Indian J Pediatr DOI 10.

1007/s12098-012-0909-3

SYMPOSIUM ON PGIMER MANAGEMENT PROTOCOLS IN GASTROINTESTINAL EMERGENCIES

Management of Acute Diarrhea in Emergency Room

Parag Dekate & M. Jayashree & Sunit C. Singhi

Received: 3 July 2012 / Accepted: 8 October 2012 # Dr. K C Chaudhuri Foundation 2012

Abstract Acute diarrhea is the second leading cause of under-five mortality in India. It is defined as the passage of frequent watery stools (>3/24 h). Recent change in consistency of stools is more important than frequency. Acute diarrhea is caused by variety of viral, bacterial and parasitic agents. The common ones are: Rotavirus, E. coli, Shigella, Cholera, and Salmonella. Campylobacter jejuni, Giardia and E. histolytica are also not uncommon. The most important concern in management of acute diarrhea in Emergency room (ER) is fluid and electrolyte imbalances and treatment of underlying infection, wherever applicable. It includes, initial stabilization (identification and treatment of shock), assessment of hydration and rehydration therapy, recognition and treatment of electrolyte imbalance, and use of appropriate antimicrobials wherever indicated. For assessment of hydration clinical signs are generally reliable; however, in severely malnourished children sunken eyes and skin turgor are unreliable. Oral Rehydration Therapy is the cornerstone of management of dehydration. Intravenous fluids are not routinely recommended except in cases of persistent vomiting and/or shock. Majority of cases can be managed in ER and at home. Hospitalization is indicated in infants <3 mo, children with severe dehydration, severe malnutrition, toxic look, persistent vomiting and suspected surgical abdomen. Supplementations with zinc and probiotics have been shown to reduce severity and duration of diarrhea; however evidence does not support the use of antisecretary, antimotility and binding agents. Education of parents about hand hygiene, safe weaning and safe drinking water etc., can help in reducing incidence of this important health problem in the country.
P. Dekate : M. Jayashree : S. C. Singhi (*) Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India e-mail: sunit.singhi@gmail.com

Keywords Children . Acute diarrhea . Oral rehydration therapy . Severe dehydration

Introduction Diarrhea remains second commonest cause of death in children under 5 y in developing countries despite improving trends in diarrhea mortality; it accounts for 15 % of all deaths of children less than 5 y in developing countries [1, 2]. On average, children < 5 y in developing countries, suffer a median of 3.2 episodes of diarrhea/child/year and up to 4.9 children/1000/year die because of diarrhea. Most of the deaths are because of fluid and electrolytes imbalance. The most common concern in Emergency management is acute fluid and electrolytes imbalances and treatment of underlying infection wherever indicated.

Definition Diarrhea Diarrhea is defined as passage of unusually loose or watery stools with an increase in the frequency, usually at least three times in 24 h period. However, it is the consistency of the stools rather than the number that is most important. Breast fed babies may normally pass 57 stools a day. Diarrhea lasting longer than 14 d is labeled as persistent diarrhea. Dysentery Presence of gross blood in the stool is the hallmark of dysentery and may be accompanied by abdominal cramps and fever.

What is Not Diarrhea? & & Passage of frequently formed stools. Passage of pasty stools in breast fed infants.

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& &

Passage of stool during or immediately after feeding due to gastrocolic reflex. Passage of frequent loose greenish yellow stools on the 3rd and 4th day of life called as transitional stools.

Etiology Common organisms causing diarrhea, their incidence and pathogenesis are given in Table 1. Viral diarrhea infects small intestinal epithelium. The onset is generally abrupt, patient is likely to be afebrile and may have associated vomiting or respiratory symptoms. Toxigenic bacteria also involves small bowels and causes secretary diarrhea (Table 2) Invasive bacterial and protozoal diarrhea involves colon. Diarrhea is bloody or mucoid and may have associated colicky abdominal pain, fever and tenesmus. Food poisoning is caused by preformed bacterial toxins. Onset is abrupt with vomiting followed by diarrhea (Table 3).

