sneak peak 1 integrated handbook of family medicine volume 2

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   Here we are launching sneak peek of volume 2.book is due to release by 31 January tentatively.One IMNCI booklet by WHO and supplement question bank with many new questions scenario based useful for DNB theory exams  is free with this volume.Last few days remaining to book at a special prize volume 2 & 3.So make most of it.Good day.

Sneak peek 1 volume 2 

Acute diarrheain infants and children

Definition:

·         An increase in frequency or decrease in consistency of stool lasting for 7 to 14 days is called as acute diarrhea.

·         Precisely stool volume more than 10gm /kg/day in infants and more than 200gm/day in children beyond 3years can be taken as diarrhoea.

·         Most acute diarrhea abates within 7days.Therefore diarrhea from 8-14days with acute onset is termed intermediate diarrhea.

Epidemiology

·         One of the major causes of infant morbidity and mortality 2nd to Respiratory diseases.

·         Average Indian child below 5 years gets 2-3 episodes of diarrhea/year.

·         Global mortality is 1.8 million/year.

·         Mortality in India due to diarrhea is 600,000-800,000 per year.

·         Age - High incidence is below 5 years &80% mortality is between 6 months to 2 years.

·         Sex - No predilection.

·         Peak incidence is in summer and rainy seasons.

·         Low socio economic status, low personal hygiene, bottle/top feeding, malnutrition, early wearing and associated systemic infections predispose for diarrhea.

Aetiology- Infectious Causes

·         Viral – Rotavirus, Enteric Adenovirus,  Norwalk agent, Calcivirus, Astrovirus,Coronavirus, HIV

·         Bacterial – Escherichia Coli, Salmonella, Shigella, Staphylococci, CampilobacterJejuni, Yersinia enterocolitica, Aeromonas, Vibrio cholerae, Clostridium difficile

·         Parasitic – Giardia, Cryptosporidium, EntamoebaHistiolytica, Strongyloides

·         Food Poisoning – Staphylococcus aureus, Clostridium Perfringens, Bacillus Cereus

·         Fungal - Candida

·         Systemic illness- LRTI, UTI, ASOM

Aetiology- Non Infectious Causes

·         Diet – Food Allergy, Food intolerance

·         Anatomic Defects – Malrotation, Hirschsprung disease, Short bowel Syndrome, Microvillus Atrophy

·         Food Poisoning – Heavy Metals, Mushrooms

·         Endocrinopathies – Thyrotoxicosis, Addison’s disease

·         Malabsorption – Disaccharidase deficiencies, Pancreatic insufficiency, Celiac disease

·         Neoplasm – Neuroblastoma, Ganglioneuroma, Zollinger- Ellison Syndrome

·         Miscellaneous – Crohns disease, Ulcerative colitis, Laxative abuse

Types of Acute Diarrhoea

·         Secretory Diarrhea – E.g. Toxin induced

·         Osmotic Diarrhea – E.g. Lactose intolerance

·         Inflammatory Diarrhea – E.g.Shigella, EHEC

·         Motility Diarrhea – E.g. Hirschsprung disease, Anorectal malformation

Secretory and Osmotic Diarrhea are more common.

Markers of Secretory Diarrhoea

·         Dehydration

·         Dyselectrolytaemia

·         Large volume stool

·         Stool Sodium > 70mEq/L

·         Stool often Alkaline

·         No effect with Discontinuation of feeding

·         Osmolality equals to ionic constituents

Markers of Osmotic Diarrhoea

·         Children often stable

·         Stools – Small or large volume, watery or loose

·         Stool sodium < 50 mEq/L

·         Stool Osmolality – Less than the ionic constituents

·         Stool Reaction – Acidic (pH < 5.5)

·         Discontinuation of feed results in improvement

·         Perianal excoriation

·         Abdominal distension before passing stool

Pathophysiology of Acute Diarrhea

·         Diarrheal losses are drawn from extra cellular compartment which constitutes circulating blood, interstitial fluid and body secretions

·         Normally extracellular fluid turnover is 3 to 4 times greater than adults.

·         Loss of fluid in diarrhoeal stool causes early and significant dehydration in Infants.

·         Proportionate loss in Na+ results in isotonic dehydration (80%).

·         More loss of Na+ than Water results in hyponatraemic (Hypotonic) dehydration – 15%.

·         More loss of water results in hypertonic dehydration – 5%.

