GP Clinics Vol 12 No 5 F18 Ambekar Article

Dr Amdekar's Revision Notes

A Way To Clinical Perfection

Acute Diarrhea in Children: How to Stop?

Yeshwant K Amdekar, MD, DCH, FIAP*

Consultant Pediatrician, Jaslok Hospital and Research Center and Breach Candy Hospital, Mumbai.

*Dr Amdekar is a practicing pediatrician for 50 years and a visiting consultant at SRCC Hospital, Mumbai. He has been a teaching faculty at the Institute of Child Health, Grant Medical College and JJ Group of Hospitals, Mumbai. He has also been the past President of Indian Academy of Pediatrics (IAP) and a member of editorial committee of Indian Pediatrics–the official journal of IAP

ABSTRACT: Diarrhea is nature’s attempt of eliminating harmful substances present in intestinal tract. Thus, there is no need to control diarrhea. However, while driving away something that is harmful, fluids and electrolytes are also lost along with nutritional elements that need to be replaced. In case of watery stools, diarrhea stops within 2-3 days without any specific treatment. However, in case of loose stools with mucus and / or blood (dysentery), antibiotic may be necessary to cure the disease. In either case, there is no need of any drug to stop diarrhea. In fact, such drugs could be harmful.

Key words: diarrhea

WHAT IS DIARRHEA?

Diarrhea is defined by the World Health Organization as the passage of three or more loose or liquid stools per day. However, diarrhea is better defined as a change in pattern of bowel movement characterized by an increased frequency of liquid stools. Since a change in bowel movement pattern is an important part of the definition, occurrence of a single loose stool that is different from the normal pattern of bowel movements does classify as diarrhea.

Dysentery is characterized by mucus and blood in the stool. Bloody diarrhea is typically present in shigellosis and salmonellosis (not typhoid but salmonella enteritis) and also in amebiasis.

WHAT DOES NOT CONSTITUTE DIARRHEA?

A normal neonate exclusively breast-fed may pass as many as 1015 loose watery stools per day that are golden yellow in color without obnoxious smell. However, this is normal for the infant as there is no change in bowel pattern. Such a neonate with so many watery stools per day is happy, feeds well and gains weight normally. Thus, this is not diarrhea.

Similarly, an increase in stool frequency of normal consistency may not constitute diarrhea until there is a change in consistency. For example, an increase in stool frequency in young infants is not diarrhea because it is usually attributed to an increase in the gastrocolic reflex.

Similarly, in children with habitual constipation, watery stool may leak out by the side of the impacted hard stool. This is often misdiagnosed as diarrhea because of loose stool. However, the loose stool may actually be caused by constipation. Neurological disease may result in the loss of tone in the anal sphincter and can also cause fecal incontinence, causing stool to leak unexpectedly from the rectum. Nevertheless, this is obviously not diarrhea.

TYPES OF DIARRHEA

Secretory diarrhea. It is defined as watery, voluminous diarrhea resulting from increased stimulation of ion and water secretion, inhibition of their absorption, or both.

YK Amdekar

Dr Amdekar's Revision Notes

“RED FLAG” signs (early signs for referral)

• Dehydration (reduced urine output, lethargy)

• Shock (delayed capillary refill)

• Electrolyte/acid-base disturbance (drowsiness, deep and rapid respiration)

• Abdominal distension (poor peristalsis)

• Persistent vomiting

• Malnourished child – grade 3-4

Secretory diarrhea is present in people infected with cholera and is seen in rotaviral diarrhea that kills nearly a million infants and children worldwide each year.

Osmotic diarrhea. Osmotic diarrhea occurs when too much water is drawn into the bowels. Osmotic diarrhea may result from the malabsorption or inability to digest or absorb certain carbohydrates o as occurs during the excess consumption of dairy products or fruit juices. It may also be due to the large intake of vitamin C or magnesium as occurs from the ingestion of magnesiumcontaining antacids.

Inflammatory diarrhea. It results from either infection as found in bacterial or parasitic infections or autoimmune problems such as inflammatory bowel disease such as Crohn’s disease or ulcerative colitis. It can also be due to tuberculosis, colon cancer, and enteritis.

