|Clinical Guidelines and Treatment Manual (Médecins Sans Frontières, 1993)|
|Chapter 3 - Gastro-intestinal diseases|
Loose, frequent stools. Different cultures have different definitions, but as a guide, diarrhea means at least 3 loose or watery stools in a day.
- Dehydration: the principal reason for the mortality attributable to diarrhea
- Negative effect on nutritional status
Clinical assessment of the patient
- Duration of illness.
- Frequency and consistency of stools (blood, mucus).
- Frequency and duration of vomiting.
- Output, colour and quantity of urine.
- Fever or convulsions.
- Type and quantity of fluids and food ingested.
- Presence of blood or mucus in the stool.
- Presence of other cases in the household.
- Temperature (rectal if possible).
- Respiration (acidosis: Kussmaul breathing).
· as a baseline to monitor rehydration,
· as an indicator of degree of dehydration.
- Nutritional status.
CLINICAL EVALUATION OF DEGREE OF DEHYDRATION
See table 4.
Direct smear, if available, to look for trophozoites of entamaeba hystolitica or giardia lamblia.
- Prevent dehydration.
- Replace fluid if dehydration already exists.
- Maintain nutrition.
PREVENTION OF DEHYDRATION
Cases of diarrhea with no signs of dehydration:
- Advise increasing fluid intake (water, soup, juices, rice water).
- Encourage the use of home-made sugar / salt solutions.
- Continue breast feeding and normal diet.
- Warn mother to bring child back if:
· signs of dehydration appear (explain),
· diarrhea persists.
- Two tasks:
· Rehydration: correct the deficit in water and electrolytes.
· Maintenance: replace continuing losses (diarrhea and vomiting).
- Two methods of fluid replacement:
· ORS: for mild to moderate dehydration, give by mouth or by nasogastric tube if child unable or unwilling to drink.
· Ringer's lactate: for severe dehydration or if there is intractable vomiting.
- Quantities of fluid are calculated according to the condition of the patient (see tables 6 and 7). As a general rule, for severe dehydration 200 ml/kg/day should be given with the first half during the first 4 hours. For moderate dehydration, give 100 ml/kg/day with first half given during first 4 hours.
- Mild cases can be treated as outpatients, after the mother has been shown how to use ORS. Moderate and severe cases require supervision as to the evolution of the diarrhea and progress of rehydration.
- If it is impossible to place an IV line in a severely dehydrated child, fluids are sometimes given intraperitoneally or subcutaneously. However these techniques should not be encouraged, as they are less safe and no more effective than giving ORS by nasogastric tube.
Note: solution of salt-sugar: 2 pinches of salt (3 g), 4 tablespoons of sugar, or 8 pieces (40 g), dissolved in 1 liter of boiled water, cooled and with added fruit juice.
Table 6: Rehydration protocol
- The volumes indicated are guides only.
- Before using this table, consider all of the following:
· Rehydration must be evaluated in terms of clinical signs, not in terms of volume of fluids given.
· If necessary, the volumes given below can be increased or else the initial high rate of administrahon can be maintained until there is clinical improvement.
· Periorbital edema is a sign of fluid overload in infants.
· Maintenance therapy (table 7) should begin as soon as signs of dehydration have resolved, but not before.
Table 7: Maintenance therapy
- fluids to be given after correction of dehydration;
- adapt re-hydration treatment to the clinical status of the patient;
- to avoid hyrpernatremia altemate ORS and water.
It has been shown that there is no physiological reason for discontinuing food during bouts of diarrhea and that continued nutrition is beneficial to both adults and children. Continued feeding should be encouraged.
- Remember that 50-60 % of acute gastro-enteritis is viral (see table 5).
- Certain antibiotics are used to treat specific intestinal infections.
- Other anti-diarrhoea indications (e.g. absorbents) are contraindicated in children.
- Always treat the fever and consider other causes for the diarrhoea (e.g. malaria, otitis, pneumonia).
Prevention of diarrhea
Directed at mothers in dispensaries, MCH clinics and feeding centers, at the time ORS is prescribed.
· on its own up to age 4 months
· continue up to age 2 years
2) Solid foods ("weaning foods" is a very poor term): introduce these from about age 4 months
3) Food preparation
4) Drinking water
- Provision of safe drinking water in sufficient quantities
- Disposal of feces
- This is only ever considered in cholera epidemics. It is of doubtful efficacy in controlling an outbreak and can only be justified in a sequestered populations: a ship, a medium size where the attack rate is high (more than 2 %) and where it is possible to administer an effective prophylactic dose under supervision to the whole group concerned.
- In endemic situation, it can be given to close family contacts.
- Doxycyclineshould be choosen.
Composition of ORS sachets (to be dissolved in 1 litre of clean water (do not tell mothers to boil the water as this is very expensive in terms of time and fuel, and also unnecessary). (See table C).