DIARRHEA IN CHILDREN

Mentor:
dr. Pulung M. Silallahi, Sp.A
Written by:
Sintami Rosmalinda (1102011260)
FACULTY OF MEDICINE YARSI
PEDIATRIC DEPARTMENT
RADEN SAID SUKANTO POLRI HOSPITAL- JAKARTA
PERIOD 3 AUGUST 2015 11 OCTOBER 2015

DEFINITION
Diarrhea is the reversal of the normal net
absorptive status of water and electrolyte
absorption to secretion.
The augmented water content in the stools
(above the normal value of approximately 10
mL/kg/d in the infant and young child, or 200
g/d in the teenager and adult)

EPIDEMIOLOGY
Leading cause of childhood morbidity &
mortality in developing countries
Important cause of malnutrition
80% of deaths due to diarrhea occur in the
first two years of life
Children <3 years of age in developing
countries experience around three episodes
of diarrhea each year

Why is diarrhea dangerous ?

Diarrhea can cause malnutrition and can make

it worse because:
Nutrients are lost from the body in diarrhea
A child with diarrhea may not be hungry
Mother may not feed children with they have
diarrhea, or even for some days after the
diarrhea is better.

ETIOLOGY
Bacterial :

10-20% of infectious diarrhea but responsible for

most cases of severe diarrhea
Shigella sp.
Salmonella
E. coli
Vibrio cholerrae
Bacilus cereus
Clostridium perfringens
Staphylococcus aureus
Campylobacter aeromonas

Escherichia coli
Enterotoxigenic E. coli (ETEC) causes travelers diarrhea.
Enteropathogenic E. coli (EPEC) rarely causes disease in
adults.
Enteroinvasive E. coli (EIEC) causes bloody mucoid (dysentery)
diarrhea; fever is common.
Enterohemorrhagic E. coli (EHEC) causes bloody diarrhea,
severe hemorrhagic colitis, and the hemolytic uremic
syndrome in 68% of cases; cattle are the predominant
reservoir of infection.
Enteroadherent E.coli (EAEC) adhesive to small intestine and
causes watery diarrhea more than 7 days (prolonged diarrhea)

Campylobacter sp
Infection is associated with watery diarrhea; sometimes
dysentery.
Poultry is an important source of Campylobacter
infections in developed countries, and increasingly in
developing countries, where poultry is proliferating
rapidly.
The presence of an animal in the cooking area is a risk
factor in developing countries.

Shigella sp.
Hypoglycemia, associated with very high case
fatality rates (CFRs) (43% in one study) occurs more
frequently than in other types of diarrheal diseases
S. sonnei is common in developed countries, causes
mild illness, and may cause institutional outbreaks.
S. flexneri is endemic in many developing countries
and causes dysenteric symptoms and persistent
illness; uncommon in developed countries.
S. dysenteriae type 1 (Sd1) the only serotype that
produces Shiga toxin, as does EHEC

Vibrio cholerae:
In the absence of prompt and adequate rehydration,
severe dehydration leading to hypovolemic shock and
death can occur within 1218 h after the onset of the
first symptom.
Stools are watery, colorless, and flecked with mucus;
often referred to as rice- watery stools.
Vomiting is common; fever is typically absent.
There is a potential for epidemic spread; any infection
should be reported promptly to the public health
authorities.

Salmonella:
In nontyphoidal salmonellosis
(Salmonella
gastroenteritis), there is an acute onset of
nausea, vomiting, and diarrhea that may be
watery or dysenteric in a small fraction of cases.
The
elderly
and
people
with immunecompromised status for any reason (e.g.,
hepatic and lymphoproliferative disorders,
hemolytic anemia), appear to be at the greatest
risk.

Viral

70-80%
of
infectious
developed countries
Rotavirus
Adenovirus
Norovirus (Norwalk-like)
Coronaviral
Astovirus

diarrhea

in

Rotavirus
Leading
cause
of
severe,
dehydrating
gastroenteritis among children.
Nearly all children in both industrialized and
developing countries get infected by
the time they are 35 years of age.
Neonatal infections are common, but often
asymptomatic.
The incidence of clinical illness peaks in
children between 4 and 23 months of age.

Adenovirus
infections most commonly cause illnesses of
the respiratory system.
depending on the infecting serotype, this
virus may cause gastroenteritis especially in
children.

