management of diarrhoea
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MANAGEMENT OF DIARRHOEA
By Dr Ashka Shah
PRINCIPLES OF MANAGEMENT Oral rehydration therapy Enteral feeding & diet selection Zinc supplements Additional therapies
probioticsantibioticsRececardotril
Signs Classification of dehydration
Treatment
No signs of dehydration
No dehydration Follow Plan A
Two of the following signs
Some dehydration
Follow plan B
•Restless, irritable•Sunken eyes•Tear absent•Dry mouth &tongue•Skin goes slowly•Thirst, drinks eagerly
PLAN OF MANAGEMENT
Signs Classification of
dehydration
Treatment
Two of the following signs
Severe dehydration
Follow plan C
•Unconcious•Floppy•Refusal to feed•Unable to drink•Very sunken eyes•Skin goes back very slowly
PLAN OF MANAGEMENT
PLAN A Cases with No Signs of Dehydration fluid loss is <5% of the body weight, children may
not show any clinical signs of dehydration Correct fluid deficit and ongoing fluid losses Give HAF or ORS Plan A involves counselling the child's mother about
the 3 Rules of Home treatment. GIVE EXTRA FLUID (as much as the child will take) CONTINUE FEEDING WHEN TO RETURN
PLAN-BCases with signs of Some Dehydration
REHYDRATION THERAPY Amount of ORS to be given in first
4 hrsAge < 4 months
4 -12 months
12m- 2 yrs
2-6 yrs
Wt (kg) < 6 6 - < 10 10 - <12 12 - 19
ORS(ml) 200-400 400-700 700-900 900-1400
Glass(No.)
1 - 2 2 - 3 3 – 4 4 - 7
PLAN B Use the child’s age only when we do not know
the weight. The approximate amount of ORS required (in
ml) can also be calculated by multiplying the child’s weight (in kg) × 75
Show the mother how to give ORS solution After 4 hours
Reassess and classify the child for dehydration Select the appropriate plan to continue treatmentBegin feeding the child in clinic
PLAN B After signs of severe dehydration
disappear & child is able to drink, further therapy should be continued with ORS as per plan A or B
Before the mother leaves the hospital two packets of ORS must be given.
PLAN C Cases with signs of Some Dehydration 1% diarrhoea may develop severe dehydration. Children with severe dehydration must be admitted. Child is rehydrated quickly by using I/V infusion. I/V infusions recommended :
R/L solution N/S when R/L is not available 1/2 N/S with 5% dextrose is acceptable
Plain glucose is unsuitable solution
PLAN C Reassess the infant every 15-30 min. until a
strong radial pulse is present. Thereafter, reassess the infant by skin pinch
and level of consciousness at least every 1-hour
Also give ORS (about 5 ml/kg/hour) as soon as the infant can drink: usually after 3-4 hours
Reassess the infant after 6 hours & classify dehydration then choose the appropriate plan (A,B, or C) to continue treatment
PLAN C After signs of severe dehydration
disappear & child is able to drink, further therapy should be continued with ORS as per plan A or B
Before the mother leaves the hospital two packets of ORS must be given.
ORAL REHYDRATION THERAPY It is a balanced mixture of glucose and
electrolytes Almost all deaths from diarrhoea can be
prevented by ORS
MECHANISM OF ACTIONSodium promotes absorption of water from the intestineGlucose promotes the absorption of sodium and water from the intestine
Ingredients Old-ORS New-ORS (WHO-ORS) (Reduced osmolarity ORS)
Sodium (mmol/L) 90 75Potassium (mmol/L) 20 20Chloride (mmol/L) 80 65Citrate (mmol/L) 10 10Glucose (mmol/L) 111 75Osmolarity (mosml/L) 311 245
ORAL REHYDRATION THERAPY
LIMITATION OF ORS Does not reduce the diarrhea stool volume and
duration Parents are concerned to stop the diarrhea but not the
dehydration due to diarrhea It is not or less effective in
ShockAn ileusIntussusceptionCarbohydrate intoleranceSevere emesisHigh stool output
ENTERAL FEEDING AND DIET SELECTION After rehydration completion, food should be
reintroduced Continue oral rehydration to replace ongoing
lossesStart breast feeding as soon as possible
Food with complex carbohydrate is preffered Avoid fatty food or food with simple sugars
(juices, carbonated soda) Energy density should be 1kcal/grm
Energy intake should be 100 kcal/kg/day and protein intake of 2-3 grm/kg/day.
