIARRHEA  It is passage of stool at least twice the normal bowel movement wherein the stools follow the shape of the container.  It is also defined in infants and children as a stool output of greater than 10 g/kg/day (normal=5-10 g/kg/day) and more than the adult limit of 200 g/24 hour. Nelson’s Textbook of Pediatrics. 17 th ed.  It is passage of stool at least twice the normal bowel movement wherein the stools follow the shape of the container.  It is also defined in infants and children as a stool output of greater than 10 g/kg/day (normal=5-10 g/kg/day) and more than the adult limit of 200 g/24 hour. Nelson’s Textbook of Pediatrics. 17 th ed.

4. Classification of Diarrhea Acute Diarrhea  It is the passage of loose and watery stool of less than two weeks duration. Chronic/Persistent Diarrhea  It is the passage of loose and watery stool of two weeks or longer duration. Acute Diarrhea  It is the passage of loose and watery stool of less than two weeks duration. Chronic/Persistent Diarrhea  It is the passage of loose and watery stool of two weeks or longer duration.

5. CLINICAL TYPES OF DIARRHEA Acute watery diarrhea (includes cholera): lasts several hours or days; main danger is dehydration Acute bloody diarrhea: “dysentery” causing major damage to intestinal mucosa, sepsis and malnutrition Persistent diarrhea: lasts 14 days or longer that results in malnutrition and serious non-intestinal infection Diarrhea with severe undernutrition: major dangers are: severe systemic infection, dehydration, heart failure, vitamin and mineral deficiency The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4 th rev. WHO document 2005

6. For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask about cough or difficult breathing and then ASK: DOES THE CHILD HAVE DIARRHEA? If NO If YES Does the child have diarrhea? IF YES, ASK: LOOK, LISTEN, FEEL: œ For how long? œ Look at the child’s general condition. Is the child: œ Is there blood in the stool Lethargic or unconscious? Restless or irritable? œ Look for sunken eyes. œ Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? œ Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly? CLASSIFY the child’s illness using the colour-coded classification tables for diarrhea. Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and anaemia, immunization status and for other problems. Classify DIARRHEA

7. Assessment of Child with Diarrhea Dehydration –General condition –Sunken eyes –Thirst –Skin elasticity Persistent diarrhea Dysentery

8. Does the child have diarrhea? IF YES, ASK:  For how long?  Is there blood in the stool? LOOK, LISTEN, FEEL: Look at the child’s general condition, is the child:  Lethargic or unconscious?  Restless or irritable? Look for sunken eyes Offer the child fluid. Is the child:  Not able to drink or drinking poorly?  Drinking eagerly, thirsty ? Pinch the skin of the abdomen.  Does it go back: Very slowly (> than 2 secs)? Slowly?

9. Two of the following signs: Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly SEVERE DEHYDRATION If child has no other severe classification: — Give fluid for severe dehydration (Plan C). OR If child also has another severe classification: — Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding If child is 2 years or older and there is cholera in your area, give antibiotic for cholera. Two of the following signs: Restless, irritable Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly SOME DEHYDRATION Give fluid and food for some dehydration (Plan B). If child also has a severe classification: — Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding Advise mother when to return immediately. Follow-up in 5 days if not improving. Not enough signs to classify as some or severe dehydration.NO DEHYDRATION Give fluid and food to treat diarrhoea at home (Plan A). Advise mother when to return immediately. Follow-up in 5 days if not improving. CLASSIFICATION TABLE FOR DEHYDRATION SIGNSCLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)

10. Four Rules for Home Treatment of Diarrhea (Treatment Plan A) Rule 1: Give more fluids than usual Rule 2: Zinc supplementation at 20 mg/day for 10-14 days (10 mg for infants < 6 months) Rule 3: Continue to feed the child Rule 4: When to return to the clinic Diarrhea Treatment Guidelines for Clinic-Based Health Care Workers

