2. INTRODUCTION
• Leading cause of childhood morbidity & mortality in
developing countries
• Important cause of malnutrition
• 80% of deaths due to diarrhoea occur in the first two years
of life.
• Children <3 years of age in developing countries experience
around three episodes of diarrhoea each year.
4. Clinical Types
Acute watery diarrhoea :
Lasts several hours or days
Main danger is dehydration
Weight loss occurs if feeding is not continued;
Acute bloody diarrhoea:
Also called dysentery
Main dangers - damage of the intestinal mucosa,
sepsis and malnutrition
Other complications : dehydration , HUS
5. Persistent diarrhoea :
Lasts 14 days or longer a/w malnutrition
Main danger - malnutrition & serious non-intestinal
infection
Other complications : dehydration
Diarrhoea with severe malnutrition :
Main dangers - severe systemic infection ,
dehydration,
heart failure and vitamin and mineral deficiency.
6. Key facts
• Diarrhoeal disease is the second leading cause of
death in children under five years old. It is both
preventable and treatable.
• Each year diarrhoea kills around 760 000 children
under five.
• A significant proportion of diarrhoeal disease can
be prevented through safe drinking-water and
adequate sanitation and hygiene.
• Globally, there are nearly 1.7 billion cases of
diarrhoeal disease every year.
• Diarrhoea is a leading cause of malnutrition in
children under five years old.
9. Pathophysiology of acute diarrhea
• Increased secretion of fluid and electrolytes
• Decreased digestion and absortion of nutrients
• Abnormal transit due to aberrations of intestinal
motility
10. Assessment of the child with diarrhoea
History
Ask the mother or other caretaker about:
• Presence of blood in the stool;
• Duration of diarrhoea;
• Number of watery stools per day;
• Number of episodes of vomiting;
• Presence of fever, cough, or other important
problems (e.g. convulsions, recent measles);
• Pre-illness feeding practices;
• Type and amount of fluids (including breastmilk) and
food taken during the illness;
• Drugs or other remedies taken;
• Immunization history.
11. LAB INVESTIGATIONS FOR DIARRHOEA
Investigations are not routinely done in case of no or
some dehydration
I) STOOL: MICROSCOPY : low sensitivity & specificity
a) leucocyte (>10/hpf )- Invasive diarrhoea
b) hanging drop – V. cholera.
c) culture & sensitive - persistant diarrhoea
II) BLOOD TESTS
a) CBC
b) S. electrolyte
c) BUN & creatinine
12. Dysentery:
Mucous & blood in stool
Persistent diarrhoea:
Min 14 days
Malnutrition with diarrhoea:
Weight-for-length or weight-for-age indicate moderate
or severe malnutrition
Oedema with muscle wasting
Obvious marasmus
13. Dehydration
• During diarrhoea there is an increased loss of
water and electrolytes (Na, Cl , K , and HCO3 )
in the liquid stool.
• Dehydration occurs when these losses are not
replaced adequately and a deficit of water
and electrolytes develops.
14. DEGREES OF DEHYDRATION
• Early dehydration – no signs or symptoms.
• Moderate dehydration:
– thirst
– restless or irritable behaviour
– decreased skin elasticity
– sunken eyes
• Severe dehydration:
– symptoms become more severe
– shock, with diminished consciousness, lack of urine
output, cool, moist extremities, a rapid and feeble pulse,
low or undetectable blood pressure, and pale skin.
15. Prevention
• access to safe drinking-water;
• use of improved sanitation;
• hand washing with soap;
• exclusive breastfeeding for the first six months of
life;
• good personal and food hygiene;
• health education about how infections spread;
and
• rotavirus vaccination.
16. Treatment Plan A: home therapy to
prevent dehydration and malnutrition
• Children with no signs of dehydration need
extra fluids and salt to replace their losses of
water and electrolytes due to diarrhoea. If
these are not given, signs of dehydration may
develop.
17. four rules of
Treatment Plan A:
• Rule 1: give the child more fluids than usual
Suitable fluids : two groups:
• Fluids that contain salt :
• ORS (Oral Rehydration Salts) solution
• Salted drinks (e.g Salted rice water or a salted yoghurt drink)
• Vegetable or chicken soup with salt.
• Fluids that do not contain salt, such as:
• Plain water
• Water in which a cereal has been cooked
• Unsalted soup
• Yoghurt drinks without salt
• Green coconut water
• Weak tea (unsweetened)
• Unsweetened fresh fruit juice.
