19 FEB 2011 Mejino, Carmelou Melgarejo, Ivy Mendoza, Alvin Mendoza, Diana.

IMCI GUIDELINESDIARRHEA

19 FEB 2011Mejino, Carmelou

Melgarejo, IvyMendoza, Alvin

Mendoza, Diana

OUTLINE Definition of Diarrhea Assessment of Child with Diarrhea Discussion of IMCI Guidelines on

Diarrhea

DEFINITION: DIARRHEA It is passage of stool at least twice the normal

bowel movement wherein the stools follow the shape of the container.

It is also defined in infants and children as a stool output of greater than 10 g/kg/day (normal=5-10 g/kg/day) and more than the adult limit of 200 g/24 hour.

Nelson’s Textbook of Pediatrics. 17th ed.

Classification of Diarrhea Acute Diarrhea It is the passage of loose and watery

stool of less than two weeks duration.

Chronic/Persistent Diarrhea It is the passage of loose and watery

stool of two weeks or longer duration.

CLINICAL TYPES OF DIARRHEA• Acute watery diarrhea (includes cholera): lasts

several hours or days; main danger is dehydration• Acute bloody diarrhea: “dysentery” causing major

damage to intestinal mucosa, sepsis and malnutrition

• Persistent diarrhea: lasts 14 days or longer that results in malnutrition and serious non-intestinal infection

• Diarrhea with severe undernutrition: major dangers are: severe systemic infection, dehydration, heart failure, vitamin and mineral deficiency

The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev. WHO document 2005

For ALL sick children ask the mother about the child’s problem, check for general danger signs,ask about cough or difficult breathing and then

ASK: DOES THE CHILD HAVE DIARRHEA?

If NO If YES

Does the child have diarrhea?IF YES, ASK: LOOK, LISTEN, FEEL:œ � For how long? œ � Look at the child’s general condition. Is the child:œ � Is there blood in thestool Lethargic or unconscious? Restless or irritable? œ � Look for sunken eyes.

œ � Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty?

œ � Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?

CLASSIFY the child’s illness using the colour-coded classification tables for diarrhea.

Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition andanaemia, immunization status and for other problems.

Classify DIARRHEA

Assessment of Child with Diarrhea

• Dehydration– General condition– Sunken eyes– Thirst– Skin elasticity

• Persistent diarrhea• Dysentery

Does the child have diarrhea?IF YES, ASK: For how long? Is there blood in the stool?

LOOK, LISTEN, FEEL:Look at the child’s general condition, is the child: Lethargic or unconscious? Restless or irritable?

Look for sunken eyesOffer the child fluid. Is the child: Not able to drink or drinking poorly?Drinking eagerly, thirsty?

Pinch the skin of the abdomen. Does it go back: Very slowly (> than 2 secs)? Slowly?

Two of the following signs:•Lethargic or unconscious•Sunken eyes•Not able to drink or drinking poorly•Skin pinch goes back very slowly

SEVEREDEHYDRATION

If child has no other severe classification:— Give fluid for severe dehydration (Plan C). ORIf child also has another severe classification:— Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.Advise the mother to continue breastfeedingIf child is 2 years or older and there is cholera in your area, give antibiotic for cholera.

Two of the following signs:•Restless, irritable•Sunken eyes•Drinks eagerly, thirsty•Skin pinch goes back slowly

SOMEDEHYDRATION

Give fluid and food for some dehydration (Plan B).•If child also has a severe classification:— Refer URGENTLY to hospital with mothergiving frequent sips of ORS on the way.Advise the mother to continue breastfeeding•Advise mother when to return immediately.•Follow-up in 5 days if not improving.

Not enough signs to classify as some or severe dehydration. NO

DEHYDRATION

Give fluid and food to treat diarrhoea at home (Plan A).Advise mother when to return immediately.Follow-up in 5 days if not improving.

CLASSIFICATION TABLE FOR DEHYDRATION

SIGNS CLASSIFY ASIDENTIFY TREATMENT

(Urgent pre-referral treatments are in bold print.)

