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5 Diarrhoea

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Contents

Objectives

When you have completed this chapter you should be able to:

Diagnosis and causes of diarrhoea

5-1 What is diarrhoea?

Diarrhoea (or diarrhoeal disease) is defined as the passage of frequent, loose, watery stools at least 3 times a day. Diarrhoea is not a single condition but simply a clinical sign, which has many different causes. With diarrhoea excessive amounts of water and electrolytes (such as sodium and potassium) are lost into the stool.

5-2 Is diarrhoea common?

Yes, it is one of the commonest problems in childhood throughout the world.

5-3 Can diarrhoea be dangerous?

Yes. Diarrhoea can be life-threatening if it is severe. Diarrhoea causes a loss of fluid and electrolytes in the stool, which can result in dehydration and electrolyte imbalance. The correct management of diarrhoea is important as diarrhoea is one of the leading causes of death in children, especially in poor countries. Each year about 2.5 million children worldwide die of diarrhoea.

Diarrhoea is a leading cause of infant death worldwide.

5-4 What are the common causes of diarrhoea?

The 2 commonest causes of diarrhoea are:

Note
Less common causes of diarrhoea include food poisoning (bacterial toxins), a side effect of antibiotics (bacterial overgrowth), some drugs which increase gut motility, coeliac disease and cystic fibrosis (malabsorption).

5-5 What infections cause diarrhoea?

  1. Infections of the bowel:
    • Viruses, such as Rota virus and measles. Rota virus is the commonest cause of severe dehydrating diarrhoea in children in many countries. There is now an effective vaccine.
    • Bacteria, such as E. coli (Escherichia coli), Shigella, Salmonella, Campylobacter and Cholera are commoner causes of diarrhoea than viruses in developing countries.
    • Protozoa (small one-celled organisms), such as Giardia, Amoeba and Cryptosporidium.
  2. Infections outside the bowel:
    • Children with bacterial infections, such as otitis media, septicaemia and urinary tract infection may also have diarrhoea.
    • In some children who present with diarrhoea, the infection is not in the bowel but elsewhere.

Rota virus infection of the bowel is the commonest cause of severe dehydrating diarrhoea in children.

5-6 What food intolerances cause diarrhoea?

  1. Carbohydrate intolerance especially lactose intolerance.
  2. Protein intolerance especially cow’s milk protein intolerance.

Diarrhoea due to carbohydrate induced intolerance may be caused by the excessive intake of fruit juice especially apple juice (fructose intolerance).

Both lactose intolerance and cow’s milk protein intolerance usually cause persistent diarrhoea following earlier damage to the bowel caused by gastroenteritis.

5-7 What is gastroenteritis?

Gastroenteritis (or acute diarrhoeal disease) is an acute infection of the bowel resulting in watery diarrhoea without visible blood or mucus in the stool. It is caused by a wide range of organisms which interfere with the normal functioning of the cells that line the bowel wall, resulting in loss of water and electrolytes into the stool. It is the commonest form of diarrhoea in childhood. Vomiting and abdominal cramps in older children are common with gastroenteritis but pyrexia is absent or only mild.

Gastroenteritis is usually caused by Rota virus or E. coli. Rota virus is highly infectious and seen in both poor and wealthy communities especially in children less than 1 year old. The infection is usually spread from the stool of the infected person by unwashed hands or contaminated water or food (the faecal–oral route). Poor hygiene or sanitation may result in outbreaks of gastroenteritis. Gastroenteritis usually presents as acute diarrhoea. However, if the bowel mucosa is damaged by the infection, gastroenteritis may also result in persistent diarrhoea.

Gastroenteritis is an acute infection of the bowel, causing diarrhoea.

Note
Rota virus causes direct bowel mucosal damage while most types of E. coli produce toxins which interfere with the normal function of the bowel wall leading to excess water and electrolyte loss.

5-8 What is acute diarrhoea?

Acute diarrhoea is watery diarrhoea which lasts less than 2 weeks (14 days). Acute diarrhoea is usually due to gastroenteritis (an acute infection of the bowel).

Note
Often the term gastroenteritis and acute diarrhoea are used interchangeably. However, acute diarrhoea is not always caused by an infection of the bowel but can also result from an infection elsewhere in the body or food intolerance.

5-9 What is persistent diarrhoea?

Diarrhoea usually recovers within 7 days. However, if diarrhoea does not recover by 2 weeks (14 days), it is called persistent (prolonged or chronic) diarrhoea. Persistent diarrhoea is common in malnourished children and children with HIV infection. Although about 10% of diarrhoea becomes persistent it is responsible for up to 50% mortality associated with diarrhoeal disease. Therefore it is important to manage acute diarrhoea correctly before it becomes persistent.

Diarrhoea for more than 14 days is persistent diarrhoea.

5-10 What is the relationship between diarrhoea and malnutrition?

Diarrhoea is commoner and more severe in children with malnutrition (i.e. undernutrition). Therefore malnourished children often have persistent or repeated diarrhoea. In addition, malnourished children are more likely to develop severe diarrhoea and die from it. There is therefore a close relationship between diarrhoea and malnutrition.

Diarrhoea is both common and more severe in children with malnutrition.

Persistent or repeated diarrhoea may result in weight loss and malnutrition in children who were previously well-nourished. Diarrhoea, especially persistent diarrhoea, often precipitates marasmus or kwashiorkor in children who already are mildly malnourished. Therefore, both malnutrition and diarrhoea often occur in the same children. The one con­dition often makes the other condition worse.

Diarrhoea may precipitate or aggravate malnutrition.

5-11 Is diarrhoea common in children with HIV infection?

Yes, diarrhoea is common and may be the presenting sign in children with HIV infection.

