What is diarrhoea?

It is the passage of liquid or watery stools more than 3 times a day. A recent change in character of stool is more important.

What is dysentery?

Gross blood through the stool is the hallmark of dysentery and may be accompanied by abdominal cramps and fever.

What is not diarrhoea?

*Passage of frequently formed stools.

*Passage of pasty stools in breast fed infants.

*Passage of stool during or immediately after feeding due to gastrocolic reflex.

*Passage of frequent loose greenish yellow stools on the 3rd and 4th day of life called as transitional stools.

What are the consequences of diarrhoea?

Dehydration and malnutrition leading to death.

Why does diarrhoea cause malnutrition?

*Impaired intestinal absorption causes loss of nutrients in diarrhoea.

*Increased catabolism(waste of energy) due to infection.

*A child with diarrhoea is often not hungry.

*Mothers withhold food during diarrhoea.

*Doctors do not emphasise proper feeding during diarrhoea.

What are the common causes of diarrhoea?

*Rotavirus is the commonest cause of dehydrating diarrhoea in children.

*Cholera is seen in epidemics.

*Shigella is the most common cause of dysentery.

*Giardia and amoebiasis are uncommon causes of acute diarrhoea.

How do you assess a child with diarrhoea?

The history that will be associated are --

* Stool frequency, quantity and type of stool

* Blood in the stool

* Fever

* Decreased passage of urine

* Vomiting - pronounced in rotaviral diarrhoea

* Abdominal distension

* Altered sensorium

* Feeding history

Examination: On examination the condition will vary from well alert to lethargic and drowsy. The condition maybe sometimes restless.

Eyes may be normal, sunken or very sunken or dry. Tears may be present or absent.

The tongue will become dry from moist condition and thirst will increase with the dryness of tongue and mouth.

All the above mentioned conditions will vary upon the degree of severity of dehydration.

What investigations are helpful?

*Stool routine is not of much value as more than 10 leukocytes per HPF are also seen in rotaviral diarrhoea. There is no role of stool pH and reducing substances in acute diarrhoea as the lactose intolerance in this condition is self-limiting. Trophozoites of giardia and E. Histolytica may be sometimes demonstrated rarely.

*Stool culture usually grows E. coli which may be a commensal.

*Serum electrolytes may be needed in very dehydrated patients.

What is Oral Rehydration Therapy (ORT)?

It is the cornerstone of management of diarrhoea. The term ORT includes --

*WHO ORS (Oral Rehydration Solution/Saline)- Lancet calls it the most important medical achievement of the last century.

*Home made salt sugar solution

*Food based solutions

*Culturally acceptable fluids in presence of continued feeding.

How do you give fluid therapy in diarrhoea?

Plan A - To prevent dehydration:

*Provide normal daily fluid requirements.

*Breast milk or full strength animal or formula milk.

*Semisolid food if eaten by child.

*Replace ongoing losses.

*Home available fluids- plain water, lemon water, curd water, coconut water, rice kanji, dal without salt .These fluids along with food provide ORT.

*Avoid aerated drinks, tea or plain glucose water without salt as it may cause osmotic diarrhoea.

*Salt Sugar Solution: A finger pinch of salt plus 1 teaspoon of sugar in a glass of water.

*WHO ORS:

What are the danger signs?

*Many water stools

*Repeated vomiting

*Marked thirst

*Eating or drinking poorly

*Fever- high grade

*Blood in the stool

*Drowsy child

*Marked oliguria

Plan B- Rehydration therapy in a child with some dehydration:

*75 ml per kg body weight ORS in 1st 4 hrs and then reasess.

*In children less than 6 months, give 100-200 ml water if not breast-fed.

*ORS is effective in 95 per cent cases.

When is it not effective?

*High rate of purging > 15 ml /kg /hr

*Persistent vomiting>3/hr

*Incorrect administration or preparation of ORS

*Abdominal distension and ileus

*Altered sensorium

Plan C - Severely dehydrated children:

Ringer lactate or Normal saline given Intravenously 100 ml /kg

What are the indication for antibiotics?

*Malnourished or premature infants

*Gross blood in stool

*Associated non GI infections e.g. pneumonia

What is the dietary management in diarrhoea?

*Children should continue to be fed during acute diarrhoea because feeding is physiologically sound and prevents or minimises the deterioration of nutritonal status.

*In acute diarrhoea breast-feeding should be continued with ORS uninterrupted even during dehydration.

*Optimally energy dense foods with the least bulk are recommended for routine feeding and those available in the household should be offered during diarrhoea in small quantities but frequently.

*Staple foods that do not provide optimal calories per unit weight should be enriched with fats,oil or sugar e.g khichri with oil, rice with milk or curd and sugar,mashed potatoes with oil and lentil.

*Foods with high fibre content e.g coarse fruits and vegetables to be avoided.

*In non-breast fed infants, cow or buffalo milk can be given undiluted after correction of dehydration together with semisolid foods. Milk should not be diluted with water. Alternatively milk cereal mixtures can be used.

*Routine lactose free feeding is not required in acute diarrhoea even when reducing substances are detected in the stools. Lactose malabsorption meriting dietary modification is very uncommon in acute diarrhoea.

*During recovery, an intake of at least 125 per cent of normal should be attempted with energy dense foods till nutritional status is normal as measured for age.