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1 Overview of Diarrhea in Children

Diarrhoeal disease is the second leading cause of death in children under five years old, and is
responsible for killing around 525 000 children every year. Diarrhoea can last several days, and
can leave the body without the water and salts that are necessary for survival. In the past, for
most people, severe dehydration and fluid loss were the main causes of diarrhoea deaths. Now,
other causes such as septic bacterial infections are likely to account for an increasing proportion
of all diarrhoea-associated deaths. Children who are malnourished or have impaired immunity as
well as people living with HIV are most at risk of life-threatening diarrhoea.

Diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more
frequent passage than is normal for the individual). Frequent passing of formed stools is not
diarrhoea, nor is the passing of loose, "pasty" stools by breastfed babies (WHO, 2017).

Diarrhoea is usually a symptom of an infection in the intestinal tract, which can be caused by a
variety of bacterial, viral and parasitic organisms. Infection is spread through contaminated food
or drinking-water, or from person-to-person as a result of poor hygiene.

Interventions to prevent diarrhoea, including safe drinking-water, use of improved sanitation and
hand washing with soap can reduce disease risk. Diarrhoea should be treated with oral
rehydration solution (ORS), a solution of clean water, sugar and salt. In addition, a 10-14 day
supplemental treatment course of dispersible 20 mg zinc tablets shortens diarrhoea duration and
improves outcomes.

2 Diarrheal disorders by etiology (Cause)

1. Viral gastroenteritis (viral diarrheal diseases)

Rotavirus enteritis

Adenovirus enteritis

2. Bacterial gastroenteritis (bacterial diarrheal diseases)

i. Campylobacter enteritis (causative agent: Campylobacter jejuni)

ii. Salmonella enteritis (causative agent: Salmonella enteritidis, S. typhimurium)

 iii. Typhoid fever (causative agent: Salmonella typhi)

iv. Paratyphoid fever (causative agent: Salmonella paratyphi)

v. Shigellosis (causative agent: Shigelladysenteriae, flexneri, boydii, sonnei)

vi. Cholera (causative agent: Vibrio cholerae)

vii. Infections caused by Escherichia coli

3. Gastrointestinal parasitosis

i. Protozoa: Toxoplasmosis (causative agent: Toxoplasma gondii), Toxocarosis

(Toxocaracanis / cati), Giardiasis (Giardia lamblia), Amoebiasis (Entamoebahistolytica),
Cryptosporidiosis (Cryptosporidium parvum)

ii. Nematodes: Ascariasis (caused by: Ascaris lumbricoides), Trichuriosis

(Trichuristrichiura), Trichinella spiralis, Enterobiosis (Enterobiusvermicularis),
Strongyloidesstercoralis, Ancylostomaduodenale, Necator americanes, Dracunulus

iii. Cestodes: Teniosis (agents: Taenia solium, Taenia saginata), Diphyllobothriumlatum,

(Hymenolepis nana), Echinococcusgranulosus

4. Enterotoxicosis - caused by enterotoxins

5. Drug-induced diarrhea - Pseudomembranous enterocolitis

3 Behaviors that increase the risk of Diarrhea

A number of spaces behavior help enteric pathogens to spread and this increase the risk of
diarrhea. These involve failure to breast feed exclusively for the first 4-6 months of life.

I. The risk of developing severe diarrhea, many times in greater in non-breast feed infants,
than in infants who are exclusive breast feed, the risk of death from diarrhea is also
substantially greater.
II. Using bottle to feeds: these easily become with contaminated faucal bacteria and difficult
to clean when milk is added to an unclean bottle it becomes contaminated. If it is not
consumed immediately, bacteria growth occurs.
III. Failure to dispose offences hygienically (including infants faces). It is often believed that
infant faeces are harmless, where as they actually contain large, number of infectious
virus or bacteria, animal’s faeces can transmit certain infection to mandicuf.
IV. Drinking water that is contaminated with faecal bacteria water may be contaminated at its
sources or during storage in the home contamination, in the home may occur when
storage container is not covered or when a contaminated. Hand comes in contact with the
water while collecting it.
V. Storing cooked food at room temperature, when food is cooked then saved to be used
later, it easily be contaminated for example by contact with contaminated surface or
containers. If food is kept for several hours at room temperature, bacteria in it can be
multiplying many times, (Vincejo et al., 2015).

4 Pathophysiology

1. Changes in the intestinal mucosa (impaired absorption, digestion, secretion, and motility)
lead to excessive loss of water and electrolytes, especially sodium and potassium,
metabolic acidosis, and subsequent dehydration.

