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Acute Diarrhea in
      children

         PRESENTED BY:
A.PRIYADHARSHINI M.Sc(N),
LECTURER,
DEPT. OF PAEDIATRIC NURSING,
GWALIOR
Is just a little case of
diarrhea…
   Second leading causes of all death
    worldwide
   Most common cause of morbidity and
    mortality in children worldwide
Definition
   Stool weight in excess of 200 gm/day
   3 or more loose or watery stools/day
   Alteration in normal bowel movement
    characterized by decreased
    consistency and increased frequency
   Less than 14 days in duration
Epidemiology
   1.2-1.9 episodes per person annually
    in the general population
   2.4 episodes per child <3 years old
    annually
   5 episodes per year for children <3
    years old and in daycare
   Seasonal peak in the winter
Etiology
   Viral: 70-80% of infectious diarrhea in
    developed countries
   Bacterial: 10-20% of infectious
    diarrhea but responsible for most
    cases of severe diarrhea
   Protozoan: less than 10%
Viral Diarrhea
   Rotavirus
   Norovirus (Norwalk-like)
   Enteric Adenovirus
   Astrovirus
Rotavirus
   Leading cause of hospitalization for
    diarrhea in children
   Most prevalent during winter season
   Fecal-oral transmission: viral shedding
    can persist for 21 days
   Acute onset of fever followed by watery
    diarrhea (10-20 BM/day) and can persist
    for up to a week
Norovirus
   Most common cause of diarrheal
    outbreaks/epidemics
   Multiple modes of fecal-oral
    transmission
   Acute onset of nausea and vomiting,
    watery diarrhea with abdominal
    cramps and can persist for 1-3 days
Enteric Adenovirus
   Primarily affects children < 4 years old
   Fecal-oral transmission
   Clinical picture similar to rotavirus
    (fever and watery diarrhea)
Astrovirus
   Primarily affects children < 4 years old
    and immunocompromised
   Seasonal peak in the winter
   Fecal-oral transmission: viral shedding
    can occur for several weeks
   Fever, nausea and vomiting, abdominal
    pain, and diarrhea lasting up to a week
Summary of Viral
Diarrhea
   Most likely cause of infectious diarrhea
   Rotavirus and Norovirus are most
    common
   Symptoms usually include low grade
    fever, nausea and vomiting, abdominal
    cramps, and watery diarrhea lasting up to
    1 week
   Viral shedding can occur for weeks after
    symptoms resolve
Bacterial Diarrhea
   Campylobacter
   Salmonella
   Shigella
   Enterohemorrhagic Escherichia coli
Campylobacter
   Most common bacterial pathogen
   Transmitted through ingestion of
    contaminated food or by direct contact
    with fecal material
   Symptoms include diarrhea (+/- blood),
    abdominal cramps (can be severe),
    malaise, fever
   Usually self-limited and does not require
    antibiotics
Salmonella
   Most common in children <4 years old
    and a peak in the first few months of life
   Transmitted via ingestion of
    contaminated food and contact with
    infected animals
   Symptoms include fever, diarrhea, and
    abdominal cramping
   Antimicrobial therapy can prolong fecal
    shedding
Shigella
   Fecal-oral transmission
   Symptoms include fever, abdominal
    cramps, tenesmus, and mucoid stools
    with or without blood
   Can lead to serious complications
   Antimicrobial treatment shortens
    duration of illness and limits fecal
    shedding
E. Coli O157:H7
   Transmission via contaminated food and
    water
   Symptoms include bloody diarrhea,
    severe abdominal pain, and sometimes
    fever
   Can lead to serious complications
   Antibiotics have no proven benefit and
    may increase the risk of complications
Summary of Bacterial
Diarrhea
   Can affect all age groups
   Fecal-oral transmission, often through
    contaminated food
   Typical symptoms include bloody
    diarrhea, severe cramping, and malaise
   Antibiotic treatment not always necessary
Physical Exam
   Vitals, vitals, vitals!
   Abdominal exam
   Presence of occult blood
   Signs of dehydration
Laboratory Evaluation
   Unnecessary for patients who present
    within 1 day from onset of diarrhea
   Warning signs/symptoms: bloody
    diarrhea, high fever, severe abd pain,
    dehydration.
   Fecal leukocytes followed by bacterial
    culture, ova & parasites, viral antigens
   CBC, chemistries
Treatment
   Fluid replacement
    – Fluids or Oral Rehydration Solutions (ORS)
    – Parenteral rehydration
   Early refeeding
   Symptomatic Treatment
    – Oral bismuth
    – Loperamide
   Antibiotics
Fluid Replacement
   ORS: Infalyte, Pedialyte, Naturalyte
    and Rehydralyte
   Must be used or thrown out 24 hours
    after opening/mixing
AAP Guidelines
   Diarrhea with no dehydration – normal
    diet and supplemental ORS with each
    diarrheal episode.
   Diarrhea with some dehydration –
    seek medical care, give ORS in the doctor's
    office, and cont. ORS and normal diet at
    home.
   Moderate - severe dehydration –
    consider intravenous hydration, especially if
    patient is also vomiting
Early Refeeding
   Luminal contents help promote growth
    of new enterocytes and facilitate
    mucosal repair
   Can shorten duration of the disease
   Lactose restriction is not necessary
    except in severe disease
Symptomatic Treatment
   Only in patients who are afebrile and
    have nonbloody diarrhea
   Loperamide – inhibits peristalsis and has
    antisecretory properties
   Bismuth subsalicylate – may help with
    nausea, vomiting, and abdominal pain,
    as well as shorten duration of illness
Antibiotics
   antibiotic therapy generally not
    beneficial and can be harmful
   Those with more than eight stools/day,
    diarrhea >1 wk, volume depletion,
    immunosuppresion, or warning signs
   Fluoroquinolone or Azithromyzin
Specific Antibiotic
Therapy
   Viral – of course not!
   Campylobacter – only if severe
   Salmonella – can prolong fecal
    shedding, only prescribe if severe
   Shigella – proven beneficial
   E. Coli O157:H7 – can be harmful
   Zinc Supplementation in AD