apathy may be present in both the types of malnutrition. In such children thirst, dry tongue and mouth (inner side of cheek), and signs of hemodynamic compromise (fast thread pulse, delayed capillary refill time and orthostatic changes in BP, and hypotension) are most reliable indicators of dehydration [4]. On abdominal examination children with uncomplicated diarrhea generally tend to have diffuse abdominal tenderness and loud bowel sounds. Presence of localized tenderness, rebound tenderness to absent bowel sounds indicates a possible surgical cause. Palpation of a loop of bowel or a mass suggests intussusception, enterocolitis or inflammatory bowel disease. Laboratory Investigations Laboratory investigations are not required routinely in majority of cases of acute diarrhea. Indications for selective use of laboratory investigations are as summarized in Table 7.

Differential Diagnosis of Acute Diarrhea [3, 9] Clinical Evaluation [24, 810] The objectives of initial clinical evaluation of the patient in emergency department are: 1. Assessment of the severity of the illness, grade of dehydration and rehydration needs. 2. Identification of likely causes on the basis of the history and clinical findings. A rapid assessment of airway, breathing and circulation should be done in all children at presentation. Tachycardia, prolonged capillary refill time, decreased urine output, altered mental status and hypotension indicates presence of shock and calls for oxygen, and fluid resuscitation with 20 ml/kg normal saline bolus. History and Examination Further history and examination [24, 810] should include information as shown in Table 4. Hydration status is assessed from stool frequency, heart rate, pulse volume, capillary refill time, skin turgor, sunken eyes or fontanelle and activity level, or change in weight from the previous weight. Grading of hydration status based on clinical signs is shown in Table 5 and that based on change in weight in Table 6. Some of the typical signs of dehydration may not be reliable in malnourished children. Marasmic children may have sunken eyes, and diminished skin turgor without dehydration. Skin turgor may be masked by edema in children with Kwashiorkor; irritability and Systemic Disease with Acute Diarrhea Infants and young children with systemic disease can sometimes present with acute diarrhea. They generally have systemic signs of sepsis and sick look, but not necessarily. In such children following clinical diagnosis should be kept in mind. & & & & & Otitis media, bacterial pharyngitis Urinary tract infection Pneumonia Meningitis Bacterial sepsis

Diarrhea with Surgical Acute Abdomen When symptoms of colicky abdominal pain, vomiting and lethargy accompany bloody diarrhea, and abdominal palpation reveals a mass, intussusception, malrotation, and subacute intestinal obstruction should be ruled out. Sometimes because of ingested food stools may appear red (e.g., From beet, red candies, popsicles, cranberries etc.) or tarry (bismuth containing anti-diarrhea, Iron-spinach, chocolate etc.) mimicking blood in stools.

Management [2, 4] Majority of the patients with diarrhea having mild or no dehydration can be treated on ambulatory basis at home. Some patients may need a brief period of observation while patients

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Table 1 Etiological causes of diarrhea with incidence and pathogenesis [36] Incidence Causes 1520 % of diarrhea Responsible for upto 50 % of diarrhea associated with clinical dehydration in children aged 624 mo. Pathogenesis Cytopathic to small intestinal epithelial cells

Category

Agent

Viruses

Rotavirus

Bacteria Causes upto 510 % of acute diarrhea in all age groups

Enterovirus Adenovirus 25 % Enterotoxigenic E. coli (ETEC) Causes up to 25 % diarrhea in all age groups

Shigella

Virus replication and cytopathic effect on small intestinal cells Cytolysis, cytokine production, and induction of host inflammatory response Produces heat labile (LT) and/or heat stable (ST) enterotoxins causing secretory diarrhea of small intestine Dysentery syndrome by invasion of large bowel and enterotoxin mediated small bowel diarrhea Toxin mediated secretory diarrhea

Vibrio cholera

Non typhoidal salmonella Campylobacter jejuni Protozoal Giardia duodenalis[5]

Frequent cause of diarrhea in endemic areas in children 210 y of age. Accounts for 510 % hospitalization in non endemic areas. Causes 210 % of diarrhea in developing countries Causes 515 % of all diarrhea. It is a zoonosis Most common protozoal infection causing diarrhea

