Professor Lee Way Seah

Head
Department of Paediatrics
Faculty of Medicine
University Malaya
 Childhood Acute Diarrhoea:
Burden of the Disease

 Acute diarrhoea is the second most important cause

of childhood mortality worldwide.
Murray & Lopez. Lancet 1997

 Each year, approximately 1.9 million children

younger 5 years of age died of acute diarrhoea.

Boschi-Pinto et al. Bull World Health Org 2008

 Definition of Diarrhoea

 Passage of unusually loose or watery stools, usually

at least 3 times in a 24-hour period.
 The consistency of the stools, rather than the
number that is most important.

Remember:
 Frequent passing of formed stools is NOT diarrhoea.
 Breastfed babies also pass loose, `pasty’ stools
sometimes up to 6 or 7 times a day; this is NOT to
be regarded as diarrhoea.
 Issues with Acute Diarrhoea

 Volume of fluid loss through stools vary from 5 ml/kg

body weight/day to ≥ 200 ml/kg body weight/day.

 Dehydration and electrolyte losses associated with

untreated diarrhoea cause the primary morbidity of AGE.

 Diarrhoea can be the initial signs of non-GIT illness,

including meningitis, bacterial pneumonia, otitis media,
and UTI.

 Vomiting alone can be first symptom of a variety of

diverse conditions.
 Clinical Types of Diarrhoeal Diseases

Acute watery diarrhoea

 Lasts several hours or days.
 Main danger – dehydration

Acute bloody diarrhoea (dysentery)

 Main dangers – damage to intestinal mucosa,
sepsis, malnutrition
 Dehydration may also occur

World Health Organization.

The Treatment of Diarrhoea – A Manual for Physicians and other Senior Health Workers
World Health Organization, 2005
 Clinical Types of Diarrhoeal Diseases

Persistent diarrhoea
 Lasts 14 days or longer
 Main dangers – malnutrition, serious infections, ±
dehydration

Diarrhoea with severe malnutriton

 Main dangers – severe systemic infection,
dehydration, heart failure, vitamins and minerals
deficiency.

World Health Organization.

The Treatment of Diarrhoea – A Manual for Physicians and other Senior Health Workers
World Health Organization, 2005
 Causative Agents of Acute Diarrhoea

Bacteria Viruses Parasites

Aeromonas sp. Astrovirus Cryptosporidium

Bacillus cereus Calicivirus Cyclospora spp.
Clostridium perfringens Coronavirus Ent. histolytica
Clostridium difficile Enteric adenovirus Giardia lamblia
E. coli Norovirus Isospora belli
Ples shigelloides Rotavirus St. stercoralis
Salmonella
Shigella
S. aureus
V cholerae / parahaemolyticus
Yersinia enterocolitica
 Important Causative Agents of
Gastroenteritis by Nature of Stool
Watery / mucous
≤2y RV, astroviruses, calicivirus,
enteric adenovirus,
EPEC, ETEC,

2-5 y ETEC, RV, Shigella

Dysenteric / Bloody
≤2y Shigella, STEC,
Campylobacter jejuni

2-5 y Shigella, STEC,

non-typhoidal Salmonella,
E. histolytics
 Important Causative Agents of
Gastroenteritis in Malaysia

Virus:
 Rotavirus – most important
 Enteric adenovirus

Bacteria:
 Non-typhoidal Salmonella – most important
 Campylobacter, Shigella, E. coli

Lee WS, et al. Singapore Paediatr J; 1997

Lee WS, et al. J Paediatr Child Health; 2003
Lee WS, et al. J Paediatr Child Health; 2006
Poo MI, Lee WS. Med J Malaysia; 2007
 Important Causative Agents of
Gastroenteritis in Malaysia

Hospitalised Child:
 Rotavirus: ~ 40 – 50%
 Severe vomiting and diarrhoea, severe dehydration

Outpatient:
 Non-typhoidal Salmonella – most important
 Rotavirus: ~ 10%
 Assessment in Acute Diarrhoea

Aims of assessment:
1. Identify the presence of, the degree, type of
dehydration
2. Identify the aetiological agent, if appropriate
3. Identify co-morbidity, complications, nutritional
status
4. To ascertain the best possible mean and place of
managing the child.
 Assessment: History

 Clinical history: assess onset, frequency, quantity, &

character (bile, blood, or mucus) of vomiting and
diarrhoea.
 Oral intake (including breast milk and other fluids and
food)
 Urine output; weight before illness (if available)
 Associated symptoms (fever, changes in mental status)
 Past medical history (underlying medical problems, history
of other recent infections, medications,
immunocompromised states)
 Social history
 Assessment: Physical Examination

