INFECTIOUS DIARRHEA

BACKGROUND

Diarrhea refers to the passage of loose or watery stools or an increased frequency of stools for the child and occurs at some point in the life of nearly every child. Diarrhea is not a disease, but is a symptom of a number of illnesses. Diarrhea can lead to dehydration, which alters the child's natural balance of water, and to electrolyte (sodium, potassium, chloride) imbalance. It can be serious if not treated promptly.

DISEASE OCCURRENCE IN POPULATION:

According to the World health organization (WHO), diarrheal diseases in children remain second leading cause of death in children under 5 year of age.

In Pakistan 100-150 children die every day as a result of diarrhoeal-related illnesses. Between 60 and 75 million people are affected by diarrhoeal-related illnesses annually, and 60 per cent of under five deaths are due to water- and sanitation-related diseases.

In Pakistan, every child on average suffers from 5-6 episodes of diarrhea per year. The reported prevalence of diarrhea in Punjab is found as 7.8%.

RISK FACTORS:

Risk factors for infectious causes of diarrhea include:

• Travel to foreign countries, attendance at day care, foster home and school as well as sick contacts at home.
• Recent antibiotic use can also put children at risk for developing diarrhea.
• Poor hygiene and lack of sanitation increase the incidence e.g. bad water in the developing world.
• Compromised immune system.

SIGN AND SYMPTOMS:

Diarrhea may also be accompanied by:

• Urgency with bowel movements, which means that children feel that they have to get to the bathroom immediately
• Abdominal pain and / or bloating
• Rectal pain
• Nausea and / or vomiting
• Weight loss
• Fever

Individuals with diarrhea are at risk for dehydration, which occurs when someone is unable to take in sufficient fluid orally to meet their daily requirements and compensate for losses in their stools. Signs of dehydration include:

• decrease in urine output / wet diapers
• dry lips and mouth
• lack of tears when crying
• increased irritability and fussiness
• increased sleepiness / decreased energy level

DIAGNOSTIC TEST:

The doctor will carry out certain tests and analysis for a proper diagnosis. Assessing the medical history of the patient and physical examination are the basic steps, after which, if needed, the doctor will carry out certain tests to determine the severity of diarrhoea. These tests include:

• Stool Culture: To check if any harmful bacteria has infected the digestive tract and is causing diarrhoea by analysing stool sample in laboratory.
• Colonoscopy: To view the colon (large intestine) and check for any abnormal growth, swelling or bleeding, by entering a colonoscope through the rectum to the colon.
• Sigmoidoscopy: To view the inside of the colon and check for causes of diarrhoea; by entering a sigmoidoscope into the colon which blows air into it so that it can be viewed properly.​
• Blood test: A complete blood count test can help determine what's causing your diarrhea.
• Imaging tests: to rule out structural problems
• Tests to check for food intolerance or allergies.

TREATMENT OPTIONS:

Treatment will depend on child’s symptoms, age, and general health. It will also depend on how severe the condition is.

DIETARY RECOMMENDATIONS: Children who are not dehydrated should continue to eat a regular diet and infants who are breastfeeding should continue to do so unless the parent(s) is told otherwise by their clinician. Dehydrated children require rehydration (replacement of lost fluid) and suitable oral rehydration solutions are the most physiologic. After being rehydrated, severely affected children will be able to resume a normal diet.

Specific suggestions for children who are not dehydrated and are tolerating a regular diet include the following:

• Most children with diarrhea tolerate full-strength cow's milk products. It is not necessary to dilute or avoid milk products, except in children with known allergies to cow's milk.
• Recommended foods include a combination of complex carbohydrates (rice, wheat, potatoes, bread), lean meats, yogurt, fruits, and vegetables. High-fat foods are more difficult to absorb and should be avoided.
• The unnecessary restriction of a child's diet to clear liquids or the BRAT diet (bananas, rice, applesauce, toast) results in inadequate intake of nutrients (caloriesand / or protein). Giving only clear liquids for several days can actually prolong diarrhea (called "starvation stools").
• Sports drinks should be avoided because they have too much sugar and have inappropriate electrolyte levels for the patient with diarrhea. If fruit juice is to be given, it is suggested to start with half-strength apple juice (apple juice mixed with an equal amount of water) and then letting the child drink whatever they prefer.