Entamoeba histolytica [6]

Cryptosporidium [7]

Annually 0.09 episodes/child of E. histolytica-associated diarrhea and 0.03 episodes/child of E. histolytica-associated dysentery Causes a self-limited diarrheal illness in healthy individuals and persistent diarrhea in immunocopromised children

Intracellular invasion of ileal epithelium Invasive and toxigenic diarrhea Damage to the endothelial brush border, enterotoxins, immunologic reactions, and altered gut motility and fluid hypersecretion Excystation in the small bowel and invasion of the colon by the trophozoites Infects distal small intestine and proximal colon, no cytopathic effect. Causes villous atrophy, lymphocytic infiltration etc.

Indian J Pediatr Table 2 Etiologic agents and and pattern of small vs. large bowel diarrhea [3, 4] Site Small bowel diarrhea Organisms Rotavirus, Salmonella, V. cholera, Giardia, Cryptosporidium Shigella, Enteroviruses, E. coli, C. jejuni, E. histolytica Characteristics Frequent, large quantity, watery, greenish to white stools Semi-loose, small quantity, with or without blood in the stool Onset, frequency, quantity Character: bile, blood and mucus Vomiting (color and frequency) Fever Oral acceptance Abdominal distension Level of consciousness, abnormal movements Urine output (passage of urine in last 6 h) Perianal excoriation or redness Underlying medical condition Past medical history Epidemiological history General appearance, alertness Temperature Pulse rate, volume Respiratory rate (acidotic breathing) Blood pressure Capillary refill time Mucus membrane (tongue, inner cheek) Sunken fontanels, sunken eyes Skin turgor Glasgow coma score (GCS) Signs of malnutrition Change in body weight (if previous body weight known) Table 4 History and clinical evaluation of diarrhea patient [2, 4, 8, 9] History Assessment of dehydration

Large bowel diarrhea

having severe dehydration and a selective group of very young, malnourished, toxic-sick looking patients need hospitalization as shown below. Indications for Observation in Emergency Department & & & & Stable newborns and infants with diarrhea without features of toxicity and dehydration. Patient with moderate dehydration accepting orally well. Malnourished children with mild dehydration. Patients with diarrhea without dehydration with decreased oral intake. Indications for Hospitalization [24, 10] & & & & & & & & & & & Severe dehydration requiring intravenous hydration. Newborns and infants <3 mo of age with dehydration. Malnourished children with dehydration. Toxic appearance, changing mental status (GCS<11) or seizures. Fever >38.5 C for infants > 3 mo or >39 C for children 636 mo-old. Suspected surgical cause: localizing findings and enterocolitis need surgical consult. High output diarrhea (>10 large volume stool/day). Persistent vomiting, or diminished or no oral intake . Suboptimal or no response to oral rehydration therapy (ORT) or further deterioration. Inability of caregivers to administer ORT. History of premature birth, chronic medical conditions or concurrent illness.

Treatment of a Child with Diarrhea Presenting in Shock It is difficult to distinguish between hypovolemic shock caused by severe dehydration and septic shock initially. All children in shock should be given 20 ml/kg of rapid fluid bolus in first hour with continuous monitoring of pulse rate, pulse volume, respiratory rate, capillary refill time and urine output. If shock improves at the end of the bolus (reflected by decrease in pulse rate, respiratory rate, improved pulse volume, capillary refill time and urine output), a diagnosis of hypovolemic shock (severe dehydration) should be considered and oral rehydration therapy should be started as detailed later. If there is worsening or no improvement at end of initial fluid bolus, septic shock should be considered and appropriately managed as per the septic shock guidelines (management of septic shock is beyond the scope of this protocol, please refer to septic shock guidelines elsewhere). Oral Rehydration Therapy (ORT) Oral rehydration therapy (ORT) is the administration of fluid by mouth to prevent or correct dehydration that occurs as a consequence of diarrhea. ORT is the standard for efficacious and cost-effective management of acute gastroenteritis, both in developing and developed countries. Oral rehydration solution (ORS) is the fluid specifically developed for ORT. Composition of standard ORS is shown in Table 8. A more effective, lower-osmolarity ORS (with reduced concentrations of sodium and glucose, associated with less vomiting, less stool output, and a reduced need for intravenous infusions in comparison with standard ORS) has been developed for global use [2, 8, 10].