 Accurate body weight

 Vital signs (temperature, heart rate, respiratory rate, blood
pressure)
 General conditions
 Eyes: sunken eyes, presence / absence of tears
 Mucus membrane – moist or dry
 Respiratory pattern
 Bowel sounds
 Extremities (perfusion, capillary filling time)
 Skin turgor (anterior abdominal wall)
 Inspection of stool (presence of blood or mucus)
CDC 2003
Skin Turgor
 Assessment of dehydration
in Acute Diarrhoea
Symptom Minimal or no dehydration Mild to moderate Severe dehydration
(<3% loss of body weight) dehydration (> 9% loss of body weight)
(3-9% loss of body weight)

Mental status Well, alert N, fatigued or restless, irritable Apathetic, lethargic, unconscious
Thirst Drinks N, might refuse liquids Thirsty, eager to drink Drinks poorly, unable to drink
Heart rate N N / increased Tachycardia, with bradycardia in
most severe cases
Quality of pulse N N to decreased Weak, thready, or impalpable
Breathing N Normal, fast Deep

Eyes N Slightly sunken Deeply sunken

Tears Present Decreased Absent

Mouth and tongue Moist Dry Parched (very dry)

Skin fold Instant recoil Recoil in < 2 seconds Recoil in > 2 seconds
Capillary refill N Prolonged Prolonged, minimal
Extremities Warm Cool Cold, mottled, cyanotic
Urine output N to decreased Decreased Minimal

Adapted from WHO 1995, CDC 2003

 Is This Child Dehydrated?
Points to Remember

 Clinical signs for dehydration: imprecise

Steiner MJ et al. JAMA 2004

 Best measure of dehydration - % loss of body

weight
Guarino et al. J Pediatr Gastroenterol Nutri 2008

 Classification into severity of dehydration –

useful for fluid management
How to know % loss of body weight if the child already came
with dehydration and no info of prev N weight?
 Is This Child Dehydrated?
Points to Remember

Most useful physical signs

 Prolonged capillary refill time (normal 1.5 – 2 s)
 Abnormal skin turgor
 Abnormal respiratory pattern

 Only indicates presence or absence of

dehydration
 Not precise for degree of dehydration

Steiner MJ et al. JAMA 2004

Duggan C, et al. J Pediatr Gastroenterol Nutri 1996
 Assessment of Dehydration

Simplified ways of assessing dehydration and amount

of fluid to be delivered:
Assessment Fluid deficit as % of Fluid deficit in ml/kg
body weight of body weight

No signs of < 5% < 50 ml/kg

dehydration

Some dehydration 5-10% 50 – 100 ml/kg

Severe dehydration > 10% > 100 ml/kg

WHO 2005
 Bacterial vs. Viral?

 High fever (> 400C), overt faecal blood, abdominal pain,

CNS involvement (irritability, apathy, seizures, coma) –
suggest bacterial aetiology
Finkelstein JA et al. Am J Emerg Med 1989

 Vomiting & respiratory symptoms (but really tho? Do all

viral diarhoea presents with respiratory symptos??) –
suggest viral aetiology
Koopman JS, et al. Am J Epidemiol 1984
Jonas A, et al. Isr J Med Sci 1982

 RV causes more severe vomiting and dehydration

 Considerable overlap
ESPGHAN 2008
 Diagnostic Workup

Blood:
 Lab tests of dehydration are imprecise

 Urea, Na+, K+, pH, HCO3

 ( ± Ca, Mg, glucose in young infants)

 Complete blood count

Urine:
 Specific gravity

 Not microscopy
 Diagnostic Workup

Stool:
 Stool C+S: not routinely done
 But necessary if profuse watery stools (cholera),
blood & mucous in stool (bacterial dysentery)

 Virus – not usually indicated

 Parasites – if clinically indicated

 Reducing substances (only in watery stool)

 Important Pointers in Management of
Childhood Acute Diarrhoea

 Identification of children at risk of severe disease

 Prevention / correction of dehydration & electrolytes

imbalances

 Prevention & treatment of complications (invasive disease,

severe electrolytes derangement, metabolic & other
complications, malnutrition)

 Drug(s) treatment: supplementary role

 Provisions of adequate & appropriate nutrition

 When to Refer for Hospital Care?