Clinical Features

History & Examination

·         Stool volume and character, urine output

·         Vomiting, Abdominal pain/distension

·         Pyrexia, Altered sensorium

·         Pre illness feeding pattern, Immunization, Nutritional status

·         Other systemic infection

·         Icterus, Pallor, Clubbing, Pedal oedema

·         Signs of dehydration

·         Bowel sounds, Tenderness,

·         Abdominal organomegaly

Features of Dehydration

	Mild	Moderate	Severe
Generalcondition	Well,alert	Restless,irritable	Lethargic or unconscious,floppy
Eyes	Normal	Sunken	Very sunken and dry
Tears	Present	Absent	absent
Mouth & tongue	Moist	Dry	Very dry
Skin turgor	Drink normally,no thirst	Thirst,drinks eagerly	Drinks poorly or not able todrink
Thirst	Goes  back quickly	Goes back slowly	Goes back very slow > 2 seconds
Hydration status	No signs of dehydration	Has two or more signs -some dehydration	Has two more signs -severe dehydration

Clinical Picture in isotonic, hypotonic and hypertonic dehydration

Criteria	Isotonic	Hypertonic	Hypotonic
Temperature	Cold	Cold or hot	Cold
Turgor	Poor	fair	Very poor
Feel	Dry	thickened	Clammy(moist)
Mucous membrane	Dry	parched	Slightly moist
Eyes	Sunken & soft	sudden	Sunken eyes & soft
Anterior fontanel	Depressed	depressed	depressed
Sensorium	Drowsy	Very irritable	comatose
Pulse	Rapid	Moderately rapid	rapid
Blood pressure	Low	Moderately low	low

Clinical Picture in certain special situations

Conditions	Physical Signs
Acidosis	Breathing increased in depth and rate
Hypokalaemia	Abdominal distension, paralytic ileus, hypotonia, hyporeflexia, mental apathy, ECG changes
Hypomagnesaemia	Tetany  Muscular twitching

Complications of Acute Diarrhoea

·         Dehydration

·         Acute renal failure

·         Venous Thrombosis - Cerebral, Renal

·         HUS ( HeamolyticUraemic Syndrome)

·         Malabsorption

·         Food Intolerance

·         Intussusceptions

·         Disseminated Intravascular Coagulation

·         Persistent Diarrhea

·         Dyselectrolytaemia

Investigation in a child with acute severe diarrhoea

·         Stool - Ova, Cysts, Trophozoites, Leucocytes

·         Hanging drop for V. cholerae

·         Culture practically not required

·         Blood tests - CBC, PBF for band cells

·         Serum Electrolytes

·         BUN and Creatinine

·         Culture and sensitivity

·         Urine - R/M, Culture may be required

·         Septic screen if required

·         Serum electrolytes are not required in those to be hydrated by ORS but it is recommended in some dehydration with doughy feeling of skin andwhere findings are inconsistent with straight forward diarrhea.

Management

·         Prevention of Dehydration

·         Treatment of Dehydration

·         Nutritional support

·         Ancillary therapy

Acute Diarrhoea without Dehydration (Plan - A)

Asses Risk of Dehydration

High risk	Low risk
Age < 6 months Vomiting > 4 times /day Liquid motions > 8 times /day	Age ≥ 6 months Vomiting ≤ 4 times /day Stool ≤ 8 times /day

·         If low risk continue ususual fluids > Encourage totake more>Discharge with ORS Packets and care to be take at home

·         If high risk  > admit for obseravation >Maintaiance fluid for ongoing loss>ORS 10 ml/kg/each stool or vomititng > Reassess  every 4 hours >Good hydration stable on ORS > discharge with ORS packets and care to be take at home

·         But still dehydrated  >  treat as some dehydration and start plan B

Acute diarrhea with some dehydration (plan B)

·         Admit the patient > assess the patient > check for doughy skin > investigate blood for urea, creatinine & electrolytes

·         Na < 150 Eq/L > Admit ORS 30 -80 ml/kg over 4 hours > reassess > if no dehydrationtreat as plan A

·         Na > 150 Eq /L > admit > rehydrate over 12 hours with Deficit and maintenance fluid with ORS >Review every 2 hours>Dehydration continues give NGT/IV Fluids or No Dehydration Treat as Plan – A

Maintenance fluid - 100 ml/kg ORSfor 1st 10 kg then 50 ml/kg for next 10 kg.