11. Fluids that normally contain salt –ORS solution –Salted drinks (salted rice water, salted yoghurt drink) –Vegetable or chicken soup with salt Fluids that do not contain salt –Plain water –Water in which a cereal has been cooked –Unsalted soup –Yoghurt drinks without salt –Green coconut water –Weak tea –Unsweetened fresh fruit juice The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4 th rev. WHO document 2005 FLUIDS TO GIVE Wherever possible, these should include at least one fluid that normally contains salt Plain clean water should also be given

12. DO NOT GIVE THESE FLUIDS!!! Drinks sweetened with sugar –Commercial carbonated beverages –Commercial fruit juices –Sweetened tea Other fluids to avoid –Those with stimulant, diuretic and purgative effect Coffee Some medicinal teas or infusions The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4 th rev. WHO document 2005

13. Treatment Plan B Oral Rehydration Therapy for children with some dehydration

14. Approximate amount of ORS solution to give in the first 4 hours AgeLess than 4 mos. 4-11 months 12-23 months 2 – 4 years 5 – 14 years 15 years older WeightLess than 5 kg. 5-7.9 kgs. 8 –10.9 kgs. 11-15.9 kgs. 16-29.9 kgs. 30 kgs. or more In ml200 - 400 400 - 600 600 - 800 800 - 1200 1200 - 2200 2200 - 4000 In local measure TPB

15. TREATMENT PLAN C To treat Severe Dehydration quickly

16. Treatment Plan C Age First give 30 ml/kg in Then give 70 ml/kg in Infants (under 12 months) 1 hour* 5 hours Older30 minutes* 2 ½ hours * Repeat once if radial pulses very weak or or not detectable Reassess the patient every 1-2 hours.If hydration is not Improving, give the IV more rapidly Also give ORS (about 5 ml/kg) as soon as the patient can drink, usually after 3-4 (infants) or 1-2 hrs. (older patients)

17. Dehydration present SEVERE PERSISTENT DIARRHEA Treat dehydration before referral unless the child has another severe classification. Refer to hospital. No dehydrationPERSISTENT DIARRHEA Advise the mother on feeding a child who has PERSISTENT DIARRHOEA. Follow-up in 5 days. SIGNSCLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

18. Blood in the stoolDYSENTERY Treat for 5 days with an oral antibiotic recommended for Shigella in your area. Follow-up in 2 days. CLASSIFICATION TABLE FOR DYSENTERY SIGNS CLASSIFY AS IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)

19. 4 Key Elements for effective clinical management of acute diarrhea Replacement of fluids, usually by ORT to prevent dehydration in the home and to treat dehydration Continued feeding, especially breastfeeding, during diarrhea episodes and in convalescence No use of antidiarrheal drugs and selective use of antibiotics Effective instruction of the child’s mother on – how to take care of the sick child at home –the indications for follow-up –methods of preventing future episodes of diarrhea

20. Etiologic Agents for most cases of diarrhea OrganismProportion of casesEffectiveness of antibiotics in Tx Rotavirus ETEC No agent found Shigella Campylobacter spp Vibrio Cholera Nontyphoid salmonella Up to 50% in health facilities; 5-10% in community Up to 25% in all ages 25% or more 5 – 10% 5-15% 5 – 10% in endemic areas Up to 10% of cases Not effective Effective Effective only if given early in course of disease Effective Not effective in usual uncomplicated diarrhea WHO

21. 4 conditions where antimicrobials are indicated Cholera - Tetracycline Shigella dysentery - Nalidixic acid Giardiasis - Metronidazole Amoebiasis - Metronidazole

22. Antimicrobial % resistance of Enteric pathogens Pathogen S. typhi Antimicrobial Chloramphenicol Cotrimoxazole Ampicillin 2002 0 3 2 2003 1 0 2004 0 1 Nontyphoidal Salmonella Chloramphenicol Cotrimoxazole Ampicillin Ciprofloxacin 16 15 24 4 21 31 47 8 18 20 2 0 ShigellaChloramphenicol Ampicillin Cotrimoxazole Nalidixic acid Ciprofloxacin 78 73 0 43 50 78 0 12 60 50 67 0