Till date, diarrheal disease remains one of the leading causes of morbidity and mortality in children worldwide and its impact is seen greatly in the tropics and less developed nations of the world. Acute diarrhea disease can cause death in less than 24 hours from it onset and such deaths result from severe dehydration which leads to hypovolaemia (reduction in the effective fluid volume in the body) and metabolic acidosis and other electrolyte derangement.
Diarrhea has been defined by the World Health organization (WHO), as passage of three or more loose or watery stools (based on the consistency of the fluid) in a 24hr period or the passage of stool with change in frequency and consistency that varies from what that is normal for the individual i.e. any change in the frequency or consistency of an individual’s stool can be classified as diarrhea.
Diarrhea is commonly seen in pediatric practice and it can pose great threat to the patient and to the attending physician. Most pediatricians describe diarrhea in children as an increase in the frequency of the number of stools which is more than what is normal for the age of the child and a loose stool is one that would take the shape of a container because of the increase in the fluid concentration of the stool.
Common terminologies used in the context of diarrhea:
- Acute watery diarrhea: this is the passage of frequent loose or watery stools without visible blood in the stool and such occurrence has a duration of <14 days. It begins suddenly with no preceding episode and is usually self limiting. Vomiting may occur and fever may also be present. Majority subsides within 7 days with prompt and adequate medical treatment
- Dysentery: this is a distinct form of diarrheal disease with visible blood in the stool. It is characterized by passage of stool that may be of small-volume, frequent bloody stools with mucus, tenesmus, urgency and severe abdominal cramps.
- Persistent diarrhea: This is diarrhea that begins acutely but is of a longer duration (lasting for a duration greater than 14 days) usually of an infective origin. The episode may begin either as watery diarrhea or as dysentery.
- Chronic diarrhea: Recurrent or long lasting diarrhea due to non infectious causes such as sensitivity to gluten or inherited metabolic disorders.
- Intractable and protracted diarrhea: Episodes of chronic or persistent diarrhea for which no cause can be established.
- TODDLER’S DIARRHOEA: Recurrent episodes of mild to moderate diarrhea, of variable duration, in toddlers for which no cause can be found, no constitutional symptoms or nutritional impairment
Behaviors that increase the risk of diarrhea:
- Failing to breast feed exclusively for the first 6 months of life
- Using infant feeding bottles which are easily contaminated by pathogens
- Storing cooked food at room temperature promotes the proliferation of pathogens that can cause diarrhea
- Consumption or the usage of water that is contaminated with fecal bacteria
- Poor personal and child care hygiene e.g. failure to wash hands after defecation, failure to dispose of feaces (including infant feaces) properly and unhygienic child rearing practices
Host factors that increase susceptibility to diarrhea in children:
- Age: most diarrheal episodes occur during the first two years of life. Incidence is highest in the age group 6-11 months, when weaning often occurs. However, diarrhea can occur at any age
- Severe Malnutrition
- Immunodeficiency or immunosuppresion: this can be caused by HIV/ AIDS infection, diabetes mellitus, cancer, radiotherapy and chemotherapy therapy for cancers, bone marrow suppression and congenital immunodeficiency syndromes
- Seasonality: the incidence of diarrheal disease varies with the season. In tropical areas, diarrhea caused by rotavirus tends to occur throughout the year, increasing in frequency during the drier and cool months, whereas bacterial diarrhea tend to peak during the warmer, rainy season.
Common causes of diarrhea:
- Viruses: rotavirus, adenovirus, calicivirus, astrovirus, Norwalk virus and HIV
- Bacteria: E.coli, shigella, vibrio cholerae, salmonella typhi, staphylococcus and clostridium deficile
- Protozoa: entamoeba histolytica, giardia lambdia, cryptosporidium
- Osmotic diarrhea caused by malabsorption and pancreatic disease
- Motility-related diarrhea from an increase in intestinal movement e.g. hyper-motility in hyperthyroidism.
- Drug related e.g. indiscriminate use of laxatives
- Inflammatory diarrhea e.g. inflammatory bowel disease (ulcerative colitis and Crohn’s disease)
Diarrhea in Children – First Aid Treatment
Treatment of diarrhea in children is based on the 3 basic principles of rehydration which are:
- Correction of fluid deficit i.e. fluid lost from the body during the diarrhea episode
- Replacement of any ongoing fluid lose
- Administration of daily maintenance fluid and electrolyte
Home treatment should only be carried if no signs of dehydration are present or for rapid treatment of dehydration before arrival to a health facility.
The 3 basic rules of home therapy are:
- Give the child more fluids than usual to prevent dehydration;
- Give the child plenty of nutritious food to prevent malnutrition;
- Take the child to a health facility if the child does not get better in 3 days or if signs of dehydration or another serious illness develop.
Use Salt and Sugar Solution (SSS) and other recommended home fluids; Salted fluids e.g. salted rice water, salted yoghurts, vegetable soup and chicken broth or unsalted fluids e.g. green coconut water and weak tea. Salt and sugar solution should be made at home using clean utensils and purified water.
- Give a teaspoonful of SSS every 1-2 minutes for a child <2 years. Feeding bottles should not be used.
- Give frequent sips from a cup from an older child.
- If the child vomits, wait 10 minutes, then give the solution more slowly (a spoonful every 2-3 minutes)
- Continue to breast feed frequently.
- If the child is not being breast fed, give the usual milk.
- If the child is 6 months or older, or already taking solid food:
- Also give cereal or another starchy food mixed if possible with beans, vegetables, and meat or fish (add 1-2 teaspoonfuls of vegetable oil to each serving)
- Give fresh fruit juice or mashed bananas to provide potassium.
- Give freshly prepared foods. Cook and mash or grind food well.
- Encourage the child to eat; offer food at least 6 times a day.
- Give the same foods after diarrhea stops, and give an extra meal each day for two weeks
Take the child to a health facility if: the child does not get better in 3 days, or develops any of the following:
- Watery stool still persist
- Repeated and excessive vomiting
- Marked thirst
- Poor feeding
- Blood in the stool
- Sunken eyes and dry wrinkle skin