Acute diarrhoea with severe dehydration (plan - C)

·         With Circulatory Compromise Admit>Investigateblood for urea, creatinine & electrolytes >Rapid bolus of Ringer lactate/Normal saline 20 ml/kg > Circulation restored>Serum Na+> 150 mEq/L(Treat as Plan - B) and < 150 mEq/L(Treat as Plan - B) 

·         Circulation not restored> Further bolus of NS maximum 40 ml/kg >Not Improved > admit to Intensive care unit >Consider Ventilation

·         Circulation restored > treat as plan B

Composition of fluids for intravenous & oral rehydration

Oral	Osmolality mOsm/L	Glucose mmol/L	Sodium mmol/L	Chloride Mmol/L	Potassium Mmol/l	Base (citrate) mmol/l
WHO ORS	311	111	90	80	20	10
WHO Low Osmolar ORS	245	75	75	65	20	10
IAP recommended ORS	224	84	60	50	20	10
Intravenous fluid
Ringer lactate	280		130	110	04	25 (bicarb)
Normal saline	308		154	154

Components of Fluid Required                                                        

Deficit Fluid:

·         Some dehydration (3-8%) – 30-80 ml/ kg.

·         Serve dehydration (> 9%) – 100 ml/ kg.

·         To be replaced by N/2 fluid (0.45% NaCl)

Maintenance Fluid:

·         100ml/kg/24 hours for first 10 kg body weight.

·         50ml/kg/24 hours for next 10kg body weight.

·         20ml/kg/24 hours thereafter.

·         To be replaced by N/5 fluid within 1st Year. The Salt concentration will increase gradually not to exceed Na+ 3-4 mEq/kg body weight. K+ 20mEq/litre should be added.

On-going Loss:

·         Measured as the actual stool volume/weight.

·         Reassessing the grade of dehydration after 4 to 8 hours.

·         With each stool roughly 10ml/kg.is lost.

·         To be replaced by N/2 (0.45 NaCl) solution.

Time of Replacement

·         IV deficit should be given over 6 to 8 hours.

·         Maintenance & on-going loss over 16 hours for the day or after 1st hour infusion rest fluid and electrolytes for the day should be calculated and divided in 23 hours.

·         Reassessment to continue every 4 to 8 hours.

Management of feeding during Acute Diarrhea

·         Breast Feed: Continue Breast feeding throughout rehydration and maintenance phase.

·         Formula feed: Restart feed at full strength as soon as rehydration is complete (ideally after 4 hours).

·         Weaned Children:Continue child’s normal fluid and solidfollowing rehydration. Avoid fatty foods or foods high in simple sugar.

Indication of Chemotherapy / Antibiotics

·         Self limiting infection

·         Unnecessary in most cases

·         Indicated in

·         Infants under 6 months of age.

·         Immunocompromised infants.

·         Clinical suspicion of bacteraemia.

Chemotherapy for Bacterial & Protozoa Diarrhea

Aetiology	chemotherapy
Shigella	Nalidixic acid, Cotrimoxazole, Ampicillin
Enteroinvasive E:coli	Nalidixic acid, Cotrimoxazole, Ampicillin, InjectionGentamicin (in case of    septicaemia)
Salmonella	Ampicillin, Chloramphenicol
Campylobacter Jejuni	Erythromycin, Furazolidin, Chloramphenicol, Gentamicin
Vibrio cholerae	Furazolidin, Cotrimoxazole, Tetracycline, Erythromycin,
E. histolytica	Metronidazole, Tinidazole, Secnidazole, Paromomycin
Giardia	Metronidazole, Tinidazole, Secnidazole, Ornidazole,Furazolidine

Zinc in the Treatment of Acute Diarrhea

·         As adjunct to oral rehydration & offers modest benefit.

·         20mg of elemental Zn during the period of Diarrhea and 7 days following it.

·         Not recommended below 3 months.

·         Zn Sulphate/Gluconate/Acetate can be used

Probiotics in the Treatment of Diarrhea

·         Probiotics are non-pathogenic micro-organisms.

·         Beneficial effect in Rotavirus Diarrhea.

·         It reduces the duration of Diarrhea in most cases

Antidiarrheal drugs

Contraindicated in Infants & Children

Prognosis

·         Mortality is high in newborns& Infants.

·         Malnutrition carries poor prognosis.

·         Systemic diarrhea/diarrhea with resistant invasive pathogens increase risk of fatality.

·         Serve dehydration with shock and dyselectrolytemia have adverse effect on outcome.

·         Prompt and adequate therapy helps in better outcome.

Prevention

·         Improvement of Nutritional status.

·         Safe drinking Water Supply in community.

·         Exclusive Breast feeding till 6 Months.

·         Easy availability of ORS sachets.

·         Hand washing before handling food.

Vaccines:

·         Rotavirus vaccine

·         ETEC Vaccine

·         Cholera Vaccine

·         Typhoid Vaccine