Recurrent diarrhea is associated with many a number of complications. Out of them dehydration,malnutrition ,failure to thrive, electrolyte imbalances, micro nutrient deficiencies (vitamins & minerals) and severe systemic infections. Here an extensive description is given about these and the relevant management facts are given then and there.

1. Complications associated
with Recurrent diarrhea
Amila Weerasinghe
21st Batch
Faculty of Medical Sciences
University of Sri Jayewardenepura
Sri Lanka
14/07/2016

2. Complications associated
1. Dehydration
2. Malnutrition
3. Failure to thrive
4. Electrolyte imbalances
5. Micro nutrient deficiencies (vitamins &
minerals)
6. Severe systemic infections.

3. 1. Dehydration
• During diarrhoea there is an increased loss of
water and electrolytes(sodium, chloride,
potassium, and bicarbonate) in the liquid stool.
• Water and electrolytes are also lost through
vomit, sweat, urine and breathing.

4. • Dehydration occurs when these losses are not
replaced adequately and a deficit of water
and electrolytes develops.

7. Essential needs in the management
1. Correction of the existing water and
electrolyte deficit
2. Replacement of ongoing losses.
3. Provision of normal daily fluid requirement.

8. Correction of the existing water
and electrolyte deficit
• Some dehydration - ORS solution by mouth.
• However , in cases with
severe dehydration,
frequent and severe vomiting, or
in the presence of complications that prevents
successful oral therapy,
– intra venous therapy is needed.

9. Some dehydration
• Approximate amount of ORS solution to be
given in the first 04 hours
Mild to moderate (5-10%) dehydration
75 ml/kg in 4 hours

10. • Vomiting does not prevent successful use of
ORS solution.
Slow administration of ORS solution is useful
in children with vomiting.

11. It is a Medical Emergency
Severe dehydration

12. • Children with severe dehydration need
intravenous fluids, as there is a risk of
impending shock.
• Start IV Ringer Lactate fluid immediately.
(rapid infusion of 10 -20 mL/kg )
• Normal saline could be used if Ringer Lactate
solution is not available,

13. If the patient can drink,
• ORS should be given while the drip is set up.
If intravenous access is impossible,
 attempt intra osseous administration,
 give ORS through naso-gastric tube
Reassess the patient every 1-2 hours.
If hydration is not improving, give the IV drip
more rapidly.

14. Management of children who present
with severe dehydration and in
impending shock
• Airway, Breathing and Circulation should be
assessed and established quickly.
• Give rapid iv infusion of 10 to 20 ml/Kg
body of normal saline or Hartmann solution.
• Reassess the patient every 1-2 hourly and
adjust the fluid therapy

15. • Accordingly.
If hydration is not improving, give the IV drip
more rapidly.
• When the child can tolerate oral fluids about
5 ml/kg/hour of ORS should be
recommenced.

16. Types of dehydration, patients
present with
• Isotonic dehydration
• Hyponatraemic dehydration
• Hypernatraemic dehydration

17. Hyponatraemic dehydration
• Drink large amount of water and hypotonic solutions
• Greater net loss of sodium than water
• Fall in plasma sodium
• Shift of water from extra to intracellular
compartments
• Increase in intracellular volume
• Cerebral oedema
• Convultions

18. Hypertonic dehydration
• Excessive content of sugar (e.g. soft drinks,
commercial fruit drinks, too concentrated infant
formula) or salt.
• High insensible water losses. ( High fever or
hot/dry environment)
Water loss exceeds the relative sodium loss.

19. • Plasma sodium concentration increases
• Extracellular fluid becomes hypertonic
• Shift of water from intra to extra cellular
compartment
Signs
Depressed fontanelle
Reduced tissue
elasticity
Sunken eyes
Cerebral shrinkage
Jittery movements
Increased muscle tone with
hyperreflexia
Altered conciousness
seizures

20. • Hypernatraemic dehydration should be
corrected slowly over a period of 12 hours
• It is not corrected rapidly..

21. Isotonic dehydration
• Occurs when the out put exceeds the amount
of the input.
• The fluid taken orally is isotonic solutions.
• Much better than having hypo/hypertonic
dehydrations.

22. Replacement of ongoing losses
• Offer as much fluid as the child wants.
• Add approximately 50 to 100 ml of ORS or
any other fluid for each stool.
• Depending on the stool volume fluid intake
should be increased.

23. Provision of normal daily fluid
requirement.
• Breast feeding should be continued.
• If on formula milk, continue in the same
dilution.
• Offer as much fluid as possible to drink in
addition to ORS solution.

24. Prevention of dehydration
• Give the child more fluids than usual to prevent
dehydration
• Home based fluids and ORS solutions such as
kanjee should be used.
• Give as much fluid as the child wants.
• As a guide approximately 50 ml of fluid should
be given after each stool.
• Watch for signs of dehydration.

25. Feeding practices and maintenance
of nutrition
• Encourage the mother to continue breast-feeding
• Formula feeds need not be diluted
• Food intake should never be restricted during or
following diarrhoea
• Maintain the intake of energy and other nutrients
at as high a level as possible

26. • Continued feeding speeds the recovery of
normal intestinal function
• Dietary modifications may be necessary in
lactose intolerance and in conditions like post
gastroenteritis syndrome.

27. 2. Malnutrition
• During diarrhoea,
– decreased food intake,
– decreased nutrient absorption, and
– Increased nutrient requirements
• Children who die from diarrhoea, despite good
management of dehydration, are usually
malnourished.

28. These often combine to cause weight loss and
failure to grow.
The child’s nutritional status declines and any
pre-existing malnutrition is made worse.

