When you have completed this unit you should be able to: Define and diagnose diarrhoea. Understand the importance and danger of diarrhoea. List the causes and complications of diarrhoea. Diagnose and grade the severity of dehydration. Manage diarrhoea. Treat dehydration. Prevent diarrhoea.
Yes, it is one of the commonest problems in childhood throughout the world.
Diarrhoea (or diarrhoeal disease) is defined as the passage of frequent, loose, watery stools at least 3 times a day. Diarrhoea is not a single condition but simply a clinical sign, which has many different causes. With diarrhoea excessive amounts of water and electrolytes (salts such as sodium and potassium) are lost into the stool.
Infants under 6 months of age Malnourished infants Children with AIDS
Yes, diarrhoea is common and may be the presenting sign in children with HIV infection. In children with HIV infection, diarrhoea is not only more frequent but also more severe and takes longer to recover. Diarrhoea is often persistent in children with HIV infection and is a common cause of death.
Diarrhoea is commoner and more severe in children with malnutrition (i.e. undernutrition). Therefore malnourished children often have persistent or repeated diarrhoea. In addition, malnourished children are more likely to develop severe diarrhoea and die from it. There is therefore a close relationship between diarrhoea and malnutrition. Diarrhoea is both common and more severe in children [...]
Diarrhoea usually recovers within 7 days. However, if diarrhoea does not recover by 2 weeks (14 days), it is called persistent (prolonged or chronic) diarrhoea. Persistent diarrhoea is common in malnourished children and children with HIV infection. Diarrhoea for more than 14 days is persistent diarrhoea.
Acute diarrhoea is watery diarrhoea which lasts less than 2 weeks (14 days). Acute diarrhoea is usually due to gastroenteritis (an acute infection of the bowel). Often the term gastroenteritis and acute diarrhoea are used interchangeably. However, acute diarrhoea is not always caused by an infection of the bowel but can also result from an [...]
Gastroenteritis (or acute diarrhoeal disease) is an acute infection of the bowel resulting in watery diarrhoea without visible blood or mucus in the stool. It is caused by a wide range of organisms which interfere with the normal functioning of the cells that line the bowel wall, resulting in loss of water and electrolytes into [...]
Carbohydrate intolerance especially lactose intolerance. Protein intolerance especially cow’s milk protein intolerance. Both lactose intolerance and cow’s milk protein intolerance usually cause persistent diarrhoea following earlier damage to the bowel caused by gastroenteritis. Diarrhoea due to carbohydrate induced intolerance may be caused by the excessive intake of fruit juice especially apple juice (fructose intolerance).
Infections of the bowel: Viruses, such as Rota virus and measles. Rota virus is the commonest cause of diarrhoea in children. Bacteria, such as E. coli (Eschericia coli), Shigella, Salmonella, Campylobacter and Cholera. Protozoa (small one-celled organisms), such as Giardia, Amoeba and Cryptosporidium. Infections outside the bowel: Children with bacterial infections, such as otitis media, [...]
The 2 commonest causes of diarrhoea are: Gastroentestinal infections Food allergy or intolerance Less common causes of diarrhoea include food poisoning (bacterial toxins), a side effect of antibiotics (bacterial overgrowth), some drugs which increase gut motility, coeliac disease and cystic fibrosis (malabsorption).
Yes. Diarrhoea can be life threatening if it is severe. Diarrhoea causes a loss of fluid and electrolytes in the stool, which can result in dehydration and electrolyte imbalance. The correct management of diarrhoea is important as diarrhoea is one of the leading causes of death in children, especially in poor countries. Each year about [...]
Some bacteria which cause diarrhoea, can invade the bowel wall and spread into the blood stream resulting in septicaemia. Septicaemia usually complicates diarrhoea with infections caused by Salmonella, Shigella and Campylobacter. Septicaemia is commoner in dysentery than in watery diarrhoea. Typhoid is a septicaemia caused by a bowel infection with Salmonella typhi. These children are [...]
Dysentery is a form of diarrhoea where the stool is not simply watery, but also contains visible blood and mucus. Dysentery is usually caused by organisms which invade and damage the bowel wall. These children usually look ill (toxic) and have a high temperature. Dysentery is usually caused by Shigella, Salmonella, Campylobacter, Amoeba and some [...]