In children with HIV infection, diarrhoea is not only more frequent but also more severe and takes longer to recover. Diarrhoea is often persistent in children with HIV infection and is a common cause of death.

5-12 Which infants are at greatest risk of dying from diarrhoea?

5-13 What is cholera?

Cholera is a severe, highly infectious form of watery diarrhoea which is common in undeveloped countries. Cholera occurs in epidemics as has happened in some areas of South Africa in recent years. It is caused by a bowel infection with Vibrio cholerae. The stools in cholera are typically watery with small pieces (flecks) of mucus (‘rice water stools’). Cholera can rapidly lead to dehydration and death, even in adults. Always think of cholera if there is a local epidemic, especially with severe dehydration in an older child.

5-14 What is dysentery?

Dysentery is a form of diarrhoea where the stool is not simply watery, but also contains visible blood and mucus. Dysentery is usually caused by organisms which invade and damage the bowel wall. These children usually look ill (toxic) and have a high temperature. Dysentery is usually caused by Shigella, Salmonella, Campylobacter, Amoeba and some types of E. coli. The commonest cause of dysentery is Shigella. Dysentery is severe if there are signs of dehydration.

Dysentery is diarrhoea containing blood and mucus.

Note
With dysentery, the organisms invade and damage the bowel wall, causing bleeding and the secretion of mucus.

5-15 What is typhoid?

Some bacteria which cause diarrhoea, can invade the bowel wall and spread into the blood stream resulting in septicaemia. Septicaemia usually complicates diarrhoea with infections caused by Salmonella, Shigella and Campylobacter. Septicaemia is commoner in dysentery than in watery diarrhoea.

Typhoid is a septicaemia caused by a bowel infection with Salmonella typhi. These children are very ill and may die if not treated early with antibiotics.

Note
Children with typhoid may appear severely ill and toxic with only mild diarrhoea or no diarrhoea at all.

The complications of acute diarrhoea

5-16 What are the complications of acute diarrhoea?

Severe dehydration, with or without shock is the commonest cause of death in infants with diarrhoea and by far the most important complication.

Dehydration is the most important complication and the commonest cause of death in infants with diarrhoea.

5-17 How can you recognise dehydration?

Dehydration develops when excessive amounts of fluid are lost from the body. Diarrhoea can rapidly lead to dehydration, especially if vomiting is also present. Both the history and the clinical examination are important in assessing whether a child is dehydrated.

In all children with diarrhoea the following signs must be looked for:

Note
In an attempt to keep the intravascular volume as normal as possible, interstitial and intracellular fluid is moved into the intravascular compartment (serum). This dehydrates the tissues resulting in loss of skin turgor, sunken eyes and a sunken fontanelle.

5-18 How can you recognise loss of skin turgor?

The normal skin turgor is the elasticity (stretch) which enables skin to rapidly return to its previous position after it is gently pinched into a tent shape for 2 seconds. Normally skin returns to its position immediately after being pinched and then released. With decreased skin turgor, the skin takes longer than normal to return to its previous position. Decreased skin turgor is caused by a loss of fluid from the skin. The greater the loss of skin turgor, the longer it takes for the skin to go back to the normal position.

Skin turgor is best tested over the abdomen. Using the thumb and first finger, a fold of skin on one side of the umbilicus is lifted and gently squeezed for 2 seconds and then released. Observe how quickly or slowly the skin returns to its normal position.

Note
Wasted newborn infants and marasmic children may have decreased skin turgor without being dehydrated (lack of subcutaneous fat) while decreased skin turgor can be difficult to detect in fat children who are dehydrated.

5-19 How can the degree of dehydration be assessed?

  1. All children with diarrhoea must be examined for signs of dehydration. The degree of dehydration can be roughly assessed clinically into ‘no visible’ dehydration, ‘some’ dehydration or ‘severe’ dehydration. This is important as it is essential to identify children with severe dehydration.
  2. ‘No visible’ dehydration: The child has no signs of dehydration or not enough signs to be classified as ‘some dehydration’. However, many children with ‘no visible dehydration’ have still lost more fluid than normal. They often are thirsty and pass little urine.
  3. ‘Some’ dehydration: They have 2 or more of the following signs:
    • Very thirsty and drinks eagerly
    • Restless and irritable
    • Sunken eyes
    • Moderate degree of decreased skin turgor. When pinched, the skin takes longer than usual, but less than 2 seconds, to return to normal.
  4. ‘Severe’ dehydration: They have 2 or more of the following signs:
    • Not able to drink or drinks very poorly
    • Lethargic or unconscious
    • Eyes very sunken.
    • Severe decrease in skin turgor. When pinched, the skin takes 2 seconds or more to return to normal.
    • Shock with delayed capillary filling time

Severe dehydration leads to shock, acidosis, electrolyte loss, ileus, hypoglycaemia and possibly death.

Always start by first looking for signs of severe dehydration. If the child has 2 or more signs of severe dehydration, then the child is classified as severe dehydration. If the child does not have 2 or more signs of severe dehydration, then look for signs of some dehydration. If there are 2 or more signs of some dehydration, the child is classified as some dehydration. If there are no signs or only 1 sign of some dehydration present the child is classified as no visible dehydration.

The degree of dehydration must always be assessed in children with diarrhoea.

Note
Children with ‘some’ dehydration often also have a dry mouth, poor urine output and do not look well. Children with ‘severe’ dehydration appear severely ill and usually have acidotic breathing. They also may have signs of shock with a rapid, weak pulse, cold peripheries, and lethargy or depressed level of consciousness.

5-20 How can weight loss help to decide the degree of dehydration?

