By: Dr. Deepak Seth
Contributed by: Dr. Neeraj Jain
We all know and keep on experiencing physiological increase in number of motions (should not 'fear' (!) of Diarrhea) Acute mild to severe and chronic Diarrhea. It may keep on recurring or is persistent and keeps on troubling parents as well as treating doctors AND UNFORTUNATELY some (or majority) of patients keep on getting different, un-required and harmful 'treatment' from different doctors.
IS IT NOT OUR DUTY THAT IN OUR TROPICAL COUNTRY, WHERE WE KNOW THAT THIS PROBLEM IS SO COMMON AND HOW MAJORITY OF 'POOR CHILDREN' ARE BEING TREATED WE MUST TAKE SERIOUS STEPSTO KNOW THE SUBJECT IN TRUTH AND REALITY.
Recurrent diarrhea: Here, a child gets current episodes of acute diarrhea, clearly separated by intervening non-diarrheal periods. Arbitrarily, more than 6 episodes per year or >3 episodes/6 months or more than 2 episodes in 3 months may be defined as recurrent diarrhea.
Persistent diarrhea: A diarrheal illness starting as acute watery diarrhea, persisting for 15 days or more, is called persistent diarrhea. This is usually seen in early infancy. The term intractable diarrhea is used to define those cases of protracted diarrhea where the cause is not easily discernible, and the response to treatment is extremely unsatisfactory, The term protracted diarrhea has been applied when weight loss accompanies persistent diarrhea.
Chronic diarrhea: The onset is insidious and the course is sub-acute or chronic, with the passage of large amounts of semisolid stools. The diarrhea is usually of more than 1 month duration, Intervening normal periods may occur. This may occur at any age but is seen more often in older infants and children.
Now taking the problem in short
RECURRENT ACUTE DIARRHEA
This type of clinical syndrome is caused by recurrence of factors that cause acute diarrhea; especially recurrent infections of the gut. Each episode of recurrent acute diarrhea should be analyzed like an episode of acute diarrhea and managed accordingly. The most common predisposing factor for recurrence is an unhygienic environment, especially a contaminated water supply from tube wells, hand pumps or wells. Proper treatment of the acute episode, together with advice regarding the boiling of water and feeding bottle, is usually enough the mother should be advised about the usefulness of continued feeding of infant during the diarrheal episode (to maintain normal nutritional status), as malnutrition is also an important predisposing factor in causing recurrent diarrhea.
Nutritional advice, regarding additional food appropriate-far-age, should also be given. The child should be kept under close supervision to ensure adequate weight gain and to prevent development of malnutrition.
HOW THE CHILD IS WHOSE ACUTE DIARRHEA FAILS TO SETTLE DOWN IN 5-7 DAYS MANAGED?
Although this is not yet persistent diarrhea, but the fact remains that most parents (and the physician) would be very concerned even when the diarrhea is of 7 days' duration. A review of literature indicates that most episodes are a part of the natural history of the disease, being in nature and require no active management. However, some children do have problems and our job is to identify these cases. We should do (i) through clinical examination to detect dehydration and any systemic infection. (ii) Recording weight and comparing with any' previous record. Also recording the weight daily during the episode. (iii) Stool examination for ova and cyst, pH and reducing substances.
If the clinical examination is normal, the child is well hydrated, is maintaining or gaining weight and has normal stool examination, then no active intervention is required. Increase in non-milk calories (like cereals, pulses, curd, and banana) and some decrease in milk, while maintaining adequate calorie intake,' is all that is generally required.
Even children with LACTOSEINTOLERANCE (pH <5.5>14 days duration.
PERSISTENT/PROTRACTED DIARRHEA
This is a common and often baffling clinical problem. It is estimated to occur following 10-14 percent of episodes of acute diarrhea. It is seen more often in young infants «6 months) especially those on top-feed. Also, it is more common in malnourished children. Various causes, that may be responsible for persistent diarrhea are: (i) Resistant infection (ii) Unsuspected parenteral infection (iii) Malnutrition (iv) Disaccharidase-deficiency, including lactose-intolerance (v) Cow's milk protein intolerance (vi) Antibiotic induced diarrhea (vii) Soya protein and other food allergies (viii) Immuno-deficiency syndromes. .
In persistent or protracted diarrhea syndrome, the underlying common pathology is a persistent intestinal mucosal injury, with inadequate or no regeneration. The factors mentioned above, individually or collectively; play an important role in perpetuating mucosal injury. The maintenance of normal nutritional intake during episodes of acute diarrhea is most important for the prevention of the persistent stage. The hallmark of children with
protracted diarrhea is failure to thrive.