Cholera is a severe, highly infectious form of watery diarrhoea which is common in undeveloped countries. Cholera occurs in epidemics as has happened in some areas of South Africa in recent years. It is caused by a bowel infection with Vibrio cholerae. The stools in cholera as typically watery with small pieces (flecks) of mucus [...]
The normal skin turgor is the elasticity (stretch) which enables skin to rapidly return to its previous position after it is gently pinched into a tent shape for 2 seconds. Normally skin returns to its position immediately after being pinched and then released. With decreased skin turgor, the skin takes longer than normal to return [...]
Dehydration develops when excessive amounts of fluid are lost from the body. Diarrhoea can rapidly lead to dehydration, especially if vomiting is also present. Both the history and the clinical examination are important in assessing whether a child is dehydrated. In all children with diarrhoea the following signs must be looked for: Offer the child [...]
Dehydration Shock Acidosis Electrolyte loss Ileus Hypoglycaemia Septicaemia Malnutrition Severe dehydration is the commonest cause of death in infants with diarrhoea and by far the most important complication. Dehydration is the most important complication and the commonest cause of death in infants with diarrhoea.
The most important sign of shock is a delayed capillary filling time of more than 3 seconds. The capillary filling time is measured by pressing on the sole of the child’s foot or palm of the hand, then releasing the pressure and counting how many seconds it takes for the pale area to regain its [...]
Shock (hypovolaemic shock in dehydration) is the failure of the heart to maintain adequate circulation due to the loss of fluid. With excessive fluid loss in the stools, the volume of fluid in the circulation falls and there is not enough fluid to allow normal blood flow to the small capillaries of the body. As [...]
Weight loss is the best measure of the degree of dehydration. Unfortunately the child’s weight at the onset of the diarrhoea is often not known. Therefore, this method of assessing the degree of dehydration is only of limited use. With ‘some’ dehydration, less than 10% of body weight is lost while 10% or more of [...]
All children with diarrhoea must be examined for signs of dehydration. The degree of dehydration can be roughly assessed clinically into ‘no visible’ dehydration, ‘some’ dehydration or ‘severe’ dehydration. This is important as it is essential to identify children with severe dehydration. ‘No visible’ dehydration: The child has no signs of dehydration or not enough [...]
Repeated, severe vomiting A markedly distended abdomen Bile stained vomiting Passing a lot of blood and mucus with little stool Severe, continuing abdominal pain (not just intermittent cramping pains) These children must be referred to hospital urgently for further investigation.
Some infants with diarrhoea appear very ill and have bacteria circulating in their blood. This is called septicaemia. Septicaemia should be suspected if the child has a high temperature (pyrexia) or appears a lot sicker that you would expect for the degree of dehydration or does not improve after the dehydration is corrected. Septicaemia is [...]
Hypoglycaemia in children is defined as a blood glucose concentration of less than 3 mmol/l. Severe diarrhoea, especially in malnourished children who refuse feeds or have severe vomiting, may cause hypoglycaemia. This can result in loss of consciousness or convulsions. Hypoglycaemia must always be suspected in children with diarrhoea who have fits or a decreased [...]
Ileus is distension of the abdomen due to a decrease or absence of the bowel movements (peristalsis). No bowel sounds can be heard. This lack of peristalsis is due to infection and loss of potassium. Ileus usually does not cause abdominal pain or bile stained vomiting.
Children with diarrhoea lose both fluid and electrolytes in the stool. Important electrolytes which are lost include sodium, potassium, calcium, magnesium, chloride, phosphate, and bicarbonate. Electrolytes are also lost with excessive vomiting. Children with diarrhoea lose excessive amounts of fluid and electrolytes in the stool. An electrolyte imbalance (too much or too little of one [...]
With poor peripheral perfusion due to shock, many cells in the body no longer receive enough oxygen and, therefore, are no longer able to produce energy by fully breaking down carbohydrates and fats. This failure of metabolism results in the formation and accumulation of lactic acid, which causes metabolic acidosis. Metabolic acidosis is made worse [...]
