Control of Diarrhoeal diseases (CDD)
The 500,000,000 children under 5 y of age are the major victims of diarrhoea, & it is estimated that U5 children may develop 1-12 episodes (attacks) of diarrhoea per year, which will lead to growth failure & complications.Control of Diarrhoeal diseases (CDD)
Annually, 3,000,000 children die from diarrhoea all over the world. This means 6 children per minute. A high percentage of hospital beds are occupied by children with diarrhoea. These present at the late stage of severe dehydration, which requires admission to hospital, professional care, drugs, fluids, giving sets, etc. These are of very high cost. The prognosis is usually bad probably ending in death.Control of Diarrhoeal diseases (CDD)
Diarrhoea: Passage of liquid or watery stool for at least 3 times during 24 hours. Consistency is more important than frequency. Note that breast fed infants usually pass semi-solid, pasty and yellow stools. Sometimes, they pass stool after each breast feed. This is not diarrhoea.Control of Diarrhoeal diseases (CDD)
Diarrhoea can be Acute which lasts for less than 14 days, or Persistent which lasts for 14 days or longer. There may be blood in the stool which is called Dysentery, which can be amoebic or bacillary.
Control of Diarrhoeal diseases (CDD)
Diarrhoea is caused by: -Viruses -Bacteria -Protozoa. The contributing factors to diarrhoea are -Unclean water, -Dirty hands (preparing+ or eating) -Food spoilt by high temperature.Control of Diarrhoeal diseases (CDD)
Diarrhoea leads to malnutrition which is manifested by growth retardation & under weight, The degree of malnutrition directly correlates to the duration of the diarrhoea (25gm loss of weight for each day of diarrhoea). This growth deficit is multi-factorial.Factors leading to growth deficit in a baby with diarrhoea:
Reduced food intake: due to anorexia (loss of appetite) and withholding food from the child by the mother. Reduced absorption of nutrients due to rapid gut transit time, and enteropathy leading to such mal-absorption.Factors leading to growth deficit in a baby with diarrhoea:
Catabolic losses through vomiting (loss of nutrients) and fever leading to energy expenditure. This malnutrition will lead to reduced immunity leading to further episodes of diarrhoea. Those at particular risk are infants who are artificially fed and those who are at the weaning age (due to inadequate feeding, contaminated feeds and low resistance to infection).Malnutrition (PEM)
Diarrhoea (FEM)Death
Death
The PEM/FEM Cycle
Factors leading to growth deficit in a baby with diarrhoea:
Diarrhoea & MalnutritionDiarrhea is a major contributor to poor nutritional status, to prevent the development of malnutrition and promote repair of bowel: Breast feeding should be continued. Older children should be given solid food after 4-6 hours of oral rehydration. An extra daily meal should be given for at least two weeks after treatment.
Dehydration
Diarrhoea is a protective mechanism. It washes away micro-organisms and toxins from the gastro-intestinal tract. It is usually self limiting and is not a killer. It is a defence mechanism where the body will increase peristalsis & fluid loss.Dehydration
The killer is Dehydration. The amount of fluid in a child is limited & this will lead to a fluid- electrolyte deficit. Dehydration: Is a deficit in water and electrolytes (Sodium, Potassium, Chloride and Bicarbonate) resulting from losses in stool, vomiting, urine, fever, sweat and breathing. When these losses are not adequately replaced, this deficit will develop.Plan C (Hospital)
Plan B (PHC)Plan A (Home)
Treatment
Severe Dehydration
Some dehydration
No Dehydration
Classification
Goes Back Very Slowly (2 or more sec)
Goes Back Very Slowly (1 sec)
Goes Back Quickly
Skin pinch
Unable to drink
Eager to drink
Drinks normally
Thirst
Sunken*
Sunken *
Normal
Eyes
Lethargic, Unconscious
Restless, Irritable
Well, Alert
General Condition
C
B
A
Classification
Sign
Assessment of Diarrhoea cases for dehydration