!    Responsible for > 200 enzymes in body.
!    Improves the immune function &
     absorption.
!    Supplementation in AD and PD helpful in
     20-30% reduction in diarrhea.
!    42% lower rate of treatment failure or
     death.
                    – Dosages
    – o Infants 10mg daily x 2 weeks.
    – o Older children 20mg daily x 2 weeks.
    – o Persistent diarrhea x 4 weeks
Home Available Fluids

Recommended
 Salt sugar solution
 Lemon water(Sikanjabi)
 Rice water / Kanjee
 Soups
 Dal water
 Lassi
 Coconut water
 Plain water
Not recommended
 Simple sugar solution

 Glucose solution

 Carbonated soft drinks

 Fruit juices-tinned or fresh

 Fluids for athletes

 Gelatin desserts

 Tea/Coffee
Nursing management:

   Restoring fluid and electrolyte balance
    by ORS and IV therapy.
   Prevention of spread of infection by
    good hand washing practices, hygienic
    disposal of stools, care of diapers,
    general cleanliness and universal
    precautions.
   Preventing skin breakdown by
    frequent change of diaper, keeping the
    perineal area dry and clean
   Providing adequate nutritional intake
    by appropriate dietary management
   Reducing fear and anxiety by
    explanation, reassurance, answering
    questions and providing necessary
    informations.
   Giving health education for prevention
    of diarrhea, home management of
    diarrheal diseases, importance of
    ORS, dietary management etc..
References
   Dennehy P.H., Acute Diarrheal Disease in Children:
    Epidemiology, Prevention, and Treatment. Infect Dis
    Clin North A 2005;(19) 3:
   Wanke C.A., Approach to the patient with acute
    diarrhea. Up To Date (updated Jan. 4, 2005)
    www.uptodate.com/
   Blacklow N.R., Epidemiology of viral gastroennteritis in
    adults. Up To Date (updated March 3, 2005)
    www.uptodate.com/
   Thielman N.M., (2004) Acute Infectious Diarrhea. N Engl
    J Med 2004;350:38-47.
   Burkhart D.M., Management of Acute Gastroenteritis in
    Children. Am Fam Physician. 1999 Dec;60(9):2555-63