Weight loss is the best measure of the degree of dehydration. Unfortunately the child’s weight at the onset of the diarrhoea is often not known. Therefore, this method of assessing the degree of dehydration is only of limited use. With ‘some’ dehydration, less than 10% of body weight is lost while 10% or more of body weight is lost with ‘severe’ dehydration. A child may lose up to 5% of body weight (and body fluid) before the signs of dehydration can be recognised. It is useful to compare the child’s present weight with that last record in the Road-to-Health Booklet.

Note
If a child is 10% dehydrated, 10% of the body weight will have been lost as fluid in the stool or vomitus (i.e. 100 ml/kg as 1 ml of body fluid weighs 1 g).

5-21 What is shock?

Shock (hypovolaemic shock in dehydration) is the failure of the heart to maintain adequate circulation due to the loss of fluid. With excessive fluid loss in the stools, the volume of fluid in the circulation falls and there is not enough fluid to allow normal blood flow to the small capillaries of the body. As a result, blood flow slows down or stops in the capillaries and the body cells do not receive enough oxygen and food. Shock presents with:

The blood pressure may still be normal in the early stages of shock. Shock is a very serious sign and indicates that the child will probably die unless immediate treatment is started.

Shock is the failure of the peripheral circulation due to the loss of fluid.

5-22 How is a delayed capillary filling time measured?

The most important sign of shock is a delayed capillary filling time of more than 3 seconds. The capillary filling time is measured by pressing on the sole of the child’s foot or palm of the hand, then releasing the pressure and counting how many seconds it takes for the pale area to regain its pink colour. Pressing on the nail of the middle finger can also be used to measure the capillary filling time. In order to count in seconds, and not too fast or too slow, it is useful to count ‘one crocodile, two crocodiles, three crocodiles, etc’. The return of colour to the pale area is due to the capillaries filling once more with blood. Therefore, this is a good way of assessing the state of the peripheral circulation (the blood flow through the capillaries). Slow filling of the capillaries shows that the blood is not circulating properly.

A delay in the capillary filling time is the best way of diagnosing shock.

5-23 What causes acidosis in children with diarrhoea?

With poor peripheral perfusion due to shock, many cells in the body no longer receive enough oxygen and, therefore, are no longer able to produce energy by fully breaking down carbohydrates and fats. This failure of metabolism results in the formation and accumulation of lactic acid, which causes metabolic acidosis. Metabolic acidosis is made worse in diarrhoea by the loss of bicarbonate in the stool. The use of aspirin (salicylates) may also make the acidosis worse.

Children with a metabolic acidosis develop rapid sighing (deep) breathing. The clinical diagnosis of acidosis can be confirmed by blood gas analysis.

Note
The blood gas analysis in an infant with a metabolic acidosis shows a low pH and low stan­dard bicarbonate together with an increased base deficit. In an attempt to correct the acidosis, the child often hyperventilates which lowers the pCO₂.

5-24 Why do children with diarrhoea lose electrolytes?

Children with diarrhoea lose both fluid and electrolytes in the stool. Important electrolytes which are lost include sodium, potassium, calcium, magnesium, chloride, phosphate,and bicarbonate. Electrolytes are also lost with excessive vomiting.

Children with diarrhoea lose excessive amounts of fluid and electrolytes in the stool.

An electrolyte imbalance (too much or too little of one or more of the electrolytes) may be caused by dehydration or using an incorrect re­hydration fluid. Electrolyte imbalance presents as floppiness (hypotonia), drowsiness or fits.

Note
Children who lose more water than sodium develop hypertonic (hypernatraemic) dehydration. These children are very irritable and may have convulsions. The diagnosis may be missed as the signs of dehydration are less obvious.

5-25 What is ileus?

Ileus is distension of the abdomen due to a decrease or absence of the bowel movements (peristalsis). No bowel sounds can be heard. This lack of peristalsis is due to infection and loss of potassium. Ileus usually does not cause abdominal pain or bile stained vomiting.

5-26 What is the danger of hypoglycaemia?

Hypoglycaemia in children is defined as a blood glucose concentration of less than 3 mmol/l. Severe diarrhoea, especially in malnourished children who refuse feeds or have severe vomiting, may cause hypoglycaemia. This can result in loss of consciousness or convulsions. Hypoglycaemia must always be suspected in children with diarrhoea who have fits or a decreased level of consciousness.

Hypoglycaemia is a very serious complication that requires urgent diagnosis and immediate treatment with intravenous glucose. Hypo­glycaemia can be confirmed by measuring the blood glucose concentration with a reagent strip.

5-27 How is septicaemia recognised?

Some infants with diarrhoea appear very ill and have bacteria circulating in their blood. This is called septicaemia. Septicaemia should be suspected if the child has a high temperature (pyrexia) or appears a lot sicker than you would expect for the degree of dehydration or does not improve after the dehydration is corrected. Septicaemia is commoner in infants below 3 months, in malnourished children and in children with dysentery. Associated HIV infection makes septicaemia more likely, more serious and more dangerous.

5-28 What signs suggest that the diarrhoea may have a surgical cause?

These children must be referred to hospital urgently for further investigation.

Treatment of diarrhoea

5-29 What is the management of a child with acute diarrhoea?

  1. The most important aspect of management is to start oral rehydration therapy as early as possible to prevent dehydration from occurring. Oral rehydration solution should be used. With frequent, small drinks most children with mild diarrhoea can be adequately managed without developing dehydration.
  2. Breastfeeding, formula or solid feeds should be continued unless the child has severe vomiting, ileus or shock. Feeding should not be stopped for more than 4 hours.
  3. The clinical condition of the child must be continually assessed for signs of complications, especially dehydration.
  4. Treat the complications if they occur.

It is crucial to identify and treat shock or severe dehydration as they are associated with risk of dying.