ORAL REHYDRATION THERAPY: Oral rehydration therapy (ORT) was developed as a safer, less expensive, and easier alternative to intravenous fluids. Oral rehydration solution (ORS) contains glucose (a sugar) and electrolytes (sodium, potassium, chloride) that are lost in children with vomiting and diarrhea. Various rehydration solutions are available. Parents should check with a healthcare provider to determine which solution is preferred. A child who is moderately or severely dehydrated needs to be evaluated by a healthcare provider. If a child refuses to accept ORS because of vomiting and / or becomes moderately to severely dehydrated, as indicated by decreased urination (>6 hours since passing most recent urine), lethargy, or other features, the child requires professional evaluation and treatment.

ORS may be given at home to a child who is mildly dehydrated, refusing to eat a normal diet, or has vomiting and / or diarrhea. If needed, ORS can be given in frequent, small amounts by spoon, bottle, or cup over three to four hours. A pediatrician may provide specific instructions for oral rehydration to their patients. One method is described below:

• Parents should first measure out the total amount to be given with a standardized medicine syringe or measuring cup or spoon, rather than a regular cup or spoon.
• A total volume of 5 teaspoons per pound, or 50 milliliters per kilogram, should be given over four hours. For a 20 pound child, this would equal 100 teaspoons; for a 9 kg child, this would equal 450 milliliters.
• The fluid can be given by teaspoonfuls (approximately equal to 5 milliliters each) every one to two minutes, or as tolerated.
• After the total amount has been given, a normal diet can be resumed.

MEDICATIONS: Medications such as antibiotics and antidiarrheal agents are generally not necessary and could be harmful for infants or children with diarrhea. Rarely, antibiotics may be used in cases of bacterial infection when a specific cause of the diarrhea has been found or is strongly suspected, particularly after recent travel. Inappropriate use of antibiotics will not improve diarrhea. Furthermore, antibiotics can cause side effects and lead to development of antibiotic resistance.

Antidiarrheal agents are not recommended for infants or children, since the benefits do not outweigh the risks. One risk of using an antidiarrheal agent is that it could mask worsening symptoms and delay treatment.

PROBIOTICS: There are "healthy" bacteria (called probiotics) that may help reduce the duration of diarrhea (by about 12 to 30 hours). Some of these are available in drug stores without a prescription. While it is not unreasonable to use them, their overall benefit is small and they can be expensive.

PRECAUTIONS:

• Exclusive breastfeeding until age six months, and continued breastfeeding with complementary foods until two years of age. Complementary feeding may be considered in younger infants if growth is inadequate.
• The consumption of safe food and water. If available, water brought to a rolling boil for at least five minutes is optimal for preparing food and drinks for young children.
• Handwashing after defecating, disposing of a child's stool, and before preparing meals.
• The use of latrines; these should be located more than 10 meters and downhill from drinking water sources.
• Immunizations: Rotavirus vaccine for infants is strongly recommended.
  

REFERENCES:

• http://www.who.int/mediacentre/factsheets/fs330/en/ Accessed on 9-Mar-2017
• Pakistan Strategic Country Environment Assessment – World Bank 2006
• UNICEF_Annual_Report_2013_-_Version_11.1 (https://www.unicef.org/pakistan/FINAL_UNICEF_Annual_Report_2013_-_Version_11.1.pdf Accessed on 9-Mar-17)
• http://floods2010.pakresponse.info/Nutrition/surveys/MICS_Punjab_2007- 08.pdf Accessed on 9-Mar-17
• Meeting of the immunization Strategic Advisory Group of Experts, April 2009--conclusions and recommendations. Wkly Epidemiol Rec 2009; 84:220.
• https://www.uptodate.com/contents/acute-diarrhea-in-children-beyond-the-basics?source=search_result&search=diarrhea%20in%20children&selectedTitle=5~150
• http://www.mayoclinic.org/diseases-conditions/diarrhea/diagnosis-treatment/diagnosis/dxc-20232996