Dr Sudhanshu Mishra Asst Professor Dept of Community

Dr. Sudhanshu Mishra Asst. Professor Dept. of Community Medicine CIMS & H

CONTENTS INTRODUCTION PROBLEM - WORLD - INDIA CLASSIFICATION CAUSES DEHYDRATION CLASSIFICATION OF DEHYDRATION PRINCIPLES OF MANAGEMENT

CONTENTS ROLE OF ZINC ROLE OF PROBIOTICS DDCP IMNCI F-IMNCI

INTRODUCTION Diarrhoea is defined as passage of unusually loose or watery stools usually at least three times in a 24 hour period. (WHO) However it is the consistency of the stools rather than the number that is more important. Passage of even one large watery stool in young child is diarrhoea. Frequent passage of normal stool is no diarrhoea.

INTRODUCTION 6 -12 months of age are affected severely & account for high mortality. Dehydration occurs when water & salts are not replaced adequately -may lead to shock & death. Diarrhoea also produces under nutrition and growth failure. Diarrhoeal disease constitute one of the important “nutritional leak” in young children. Even a brief episode of diarrhoea leads to the loss of 1 -2 % of body weight in children.

MAGNITUDE OF THE PROBLEM: WORLD Diarrhoeal disease is the 2 nd leading cause of death in children under 5 yrs of age. Globally, there about 2 Bn cases of diarrhoeal disease every yr. Diarrhoeal disease kills 1. 5 Mn children every yr. African and South-East Asian regions together account for nearly 78% of them. India alone contributes about 20% of all global under-5 diarrhoeal deaths. It is both preventable and treatable.

MAGNITUDE OF THE PROBLEM: WORLD In developing countries, children under three years old experience on an average three episodes of diarrhoea every year Each episode deprives the child of the nutrition necessary for growth As a result, diarrhoea is a major cause of malnutrition, and malnourished children are more likely to fall ill from diarrhoea. It makes a vicious cycle

Leading causes of deaths in children under 5 yrs Other Malaria* 5% Measles* 7% 32% Diarrhoea* 19% Malnutrition* 54% Perinatal 18% 19% ARIs* * Based on data taken from The Global Burden of Disease 1996, edited by Murray CJL and Lopez AD, and Epidemiologic evidence for a potentiating effect of malnutrition on child mortality, Pelletier DL, Frongillo EA and Habicht JP, Am. J Public Health 1993; 83: 1130 -1133

CAUSES OF DEATH IN CHILDREN IN DEVELOPING COUNTRIES, 2002* (in thousands) Rank 1. 2. 3. 4. 5. 6. 7. 8. 9 10. 11. Cause Numbers Perinatal conditions Lower resp. inf. Diarrhoeal Diseases malaria Measles Congenital anomalies HIV/AIDS Pertussis Tetanus PEM TOTAL 2375 1856 1566 1098 511 386 370 301 185 13 10263 deaths % 23. 1 18. 1 15. 2 10. 7 5. 4 3. 8 3. 6 2. 9 1. 8 1. 3 100 * Source: World Health Report 2003

MAGNITUDE OF THE PROBLEM: INDIA NFHS-3 data projected morbidity profile of children <3 yr: Fever - 27% Acute respiratory infections -17% Diarrhoea -13% Underweight - 43%

Classification of Diarrhoea Based on clinical syndromes Acute watery diarrhoea Dysentery Persistent diarrhoea

Acute watery diarrhoea Start suddenly Most episodes recover or self limiting within 3 -7 days. These may last up to 14 days >75% of all episodes are of acute watery diarrhoea. Dysentery Diarrhoea with visible blood & mucus in the faeces. Also abdominal cramps, fever, anorexia and rapid weight loss.

Persistent Diarrhoea which lasts for > 14 days Incidence is around 5% i. e. 5% of acute diarrhoea may persist beyond 2 weeks

ORGANISMS PRODUCES ACUTE WATERY DIARRHOEA Bacteria- Account 1/3 rd of total causes E. Coli V. Cholera V. Parahaemolyticus Shigella S. bloody diarrhoea or dysentery E. coli Typhi Staph. Aureus Clostridium perfringens

Viruses- 1/3 rd of total causes Rotavirus Astroviruses Calciviruses Coronaviruses Norwalk group viruses Enteroviruses Rotavirus causes 15 -25% diarrhoea cases in developing countries