There are a number of different brands of commercially available oral rehydration solution (e.g. Sorol). They all contain a balanced mixture of electrolytes and water together with glucose. They are usually sold in the form of a powder which is packaged in a sachet (small packet). One sachet of powder should be mixed in one [...]
Oral rehydration solution (ORS) is a mixture of water, electrolytes (salts) and glucose which is given by mouth to provide energy and replace the fluid and electrolytes which have been lost. Oral rehydration solution can be: Bought commercially. Made up in the home as a sugar and salt solution.
Oral rehydration therapy (ORT) is the most important part of managing acute diarrhoea and saves the lives of millions of children worldwide each year. ORT consists of giving oral rehydration solution by mouth early in acute diarrhoea to prevent or treat dehydration. Give frequent small sips from a cup. Oral rehydration therapy saves million of [...]
Children with mild diarrhoea and no visible signs of dehydration can be treated at home with continuing feeds and oral rehydration solution. If the diarrhoea becomes worse or does not recover in 2 days the child must be seen at a clinic. Children who refuse to drink or who vomit repeatedly must be taken to [...]
Infants with acute diarrhoea may vomit. However, the vomiting usually stops once the dehydration is corrected. If the oral rehydration solution is vomited, a smaller amount should be given slowly about 10 minutes later. The best way to avoid vomiting is to give small sips of fluid frequently by cup. If severe vomiting continues, a [...]
Most cases of acute diarrhoea are caused by a virus and do not respond to antibiotics. Indication for antibiotics are: Suspected septicaemia (very ill with a high fever) Small infants (under 1 month) Severely malnourished children Dysentery (blood in the stools) Suspected cholera Infants who are sick enough to receive antibiotics should be referred to [...]
Medicine is usually not necessary and may even be dangerous in small children. Anti-diarrhoeal medication such as codeine, Imodium (loperamide) and Lomotil (diphenoxylate) decrease peristalsis and may cause ileus. They improve cramps in older children but do not prevent the loss of fluid and electrolytes from the gut. Medications which absorb water like pectin and [...]
If the child is already receiving solid food, this should be continued unless the child is vomiting a lot. Small feeds should be given frequently (at least every 4 hours). This is particularly important in children who are malnourished as diarrhoea can make the malnutrition rapidly worse. Extra feeds should be given while the child [...]
Although continuing milk feeds in infants may appear to make the diarrhoea worse, it is important to continue feeds as it helps to provide energy and replace fluid and electrolyte losses. Infants recover from diarrhoea faster if milk feeds are continued. Breastfeeding or full-strength formula should be used. There is no need to dilute feeds. [...]
The most important aspect of management is to start oral rehydration therapy as early as possible to prevent dehydration from occurring. Oral rehydration solution should be used. With frequent, small drinks most children with mild diarrhoea can be adequately managed without developing dehydration. Breastfeeding, formula or solid feeds should be continued unless the child has [...]
These children should be referred to hospital for investigation and treatment. Correct dehydration. An antibiotic is needed. Usually, nalidixic acid is given 6 hourly for 5 days (2.5 ml if 12 to 24 months; 5 ml if 2 to 5 years; 7.5 ml if older than 5 years). Dysentry is usually due to Shigella, which [...]
Children with persistent diarrhoea should be referred to hospital for investigation and further management. Correct dehydration if present. Offer oral rehydration solution even if the child is not visibly dehydrated. Consider HIV in any child with persistent diarrhoea. The stool should be cultured and examined under a microscope in an attempt to identify the cause. [...]
Most children with acute diarrhoea can be managed at home or at a primary care clinic. However, the following children should be referred to hospital for further management: Children with signs of severe dehydration or shock Children who have lost more than 10% of their body weight Children who continue to vomit despite being given [...]
It is best to give the oral rehydration solution frequently and in small volumes. Too much fluid at one time may cause vomiting. Give as much fluid as the child will take. Most children with no or only some dehydration will drink as much oral rehdration fluid as they need to replace the fluid lost. [...]
As soon as the diarrhoea is noticed. It is very important to start oral rehydration therapy as early as possible to prevent dehydration. The earlier it is started the quicker the child will get better. It is important to start oral rehydration therapy before taking the child to a doctor or nurse. Oral rehydration therapy [...]