Milk should not be diluted with water during any phase of acute diarrhoea.
Milk can also be given as milk cereal mixture e.g. dalia, milk-rice mixture.
This technique reduces the lactose load & preserving energy density.
ENTERAL FEEDING AND DIET SELECTION
ENTERAL FEEDING AND DIET SELECTION To make foods-energy dense some of
preparation are:- - Khichri with oil - Rice with curd & sugar- Mashed banana with milk or curd - Mashed potatoes with oil.
ZINC SUPPLEMENTS 10 mg/kg in infants <6 months and 20
mg/kg in >6 months of age. Benefits of zinc therapy
Reduced duration and severityprevent recurrencereduction of inappropriate use of
antibiotics
ANTIBIOTICS IN DIARRHOEA Indication
Suspected cholera with severe dehydration Bloody diarrhoea Associated non gastrointestinal infection Severely malnurished or
immunocompromised child Specific infection
PROBIOTICS It means bacteria associated with beneficial effects
for humans and animals. Can inhibit the growth and adhesion of a range of
entero-pathogens Indicated in
- Treatment and prevention of acute diarrhoea caused by rotavirus in children - Antibiotic associated diarrhoea
Probiotic strains - Lactobacillus rhamnosus GG and Bifidobacterium
lactis BB-12
POTENTIAL USES OF PROBIOTICS -diarrhoea -Helicobacter pylori infection -Inflammatory bowel disease -Cancers -To increase Immunity -Allergy -Heart disease -Urogenital tract infections
PROBIOTICS
ADDITIONAL THERAPY Antiemetics like ondansetron can be
useful during rehydration therapy. Racecadotril an enkephalinase
inhibitor is found useful to reduce stool output
Exclusive Breast Feeding Bottle feeding should be avoided Improved personal hygiene and sanitation
Wash Hand Eat clean Food Drink clean water
Immunization e.g. Measles, Rota virus Vit. A - Prophylactic doses Better Nutrition Improved case management
PREVENTION OF DIARRHOEA
ROTA VIRUS VACCINATION Rotashield vaccine -1999 Withdrawn because of its association with
intussuscption Two new oral, live attenuated rotavirus vaccines were
licensed in 2006 with very good safety and efficacy The first dose administered between ages 6-10 weeks
. subsequent doses at intervals 4-10 weeks. Vaccination should not be initiated before 6weeks and
after 12 weeks of age. All doses should be administered before 32 weeks.
ROTA VIRUS VACCINATIONRota Rix vaccine Rota Teq vaccine
Oral, live attenuated
Oral, live attenuated, pentavalent vaccine.
Contains 5 live reassortant rotaviruses
2 dose schedule 3 dose schedule
1st dose - 2 month of age at 2 month of age
2nd dose- 4 month 4 month of age…………………………
. 6 month of age
NATIONAL DIARRHOEAL DISEASE CONTROL PROGRAMME
National ORT Programme was incepted in 1985- 86 From 1992-93 the programme has become a part
of CSSM Programme. CSSM programme become a part of RCH
programme in 1997 In RCH Programme, policy of IMCI was adopted Strategy of IMCI was to address all children and not
only sick children IMCI focused on life threatening illnesses-
diarrhoea, Pneumonia, Measles, Malaria etc.
IMNCI Since 2003 - DDCP included in IMNCI
which includes Neonates of 0-7 days Incorporating national guidelines on diarrhoea, ARI ,Malaria, Anaemia, Vit. A supplementation & Immunizations
STRATEGIES OF IMNCI Ensure standard case management of diarrhoea
by training of medical and other health personnel.
Promote standard case management practices among private practitioners through IMA and IAP.
Improve maternal knowledge on home management and recognition of danger signs of diarrhoea for immediate medical care.
CASE MANAGEMENT STRATEGYCLASSIFICATION:
PINK : Child needs referral ( Inpatient care)
YELLOW : Child needs specific treatment, provide
it at home (e.g. Antibiotics, ORS)
GREEN : Child needs no medicine, give home care
LIMITATIONS OF IMNCI Outpatient Facility Based
Community activities not given adequate focus
Vertical initiatives in Non IMNCI districts sorely lacking
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