Table 3 Incubation period and likely causes of toxogenic diarrhea/ food poisoning [3, 4] Incubation period <6 h 6 24 h 16 72 h Likely causes of diarrhea Preformed toxins of B. cereus and S. aureus Preformed toxin of C. perfringes and B. cereus Vibrio, Salmonella, ETEC, Shigella, Campylobacter, Yersinia, Shiga toxin producing E.coli, Giardia, Cyclospora, Cryptosporidium

Indian J Pediatr Table 5 Assessment of dehydration [24, 8, 9]

Characteristics

Mild dehydration < 4/d Some/none Well alert Normal Present Moist Drinks normally Normal Normal Warm Normal Normal Normal

Moderate dehydration (2 signs) 410/d Some/none Restless, irritable Sunken Absent Dry Thirsty, drinks eagerly Delayed (slow return) Prolonged Cold Increased Normal to decreased Decreased and high colored

Severe dehydration (>2signs)

Watery stools Vomiting Condition Eyes Tears Tongue Thirst Skin turgor CRT Extremities Heart rate Pulse quality Urine output

>10/d Very frequent Lethargic, dry, floppy Very sunken and dry Absent Very dry Unable to drink Very delayed (>2 s) Prolonged Mottled, cynotic Increased or decreased in severe cases Weak, thread, impalpable Very scanty/anuria for 6 h

ORT consists of & & & Rehydration Maintenance therapy Prevention of ongoing losses

&

ORT may be contraindicated in children who are in hemodynamic shock or with ileus. For children who are unable to tolerate ORS via oral route (with persistent vomiting), naso-gastric feeding can be used to administer ORS. Treatment of Mild and Moderate Dehydration 1. Oral Rehydration Therapy (ORT) [2, 4, 10] & Determine amount of ORS to be given during first 4 h (Table 9) & Show the mother how to mix and give ORS solution. Give frequent small sips from a cup. If the child vomits, wait for 10 min. Then continue, but more slowly. Continue breastfeeding whenever the child wants. & Give recommended amount of ORS over 4h period as mentioned in Table 9 according to the degree of dehydration. & Reassess for the degree of dehydration after 24 h and select the appropriate plan for further rehydration. 2. Give Extra Fluids [2, 4, 11] & If breast fed, breastfeed frequently and for longer at each feed.

& & &

If the child is not exclusively breastfed, give one or more of the following home made food-based fluids (such as soup, rice water, and yoghurt drinks), or clean water. If the child wants more ORS than shown, give more. For infants less than 6 mo who are not breastfed, also give 100200 ml clean water during this period. Show the mother how much fluid to give in addition to the usual: Up to 2 y: 50 to 100 ml after each loose stool and in between them. 2 y or more: 100 to 200 ml after each loose stool and in between them.

3. Continue Feeding [2, 10] Begin feeding the child in emergency itself with whatever is appropriate for the age of the child. Avoid high fiber and bulky food, very dilute soups and food with lot of sugar.

Points to be Kept in Mind During Rehydration [4] & & & Rehydration must be assessed by clinical examination and not by fluid volume given. The volumes can be increased to achieve rehydration. Puffiness around the eyes suggests over hydration.

Table 6 Assessment of severity of dehydration as per body weight loss [2 4] Age Infants (EWL) Children and adolescents(EWL) EWL Estimated weight loss Mild dehydration 05 % of body wt. loss <3 % of body wt. loss Moderate dehydration 510 % of body wt. loss 39 % of body wt. loss Severe dehydration >10 % of body wt. loss >9 % of body wt. loss