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Acute diarrhea in children

  • 1. Acute Diarrhea in children PRESENTED BY: A.PRIYADHARSHINI M.Sc(N), LECTURER, DEPT. OF PAEDIATRIC NURSING, GWALIOR
  • 2. Is just a little case of diarrhea…  Second leading causes of all death worldwide  Most common cause of morbidity and mortality in children worldwide
  • 3. Definition  Stool weight in excess of 200 gm/day  3 or more loose or watery stools/day  Alteration in normal bowel movement characterized by decreased consistency and increased frequency  Less than 14 days in duration
  • 4. Epidemiology  1.2-1.9 episodes per person annually in the general population  2.4 episodes per child <3 years old annually  5 episodes per year for children <3 years old and in daycare  Seasonal peak in the winter
  • 5. Etiology  Viral: 70-80% of infectious diarrhea in developed countries  Bacterial: 10-20% of infectious diarrhea but responsible for most cases of severe diarrhea  Protozoan: less than 10%
  • 6. Viral Diarrhea  Rotavirus  Norovirus (Norwalk-like)  Enteric Adenovirus  Astrovirus
  • 7. Rotavirus  Leading cause of hospitalization for diarrhea in children  Most prevalent during winter season  Fecal-oral transmission: viral shedding can persist for 21 days  Acute onset of fever followed by watery diarrhea (10-20 BM/day) and can persist for up to a week
  • 8. Norovirus  Most common cause of diarrheal outbreaks/epidemics  Multiple modes of fecal-oral transmission  Acute onset of nausea and vomiting, watery diarrhea with abdominal cramps and can persist for 1-3 days
  • 9. Enteric Adenovirus  Primarily affects children < 4 years old  Fecal-oral transmission  Clinical picture similar to rotavirus (fever and watery diarrhea)
  • 10. Astrovirus  Primarily affects children < 4 years old and immunocompromised  Seasonal peak in the winter  Fecal-oral transmission: viral shedding can occur for several weeks  Fever, nausea and vomiting, abdominal pain, and diarrhea lasting up to a week
  • 11. Summary of Viral Diarrhea  Most likely cause of infectious diarrhea  Rotavirus and Norovirus are most common  Symptoms usually include low grade fever, nausea and vomiting, abdominal cramps, and watery diarrhea lasting up to 1 week  Viral shedding can occur for weeks after symptoms resolve
  • 12. Bacterial Diarrhea  Campylobacter  Salmonella  Shigella  Enterohemorrhagic Escherichia coli
  • 13. Campylobacter  Most common bacterial pathogen  Transmitted through ingestion of contaminated food or by direct contact with fecal material  Symptoms include diarrhea (+/- blood), abdominal cramps (can be severe), malaise, fever  Usually self-limited and does not require antibiotics
  • 14. Salmonella  Most common in children <4 years old and a peak in the first few months of life  Transmitted via ingestion of contaminated food and contact with infected animals  Symptoms include fever, diarrhea, and abdominal cramping  Antimicrobial therapy can prolong fecal shedding
  • 15. Shigella  Fecal-oral transmission  Symptoms include fever, abdominal cramps, tenesmus, and mucoid stools with or without blood  Can lead to serious complications  Antimicrobial treatment shortens duration of illness and limits fecal shedding
  • 16. E. Coli O157:H7  Transmission via contaminated food and water  Symptoms include bloody diarrhea, severe abdominal pain, and sometimes fever  Can lead to serious complications  Antibiotics have no proven benefit and may increase the risk of complications
  • 17. Summary of Bacterial Diarrhea  Can affect all age groups  Fecal-oral transmission, often through contaminated food  Typical symptoms include bloody diarrhea, severe cramping, and malaise  Antibiotic treatment not always necessary
  • 18. Physical Exam  Vitals, vitals, vitals!  Abdominal exam  Presence of occult blood  Signs of dehydration
