CHILD WITH DIARROEA

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Diarrhoea is present when there is frequent defaecation more than three times a day, with altered stool consistency having water content of more than 75% and increased stool quantity of more than 200 to 250 grams per day.

Types of diarrhoea

• Acute diarrhoea: lasting ≤ 14 days
• Chronic or persistent diarrhoea: lasting > 14 days

Causes

• Food intolerance, e.g. lactose intolerance.
• Food ingestion history e.g. contaminated foods, food poisoning
• Drinking contaminated water
• Viral infection e.g. rotavirus, Norwalk virus etc
• Bacterial infection e.g. E. coli, salmonella, shigella
• Parasitic infections Cryptosporidium enteritis, Entamoeba histolytica, and Giardia lamblia 
• Predisposing conditions (e.g. hospitalization, antibiotic use, immunocompromised state)
• Association with abdominal disorders (e.g., nausea and vomiting, fever, abdominal pain)

Signs and symptoms

• Fever
• Vomiting
• Excessive crying
• Abdominal cramps
• Abdominal pain
• Bloating
• Nausea
• Blood in stool

Obtain careful history of:

• Frequency of stools
• Fever
• Number of days of diarrhoea
• Blood in stools
• Report of cholera outbreak in the area
• Recent antibiotic or other drug treatment
• Attacks of crying with pallor in an infant

 Investigations

• Blood in stools
• Signs of severe malnutrition
• Abdominal mass
• Abdominal distension
• Investigations
• Stool microscopy or culture if child has bloody diarrhoea
• FBC
• Blood culture and sensitivity
• Urinalysis
• Microscopy
• RVS

Differential diagnosis

Diagnosis	Signs and symptoms
Acute watery diarrhoea	-       More than three loose stools per day -       No blood in stools
Cholera	-       Profuse watery diarrhoea with severe dehydration during cholera outbreak -       Positive stool culture for Vibrio cholerae
Dysentery	-       Blood mixed with stools (seen or reported)
Persistent diarrhoea	-       Diarrhoea lasting > 14 days
Diarrhoea with severe malnutrition	-       Any diarrhoea with signs of severe acute malnutrition
Diarrhoea associated with recent antibiotic use	-       Recent course of broad-spectrum oral antibiotics
Intussusception	-       Blood and mucus in stools -       Abdominal mass -       Attacks of crying with pallor in infant or young child

 Classification of the severity of dehydration in children with diarrhoea

Classification	Signs or symptoms
Severe dehydration	Two or more of the following signs: -       Lethargy or unconsciousness -       Sunken eyes -       Unable to drink or drinks poorly -       Skin pinch goes back very slowly (> 2 seconds)
Some dehydration	Two or more of the following signs: -       Restlessness, irritability -       Sunken eyes -       Drinks eagerly, thirsty -       Skin pinch goes back slowly
No dehydration	Not enough signs to classify as some or severe dehydration

 Treatment objectives

• To reduce the episodes of diarrhoea.
• To rehydrate the patient.
• Prevent complications and reduce hospital stay

Non-pharmacological treatment

• Health education on the cause of diarrhoea

Pharmacological treatment

Severe dehydration

Start IV fluids immediately. While a drip is being set up, give ORS solution if child can drink.

Administer 100ml/kg of Ringers lactate or normal saline (0.9% sodium chloride) as follows:

Age	First, give 30ml/kg in:	Then, give 70ml/kg in:
< 12 months	1 hour*	5 hours
> 12 months	30 minutes*	2.5 hours

^* Repeat if the radial pulse is still very weak or not detectable

As soon as the child can drink, give ORS (about 5ml/kg/hour) for 3-4 hours for infants and 1-2 hours for older children.

Some dehydration

In the first 4 h, give the child ORS solution according to the child’s weight (or age if the weight is not known), as shown below:

Age	< 4 months	4 < 12 months	12 months to < 2 years	2 years to < 5 years
Weight	< 6kg	6 to > 10kg	10kg to < 12 kg	12 to 19 kg
ORS	200 – 400ml	400 – 700ml	700 – 900ml	900 – 1400ml

Show the mother how to give the child ORS solution

• One teaspoonful every 1–2 min if the child is < 2 years
• Frequent sips from a cup for an older child.
• If the child vomits, wait 10 min; then, resume ORS solution more slowly (e.g. a spoonful every 2–3 min).
• If the child’s eyelids become puffy, stop ORS solution, reduce the fluid intake and continue with breast milk.

After 4 hours

• Reassess the child and classify the level of dehydration

Diarrhoea with no dehydration

Give ORS as shown below:

Age	Amount of ORS after each loose stool	ORS packet needed
<24months	50-100ml	500ml per day
2 – 5 years	100-200ml	1000ml per day

Age	Dose	Administration
< 6 months	10mg tablet per day	Dissolve in water or expressed milk
> 6 months	20 mg tablet per day	Chew tablet or dissolve in a drink