Every mother or caretaker should know how to make up a sugar and salt solution and have the necessary ingredients at home. The recipe for making sugar and salt solution is given in some Road-to-Health Cards.
Home made sugar and salt solution (SSS) is not quite as good as commercial oral rehydration solution as it does not contain potassium. However, it is immediately available and often lifesaving. The commonest recipe for a sugar and salt solution is: 1 litre of clean water. 8 level teaspoons of sugar. ½ of a level [...]
These children with 2 or more clinical signs of ‘some’ dehydration should initially be managed in a clinic or hospital if possible as they can progress to ‘severe’ dehydration: They can be treated with oral rehydration solution with a close watch for repeated vomiting or a refusal to drink. It is best if the oral [...]
These children are losing excessive amounts of fluid and electrolytes in their stools and therefore must still be given extra fluid and electrolytes to prevent signs of dehydration from appearing. These children should be managed at home or at a clinic using commercial oral rehydration solution or sugar and salt solution to replace fluid losses. [...]
Zinc is an important trace element which can speed up the recovery from diarrhoea and help to prevent further diarrhoea. Once the child is taking feeds well, one tablet of zinc (20 mg) should be given daily for 10 days. Children under 6 months should have half a tablet daily.
Once dehydration has been corrected, the total amount of fluid needed is normal maintenance requirements plus any ongoing fluid losses. The normal fluid needs of most infants are about 100 ml/kg daily. If possible this fluid should be given orally as rehydration solution or milk. Thirst is usually a good guide to the infant’s fluid [...]
Give intravenous Ringer’s lactate or normal saline 20 ml/kg as fast as possible. Continue to give fluid at this fast rate until the signs of shock have disappeared. An easily felt radial pulse and normal capillary filling time are very reassuring signs of a good response to management. Once shock has been corrected, Ringer’s lactate, [...]
The management of children with severe diarrhoea leading to severe dehydration is a medical emergency. Look carefully for shock in all children with severe dehydration and treat immediately. Immediately start an intravenous infusion with Ringer’s lactate (or half normal saline or half strength Darrows/dextrose solution). Give 30 ml/kg over the first half hour (30 minutes). [...]
Chlorinated tap water must be provided where ever possible. Water can be sterilized by boiling or adding chlorine tablets. If none of the above is available, water can be made safer by putting it into a clear, plastic bottle or bag and leaving it in the sun for a few hours. The ultraviolet light will [...]
Diarrhoea is far less common with: Breastfeeding to 6 months and longer if possible A supply of clean water Adequate sanitation (the safe disposal of faeces) Cup-feeding rather than bottle-feeding if formula is used Good personal hygiene, especially hand-washing before meals or handling food Protecting food from flies Breastfeeding, a clean safe water supply, appropriate [...]
Because they are exposed to the viruses and bacteria which cause diarrhoea. Their food and water may also be contaminated by these organisms. Infections which cause diarrhoea are particularly common: In infants who are bottle-fed rather than breastfed Where there is not a supply of clean water to mix formula When feeding bottles and teats [...]
Yes. The viruses and bacteria that usually cause acute diarrhoea spead easily from person to person. Acute diarrhoea is an infectious disease. With simple interventions, most cases of acute diarrhoea can be prevented. Acute diarrhoea is usually very infectious but can be prevented.
Wash hands after going to the toilet or handling a soiled nappy. Wash hands before preparing food or eating. Wash fruit and vegetables with clean water. Cover food to keep flies away. Store food in a fridge (refrigerator) or cool place. Bury or burn all food waste.
If a mother is unable to safely clean dirty bottles and teats, it is better to feed the infant by cup. Unlike a bottle, a cup can easily be cleaned with soap and water. The inside surfaces of a cup are smooth and easily reached by finger. Unlike a feeding bottle, there are no corners [...]
There are a number of simple ways to improve sanitation and reduce the risk of children getting diarrhoea. All stools must be passed or deposited into a flush, chemical or pit toilet: A simple pit toilet: The pit must be dug less than a metre wide and at least 1 to 2 metres deep, 20 [...]