This is a complex problem, with a high mortality rate and requires management at the hospital level. One need not wait for 15 days before referring the child. Once weight-loss has set in, the case should be immediately referred to a specialist. In the hospital, a child with persistent diarrhea should be thoroughly examined to look for any systemic infection. A detailed stool examination, including microscopic examination, pH and reducing substances, should also be obtained. Blood counts and blood culture may be done, to exclude any systemic infection. Urine cultures and x-ray chest should be obtained to detect any occult infection. While the results of these reports are awaited, it would be prudent to withdraw all antibiotics (unless the child is very sick or has obvious signs of infections) and milk feeds, for 2-3 days. The child may be given extra low-lactose foods instead and, perhaps, a lactobacillus preparation as well. Most children would respond to this regimen unless there is an associated systemic infection, which would then need appropriate management. However, if the child's weight does not improve, enteral/parenteral alimentation and further investigations, like jejunal biopsy and sigmoidoscopy may be required. For this the child is required to be referred to a hospital with a gastroenterology unit. '
CHRONIC DIARRHEA
Most of these cases occur in older infants and children. These cases are akin to the mal-absorption syndrome. Since there is significant mal-absorption of fat always, they may not have the typical large, fatty stools seen in mal-absorption syndrome. The diarrhea may occasionally be semi-liquid type and may resemble those of persistent diarrhea except for the absence of the acute phase. These children usually do not get dehydrated unless their condition is superimposed by acute diarrhea. This factor may often be the presenting complaint.
This type of diarrhea may be due to a variety of causes, like giardiasis, gluten enteropathy and pancreatic mal-absorption. However, in our experience, it is because of heavy contamination of the gut by non specific bacteria leading to mild mucosal damage. We like to label these children as TROPICAL ENTEROPATHY. This largely occurs in low socio-economic groups of children and most episodes tend to occur during the summer or monsoon months, when gut infections tend to be high.
In all these children, weight should be carefully recorded and followed up periodically. Also 2 - 3 stool examinations may be done to rule out giardiasis or associated worm infestation. If these children maintain a good rate of weight gain, have a good appetite and have no giardia in stools; then they require good dietary (appropriate or increased calorie intake for age) and hygiene maintenance advice.
They normally tend to outgrow their problem. Presence of giardia would warrant metronidazole therapy. However if the child is not thriving (not gaining or loosing weight) and there is no giardia in the stool, then these children would require complete investigations like D-xylose absorption, fat balance study and jejunal biopsy. Now-a-days satisfactory intestinal biopsies can be obtained through GI endoscopy and hence these children should be referred to a pediatric endoscopy unit for further investigations and management.
LACTOSE-INTOLERANCE
Lactose, the sugar present in milk, is broken down in the intestine into glucose and galactose by an enzyme lactase, which is present in the superficial layers of the intestinal villi. Acute gastroenteritis may often result in the shedding of superficial layers of intestinal villi, with resultant lactose deficiency. The lactose is thus not metabolized and absorbed by the body. The lactose within the lumen of the gut is fermented by bacterial action into lactic acid, carbon dioxide and water. Stools in such a child tend to become acidic, loose and explosive. The increased water content of the stools is due to the osmotic action of unabsorbed lactose in the intestinal lumen.
Although some degree of lactose-intolerance may occur in many children with acute gastroenteritis in the first 48 hours, it usually does not cause any therapeutic problem. Clinically significant lactose intolerance should be suspected when an infant's diarrhea is perpetuated by the ingestion of cow's milk. It occurs in only 3-5 percent of cases and usually does not occur before 5-7 days of diarrhea. The chance of developing lactose intolerance is higher in malnourished children and in children following acute watery diarrhea due to Rota virus. It is rare in invasive diarrhea (dysentery).
Clinically, lactose-intolerance may be suspected if after the reintroduction of milk, diarrhea relapses, or persists beyond 1 week or so, with the passage of watery stools containing much air and a characteristic sour smell. Due to the acidic nature of the stools and frequent cleaning of perianal area develop perianal redness and this is an important sign in diagnosing this condition. These infants usually have a good appetite, as opposed to infants with infective diarrhea.
Lactose-intolerance can be confirmed by examination of the stools for reducing substances, with the help of Benedict's reagent, which gives a orange or yellow reduction. The stool pH is usually below 5.5 in such cases. The stool pH and reducing substances, should be tested in freshly passed liquid stools (within 1/2 hour) collection on plastic nappies (better as water is not absorbed by them). Contamination with urine should be avoided. These investigations are sufficient for the routine diagnosis of lactose-intolerance. Other sophisticated tests like the estimation of lactose content of the intestinal mucosa and lactose-tolerance tests, are neither easily available nor generally required.
Lactose-intolerance is usually not total and thus most children will tolerate small amount of lactose (1-2 gm/kg/day) contained in 30-50 ml/kg cow or buffalo milk. Curd is also low in lactose. Thus, a small diet of milk and curd-khichri is a very effective. Milk-withdrawal is usually not necessary for longer than 3-5 days and it should be gradually reintroduced in the diet. If diarrhea recurs or is not controlled on lactose-restricted diet then the child would require intravenous fluids and complete elimination of milk from the diet for longer time (4 to 6 weeks).
Low Lactose Foods
Milk substitutes ............ Curd, soya milk
Cereal products .............Rice or wheat porridge, khichri
Vegetables or fruits.......mashed bananas, vegetable
Non vegetarian................freshly prepared chicken soup
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