Indian J Pediatr Table 7 Indications for various investigations in a patient with acute diarrhea and their importance [4, 10] Investigations Stool routine Stool culture Indications 1. Mucoid and bloody diarrhea 2. Suspected cholera (hanging drop preparation) 1. Toxic looking infants <1 y having polymorphs in stool 2. Suspected cholera 3. Immunocompromised children 4. Children with hemoglobinopathies 1. Newborns with diarrhea 2. Toxic infants and childrens 3. Infants <3 mo, with fever >38.5C 4. Older children with sepsis, fever, seizures and altered sensorium 1. All those requiring hospitalization 2. Seriously ill toxic patients 3. Severe dehydration/shock 4. Malnourished patients with dehydration 5. Newborns and infants <3 mo 6. Children with altered sensorium 1. All seriously ill patients 2. Patients with acidotic breathing 3. Patients with severe dehydration or shock 4. Malnourished patients with dehydration 1. Malnourished patients 2. Severely dehydrated patients 3. Patients with high output diarrhea 4. Patients having acidosis Important points Presence of leukocytes, protozoa, RBCs and bacteria. Presence of polymorphs suggest infection by invasive bacteria Available after 23d Start/change antibiotic as per sensitivity pattern

Blood counts, blood culture, CRP

Distinguishes Salmonella and Shigella infection Shigella having a marked shift to left. Start/change antibiotic as per sensitivity pattern Monitoring of systemic inflammation These parameters will guide the treatment plan and guide the response to treatment. Some abnormalities need urgent treatments (hypo kalemia, hypoglycemia, hyponatremic seizures etc. )

Blood biochemistry (Na, K, urea, creatinine, glucose)

Blood gas analysis

Will tell about metabolic acidosis, bicarbonate losses from the body, body compensation and improvement with treatment Will tell about the K+ status

ECG

Maintenance therapy should be started as soon as the signs of dehydration have gone, but not before it. A simplified algorithm for rehydration therapy of acute diarrhea is shown in Fig. 1. When to Return Mother/caretaker should be advised to return to health care facility immediately if any of the following symptoms are noticed. & & Passes many stools (>10 times/d) Is very thirsty

& & & & & &

Has sunken eyes Has fever Does not eat or drink normally Not passing urine for 6 h Having altered mentation Not getting better after 2 d

Treatment of Severely Dehydrated Children (Replacement Therapy) [2, 4, 10] Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringer s Lactate Solution (or, if not available, normal saline) divided as follows: 20 ml/kg body weight intravenously till perfusion and mental status improve; then administer 100 ml/kg ORS over 4 h or 5 % dextrose saline IV at twice maintenance fluid rate (Table 9). & Reassess the child every 12 h. If hydration status is not improving; give IV drip more rapidly. Also give ORS (about 5 ml/kg/h) as soon as the child can drink; usually after 34 h (infants) or 12 h (children).

Table 8 Composition of WHO ORS [2] Components g/L Constituents (ionic form) Sodium Chloride Glucose Potassium Citrate Total osmolality Concentration (mmol/L) 75 65 75 20 10 245

Sodium chloride Anhydrous glucose Potassium chloride Trisodium citrate, dihydrate -

2.6 13.5 1.5 2.9 -

Indian J Pediatr Table 9 Guidelines for rehydration therapy [2, 4, 10]

Degree of dehydration Mild Moderate

Age group All < 4 moa (< 6 kg) 4 12 mo (6 10 kg) 12 24 mo (10 12 kg) 24 60 mo (12 19 kg) < 12 mo

Type of fluid ORS ORS ORS ORS ORS

Volume of fluid 50 ml/kg 200 400 ml 400 700 ml 700 900 ml 900 1400 ml

Rate of administration Within 4 h Within 4 h Within 4 h Within 4 h Within 4 h

Use the childs age only when the weight is not known. The approximate amount of ORS required (in ml) in case of moderate dehydration can be calculated as 50 100 (75) ml/kg of childs body weight [2]
a b

Severe

Repeat if radial pulse is still very weak or not detectable and consider probable septic shock

RL First 30 ml/kg Within 1 hb RL Then 70 ml/kg Within 5 h 15y RL First 30 ml/kg Within 30 min RL Then 70 ml/kg Within 2.5 h If signs of dehydration are still present follow by: ORS 20 ml/kg every hour

& &

Reassess an infant after 6 h and a child after 3 h. Classify dehydration. Then choose the plan to continue treatment If ORT is not possible or feasible, same amount of fluid can be given intravenously. Type of fluid used is Ringer lactate or N/2 in 5 % dextrose (Fig. 1).

