Diarrhoea

Diarrhoea is defined as the passage of frequent, loose, watery stools 3 or more times a day. Diarrhoea may be accompanied by vomiting.

In children, the commonest cause is viral. There is therefore usually no need to prescribe antibiotics. Other diseases like malaria, pneumonia, ear infections and urinary tract infections, may be associated with diarrhoea. Fluid loss occurs quickly in this age group because of their size. If not corrected, it may result in dehydration, which can be fatal.

A complaint of diarrhoea should be taken seriously. Always ask about the frequency and the texture of the stools. Giving antibiotics in all cases of diarrhoea may worsen or prolong the condition except in special circumstances (See section on ‘Causes’ below). Enemas and laxatives should not be given to patients with diarrhoea.

Causes

Acute diarrhoea (< 2 weeks)

Infections
- Viral: e.g. rotavirus, norovirus
- Bacterial: e.g. Salmonella spp., Shigella, Campylobacter, E. coli, Vibrio cholerae
- Protozoal: e.g. Entamoeba histolytica (amoebiasis)
Drug-induced: e.g. penicillins

Chronic diarrhoea (> 2 weeks)

Chronic infections: e.g. amoebiasis, tuberculosis, opportunistic infections with HIV
Functional: e.g. irritable bowel syndrome
Inflammatory: e.g. ulcerative colitis, Crohn’s disease
Malabsorption syndromes: e.g. chronic pancreatitis
Malignancy: e.g. colon cancer
Endocrine: e.g. hyperthyroidism, diabetic autonomic neuropathy
Drug-induced: e.g. laxatives, NSAIDs

Symptoms

Frequent watery stools
Blood or mucus in the stool
Presence of fever
Reduced urine output
Associated vomiting

Signs

Adult

Anaemia
Weight loss
Anorexia
Oral lesions e.g. oral ulcers, candidiasis
Skin lesions e.g. erythema nodosum
Signs of dehydration (dry mucous membranes, reduction in skin turgor, capillary refill > 2 seconds, tachycardia, postural hypotension)
Enlarged thyroid
Abdominal masses
Rectal mass

Diagnostic Clues for Diarrhoea

Diarrhoea WITH vomiting, low grade fever with no mucus in stools: consider viral infection
Diarrhoea WITH vomiting, fever, abdominal cramps, blood and mucus in stools: consider bacterial infection
Diarrhoea WITH blood and mucus in stool WITHOUT fever: consider amoebiasis
Profuse diarrhoea present (rice water stools) WITH vomiting: consider cholera
Diarrhoea WITH excessive vomiting (especially if in more than one member of the household or group): consider food poisoning
Diarrhoea presenting with oral and/or skin lesions, weight loss etc. over long period: consider HIV
Diarrhoea alternating with constipation in adults: consider bowel malignancy

The following table can be used to assess the degree of dehydration in children with diarrhoea:

Table 1-1: Assessment of degree of dehydration in children with diarrhoea

Assessment of degree of dehydration in children with diarrhoea

% DEHYDRATION	<5% Nil	5-10% Mild-moderate	>10% Severe
LOOK AT
Condition	Well, alert	Restless, irritable	Lethargic, unconscious, floppy
Eyes	Normal	Sunken	Very sunken and dry
Mouth and tongue	Moist	Dry	Very dry
Thirst	Drinks normally, not thirsty	Thirsty, drinks eagerly	Drinks poorly
FEEL
Skin	Goes back quickly after pinching	Goes back slowly after pinching	Goes back very slowly after pinching
DECIDE
	The patient has no signs of dehydration	If the patient has two or more signs, including at least one sign underlined, there is some dehydration	If the patient has two or more signs, including at least one sign underlined, there is severe dehydration
TREATMENT PLAN	Weigh patient and use Treatment Plan A	Weigh patient and use Treatment Plan B	Weigh patient and use Treatment Plan C

Investigations

FBC
Blood film for malaria parasites
Stool routine examination
Stool for culture and sensitivity
Blood urea and creatinine

