Diarrhea

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Diarrhea

• is one of the major causes of infant morbidity
  and mortality worldwide.

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• Every year approximately 500 million episodes of
  diarrhea are registered.
• Approximately 4 million children below 5 years of
  age die per year from diarrheal diseases (every 6
  seconds one child)

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• 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.

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• 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.

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Nutritional treatment in children with diarrhea

• By Nataliya Haliyash, MD, BSN

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Diarrhea

• 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.

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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 (gt15) to continuous
  stools, evident signs of moderate to severe
  dehydration, drawn, flaccid expression, high
  pitched cry, irritable or lethargic or even
  comatose.

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Acute 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.

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Etiology of acute diarrhea
Viral agents Bacterial pathogens
Human rotavirus Small round viruses Norwalk Taunton Snow Mountain Astrovirus Wollan Enteric adenoviruses Coronaviruses Escherichia coli Campylobacter Salmonella Shigella Vibrio cholera Yersinia enterocolitica Clostridium difficile
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Parasitic pathogens Helmintic pathogens
Protozoa Giardia lamblia Cryptosporidium Entamoeba histolytica Balantidium coli Nematodes Ancylostoma duodenale Strongyloides stercoralis Necator americanus Trichuris trichiura Trematodes Schistosoma Cestodes Taenia solium Taenia saginata Diphyllobothrium latum
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Pathogenesis 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
• Toxigenic diarrhea
• Osmotic diarrhea
• Secretory diarrhea
• Invasive diarrhea
• Motility disorders

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Toxigenic 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
  Cl ions into the villous enterocytes.
• LT induce the secretion of Cl and HCO3 ions by
  crypt cells.

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Osmotic 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.

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Differential diagnosis of osmotic and secretory
diarrhea
Stools Osmotic diarrhea Secretory diarrhea
Electrolytes Nalt70 mEq/l Nagt70 mEq/l
Osmolality gt(Na K)?2 (Na K)?2
pH lt5 gt6
Reducing substances Positive Negative
Volume lt 200 ml/day gt 200 ml/day
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Secretory 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

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Invasive diarrhea

• Is caused by direct mucosal damage by the
  invasive organism
• It is similar to colitis and is usually
  associated with blood and mucous.

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Motility 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.

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Clinical characteristics of infectious
gastroenteritis in depence on enteropathologic
cause.
Organism Characteristics Comments
Rotavirus Incubation period2-3 d. Abrupt onset Fever ( 38C) for 48 hh Associated 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 Fever Loss of appetite Nausea/vomiting Abdominal pain Malaise Source of infection drinking water, food Affects all ages Self-limited
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Pathogenic Escherichia coli Incubation period highly variable Diarrhea with moist-green, watery stool with mucus becomes explosive Vomiting may be present from onset Abdominal distension Fever, intoxication Incidence higher in summer Usually interpersonal transmission, but may transmit via inanimate objects
Salmonella groups (nontyphoidae) gram-negative, non-encapsulated, nonsporulating Incubation period 6 hh-21 day Rapid onset Variable symptoms mild to severe Nausea, vomiting, and colicky abdominal pain followed by diarrhea, occasionally with blood and mucus Infants 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
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Shigella groups gram-negative, nonmotile, anaerobic bacilli Incubation period 1-7 days Onset usually abrupt Fever (to 40.5C) and cramping abdominal pain initially Febrile convulsions in 10 cases Headache, neck rigidity, delirium Transmitted directly or indirectly from infected persons
Vibrio cholerae groups 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
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Food poisoning Food poisoning Food poisoning
Staphylococcus Incub.period 4-6 hours Nausea,vomiting Severe abdominal cramps Profuse diarrhea Shock may occur in severe cases May be a mild fever Transfered via contaminated food inadequately cooked custards, mayonnaise, cream-filled desserts Self-limited (24-72 hours) Exellent prognosis
Botulism Clostridium botulinum Incub.period 12 hr 3 days Nausea,vomiting Diarrhea CNS symptoms with curare-like effect Dry mouth, dysphagia Transfered via contaminated food Variable severity mild symptoms to rapidly fatal within a few hours Antitoxin administration
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Diagnosis

• 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

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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.

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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.

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DEHYDRATION

• 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.

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Types of dehydration

1. hypotonic,
2. isotonic,
3. hypertonic

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Conditions 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

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Clinical 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.

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Clinical Manifestations Associated with Degree of
Dehydration
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Nursing 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.

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Outcome 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.

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Planning/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.

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Treatment
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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

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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

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Rehydration

• 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.

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The 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.

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The basic components of ORS

• Glucose
• Electrolytes
• in an isotonic solution.
• In the World Health Organization formula the
  glucose concentration is 2 .

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WHO recommendations for a sodium 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

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Rehydration 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.

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Composition of oral electrolyte solutions (in
mEq/l)
Na K Cl 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
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Composition of 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
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Super-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.

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Fluid needs for rehydration (in ml/kg)
Grade of dehydration Weight defficit, 0-12 mo 1-5 yrs 6-10 yrs
I (mild) 1-5 130-150 100-125 75-100
II (moderate) 6-10 170-200 130-170 100-110
III (severe) gt10 200-230 175-200 100-150
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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.

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• 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 ? - on the 1st day, ? - on the 2nd
  day.

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• 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 (50?6300 ml)
• For diuresis 40 ml/kg (40?6240 ml)
• For vomiting and stool losses 60-120 ml/kg
  (60?6360 ml)
• So, the total fluid amount on the 1st day is
• 400300240360 1300 ml (215 ml/kg)
• The total fluid amount on the 2nd day is
• 200300240360 1100 ml (185 ml/kg)

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• 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.

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Nutritional 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.

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• 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.

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• 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 (? 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
• Enterodes dissolve 5 g in 100 ml of 5 glucose
  and give 5-10 ml/kg 2-3 times/day for 3-5-7 days
• Enterosgel 1g/kg

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Probiotics

• 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

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Treatment of severe (gt10) 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.

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Adding 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.

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• Thank you for attention