Management of Acute Diarrhoea in Children
Welcome to the module on
Management of Acute Diarrhoea
(AD) in Children!
Diarrhoeal disease remains a leading
cause of morbidity and mortality amongst
children in low and middle income
countries.
Most deaths result from the associated
shock, dehydration and electrolyte
imbalance.
In malnutrition, the risk of AD, its
complications and mortality are increased.
A child presenting with AD
For more information about the
authors of this module, click here
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How to use this module
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This module aims to address deficiencies in the management of AD and
dehydration in children that we identified during a clinical audit.
We suggest that you start with the learning objectives and try to keep these
in mind as you go through the module slide by slide, in order and at your
own pace.
Print-out the diarrhoea SDL answer sheet. Write your answers to the
questions (Q1, Q2 etc.) on the sheet as best you can before looking at the
answers.
Repeat the module until you have achieved a mark of >20 (>80%).
You should research any issues that you are unsure about. Look in your
textbooks, access the on-line resources indicated at the end of the module
and discuss with your peers and teachers.
Finally, enjoy your learning! We hope that this module will be enjoyable to
study and complement your learning about AD from other sources.
Click here to move to the next slide
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Learning Outcomes
By the end of this module, you should be
competent in the management of acute
diarrhoea / dehydration.
In particular you should be able to:
1. Describe when to use oral and parenteral fluids
and what solutions to use
2. Identify the malnourished child and adjust
management accordingly
3. Describe when antibiotic treatment is indicated and
the adverse effects of the overuse of antibiotics
4. Describe the use of zinc in AD
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Definition of AD
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There is a wide range of normal stool
patterns in children which makes the
precise definition of AD difficult
According to the World Health
Organization (WHO), AD is the passage
of loose* or watery stools, three times or
more in a 24 hour period for upto14 days
In the breastfed infant, the diagnosis is
based on a change in usual stool
frequency and consistency as reported
by the mother
AD must be differentiated from persistent
diarrhoea which is of >14 days duration
and may begin acutely. Typically, this
occurs in association with malnutrition
and/or HIV infection and may be
complicated by dehydration
Diaper stained with watery stool
*Takes the shape of the container
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The burden of
diarrhoeal disease
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Despite the fact that diarrhoea can be
prevented, about 2 billion cases of
diarrhoea occur globally every year in
children under 5 years
About 2 million child deaths occur due
to diarrhoea every year
More than 80% of these deaths are in
Africa and South Asia
Diarrhoea is the third most common
cause of death (see diagram)
In Nigeria, diarrhoea causes 151,700
deaths of children under five every
year,* the second highest rate in the
world after India
* UNICEF/WHO, Diarrhoea: Why children are still
dying and what can be done, 2009
Causes of death among children
under age of five years
UNICEF: Progress for children, 2007
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Causes and risk factors for AD
• Microbial, host and
environmental
factors interact to
cause AD
• Click on the boxes
to find out more
Host factors
Diarrhoea
pathogens
Environmental
factors
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Clinical types of AD
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There are 2 main clinical types of AD
Each is a reflection of the underlying pathology and altered physiology
Clinical type
Description
Common pathogens
Acute watery
diarrhoea
This is the most common. It is of recent onset, commencing
usually within 48 hours of presentation. It is usually self limiting
and most episodes subside within 7 days. The main complication
is dehydration.
Rotavirus, E. coli,
Vibrio cholera
Acute bloody
diarrhoea
Also referred to as dysentery. This is the passage of bloody
stools. It is as a result of damage to the intestinal mucosa by an
invasive organism. The complications here are sepsis,
malnutrition and dehydration.
Shigella spp,
Entamoeba histolytica
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Q1
Write “T” or “F” on the answer sheet. When you have completed all 5
questions, click on each box and mark your answers.
a)
The incidence of AD is highest in the age group 6-11
a
months
b)
Acute diarrhoea is of duration less than 14 days
c)
Rotavirus is a more common cause of diarrhoea in
developing countries than bacterial pathogens
d)
Undernutrition is a major risk factor for persistent
b
c
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diarrhoea
e)
The largest proportion of deaths from diarrhoea occur in
e
East Asia
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Clinical scenarios
• You will now work through
a series of cases of AD
• You will learn how to assess
and manage children
according to the latest WHO
guidelines
• Start with scenario A. Try to
answer the questions
yourself before clicking on
the answers
http://www.who.int/maternal_child_adol
escent/documents/9241546700/en/inde
x.html
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Scenario A
Assessment and management of shock
This 2 year old child was
rushed into the emergency
room. She had AD and had
become very unwell.