Therapeutic End Points in Intravenous Rehydration Therapy 1. 2. 3. 4. Adequate urine output Urine specific gravity (1.0101.015) Normal serum electrolytes BUN decreased by one half every 1520 h till normalized

Fig. 1 A simplified algorithm for rehydration therapy of acute diarrhea

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5. Normal acid base status 6. Urinary K+> 40 mEq/L Antimicrobial Therapy [2, 3, 8, 10] The decision to treat with antimicrobial therapy should be made on a patient-by-patient basis, and may differ according to the age group. Antimicrobials are not needed for small bowel diarrhea and food poisoning except cholera. Large bowel diarrhea is invasive. Salmonella can cause bacteremia in about 1045 % of infected infants and neonates, while shigella and invasive E. coli can cause high fever and toxemia. In shigellosis,therapy is required in severely ill children or children with persistent symptoms. Yersinia needs treatment when there is severe disease, bacteremia or underlying illness. Timely antibiotic therapy in selected cases of diarrhea may reduce the duration and severity of diarrhea and prevent complications. While these agents are important to use in specific cases, their widespread and indiscriminate use leads to development of anitmicrobial resistance. Use of antimicrobials is recommended in the treatment of acute diarrhea when there

are signs of systemic infections, recognizable bloody diarrhea and in immunocompromised hosts as follows: 1. Diarrhea with clinical signs of sepsis: (toxic look, leukocytosis, fever > 38.5 C, septic shock): Ceftriaxone 50 100 mg/kg/d IV/IM divided 12 hourly for 710 d. 2. Diarrhea in a child with severe malnutrition: Ampicillin 200 mg/kg/d IV/IM divided 6 hourly along with gentamicin 5 mg/kg/d IV/IM 8 hourly for 710 d. 3. Neonates and very young infants (< 3 mo) with fever (> 38.5C): Cefotaxime 150 mg/kg/d IV/IM divided 8 hourly along with amikacin 15 mg/kg/d IV/IM OD for 710 d 4. Dysentry (bloody stools) and diarrhea during outbreak of shigellosis: Ceftriaxone IV/IM 50100 mg/kg/d for 7 d or Ciprofloxacin orally 2030 mg/kg/d divided 12 hourly for 710 d. 5. Suspected Cholera (Rice water stools with high purge rate i.e., > 10 large volume stools/d): Doxycycline 300 mg OD for 3 d or Azithromycin 20 mg/ kg single dose. Treatment of cholera decreases duration of disease and mortality, and controls the transmission.

Table 10 Antibiotics used in acute diarrhea as per causative agent[24, 7, 9, 10] Organism Drug of choice Doses Ceftriaxone IV IM 50100 mg/kg/d qd, bid 7 d Ciprofloxacin PO 2030 mg/kg/d bid 710 d 10 mg/kg/d of TMP and 50 mg/kg/d of SMX bid 5 d Doxycycline 300 mg OD for 3 d Azithromycin 20 mg/kg single dose Ciprofloxacin PO 2030 mg/kg/d qid for 510 d 10 mg/kg/d of TMP and 50 mg/kg/d of SMX bid 5 d Ciprofloxacin PO 2030 mg/kg/d qid for 510 d See treatment of Shigella

Shigella (severe dysentery Ciprofloxacin, ampicillin, ceftriaxone, or and EIEC dysentery) trimethoprim-sulfamethoxazole (TMP-SMX). Most strains are resistant to many antimicrobials V. cholera Doxycycline, azithromycin or ciprofloxacin TMP-SMX or ciprofloxacin No antimicrobials for uncomplicated gastroenteritis in normal hosts caused by non-typhoidal species. Treatment is indicated in infants <3 mo, patients <1 y with toxic look, severe colitis, immuno-incompetent state (malignancy, chronic GI disease, hemoglobinopathies, or HIV infection) Discontinue offending antibiotic Metronidazole (first line) Vancomycin (2nd line) Metronidazole Furazolidone or metronidazole or albendazole or quinacrine Erythromycin or azithromycin

