DIARRHEA &

DEHYDRATION
Prof. dr. S. Yati Soenarto, Ph.D., Sp.AK

WHAT IS DIARRHEA?

The passage of unusually loose or watery stools,

usually at least three times in a 24 hour period.

Consistency of the stools rather than the number is

the most important to consider diagnosis of diarrhea.
Frequent passing of formed stool diarrhea.

(WHO, 2005)

Why is diarrhea dangerous?

DIARRHEA DEATH due to LOST
(& LACK) of:
WATER &

FOOD

ELECTROLYTE

The Etiology of Children

Deaths ASIA WHO SEAR
GLOBAL

INDONESI
A
Bryce J, et.al., 2005

YR 2000 2003

WHO,2006

YR 2000
http://www.who.int/child-adolescenthealth/overview/child_health/

INDONESIA

Diarrhea-U5
:

Mortality

Morbidity

Household survey, 2001

CLASSIFICATION
Based on
duration :

Acute diarrhea
starts suddenly ,may continue for several days.
Persistent diarrhea
starts like acute diarrhea, lasts for >14 days

(WHO, 2005)

1. Osmotic diarrhea

Caused by presence of non-absorbable substance in the GI tract

Ex : lactose intolerance.
Stop with avoidance of substance causing diarrhea.
Lab investigation : low pH, reducing substance (+)

2. Secretory diarrhea
endogenous substances induce fluid secretion.
Activation of intracellular mediators (cAMP, cGMP, intracellular

Calcium)
Ex : diarrhea due to V. cholera, E. coli enterotoxin

Ghishan, 2007

3.Congenital defects of ion transport protein

Defects in Na-H exchange or Cl-/HCO3- exchange (congenital

chloride-losing diarrhea) or Sodium-Bile acid transport protein.
Symptom occurs in early age of life secretory diarrhea &
failure to thrive since neonatal period.

4. Reduction in Anatomic Surface Area

Results from the resection of the bowel short bowel syndrome
Characterized of loss of fluids, electrolyte, micro & macronutrient.

Ghishan, 2007

5. Alteration in Intestinal Motility

Various etiology (malnutrition, scleroderma, intestinal
obstruction, and DM).
Malnutrition reduce intestinal motility
overgrowth bacteria bile salt deconjugated intracellular
cAMP secretory diarrhea

Ghishan, 2007

Regulation of Absortive & Secretory Process in the

Intestine Downloaded from www.nejm.org on October 1, 2007. Copyright @ 2006

Diarrhea in Clinical Practice

1. History Taking

Feeding history
Diarrhea manifestations :
frequency of stools
number of days
blood in stools
local reports of cholera outbreak
recent antibiotic or other drug treatment
attacks of crying with pallor in an infant.
WHO Hospital Care for Children,
2006

2. Examinations
Look for:
signs of some dehydration or severe dehydration
blood in stool
signs of severe malnutrition
abdominal mass
abdominal distension.

WHO Hospital Care for Children,

2006

3. Laboratory Investigation
No need for routine stool cultures in children with
diarrhea
Electrolyte levels : in children with features of
hypernatremic dehydration
Hypernatremic dehydration can result
from ingestion of hypertonic liquids or
loss of hypotonic fluid in the stool or
urine

WHO Hospital Care for Children,

2006

5 LANGKAH
TUNTASKAN
5 STEPS
OF MANAGEMENT
FORDIARE
DIARRHEA
CASE MANAGEMENT
1. DEHYDRATION: Rehydration: IV

2.NUTRITION:

3. ETIOLOGY
(commonly infection)

4. SUCCES OF
PRACTICE:

oralit

2. CONTINUED
FEEDING

1. NEW REDUCED
OSMOLARITY ORALIT

3.ZINC

SEVERITY
& INCIDENCE

4. RATIONAL
ANTIMICROBIAL

PHARMACOLOGIC
NO ANTIMICROBIAL &
ANTIVOMITING

5. PATIENT-DOCTOR
COMMUNICATION

1. New Lo-ORS
the need of IV therapy

vomiting

-glucose 75 mmol/L
-sodium (NaCl) 75mEq/L

OUTCOME
stool output

Reducing concentration:

33% -overall 245 mOsm/L

20%
30%

WHO/UNICEF Joint Statement, 2004

AGE

AMOUNT OF ORS AFTER

EACH LOOSE STOOL

<12 MONTHS

5O-100 ml

400ml/DAY

1-4 YEARS

100-200 ml

600-800 ml/DAY

> 5 YEARS

200-300 ml

800-1000 ml/DAY

ADULT

300-400 ml

1200-2800 ML/DAY

200 ml: 1 SACCHETE

AMOUNT OF ORS TO
PROVIDE FOR USE AT
HOME

What is new in ORS?

