Childhood Diarrhea

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It is responsible for nearly 2 million deaths of children under 5 each year in the developing world. Faeces immediately after feeding by babies 3-6 months old: This is due to exaggerated gastrocolic pattern, quite normal at this stage and does not require any treatment.

Causes and Mechanisms of Diarrhea

The presence of intestinal helminthes in the feces of cases of acute diarrhea simply reflects their high prevalence in the population. Therefore, disorders that interfere with absorption in the small intestine tend to produce voluminous diarrhea.

Pathogenesis of Diarrhea

Due to a deficiency of the lactase enzyme, lactose is not absorbed in the small intestine and reaches the large intestine intact. Inflammatory disorders typically cause extraintestinal symptoms, such as fever, arthritis, anemia, leukocytosis, and/or blood or mucus in the stool.

Clinical Diagnosis of Diarrhea

The presence of fever in a child with acute diarrhea may provide some information and may indicate the need for special evaluation. A child with isolated or persistent vomiting should be considered for a disorder outside the gastrointestinal tract (throat, chest, meninges, liver, urinary tract, etc.) rather than within the gastrointestinal tract itself.

Physical Examination

The choice of fluid therapy also depends on the severity and type of dehydration. Weight loss is also a very sensitive indicator, provided the premorbid weight of the child is available. Children with some degree of dehydration are irritable, but they are alert and eager to drink fluids, and on the other hand, severely dehydrated children are lethargic, apathetic and unwilling to drink fluids.

Hyponatremic dehydration: This occurs when children with diarrhea drink too much water or hypotonic fluids that contain very low amounts of sodium or other solutes. Children with body weight between 60% and 80% of expected (mild-to-moderate malnutrition) can be managed as normal malnourished children with extra attention to nutritional intake. On the other hand, severely malnourished children (<60% body weight) with diarrhea would require hospitalization.

Tests for the presence of toxins in organisms cultured from feces, eg, isolated rabbit ileal loop dilation or GM1, enzyme-linked immunosorbent assay (ELISA), etc.

Figure 1 Signs of dehydration in a child.

Laboratory Investigations

In children with watery diarrhea with fever and/or with dehydration and in children with mucoid diarrhea, examinations may be necessary. However, if blood does not disappear even after 48 hours of appropriate antibiotic therapy, it may be worth doing a routine stool examination to rule out an occasional case of acute amebiasis. Stool cultures are of virtually no value in the clinical management of children with shigellosis and therefore stool cultures are not required.

Although only one-third of the cases of dysentery can be caused by Shigella group organisms, the other organisms must nevertheless also be treated along the lines of Shigella dysentery. When systemic infection is suspected based on localizing signs/symptoms and/or persistent pyrexia, appropriate investigations can be carried out, viz. urine routine, culture, blood culture X-ray, colony stimulating factor (CSF), etc. In children with watery diarrhoea, with fever and/or dehydration, and in case of mucoid diarrhea or where systemic infection is suspected, examinations may be necessary.

A child who is not exclusively breastfed can be given ORS solution, soup, rice water/dal, rice kanji, coconut water, barley water, curd/yogurt, lassi.

Management of Acute Diarrhea

If the child is vomiting, the ORS can be repeated slowly after 10 minutes and should be continued until the diarrhea stops. The child should receive ORS at a dose of 75 ml/kg in the first 4 hours. If the child is still dehydrated after 4 hours, the same amount of ORS may be repeated.

After 4–6 hours, the child should be reassessed for the degree of dehydration and then placed on the appropriate plan (A, B, C) for further management. High sodium content of the WHO-ORS can lead to fluid and electrolyte disturbances in the severely malnourished child, especially in those with edema. If hydration status does not improve, the child may be given a faster IV drip.

The child should also continue to receive ORS (5 ml/kg/hour) as soon as the child can drink.

Figure 1 Treatment algorithm of severe dehydration [World Health Organization (WHO)].

Drug Therapy in Diarrhea

Routine empiric use of antibiotics for infectious diarrhea should be avoided because of the self-limited nature of most cases. Antimicrobial agents used to treat bloody diarrhea If possible, the choice of antibiotic should be based on recent susceptibility data of Shigella strains isolated in the area. If information on local strains is not available, data from nearby areas or from recent regional epidemics should be used.

It is recommended that these second-line drugs be used only if local Shigella strains are known to be resistant to ciprofloxacin. If there is minimal or no improvement after 2 days, resistance to the initial antimicrobial agent is considered to be present and should be discontinued. When initial symptoms persist even after discontinuation of the antibiotic in question or in patients with moderate to severe disease, treatment with metronidazole (oral or intravenous) should be given.