2. Two main pathophysiological mechanisms: osmotic and secretory diarrhea.

3. Viruses directly damage the intestinal villi and enterocyte brush border enzymes.

4. Osmotic and secretory diarrhea are combined in the pathogenesis of rotavirus diarrhea.
Osmotic diarrhea is caused by the destruction of villi (cell lysis) via the action of NSP4-
induced glucose malabsorption (SGLT-1 inhibition) and inflammation (NK-κB, IL-8).
Secretory diarrhea is caused by crypt cell proliferation (compensatory secretory cell
proliferation), NSP4 - enterotoxin (increased intracellular calcium, chloride secretion),
vascular ischemia (microcirculatory disorders), and inflammation.

5. Enteroinvasive bacteria (Salmonella spp., Shigella spp., Campylobacter jejuni,

enteroinvasive E. coli) cause ulcerations and inflammatory infiltration of the intestinal
mucosa.

6. Some bacteria (enterotoxigenic E. coli, staphylococcal enterotoxin) stimulate active

secretion of ions and water into the intestinal lumen by their toxins (cAMP, cGMP).
 7. Non-invasive bacteria and parasites adhere to the mucosa and cause inflammatory
infiltration.

5 Diagnostics

1. Anamnesis (nutritional change, epidemic occurrence, administration of ATB, and other

drugs)

2. Stool evaluation:

3. Secretory diarrhea (most often infectious) - watery, sparse, often with fever

4. Malabsorption of carbohydrates - foamy, sour smelling, pH below 6

5. Chronic eating disorders - bulky, greasy, putrid-smelling

6. Colon inflammation (indicates an infectious etiology- Salmonella, Shigella, Yersinia,

Campylobacter) - mucus in stool, possibly bloody

7. As soon as possible, a stool sample must be sent for microbiological examination (it must
not be too thin and once stools are watery, we no longer have to cultivate pathogenic
organisms).

8. The presence of polymorphonuclear cells indicates a bacterial infection.

9. In chronic disorders, there is a positive stool test for fats, carbohydrates, reducing
substances, trypsin, and/or proteins.

10. To exclude cystic fibrosis, we examine chloride concentration in sweat.

11. Serology is not performed for acute diarrhea, but it is important in examining recurrent
and chronic diarrhea.

6 Treatment of Diarrhea in Children

Specific causes of diarrhea are treated (eg, gluten-free diet for children with celiac disease).
General treatment focuses on hydration, which can usually be done orally. IV hydration is rarely
essential. (CAUTION: Antidiarrheal drugs [eg, loperamide] are not recommended for infants and
young children.)

1. Rehydration

Oral rehydration solution (ORS) should contain complex carbohydrate or 2% glucose and 50 to
90 mEq/L (50 to 90 mmol/L) sodium. Sports drinks, sodas, juices, and similar drinks do not meet
these criteria and should not be used. They generally have too little sodium and too much
carbohydrate to take advantage of sodium/glucose cotransport, and the osmotic effect of the
excess carbohydrate may result in additional fluid loss.

ORS is recommended by the World Health Organization and is widely available in the US
without a prescription. Premixed solutions are also available at most pharmacies and
supermarkets.

If the child is also vomiting, small, frequent amounts are used, starting with 5 mL every 5
minutes and increasing gradually as tolerated ( see Oral Rehydration). If the child is not
vomiting, the initial amount is not restricted. In either case, generally 50 mL/kg is given over 4
hours for mild dehydration, and 100 mL/kg is given over 4 hours for moderate dehydration. For
each diarrheal stool, an additional 10 mL/kg (up to 240 mL) is given. After 4 hours, the patient is
reassessed. If signs of dehydration persist, the same volume is repeated.

2. Diet and nutrition

Children with an acute diarrheal illness should eat an age-appropriate diet as soon as they have
been rehydrated and are not vomiting. Infants may resume breast milk or formula.

For chronic nonspecific diarrhea of childhood (toddler's diarrhea), dietary fat and fiber should be
increased, and fluid intake (especially fruit juices) should be decreased.

For other causes of chronic diarrhea, adequate nutrition must be maintained, particularly of fat-
soluble vitamins.

2.7 Mother’s management practice of Diarrhea at home

For a long time in the past, mother’s, all over the world have had a numbers of ways by which
they used to handle their children’s.