Standard formulation of
ORS

New formulation of
ORS

Sodium 90 MEq/L
Osmolarity of 311 mmol/L

Sodium 75 mEq/L
Osmolarity 245 mmol/L

Reductionoflevelsofglucoseandsaltshortensdurationofdiarrhea
Reducedosmolaritydecreasesstooloutput
Improvedeffectivenessforchildrenwithacute,noncholeradiarrhea

History Taking
A careful feeding history is essential in the management of a child
with diarrhea. Also, inquire into the following:
diarrhea

frequency of stools
number of days
character of stools
vomiting
past medical history
local reports of cholera outbreak
recent antibiotic or other drug treatment
signs of intussusception (attacks of crying with pallor in an infant) .

World Gastroenterology Organization, 2008

WHO Hospital Care for Children, 2006

Examination

Look for:
Body weight, temperature, heart and respiratory rate, blood
preasure
signs of some dehydration or severe dehydration:

restlessness or irritability
lethargy/reduced level of consciousness
sunken eyes
skin pinch returns slowly or very slowly
thirsty/drinks eagerly, or drinking poorly or not able to drink

blood in stool
signs of Intussusception ( intraabdominal mass, mucous and
bloody stool)
signs of severe malnutrition
abdominal distension.
There is no need for routine stool cultures in children with diarrhea
WHO, 2008
!
WHO Hospital Care for Children, 2006

Classification of the severity of dehydration in children with diarrhea

SEVERE
DEHYDRATION
1. Signs
symptoms :

or

Two/more
of
the
follow :
Lethargy/unconscio
usness
sunken eyes
unable to
drink/drinks poorly
skin pinch goes
back very slowly (
2 seconds )
2. Treatment :
Give fluid for severe
dehydration
(Diarrhea
Treatment Plan C)

SOME
DEHYDRATION
1. Signs
symptoms :

or

Two/more of the
follow :
restlessness,
irritability
sunken eyes
drinks
eagerly,
thirsty
skin pinch goes
back slowly
2. Treatment :
Give fluid & food
for some
dehydration
(Diarrhea
Treatment Plan
B)
After rehydration,

NO
DEHYDRATION
1. Signs or
symptoms :
Not enough signs to
classify as some
or severe
dehydration
2. Treatment :
Give fluid & food
to treat
dehydration
diarrhoea at
home (Diarrhea
Treatment Plan
A)
Advise mother on
when to return
immediately

WHO Hospital Care for Children, 2006

Diarrhea Treatment Plan A

Counsel mother on the 4 rules of home treatment :

GIVE EXTRA FLUID (AS MUCH AS THE CHILD WILL TAKE)

Breastfeed more frequently & longer (if exclusively breastfed give ORS in
addition or if not exclusively breastfed give either ORS, food-based fluids
such as soup/rice water/etc, or clean water)
Teach mother how to mix & give ORS
Show mother how much fluid to give (up to 2 years 50-100ml, 2
years100-200ml)

GIVE ZINC SUPPLEMENTS

up to 6 months : tablet (10mg)/day for 10-14 days

6 months 1 tablet (20mg)/day for 10-14 days

CONTINUE FEEDING

WHEN TO RETURN

Full 10-14 days

Adapted from : WHO, 2006

Diarrhoea Treatment Plan A:

Treat diarrhoea at home
GIVE EXTRA FLUID (AS MUCH AS THE CHILD WILL
TAKE)

1.

TELL THE MOTHER:

In young infants, breastfeeding is a main source of extra fluid .

Breastfeed frequently and for longer at each feed.
If the child is exclusively breastfed, give ORS or cooled boiled water
in addition to breastmilk
If the child is not exclusively breastfed, give one or more of the
following: ORS solution, food-based fluids (such as soup, rice water),
or cooled boiled water.

It is especially important to give ORS at home when:

the child has been treated with Plan B or Plan C during this
visit.
the child cannot return to a clinic if the diarrhoea gets worse.

