IMCI GUIDELINES DIARRHEA

1. 19 FEB 2011 Mejino, Carmelou Melgarejo, Ivy Mendoza, Alvin Mendoza, Diana IMCI GUIDELINESDIARRHEA

2. OUTLINE • Definition of Diarrhea • Assessment of Child with Diarrhea • Discussion of IMCI Guidelines on Diarrhea

3. DEFINITION: DIARRHEA • It is passage of stool at least twice the normal bowel movement wherein the stools follow the shape of the container. • It is also defined in infants and children as a stool output of greater than 10 g/kg/day (normal=5-10 g/kg/day) and more than the adult limit of 200 g/24 hour. Nelson’s Textbook of Pediatrics. 17th ed.

4. Classification of Diarrhea Acute Diarrhea • It is the passage of loose and watery stool of less than two weeks duration. Chronic/Persistent Diarrhea • It is the passage of loose and watery stool of two weeks or longer duration.

5. CLINICAL TYPES OF DIARRHEA • Acute watery diarrhea (includes cholera): lasts several hours or days; main danger is dehydration • Acute bloody diarrhea: “dysentery” causing major damage to intestinal mucosa, sepsis and malnutrition • Persistent diarrhea: lasts 14 days or longer that results in malnutrition and serious non-intestinal infection • Diarrhea with severe undernutrition: major dangers are: severe systemic infection, dehydration, heart failure, vitamin and mineral deficiency The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev. WHO document 2005

6. For ALL sick children ask the mother about the child’s problem, check for general danger signs, ask about cough or difficult breathing and then ASK: DOES THE CHILD HAVE DIARRHEA? If NO If YES Does the child have diarrhea? IF YES, ASK: LOOK, LISTEN, FEEL: œ For how long? œ Look at the child’s general condition. Is the child: œ Is there blood in the stool Lethargic or unconscious? Restless or irritable? œ Look for sunken eyes. œ Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? œ Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly? Classify DIARRHEA CLASSIFY the child’s illness using the colour-coded classification tables for diarrhea. Then ASK about the next main symptoms: fever, ear problem, and CHECK for malnutrition and anaemia, immunization status and for other problems.

7. Assessment of Child with Diarrhea • Dehydration • General condition • Sunken eyes • Thirst • Skin elasticity • Persistent diarrhea • Dysentery

8. Does the child have diarrhea? • IF YES, ASK: • For how long? • Is there blood in the stool? • LOOK, LISTEN, FEEL: • Look at the child’s general condition, is the child: • Lethargic or unconscious? • Restless or irritable? • Look for sunken eyes • Offer the child fluid. Is the child: • Not able to drink or drinking poorly? • Drinking eagerly, thirsty? • Pinch the skin of the abdomen. • Does it go back: • Very slowly (> than 2 • secs)? • Slowly?

9. CLASSIFICATION TABLE FOR DEHYDRATION IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) SIGNS CLASSIFY AS

10. Four Rules for Home Treatment of Diarrhea(Treatment Plan A) • Rule 1: Give more fluids than usual • Rule 2: Zinc supplementation at 20 • mg/day for 10-14 days • (10 mg for infants < 6 months) • Rule 3: Continue to feed the child • Rule 4: When to return to the clinic Diarrhea Treatment Guidelines for Clinic-Based Health Care Workers

11. FLUIDS TO GIVE • Wherever possible, these should include at least one • fluid that normally contains salt • Plain clean water should also be given • Fluids that normally contain salt • ORS solution • Salted drinks (salted rice water, salted yoghurt drink) • Vegetable or chicken soup with salt • Fluids that do not contain salt • Plain water • Water in which a cereal has been cooked • Unsalted soup • Yoghurt drinks without salt • Green coconut water • Weak tea • Unsweetened fresh fruit juice The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev. WHO document 2005

12. DO NOT GIVE THESE FLUIDS!!! • Drinks sweetened with sugar • Commercial carbonated beverages • Commercial fruit juices • Sweetened tea • Other fluids to avoid • Those with stimulant, diuretic and purgative effect • Coffee • Some medicinal teas or infusions The Treatment of Diarrhea: A manual for physicians and other senior health workers. 4th rev. WHO document 2005

13. Treatment Plan BOral Rehydration Therapy for children with some dehydration

14. TPB Approximate amount of ORS solution to give in the first 4 hours

15. TREATMENT PLAN CTo treat Severe Dehydration quickly

16. Treatment Plan C *Repeat once if radial pulses very weak or or not detectable • Reassess the patient every 1-2 hours.If hydration is not • Improving, give the IV more rapidly • Also give ORS (about 5 ml/kg) as soon as the patient can drink, usually • after 3-4 (infants) or 1-2 hrs. (older patients)

17. CLASSIFICATIONTABLE FOR PERSISTENT DIARRHEA IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) SIGNS CLASSIFY AS

18. CLASSIFICATION TABLE FOR DYSENTERY IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) SIGNS CLASSIFY AS

19. 4Key Elements for effectiveclinical management of acute diarrhea • Replacement of fluids, usually by ORT to prevent dehydration in the home and to treat dehydration • Continued feeding, especially breastfeeding, during diarrhea episodes and in convalescence • No use of antidiarrheal drugs and selective use of antibiotics • Effective instruction of the child’s mother on • how to take care of the sick child at home • the indications for follow-up • methods of preventing future episodes of diarrhea

20. WHO Etiologic Agents for most cases of diarrhea

21. 4 conditions where antimicrobials are indicated • Cholera - Tetracycline • Shigella dysentery - Nalidixic acid • Giardiasis - Metronidazole • Amoebiasis - Metronidazole

22. Antimicrobial % resistance of Enteric pathogens