 Severe dehydration (> 9% of body weight), shock

 Neurological abnormalities (lethargy, seizures, etc)
 Persistent or bilious vomiting (even if no dehydration)
 Treatment failure with ORS
 Presence of systemic illness (high fever, toxic looking)
 Underlying medical conditions (heart failure, significant neuro-
developmental disabilities)
 Caregivers unable to provide adequate care at home or other
social / logistic concerns
 Suspected surgical conditions, uncertain about diagnosis
 Uncertain about degree of dehydration (obese child)

ESPGHAN 2008
 Rehydration in Acute Diarrhoea

No dehydration
 If no excessive vomiting, no admission

 If breast feeding, continue BF

 If formula-fed, continue usual feeding, offer extra water

 Older children: continue normal diet, extra water

 Rehydration in Acute Diarrhoea

Mild dehydration (<5%)

 If no excessive vomiting, no admission

 Trial of ORS 40 – 60 ml/kg within 4 – 6 hours

 Every diarrhoea episode: ORS 10 ml/kg

 If oral ORS refused / inadequate, try spoon feeding

 Enteral ORS safer & associated with shorter hospital

stay
 Rehydration in Acute Diarrhoea

Moderate dehydration
 If no excessive vomiting and in the absence of

adverse social circumstances, may still consider out-

patient treatment
 ORS 75 ml/kg within 4 – 6h

 10 ml/kg of ORS for each diarrhoeal episode

 Small and frequent feeds, regular assessment

 Hospital referral for admission for IV fluid if persistent

vomiting / worsening dehydration
 Rehydration in Acute Diarrhoea

Severe dehydration / shock

 Resuscitation (normal saline / Ringer’s lactate)

 Frequent monitoring

 Immediate referral to hospital for admission

Mean Stool Na+ and K+ (mmol/L) According
to Duration of Diarrhoea Before Admission

Cholera EPEC Rotavirus

Duration (h) Na K Na K Na K

0 – 12 98 29 67 37 53 46

13 – 24 83 37 55 38 42 42

25 – 48 63 28 44 26 32 28

48+ 46 65 44 37 34 43

Molla et al, 1991

 Electrolytes Composition,
Osmolality of Major ORS

Na K Cl HCO3 Glu Osmolality

Standard WHO (1975) 90 20 80 30 111 311

Reduced-Osmolarity 75 20 65 30 75 245
WHO (2002)
Ministry of Health 56 20 56 20 137.5 290

Santosham 1997, Lee WS, 2009

 Fluids Not Appropriate to be Used
in Rehydration Therapy

Na K Cl HCO3 Glu Osmolality

Coca cola 2 0 n/a n/a 616 618

Apple juice 3 20 n/a 0 600 - 900
Chicken broth 250 8 n/a 0 0 260
Tea 0 0 n/a 0 0
100 plus 21 3.5 11 -

Santosham 1997, Lee WS, 2009

 Assessment

Issues:
 Hypernatraemic dehydration
 Differential diagnoses
 Bacterial vs. viral causes

Diagnostic work-up
 Stool
 Urine
 Blood
 Management

 Referral for hospital care

 Rehydration – prevents & correct dehydration
 Various ORS preparations
 Fluids not appropriate

 Special consideration on hypernatraemia

Adjunctive Management: Antibiotics
 Anti-emetics

Examples: dimenhydrinate, metoclopramide,

domperidone, promethazine

Side effects:
 Drowsiness, extra-pyramidal side effects
 Can reduce ORS intake

 Not recommended
Anti-diarrhoeals
 Anti-diarrhoeals

 All anti-diarrhoeal: NOT recommended

 Smectite / racecadotril: may be useful as adjunctive together with ORS
 Nutritional Therapy / Special Formulae

 Diluted formula – not recommended

If no lactose intolerance or persistent diarrhoea

 Lactose-free formula
 Soy formula
 Hydrolysate / elemental formula:

 all not recommended

 Probiotics

 Probiotics strain / strains with proven efficacy and in appropriate dose

 Prebiotics: Not recommended
 Prevention

 Improved hygiene can prevents most but not all

acute diarrhoeal illness in children

 Promotion of breast feeding

 Probiotics prevent antibiotic-associated diarrhoea

(AAD): treating 7 may prevent 1 AAD.
 But results not consistent

 Prebiotics: no effect on prevention

Vaccines – Rotavirus Vaccines
 Question 1

The following is the most sensitive physical signs of

assessing dehydration:

A Decreased skin turgor

B Reduced sensorium
C Documented percentage reduction in weight
D Abnormal respiratory pattern
 Question 2:

The following physical signs predict viral gastroenteritis:

A Fever of over 39 degree Celsius

B Prominent vomiting
C Abdominal distension
D Irritability