Treatment must be started early and every effort must be made to prevent dehydration by replacing the fluid losses. It is important to teach mothers that acute diarrhoea is managed with oral rehydration solution and not with medicines. The mother must understand that oral rehydration solution will not stop diarrhoea but it will prevent and treat dehydration. Thirst is often a good guide to the need for oral rehydration solution. The management of most children with acute diarrhoea is both simple and cheap. Intravenous fluid (‘a drip’) is usually not necessary. There is no need for routine stool cultures in acute diarrhoea.

The early use of oral rehydration solution can usually prevent dehydration.

5-30 Will milk feeds make acute diarrhoea worse?

Although continuing milk feeds in infants may appear to make the diarrhoea worse, it is important to continue feeds as it helps to provide energy and replace fluid and electrolyte losses. Infants recover from diarrhoea faster if milk feeds are continued. Breastfeeding or full-strength formula should be used. There is no need to dilute feeds. The aim of feeding during diarrhoea is to maintain nutrition. Oral rehydration solution should be given in addition to milk feeds if the child is dehydrated and should not be used to replace feeds. Additional oral rehydration solution must also be given for ongoing diarrhoeal losses (50-150 ml per loose stool).

Milk feeds must not be stopped in infants with acute diarrhoea.

5-31 Can children with acute diarrhoea continue to be fed solid food?

If the child is already receiving solid food, this should be continued unless the child is vomiting a lot. Small feeds should be given frequently (at least every 4 hours). This is particularly important in children who are malnourished as diarrhoea can make the malnutrition rapidly worse. Extra feeds should be given while the child is recovering from the diarrhoea to improve weight gain. Feeding during diarrhoea does not increase the number of stools.

5-32 Should anti-diarrhoeal medication be used to treat acute diarrhoea?

Medicine is usually not necessary and may even be dangerous in small children. Anti-diarrhoeal medication such as codeine, Imodium (loperamide) and Lomotil (diphenoxylate) decrease peristalsis and may cause ileus. They improve cramps in older children but do not prevent the loss of fluid and electrolytes from the gut. Medications which absorb water like pectin and kaolin have no role in the management of children with diarrhoea. Antiemetics (to reduce vomiting) are also not used and can have severe side effects in young children. Traditional medicine, especially enemas, must not be given.

5-33 Should antibiotics be routinely given to children with acute diarrhoea?

Most cases of acute diarrhoea are caused by a virus and do not respond to antibiotics. Indication for systematic antibiotics are:

Infants who are sick enough to receive antibiotics should be referred to hospital for management.

Routine antibiotics should not be used to treat acute diarrhoea.

Note
Ill infants with suspected septicaemia must receive systemic antibiotics. Mild dysentery (often due to Shigella) is usually treated with oral nalidixic acid (12.5 mg/kg/dose 6 hourly for 5 days) Ceftriaxone (50 mg/kg daily) IM is used for dysentery and high fever in an unwell child while persistent diarrhoea (often due to Amoebae or Giardia) is treated with metronidazole (Flagyl).

5-34 What should you do if the child vomits a lot?

Infants with acute diarrhoea may vomit. However, the vomiting usually stops once the dehydration is corrected. If the oral rehydration solution is vomited, a smaller amount should be given slowly about 10 minutes later. The best way to avoid vomiting is to give small sips of fluid frequently by cup. If severe vomiting continues, a serious cause of the diarrhoea should be looked for, and continuous nasogastric or intravenous fluid must be started.

There is no role for antiemetics (drugs which stop vomiting) in the management of vomiting in children with acute diarrhoea. They can have serious side effects.

5-35 Can a child with acute diarrhoea be treated at home?

Children with mild diarrhoea and no visible signs of dehydration can be treated at home with continuing feeds and oral rehydration solution. If the diarrhoea becomes worse or does not recover in 2 days the child must be seen at a clinic. Children who refuse to drink or who vomit repeatedly must be taken to a clinic immediately as they are at great risk of dehydration. Counsel the mother to seek help if the infant’s eyes or fontanelle appear sunken. Most children with diarrhoea can be managed at home. The mother must know how to give rehydration solution correctly and when to bring the child back to clinic.

Children with mild diarrhoea can be treated at home with feeds and oral rehydration solution.

The guidelines for managing acute diarrhoea at home are:

  1. Give extra fluids.
  2. Continue feeding.
  3. Know when to take the child to the clinic or hospital.

5-36 What is oral rehydration therapy?

Oral rehydration therapy (ORT) is the most important part of managing acute diarrhoea and saves the lives of millions of children worldwide each year. ORT consists of giving oral rehydration solution by mouth early in acute diarrhoea to prevent or treat dehydration. Give frequent small sips from a cup.

Oral rehydration therapy saves millions of lives every year.

5-37 What is oral rehydration solution?

Oral rehydration solution (ORS) is a mixture of water, electrolytes (salts) and glucose which is given by mouth to provide energy and replace the fluid and electrolytes which have been lost. Oral rehydration solution can be:

5-38 What is commercial oral rehydration solution?

There are a number of different brands of commercially available oral rehydration solution (e.g. Sorol). They all contain a balanced mixture of electrolytes and water together with glucose. They are usually sold in the form of a powder which is packaged in a sachet (small packet). One sachet of powder should be mixed in one litre of water. The cleanest available water must be used. Sterile or boiled water (which has been allowed to cool) is best. Commercial oral rehydration solution powder should be kept in as many homes with children as possible.

Note
Standard ORS contains 90 mmol/l of sodium and 111 mmol/l of glucose. However, WHO and UNICEF have recently advised that a solution of 75 mmol/l of both sodium and glucose is preferable as it gives an effective ORS with a lower osmolality.

5-39 How can a sugar and salt solution be made at home?

