What is ORAL REHYDRATION THERAPY(ORT)?It is the cornerstone of management of diarrhoea. The term ORT includes
- Home made salt sugar solution Home made salt sugar solution.
- Food based solutions: Culturally acceptable fluids in presence of continued feeding
Why use WHO ORS?- Osmolarity is less than or equal to 300 mosm
- Glucose concentration is of 20 gms to achieve optimum sodium and water absorption.
- Sufficient sodium concentration 90 meq/ lit glucose to sodium molar ratio of 1:1
- Potassium concentration of 20 meq/lit
- Citrate concentration of 10 mmol or bicarbonate conc of 30 mmol/lit
How do you give fluid therapy in diarrhoea? PLAN A - TO PREVENT DEHYDRATION
- Provide normal daily fluid requirements.
- Breast milk or full strength animal or formula milk
- Semisolid food if eaten by child
- Replace ongoing losses
- Home available fluids- plain water,lemon water,curd water,coconut water,rice kanji, dal without salt. These fluids along with food provide ORT.
- Avoid aerated drinks, tea or plain glucose water without salt as it may cause osmotic diarrhoea.
- Salt Sugar Solution: A finger pinch of salt plus 1 teaspoon of sugar in a glass of water.
- WHO ORS
Less than 24 mths of age:- 50-100 ml per loose stool
2-10 years of age:- 100-200 ml per loose stool
More than 10 years of age:- as much as required
One teaspoon every 1-2 mins for child less than 2 years and frequent sips from cup for older children. If the child vomits, wait for 10 mins and give slowly.
What are the DANGER SIGNS?
- Many water stools
- Repeated vomiting
- Marked thirst
- Eating or drinking poorly
- Fever- high grade
- Blood in the stool
- Drowsy child
- Marked oliguria
PLAN B- REHYDRATION THERAPY IN A CHILD WITH SOME DEHYDRATION
- 75 ml per kg body weight ORS in 1st 4 hrs and then reassess.
- In children less than 6 months, give 100-200 ml water if not breast-fed.
- ORS is effective in 95% cases. ORS may not be effective if there is high rate of purging > 15 ml /kg /hr, persistent vomiting>3/hr, incorrect administration or preparation of ORS, abdominal distension and ileus, altered sensorium
PLAN C- SEVERELY DEHYDRATED CHILDREN
- Ringer lactate or Normal saline given Intravenously 100 ml /kg
|1st 30 ml /kg||over 1 hr in child <12 months|
| ||over 30 mins in child > 12 months|
|2nd 70 ml/ kg||over 5 hrs in child <12mths|
| ||over 2 ½ hrs in child>12mths|
What are the indication for antibiotics?- Malnourished or premature infants
- Gross blood in stool
- Associated non GI infections e.g. pneumonia
Q.What are the choice of antibiotics?
- Ampicillin + Gentamicin in malnourished and prematures.
- Shigella: trimethoprim+sulfa, nalidixic acid, cefatriaxone, ciprofloxacin,
Cholera -trimethoprim+sulfa, chloramphenicol, tetracycline
What should not be used in treatment of acute diarrhoea?Adsorbents-kaolin, pectin
Diphenoxylates + atropine
Combination antibiotics - nalidixic acid+ metronidazole
What is the dietary management in diarrhoea? Children should continue to be fed during acute diarrhoea because feeding is physiologically sound and prevents or minimises the deterioration of nutritional status. In acute diarrhoea, breast-feeding should be continued with ORS uninterrupted even during dehydration. Optimally energy dense foods with the least bulk are recommended for routine feeding and those available in the household should be offered during diarrhoea in small quantities but frequently. Staple foods that do not provide optimal calories per unit weight should be enriched with fats,oil or sugar e.g khichri with oil, rice with milk or curd and sugar,mashed potatoes with oil and lentil. Foods with high fibre content e.g coarse fruits and vegetables to be avoided. In non-breast fed infants, cow or buffalo milk can be given undiluted after correction of dehydration together with semisolid foods. Milk should not be diluted with water. Alternatively milk cereal mixtures can be used.
management Routine lactose free feeding is not required in acute diarrhoea even when reducing substances are detected in the stools. Lactose malabsorption meriting dietary modification is very uncommon in acute diarrhoea. During recovery, an intake of at least 125% of normal should be attempted with energy dense foods till nutritional status is normal as measured for age.