Diarrheal diseases include acute diarrhea, persistent diarrhea (diarrhea duration two weeks or more) and dysentery (blood-stained stools with fever). Diarrheal diseases are one of the most common causes of epidemic in our State. Most of the deaths in diarrheal diseases are due to dehydration which is preventable by timely and adequate replacement of fluids.
• Acute diarrhea – Cholera, Rota virus, Food poisoning, gastrointestinal disorders and medications (rare).
• Persistent diarrhea – Chronic bacterial infections, inflammatory bowel disorders, malabsorption syndrome.
• Dysentery – Amoebiasis, Giardiasis, Shigellosis.
Sign/symptom | Acute diarrhoea | Persistent diarrhoea | Dysentery |
Frequency of stools/day | Three or more | Three or more | Three or more |
Consistency of stools | Watery | Variable | Variable |
Duration of diarrhoea | Less than 2 weeks | Two or more weeks | Less than 2 weeks |
H/o fever | No | Variable | Yes |
H/o blood stained mucus | No | Variable | Yes |
Effect on appetite | No | Loss of appetite | Loss of appetite |
Dehydration | Important, may lead to severe dehydration if not treated in time. | Patient may have some dehydration. | Patient may have some dehydration |
Treatment principle | Management of dehydration is priority | Start management of dehydration. Simultaneously find cause of persistent diarrhoea and treat accordingly. | Start management of dehydration. Simultaneously start appropriate antibiotics. |
Long term effects | No long term effect for occasional episodes. Repeated attacks may lead to PEM. | If not treated correctly, child may get severe Protein Energy Malnutrition | Repeated attacks may lead to Protein Energy Malnutrition |
Sign/Symptom | Severity of symptoms and signs | ||
No dehydration | Some dehydration | Severe dehydration | |
General condition of Patient | Patient well alert | Restless and irritable | Lethargic, unconscious, floppy |
Presence of thirst | Normal/not thirsty | Thirsty, drinks water immediately when offered | Not able to drink |
Dryness of mouth and tongue | Moist mouth and tongue | Mouth and tongue dry | Mouth and tongue very dry |
Condition of eyes | Normal | Sunken | Very sunken, patient’s face looks like old man's face. |
Condition of tears | Tears appear while crying | Tears appear while crying | No tears, dry eyes even in crying child |
Skin turgor | Normal. Pinch to skin immediately goes back to normal. | Pinch slowly goes back and takes some time to become flat. | Pinch remains as it is for 2-3 seconds and then slowly goes back. |
Classification of dehydration | No dehydration | Some dehydration | Severe dehydration |
Treatment of dehydration | Plan – A | Plan – B | Plan – C |
Most important aspect in management of diarrheal diseases is correction of dehydration. Treatment of dehydration is divided into three plans as follows -
· Plan-A: For patients with no dehydration – principle is to prevent dehydration.
· Plan-B: For patients with some dehydration – principle is treatment of some dehydration and preventing patient from going into severe dehydration.
· Plan-C: For patients with severe dehydration - This is a lifesaving plan. Rehydrate patient as early as possible and prevent from going again into severe dehydration.
Description of treatment plans in details is as follows.
PLAN A
Principle of treatment
As diarrhea is continuing, there is continuous loss of water and electrolytes from body of patient which may lead to dehydration. Therefore, principle of Plan-A schedule is correction of whatever loss of water and electrolytes before the patient develops signs of dehydration. Plan-A can be advised at home to caretaker of patient. However, make sure that care taker has understood danger signs of dehydration (like thirst). Following steps are recommended in Plan-A.
a. Home available fluids
• Advise to give Home Available Fluids (HAF) e.g., sarbat, lassi, vegetable soup, kheer, buttermilk, tea, coconut water, etc. i.e., any liquid available at home to patient as much he/she can drink.
• Continue breast feeding and feeding – If child is being breastfed, then breast- feeding should be continued. Regular feeding of non-breast-fed child should also be continued.
b. ORS to prevent dehydration
If frequency and amount of diarrhea is not declining or amount of stool is large, then start ORS.
· Contents of WHO ORS are as follows – (New low osmolarity ORS).
Sodium chloride | - | 2.6grams |
Potassium Chloride | - | 1.5 grams |
Trisodium Citrate | - | 2.9 grams |
Glucose | - | 13.5 grams |
· Dissolve the packet in one litre of water to prepare ORS.
· Show caretaker how to prepare ORS. Following steps should be carried out for preparation of ORS -
- Take clean pot of one and half litre capacity and one clean spoon.
- Pour 1 litre of clean drinking water in the pot. (No need to boil water).
- Add whole packet of ORS into one-litre of water and stir till all powder is dissolved. Now ORS is ready for use
- Give ORS by cup or spoon to small children and by glass to bigger children and to adults as per indicated dose.
- If patient has vomiting, wait for 5 minutes and start again.