  • 19. Laboratory Evaluation  Unnecessary for patients who present within 1 day from onset of diarrhea  Warning signs/symptoms: bloody diarrhea, high fever, severe abd pain, dehydration.  Fecal leukocytes followed by bacterial culture, ova & parasites, viral antigens  CBC, chemistries
  • 20. Treatment  Fluid replacement – Fluids or Oral Rehydration Solutions (ORS) – Parenteral rehydration  Early refeeding  Symptomatic Treatment – Oral bismuth – Loperamide  Antibiotics
  • 21. Fluid Replacement  ORS: Infalyte, Pedialyte, Naturalyte and Rehydralyte  Must be used or thrown out 24 hours after opening/mixing
  • 22. AAP Guidelines  Diarrhea with no dehydration – normal diet and supplemental ORS with each diarrheal episode.  Diarrhea with some dehydration – seek medical care, give ORS in the doctor's office, and cont. ORS and normal diet at home.  Moderate - severe dehydration – consider intravenous hydration, especially if patient is also vomiting
  • 23. Early Refeeding  Luminal contents help promote growth of new enterocytes and facilitate mucosal repair  Can shorten duration of the disease  Lactose restriction is not necessary except in severe disease
  • 24. Symptomatic Treatment  Only in patients who are afebrile and have nonbloody diarrhea  Loperamide – inhibits peristalsis and has antisecretory properties  Bismuth subsalicylate – may help with nausea, vomiting, and abdominal pain, as well as shorten duration of illness
  • 25. Antibiotics  antibiotic therapy generally not beneficial and can be harmful  Those with more than eight stools/day, diarrhea >1 wk, volume depletion, immunosuppresion, or warning signs  Fluoroquinolone or Azithromyzin
  • 26. Specific Antibiotic Therapy  Viral – of course not!  Campylobacter – only if severe  Salmonella – can prolong fecal shedding, only prescribe if severe  Shigella – proven beneficial  E. Coli O157:H7 – can be harmful
  • 27. Zinc Supplementation in AD ! Responsible for > 200 enzymes in body. ! Improves the immune function & absorption. ! Supplementation in AD and PD helpful in 20-30% reduction in diarrhea. ! 42% lower rate of treatment failure or death. – Dosages – o Infants 10mg daily x 2 weeks. – o Older children 20mg daily x 2 weeks. – o Persistent diarrhea x 4 weeks
  • 28. Home Available Fluids Recommended  Salt sugar solution  Lemon water(Sikanjabi)  Rice water / Kanjee  Soups  Dal water  Lassi  Coconut water  Plain water
  • 29. Not recommended  Simple sugar solution  Glucose solution  Carbonated soft drinks  Fruit juices-tinned or fresh  Fluids for athletes  Gelatin desserts  Tea/Coffee
  • 30. Nursing management:  Restoring fluid and electrolyte balance by ORS and IV therapy.  Prevention of spread of infection by good hand washing practices, hygienic disposal of stools, care of diapers, general cleanliness and universal precautions.
  • 31. Preventing skin breakdown by frequent change of diaper, keeping the perineal area dry and clean  Providing adequate nutritional intake by appropriate dietary management  Reducing fear and anxiety by explanation, reassurance, answering questions and providing necessary informations.
  • 32. Giving health education for prevention of diarrhea, home management of diarrheal diseases, importance of ORS, dietary management etc..
  • 33. References  Dennehy P.H., Acute Diarrheal Disease in Children: Epidemiology, Prevention, and Treatment. Infect Dis Clin North A 2005;(19) 3:  Wanke C.A., Approach to the patient with acute diarrhea. Up To Date (updated Jan. 4, 2005) www.uptodate.com/  Blacklow N.R., Epidemiology of viral gastroennteritis in adults. Up To Date (updated March 3, 2005) www.uptodate.com/  Thielman N.M., (2004) Acute Infectious Diarrhea. N Engl J Med 2004;350:38-47.  Burkhart D.M., Management of Acute Gastroenteritis in Children. Am Fam Physician. 1999 Dec;60(9):2555-63

