Acute diarrhea is the second leading cause of death in children worldwide. It is defined as having 3 or more loose or watery stools per day for less than 14 days. The main causes are viral (70-80%), bacterial (10-20%), or protozoal (<10%). The most common viral causes are rotavirus, norovirus, enteric adenovirus, and astrovirus. Symptoms include fever, vomiting, abdominal cramps and watery diarrhea lasting up to a week. Treatment focuses on fluid replacement with oral rehydration solutions and early refeeding. Antibiotics may be used for specific bacterial causes or for severe cases. Zinc supplementation can help reduce the duration and severity of acute
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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%
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
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
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
Diarrhea is the second most frequent illness encountered by American families.
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.
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.
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
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.
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.
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 <3m/o, those with chronic GI disease, or who are immunosuppressed. Complications include bacteremia, osteomyletis, and meningitis.
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.
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.
Treatment with oral rehydration solution is simple and enables the management of uncomplicated cases of diarrhea at home, regardless of etiologic agent
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 >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
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
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
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.