Management of acute diarrhea is being discussed in the following headings:
• Management of dehydration
• Drug therapy in diarrhea
• Dietary management.
MANAGEMENT OF DEHYDRATION
As per the World Health Organization (WHO) recommendation, the following is the protocol of fluid therapy in dehydration.
Plan A: Prevention of Dehydration
• The mother should continue to breastfeed her baby frequently and for longer periods at each feed
• A child who is being exclusively breastfed should be given oral rehydration solution (ORS) or plain clean water in addition to breast milk
• A child who is not exclusively breastfed may be given ORS solution, soup, rice/dal water, rice kanji, coconut water, barley water, curd/yoghurt, lassi
Management of
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• The amount of ORS to be given to the baby should be 50–100 mL after each loose stool in a child aged less than 2 years or 100–200 mL in a child aged greater than 2 years
• The mother must be taught how to prepare ORS at home. She may also be told that this may be given as frequent small sips from a cup. If the child vomits, the ORS may be repeated after 10 minutes slowly and she should continue to give this until diarrhea stops
• Along with the oral rehydration therapy (ORT), the mother should be given instructions to give zinc supplement in the dose of 10 mg in babies less than 6 months and 20 mg in babies above 6 months per day for 10–14 days
Plan B: For Children with Physical Signs of (Some) Dehydration
• The child should be given ORS in the first 4 hours at the rate of 75 mL/kg. In case, weight of the baby is not available then the calculation may be done as in table 1
• If after 4 hours the child is still dehydrated, then same amount of ORS may be repeated. The phase of rehydration usually lasts for 6–8 hours
TABlE 1
Amount of oral rehydration solution to be given during first 4 hours according to age/weight
Age Up to 4 months 4–12 months 12 months to
2 years 2–5 years
Weight <6 kg 6–10 kg 10–12 kg 12–19 kg
Amount 200–400 400–700 700–900 900–1,400
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• After 4–6 hours, the child should be reassessed for the degree of dehyd ra tion and then put on the appropriate plan (A, B, C) for further management
• When baby is being sent home from the hospital/clinic, the mother must be educated and instructed regarding preparation and administration of the ORS, continuing feeding at home, danger signs of dehydration and revisit to the hospital in case they are present, provision of normal daily fluid requirements.
Plan C: For Children with Signs of Severe Dehydration
• Intravenous (IV) fluids should be started immediately, as any delay can lead to hypovolemic shock. The child should be offered ORS by mouth while the drip is being setup or when the child is able to drink by mouth, even when on IV fluid therapy.
The details of the amount and type of IV fluids are described later in this chapter
• In situations where IV access fails due to very poor perfusion, one must consider the intraosseous route
• Oral rehydration solution via nasogastric route may be used if intraosseous access also fails. Monitoring is very essential during the IV therapy
• All such children should be started on ORS ad lib as soon as they are able to drink, even during the course of IV fluid therapy
• Once severe dehydration has been taken care of, the child may be shifted to Plan A or Plan B depending upon the degree of dehydration. If the child is still unable to accept well orally and is vomiting or the purge rate is very high (0.5 mL/kg/hour) or has an associated systemic infection, then IV fluids would need to be continued as maintenance therapy (Figure 1).
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Figure 1 Treatment algorithm of severe dehydration [World Health Organization (WHO)].
IV, intravenous; ORS, oral rehydration solution.
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ORAl REHYDRATION THERAPY
This is done with the help of ORS, sugar-salt solution, food-based solutions, commonly available and culturally acceptable fluids.
About 90% of children with diarrhea have no dehydration at the time of their first presentation. Another 8–9% has only mild-to- moderate dehydration. Hence 98–99% of children with simple watery diarrhea can be safely rehydrated with ORS alone or other types of oral rehydration fluids, for example, sugar-salt solution (contains 40 g of sugar and 4 g of salt per liter of water), rice water with salt (contains approximately 55 g of rice and 4 g of salt per liter of water), lassi with salt, coconut water, shikanji (lemonade), soups, thin rice kanji, dal water without salt, and plain water.
Oral Rehydration Solution
Glucose electrolyte solution used orally for rehydration and maintenance was initially developed to replace diarrheal fluid losses in cholera and to reduce the need for IV fluids in developing countries. Its scientific basis rests on the fact that glucose linked enhanced sodium absorption in the small intestine remains largely intact during acute diarrhea inspite of mucosal damage or secretory intestinal pathology. Apart from glucose, sodium cotransport occurs with oligosaccharides (maltodextrins), disac charides (sugar), and starch (rice), as they all release glucose after hydrolysis. Others like amino acids, i.e., glutamine, glycine, and alanine are also known to stimulate sodium absorption. In fact, as these food components are hydrolyzed slowly in the intestinal lumen, they tend to cause lesser osmotic load and hence prove to be more efficient promoters of absorption. If a child is accepting food, then along with it plain water also can be given to prevent the dehydration while maintaining nutrition.
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Types of Oral Rehydration Solution
• World Health Organization (WHO) United Nations International Children’s Fund (UNICEF) ORS
• Low osmolarity ORS
• ReSoMal for severely malnourished children
• Super ORS rice-based maltodextrin, L alanine, L glutamine based.