- Keep ORS covered. Once prepared ORS should be used within 24 hours. Do not use ORS beyond 24 hours, as there are chances of contamination.
- If child develops swelling on eyelids, stop ORS as it indicates overdose.
- Ask her to give ORS in following doses after passage of each liquid stool.
PLAN B
Start Plan-B treatment to patients showing signs and symptoms of some dehydration as per dehydration diagnosis chart. Aim of this plan is to correct dehydration and prevent patient from going into severe dehydration.
Dose of ORS: Dose of ORS is calculated preferably according to weight of patient. Give ORS in a dose of 100ml/kg in 4 hrs. If weighing is not possible, calculate age wise ORS requirement for four hours as follows
Table -3: Age wise ORS requirement for four hours
Age | < 4 months | 4–11 months | 12–23 months | 2 – 4 years | 5 – 14 years | 15 + years |
Dose | 200-400 ml | 400 – 600 ml | 600 – 800 ml | 800 – 1200 ml | 1200 – 2200 ml | 2200- 4000 ml |
Continue breast feeding and feeding – If child is being breastfed, then breast- feeding should be continued.
Re-examination of patient: Re-examine patient after every four hours for status should also be continued.
Table-4: Management advice based on re-examination findings
Condition of patient on re- examination | Management advise |
Patient improves, no signs of dehydration on examination and diarrhoea stops | Keep patient under observation for 24 hours. Continue HAF. Observe if diarrhoea and/or vomiting start again. |
Patient improves, no signs of dehydration on examination but diarrhoea continues | Continue giving ORS in doses suggested in Plan-A, reexamine after four hours. |
Dehydration status same | Continue with Plan-B. Check whether ORS is being given in correct dose. Re-examine after four hours. |
Signs of severe dehydration appear | Switch on to Plan - C (start IV fluids). Continue to give ORS as much as possible. |
If signs and symptoms of patient are suggestive of severe dehydration, start Plan – C. This is emergency plan. Incorrect or incomplete management of severely dehydrated patient may lead to death of patient. Medical Officer must personally examine patient and treat for severe dehydration.
Principles of management
Principle of management of severe dehydration is replacing fluid loss by giving rapid IV infusion. Only Ringer's lactate should be used as IV fluid and the dose is 100ml/kg body weight.
Age group | Intensive phase | Maintenance phase | Duration of treatment | Remarks | |
Infants (0-1 year) | 30-ml/kg body wt. during first 1 hour. | 70ml/kg body wt in next 5 hours. | 6 hrs | Assess patient after every 6 hours | |
Older children and adults | 30-ml/kg body wt. in first half hour. | 70ml/kg body wt in next 21/2 hrs. | 3 hrs | Assess patient after every 3 hours | |
Re-examine patient after every six hours in infants and three hours in adults for status of dehydration with the help of dehydration diagnosis chart and decide management plan as follows -
Table-5: Treatment advice based on condition of patient
Condition of patient | Treatment advise |
Patient improves, no signs of dehydration on examination and diarrhoea stops | Keep patient under observation for 24 hours as patient may start diarrhoea/vomiting again |
Patient improves, no signs of dehydration on examination but diarrhoea continues | Continue giving ORS (Plan-A) |
Patient improves, signs of some dehydration on examination. | Stop IV fluids after required dose is administered. Continue giving ORS (Plan-B) |
Dehydration status same | Continue with Plan-C. Check for any complications like anuria. If yes carefully examine the patient and decide for referral. Continue giving IV during transportation of patient. |
Antibiotics are recommended only to suspected patients of cholera and dysentery. Other drugs like anti motility drugs, binding agents, anti-secretory agents and steroids are not of any use in management of diarrhea. They are harmful to patients and therefore not at all recommended for treatment.
Judicious use of antibiotics is appropriate in selected patients. Severely ill patients with febrile dysentery can be treated with ciprofloxacin 500mg bd for 3- 5 days.
Use of Zinc Tablets
Zinc Dosage Recommendation: Zinc is very safe drug and has a very large window of safety. Zinc dispersible tablets are to be given in each diarrheal episode along with low osmolality ORS or Oral rehydration therapy (in case ORS is not available), irrespective of type of dehydration.
Zinc administration as per age of child:
a) Children from 2-6 months: Children aged between 2-6 months should be given 10 mg of elemental zinc per day for a total period of 14 days from the day of onset of diarrhoea. A tablet of zinc contains 20 mg of elemental zinc. Therefore half tablet should be given to the children in this age group. Zinc when supplied in the form of dispersible tablets, easily dissolves in breast milk or water. Therefore, in infants below 6 months of age, the tablet should be given by dissolving in breast milk and in infants above 6 months of age, it should be given by dissolving in breast milk or water.
b) Children above 6 months: One full tablet (20mg) should be given to all children with diarrhoea above 6 months of age. It should start from the day of onset of diarrhoea and continued for a total period of 14 days.
References
No references available