Home made sugar and salt solution (SSS) is an effective oral rehydration solution but it does not contain potassium. However, it is immediately available and often lifesaving. The commonest recipe for a sugar and salt solution is:

  1. 1 litre of clean water.
  2. 8 level teaspoons of sugar.
  3. ½ of a level teaspoon of table salt.

One litre of water can be measured with a measuring jug or a 1 litre cool drink bottle. The sugar and salt must be added to the litre of clean water and mixed well. It is very important not to add too much salt. If possible, the sugar and salt solution should be given by cup or by spoon as this avoids using dirty bottles. It is dangerous to add a sachet of rehydration powder to the sugar and salt solution as this will make the solution too concentrated.

A sugar and salt solution for oral rehydration can be easily made up at home.

5-40 Who should know how to make up sugar and salt solution for oral rehydration?

Every parent or caretaker should know how to make up a sugar and salt solution and have the necessary ingredients at home. The recipe for making sugar and salt solution is given in the Road-to-Health Booklets.

5-41 When should oral rehydration therapy be started?

As soon as the diarrhoea is noticed. It is very important to start oral rehydration therapy as early as possible to prevent dehydration. The earlier it is started the quicker the child will get better. It is important to start oral rehydration therapy before taking the child to a doctor or nurse.

Oral rehydration therapy at home should be started as soon as possible, to prevent dehydration.

5-42 How much oral rehydration solution should be given?

It is best to give the oral rehydration solution frequently and in small volumes. Too much fluid at one time may cause vomiting. Give as much fluid as the child will take. Most children with no or only some dehydration will drink as much oral rehydration fluid as they need to replace the fluid lost. Children with some dehydration are usually very thirsty. However, children with severe dehydration are very ill and may refuse to drink. Usually 25 ml (5 teaspoons) can be given every 10 minutes. If the child vomits, try again in another 10 minutes. If the child refuses the fluid or continues to vomit the fluid, nasogastric or intravenous therapy may be needed. This is particularly important if a vomiting child appears to be dehydrated.

5-43 Which children with acute diarrhoea should be referred to hospital?

Most children with acute diarrhoea can be managed at home or at a primary care clinic. However, the following children should be referred to hospital for further management:

5-44 What is the management of persistent diarrhoea?

Children with persistent diarrhoea should be referred to hospital for investigation and further management. Correct dehydration if present. Offer oral rehydration solution even if the child is not visibly dehydrated. Consider HIV in any child with persistent diarrhoea.

Note
The stool should be cultured and examined under a microscope in an attempt to identify the cause. Secondary lactose intolerance is common. Often a lactose free formula (Isomil, Infasoy) is given for a few weeks.

5-45 What is the management of dysentery?

These children should be referred to hospital for investigation and treatment. Correct dehydration. An antibiotic is needed. Usually, oral nalidixic acid is given 6 hourly for 5 days (2.5 ml if 12 to 24 months; 5 ml if 2 to 5 years; 7.5 ml if older than 5 years). If unwell with a high fever give systemic antibiotics (intramuscular or intravenous ceftriaxone 50 mg/kg/dose daily).

Note
Dysentery is usually due to Shigella, which has become resistant over the years to many antibiotics. Ciprofloxacin may be required.

Management of dehydration

5-46 What is the management of a child with diarrhoea but no visible dehydration?

These children are losing excessive amounts of fluid and electrolytes in their stools and therefore must still be given extra fluid and electrolytes to prevent signs of dehydration from appearing.

  1. If the child is able to take oral rehydration solution well at the clinic, then the child should be managed at home using commercial oral rehydration solution or sugar and salt solution to replace fluid losses. Give as much fluid as the child will take. Continue with extra fluids until the diarrhoea stops.
  2. Normal feeds should be continued. Breastfeeding mothers should continue to give breastfeeds.
  3. The child should be closely observed for continuing loose stools or vomiting. Signs of dehydration must also be looked for.
  4. The mother should bring the child to the clinic immediately if the child appears to be sicker, develops signs of dehydration, refuses feeds or vomits a lot.
  5. Children with diarrhoea but no visible dehydration, who are managed at home, should return to the clinic in 2 days for a weight check , again in 5 days if the diarrhoea has not stopped and sooner if there is any deterioration or danger signs.

The aim of early home care is to prevent dehydration and continue feeding. The mother must know what fluids to use and how much to give. She must also know when to return to the clinic.

Home care with oral rehydration solution can usually prevent dehydration.

Note
Children with ‘no visible’ dehydration who do not meet the criteria needed to be classified as ‘some’ dehydration may still have lost about 5% of their body fluid (about 5% loss in body weight and therefore need extra fluids).

5-47 What is the treatment of a child with some dehydration?

These children with 2 or more clinical signs of ‘some’ dehydration should initially be managed in a clinic or hospital if possible as they can progress to ‘severe’ dehydration:

  1. They can be treated with oral rehydration solution with a close watch for repeated vomiting or a refusal to drink. It is best if the oral rehydration solution is given by cup and/or spoon.
  2. 80 ml/kg of oral rehydration solution should be given over 4 hours, i.e. about 20 ml/kg each hour. More can be given if the child wants to drink more. It is best if the child has frequent, small sips. If the child vomits, wait for 10 minutes and then try again more slowly.
  3. The degree of dehydration must be reassessed after 4 hours.
  4. If the child takes the oral rehydration solution well, is not vomiting and there are no longer signs of dehydration (and the child has gained weight) after 4 hours, the child can be sent home and return to be assessed the next day. At home the child should be managed with oral rehydration solution (as for diarrhoea with ‘no visible’ dehydration). The decision to send the child home will depend on the home circumstances. The mother must bring the child back immediately if the diarrhoea gets worse, the child vomits everything or signs of dehydration appear.
  5. It is important that the child continues to receive regular feeds (especially breastfeeds) plus oral rehydration solution until the diarrhoea stops. Oral rehydration solution does not cause the fluid loss in the stools to increase.
  6. The mother must know how to make up the rehydration solution correctly and how much to give.