Notes de l'éditeur

  1. Diarrhea is the second most frequent illness encountered by American families.
  2. Rotavirus is the leading cause of viral gastroenteritis worldwide. Virtually every child develops rotavirus gastroenteritis by three years of age. Reinfections are common, but symptoms are typically less severe or asymptomatic. The virus is transmitted principally be the fecal-oral route. Individuals handling diapers of infected chilrden can easily spread the infection if they do not wash their hands carefully. The virus can also survive on hard surfaces like toys and countertops for a limited amount of time. A very small inoculum is considered contagious.
  3. Norovirus is the major cause of epidemic viral gastroenteritis. Norovirus outbreaks affect all ages. More than 90% of young adults are seropositive, however, immunity is not long lasting and reinfections are common. Outbreaks are most common at restaurants or catered meals, in hospitals and nursing homes, in schools, daycares, and camps, and on cruise ships. Transmission is fecal-oral through consumption of contaminated food, person to person contact, and contact with contaminated objects. Norovirus is highly contagious. It can even be transmitted through the aerosolization of vomit.
  4. Adenoviruses are responsible for only a small amount of viral gastroenteritis. It predominantly affects very young children. Transmission is fecal-oral through person to person contact but much less contagious than rotavirus or noroviruses
  5. Astrovirus is a common cause of diarrhea in daycare centers and a common cause of nosocomial disease. It can also cause illness in the immunocomromised, especially AIDS patients and elderly institutionalized patients. Transmission is person to person via the fecal-oral route. There are no commercially available diagnostic tests for astrovirus in the U.S.
  6. Campylobacter is the most common bacteria isolated in foodborne diarrheal illness. Improperly cooked poultry, untreated water, and unpasteurized milk are the most common culprits. Transmission occurs by ingestion of contaminated food or by direct contact with fecal material from infected animals or people. Many farm animals and pets (esp. kittens and puppies) harbor the bacteria. Most patients recover in less than 1 week but 20% relapse or have a prolonged illness. Treatment usually shortens the duration of bacterial shedding in the stool.
  7. The major vehicles of transmission are foods of animal origin, including poultry, beef, fish, eggs, and dairy products. Salmonella attack rates are highest among people younger than 4 years old with a peak during the first months of life. Antimicrobial treatment can prolong viral shedding but is recommended for those at increased risk of invasive disease or complications, including infants &lt;3m/o, those with chronic GI disease, or who are immunosuppressed. Complications include bacteremia, osteomyletis, and meningitis.
  8. Shigella affects people of all ages. Predominant modes of transmission include person-person contact, contact with contaminated objects, ingestion of contaminated food and water, and sexual contact. Most infections are self-limited and do not require antibiotics, however, antimicrobial therapy is effective in shortening the duration of diarrhea and eradicating the organism from feces. Rare complications include bacteremia, toxic megacolon and perforation, and toxic encephalopathy.
  9. There are at least 5 types of diarrhea-producing E. Coli, but the only kind that commonly causes diarrhea in the U.S is enterohemmorhagic E. Coli o157:H7. Transmission is from ingestion of contaminated food, especially undercooked ground beef, dirty water and produce, and unpasteurized milk. The most common complication of EH E. Coli infection is HUS, defined as the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acte real dysfunction.. HUS occurs in ~8% of children with EH E. Coli and usually presents about 2 weeks after the onset of diarrhea. TTP occurs in adults and is the same disease as postdiarrheal HUS in children. Patients with bloody stools suggestive of hemorrhagic colits should have a CBC and chem. 7 checked to evaluate for HUS or TTP. If there is no laboratory abnormality 3 days after resolution of the diarrhea, the risk of developing HUS is low.
  10. Treatment with oral rehydration solution is simple and enables the management of uncomplicated cases of diarrhea at home, regardless of etiologic agent
  11. Minimal Dehydration – 10ml of fluids should be administered per kg of body weight for each episode of diarrhea OR children less than 10kg should be administered 2-4 oz for each episode of diarrhea and those weighing &gt;10kg should be administered 4-8 oz. Mild-Moderate Dehydration – administer 50-100 of ORS per kg of body weight to replace fluid deficit with additional ORS to replace ongoing losses. Start 1 tsp at a time and gradually increase the amount as tolerated. Severe Dehydration – administer intravenous fluids
  12. Regardless of the fluid used, an age-appropriate diet should also be given. Infants should be offered more frequent breast or bottle feedings. Luminal contents are a known growth factor for enterocytes and help facilitate mucosal repair after injury. Introducing a regular diet withing a few hours of rehydration has been shown to shorten the duration of the disease and has not been associated with increased morbidy
  13. Nearly 400 over-the-counter products are promoted in the U.S. for their antidiarrheal properties but only a few have been proven to be effective in RCTs. The two most common are loperamide (Imodium) and bismuth subsalicylate (Pepto Bismal). Loperamide (Imodium) inhibits intestinal peristalsis and has anitsecretory properties. It does not penetrate the CNS and has no substantial potential for addiction. It should be avoided in those with bloody or suspected inflammatory diarrhea because it can prolong fever in those with shigella, cause toxic megacolon in those with C. diff, and HUS in those with Shiga toxin-producing E. coli. Bismuth subsalicylate (Pepto Bismal) – can alleviate nausea and vomiting as well as decrease the duration of illness of viral diarrhea
  14. Because most diarrheal illnesses are self-limited or viral, and nearly half last less than 1-2 days, microbiologic investigation is usually unnecessary for patients who present within 24 hours after the onset of diarrhea, unless such patients are dehydrated or febrile or have blood or pus in their stool.