EPEC, ETEC, EIEC Salmonella

Clostridium difficile

Entamoeba histolytica Giardia lamblia

Campylobacter jejuni

PO 30 mg/kg/d divided tid 5 d PO 40 mg/kg/d qid 7 d PO 3040 mg/kg/d tid 710 d Furazolidone PO 25 mg/kg/d qid for 57 d Metronidazole PO 3040 mg/kg/d tid 7 d Albendazole PO 200 mg bid 10 d Erythromycin 50 mg/kg q8h, 5 d Azithromycin 510 mg/kg qid, 5 d

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Antimicrobials to be given in acute diarrhea when the pathogen is known are given in detail in Table 10. Other Ways of Management Significant abnormalities in serum sodium concentration can to occur in acute diarrhea. In patients receiving intravenous rehydration further management of fluid and electrolyte therapy with respect to serum sodium concentration is given in Table 11. Enteral Feeding and Diet Selection [2] Give an age- appropriate diet-regardless of the fluid used for ORT/maintenance. Infants require more frequent breastfeedings. Older children need appropriately more fluids and energy and micronutrient rich foods (Energy density 1 kcal/g). Give appropriate food (grains, dals, bananas and vegetables) as frequent, small meals throughout the day (six meals/day); avoid high fibre, bulky diet. Gradually increase energy intake as tolerated to reach an energy intake of 100 kcal/kg/d and protein intake 23 g/kg/d. A lactose free diet is often recommended, but is needed in malnourished patients or after severe enteritis. Zinc Therapy (Zinc supplementation) [2, 4, 10] Zinc deficiency is widespread among children in developing countries. Supplementation treatment with zinc (20 mg per day until diarrhea ceases) reduces the duration and severity of diarrheal episode in children in developing countries. Zinc supplements are given for 10 14 d during and after diarrhea in the doses of 10 mg/kg for infants < 6 mo of age and 20 mg/d for the children >6 mo of age. In addition to improving diarrhea, administration of zinc in community settings leads to increased use of ORS and reduction in the use of antimicrobials. Probiotics [11, 12] Used alongside rehydration therapy, probiotics appear to be safe and have clinically beneficial effects in shortening the

Increased (>145 mEq/L) Hypertonic dehydration <10 mEq/L 1/3 normal saline 10 % 1215 % > 15 %

6. Suspected amebiasis, or giardiasis (colitic stools, anorexia and weight loss, persistent diarrhea, failure to thrive): Metroinidazole oral 3040 mg/kg/d divided 8 hourly for 7 10 d, and cryptosporidium (nitazoxamide). 7. Diarrhea in an immunocompromized child (HIV infection, lymphoreticular malignancy, receiving chemotherapy, underwent organ transplantation)

3040 mEq/L 824 h (depending upon Sr. Na+ values)a 2436 h a Deficit estimation Total volume requirement Na+ concentration of repair solution Rate of replacement of total volume replacement Other of total volume replacement
a

Table 11 Classification of dehydration depending upon sodium concentration and its management [4]

Total body water Serum Sodium concentration Physiological derangement Urine sodium Treatment Level of dehydration

The maximum accepted change in serum osmolality is 11.5 mOsmol/L per hour, thus it restricts change of serum Na+ to 0.5 1 mEq/L per hour

Mild Moderate Severe

Decreased Decreased (<135 mEq/L) Normal (135145 meq/L) Hypotonic dehydration Isotonic dehydration <10 mEq/L Variable Isotonic saline normal saline <5% <5% 5% 10 % 10 % 15 % Weight in kg volume deficit Maintenance fluids (Holiday Segar formula) + Deficit volume 80100 mEq/L 5080 mEq/L 46 h 68 h 1020 h 15 h