Initially, the WHO and UNICEF formulated a glucose-based oral dehydration solution (G-ORS) to treat and prevent dehydration due to diarrhea of all causes. This remained in vogue for nearly 25 years.
Later, however, a WHO task force worked on a reduced osmolarity ORS containing 75 mEq/L sodium and 75 mmol/L glucose (total osmolarity 245 mmol/L) and recommended it as a universal solution for prevention and treatment of diarrheal dehydration to replace the earlier WHO-ORS in all types of diarrheas and at all ages. This recommendation came as a result of studies showing improved efficacy of this ORS in non-cholera diarrhea in infants and children and also with a comparable efficacy in adults with cholera. There was only a marginally elevated risk of asymptomatic hyponatremia.
It further carries the programmatic advantage of providing a single formulation for treatment and prevention of all types of diarrheas.
A range of acceptable ORS formulations are shown in table 2.
The following are the special considerations while treating diarrhea in malnourished children:
• High sodium content of the WHO-ORS may lead to fluid and electrolyte disturbances in the child with severe malnutrition, especially in those with edema
• Dehydration tends to be overdiagnosed and its severity is overestimated in severely malnourished children
• WHO has recommended that the IV route should not be used for rehydration of severely malnourished children, except in cases of shock
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TABlE 2 Composition of current and recommended oral rehydration salt solutions CompositionGlucose (mmol/L)Na+ (mmol/L)K+ (mmol/L)Cl– (mmol/L)Citrate (mmol/L)Magnesium (mmol/L)Zinc (mmol/L)Copper (mmol/L) Standard WHO-ORS (311 mmol/L)11190208010 Reduced osmolarity WHO-ORS (245 mmol/L)
7575206510 ESPGAN recommendation606020703 ReSoMal for severely malnourished children 1254540707330045 WHO, World Health Organization; ORS, oral rehydration solution; ESPGAN, European Society for Pediatric Gastroenterology and Nutrition; Na+, sodium; K+, potassium; Cl–, clorine.
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• Severely malnourished children have low total body potassium content which may lead to increased mortality. Potassium concentrations of the standard WHO-ORS may be too low to supplement adequately the low potassium levels and also to replace stool losses during diarrhea. Therefore, the WHO recommended a new formulation with sodium concentration of 45 mEq/L and potassium of 40 mEq/L which also provide buffered magnesium, zinc, and copper (ReSoMal), and is recommended by WHO for use in severely malnourished children
Super-oral Rehydration Solution and Rice-based Oral Rehydration Solution
Rice powder is predominantly starch (polysaccharide) and some amount of protein. In diarrhea, amylase activity in the intestine is normal. Amylase acts on starch and gradually breaks it down to oligosaccharides and finally to monosaccharide glucose. This process supplies a large number of glucose molecules. However, rather than all these glucose molecules being supplied at one time (as in a standard G-ORS), in rice-based ORS, the polysaccharides are broken down to glucose only gradually. Thus, there is no big osmotic load as may occur with G-ORS.
The protein in the rice powder is broken by the proteases into oligopeptides. The oligopeptides are further broken down into peptides and amino acids. As has been pointed out earlier, a sodium amino acid cotransport mechanism also exists, which is similar to the glucose sodium cotransport mechanism. This also increases sodium absorption.
When can Oral Rehydration Therapy Be Stopped?
Oral rehydration therapy can be stopped as soon as abnormal losses of diarrheal stool are under control.
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Oral rehydration therapy should also not be used in following conditions as it is usually unsuccessful in these conditions:
• Very high purge rate (>10 mL/kg/hour stool fluid losses)
• Persistent vomiting
• Severe acidosis/severe dehydration
• Convulsions/abdominal distension
• Septicemic illness
• Glucose-galactose intolerance (rare)
• Severe dyselectrolytemia (occasional success stories of ORS, not with standing).
In these cases, rehydration must be by IV fluids.
Oral Rehydration Therapy in Newborns
Diarrhea in newborns may be due to two reasons. One, in which a normal breastfed baby has an increased frequency (normal increased frequency), and the other, in which it is due to a systemic bacterial illness like septicemia, meningitis, etc. Use of ORT in both these conditions is not indicated. In the first instance, it is not required (and may lead to sodium and water retention), and in the second instance, immediate hospitalization and management with IV fluids and antibiotics is what is actually needed. Delay in hospitalization, because of the temptation to use ORT at home, can be dangerous in this situation.
Some Practical Aspect of Oral Rehydration Therapy
Nonacceptance or refusal to take ORS is a very common problem.
This may be because the child is not really dehydrated. However, if the child is dehydrated but not accepting ORS then it must be assessed for a systemic infection and given IV antibiotics.
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Vomitings are also frequently associated in children with diarrhea, and because of this, the child may not be able to accept ORS. Vomits are more likely to occur if the child is allowed to take gulps of ORS from a glass/cup. Small sips given frequently are usually well retained and these should be offered in cases of vomiting.
There is no need of boiling water for making ORS or boiling it after mixing ORS. If a fridge is available then a prepared solution can be kept up to 12 hours.