Q2. How would you proceed?
Write down your answer before
moving to the next slide!
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Scenario B
Clinical assessment of dehydration
This 2 year old child presented
with AD. She did not have features
of shock or SAM but was
assessed to have severe
dehydration.
Q4. List the 4 clinical signs
recommended for
classifying a child as
severely dehydrated
Write down your answers and then
go to the next slide
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Scenario C
Clinical assessment of dehydration
A mother brought her 2 year old male child to the
hospital because of AD. On examination, he
was irritable and his skin pinch goes back
slowly (1 second)
Q8: Write down your assessment of this child’s hydration status
Q9: List 2 other key clinical signs consistent with this degree of
dehydration
Write down your answer and then go to the next slide
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Scenario D
A child with bloody diarrhoea
A child was brought to the emergency room
because of bloody diarrhoea of 3 days duration
with associated vomiting and fever.
When examined, there were no signs of
dehydration or SAM.
Q11: What it is the most likely diagnosis in this child?
Q12: How will you treat?
Write down your answers and then move to the next slide
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Answers: Scenario D
Q11:
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This child has acute bloody diarrhoea also called dysentery
Most episodes are due to Shigella spp
The diagnostic signs of dysentery are frequent loose stools with visible red blood
Other findings in the history or on examination may include
– Abdominal pain
– Fever
– Convulsions
– Lethargy
– Dehydration
– Rectal prolapse
Q12:
All children with severe dysentery require antibiotic treatment for 5 days
– Give an oal antibiotic to which most strains of shigella in your localiity are sensitive
– Examples of antibiotics to which shigella strains can be sensitive are ciprofloxacin and other
fluoroquinolones
Also manage any dehydration
Ensure breastfeeding is continued for childen still breastfeeding and normal diet for older childen
Follow-up the child
Go to Case Scenario E
Scenario E
Clinical assessment of dehydration
This 2 year old male child was brought to the
Children’s emergency room with diarrhoea for 6
days. He had angular stomatitis, peri-anal
ulceration, weighed 7.0 kg and the MUAC was
10.2 cm.
His hands were cold, pulse weak and fast and
skin pinch went back very slowly. However, he
appeared to be fully conscious and was not
lethargic.
The resident doctor gave 140ml of normal saline by rapid IV infusion but his
condition deteriorated.
Q13: What important condition needs to be recognised in this child?
Q14: Was the doctor’s management correct?
Q15: List 2 pathophysiological mechanisms in this condition that affect
fluid management.
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Answer: scenario E - Fluid management in
children with SAM
Q13: The child has severe acute malnutrition: SAM
Q14: No. Dehydration is difficult to diagnose in SAM and it is often over
diagnosed. The doctor’s choice of IV normal saline, amount of fluid and
rapidity of given IV fluid were all incorrect and may have caused the child’s
deterioration
Q15: The pathophysiological mechanisms that affect fluid management are:
• Although plasma sodium may be very low, total body sodium is often
increased due to
– increased sodium inside cells
– additional sodium in extracellular fluid if there is nutritional oedema
– reduced excretion of sodium by the kidneys
• Cardiac function is impaired in SAM
This explains why treatment with IV fluids can result in death from
sodium overload and heart failure.
• The correct management is reduced sodium oral rehydration fluid (ORF;
e.g. ReSoMal) given by mouth or naso-gastric tube if necessary. The
volume and rate of ORF are much less for malnourished than wellnourished children (see next slide)
IV fluids should be used only to treat shock in children with SAM who are
also lethargic or have lost consciousness!
