CLINIC CONSULT Childhood Diarrhea PRELIMS.indd 1 18-12-2013 14:38:15 PRELIMS.indd 2 18-12-2013 14:38:15 CLINIC CONSULT Childhood Diarrhea Authors Ajay Kalra MD DCH MNAMS FIAP Erstwhile Professor S.N. Medical College Agra 282 002, Uttar Pradesh, India Vipin M Vashishtha MD FIAP Director & Consultant Pediatrician Mangla Hospital & Research Center Bijnor 246 701, Uttar Pradesh, India JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD. New Delhi • London • Philadelphia • Panama PRELIMS.indd 3 18-12-2013 14:38:15 Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Offices J.P. Medical Ltd Jaypee-Highlights Medical Publishers Inc 83 Victoria Street, London City of Knowledge, Bld. 237, Clayton SW1H 0HW (UK) Panama City, Panama Phone: +44-2031708910 Phone: +1 507-301-0496 Fax: +02-03-0086180 Fax: +1 507-301-0499 Email: [email protected] Email: [email protected] Jaypee Medical Inc Jaypee Brothers Medical Publishers (P) Ltd The Bourse 17/1-B Babar Road, Block-B, Shaymali 111 South Independence Mall East Mohammadpur, Dhaka-1207 Suite 835, Philadelphia, PA 19106, USA Bangladesh Phone: +1 267-519-9789 Mobile: +08801912003485 Email: [email protected] Email: [email protected] Jaypee Brothers Medical Publishers (P) Ltd Bhotahity, Kathmandu, Nepal Phone: +977-9741283608 Email: [email protected] Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2014, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. Inquiries for bulk sales may be solicited at: [email protected] Clinic Consult: Childhood Diarrhea First Edition: 2014 ISBN 978-93-5152-122-8 Printed at PRELIMS.indd 4 18-12-2013 14:38:16 Preface Diarrhea remains the most common problem of children in developing countries. Yet, it is the one most unjudiciously treated. This underscores the need to keep oneself updated on the subject and follow rationale mode of management. We hope that this Clinic Consult will help practitioners to be able to do so. Ajay Kalra Vipin M Vashishtha PRELIMS.indd 5 18-12-2013 14:38:16 PRELIMS.indd 6 18-12-2013 14:38:16 Acknowledgements We have consulted various resource literature to write this book. We are grateful to all those who are mentioned in the bibliography. We are also grateful to the publishers for the wonderful job done. PRELIMS.indd 7 18-12-2013 14:38:16 PRELIMS.indd 8 18-12-2013 14:38:16 Contents Preface v Acknowledgements vii Chapter 1 Diarrhea in Children 1 Chapter 2 Causes and Mechanisms of Diarrhea 5 Chapter 3 Pathogenesis of Diarrhea 10 Chapter 4 Clinical Diagnosis of Diarrhea 14 Chapter 5 Physical Examination 19 Chapter 6 Laboratory Investigations 25 Chapter 7 Management of Acute Diarrhea 28 Chapter 8 Drug Therapy in Diarrhea 42 PRELIMS.indd 9 18-12-2013 14:38:16 Clinic Consult: Childhood Diarrhea Chapter 9 Dietary Management 54 Chapter 10 Persistent/Protracted/Recurrent/Chronic Diarrhea 57 Chapter 11 Celiac Disease 68 Chapter 12 Lactose Intolerance 70 Chapter 13 Cow’s Milk Protein Intolerance 74 Chapter 14 Vaccines Against Diarrheal Diseases 76 Bibliography 81 Normal lactose digestion Lactose intolerance x PRELIMS.indd 10 18-12-2013 14:38:16 CHAPTER 1 Diarrhea in Children INTRODUCTION Diarrhea is a leading cause of morbidity and mortality in developing countries. Each year in developing countries, roughly 4 billion episodes of acute diarrhea take place. In India, a child suffers, on an average, of 10–15 episodes of diarrhea in the first 5 years of life. Of these, 3–6 episodes (average 4.2) may occur in the very first year of life, especially in the urban slums and rural areas. It is responsible for nearly 2 million deaths of children below 5 years age every year in the developing world. The surface area of intestinal mucosa of a child from where the diarrheal fluids are secreted is fairly large. Therefore, a child may lose almost as much water and electrolytes from the body during the episode of diarrhea as an adult. Loss of 1 liter of fluid from the body of a child weighing 7 kg may be more dangerous compared with a similar depletion