ACUTE DIARRHOEA IN CHILDREN Epidemiology and Definition Definition • Acute diarrhea is defined as the abrupt onset of or more loose stools per day and lasts no longer than 14 days Epidemiology • Diarrhoeal disease is the second leading cause of death in children under five years old • Responsible for killing around 525 000 children every year • Globally, there are nearly 1,7 billion cases of childhood diarrhoeal disease every year • Widespread throughout developing countries and in lowincome countries • Among the notifiable diseases in Viet Nam, diarrheal diseases are one of the top ten causes of morbidity and mortality in Viet Nam recently In 2009 there were 930.496 cases with four fatal cases reported Causes and risk factors for Acute diarrhoea (AD) Host factors Biological factors increase susceptibility to AD  Age: The incidence of AD peaks at around age 6-11 months, remains high through 24 months and then decreases  Failure to get immunised against rotavirus  Failure of measles vaccination; measles predisposes to diarrhoea by damage to the intestinal epithelium and immune suppression  Malnutrition is associated with an increased incidence, severity and duration of diarrhoea  Immunodeficiency: measles, HIV and etc Behavioral factors increase the risk of AD  Not breastfeeding exclusively for months  Using infant feeding bottles: they easily become contaminated with diarrhoea pathogens and are difficult to clean  Not washing hands after defecation, handling faeces or before handling food Environmental factors These include:  Seasonality:The incidence of AD has seasonal variation in many regions  In temperate climates, viral diarrhoea peaks during winter whereas bacterial diarhoea occurs more frequently during the warm season  In tropical areas, viral and bacterial diarrhoeal occur throughout the year with increased frequency during drier, cooler months  Poor domestic and environmental sanitation especially unsafe water  Poverty Common causes of AD  More than 20 viruses, bacteria and parasites have been associated with acute diarhoea  Worldwide, rotavirus is the commonest cause of severe dehydrating diarrhoea causing 0.6 million deaths annually, 90% of which occur in developing countries  The incidence of specific pathogens varies between developed and developing countries  In developed countries, about 40% of AD cases are due to rotavirus and only 10-20% are of bacterial origin while in developing countries, 50-60% are caused by bacteria while 15-25% are due to rotavirus Other viral agents  Enteric adenoviruses  Astrovirus  Human calciviruses (norovirus and sapovirus) Bacteria       • E coli (EAEC, EPEC, EIEC) Shigella spp Staphylococcus spp Salmonella spp Yersinia enterocolitica Campylobacter jejuni Vibrio cholera Parasites  Entamoeba histolitica  Girdia lamblia  Cryptosporidium  Trichuris trichuria  Strongyloides stercoralis Pathophysiology of acute diarrhea When diarrhea occurs, the ability to absorb water in the intestinal tract decreases, leading to the excretion of water in the stool PARACLINICAL o Enzyme immunoassay (EIA) for detection of viral antigen +May show the offending viral pathogen (rotaviruses, noroviruses, astroviruses, adenoviruses) +Rarely required Ordered only for epidemiological purposes when there is a public health imperative to identify the pathogen and establish its source COMPLICATION Dehydration Electrolyte disturbances Metabolic acidosis Malnutrition Treatment Plan A: Treat for Diarrhoea at Home Plan A : Treat for Diarrhoea at Home Give Extra Fluid  TELL THE MOTHER It is especially important to give ORS at home when: • The child has been treated with Plan B or Plan C • The child cannot return to a clinic if the diarrhoea gets worse Plan A : Treat for Diarrhoea at Home Give Extra Fluid  SHOW THE MOTHER  TEACH THE MOTHER HOW TO MIX AND GIVE ORS GIVE THE MOTHER PACKETS OF ORS TO USE AT HOME  Tell the mother to: • Up to years: 50 to 100 ml after each loose stool HOW MUCH FLUID TO GIVE IN ADDITION TO THE USUAL FLUID INTAKE: • years or more: 100 to 200 ml after each loose stool • Give frequent small sips from a cup • If the child vomits, wait 10 minutes then continue - but more slowly • Continue giving extra fluid until the diarrhoea stops Plan A : Treat for Diarrhoea at Home GIVE ZINC (age months up to years)  TELL THE MOTHER HOW MUCH ZINC TO GIVE (20 mg tab) months up to months months or more 1/2 tablet daily for 14 days tablet daily for 14 days  SHOW THE MOTHER HOW TO GIVE ZINC SUPPLEMENTS - Infants - dissolve tablet in a small amount of expressed breast milk, ORS or clean water in a cup - Older children - tablets can be chewed or dissolved in a small amount of water CONTINUE FEEDING (exclusive breastfeeding if age less than months) WHEN TO RETURN  Give recommended amount of ORS over 4-hour period  DETERMINE AMOUNT OF ORS TO GIVE DURING FIRST HOURS (**) Use the child's age Plan B: Treat for Some Dehydration with ORS Weight