Parasites E. histolytica- Dysentery Giardia intestinalis Trichuriasis Cryptosporidium parvum 1/3 rd causes can’t be pin pointed

RISK FACTORS OF DIARRHOEA Bottle fed babies have more chances to develop diarrhoea because of unclean bottles Flies can also bring germs to uncovered food Drinking contaminated water Unclean food, milk, unclean hands & unclean utensils

SIGNS OF DEHYDRATION

SIGNS OF DEHYDRATION & TREATMENT PLAN Signs Classification of Treatment Reflected by the following dehydration signs in addition to above signs unconscious , difficult to wake Lethargic or No No signs of dehydration Follow Plan A dehydration Floppy Two of the Some dehydration Follow planand B Refusal for feed/breastfeed in young infant following signs to d rink. Unable • Restless, irritable • Sunken eyes • Tear absent • Dry mouth &tongue • Skin goes slowly • Thirst, drinks eagerly

SIGNS OF DEHYDRATION & TREATMENT PLAN Signs by the following Classification Treatment Reflected signs inofad dition to above signs dehydration Lethargic or unconscious , diffic ult to wake Two of Floppy the Severe Follow plan C following signs dehydration Refusal for f eed/breastfeed in young infant and Unable to d rink. • Unconcious • Floppy • Refusal to feed • Unable to drink • Very sunken eyes • Skin goes back very slowly

PRINCIPLES OF MANAGEMENT OF ACUTE DIARRHOEA In early stages of diarrhoea when ORS packets are not immediately available, HAF is given and continue feeding CONTINUE BREAST FEEDING BUT -Soft drinks -Sweetened fruit juices -Sweetened tea should not be used. These have high osmolarity and can lead to worsening of diarrhoea and further leading to dehydration.

PRINCIPLES OF MANAGEMENT OF ACUTE DIARRHOEA Rationale use of drugs ORS is the drug of choice for all cases of diarrhoea It is life saving when used timely, in adequate quantities Only a small proportion of cases of diarrhoea (dysentery, cholera and need associated illnesses) specific antimicrobials

PRINCIPLES OF MANAGEMENT OF ACUTE DIARRHOEA Drugs Like - Anti-motility drugs - Stimulants - Steroids MUST NOT BE USED as they provide pseudo sense of protection among mothers and distract their attention from correct treatment Their marketing has been banned in India

ORAL REHYDRATION SALT(ORS) It is a balanced mixture of glucose and electrolytes Almost all deaths from diarrhoea can be prevented by ORS MECHANISM OF ACTION Sodium promotes absorption of water from the intestine Glucose promotes the absorption of sodium and water from the intestine

Cases with No Signs of Dehydration Plan A In early stages, when fluid loss is <5% of the body weight, children may not show any clinical signs of dehydration Give HAF or ORS Plan A involves counselling the child's mother about the 3 Rules of Home treatment. GIVE EXTRA FLUID (as much as the child will take) CONTINUE FEEDING WHEN TO RETURN

Cases with signs of Some Dehydration Children who have dehydration should be kept under observation in the hospital/ health center for a few hours and given prepared ORS solution during the period Purpose: Correct fluid deficit and ongoing fluid losses

Cases with signs of Some Dehydration Plan-B REHYDRATION THERAPY Amount of ORS to be given in first 4 hrs Age <4 months 4 -12 months 12 m- 2 yrs 2 -6 yrs Wt (kg) <6 6 - < 10 10 - <12 12 - 19 ORS(ml) 200 -400 400 -700 700 -900 900 -1400 Glass(No. ) 1 -2 2 -3 3– 4 4 -7

Cases with signs of Some Dehydration Use the child’s age only when we do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child’s weight (in kg) × 75 For infants who are not breastfed, also give 100 -200 ml of clean water during this period. The breastmilk and water will help prevent hypernatraemia in infants. Show the mother how to give ORS solution After 4 hours Reassess and classify the child for dehydration Select the appropriate plan to continue treatment Begin feeding the child in clinic

Cases with signs of severe dehydration Plan-C 1% diarrhoea may develop severe dehydration. Children with severe dehydration must be admitted. Child is rehydrated quickly by using I/V infusions recommended : R/L solution N/S when R/L is not available 1/2 N/S with 5% dextrose is acceptable Plain glucose is unsuitable solution