Hypermotility diarrhea. This type of diarrhea is caused by the rapid movement of food though the intestine (hypermobility) and refers to an increase in intestinal motility that hinders absorption due to rapid transit of intestinal contents.

Hyperthyroidism can produce hypermotility. Hypermotility diarrhea is rare in children. An increased incidence of the gastrocolic reflex is normal in infants and young children, in which case they pass normal but more frequent stools after each feed. It can also be due to anxiety and

an increase in stress as observed in children who get an urge to pass stools just before going for examination.

BASIS OF TREATING ACUTE DIARRHEA

Step 1—Look for “red flag” signs (Box above) that demand urgent action. These include signs of dehydration (drowsiness, oliguria, tachycardia, loss of skin turgor, depressed fontanelle and dry tongue), electrolyte and acid-base disturbance (hyponatremia resulting in drowsiness, abdominal distension and sluggish deep tendon reflexes suggestive of hypokalemia, deep and rapid respiration indicating acidosis), convulsion (due to dyselectrolytemia, spread of infection to the brain, polycythemia or cortical venous thrombosis) and signs of shock (delayed capillary refill, cold and clammy extremities, weak peripheral pulses and hypotension). Any of such signs merits immediate referral for hospitalization.

Step 2—Judge the severity of dehydration. For practical purpose,

the severity of dehydration is divided into three grades, each one necessitating different actions. First degree dehydration is the least severe and third degree dehydration is the most severe.

History and physical examination helps to indicate the degree of dehydration as shown in Table 1.

Step 3—Guess probable etiology. Based on the type of stool. Determining the type of stool is very important in making a correct diagnosis and treating diarrhea (Table 2).

Watery diarrhea suggests mostly viral infection. However non-invasive toxigenic diarrhea due to a bacterial infection such as E. coli may also result in watery diarrhea. Moreover, such a child may be highly febrile and toxic as opposed to a child experiencing a viral infection.

Watery stools with anal excoriation also known as red anus, suggests osmotic diarrhea as a result of carbohydrate malabsorption. However, such a child is not febrile or toxic.

Blood and mucus in stools are indicative of invasive bacterial infection or autoimmune disease such as Crohn’s disease or ulcerative colitis. These children are usually highly febrile and sick. Acute amoebic dysentery is rare especially in young children. Large bulky whitish or grayish foul-smelling stool suggests giardiasis.

Based on nutritional state, age and feeding pattern. Well-nourished infants and toddlers commonly suffer from a viral infection while a malnourished child at that age has an increased risk of acute bacterial infection.

Bottle-fed infants are more at risk

Table 1 – Degree of dehydration

Acute Diarrhea in Children: How to Stop?

Possible etiology

of bacterial infection than breastfed infants. Older children rarely suffer from severe viral diarrhea though cholera may occur at any age. Parasitic infections are more common in older children and do not present with severe diarrhea, but abnormal and frequent stools are common. Autoimmune inflammatory bowel disease is common in older children.

Parenteral diarrhea. Diarrhea is at times seen in children suffering from pneumonia, meningitis, UTI or otitis media. Diarrhea in such cases is caused by toxin produced by bacteria, is short lasting and not a major symptom. Stool microscopy usually does not reveal any abnormality.

INVESTIGATIONS

No routine investigations are required in acute diarrhea when the etiology is easily guessed by the pattern of stool and clinical status of the child as discussed above. However, stool microscopy is useful when parasitic infection is suspected. The presence of a few pus cells does not justify treatment with an antibiotic as it is not considered specific to a bacterial infection.

Fecal reducing substances is a test on a stool sample to diagnose lactose intolerance. However, presence of reducing substance in a stool sample is common in diarrhea of every cause. Hence, there is no need to look for it except in case of persistent chronic diarrhea in a malnourished child. Presence of reducing substance in a stool sample in case of acute diarrhea

does not justify using lactose-free milk such as soya milk. Stool culture is not recommended in diagnosing etiology of acute diarrhea and finding E. coli may not indicate that the cause of infection is bacterial as there are commensals in GI tract. So, in short, no investigations are necessary in the case of acute diarrhea.