18. • Unsuitable fluids
• Drinks sweetened with sugar, which can cause
osmotic diarrhoea and hypernatraemia.
• Some examples are:
• Commercial carbonated beverages
• Commercial fruit juices
• Sweetened tea.
• With stimulant, diuretic or purgative effects, for
example:
• Coffee
• Some medicinal teas or infusions.
19. • How much fluid to give
• The general rule is: give as much fluid as the child
or adult wants until diarrhoea stops.
• Children under 2 years of age: 50-100 ml (a
quarter to half a large cup) of fluid;
• Children aged 2 up to 10 years: 100-200 ml (a
half to one large cup);
• Older children and adults: as much fluid as they
want.
20. • Rule 2: Give supplemental zinc (10 - 20 mg) to the
child, every day for 10 to 14 days
• Dose : infant – 0.5 mg/kg/day
<6 mth – 10 mg/day
>6 mth – 20 mg/day
• Preparations : zinconia 20mg/5ml
zincovit 10mg/5ml
21. • Rule 3: Continue to feed the child, to prevent
malnutrition
• Food should never be withheld
• Breastfeeding should always be continued.
• Aim - give as much nutrient rich food as the child
will accept.
22. • Rule 4: take the child to a health worker if there are
warningsigns of dehydration or other problems
• Starts to pass many watery stools;
• Has repeated vomiting;
• Becomes very thirsty;
• Is eating or drinking poorly;
• Develops a fever;
• Has blood in the stool; or
• The child does not get better in three days.
23. Treatment Plan B: oral rehydration therapy for
children with some dehydration
25. Bacteria Antibiotic
Salmonella typhi,
Salmonella paratyphi
Ampicillin,† chloramphenicol,† TMP-SMZ, cefotaxime,
ciprofloxacin‡
Nontyphoidal
Salmonella
Usually none (if ≥ 3 months old); ampicillin, cefotaxime,
ciprofloxacin‡
Shigella ( Dysentery ) Children: Third-generation cephalosporin, TMP-SMZ
Nalidixic acid
Adults: fluoroquinolones‡
Escherichia coli
Enterotoxigenic Usually none if endemic; TMP-SMZ or ciprofloxacin for
traveler's diarrhea
Enteroinvasive TMP-SMZ, ampicillin if susceptible
Enteropathogenic TMP-SMZ or an aminoglycoside
Enterohemorrhagic Usually none
Enteroaggregative TMP-SMZ or an aminoglycoside
Campylobacter jejuni Mild disease needs no treatment; erythromycin or
azithromycin for diarrhea; aminoglycoside, ciprofloxacin,‡
26. Bacteria Antibiotic
Yersinia enterocolitica None for uncomplicated diarrhea;
TMP-SMZ; gentamicin or cefotaxime
for extraintestinal disease
Vibrio cholerae Tetracycline, doxycycline, TMP-SMZ
Clostridium difficile Oral metronidazole,§ oral
vancomycin
Entamoeba histolytica Metronidazole§ followed by
iodoquinol to treat luminal infection
Giardia lamblia Metronidazole,§ quinacrine,
furazolidone, others
Cryptosporidium parvum None; azithromycin or paromomycin
and octreotide in persons with
HIV/AIDS
27. Anti secretory agents
• Racecadotril
• also known as acetorphan
• acts as a peripherally acting enkephalinase inhibitor.
• antisecretory effect—it reduces the secretion of
excessive water and electrolytes into the intestine.
• Role is controvertial.
• Dose: 1.5mg/kg/dose up to 4 doses a day
• Duration : 5 days but not >7 days
• Adverse effects : vomitting , fever , hypokalemia , ileus ,
bronchospasm , skin rashes.
28. ORAL REHYDRATON SOLUTION
ORS -special combination of dry salts that,
when properly mixed with clean water, can help
rehydrate the body when a lot of fluid has been
lost due to diarrhoea.
Basis of ORS – Glucose linked absorption of
sodium remains intact irrespective of etiology
of diarrhoea.
29. TYPES OF ORS FORMULATIONS
• Glucose based ORS
• Rice based ORS
• Low osmolarity ORS
• Home available ORS
• Mineral based ORS(zinc)
33. • Muscular dystrophy is a heterogeneous group
of inherited disorders recognized by
progressive degenerative muscle weakness
and loss of muscle tissue (started in
childhood).
• Affect muscles strength and action.
• Generalized or localized.
