Diarrhea Management in Practice: Nestle

Speaker: Dr. S. K. Mittal Presented at:  Nestlé Nutrition Institute, Delhi

Summary

In this video, Dr. S. K Mittal, speaks about ways to prevent the symptoms of Diarrhoea – the number two cause of ‘under five’ mortality in India. The talk makes a clinical appraisal of the types of diarrhoea while distinguishing the three distinct forms i.e. watery, mucoid and invasive. Dr. Mittal emphasizes on the assessment of dehydration during acute diarrhoea as being one of the key steps in resolution. He also speaks of linking any associated infection and talks of nutritional status and remedies to for lactating mothers while offering advice to fellow practitioners. Lastly, the video discusses the response to treatment with scenarios.

Diarrhoea is a symptom not a diagnosis. There are varieties of GI infective/ inflammatory/ toxic/dietary factors that can cause diarrhoea. Quite often parenteral infections (like UTI, otitis media, Meningitis etc.) cause diarrhoea. Like any other symptom (fever, cough, vomiting etc.) it requires a diagnosis. As usual diagnosis comes from analysis of the index symptom, associated features and detailed clinical examination. There are three types of Diarrhoea-watery, mucoid, invasive. During physical examination the following should be noted like duration, severity. Associated features like vomiting, fever, lethargy and others should also be looked into. Thorough physical examination signs of systemic infection, severity of dehydration and degree of malnutrition (determines duration and outcome) needs to be determined.

Physical Examination is used for assessment of dehydration, it determines management, outcome. Change of sensorium from active, thirsty, irritable child in none or some dehydration, child becomes lethargic refusing to drink in severe dehydration. In clinical practice urine not passed for more than 6-8 hours should alert that there is a need to admit in hospital. If child just has watery diarrhoea with no dehydration, no systemic infection and no malnutrition then no investigations are required. If child has AWD and some dehydration can be managed on ORS with no systemic infection and no malnutrition then a routine stool microscopy may be required. If you admit and want to give IV then do as with severe dehydration. If the child has acute watery diarrhoea with severe dehydration then start stool microscopy (to exclude cholera), electrolytes, blood urea, ABG (if possible) before starting IV fluids. If child has fever or if systemic infection is suspected then get TLC/DLC/CRP/Routine urine and may be blood culture. Urine cultures arid blood cultures are more informative than stool culture in infantile diarrhoea.

The treatment involves administering ORS ad lib. Emphasis on proper reconstitution, by dissolving all in 1 L, keeping in fridge and giving adequate amounts (100-200ml/loose stool). Small sips with cup and spoon helps stop vomiting. Antiemetic should be administered if required; 1-2 doses Domstal/Perinorm are preferable. Continue feeding the infant for which breast feeding is a must. Always top milk feeding is advised and should be restored undiluted as soon as dehydration corrected. Dehydration should get corrected within 8-24 hours. Improvement in appetite should be seen in within 48 hours. Diarrhoea treatment may take 3-7 days. Usually frequency goes down and then the consistency improves.