DiarrheaDiarrhea DiarrheaDiarrhea

is one of the major causes of infant morbidity and mortality

worldwide.

Every year approximately 500 500 millionmillion episodes of diarrhea

are registered.Approximately 4 million4 million children

below 5 years of age die per year from diarrheal diseases

(every 6 seconds – one childevery 6 seconds – one child)

Infection is the major cause of acute diarrhea. So, very often synonym to it is acute gastroenteritis.

In developing countries, an estimated overall incidence of acute gastroenteritis ranges from 6 to 12 episodes of diarrhea per year in children under 5 years of age compared to 1.3 to 2.3 episodes in developed countries.

The economic burden of acute gastroenteritis is enormous. In the US alone, gastroenteritis accounts for more than 220,000 hospital admissions per year in children under 5 years of age (10 % of all hospitalizations in this age group), resulting in an estimated direct annual cost of $2 billion.

It is well accepted that diarrhea of infancy is associated with malnutrition and is primarily a nutritional disease.

Thus, the main objective of treatment is immediate and adequate nutritional support.

Appropriate nutrient supply during the acute stage can also prevent progression to the protracted diarrhea of infancy.

Nutritional treatment Nutritional treatment in children with in children with diarrheadiarrhea

Nutritional treatment Nutritional treatment in children with in children with diarrheadiarrhea

By Nataliya Haliyash, MD, BSNBy Nataliya Haliyash, MD, BSN

DiarrheaDiarrheaDiarrheaDiarrhea

is increase in the number of stools and/or a decrease in their consistency as a result of

malabsorption or alterations of water and electrolyte transport by the

alimentary tract.

Diarrhea may be acute or chronic.

Grades of diarrhea Grades of diarrhea

Mild diarrhea – 4 to 7 loose stools each day as a rule without other evidence of illness

Moderate diarrhea – 8 to 15 loose or watery stooles daily with elevated temperature, vomiting, irritability, mild dehydration

Severe diarrhea – numerous (>15) to continuous stools, evident signs of moderate to severe dehydration, drawn, flaccid expression, high pitched cry, irritable or lethargic or even comatose.

Acute gastroenteritisAcute gastroenteritisAcute gastroenteritisAcute gastroenteritis

is characterized by the passage of ≥3 loose or watery stools in an 24 hour period, or the passage of one or more bloody stools, with or without vomiting, nausea, fever, and abdominal pain.

Acute gastroenteritis usually refers to an illness lasting no longer than 10-14 days.

Etiology of acute diarrheaEtiology of acute diarrheaEtiology of acute diarrheaEtiology of acute diarrhea

Viral agentsViral agents Bacterial pathogensBacterial pathogens

Human rotavirus

Small round viruses:NorwalkTauntonSnow MountainAstrovirusWollan

Enteric adenoviruses

Coronaviruses

Escherichia coli

Campylobacter

Salmonella

Shigella

Vibrio cholera

Yersinia enterocolitica

Clostridium difficile

Parasitic pathogensParasitic pathogens Helmintic pathogensHelmintic pathogens

Protozoa:Giardia lambliaCryptosporidiumEntamoeba histolyticaBalantidium coli

Nematodes:Ancylostoma duodenaleStrongyloides stercoralisNecator americanusTrichuris trichiura

Trematodes:Schistosoma

Cestodes:Taenia soliumTaenia saginataDiphyllobothrium latum

Pathogenesis of Acute DiarrheaPathogenesis of Acute DiarrheaPathogenesis of Acute DiarrheaPathogenesis of Acute Diarrhea

Diarrhea results when the net intestinal fecal loss of fluid and salt exceeds the absorbed amount.

There are 5 pathogenic forms of diarrhea:

1. Toxigenic diarrhea

2. Osmotic diarrhea

3. Secretory diarrhea

4. Invasive diarrhea

5. Motility disorders

Toxigenic diarrheaToxigenic diarrheaToxigenic diarrheaToxigenic diarrhea

Toxins from bacteria, like enterotoxigenic E.coli or Vibrio cholerae, bind to specific receptors:

labile toxin (LT) raises the level of cyclic guanosine monophosphate (cGMP) in the intestinal mucosa,

stable toxin (ST) increases the adenasine 3 ׳5:׳ -cyclic monophosphate (cAMP)

This leads to blocking the absorption of Na and Clˉ ions into the villous enterocytes.