Diarrhoea Treatment Plan A:

Treat diarrhoea at home
TEACH THE MOTHER HOW TO MIX AND GIVE ORS. GIVE THE MOTHER
6 PACKETS OF ORS (200 ml) TO USE AT HOME.
SHOW THE MOTHER HOW MUCH FLUID TO GIVE IN ADDITION TO THE
USUAL FLUID INTAKE:

Up to 2 years 50 to 100 ml after each loose stool

2 years or more 100 to 200 ml after each loose stool

Tell the mother how to give ORS solution:

Give frequent small sips from a cup.
If the child vomits, wait 10 minutes. Then continue, but more
slowly.
Continue giving extra fluid until the diarrhoea stops.

Diarrhea Treatment Plan B

Give recommended amount of ORS in clinic over 4-hour
period
AGE

Up to

4 months up to

12 months up
to

2 years up
to

4 months

12 months

2 years

5 years

WEIGHT

<6 kg

6-<10kg

10-<12kg

12-19kg

In ml

200-400

400-700

700-900

900-1400

Show mother how to ORS as in treatment plan A

After 4 hours :

Reasses
Select appropriate plan for continue treatment
Begin feeding in clinic

If mother must leave before completing treatment :

Explain 4 rules of home treatment

Adapted from : WHO, 2006

Diarrhoea Treatment Plan B:

Treat some dehydration with ORS
Give recommended amount of ORS in clinic over a 3-hour period.
ORS = (weight (kg)) x 75ml

If the child wants more ORS than shown in the guides above, give
according to present fluid loss.

For children under 6 months unable to breastfeed, give also 100-200 ml

of cooled boiled water throughout this periode.

Begin feeding immediately after child is willing to eat.

Continue breastfeeding.
SHOW MOTHER HOW TO GIVE ORS.

Give frequent small sips from a cup.

If the child vomits, wait 10 minutes. Then continue, but more slowly.
Continue breastfeeding whenever the child wants.

Give Zinc tablets.

Diarrhoea Treatment Plan B:

Treat some dehydration with ORS

AFTER 3 HOURS:

Reassess the child and classify the child for dehydration.

Select the appropriate plan to continue treatment.

IF MOTHER MUST LEAVE BEFORE COMPLETING

TREATMENT:

Show her how to prepare ORS solution at home.

Show her how much ORS to give to finish 3-hour treatment at
home.
Give her enough ORS packets to complete rehydration. Also
give her 6 packets as recommended in Plan A.
Explain the 4 Rules of Home Treatment: Extra fluids, Continue
feeding, Give zinc supplements, Advise mother when to return

Diarrhea Treatment Plan C

YES

IV
fluids

Start immediately & give ORS if

possible

NO
YES

Is IV available
within 30
minutes?
NO

Refer immediately & if possible tell mothe

to give ORS during trip

NG tube

YES

Rehydrate via NG
tube

NO
Refer
urgently
to hospital

Adapted from : WHO, 2005

DIARRHOEA TREATMENT PLAN TREAT

SEVERE DEHYDRATION QUICKLY
Start IV fluid immediately. If the child can drink, give ORS by moth while the drip is set up. Give 100 ml/kg Ringers
lactate solution or Ringer asetat (or, if not available, normal saline), devided as follows:

START HERE

Can you give

intravenous (IV)
fluid immediately

YES

NO
Is IV treatment
available
nearby (within
30 minutes)

YES

NO
Are you trained to
used a nasogastric
(NG) tube for
rehydration

YES

NO

Can the
child drink?

First, give 30 ml/kg in

Then, give 70 ml/kg in

< 12 months old

1 hour

5 hours

>12 months old

30 minutes

2 hours

*Repeat once if radial pulse is still very weak or not detectable

Reassess the child every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly
Also give ORS (about 5ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours
(children) and give the child zinc according to recommended dosage schedule.
Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate
plan (A,B, or C) to continue treatment.

Refer URGENTLY to hospital for IV treatment

If the child can drink, provide the mother with ORS solution and show her to give frequent
sips during the trip

Start rehydration by tube (or mouth) with ORS solution: give 20 mg/kg/hour for
6 hours (total of 120 mg/kg)
Reassess the child every 1-2 hours:
If there is repeated vomiting or increasing abdominal distension, give the fluid
more slowly
If hydration status is not improving after 3 hours send the child for IV therapy
After 6 hours, reassess the child. Classify dehydration. Then choose the
appropriate plan (A,B, or C) to continue treament.
Refer URGENTLY

NO

to hospital for IV or
NG treatment

Note: if possible, observe the child for at least 6 hours

after rehydration to be sure the mother can maintain
hydration giving the child ORS solution by mouth