Treatment

Treatment Objectives

To prevent dehydration
To replace lost fluid
To maintain nutrition by ensuring adequate dietary intake during illness
To maintain personal hygiene
To eliminate infecting organisms where appropriate

Non-pharmacological treatment

Keep surroundings clean
Improve personal hygiene e.g. hand washing after toilet
Adequate fluid intake - oral and intravenous as necessary (See section on ‘Fluid management for children with diarrhoea’)
Maintain adequate nutrition as can be tolerated

Pharmacological Treatment

Bacterial gastroenteritis (fever, abdominal cramps, blood and mucus in stools)

Note: No antibiotics are required for suspected viral gastroenteritis. Adequate rehydration is the main requirement.

1^st Line Treatment

Evidence Rating: [A]

Ciprofloxacin, oral,

Adults

500 mg 12 hourly for 5 days

Children (for all child age groups)

15 mg/kg 12 hourly for 5 days

2^nd Line Treatment Evidence Rating: [A]

Cefuroxime, IV,

Adults

750 mg 8 hourly

Children

25 mg/kg body weight 12 hourly

Neonates

>7 days; 25 mg/kg body weight 8 hourly

< 7 days; 25 mg/kg body weight 12 hourly

Then

Cefuroxime, oral,

Adults

250 mg 12 hourly for 5-7days

Children

12-18 years; 250 mg 12 hourly for 5-7 days

2-12 years; 15 mg/kg body weight for 5-7 days (max. 250 mg 12 hourly)

3 months-2 years 10 mg/kg body weight for 5-7 days (max. 125 mg 12 hourly)

Note: Suspension can only be given to children above 3 months, however the IV can be given to neonates

Amoebic dysentery suspected (patient failing to respond to empirical treatment for bacterial gastroenteritis within 2 days or based on stool microscopy)

Evidence Rating: [A]

Metronidazole, oral,

Adults

800 mg 8 hourly for 5 days

Children

8-12 years; 400 mg 8 hourly for 5 days

4-7 years; 200 mg 8 hourly for 5 days

0-3 years; 100 mg 8 hourly for 5 days

Cholera: profuse diarrhoea (rice water stool) + vomiting

1^st Line Treatment Evidence Rating: [A]

Tetracycline, oral,

Adults

500 mg 6 hourly for 3 days

Children

Not recommended

Doxycycline, oral,

Adults

100 mg 12 hourly for 3 days

Children

Not recommended

Erythromycin, oral,

Adults

500 mg 8 hourly for 5 days

Children

>13 years; 500 mg 8 hourly for 5 days

6-12 years; 250-500 mg 8 hourly for 5 days

2-6 years; 250 mg 6 hourly for 5 days

1 month-2 years; 125 mg 6 hourly for 5 days

Neonates

12.5 mg/kg 6 hourly for 5 days

Zinc supplementation for diarrhoea

Evidence Rating: [A]

Zinc supplement, oral,

Adults

Not required

Children

>6 months; 20 mg/day for 10-14 days

< 6 months; 10 mg/day for 10-14 days

Referral Criteria

Refer patients who fail to improve, or get worse, despite therapy for acute diarrhoea. Refer all patients with chronic diarrhoea to a specialist for further evaluation and management.

Treatment algorithm

Fluid management for children with diarrhoea

Treatment Plan A–No dehydration

Child can be treated safely at home
Instruct mother to give home-based fluids like rice water, koko, soup, water, and Oral Rehydration Salt (ORS).
Breastfed babies should be given breast milk and ORS
Give as much as child wants of all the fluids
Child should continue to feed
Ask the mother to return to the health facility if the child gets worse, passes more watery stools, vomits repeatedly, becomes very thirsty, eats or drinks poorly or is not better in 2 days
Instruct mother on how to prevent diarrhoea
ORS currently recommended for use in mild to moderate diarrhoea has a reduced sodium and glucose concentration (low osmolarity).