LT induce the secretion of Clˉ and HCO3ˉ ions by crypt cells.

Osmotic diarrheaOsmotic diarrheaOsmotic diarrheaOsmotic diarrhea

Characterized by a positive osmotic gap of the stool

Clinically, osmotic diarrhea is distinguished by the fact that the diarrhea diminishes when the patient fasts or stops eating the poorly ingested solute.

Differential diagnosis of Differential diagnosis of osmotic and secretory diarrheaosmotic and secretory diarrheaDifferential diagnosis of Differential diagnosis of osmotic and secretory diarrheaosmotic and secretory diarrhea

Stools Stools Osmotic diarrheaOsmotic diarrhea Secretory diarrheaSecretory diarrhea

Electrolytes Na<70 mEq/l Na>70 mEq/l

Osmolality >(Na + K)2 =(Na + K)2

pH <5 >6

Reducing substances

Positive Negative

Volume < 200 ml/day > 200 ml/day

Secretory diarrheaSecretory diarrheaSecretory diarrheaSecretory diarrhea

There is no positive osmotic gap and the stool osmolality is equal to the ionic constituents: (Na + K)2 = stool osmolality

Food ingestion does not usually affect the stool volume

The stool is watery without blood or pus and is characterized by very high volume and ion output

Invasive diarrheaInvasive diarrheaInvasive diarrheaInvasive diarrhea

Is caused by direct mucosal damage by the invasive organism

It is similar to colitis and is usually associated with blood and mucous.

Motility disordersMotility disordersMotility disordersMotility disorders

Hypermotility can cause diarrhea by reduction of contact time between intestinal mucosa and its contents, despite normal absorption function of the cell

Hypomotility can be primary, as in idiopathic intestinal pseudo-obstruction syndrome, or secondary to neuronal disorders.

Clinical characteristics of infectious Clinical characteristics of infectious gastroenteritis in depence on gastroenteritis in depence on enteropathologic cause.enteropathologic cause.

Clinical characteristics of infectious Clinical characteristics of infectious gastroenteritis in depence on gastroenteritis in depence on enteropathologic cause.enteropathologic cause.

Organism Organism Characteristics Characteristics Comments Comments

Rotavirus

Incubation period:2-3 d.

Abrupt onsetFever (≥ 38°C) for 48 hhAssociated upper resp.tract infection

Incidence higher in cool weather

6- to 24-month-old infants are more vulnerable

Norwalk-like viruses

Inc.period:

1-2 days

FeverLoss of appetiteNausea/vomitingAbdominal painMalaise

Source of infection: drinking water, food

Affects all ages

Self-limited

Pathogenic Pathogenic Escherichia coliEscherichia coli

Incubation period: highly variable

Diarrhea with moist-green, watery stool with mucus; becomes explosiveVomiting may be present from onsetAbdominal distensionFever, intoxication

•Incidence higher in summer•Usually interpersonal transmission, but may transmit via inanimate objects

Salmonella Salmonella groups groups (nontyphoidae)(nontyphoidae) – gram-negative, non-encapsulated, nonsporulating

Incubation period: 6 hh-21 day

Rapid onsetVariable symptoms – mild to severeNausea, vomiting, and colicky abdominal pain followed by diarrhea, occasionally with blood and mucusInfants may be afebrile and nontoxic

•Highest incidence in children younger than 9 years, especially infants•Transmission – via contaminated food and drink, more commonly poultry and eggs

Shigella Shigella groupsgroups – gram-negative, nonmotile, anaerobic bacilli

Incubation period: 1-7 days

Onset usually abruptFever (to 40.5°C) and cramping abdominal pain initiallyFebrile convulsions in 10 % casesHeadache, neck rigidity, delirium

Transmitted directly or indirectly from infected persons

Vibrio choleraeVibrio cholerae groupsgroups

Inc.period: 1-3 days

Sudden onset of profuse, watery diarrhea without cramping, tenesmus, or anal irritation