Protozoan:

less than 10%

Entamoeba histolytica
Giardia lamblia
Balantidium coli
Trichuris trichura
Chryptosporidium parvum
Strongyloides stercoralis

 These agents account for a relatively small

proportion of cases of infectious diarrheal illnesses
among children in developing countries.
G. intestinalis has a low prevalence (approximately
25%) among children in developed countries, but
as high as 2030% in developing regions.
Cryptosporidium and Cyclospora are common
among children in developing countries; frequently
asymptomatic.

Non infectious

malabsorption
food poisoning
allergic
motility disorder
immunodeficiency
anxiety

RISK FACTOR DIARHEA

5F

Faeces
Flies
Food
Fluid
Finger

CLASSIFICATION
Acute diarrhea
Acute diarrhea starts suddenly and may
continue or several days. It is caused by
infection of the bowel.
Chronic diarrhea
Persistent diarrhoea is diarrhoea that starts
like acute diarrhoea but lasts for 14 days or
more.

According to Patophisiology :
Osmotic diarrhea
Secretoric diarrhea

How Diarrhea Causes

Dehydration ?

When the bowel is healthy, water and salts pass

from the bowel into the blood.
When there is diarrhea, Less water and salts pass
into the blood, and more pass from the blood into
the bowel. Thus, more than the normal amount of
water and salts are passed in the stool.
This larger than normal loss of water and salts
from the body results in dehydration.
It occurs when the output of water and salts is
greater than the input.

Osmotic Diarrhea
Excess amounts of poorly absorbed substances that remain
in intestina lumen
Substances exert osmotic effect
Obligate water retention in intestinal lumen
Lactose, lactulose, magnesium, polyethene glycol (PEG)

Secretory Diarrhea
Abnormal ion transport in intestinal epithelial
cells due to abnormal mediators
Decreased absorption of electrolytes
Electrolytes: major solutes in intestinal
lumen
Electrolytes account for most luminal
osmolality

ABNORMAL MEDIATORS
Changes in cAMP, cGMP, intracellulae Ca2+,
protein kinases
Bacterial toxins
E. coli
Cholera

ASSESING CHILD WITH

DIARRHEA

Ask
How many liquid stools per day has the child
had?
For how long has the child had diarrhea?
Is there blood (more than 1 or 2 streaks) in the
stool?
Has
there
been
vomiting?
If so, has there been more than a small amount?
How frequently has the child vomited?
Is
the
child
able
to
drink?
If so, is he/she thirstier than normal, does
he/she drink eagerly?

Look

What is the childs general condition?

Is he/she well and alert?
Is he/she restless or irritable?
Is he/she lethargic or unconscious?
Is he/she severely malnourished?
Are his/her eyes normal or sunken?

Feel
When the skin is pinched, does it go back quickly, slowly,
or very slowly (longer than 2 seconds)? In a baby, the
health worker should pinch the skin of the abdomen or
thigh.
Note:
Pinching the skin may give misleading information
In the severely malnourished patient, the skin may go
back slowly even if the patient is not dehydrated.
In the obese patient, the skin may go back quickly even
if the patient is dehydrated.

Weigh the Child

If the child has been weighed routinely and his
weight has been recorded, compare the childs
present weight with his last recorded weight.
Has there been any weight loss during the diarrhea?
If so, were less than 25 grams lost for each kilogram
of the childs weight?
Were 25-100 grams lost for each kilogram of the
childs weight?
More than 100 grams for each kilogram of weight?

TREATMENT OF DIARRHEA

1.
2.
3.
4.
5.

FLUID
ZINC
NUTRITION
SELECTIVE ANTIBIOTICS
ADVICE TO THE PARENTS

INVESTIGATIONS FOR
DIARRHEA
Investigations are not rooutinely done in case of no or some
dehydration
STOOL: MICROSCOPY : low sensitivity and specificity
a. Leucocyte (>10/hpf) invasive diarrhea
b. Hanging drop vibrio cholera
c. Culture & sensitive peristant diarrhea
BLOOD TEST
d. Complete blood count
e. Serum electrolyte
f. BUN & creatinine
Clinitest

Classify
Diarrhea
Dehydration

for

If Diarrhea 14 Days or More

Antimicrobial agents for the treatment

of specific causes of diarrhea

Prevention

Breast-feeding
Water supply
Sanitation improvements
Food hygiene

Complication

Fluid and electrolyte imbalance

Enteric fever
Hemolytic uremic syndrome
Reiter syndrome

THANK YOU