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End of clinical
scenarios
The next few slides are on how to
assess nutritional status, indications
for laboratory investigations, rational
use of antibiotics and usage of zinc
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Assessment of nutritional status
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Assessment of nutritional status is important in
children with diarhoeal disease to identify
those with severe acute malnutrition (SAM)
This is because abnormal physiological
processes in SAM markedly affect the
distribution of sodium and therefore directly
affect clinical management
In patients with SAM, although plasma sodium
may be very low, total body sodium is often
increased due to:
– increased sodium inside cells as a result
of decrease activity of sodium pumps
– additional sodium in extracellular fluid if
there is nutritional oedema
– reduced excretion of sodium by the
kidneys
A West African child with
kwashiokor
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Methods of nutritional assessment
Nutritional assessment can be done by:
• Looking for visible signs of severe
wasting such as muscle wasting and
reduced subcutaneous fat
• Looking for other signs of
malnutrition: angular stomatitis,
conjuctival and palmar pallor, sparse
and brittle hair, hypo- and
hyperpigmentation of the skin
• Looking for nutritional oedema
(pitting oedema of both feet)
• Use of anthropometry such as
Weight-for-Height z-score (WHZ; < 3.0) or Mid-Upper Arm
Circumference (MUAC < 11.5cm in
children aged 6-60 months)
Muscle wasting and loss of
subcutaneous fat in a West African child
with marasmus
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MUAC: recommended for nutritional assessment in dehydration
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MUAC is widely used in community
screening of malnutrition because
it is easy to perform, accurate and
quick
MUAC is measured using Shakir’s
strip or an inelastic tape measure
placed on the upper arm midway
between acromion process and
olecranon
Dehydration reduces weight;
MUAC was less affected by
dehydration than WFLz score in a
recent study*
*http://www.nutritionj.com/content/10/1/92
Mid-Upper Arm Circumference
(MUAC):
•<115mm: SAM
•110 - 124mm: Moderate Acute
Malnutrition (MAM)
•125 - 135mm: risk of acute malnutrition
•>135mm: child well nourished
www.motherchildnutrition.org/
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Laboratory investigations
AD is usually self-limiting and investigations to identify the infectious agent are
not required
A. Indications for stool microscopy, culture and sensitivity
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Blood and mucus in the stool
High fever
Suspected septicaemic illness
Diagnosis of AD is uncertain
B. Indications for measurement of Urea and Electrolytes
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Severe dehydration or shock
Children on IV fluid
Children with severe malnutrition
Suspected cases of hypernatreamic dehydration
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Rational use of antibiotics
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Even though bacterial pathogens are the commonest cause of AD in
developing countries, there should be cautious and rational use of
antibiotics to discourage development of microbial resistance, avoid side
effects and reduce cost
Antibiotics should be used for:
– Severe invasive bacterial diarrhoea eg Shigellosis
– Cholera
– Girdiasis
– Suspected or proven sepsis
– Immunocompromised children
Antibiotics are contraindicated in:
• E. coli 0157: H7 because they increase the risk of Haemolytic Uraemic
syndrome (HUS)
• Uncomplicated salmonella enteritis because they prolong bacteria shedding
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Zinc and diarrhoea
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Zinc deficiency is common in developing
countries and zinc is lost during diarrhoea
Zinc deficiency is associated with impaired
electrolyte and water absorption,
decreased brush border enzyme activity
and impaired cellular and humoral
immunity
Treatment with zinc reduces the duration
and severity of AD and also reduces the
frequency of further episodes during the
subsequent 2-3 months
WHO recommends that children from
developing countries with diarrhoea be
given zinc for 10-14 days
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10mg daily for children <6 months
20 mg daily for children >6 months
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How can we prevent diarrhoeal
disease?
This involves intervention at two levels:
• Primary prevention (to reduce disease transmission)
– Rotavirus and measles vaccines
– Handwashing with soap
– Providing adequate and safe drinking water
– Environmental sanitation
• Secondary prevention (to reduce disease severity)
– Promote breastfeeding
– Vitamin A supplementation
– Treatment of episodes of AD with zinc
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End of module
• Well done! You have completed this module
• Make sure that you repeat the module until you have a
good score in the assessment
• It is vital that you now apply the knowledge you have
gained from this module into your management of
children with AD
• Please do let us know if you think that there are any
ways that this module could be changed as a learning
resource that is effective in improving practice
• Please e-mail any comments to Dr. Senbanjo at
senbanjo001@yahoo.com
Authors and
acknowledgements
Authors/Acknowledgement
Authors:
Dr. Idowu Senbanjo, Lecturer/Consultant
Paediatrician, Department of Paediatrics and
Child Health, Lagos State University College of
Medicine, Ikeja, Lagos, Nigeria.
Dr. Chinlye Ch‘ng, Consultant
Gastroenterologist/Hepatologist, Abertawe
Bro Morgannwg University Health Board,
Singleton Hospital, Swansea, UK.
Prof. Steve Allen, Professor of Paediatrics and
International Health, RCPCH International
Officer and David Baum Fellow, The
College of Medicine, Swansea University, UK.
Acknowledgement
We would like to acknowledge the British
Society of Gastroenterology for awarding
an educational grant which supported Dr.
Senbanjo in developing this module.
Permissions
Please note that consent was obtained
from parents/carers to use the images in
this module for teaching purposes only.
The images should not be used for any
other purpose.
We are very interested to receive feedback regarding any aspect of this module,
especially if it helps us to improve it as a learning resource. Please e-mail any comments
to Dr. Senbanjo at senbanjo001@yahoo.com
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