Stools are intermittemt at first, then almost continuous

Stools are whitish, almost clear, with flecks of mucus – “rice water stools”

Rare in infants

Mortality is high

Transmitted via contaminated food or water

Food poisoning:Food poisoning:

StaphylococcusStaphylococcus

Incub.period:

4-6 hours

Nausea,vomitingSevere abdominal crampsProfuse diarrheaShock may occur in severe casesMay be a mild fever

•Transfered via contaminated food – inadequately cooked: custards, mayonnaise, cream-filled desserts•Self-limited (24-72 hours)•Exellent prognosis

BotulismBotulism

Clostridium Clostridium botulinumbotulinum

Incub.period:

12 hr – 3 days

Nausea,vomitingDiarrheaCNS symptoms with curare-like effectDry mouth, dysphagia

Transfered via contaminated food

Variable severity – mild symptoms to rapidly fatal within a few hours

Antitoxin administration

DiagnosisDiagnosis

Diagnosis is based on: the history, physical exam, and laboratory

studies focused on evaluating the child's hydration status and identifying the causative agent.

The history should include the following data:– • Recent exposure to infectious agents– • Travel history– • Exposure to contaminated food and water

supplies– • Exposure to turtles– • Attendance at a day-care center

If no systemic manifestations are present:If no systemic manifestations are present:

Diagnostic laboratory tests are not indicated.

Stool cultures should be performed for:– children with a fever lasting more than 24

hours,– blood or mucus in the stool, – a family or household member with similar

symptoms, – or a positive stool white blood cell stain.

Treatment Treatment Treatment Treatment

The main treatment aims are: To prevent dehydration – restoration

and maintenance of adequate hydration and electrolyte balance.

Nutritional support, adequate to prevent protracted diarrhea and malnutrition.

DEHYDRATIONDEHYDRATION

Dehydration is a critical condition that results from an extracellular fluid loss.

Since a large portion of a child's body fluid is located in extracellular spaces, a child is more susceptible to dehydration states than an adult.

Dehydration that is not corrected will lead to hypovolemic shock and death.

Types of dehydrationTypes of dehydration

1. hypotonic,

2. isotonic,

3. hypertonic

Conditions causing dehydrationConditions causing dehydration

Vomiting Diarrhea Burns Hemorrhage Nasogastric suctioning and drainage loss NPO status or inadequate fluid/food intake

due to illness Overuse of diuretics or enemas Adrenal insufficiency

Clinical ManifestationsClinical Manifestations

Depend on the degree of dehydration. Weight loss Rapid-thready pulse Hypotension Decreased peripheral circulation Decreased urinary output Increased specific gravity decreased skin turgor dry mucous membranes absence of tears a sunken fontanel in infants.

Clinical Manifestations Associated with Degree of DehydrationClinical Manifestations Associated with Degree of Dehydration

Nursing DiagnosesNursing Diagnoses

Nursing diagnoses appropriate for a child with dehydration may include:

1. Deficient fluid volume related to excessive fluid volume loss or inadequate fluid intake.

2. Risk for injury (fall) related to orthostatic (postural) hypotension.

3 . Deficient knowledge (caregiver) related to lack of exposure to information about preventing/detecting dehydration.

Outcome IdentificationOutcome Identification

1. The child will receive sufficient fluids to replace losses.

2. The child will exhibit signs of adequate hydration.

3. The child will not fall or sustain other injuries while hypotensive or lethargic.

4. Caregivers will demonstrate understanding of conditions that can lead to dehydration and of the early signs and symptoms.

Planning/ImplementationPlanning/Implementation

Nursing interventions include:– administration of IV fluids,– assessment of daily weight, vital signs, and

maintenance of accurate intake and output records.

– Injury due to falls can be prevented by making sure that the side rails of the bed are raised, assessing level of consciousness, and monitoring the serum sodium level.

– An elevation in serum sodium will cause the brain cells to dehydrate and result in a loss of consciousness if not corrected quickly.

TreatmentTreatment

What about antimicrobial therapy?What about antimicrobial therapy?What about antimicrobial therapy?What about antimicrobial therapy?