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duration and reducing stool frequency in acute infectious diarrhea [11, 12]. There are varieties of microorganisms (Lactobacillus, Bifidobacterium) that have good safety record; therapy has not been standardized and most effective and safe organisms and regimens for specific groups have not been identified. The authors give their patients probiotics for 5 d. Antimotility Agents [2, 4, 10] Gut stasis following use of antimotility agents may lead to invasion of the bowel wall by infecting organisms leading to worsening of the condition. These agents are contra-indicated in children with dysentery and probably should not be given to infants and young children.
Fig. 2 Algorithm for management of a patient with diarrhea

Antiemetic Agents [2, 4, 10] Phenothiazines are of little value and are associated with potentially serious side effects. Ondensetron is an effective and less toxic antiemetic agent (Dose: 2 mg in children 815 kg, 4 mg in children >1530 kg, 8 mg in children >30 kg). A comprehensive approach to management of acute diarrhea is shown in Fig. 2. Specific Aspects of Management of Acute Diarrhea in Children with Severe Malnutrition Diarrhea is a serious and often fatal event in children with severe malnutrition [13, 14]. Management of acute diarrhea in these children presents unique challenges as

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malnutrition predisposes to severe and prolonged diarrhea due to underlying micronutrient deficiency (particularly zinc) that causes suppressed immune function. Care of these children, in addition to correction of dehydration, must focus on management of malnutrition, continuation of feeding which lessens weight loss and early detection and treatment of underlying infections and probable sepsis [14].

edema and appearance of periorbital puffiness indicates overhydration. Prevention [2, 3, 7, 8] Use this opportunity to educate parents about following measures to prevent further episodes of diarrhea: Safe water and sanitation, hand hygiene, exclusive breast feeding for initial 6 mo, appropriate and safe weaning, safe food handling habits, Vitamin A supplementation and vaccinationagainst Rotavirus, Typhoid fever, and Measles.

Assessment of Dehydration As mentioned earlier, typical signs of dehydration such as skin turgor, sunken eyes, mental status and peripheral temperature are unreliable for assessment of hydration status in a malnourished child. In such children thirst, dry tongue and inner side of cheek, and signs of hemodynamic compromise (fast weak or absent pulses, delayed capillary refill time and orthostatic changes in BP, and hypotension) and reduced or absent urine flow indicates severe dehydration [4].

Conflict of Interest None.

Role of Funding Source

None.

References
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Principles of Treatment Malnourished children in shock should be treated as per details given in the section earlier. Children with signs of sepsis or in a state of severe malnutrition should receive systemic broad spectrum antibiotics. General principles of dehydration correction remain same as that for any child with diarrhea with following exceptions: i. Reduced Osmolarity ORS [RO-ORS] with potassium supplements should be preferred for rehydration and maintenance. ii. Dehydration should be corrected slowly over 12 h. iii. ORT should be given at 10 ml/kg/h for first two hours followed by at 510 ml/kg every hour for next 410 h (by oral/nasogastric tube), adjusting it based on the capability of child to drink, volume of fluid loss in stools and vomiting. iv. Careful frequent reassessment is needed for signs of rehydration and overhydration. v. Overhydration in a malnourished child is dangerous and can precipitate heart failure because of poor cardiac reserve and pumping capability contributed by underlying nutritional cardiomyopathy, anemia with volume overloaded state and acute illness related decompensation. An increase in pulse rate with improved pulse volume, increase in respiratory rate, crepitation over basal lung regions, appearance or increase in

Indian J Pediatr 11. Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev. 2010;11:CD003048. doi:10.1002/14651858. CD003048.pub3. 12. Szajewska H, Mrukowicz JZ. Probiotics in the treatment and prevention of acute infectious diarrhea in infants and children: a systematic review of published randomized, doubleblind, placebo-controlled trials. J Pediatr Gastroenterol Nutr. 2001;33:S1725. 13. Sachdev HP, Kumar S, Singh KK, Satyanarayana L, Puri RK. Risk factors for fatal diarrhea in hospitalized children in India. J Pediatr Gastroenterol Nutr. 1991;12:7681. 14. Uysal G, Skmen A, Vidinlisan S. Clinical risk factors for fatal diarrhea in hospitalized children. Indian J Pediatr. 2000;67:32933.