Recurrences of infection are seen in up to 33% and should be treated as initial therapy with metronidazole as the drug of choice.

Dietary Management

Along with this child's usual diet, he should be given plenty of plain water. Contrary to popular belief, most children tolerate small amounts of fats and oils which are rich sources of energy and diarrhea does not get worse. In about 5% of cases of acute diarrhea in the community, the illness may last more than 2 weeks or 3 weeks, due to persistent colonization of the upper small intestine by microbes, dietary allergies (especially in very young infants) and carbohydrate intolerance (because of intestinal damage resulting in low levels of disaccharidases).

Infants and children with reduced host immunity, such as after an attack of measles, or delayed repair of intestinal damage due to protein-energy malnutrition (PEM) are more prone to prolonged diarrhea. Younger babies who are weaned too early develop intolerance to food proteins such as cow's milk or even soy milk. Protozoal infections with Giardia lamblia or Entamoeba histolytica and inadequate treatment of acute diarrhea are other important causes.

A study has shown that 10% of even rotavirus diarrhea can last as long as 21 days but may not have other clinical problems.

Persistent/Protracted/Recurrent/

Chronic Diarrhea

If the child is given semi-diluted milk for a few days, gradually increasing the concentration of the milk given over the next week, most cases of long-term diarrhea will improve. Malnutrition: While malnutrition prolongs the duration of diarrhea, diarrhea itself contributes to worsening nutritional status, setting up a vicious cycle of malnutrition-diarrhea-malnutrition. It is for this reason that adding zinc to therapeutic regimens has helped to control and prevent diarrhea.

In these babies, the exclusion of cow's milk in all forms of maternal death leads to relief. In children aged 6 months to 2 years, the most common causes may be giardiasis, cow's milk allergy and celiac disease. These supplements should be given every day at a dose of two recommended daily allowances (RDA).

If the child's condition improves, he can gradually increase the amount of milk and other foods in his diet.

Figure 1 Chronic diarrhea: management algorithm.

Celiac Disease

It is more frequently diagnosed in India due to wheat becoming a large part of the food menu. It usually manifests itself in children after infancy, as the introduction of gluten-containing foods occurs in such children. The symptoms are chronic diarrhoea, failure to thrive, pallor and short stature as common features.

Tentative diagnosis is by obtaining positive immunoglobulin A (IgA) isotype serological markers, serum antigliadin (AGA), tissue transglutaminase antibody (tTG) or anti-endomysial antibody (EMA). The control is by complete withdrawal of wheat and other sources of gluten (e.g. rye, barley) for life. This can be self-destructive and increases the risk of non-Hodgkin's intestinal lymphomas and.

A Swedish study showed that the possible cause of increased incidence of celiac disease could be due to early cessation of breastfeeding and early introduction of cereals.

Lactose Intolerance

Typical is frequent, loose, watery stools, often with excessive flatus and associated with urgency that occurs several hours after the ingestion of lactose-containing substances. Bloating, abdominal pain and flatulence that occur one to several hours after ingesting milk or dairy products may indicate lactose intolerance. A reduced pH (<5.5) in freshly passed feces (within 15-30 minutes) is usually sufficient to diagnose lactose intolerance.

This is done by challenging the patient after a fast with 2 g/kg (up to 50 g) of lactose. If blood glucose does not increase more than 20 mg/dL and symptoms develop, a diagnosis of lactose intolerance is likely. Reducing dietary lactose instead of completely eliminating it often helps to overcome the problem.

Mild lactose intolerance is seen in most watery diarrheal episodes in the first 2 to 3 days, but is of little significance.

Cow’s Milk Protein Intolerance

Vaccination against cholera was first tested in the 19th century and played a role in controlling epidemics. An effective oral bivalent whole-cell cholera vaccine against Vibrio cholera O1 and O139 has been used in Vietnam since the 1990s. Results of studies have shown that the vibriocial antibody response rate was 80% in children and 53% in adults.

Vaccines Against Diarrheal Diseases

It is recommended to be given in two doses 15 days apart in children over 1 year old, the vaccination to be repeated after 3 years. It should be noted that cholera vaccines are only effective in endemic situations. It is in the form of a lyophilized powder to be reconstituted with the liquid diluent before oral administration.

The vaccine should be given in two doses, the interval between these doses being at least 4 weeks. The earliest dose that can be given is 6 weeks and the latest time for this first dose is 12 weeks. However, the IAP is of the opinion that if the RV1 vaccine is to be administered in a 2-dose schedule, the first dose should start at 10 weeks of age instead of 6 weeks in order to achieve a better immune response.

Giving the vaccine after 8 months of age may pose a risk of intussusception and is therefore not recommended after this age.

Bibliography

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