from an adult of 70 kg weight. Out of all cases of diarrhea, nearly 2–3% would have a significant disturbance in the electrolyte balance and acid base status of the body and this may prove fatal, if fluids and electrolytes are not replaced immediately. Diarrhea has been shown to have significant impact on nutrition. Even a brief episode of diarrhea leads to the loss of 1–2% of body ch-01.indd 1 18-12-2013 14:31:00 Clinic Consult: Childhood Diarrhea weight per day. Infants and young children in developing countries are sick for nearly 30 days per year because of diarrhea. Therefore, such creeping deficit may accumulate to become a major nutritional hazard. If diarrhea becomes unusually prolonged, or is recurrent, the child further becomes severely malnourished. Moreover, the appetite is impaired, and food is often withheld from the child by the mother due to the belief that starvation may provide rest to the bowel and thus promote early recovery. Further, atrophy of the intestinal epithelium in cases of malnutrition causes malabsorption and accentuates malnutrition. A vicious cycle of diarrhea–malnutrition–diarrhea sets in, contributing to a large majority of early childhood deaths either directly or indirectly. DEFINITION When a person has watery motions, it is called diarrhea. Diarrhea does not always mean many motions. Even one watery motion can be diarrhea. This is also regardless of its cause, its color, or any illness associated with it. Diarrhea can be very dangerous, especially in very small or weak children. This is because diarrhea leads to dehydration, which may cause death. That is why one must start treating a child for diarrhea as soon as the child passes even one watery motion. Young infants usually pass about 5 g of stool per kg of body weight per day, while diarrhea results in stool output greater than 10 g/kg/day. WHAT IS NOT DIARRHEA? • Frequent semiformed or watery greenish yellow stools in the initial days of life (transitional stools). Due to some weight 2 ch-01.indd 2 18-12-2013 14:31:00 Diarrhea in Children loss, they are often thought of as diarrhea. It is self-limiting and requires no treatment • Formed or pasty stools frequently passed in exclusively breastfed babies • Passing a stool immediately after feed by infants 3–6 months of age: It is due to exaggerated gastrocolic pattern, quite normal at this stage and requires no treatment CLASSIFICATION OF DIARRHEA Acute diarrhea: It is passage of several watery and loose stools in a day which generally terminate within 7 days (only rarely 14–28 days). Persistent diarrhea: World Health Organization (WHO) defines this as a diarrheal illness, which begins acutely and lasts for 14 days or more. More than 60% episodes occur in infants less than 6 months and 90% before 1 year of age. Chronic diarrhea: It is diarrhea of more insidious onset with stools, which are less watery in nature and semisolid. Their frequency may be four to five times per day. It is seen more in children above 3 years of age. Dysentery: It is presence of visible blood in stool. It is usually accompanied by pus and abdominal cramps and fever. Shigella is the most common cause requiring treatment with antibiotics. Acute infective diarrhea may be both “noninflammatory” or “inflammatory”. Noninflammatory diarrhea is due to enterotoxin produced by bacteria, destruction of villus (surface cells) by viruses, or adherence by parasites. Diarrhea may be inflammatory due to bacteria that invade intestine directly or produce cytotoxins. 3 ch-01.indd 3 18-12-2013 14:31:00 Clinic Consult: Childhood Diarrhea KEY MESSAGES Diarrhea is a leading cause of morbidity and mortality in children in the developing world It can lead to dehydration and associated acid–base disturbances which, if not recognized and treated, can prove fatal Recurrent/prolonged diarrhea can cause malnutrition and failure to thrive Many normal physiological stooling patterns are confused with diarrhea and treated unnecessarily.