29. Wasting (indicates acute malnutrition):
• Moderate wasting – weight/height SD <-2 to -3
• Severe wasting – weight/height SD <-3
Stunting (indicates chronic malnutrition):
• Moderate stunting – height or length SD <-2 to -3
• Severe stunting – height or length SD <-3

30. • Moderate malnutrition – moderate wasting or
stunting
• Severe malnutrition – severe wasting, severe
stunting, OR edematous
malnutrition

31. • So this may lead to PROTEIN-ENERGY
MALNUTRITION (marasmus, kwashiorkor)
• Other than this micronutrient deficiencies
can occur. (vitamins and minerals)

32. It is the most common form of PEM
It is characterized by the
 wasting of muscle mass and
 the depletion of body fat stores.
It is caused by inadequate intake of all nutrients,
but especially dietary energy sources (total calories)
Marasmus

34. Kwashiorkor
It is characterized by
marked muscle atrophy
normal or increased body fat.
Pure kwashiorkor is characterized by
inadequate protein intake in the presence of
fair to good energy intake.
Anorexia is almost universal

38. 3. Failure to thrive
• Inadequate weight gain when plotted in a
centile chart
• Mild failure – fall across 2 centile lines within 6
months ( -2SD and -3SD )
• Severe failure – fall across 3 centile lines
within 6 months ( less than -3SD)

39. • Occurs mainly due to problems with
–Inadequate intake ( Non organic/
environmental, organic – chronic illnesses )
–Inadequate retention ( diarroea, vomiting)
–Malabsorption (coeliac disease, cowsmilk
protein intolerance)

40. Recommended food items to include
in a meal of a diarroea child
• Lime juice - Fluid + Pottasium
• Yoghurt – Probiotics
• Kanjee – Fluid + Energy
• Cream cracker biscuit – Energy
• Bananas ( Anamalu/Ambun) – Energy + Fibre
+ Protein

44. 4. Electrolyte imbalances
• Hypertonic / hypotonic dehydration
To avoid use isotonic solutions for rehydration
(standard WHO ORS solution, 0.9% normal
saline, hartmans solution)
• With severe malnutrition
sodium retention
reduced potasium and magnesium levels

45. Improved ORS formulation
• The need for unscheduled supplemental
intravenous therapy in children was reduced
by 33%.
• Stool output was reduced by about 20%
• Incidence of vomiting was reduced by about
30%.

46. The new formula could safely be used in the
prevention of dehydration.
As well as in the treatment of dehydration.

49. Instructions for mothers regarding
ORS
• Read the instructions clearly given in the packet.
• Sachets available for 1L and 200ml of water.
• Don’t add sugar, salt or anything
• After prepared use within 24 hours and discard
the remaining.
• Give as demanded by the child.

50. • But if the child is severley malnourished then the
standard WHO ORS is not given for rehydration.
(hypernatraemia,hypokalaemia,
hypomagnesimia)
• Becouse it contains high sodium and
low pottasium levels.
• ReSoMal rehydration fluid is given.

52. ReSoMal contains
Glucose (125 mmol/L),
Sodium (45 mmol/L),
Potassium (40 mmol/L),
Magnesium (3 mmol/L),
Zinc (0.3 mmol/L),
Copper (0.045 mmol/L).

53. 5. Micronutrient deficiencies
• Essential fatty acid deficiencies (linoleic and
linolenic acid)
• Fat soluble vitamin deficiencies (A,D,E.K)
• Water soluble vitamin deficiencies ( folate,
B1,B2,B3,B6,B12,C)
• Minerals ( iron, zinc, copper, selenium, iodine,
Calcium, phosphate, and magnesium )

54. Essential fatty acid deficiencies
(linoleic and linolenic acid)
• Scaly dermatitis
• Alopecia
• Thrombocytopenia.
• Effect on growth, and cognitive and visual
function in infants

57. Vit D

58. Folate
• Megaloblastic anaemia

59. Thiamine
Vit B1

60. Vit B2

61. Vit B3 - Niacin

62. Vit C – Scurvey

63. Iron

66. Zn supplimentation
• Zinc supplementation
(10-20 mg per day until cessation of diarrhoea)
Reduces the severity and duration of diarrhoea
in children less than 5 years
• Short course supplementation with zinc
(10-20 mg per day for 10 to 14 days .
Reduces the incidence of diarrhoea for 2 to 3
months

67. Probiotics
• Derived from food sources, especially cultured
milk products.
• Suppression of growth or epithelial binding /
invasion by pathogenic bacteria .
• Improvement of intestinal barrier function
• Modulation of the immune system
• Modulation of pain perception

68. What are the downsides to taking
probiotics?
• Probiotics are not regulated by the Food and
Drug Administration (the FDA) the way
standard medicines are.
• That means that the companies that package
probiotics don't have to prove that the
ingredients listed on the label are actually in
the bottle.

70. BIFILAC TM
• Capsules №20
• Ingredients of the preparation: Each capsule
contains:
Probiotic composite 100,0 mg
• (lactobacillus acidophillus- 500 mln. CFU,
bifidobacterium bifidum- 300 mln. CFU,
enterococcus faecum- 200 mln. CFU)
• Vitamin С
Echinacea extract

71. 6. Severe systemic infections.
• The severely malnourished child is at high risk
for infection.
• Because of diminished immune defenses, and
is typically exposed to infection because of
inadequate sanitation and food preservation.
• Dehydration is also common in these children
because of acute or persistent diarrhea.

72. Important
Anti diarrhoeal and anti spasmodic drugs are
never indicated for the treatment of acute
diarrhoea in children.
If the child continues to vomit non-sedative anti
emetics ( Ondansetrone ) could be used.