Diarrhea resident survival guide (pediatrics)

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Resident
Survival
Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usman Ali Akbar, M.B.B.S.[2]

Synonyms and Keywords: Approach to diarrhea in pediatric patients, Approach to infectious causes of diarrhea, Oral Rehydration therapy in children

Diarrhea resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Diarrhea remains one of the leading causes of preventable death in developing countries, especially among children under 5 years of age. Diarrhea is defined as an increase in the number of stools such as more than three bowel movements each day or the presence of loose stools comparative to normal stool consistency. Acute diarrhea is when diarrhea occurs for less than 3 weeks in total and it is chronic when it lasts longer than three weeks. Hydration status plays an important role in the management of pediatric diarrheal illness. The risk of dehydration due to fluid and electrolyte losses is inversely proportional to the child's age hence, the younger the child, the greater is the risk of dehydration. The type of dehydration whether it is isotonic, hypotonic, or hypertonic is usually independent of the responsible agent. Fluid loss due to diarrhea and vomiting can be life-threatening if it is as high as three times the circulating blood volume (80–125–250 mL per kg body weight per day). To keep the blood volume constant, the body usually extracts fluid from the intracellular space which can predispose it to dehydration. Complications and hospitalization due to dehydration can usually be prevented by the early and adequate oral administration of a rehydration solution (glucose-electrolyte solution) and normal food for the child’s age.

Causes

Life Threatening Causes Common Causes Miscellaneous

FIRE: Focused Initial Rapid Evaluation

  • A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention:[2]


 
 
 
 
 
 
 
 
 
 
Patient presents with acute diarrhea in emergency
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild Dehydration
 
 
 
 
 
Moderate Dehydration
 
 
Severe Dehydration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Home treatment with ORS, patient prescription, and dietary recommendations
 
 
 
 
 
Is there any evidence of dehydration or >8 watery stools in 24 hours or >4 episodes of vomiting in 24 hours or <6 months old
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Give ORS by spoon or syringe according to age and weight
  • Infants 5—9 kg: 2.0 mL every minute (120 mL/hr)
  • Infants 9—12 kg: 2.5 mL every minute (150 mL/hr)
  • Toddlers 12-15 kg: 3.0 mL every minute (180 mL/hr)
  • If there is no vomiting, then larger volumes at longer intervals: 10-15 mL every 5 or 20-30 mL every 10 minutes Racecadotril in 5 mL of water)
  • <9 kg: 10 mg, 10-15 kg: 20 mg, 16-29 kg: 30 mg
 
 
 
 
Intensive Care
 
 
 
 
 

Complete Diagnostic Approach

 
 
 
 
 
 
 
 
Patient with history of diarrhea
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild Dehydration
There are no specific signs and symptoms
 
 
Moderate Dehydration

Initially, the signs and symptoms that develop include:
- Thirst
- Restless or irritable behavior
- Decreased skin turgor
- Sunken eyes
- Sunken fontanelle

(in infants)
 
Severe Dehydration
[5]

These effects become more pronounced and the patient may develop evidence of hypovolaemic shock including:
- Diminished consciousness
- Lack of urine output
- Cool moist extremities
- Rapid and feeble pulse (the radial pulse maybe undetectable)
- Low or undetectable blood pressure
- Peripheral cyanosis.

Death follows soon if rehydration is not started quickly
 

Treatment

 
 
 
 
 
 
 
 
 
 
Patient presents with acute diarrhea in emergency
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild Dehydration
 
 
 
 
 
Moderate Dehydration
 
 
Severe Dehydration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Children with no signs of dehydration are given extra fluids and salts to replace losses due to diarrhea.[7]

Following fluids can be given in such cases:

  • ORS
  • Salted drinks eg. salted rice water or salted yogurt drink
  • Vegetable or chicken soup with salt
  • Home-based ORS: 3 gm of table salt and 18 gm of common sugar in one liter of water.
  • Plain water should also be given.
  • Commercial carbonated beverages, fruit juices, sweetened tea, coffee, medicinal tea should be avoided.
 
 
 
 
 
Oral rehydration therapy for children with moderate dehydration:
  • ORS + Zinc supplementation should be started
  • After 4 hours, reassess the child and decide what treatment needs to be given next as per the Grade of dehydration.
  • Children who continue to have dehydration even after 4 hours should receive ORS by nasogastric tube or RL intravenously (75 ml/kg in 4 hours).
  • If abdominal distension, then oral rehydration should be withheld and only IV rehydration should be given.
  •  
    *Start IV fluids immediately.
  • If the patient can drink, give ORS by mouth until the drip is set up.
  • Give 100 ml/kg Ringer Lactate solution divided as follows:
  • First, give 30 ml/kg and then give 70 ml/kg in infants (under 12 months) in 1 hour.
  • Reassess the patient every 1-2 hours.
  • If hydration is not improving, give the IV drip more rapidly as follows:
  • After six hours (infants) or three hours (older patients), evaluate the patient using the assessment chart.
  • Then choose the appropriate Treatment Plan (A, B or C) to continue the treatment.
  •  

    Do's

    Don'ts

    References

    1. "Diarrhoeal disease". WHO (in Afrikaans). Retrieved 2020-12-15.
    2. Koletzko, Sibylle; Osterrieder, Stephanie (2009-09-25). "Acute Infectious Diarrhea in Children". Deutsches Ärzteblatt International. 106 (33). doi:10.3238/arztebl.2009.0539. PMID 19738921. Retrieved 2020-12-15.
    3. https://apps.who.int/iris/bitstream/handle/10665/43209/9241593180.pdf;jsessionid=E1E068378A53790D37702AB3086551B4?sequence=1
    4. http://www.doiserbia.nb.rs/img/doi/0370-8179/2015/0370-81791512755R.pdf
    5. Parker, Michelle W.; Unaka, Ndidi (2018-08-01). "Diagnosis and Management of Infectious Diarrhea". JAMA pediatrics. American Medical Association (AMA). 172 (8): 775. doi:10.1001/jamapediatrics.2018.1172. ISSN 2168-6203. PMID 29889925.
    6. https://apps.who.int/iris/bitstream/handle/10665/43209/9241593180.pdf;jsessionid=E1E068378A53790D37702AB3086551B4?sequence=1
    7. Vega, Roy M.; Avva, Usha (2020-08-08). "Pediatric Dehydration". NCBI Bookshelf. PMID 28613793. Retrieved 2020-12-15.
    8. Camilleri, Michael; Sellin, Joseph H.; Barrett, Kim E. (2017). "Pathophysiology, Evaluation, and Management of Chronic Watery Diarrhea". Gastroenterology. Elsevier BV. 152 (3): 515–532.e2. doi:10.1053/j.gastro.2016.10.014. ISSN 0016-5085.
    9. Aranda-Michel, Jaime; Giannella, Ralph A (1999). "Acute diarrhea: a practical review". The American Journal of Medicine. Elsevier BV. 106 (6): 670–676. doi:10.1016/s0002-9343(99)00128-x. ISSN 0002-9343.