In about 30 % of patients no specific agent can be found

Most of the isolated pathogenic organisms are viral

The majority of the bacterial pathogens are self-limited

In some cases, antimicrobial therapy prolongs the infection duration

Antibiotic therapy has no effect on fluid transport nor on nutritional support

When should antibiotics be used?When should antibiotics be used?When should antibiotics be used?When should antibiotics be used?

In young infants In immunocompromised patients When a systemic bacteremia is

suspected. In case of specific persisting infection

caused by Yersinia, Campylobacter, and Giardia

RehydrationRehydration RehydrationRehydration

In the majority of cases of acute diarrhea with mild or moderate dehydration, this aim can be achieved with oral rehydration solutions (ORS)

Severe dehydration requires immediate admission to hospital and intravenous replacement of fluid and electrolytes.

The rationale for the use of ORSThe rationale for the use of ORSThe rationale for the use of ORSThe rationale for the use of ORS

1. During diarrhea, the normal mechanism for water and sodium absorption is impaired, so, the replacement of water or saline fluids alone will only lead to more diarrhea.

2. The sodium-glucose-coupled transport generally remains intact. This mechanism stimulates water transport by solvent drag.

The basic components of ORSThe basic components of ORSThe basic components of ORSThe basic components of ORS

Glucose Electrolytes

in an isotonic solution.

In the World Health Organization formula the glucose concentration is 2 %.

WHO recommendations for a WHO recommendations for a sodium concentrationsodium concentration

WHO recommendations for a WHO recommendations for a sodium concentrationsodium concentration

90 mEq/l, essentially for treatment of cholera

30-60 mEq/l for countries, where cholera is not a concern and the stool sodium concentration in diarrheal illness is much lower

30-40 mmol/l for neonates up to 2 mo whose kidneys have less capacity to excrete excess amounts of fluid and salt

Rehydration FluidsRehydration Fluids

The World Health Organization recommends the following electrolyte concentrations for rehydration fluids:– 20 g glucose/L, – 90 mEq sodium/L, – 80 mEq chloride/L,– 20 mEq potassium/L, – and 30 mEq bicarbonate/L.

Encourage caregivers to look at product labels and make sure that the rehydration fluid they are choosing has the above electrolyte concentrations.

Composition of oral electrolyte Composition of oral electrolyte solutions (in mEq/l)solutions (in mEq/l)Composition of oral electrolyte Composition of oral electrolyte solutions (in mEq/l)solutions (in mEq/l)

Na+ K+ Clˉ Other anion CHO(%)

WHO solution 90 20 80 30 2

Gastrolyte 90 20 80 30 2

Pedialyte 45 20 35 30 2.5

Rehydralyte 75 20 65 30 2.5

infalyte 50 20 40 30 2

Composition of Composition of “clear liquid” solutions “clear liquid” solutions

Composition of Composition of “clear liquid” solutions “clear liquid” solutions

Na+ K+ CHO(%)

Pepsi Cola 1-2 0.1 10.9

Coca Cola 1-2 0.1 10

Root beer 6 0.6 10.6

Super-ORSSuper-ORSSuper-ORSSuper-ORS

Recent studies demonstrate the advantage of short glucose polymers as the carbohydrate source in ORS

Traditionally it is widely used rice water + 3-5 % sugar syrup.

Or carrot decoction: 500 g of cleansed carrot boil in 1 l of water during 1 hour, then mash it to homogenous mass and add boiled water up to 1 l. Boil for 10 min. Add 3 tsf of lemon juice. Give 1-2 teaspoon every 5-10 min up to 400 ml/day.

Fluid needs for rehydration Fluid needs for rehydration (in ml/kg)(in ml/kg)

Fluid needs for rehydration Fluid needs for rehydration (in ml/kg)(in ml/kg)

Grade of Grade of dehydrationdehydration

Weight Weight defficit, %defficit, % 0-12 mo0-12 mo 1-5 yrs1-5 yrs 6-10 yrs6-10 yrs

I

(mild)1-5 130-150 100-125 75-100

II

(moderate)6-10 170-200 130-170 100-110

III

(severe)>10 200-230 175-200 100-150

Calculating fluid loss from weight loss:Calculating fluid loss from weight loss:

Fluid lost can be calculated according to weight lost.