If the infant refuses to drink fluids or vomits repeatedly after drinking, a continuous naso­gastric drip should be started at 20 ml/kg/hour. If there are still signs of ‘some’ dehydration after 4 hours, continue with the oral or nasogastric rehydration solution and assess again after a further 4 hours. If signs of severe dehydration develop, manage the child for ‘severe’ dehydration.

The lives of most children with diarrhoea can be saved by the simple, cheap use of oral rehydration therapy at home or in a local primary care clinic.

Children with some dehydration are treated at a clinic or hospital with extra fluids in addition to continuing normal feeds.

Note
The WHO recommends 75 ml/kg of oral rehydration solution over 4 hours (ie. 20 ml/kg/hour).

5-48 What is the treatment of a child with severe dehydration?

The management of children with severe diarrhoea leading to severe dehydration is a medical emergency. Look carefully for shock in all children with severe dehydration and treat immediately.

  1. Immediately start an intravenous infusion with Ringer’s lactate (or half normal saline or half strength Darrows/dextrose solution) for severe diarrhoea without shock.
  2. Give 20 ml/kg over the first half hour (30 minutes). Continue to give 20 ml/kg/hour over 4 to 6 hours. Most infants are therefore rehydrated with 100 ml/kg over 4 to 6 hours. If children are younger than 3 months, have associated respiratory or cardiac disease, have hypernatraemia or severe malnutrition, they must be rehydrated slower over 12 to 24 hours at 10 ml/kg/hour with frequent re-assessment for signs of fluid overload.
  3. All severely dehydrated children must be closely observed and reassessed every half hour. If the clinical signs of dehydration have not improved after an hour, fluid should be given faster. Careful assessment after 3 hours is needed to decide whether further management should be for ‘no visible’, ‘some’ or ‘severe’ dehydration.
  4. If an intravenous infusion cannot be started, pass a nasogastric tube and give 20 ml/kg/hour over 6 hours (i.e. 120 ml/kg). Nasogastric rehydration is slower than intravenous rehydration as it takes time for the fluid to be absorbed. If there is repeated vomiting or abdominal distension, give the nasogastric fluid slower or try again to start an intravenous infusion.
  5. Only once intravenous or nasogastric rehydration has been started, should the child be moved urgently to hospital. Always start replacing fluid before moving the child. One of the commonest mistakes made is to rush the child to hospital before starting intravenous or nasogastric fluid. If no equipment is available to give fluid fast, try to get the child to drink from a cup or syringe while being urgently transported to hospital.
  6. Oral rehydration solution should be started when the child is able to drink. Feeds should not be stopped for longer than 4 hours. Breastfeeding should always continue unless the child is shocked.

Never rehydrate an infant or child with 5% or 10% dextrose only as they need electrolytes as well as fluid and glucose. Rehydration fluids must always contain some glucose (dextrose).

Children with severe dehydration should be rehydrated with 100 ml/kg of fluid intravenously over 4-6 hours.

Note
In infants under 1 year it is best to give 30 ml/kg for the first hour while the remaining 70 ml/kg is given slower over a further five hours. Therefore, small infants are rehydrated slower with 100 ml/kg over 6 hours.

The amount and rate of fluid needed to correct severe dehydration has been controversial for many years. The Red Cross Children’s Hospital in Cape Town, South Africa, recommends 20 m/kg over the first 30 minutes followed by 10 ml/kg over the next 4 hours. This regimen avoids the dangers of rehydrating a child too fast.

5-49 What is the treatment of dehydration resulting in shock?

Give intravenous Ringer’s lactate or normal saline 20 ml/kg as fast as possible (10 ml/kg/hour in the severely malnourished child). Reassess the child as soon as the bolus has been given. Repeat the bolus again if signs of shock persist. Continue to repeat until the child is no longer shocked. If 60 ml/kg has been given and the child is still shocked consider other causes of shock. This child will need intensive care.

An easily felt radial pulse and normal capillary filling time are very reassuring signs of a good response to management. Once shock has been corrected, Ringer’s lactate, half normal saline or half Darrows/dextrose solution is then given at the standard rate for severe dehydration (i.e. 20 ml/kg per hour).

20 ml/kg of intravenous fluid is given as fast as possible if shock is present.

If it is not possible to start an intravenous line, the intraosseous route can be used in young children if the health worker is trained in this technique. A nasogastric drip can be used if neither intravenous or intraosseous routes are available. Haemaccel, fresh frozen plasma or stabilised human serum (SHS) are not used to treat shock from dehydration. Using the intraosseous route in children under 6 years of age can be a life-saving procedure.

In an emergency with ongoing shock, where several attempts to place an intravenous line have failed, use the intraosseous route. The most suitable site is 2 cm below the tibial tuberosity on the flat surface of the tibia (shin bone). A wide-bore needle (15–18 gauge) can be used if a needle with stylet is not available. In children under 18 months, an 18 × 1.5 or 20 × 1.5 lumbar puncture needle is suitable. Hold the needle perpendicular to the skin and with a twisting movement push it into the flat part of the tibia until a ‘give’ is felt; the needle is now in the bone marrow. Do not advance it any further. In a shocked patient, fluid must be introduced under pressure (use a 20 ml syringe as a ‘push-in’ or a sphygmomanometer cuff wrapped around a collapsible IV plastic fluid container). The dosage and volume of drugs and fluid are the same as for direct IV infusion.

5-50 What fluids should be given once dehydration has been corrected?