INTRAVENOUS REHYDRATION
This is done by use of the following IV fluids (Table 3):
• Ringer’s lactate/Ringer’s lactate with 5% dextrose (most preferred)
• Normal saline (0.9% NaCl)
• N/2 saline—replacement of stool losses.
TABlE 3
Composition of intravenous solutions
Fluid Sodium
(Na+) Chlorine
(Cl–) Potassium
(K+) Calcium (Ca2+) Lactate Normal saline
(0.9% NaCl) 154 154 – – –
Half normal saline
(0.45% NaCl) 77 77 – – –
One-fourth normal
saline (0.225% NaCl) 38.5 38.5 – – –
Ringer’s lactate 130 109 4 3 28
Electrolyte
phosphorous 26 22 19 – –
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EMERGENCY REPLACEMENT IN HYPOVOLEMIC SHOCK
This is done by giving the IV fluids as in table 4.
The child should be reassessed every 15–30 minutes. If hydration status is not improving then the child may be given IV drip more rapidly. Also, the child should continue to get ORS (5 mL/kg/hour) as soon as the child can drink.
The child should be assessed after 3 hours and in infant after 6 hours. Dehydration may be classified afresh and the appropriate plan (A, B, or C) should be continued.
INTRAOSSEOUS INFUSION
In an emergency where due to shock the veins are collapsed and not accessible, intraosseous infusion will need to be given into the bone marrow. The preferred site is the proximal tibia as shown in figure 2.
A needle of 15–18 gauge (or if not available even a 21 gauge needle or any large bore needle) is used. The needle is inserted at 90° angle with the bevel pointing toward the foot and pushed gently but firmly with drilling or twisting motion. It is stopped being pushed when there is a sudden decrease in resistance or
TABlE 4
Protocol of giving intravenous (IV) fluids in hypovolemic shock
Age First 30 mL/kg Then 70 mL/kg
<12 months Over 1 hour* Next 5 hours
>12 months Over 30 minutes* Next 2½ hours
*Repeat again, if pulse is weak or still not detectable.
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blood is aspirated by a 5 mL syringe. Using another 5 mL syringe prefilled with normal saline, 3 mL of this fluid is injected slowly to confirm that there is no leakage or infiltration. The needle is then secured into position and IV fluid is given through the infusion equipment. The intraosseous infusion should be stopped as soon as the venous access is available and should not continue for more Figure 2 Intraosseous infusion—infusion needle placed in the anterior surface of the leg at the junction of the upper and middle third of the tibia.
Source: World Health Organization. Pocket Book of Hospital Care for Children:
Guidelines for the Management of Common Illnesses with Limited Resources, illustrated edition. Mumbai, India: Medica Press International; 2005. pp. 122-30.
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than 8 hours. Complications include incomplete penetration of the bony cortex (infiltration occurs under the skin), penetration of the posterior bone cortex (calf becomes tense), and infection (local cellulitis).
MAINTENANCE THERAPY BY INTRAVENOUS FLUIDS
This would be needed if the child has vomiting and unable to accept well orally or the purge rate is very high or has systemic infections.
The amount of maintenance fluid needed is as in tables 5 and 6.
Maintenance Electrolytes
• Sodium: 2–3 mEq/kg/24 hour
• Potassium: 1–2 mEq/kg/24 hour.
TABlE 6
Maintenance fluid requirements based on age
Age mL/kg/2 hour Age mL/kg 24 hour
10 days to 3 months 150 1–3 years 100
3–6 months 130 3–7 years 80
6 months to 1 year 120 >7 years 60
TABlE 5
Body weight method for calculating maintenance fluid volume Body weight Fluid per day
0–10 kg 100 mL/kg
11–20 kg 1,000 mL + 50 mL
>20 kg 1,500 mL +20 mL/kg for each kg >20 kg
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Calculating Rate of Infusion
The IV Fluids need to be given accurately and this can be monitored.
If a syringe pump is available, then this monitoring is done digitally.
Otherwise, this can be done by counting the drops per minute. The calculation is as per the formula given below:
Total volume to be given in mL Rate in mL/hour.
Duration in hours =
As the microtipped IV set is designed to provide 60 drops in 1 mL, the rate in mL/hours equals the drops per minute. An example of this is that if 480 mL of IV Fluid is required in 24 hours then the rate of infusion will be:
Total volume to be given in mL 480 mL 20 mL/hour.
Duration in hours =24 hours=
Breastfeeding should be continued to prevent dehydration
Babies not exclusively breastfed should be given oral rehydration fluids
Zinc supplements should be given along with oral rehydration
In severe dehydration, parenteral fluids should be started based on body weight or age
Ringer’s lactate/Ringer’s lactate with 5% dextrose is the fluid of choice for parenteral rehydration.
KEY MESSAGES
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It needs to be emphasized that diarrhea-like fever is only a symptom and not a disease per se. It can be caused by a number of factors and by different pathogenetic mechanisms. It is important to identify the underlying cause and to treat the same rather than to take action for stopping the symptom of diarrhea. In majority of cases, acute