Four Rules for Home Treatment of Diarrhea

(Treatment Plan A)• Rule 1: Give more fluids than usual• Rule 2: Zinc supplementation at 20 mg/day for 10-14 days

(10 mg for infants < 6 months)• Rule 3: Continue to feed the child• Rule 4: When to return to the clinic

Diarrhea Treatment Guidelines for Clinic-Based Health Care Workers

• Fluids that normally contain salt– ORS solution– Salted drinks (salted rice

water, salted yoghurt drink)– Vegetable or chicken soup

with salt

• Fluids that do not contain salt– Plain water– Water in which a cereal

has been cooked– Unsalted soup– Yoghurt drinks without salt– Green coconut water– Weak tea– Unsweetened fresh fruit

juice

The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev. WHO document 2005

FLUIDS TO GIVE•Wherever possible, these should include at least one fluid that normally contains salt•Plain clean water should also be given

DO NOT GIVE THESE FLUIDS!!!• Drinks sweetened with sugar

– Commercial carbonated beverages– Commercial fruit juices– Sweetened tea

• Other fluids to avoid– Those with stimulant, diuretic and purgative effect

• Coffee• Some medicinal teas or infusions

The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev. WHO document 2005

Treatment Plan B

Oral Rehydration Therapy for children with some dehydration

Approximate amount of ORS solution to

give in the first 4 hours Age Less

than 4 mos.

4-11 months

12-23 months

2 – 4 years

5 – 14 years

15 years older

Weight Less than 5 kg.

5-7.9 kgs.

8 –10.9 kgs.

11-15.9 kgs.

16-29.9 kgs.

30 kgs. or more

In ml 200 -400

400 - 600

600 - 800

800 -1200

1200 - 2200

2200 - 4000

In local measure

TPB

TREATMENT PLAN C To treat Severe

Dehydration quickly

Treatment Plan C Age First give

30 ml/kg inThen give 70 ml/kg in

Infants (under 12 months)

1 hour* 5 hours

Older 30 minutes* 2 ½ hours

*Repeat once if radial pulses very weak or or not detectable•Reassess the patient every 1-2 hours.If hydration is not Improving, give the IV more rapidly•Also give ORS (about 5 ml/kg) as soon as the patient can drink, usually after 3-4 (infants) or 1-2 hrs. (older patients)

•Dehydration present

SEVEREPERSISTENTDIARRHEA

•Treat dehydration before referral unless the child has another severe classification.•Refer to hospital.

•No dehydration PERSISTENTDIARRHEA

•Advise the mother on feeding a child who has PERSISTENT DIARRHOEA.•Follow-up in 5 days.

SIGNS CLASSIFY ASIDENTIFY TREATMENT

(Urgent pre-referral treatments are in bold print.)

CLASSIFICATION TABLE FOR PERSISTENT DIARRHEA

•Blood in the stool DYSENTERY

•Treat for 5 days with an oral antibiotic recommended for Shigella in your area.•Follow-up in 2 days.

CLASSIFICATION TABLE FOR DYSENTERY

SIGNS CLASSIFY ASIDENTIFY TREATMENT

(Urgent pre-referral treatments are in bold print.)

4 Key Elements for effectiveclinical management of acute diarrhea

• Replacement of fluids, usually by ORT to prevent dehydration in the home and to treat dehydration

• Continued feeding, especially breastfeeding, during diarrhea episodes and in convalescence

• No use of antidiarrheal drugs and selective use of antibiotics

• Effective instruction of the child’s mother on– how to take care of the sick child at home– the indications for follow-up– methods of preventing future episodes of diarrhea

Etiologic Agents for most cases of diarrhea Organism Proportion of cases Effectiveness of

antibiotics in Tx•Rotavirus

•ETEC•No agent found•Shigella •Campylobacter spp

•Vibrio Cholera

•Nontyphoid salmonella

Up to 50% in health facilities; 5-10% in communityUp to 25% in all ages25% or more5 – 10%5-15%

5 – 10% in endemic areas

Up to 10% of cases

Not effective

Not effectiveNot effectiveEffectiveEffective only if given early in course of diseaseEffective

Not effective in usual uncomplicated diarrhea

WHO

4 conditions where antimicrobials are indicated

• Cholera - Tetracycline• Shigella dysentery - Nalidixic acid• Giardiasis - Metronidazole• Amoebiasis - Metronidazole

Antimicrobial % resistance of Enteric pathogens

PathogenS. typhi

AntimicrobialChloramphenicolCotrimoxazoleAmpicillin

2002032

2003100

2004011

Nontyphoidal Salmonella

ChloramphenicolCotrimoxazoleAmpicillin Ciprofloxacin

1615244

2131478

182020

Shigella ChloramphenicolAmpicillinCotrimoxazoleNalidixic acidCiprofloxacin

78730

435078012

60506700