How to prepare ORS

ORS: Dissolve the contents of one sachet of ORS in 600 ml or 1000 mls depending on type of ORS.

To get 600 ml, use 2 small (300 ml) soft drink bottles or 1 big beer bottle
To get 1000 ml, use 1L mineral water bottle The child or adult should drink AS MUCH of it as he/she wants. If the child vomits, the mother should wait about 10 minutes and give it again

Table 1-2: Treatment by Fluid Therapy - Plan A
Age	ORS Basic Amount	ORS for every extra stool passed
<2 years	500 ml or more	50–100 ml
2–10 years	1000 ml or more	100–200 ml
>10 years	2000 ml or more	100–200 ml

Treatment Plan B–mild to moderate dehydration

For the child with mild-moderate dehydration, use treatment Plan B

Child to be treated in the health facility
Give ORS over the first 4 hours as shown in the Table for Plan B
If child vomits, wait 10 minutes and start again
Continue with other fluids the child will accept
Instruct mother to continue breast feeding if child is breastfeeding
Observe stools passed and record quantity
Check for signs of worsening dehydration
If eyes become puffy, it means too much fluid has been given so stop ORS and re-evaluate
Reassess state of dehydration after 4 hours
If clinical state has improved with no dehydration - go to plan A
If there is still mild-moderate dehydration repeat plan B
If condition is worsening - go to plan C

Table 1-3: Treatment by Fluid Therapy - Plan B
Weight	<6 kg	6 -<10 kg	10-<12 kg	12–19 kg
Age*	Up to 4 months	4 months up to 12 months	12 months up to 2 years	2 years up to 5 years
Amount of ORS	200-400 ml	400-700 ml	700-900 ml	900-1400 ml

*Use the child’s age only when you 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) by 75

Treatment Plan C–Severe dehydration

A child with severe dehydration requires urgent treatment with IV fluids in hospital
If the child can drink, give ORS by mouth while the IV line is being set up
Start IV fluids immediately. Give 100 ml/kg Ringer’s lactate solution or, if not available, normal saline or cholera replacement fluid (5:4:1), divided as shown in the Table for Plan C below:
If you cannot give the above treatment and cannot pass a nasogastric tube, refer to a health facility that can do so.
Reassess the child every 1-2 hours. If hydration status is not improving, give the IV fluid more rapidly than as stated in the Table for Plan B
Also give ORS (about 5 ml/kg body weight/hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1–2 hours (children)
Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment
Assess child hourly. If not improving or dehydration is worse, increase drip rate
Do not stop the IV fluids until the child has been observed to retain the ORS for at least 1 hour and there is improvement in the clinical condition
Continue ORS on treatment plan B and continue to observe child until child has no signs of dehydration, then move to Plan A
Severe diarrhoea may be complicated by marked fluid loss accompanied by loss of potassium (hypokalaemia) or on the other hand, impaired renal function leading to acidosis and elevated blood potassium (hyperkalaemia)
When the patient is passing adequate amounts of urine, probably indicating good renal function, start potassium containing foods such as coconut water and fresh fruits (e.g. banana)
If there is clinical and/or laboratory evidence of severe hypokalaemia, potassium should be given by the intravenous route using potassium chloride but only in a hospital. Potassium containing fluids such as half strength Darrow’s solution or Ringer’s lactate may be added
If possible infants and children should continue to breastfeed or eat during the period of diarrhoea

Table 1-4: Treatment by Fluid Therapy - Plan C
Age	First give 30 ml/kg in:	Then give 70 ml/kg in:
Infants (<12 months)	1 hour*	5 hours
Children (12 months up to 5 years)	30 minutes*	2½ hours

*Repeat once if radial pulse is still very weak or not detectable.

Note: Anti-diarrhoeal medicines like Mist Kaolin, diphenoxylate/atropine, codeine, loperamide should not be used in the treatment of diarrhoea in children and are likely to do more harm than good. Similarly, antibiotic preparations with kaolin or pectin are of no therapeutic value in the management of diarrhoea.