Pepared by group five

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Name of participant
Osman mohammed ID No:4572/09
Omed Obang Agang IDNo:4571/09
Saladin Bakari ID No:4591/09

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Objectives of the Presentation
Able to define diarrhea
Learn epidemiology and burden of diarrhea
List etiology/cause/ of diarrhea
Explain pathophysiology of Neonatal diarrhea
Mention types and clinical features of diarrhea
Able to manage a neonatal with diarrhea
Learn the different complications of diarrhea and the
management

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Topic out line
Diarrhea:
Definition
Epidemiology
Types
Etiology/cause
Pathogenesis
Risk factors
Clinical manifestations / sign and symptom
Treatment
Nursing Intervention
Reference

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Definition
The term diarrhea comes from greak word
diarrhoia,meaning to flow though.
Three or more loose or watery stools in a 24-hour
period
Gastroenteritis denotes infection of gastroeninterates
tract caused by bacteria,viral,or parasitic pathogens
Incase of neonatal birth asphsia,pothotherapy,out
berak and gastric volume increase necrotaz ecolitis
If mother; complaint that the child has diarea
There are non infectious cause of diarrhea,but sepsis is
the most common cause during the new born priod 5
Defn. NEC
Non obstructive acute abdominal damage
characterized by necrotic damage of intestannal
mucosa.
Acute gastrointestanal dieases like ,abdominal
distetion and bloody diarrhea.
It usually affectis premature infats, but it has also been
interm babies, mostly with a back ground of
congenital heart and endicrone diases and too rarely in
order, immunologic compromasize infants.

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Epidemiology:
account for 18% of childhood deaths

estimated 1.8 million deaths per year globally.

WHO, >700 million episodes of diarrhea annually

in children <5 yr of age in developing countries.

overall incidence of diarrhea is 3.2 episodes per

child year

It is common in children, especially those between

6 months and 2 years of age.

Ethiopia: 20% of U5 mortality.

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Epidimology NEC
Incase of NEC an annualy worldrate rangig from 0.3 to 2.4
case per 1000 live premature babies and fuull term neonate
of 0.05 per 1000 live birth.
NEC records an overall incedense of 2-5% in all premature
and up to 13% in babies weighting at less than 1500gr.
Male and blach babies seem to be affeted with higher
frequncey than female and white.
Occuring with in first day/week of life.

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Diarrhea: types
acute diarrhea: lasting less than 14 days
persistent diarrhea: lasting 14 days/ more
-developing world
Dysentery: diarrhea with blood in the stool, with
or with out mucus.

Chronic diarrhea: lasting 14days or more developed

world

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Etiology /cause diarrhea in NEO
1.Maternal uterine infection or fever
any time from the onset of labour to
three days after birth,or rupture of membranes
for morethan 18 hours before
birth Time of onset day 1 to 3
2. Baby receiving food/fluid other
than breast milk
Time of onset after other food/fluid started

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Con.
Baby reciveng phototherapy .Time onset after
phototherapy started
Out break of diarrhea among other baby with nurser
Nasocomial infection of diarrhea.if the diarrhea
daveloped While the baby was Hospitalized and more
than one baby with diarrhea from the same ward is
seen with in a two days of priod,suspect a Nasocomial
infection.
Poor or no feeding due to Asphaxia time on set day 2-
10.Incase of necrotiz entroclitis.
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Cont Icase of NEC
Incase of NEC not yet clearly under stood,seems to be
related to multiple factors such as
prematurety,Ischemia,enteral feeding and infective
agents.play role in NEC deteminism

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PATHOGENESIS OF INFECTIOUS DIARRHEA
The greatest volume of intestinal water is absorbed in
the small bowel; the colon concentrates intestinal
contents against a high osmotic gradient.

The small intestine absorb 10-11 L/day of ingested &

secreted fluid, whereas the colon absorbs 0.5-1 L.

Thus, disorders of small bowel produce voluminous

diarrhea, whereas disorders of colonic absorption
produce lower volume.
e.g. dysentry-
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Pathogenesis of diarrhea
Non-inflammatory diarrhea: through
enterotoxin production by some bacteria
destruction of villus (surface) cells by viruses
adherence by parasites, and
adherence and/or translocation by bacteria

Inflammatory diarrhea:
is usually caused by bacteria that directly invade the intestine
or produce cytotoxins

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Pathogenesis of diarrhea
Under normal circumstances the absorptive process
for water and electrolytes exceeds secretion.

