DIARRHOEA IN IMCI

 DIARRHOEA

Definitions

1. It is the passage of more than 300g per day of loose Stool (Parveen Kumar, 1992).

2. Passage of loose stool more than 3 times a day (Joan Llewellyn, 1986)

3. Three or more loose or watery stools in a 24hrs period (ITG, 200).

 

ASSESSMENT

Ask all the children about diarrhea. If the caretaker’s answer is NO, you do not need to assess the child further about diarrhea. If YES, continue assessing for dehydration, persistent diarrhea and dysentery. Ask for how long? Diarrhea that last for 14 days or more is persistent diarrhea. Diarrhea that has blood in it is dysentery.

CAUSES OF DIARRHOEA

Infection of the Gut; viruses, bacterials, amoeba and girdia can all cause infections which can damage the wall of the gut and prevent proper digestion and absorption of food.

Malnutrition: it weakens the gut wall, so the food cannot be digested, but passes out as stool.

Osmotic Diarrhea: the patient could have ingested a non-absorbable substance like Lactulose.

Dirty environment it can be transmitted by the 5 F (Flies, Formite, food, feces and fingers).

 

NOTE

Diarrhea in an infant less than 1 week of age is seldom an isolated problem. It should always be considered as a sign of neonatal sepsis.

 

CLINICAL FEATURES

Clinical manifestations are categorized according to the severity of the dehydration. And treatment is also according the severity of the dehydration. The classifications are as follows:

Ø  Diarrhea with no or with mild dehydration

Ø  Diarrhea with some dehydration

Ø  Diarrhea with severe dehydration.

Ø  There are not enough signs to classify the dehydration as Severe or Some dehydration.

 

DIARRHEA WITH NO OR WITH MILD DEHYDRATION

Management

This classification of diarrhea is usually treated at home. Give fluid and food to treat diarrhea at home. Advise the caretaker on when to return to the clinic or hospital. Treat according to Plan A diarrhea with no or with mild dehydration.

Three rules of treatment of Diarrhea at home

1. Give the Child More Fluids Than usual to Prevent Dehydration.

Use recommended home fluids, including salt and sugar solution, ORS, food based fluids such as soup, rice, yoghurt. But if the child is less than 6 months old and is not yet taking solid foods, give ORS rather than a food-based solution. Give the fluids until the diarrhea stops.

2. Give the Child Plenty of Foods To Prevent Malnutrition.

Continue to breast feed frequently. If the child is not breastfed give the usual formular or milk.

If the child is 6 months or older or already taking solid foods; In addition, give cereal or another starchy food mixed if possible with pulses, vegetables, meat or fish.  Add 1 or 2 teaspoonful of vegetable oil to each serving. Give fresh fruit juices or mashed Banana to provide potassium. Give freshly prepared food. Cook and mash or grind food well. Offer food at least 5 to 6 times every day.

3. Take the child to the Health Workers if the child does not get better in five days, or develops any of the following; many watery stools, eating or drinking poorly, repeated vomiting, fever and marked thirsty and blood in stool.

 

SOME DEHYDRATION

This is classified if any two of the following are present; restless, irritable, sunken eyes, drinks eagerly, thirsty and skin pinch goes back slowly.

 

MANAGEMENT

If the child has no severe classification, give fluids according to treatment plan B

If the child has severe classifications refer to the hospital immediately.

APPROXIMATE ORS TO GIVE IN THE FIRST 4 HOURS

AGE	<4 month	4-11month	12-23month	2-4 years	5-14 years	15 years
Weight	< 5kg	5-7.9kg	8-10 kg	11-15 kg	16-29 kg	30 kg
Mils	200-400	400-600	600-800	800-1,200	1,200-2,200	2,200-4000

 

 

If the child wants more ORS than shown, give more. Encourage the mother to continue breastfeeding. For infants under 6 month who are not breastfed, also give 100 to 200mls of clean water during this period of time. After 4 hours, re-assess the child to find out if there is any improvement in the condition.

 

 

SEVERE DEHYDRATION

In severe dehydration two of the following signs have to be present; Lethargic or unconscious, sunken eyes, not able to drink or drinks poorly and if skin pitch goes back slowly.

Skin pinch

Locate the area on the Childs abdomen half way between the umbilicus and the side of the abdomen. To do the skin pitch, use your thumb and first finger. Do not your fingertips because this will cause pain. Place your hand so that when you pitch the skin, the folds of skin will be line up and down the child body, and not across the Childs body. Firmly pick up all the layers of skin and the tissue under them.  Pinch the skin for a second and then release it.

 

MANAGEMENT

If the child has no other severe classification, give fluids according to plan C.

If the child has another severe classification refers urgently to the hospital, give the caretaker ORS to give to the child on the way to the hospital. If you can give intravenous (i.v) fluids immediately, start I.V Fluids immediately. If the patient can drink, give ORS by mouth while the drip is being set up; give 100ml/Kg Ringers Lactate solution as shown below.

Age	First give 30mls/Kg in	Then give 70ml/kg in
Infant < 1 year	1 hour	5 hours
1 – 5 years older	30 minutes	2hrs 30minutes

 

Repeat once if radial pulse is still very weak or not detectable. Re-assess the patient every 1-2 hour if hydration is not improving; give the I.V drip more rapidly. Also, give ORS about 5ml/Kg/hr as soon as the patient can drink; usually after 3 to 4 hrs (infant) or 1 to 2 hrs for older. Reassess the infant after 6hours and for older children after 3hours.

 

If the I.V line is not available, send patients for i.v treatment immediately. Start rehydration by tube with ORS 20ml/Kg/hr for 6hrs. Re-assess the patient every 1 to 2 hours.

If there is repeated vomiting or increased abdominal distention, give fluids more slowly.

 

If dehydration has not improved for more than 3 hours, send the patient for i.v therapy. After 6 hours, re-assess the patient. If diarrhea persists for 14days it is classified as persistent diarrhea. Refer to the hospital for treatment and investigation if; there is blood in stool which is considered as dysentery. Treat with appropriate antibiotics.