Diarrhea at home some of this method is effective in solving the problem, while some have
yielded some position results. With general improvement in public health activates the world
effort over, creation of awareness among mother’s has brought about better ways of handling
diarrhea, and therefore, reduced to a large extent, morbidity and mortality rate due to diarrhea
disease.

Diarrhea disease is a common illness and can be life threatening mother’s are used to dealing
with diarrhea and have an example repertoire of home base practices, traditional treatment and
western style to manage diarrheal episodes. However, programmed planners often over look and
or underestimate this knowledge and by so doing, then constraint the possible impact of
educational, messages and intervention programmed designed to treat diarrhea and to promote
ORT. Martin’set’al all from rural Mexico address the “popular epidemiology” of diarrhea in an
effort to highlight data that may proved useful planners of diarrhea management programmed.

The nature of feeding, home remedy practices and consultation with health care providers during
illness of children n mat lab, a rural sub-district of Bangladesh were studied by Bhuita about half
of the mother’s initiated home remedies for treating their children, the treatment includes:-

Pouring water on the head, feeding twice of herbs, using sanctified water and ORT. The type of
treatment was depended on the nature of illness. The used of ORT was low with regards to
nutrition during episodes, breast feeding was discontinued for 16% of the episodes the reduction
was the highest for fever with cough followed by fever and diarrhea a reduction of intake of
other foods was observed for 10%. The reduction was highest for dysentery followed by diarrhea
and fever with or without cough total withdrawal of foods other than breast milk was highest for
diarrhea. Contact at least one healthcare providers of any type by the 15 th days of illness were
made for 4% of the episodes.

The contact rate was significantly greater for children living in the health intervention area for
boy’s, for infant, for richer household and severe cases. A higher contact rate in case o diarrhea
illness was observed for children of illiterate mother’s than that of literate ones.
A number of studies have been conducted in Africa countries to ascertain mother’s level of
knowledge with regards to home management of diarrhea. In one of these studies, it was found
by Ahmed et al., in a saudanes rural community that the oral rehydration solution (ORS) use rate
was very low (2-1-43.8)

Although awareness about ORS was high (100%) only 25% prepared and used it correctly.
However, home – medi – fluids. Including vice water, custard, pap, were used by 45% of the
mother’s regarding feeding practice during diarrhea episodes. About 45% of the regarding
feeding practice during diarrhea episodes. About 45% of illiterate mother’s stop breast feeding
and food during diarrhea compared to 30% of illiterate mother’s. harmful practices used in
caring for children with diarrhea include fumigation (50%) centralization and removal teeth buds
(45% of illiterate mother’s , 10% literate mother’s with holding of breast feeding and
indiscriminate use of drugs and herbs 30%) .

In Nigeria, the home – management – practice of different centers has indicated one of such
studies conducted by eneabong in the 2000 among market women In Enugu state shows that in
68% of cases drugs were used along or in conjunction with S.S.S or other forms of treatment.
These drugs prescribed by medical personnel (40%) patient medicine stores (28%) or mother
themselves (30%) about (26%) and 39% of the mother’s treated respectively, while only 23%
used S.S.S alone.

The drugs used were mainly anti-microbial (34%) and combination of anti-malaria, anti- acid,
analgesic, and some local herbal preparation (21%) the result of study indicates the evidence of
unnecessary used of drugs and ignorance about their potential adverse effects there underscore
the need for appropriate primary care education among the market women in Nigeria.

In a preliminary study on attitude of people in two state of Nigeria, cross river and Akwa- ibom
on diarrhea disease and it’s management carried out by ikpatt NN and young mu, 60
respondents. Among 561 residents through the person ill with diarrhea should neither eat solid
food nor drinking. In addition 106 people believed that mother’s should not breast feed a child
during a diarrheal episodes radio, Tv, hospital, clinics and health centers informed 95.4% of the
people about S.S.S.
They tend to believed SSS does adequately treat diarrhea, while 6.6% claimed that they would
not administered it to their children when they experience a diarrhea episodes. Just 12.7% had no
knowledge at all on how to prepare it, 28.5% did use only SSS when their children catch up with
diarrhea many other respondents used SSS with anti-biotic and anti-diarrheal. Leading traditional
remedies for diarrhea and dehydration include plantain, (16.7% (15.5%). Native water (7.1%)
these results indicate the needs to promote ORT in these two Nigerian states. Health workers
should target every members of the house hold so that each one can learn about ORT, on how to
prepare and administer sugar salt solution (S.S.S).