Diarrhea results when there is an alteration of these

mechanisms.
Absorption =>Villous
Na, Amino acid, Glucose
Glucose facilitates the absorption of Na 25x
Secretion => Crypts
Chloride
e.g. V.cholera toxin mediated conversion of ATP CAMP

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Mechanism of water absorption in the GIT
is absorbed passively, always following a solute.
three basic mechanisms of solute absorption:
1. "neutral" sodium chloride (NaCl) absorption
Na/H cation exchanger and Cl/HCO3 anion exchanger

2. "electrogenic" sodium absorption

Na/K ATPase active transport
It is this absorption mechanism that is commonly damaged
during acute enteric infection, resulting in diarrhea.

3. sodium co-transport.
Sodium absorption is coupled to glucose, aminoacids.
Is intact during most acute diarrheal disorders.
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Mechanism of water absorption in the GIT

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Mechanism of diarrhea
1. Osmotic diarrhea
Occurs in:
Digestive enzyme deficiencies
Ingestion of unabsorbable solute

Gradient of water absorption is toward the intestinal

lumen leading to diarrhea.

Examples:
Damage to intestinal epithelial cells by rotavirus and shigella
leading to malabsorption and diarrhea is due to this mechanism.
Sweetened drinks sucrose, coca cola
Laxative mgso4
Lactase deficiency
No stool leukocytes

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Mechanism of diarrhea
2. Secretory Diarrhea
Defect:
There is active secretion of water in to the lumen
Increased secretion
Decreased absorption(virus villus damage)
Examples:
Cholera, staphylococcus aureus, c.perfringens
Toxinogenic E.coli, rotavirus
Comments:
Persists during fasting
No stool leukocytes

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Mechanism of diarrhea
3. Exudative Diarrhea:
Defects:
there is inflammation
Decreased colonic reabsorption
Increased motility
Examples:
Bacterial enteritis
Comments:
Blood, mucus and WBCs in stool

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Mechanism
4. Increased motility:
Defect:
Decreased transit time
Example:
Irritable bowel syndrome, thyrotoxicosis, post
vagotomy dumping syndrome

5. Decreased motility:
Defect:
Defect in neurotransmiting
unitsstasis(bacterial over growth)
Example:
Psedo-obstruction, blind-loop

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Risk factors.
Premature rupture of membrane
Out break of diarrea infection
Asphyaxia due to fetal distrees
Prematurity of new born
Phototherapy
Food or feeding other than breast feed

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RISK FAKTORS IN CASE OF NEC
Food or feeding other than breast feed
Premature new born
Ischemia
Infective agents (infection intestane flora)
Bawol in maturity,incompilty substrets digetion and
absorption and incompetence defensive machanism
and inproprate use of antibiotics could increase the
virulense of microrganism, like E.coli and
closterdium,frequntly impalicated in NEC
pathogenesis.

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Clinical manfestation.s/sympto
Watery, greenish stools that continue
even if the baby is not breastfed
Blood in stool
Vomiting(IF the cause is outbreack)
Poor or no feeding
Baby looks ill
Floppiness
Lethargy
Loose yellow stool(phototherapy)
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Necrotizing enterocolitis,S/S
Floppiness or lethargy
Baby looks ill
Abdominal distension,tenderness
Small baby (less than 2.5 kg at birth or born before 37
weeks gestation)
Blood or bile in vomitus
Blood or mucus instool
Pallor
Progressive signs of ill health(temperature instability
and/or apnoea)
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Clinical manifestation s/syptom
Most related to the infecting pathogen and the
dose/inoculum.

development of complications
dehydration and electrolyte imbalance

nausea and vomiting

blood in the stool

abdominal cramps, tenesmus

fever
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Clinical evaluation:
Assess degree of dehydration

Obtain appropriate contact or exposure Hx

Clinically determine the etiology /cause/of diarrhea

How to assess with diarrhea:

Ask duration
Ask if there is blood in the stool
Look if the child is lethargic or unconscious, irritable or restless
Look for sunken eyes
Check if drinking eagerly, poorly or normally or unable to drink

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Clinical
Mistakes in taking a skin pinch:
Pinching either too close to the midline or too far
laterally

Pinching the skin in an horizontal direction

Not pinching the skin long enough

Releasing the skin so that the finger and thumb remain

in a closed position
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Clinical

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How to classify dehydration
all children with diarrhea are classified for
dehydration.

if the child has had diarrhoea for 14 days or more,

classify the child for persistent diarrhea.

if the child has blood in the stool, classify the child for
dysentery.