• Skeletal muscle and other organs may involve
34.
35. • Causes
– Inheritance
– Dominant genes
– Recessive gene
• Risk
– Because these are inherited disorders, risk include a
family history of muscular dystrophy
46. DMD: Diagnosis
• Gait
• Absent DTR
• Ober test
• Thomas test
• Meyeron sign - child slips
through truncal grasp
• Macroglossia
• Myocardial deterioration
• IQ ~ 80
• Increase CPK (200x)
• Myopathic change in
EMG
Bx: m. degeneration
• Immunoblotting:
Absence dystrophin
• DNA mutation
analysis
47.
48.
49. Becker Muscular Dystrophy
• Milder version of DMD
• Etiology
– single gene defect
– short arm X chromosome
– altered size & decreased amount of
dystrophin
50. Clinical features
• Less common
– 1: 30000 live male birth
• Less severe
• Family history: atypical MD
• Similar & less severe than DMD
• Onset: age > 7 years
• Pseudohypertrophy of calf
• Equinous and varus foot
• High rate of scoliosis
• Less frequent cardiac involvement
51. Diagnosis
• The same as DMD
• Increase CPK (<200x)
• Decrease dystrophin and/or altered size
Natural history
– Slower progression
– ambulate until adolescence
– longer life expectancy
Treatment
– the same as in DMD
– forefoot equinous: plantar release, midfoot dorsal-
wedge osteotomy
59. • Classification
–Pelvic girdle type
• common
–Scapulohumeral
type
• rare • Diagnosis
– Same clinical as
DMD/BMD carriers
– Moderately elevated
CPK
– Normal dystrophin
60. • Natural history
– Slow progression
– After onset > 20 y: contracture & disability
– Rarely significant scoliosis
• Treatment
– Similar to DMD
– Scoliosis: mild, no Rx.
61. Fascioscapulohumeral Muscular
Dystrophy
• Etiology
– Autosomal dominant
– Gene defect (FRG1)
– Chromosome 4q35
• Epidemiology
– Female > male
• Clinical
manifestation
– Age of onset: late childhood/
early adult
– No cardiac, CNS
involvement
– Winging scapula
– Markedly decreased
shoulder flexion & abduction
– Horizontal clavicles
– Rare scoliosis
62.
63. • Muscle weakness
–face, shoulder, upper arm
• Sparing
–Deltoid
–Distal pectoralis major
–Erector spinae
64. • “Popeye”
appearance
– Lack of facial mobility
– Incomplete eye
closure
– Pouting lips
– Transverse smile
– Absence of eye and
forehead wrinkles
POPEYE ARMS
65. • Diagnosis
– PE, muscle biopsy
– Normal serum CPK
• Natural history
– Slow progression
– Face, shoulder m.
pelvic girdle,
tibialis ant
– Good life
expectancy
• Treatment
– Posterior
scpulocostal fusion/
stabilization
(scapuloplexy)
66. Distal Muscular Dystrophy
• Autosomal dominant trait
• Rare
• Dysferlin (mb prot) defect
• Age of onset: after 45 yrs
• Initial involvement: intrinsic
hands, claves, tibialis
posterior
• Spread proximally
• Normal sensation
73. `Classical form' of the disease is seen in
adolescent or early adult life with variable
presenting features.
• Muscular weakness,
• myotonia,
• mental retardation,
• cataract,
• neonatal problems
• 18% remain asymptomatic.
74. Summary
Clinical DMD LGMD FSMD DD CMD
Incidence common less Not common Rare Rare
Age of onset 3-6 y 2nd decade 2nd decade 20-77 y At/ after
birth
Sex Male Either sex M = F Either sex Both
Inheritance Sex-linked
recessive
AR, rare AD AD AD Unknown
Muscle
involve.
Proximal to
distal
Proximal to
distal
Face &
shoulder to
pelvic
Distal Generalized
Muscle
spread until
late
Leg, hand,
arm, face,
larynx,eye
Upper ex,
calf
Back ext,
hip abd,
quad
Proximal -
75. Clinical DMD LGMD FSMD DD CMD
Pseudo
hypertrophy
80%
calf
< 33% Rare no No
Contracture Common Late Mild, late Mild, late Severe
Scoliosis
Kyphoscoliosis
Common, late Late - - ?
Heart Hypertrophyt
achycardia
Very rare Very rare Very rare Not
observed
Intellectual decrease Normal Normal Normal ?
Course Stead, rapid Slow Insidious benign Steady