MANAGEMENT

Oral rehydration therapy (ORT). ORT is the main recommendation for the management of acute diarrhea. ORT has changed over the years from merely using WHO/UNICEF oral rehydration solution to using any home fluids to a recent concept of administering any additional fluids and continuing nutrition. Since diarrhea is considered by many to be a “nutritional disease”, in other words, that diarrhea promotes malnutrition and malnutrition accentuates diarrhea. Management of diarrhea must consider both elements – fluids and nutrition.

Oral rehydration solution (ORS). ORS can consist of any fluids

including home fluids such as rice kanji, soups and water with salt and sugar. An ideal solution for rehydration is a low osmolar electrolyte solution (245 mmol/L). Earlier advocated solutions were of higher osmolarity (311 mmol/L), more suitable for cholera infection (Table 3).

ORS should be administered as required and ideally after each stool movement. Urine output should be monitored and also heart rate, as both improve as hydration is restored to normal levels. Vomiting generally does not come in the way of adequate resuscitation as it stops within 24 hours of the onset of diarrhea.

Antiemetic drugs. These drugs are rarely necessary as vomiting is transient and self-limiting. However, in cases of severe vomiting, metoclopramide or domperidone may be used on an SOS basis. Such drugs are not required beyond 24 hours.

Zinc supplement. It is found to be useful especially in children <5 years of age, as it helps reduce stool volume and also the duration of diarrhea. However, it should be continued for a week after diarrhea is controlled. Oral zinc solutions are now freely available and it is the only drug necessary for the treatment of diarrhea in most children.

Diet in acute diarrhea. There is no need to modify the diet in acute diarrhea. Breast milk should never be stopped nor any other food. However, children should not be forced to eat as they may have temporarily lost their appetite. Most of the children with diarrhea will be thirsty and so will continue to consume fluids. Table

Specific treatment. Antibiotics are justified in the treatment of invasive diarrhea with the presence of blood and mucus in stools. It being gram-negative bacterial infections, co-trimoxazole or amoxicillin are the drugs of choice. Drug resistance is rare for community acquired bacterial infections though occasionally one may meet drug-resistant shigellosis and salmonellosis for which third generation cephalosporin may be considered. Metronidazole may be used particularly for amebiasis or giardiasis.

Dr Amdekar's Revision Notes

Acute Diarrhea in Children: How to Stop?

Drugs used in the past, such as binding agents and loperamide are not indicated and in fact harmful. Similarly, enzyme preparations are not necessary. Probiotics and prebiotics are also not indicated for the treatment of acute diarrhea as are fixed drug combinations such as an antibiotic combined with an anti-parasitic drug.

In summary, diarrhea is primarily a “nutritional disease”. This means that malnutrition predisposes to diarrhea and diarrhea worsens the nutritional

state. Thus, maintaining good nutrition by exclusive breast feeding for the first 6 months followed by continuation of breast feeds along with complimentary feeds is the best way to prevent diarrhea. ORS is considered to be the best invention of the past century and its use has saved many lives. Thus, ORS is considered the best treatment of diarrhea. Zinc supplementation leads to quicker recovery. In contrast, diet should not be changed in acute diarrhea and other drugs are rarely necessary.

CME questions on

Acute Diarrhea in Children: How to Stop?

Most important parameter in definition of diarrhea is: a) Frequency of stools b) Consistency of stools c) Change in bowel pattern d) Smell of stools

Physical examination in diarrhea should include: a) Pulse rate b) Respiratory rate c) Abdominal distension d) Drowsiness e) All of the above

Diarrhea may be a manifestation of: a) Meningitis b) Urinary tract infection c) Ear infection d) Pneumonia e) None of the above

In routine clinical practice, following test is necessary: a) Stool culture b) Stool lactose c) Stool microscopy d) None of the above

Ideal treatment of diarrhea in exclusively breastfed infant is: a) Antibiotic b) Anti-parasitic c) Probiotic d) None of the above

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