Once dehydration has been corrected, the total amount of fluid needed is normal maintenance requirements plus any ongoing fluid losses. The normal fluid needs of most infants are about 100 ml/kg daily. If possible this fluid should be given orally as rehydration solution or milk. Thirst is usually a good guide to the infant’s fluid needs.

5-51 What is the value of zinc supplements in managing a child with diarrhoea?

Zinc is an important trace element which can speed up the recovery from diarrhoea and help to prevent further diarrhoea. Once the child is taking feeds well, one tablet of zinc (20 mg) should be given daily for 10 days. Children under 10 kg should have half a tablet (10 mg) daily.

Prevention of diarrhoea

5-52 Is acute diarrhoea preventable?

Yes. The viruses and bacteria that usually cause acute diarrhoea spread easily from person to person by the faecal-oral route. Acute diarrhoea is an infectious disease. With simple interventions, most cases of acute diarrhoea can be prevented.

Acute diarrhoea is usually very infectious but can be prevented.

5-53 Why do children commonly get diarrhoea?

Because they are exposed to the viruses and bacteria which cause diarrhoea. Their food and water may also be contaminated by these organisms. Infections which cause diarrhoea are particularly common:

Diarrhoea is usually due to contaminated food or water.

Note
Faeces left on the open ground or washed into the water supply by rain, pit toilets that overflow, and vegetables ‘freshened’ with contaminated water are all common sources of infection. Infected food (e.g. eggs and shellfish) can also result in diarrhoea. The importance of hand washing cannot be overestimated.

5-54 How can the risk of diarrhoea be reduced?

Diarrhoea is far less common with:

Breastfeeding, a clean safe water supply, appropriate handwashing and good sanitation will prevent most cases of diarrhoea. Well-nourished children are less likely to get severe diarrhoea than malnourished children. Breast milk contains many substances (antibodies and immune cells) which protect the gut from infection and it thereby protects the infant from diarrhoea caused by infection.

Breastfeeding is an important way of preventing diarrhoea in young infants.

Note
Recent research shows that probiotics, such as bifidobacteria, added to formula feeds can reduce the risk of gastroenteritis.

5-55 How can a safe water supply be obtained?

  1. Chlorinated tap water must be provided where ever possible.
  2. Water can be sterilised by boiling or adding chlorine tablets.
  3. If none of the above is available, water can be made safer by putting it into a clear, plastic bottle or bag and leaving it in the sun for a few hours. The ultraviolet light will kill most viruses or bacteria in the water.

If the water is cloudy or dirty it should be filtered or be allowed to stand until the clear water at the top can be gently poured off. The clear water must then be sterilised.

Note
A simple water filter can be made in a container with holes in the bottom. At the base of the container place a few centimetres of small pebbles. Cover these with a few centimetres of sand (not clay). Place the container on top of a second container in order to catch the drops of filtered water. The dirty water can now be poured into the top container to filter down into the second container.

5-56 How can sanitation be improved?

There are a number of simple ways to improve sanitation and reduce the risk of children getting diarrhoea. All stools must be passed or deposited into a flush, chemical or pit toilet:

  1. A simple pit toilet: The pit must be dug less than a metre wide and at least 1 to 2 metres deep, 20 metres or more away from houses or water sources. The deeper the pit the better. The pit must be covered with a slab or platform, having a single round hole which must be covered with a lid to keep out flies and keep in the smell. Throwing in lime, ash or soil after each use will help control flies and smell.
  2. A Ventilated Improved Toilet (VIP Toilet): The pit should be covered by a slab with 2 holes. An outhouse should be built over the larger, central hole while a ventilation pipe should be placed in the second smaller hole which is at one end of the slab. The top of the ventilation pipe must be covered with a fly screen. The door of the toilet should face into the wind. The outhouse should be dark inside with no cover over the seat. Air flow in the pit is down the large hole and up the small hole. Smell and flies escape up the pipe where the flies are trapped. Thousands of VIP toilets have been installed in many rural areas in South Africa.

Effective, cheap sanitation can be provided with a pit or VIP toilet.

Where affordable, a chemical or flush toilet should be used. If no toilet is available, all stools must be buried immediately.

5-57 Why is cup-feeding safer than bottle-feeding?

If a mother is unable to safely clean dirty bottles and teats, it is better to feed the infant by cup. Unlike a bottle, a cup can easily be cleaned with soap and water. The inside surfaces of a cup are smooth and easily reached by finger. Unlike a feeding bottle, there are no corners for milk and bacteria to lodge in.

Cup-feeding is safer than bottle-feeding.

5-58 How can hygiene be improved?

Case study 1

A mother brings her 9-month-old child to a local clinic. The child has had loose stools for 2 days. The mother has stopped bottle feeds of formula and given sugar and salt solution as advised by a general practitioner. Oral antibiotics and an anti-diarrhoea medication were started. On examination the child has no signs of dehydration. Other than the loose, watery stools, the child appears healthy. The older sibling had loose stools the week before.

1. What is the diagnosis?

The child has acute diarrhoea with no visible dehydration. The diarrhoea is probably due to a bowel infection with Rota virus. The infection probably spread from the sibling.

2. What could have been done to prevent the diarrhoea?

Good hygiene with handwashing after going to the toilet and before meals. Breastfeeding rather than formula feeds also reduces the risk of diarrhoea. Formula feeds are best given by cup rather than bottle.

3. Do you agree with the use of a sugar and salt solution?

Yes. Oral rehydration solution or a home made sugar and salt solution is the correct management of diarrhoea to prevent dehydration.

4. Should feeds be stopped when children have diarrhoea?

No. It is very important that feeds are continued. Stopping feeds does not improve the diarrhoea and may lead to malnutrition.