Cases with signs of severe dehydration Plan-C Rate & Quantities of I/V infusion for severe dehydration Age 30 ml/kg 70 ml/kg 100 ml/kg Infant First hour Next 5 hrs 6 hrs Older children First 30 mins Next 2. 5 hrs 3 hrs

Cases with signs of severe dehydration Plan-C Reassess the infant every 15 -30 min. until a strong radial pulse is present. Thereafter, reassess the infant by skin pinch and level of consciousness at least every 1 -hour Also give ORS (about 5 ml/kg/hour) as soon as the infant can drink: usually after 3 -4 hours Reassess the infant after 6 hours & classify dehydration then choose the appropriate plan (A, B, or C) to continue treatment

Cases with signs of severe dehydration After signs of severe dehydration disappear & child is able to drink, furtherapy should be continued with ORS as per plan A or B Before the mother leaves the hospital two packets of ORS must be given.

Recommendations for use of zinc in clinical management of acute diarrhoea : WHO/UNICEF Joint statement (2001), IAP 2003, GOI 2007 20 mg per day of Zn supplementation for 14 days starting as early as possible after onset of diarrhoea 10 mg per day for infants 2 -6 months

Factors Suggesting Zinc Deficiency in a Population High phytate staple foods Low intake of “flesh” food High prevalence of stunting High rate of diarrhoea Nutritional iron deficiency

Role of Probiotics

Probiotics: - means "for life" and is currently used to name bacteria associated with beneficial effects for humans and animals. Coined in 1960 to name substances which promoted the growth of other organisms.

Effect of probiotics in diarrhoea The strongest evidence of a beneficial effect has been for the following probiotics - Lactobacillus rhamnosus GG and Bifidobacterium lactis BB-12 These probiotics are effective for both treatment and prevention of acute diarrhoea caused mainly by rotavirus in children Antibiotic associated diarrhoea has also been found to respond when probiotics have been used as prophylaxis and also for therapy

Probiotic strains - Can inhibit the growth and adhesion of a range of entero-pathogens - Animal studies have indicated beneficial effect in Salmonella. Traveler's diarrhoea due to bacterial infection has been benefited The most highlighted beneficial effect of probiotics has been on acute diarrhoea caused by rotavirus in children.

POTENTIAL USES OF PROBIOTICS -diarrhoea -Helicobacter pylori infection -Inflammatory bowel disease -Cancers -To increase Immunity -Allergy -Heart disease -Urogenital tract infections

FEEDING IN DIARRHOEA Children should continue to be fed during diarrhoea. Milk should not be diluted with water during any phase of acute diarrhoea. Milk can also be given as milk cereal mixture e. g. dalia, milk-rice mixture. This technique reduces the lactose load & preserving energy density.

FEEDING IN DIARRHOEA To make foods-energy dense some of preparation are: - Khichri with oil - Rice with curd & sugar - Mashed banana with milk or curd - Mashed potatoes with oil. Breast feeding should be continued uninterrupted even during rehydration with ORS.

Dysentery Requires antibiotic therapy However if there is only mucus, child should be treated as for acute diarrhoea without antibiotics Shigellae responds to cotrimoxazole 1 Tab BD x 5 days for < 2 months. 2 Tab BD x 5 days for 2 -12 months. 3 Tab BD x 5 days for 1 -5 years of age. OR Nalidixic acid 55 mg/kg/day in 4 doses x 5 days.

Cholera: - Antibiotics used are: Doxycycline- 6 mg/kg/day a single dose x 3 days or Tetracyline - 50 mg/kg/day 4 doses x 3 days or Erythromycin -30 mg/kg/day 3 doses x 3 days. Acute Amoebiasis: Metronidazole -30 mg. /kg/ day 3 doses x 5 -10 days. Acute Giardiasis: Metronidozole -15 mg/kg/day 3 doses x 5 days.

Persistent diarrhoea: The treatment for persistent diarrhoea requires special feeding and giving vitamin A and zinc The mother of a child with persistent diarrhoea will be advised on feeding her child Diet: -Cereals + legumes -Cereal+ milk or curd or some oil are considered good foods. -Eggs (boiled & mashed added to the basic cereals). In case, if diarrhoea persists after 6 days of treatment, these children should be admitted for further treatment.