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Classify Dehydration

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Classify dehydration
Isonatremic/isotonic: 70-80%
Equal amount of fluid and sodium loss

Hyponatremic: 10-15%
More sodium loss than water; e.g oral H2O intake
More substantial intravascular depletion due to shift of water
from the extra vascular space.

Hypernatremic dehydration: 10-20%

More water loss than sodium; e.g high salt intake, fever
More serious cxn due to hypernatremia
Needs gradual correction over 2-4 days

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Degree of dehydration

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Probable Diagnosis
Diarrhoea due to sepsis (Maternal uterine
Infection).
Infectious diarrhoea (fluid other than breast
milk).
Nosocomial diarrhoea of infectious.
Necrotizing enterocolitis(Poor or no feeding
Asphyxia).

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GENERAL MANAGEMENT

Allow the baby to begin breastfeeding

If the baby cannot be breastfed, give expressed
breast milk using an alternative feeding method.
If the mother is giving the baby any food or fluid
other than breast milk, advise her to stop giving
them.

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MGT.cont.
Give oral rehydration solution (ORS) for every
diarrhoeal stool passed:
- If the baby is able to feed, have the mother
breastfeed more often,
or give ORS 20 ml/kg body weight between
breastfeeds using a cup,
cup and spoon, or other device .
- If the baby is not feeding well, insert a gastric
tube and give ORS 20 ml/kg body weight by tube.

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If prepackaged ORS is not available,
make ORS as follows:
- Use recently boiled and cooled water;
- To 1 litre of water, add:
- sodium chloride 3.5 g;
- trisodium citrate 2.9 g (or sodium bicarbonate 2.5 g);
- potassium chloride 1.5 g;
- glucose (anhydrous) 20 g (or sucrose [common
sugar] 40 g).

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Cont.
If the baby has signs of dehydration or sepsis, establish an IV line
and give IV fluid while allowing the baby to continue to breastfeed
- If there are signs of dehydration, increase the volume of fluid by
10% of the babys body weight on the first day that the dehydrationis
noted;
- If the baby receives a sufficient volume of fluid to meet rehydration
and maintenance requirements and to replace ongoing
losses, the useof ORS is not necessary.

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Cont
Assess the baby again in 12 hours:
If the baby is still having diarrhoeal stools,
continue the increased volume of IV fluid for an
additional 24 hours;

If the baby has not had a diarrhoeal stool in the

last 12hours, adjust fluid to maintenance volume
according to the baby's age.

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MANAGEMENT OF NOSOCOMIAL
DIARRHOEA
If the diarrhoea developed while the baby was
hospitalized and more than one baby with
diarrhoea from the same ward is seen within a
two-day period, suspect a nosocomial infection
Isolate the baby from other babies, if possible.
Treat for sepsis .
Continue to provide general management for
diarrhoea

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Management for necrotizing
entirocolitis
Estaablish an IV line if one is not already in place and
give only IV fluid at maintenance volume according to
babys age for the first five days.
Treat for sepses and ensure that the baby is not feed
for first five days.
Insert a gastric tube and insure free drainage

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Nursing Intervention
Acess about breast feeding degre of dehayderation.
Give orderd drug incase of sepsis and maintenance fluid incase of
resestaion
Advise the mother about breast feeding and
hyieghen,position,atachement,frequency of feed with in 24
Preparing ORS if theres no packd ORS available
Check vital sign,manage complication of dehadretion
If admet of new born maintane room tempreture for prevention of
hypothermia and hypoglycemia.
Monitor fluid intake and out put (mantaien urine out put 1-3ml/Kg/hr)
incase of NEC

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Referance
Jimmaa University lecture Note
Doctor Jonsonsan
Manual of neonatology 6th Edition
Fanaroff and martine /neonatal and prenatal
mwdicine 9th Edition
Maternal new born nursing and womens heath care
(7th )edition.

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The End
Thank U

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