5. Would you have prescribed an antibiotic?

There is no need for an antibiotic in acute diarrhoea unless the diarrhoea is caused by dysentery or an infection outside the bowel, such as an acute otitis media (ear infection). Neither is there an indication for anti-diarrhoeal or antiemetic medications.

6. Does this child need to be kept at the clinic or admitted to hospital?

No. A child with no visible dehydration can be managed at home after an observed trial of oral rehydration solution. The child should be brought back to the clinic in 5 days, or sooner if the diarrhoea becomes worse or the child’s general condition deteriorates. The child should be observed for continuing loose stools or vomiting. The aim of early home care is to prevent dehydration and continue feeding. The mother must know what fluids to use and how much to give. She must also know when to return to the clinic.

Case study 2

An ill 9-month-old child with diarrhoea and signs of severe dehydration is brought to a local hospital. He is shocked and breathing fast. The mother says he has had watery stools all day and vomits all feeds. The family live in a poor area with no formal toilets. Drinking water is collected from a stream. When compared to the weight recorded in the child’s Road-to-Health Booklet 2 weeks before, 15% body weight has been lost.

1. What are the signs of severe dehydration?

If 2 or more of these signs are positive, a diagnosis of severe dehydration is made. The weight loss of more than 10% also suggests severe dehydration.

2. What are the signs of shock?

3. Why is this child breathing fast?

He is probably acidotic. However, he may also have pneumonia.

4. How should shock due to dehydration be treated?

It is very important that the child is given intravenous fluid immediately and fast. Usually Ringer’s lactate or normal saline is used, starting with 20 ml/kg. The signs of shock must be carefully observed. If the child is still shocked after the first 20 ml/kg, repeat this amount fast. If it is not possible to start an intravenous infusion, the fluid should be given via an intraosseous route or a nasogastric tube if this is not possible. The child should be transferred immediately to hospital.

5. How is severe dehydration corrected?

Once the shock is corrected, the child should receive half strength Darrows/ dextrose intravenously (or via a nasogastric tube) to treat the severe dehydration. Usually 30 ml/kg is given over 30 minutes followed by 70 ml/kg over 2 ½ hours. Start oral rehydration solution once the child is fully conscious and able to take fluids.

6. Why does this child have diarrhoea?

Probably because there are no toilets or clean drinking water. If clean tap water is not available, water can be sterilised by boiling or adding chlorine tablets. If this cannot be done, water can be made safer by putting it into a clear, plastic bottle or bag and leaving it in the sun for a few hours. The ultraviolet light will kill most viruses or bacteria in the water.

7. What can be done if no toilet is available?

A simple pit toilet can be made. A Ventilated Improved Toilet (VIP Toilet) would be even better. Some plan must always be made to get rid of waste safely.

Case study 3

A child of 2 years has a one-month history of loose stools. The child has some dehydration. The weight falls below the third centile. It is noticed that the child has generalised lymphadenopathy. The grandmother says that the child’s mother died a few months before.

1. What is your diagnosis?

This child has persistent diarrhoea as the loose stools have been present for more than 14 days.

2. How is ‘some’ dehydration recognised?

The child does not have severe dehydration but 2 or more of the following signs:

3. What is the correct treatment of ‘some’ dehydration?

These children should be treated at a clinic or in hospital. Usually oral rehydration solution is given with a close watch for repeated vomiting or a refusal to drink. It is best if the oral rehydration solution is given by cup. 80 ml/kg of oral rehydration solution should be given over 4 hours, i.e. about 20 ml/kg each hour. More can be given if the child wants to drink more. Usually the fluid is given by cup or spoon. It is best if the child has frequent, small sips. If the child vomits, wait for 10 minutes and then try again more slowly. The degree of dehydration must be assessed after 4 hours.

4. When can this child be sent home?

Children with acute diarrhoea and ‘some’ dehydration can be sent home if they take the oral rehydration solution well, are not vomiting and there are no signs of dehydration after 4 hours. It is important that the child continues to receive regular feeds. The decision to send the child home will depend on the home circumstances. The child must continue to be offered rehydration solution frequently and return to be assessed the next day. The mother must bring the child back immediately if the diarrhoea gets worse, the child vomits everything or signs of dehydration appear. However, as this child has persistent diarrhoea, she must be admitted to hospital for investigation and further management.

5. What is the relationship between diarrhoea and malnutrition?

Diarrhoea, especially persistent diarrhoea, can lead to malnutrition while children with mal­nutrition are at high risk of getting severe diarrhoea. Therefore, the one often leads to the other.

6. What illness must be suspected in this child?

AIDS. HIV infection often presents clinically with persistent or recurrent diarrhoea. The generalised lymphadenopathy suggests HIV infection. This child’s mother may have died of AIDS.

Case study 4

An 8-year-old child presents with a week’s history of loose stools containing both blood and mucus. The child has a temperature and looks ill. There are no signs of dehydration.

1. What is the importance of blood in this child’s stool?

It indicates that he has dysentery.

2. What may the cause be?

As the child is ill with a temperature, typhoid (Salmonella) or Shigella or amoebic dysentery must be suspected. The commonest cause of dysentery is Shigella.

3. How should this child be managed?

Children with dysentery should be referred to hospital for investigation and treatment. An antibiotic, usually nalidixic acid, is given 6 hourly (7.5 ml as the child is older than 5 years). If the child is ill with fever and dysentery, IM or IV ceftriaxone 50 mg/kg should be given. Oral rehydration solution should also be given.

4. What simple steps can reduce the risk of diarrhoea and dysentery?

Making sure that there is:

5. How can a safe water supply be obtained?

6. What trace element may help the recovery from diarrhoea?

Zinc. One dissolved tablet should be taken daily for 10 days.

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