Prevention of Diarrhoea: Exclusive Breast Feeding Bottle feeding should be avoided Wash Hand Eat clean Food Drink clean water Immunization e. g. Measles, Rota virus Vit. A - Prophylactic doses Nutrition

Rota virus vaccination Rotashield vaccine -1999 Withdrawn because of its association with intussuscption Two new oral, live attenuated rotavirus vaccines were licensed in 2006 with very good safety and efficacy The first dose administered between ages 6 -10 weeks. subsequent doses at intervals 4 -10 weeks. Vaccination should not be initiated before 6 weeks and after 12 weeks of age. All doses should be administered before 32 weeks.

Rota Rix vaccine Oral, live attenuated 2 dose schedule Rota Teq vaccine Oral, live attenuated, pentavalent vaccine. Contains 5 live reassortant rotaviruses 3 dose schedule 1 st dose - 2 month of age at 2 month of age 2 nd dose- 4 month of age ……………. 6 month of age

WHO Recommendation for Rota virus vaccination Geneva and Seattle, June 5, 2009 — WHO has recommended that rotavirus vaccination be included in all national immunization programmes The new recommendation by the WHO's Strategic Advisory Group of Experts (SAGE), extends an earlier recommendation made in 2005 on vaccination in the America and Europe, where clinical trials had demonstrated safety and efficacy in low and intermediate mortality populations.

Challenges for ORT reduces mortality but does not decrease episode duration or their consequences, such as malnutrition Adherence to ORT is poor because caregivers want to reduce illness duration This leads to use of antibiotics or other treatment of no proven value Unfortunately, knowledge and use of appropriate home therapies, including ORT, may be declining in some countries

SEARCH FOR ADJUNCT THERAPIES 12 -59 months old Indian children with zinc deficiency had 1. 5 times more diarrhoea and 3. 5 times more ALRI than non zinc deficient children.

NATIONAL DIARRHOEAL DISEASE CONTROL PROGRAMME NDDCP was launched in 1981 Main objective were reduction of mortality through introduction of ORT. Goals were: Reduce diarrhoeal associated mortality in children <5 years by 30% by 1995 and by 70% by 2000 A. D. Reducing CFR to less than 1%. Improvement in water and sanitation facilities was the long term goal of NDDCP

NATIONAL DIARRHOEAL DISEASE CONTROL PROGRAMME National ORT Programme was incepted in 1985 - 86 From 1992 -93 the programme has become a part of CSSM Programme. CSSM programme become a part of RCH programme in 1997 In RCH Programme, policy of IMCI was adopted Strategy of IMCI was to address all children and not only sick children IMCI focused on life threatening illnesses-diarrhoea, Pneumonia, Measles, Malaria etc.

Contd. Indian version of IMCI guidelines renamed as IMNCI. Since 2003 - DDCP included in IMNCI which includes - Neonates of 0 -7 days - Incorporating national guidelines on diarrhoea, ARI , Malaria, Anaemia, Vit. A supplementation & Immunizations.

STRATEGIES OF IMNCI Ensure standard case management of diarrhoea by training of medical and other health personnel. Promote standard case management practices among private practitioners through IMA and IAP. Improve maternal knowledge on home management and recognition of danger signs of diarrhoea for immediate medical care.

Increase availability of ORS by providing free ORS packets at health facilities and outreach depots. Increase accessibility by marketing ORS through the PDS and commercial outlets. Monitor hospital based data on ORS use rate, CFR & other parameters. Promote exclusive breast feeding for the first 6 months, proper weaning, infant immunization including measles immunization and Vit A prophylaxis.

Case management strategy CLASSIFICATION: PINK : Child needs referral ( Inpatient care) YELLOW : Child needs specific treatment, provide it at home (e. g. Antibiotics, ORS) GREEN : Child needs no medicine, give home care

Limitations of IMNCI Outpatient Facility Based Community activities not given adequate focus Vertical initiatives in Non IMNCI districts sorely lacking

F-IMNCI From November 2009 - IMNCI has been re baptized as F-IMNCI, (F -Facility) with added component of: Asphyxia Management and Care of Sick new born at facility level, besides all other components included under IMNCI

DIARRHOEA CAN BE PREVENTED Promote exclusive breastfeeding Immunization against measles Using sanitary latrines Keeping food and water clean Washing hands before eating & after defecation.

MESSAGES: ORS is best drink. A child with diarrhoea needs more food and frequent breast feeding. A child who is recovering from diarrhoea needs an extra meal every day for at least 2 weeks. Medicine other than ORS should not be used except on medical advice.

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