Diarrhea in Children

Acute Diarrhea

Acute diarrhea is defined as diarrhea lasting less than seven days and is usually caused by an infection.

Persistent Diarrhea

Persistent diarrhea starts as acute diarrhea but lasts for more than fourteen days, also due to an infection.

Chronic Diarrhea

Chronic diarrhea is a rare condition defined as diarrhea lasting more than fourteen days but is non-infectious, often associated with malabsorption.

Definition of Diarrhea

Diarrhea is defined by a change in stool consistency, from solid to watery. It is a better definition than an increase in stool frequency (more than three episodes per day).

Causes of Acute Diarrhea

  • Viral Infections: Most common cause.
    • Rotavirus: The most common overall viral cause.
    • Other viruses: Norvak virus, adenovirus, astrovirus, and calcivirus.
  • Bacterial Infections: Common overall bacterial cause is E. Coli.
    • E. Coli (ETEC - Enterotoxigenic E. Coli): Most common type of E. Coli.
    • Other bacteria: Salmonella, Shigella, and Campylobacter.
  • Parasitic Infections: Not common in the general pediatric population but more common in immunodeficient children.
    • Giardia: Most common parasite.
    • Others: Entamoeba histolytica and Cryptosporidium.
    • Cryptosporidium: Most common parasitic cause of diarrhea in HIV-infected children.

Dysentery

Dysentery is characterized by loose stools with blood. It is almost always bacterial in origin.

  • Shigella (Shigella flexneri): The most common cause of dysentery in children.

Rotavirus Diarrhea

Rotavirus diarrhea typically does not require antibiotics; the main concern is dehydration.

Assessment of Dehydration

  1. No Dehydration: Child is active and alert.
  2. Some Dehydration: Child is thirsty and slightly irritable; fluid loss of 50-100 ml/kg.
  3. Severe Dehydration: Child is lethargic; fluid loss of more than 100 ml/kg.

Skin Pinch Test (Skin Turgor)

  • No Dehydration: Skin response time is quick (less than one second).
  • Some Dehydration: Skin response time is slow (less than two seconds).
  • Severe Dehydration: Skin response time is very slow (more than two seconds).

Management Plans for Dehydration

  1. Plan A (No Dehydration): Replacement of ongoing losses with ORS.
    • Less than 6 months: 50 ml ORS for every loose stool (one-fourth of a glass).
    • 6 months to 2 years: 50-100 ml ORS for every loose stool (one-fourth to half of a glass).
    • More than 2 years: 200 ml ORS for every loose stool (one glass).
  2. Plan B (Some Dehydration): Correction of dehydration with rehydration using ORS.
    • Rehydration: 75 ml/kg ORS, replace ongoing losses, and meet daily fluid requirements.
  3. Plan C (Severe Dehydration): Requires intravenous fluids.
    • RL (Ringer Lactate) is preferred over normal saline.
    • Rehydration: 100 ml/kg of fluid.
      • Initial 30 ml/kg over 1 hour (if less than 1 year old) or 30 minutes (if more than 1 year old).
      • Remaining 70 ml/kg over 5 hours (if less than 1 year old) or 2.5 hours (if more than 1 year old).

Holliday-Segar Formula

Used to calculate daily fluid requirements.

  • 0-10 kg: 100 ml/kg
  • 10-20 kg: 1000<br/>ewlineml+50<br/>ewlineml1000 <br /> ewline ml + 50 <br /> ewline ml per kg for every kg above 10 kg
  • More than 20 kg: 1500<br/>ewlineml+20<br/>ewlineml1500 <br /> ewline ml + 20 <br /> ewline ml per kg for every kg above 20 kg

Example: For a 22 kg child:

1500<br/>ewlineml+(2<br/>ewlinekg<br/>ewline∗<br/>ewline20<br/>ewlineml/kg)=1540<br/>ewlineml1500 <br /> ewline ml + (2 <br /> ewline kg <br /> ewline * <br /> ewline 20 <br /> ewline ml/kg) = 1540 <br /> ewline ml per day

Oral Rehydration Solution (ORS)

Current WHO-recommended low osmolarity ORS has a total osmolarity of 245 mOsm/L.

  • Sodium: 75 mEq/L
  • Glucose: 75 mmol/L
  • Potassium: 20 mEq/L
  • Chloride: 65 mEq/L
  • Citrate: 10 mEq/L

Role of Zinc

  • Helps in epithelialization of the gastrointestinal tract.
  • Decreases the severity of loose stools.
  • Decreases future recurrence of diarrhea.

Dosage:

  • Less than 6 months: 10 mg per day.
  • More than 6 months: 20 mg per day.

Duration: 14 days, irrespective of age.

Medications to Avoid

  • Anti-motility agents (e.g., Loperamide).
  • Anti-secretory agents (e.g., Racecadotril).
  • Probiotics (no current recommendation).

Indications for Antimicrobial Treatment

  1. Dysentery: Almost always bacterial; use antibiotics.
    • Commonly used: Third-generation cephalosporins (e.g., Cefixime), Ciprofloxacin, or Azithromycin.
  2. Severe Malnutrition: Bacterial infections are highly likely.
    • Usual combination: Ampicillin with Gentamicin.
  3. Established Diagnosis of Cholera:
    • Drug of choice: Doxycycline.
  4. Proven Case of Giardiasis or Amebiasis:
    • Drug of choice: Metronidazole.

Persistent Diarrhea in Children

Diarrhea lasting for more than fourteen days is due to an infection. It starts as acute diarrhea but persists.

Risk Factors for Persistent Diarrhea

  • Age: Less than one year (especially 6 months to 1 year).
  • Low Birth Weight/SGA Babies and Malnutrition: Delayed mucosal healing.
  • Specific Organisms: Entero-adherent E. Coli, Entero-aggregatory E. Coli, Salmonella, and Shigella.
  • Lactose Intolerance: Both a risk factor and a consequence.
  • CMPA (Cow Milk Protein Allergy): Allergy to cow milk proteins like beta-lactoglobulins and casein.

Consequences of Persistent Diarrhea

  • Nutritional deficiency, especially micronutrient deficiency (e.g., Vitamin A deficiency).
  • Lactose intolerance.

Lactose Intolerance in Persistent Diarrhea

  • Lactase enzyme is present at the tip of the villi.
  • Persistent diarrhea leads to loss of the tip of villi, reducing lactase activity.
  • Undigested lactose is converted into lactic acid and hydrogen by colonic bacteria.
  • Lactic acid: perianal rash or excoriation.
  • Hydrogen: explosive stools or gaseous stools.
    This condition is called acquired or secondary lactose intolerance.

Management of Persistent Diarrhea

  • ORS according to the level of dehydration.
  • Zinc (same dose and duration as acute diarrhea).
  • Vitamin A supplementation (single dose).
    • Less than 6 months: 50,000 IU.
    • 6-12 months: 100,000 IU.
    • After 12 months: 200,000 IU.
  • Decrease or avoid lactose in the diet.
    • Diet A (Low Lactose): Dilute milk by mixing with rice (rice milk gruel) or suji, or mix rice with curd.
    • Diet B (No Lactose): Completely avoid milk and dairy products; give cereals, glucose for carbohydrate intake, and egg or chicken protein recipes for protein.
    • Diet C (No Lactose, No Starch): Monosaccharide-based diet; plain glucose as a source of carbohydrate, and egg white or chicken purees for protein.