One kilogram of body weight equals 1 L of water.

Therefore, each kilogram of weight lost is equal to 1,000 ml of fluid lost.

It is important to know the last weight of the child before the beginning of diarrhea

The total amount of rehydration fluid is counted per factual weight

The total amount of rehydration fluid is divided per 2 days: ⅔ - on the 1st day, ⅓ - on the 2nd day.

For example:The child with body weight 6 kg have lost 10 %

from last weighing due to diarrhea.So, we have to prescribe 600 ml of fluid for

rehydration: 400 ml on the 1st day, 200 ml on the 2nd day.

Additionally, for perspiration 50 ml/kg (506=300 ml) For diuresis 40 ml/kg (406=240 ml) For vomiting and stool losses 60-120 ml/kg

(606=360 ml)So, the total fluid amount on the 1st day is 400+300+240+360 = 1300 ml (215 ml/kg)The total fluid amount on the 2nd day is200+300+240+360 = 1100 ml (185 ml/kg)

50 % of this amount is given as oral electrolyte solutions

50 % as herbal teas, herbal decoctions (Hamomilla, Rosa canina, Fenhel)

Raisins water is prepared:Put 7-9 raisins into just boiled water (250

ml). Keep it covered for 15-20 min. Cool. Give it to child.

Nutritional therapyNutritional therapyNutritional therapyNutritional therapy

In this question opinions differ: “bowel rest” versus “early feeding” is still controversial.

Generally, formula feeding should be introduced gradually by starting with dilute mixtures.

In practice, refeeding can start gradually after 24 hr of only fluid intake, i.e.,”bowel rest”.

An exception is made for nursing infants, who should continue their regular feeding.

Children already on solid foods are easier to handle. Food with a high content of disaccharides and monosaccharides (fruits, sweets) should be withheld in the convalescent period. Foods with starch carbohydrates (cereal, rice, noodles, bananas, potatoes, carrot) should be encouraged.

It is important to give often small food-intakes (up to 8-10 times per day)

Administration of pancreatini (0.2 3-4 times per day immideately after food) or panzynormi (⅓ tab. 2 times per day for infants under 6 mo) for 3-7 days is effective.

Enterosorbent drugs are given 1.5 hr after and 1 hr before any food or drug intake from the onset of diarrhea:

• EnterodesEnterodes : dissolve 5 g in 100 ml of 5 % glucose and give 5-10 ml/kg 2-3 times/day for 3-5-7 days

• EnterosgelEnterosgel : 1g/kg

ProbioticsProbiotics ProbioticsProbiotics

For infants under 6 mo: Bifidumbacterin – 2-3 doses 3 t/day for

3 weeks Lactobacterin – 2-3 doses 2 t/day for 3

weeks L.acidophilus – 5 doses once daily 1-3

weeks For children older 6 mo: Coli-bacterin – 2-5 doses 2 t/day for 3-4

weeks

Treatment of severe (>10%) dehydration:Treatment of severe (>10%) dehydration:

Treat as an emergency. Begin IV therapy (40 ml/kg/hr) until child

improves; then offer 50-100 ml/kg ORS. Obtain and monitor electrolyte levels. Reassess frequently. Provide ORS when alert.

Adding Potassium to Intravenous SolutionsAdding Potassium to Intravenous Solutions

Be sure that the child is able to void (1 -2 ml/kg/hr) before adding potassium to the IV.

Children who are dehydrated are oliguric and can become anuric. An anuric child will not be able to excrete electrolytes that are in the IV solution; therefore, if potassium is added to the IV, it would result in an elevated serum potassium. An elevated serum potassium can cause cardiac irritability and ventricular fibrillation.

Always check the dose and dosage calculations prior to giving. Never give more than 40 mEq/L at a rate not to exceed 1 mEq/kg/hr.

After adding potassium to an IV bag, shake it to make sure the potassium is equally distributed.

Never give potassium by IV push.Never give potassium by IV push.

Thank you for attentionThank you for attention