Notes: In the past they used to classify eyes to normal, sunken & very sunken but there is no such thing as very sunken. Sometimes, genetically the eyes are sunken so look at the mother or the father (look at their eyes) or ask them if they think that the eyes of the child look more sunken than usual. *Thirst: eager to drink means that the child wants more fluid & follows the spoon or glass with his head.*Skin pinch: expose the abdomen & take a pinch with your thumb and index finger along the longitudinal axis. The degree of the dehydration can be easily demonstrated by pinching the dorsum of your hand (pinch goes back quickly), that of your parents (slowly) and your grandparents (very slowly). This is due to the loss of skin elasticity when people get older.*In a diarrhoea case, sometimes we don’t have the 4 signs in the same category. Two signs in the category, are enough to classify the case. E.g. 1 sign in A & 1 sign in B + 2 signs in C, so we classify as C.Assessment of Diarrhoea cases for dehydration
Treatment plans; Plan AThe aim is to prevent dehydration from occurring.The steps are:Give extra fluid: ORS (Oral Dehydration Solution) & home fluids. Continue feeding of children (breast or other).Teach the mother to:How to prepare and give ORS (1 litre of water “2 milk bottles or 4 bottles of Coke” then we add the sachet & give by cup & spoon or by cup directly, to be used within 24 hr of preparation, “she must discard what remains after 24h”, to give him 50-100 ml every time the child passes stool.Signs of dehydration & the danger signs by showing her pictures of the main signs of dehydration & telling her to bring her child immediately to the health centre if such signs occur.
Treatment plans; Plan B
The aim is to correct dehydration. The steps are:Give ORS in the health centre: Child’s weight (kg) x 75 ml = volume given over a 4 hr period. Assess every hour.Continue feeding or breast feeding.Give 100-200 ml of clean water.Teach mother to prepare & give ORS correctly (cup and spoon), as in plan A.Assess every hour.If the child vomits the ORS, wait for 10 minutes and then restart giving him the solution slowly.Reassess after four hours, classify according to the hydration status, and use the appropriate plan accordingly.Note: Puffiness of the face & eyes is a sign of over hydration. In that case, give the fluid slowly.Following 2.5 hours
First 30 minutes12+
Following 5 hours
First hour
Less than 12
70ml/Kg body weight
30ml/Kg body weight
Amount of IV fluid/unit time
Age in Months
Note: DO NOT attempt Naso-Gastric tube as it is not practiced in this country. The steps are: Reassess every hour, if no improvement, give fluid more rapidly. If the patient can drink, give ORS in 5ml/kg body weight/hr Reassess after completion, classify according to the hydration status & choose the appropriate plan accordingly.
Treatment plans; Plan C
The aim is to correct dehydration urgently (immediately).Route: Intra-Venous or Naso-Gastric tube (we have to act quickly) In IV: give Ringer’s lactate solution. If it is not available, use normal saline. Calculate the amount of fluid using the following formula: Weight (kg) x 100ml over a period of 3 hours for children over the age of one year, and over 6 hours for infants, according to the following table:Oral Rehydration Solution
Composition: Sodium chloride: 3.5 gm, NaHCO3: 2.5 gm, KCl: 1.5 gm, Glucose: 20 gm, In 1000ml (1litre) of water. Some replace NaHCO3 by 2 gm Tri-sodium Citrate Di-hydrate which lessens vomiting, is tastier and more stable in humid and hot areas. Advantages of ORS: Cheap, effective and easy to give at home by the mother. This is why 95% of the cases are treated by ORS, as children will not develop dehydration, when they get diarrhoea.
Oral Rehydration Solution
Preparation of ORS: The water should be boiled and cooled before the powder is added to avoid the loss of bicarbonate, and changes of concentration. In winter, warm the solution to 40oC to increase acceptability, increase the rate of absorption, decrease vomiting & decrease the risk of a drop in the body temperature when large volumes are consumed. If no ORS is available we use home prepared fluids or household food solutions, rice water, soups , fruit juices salt and sugar solution (one teaspoon of salt + one table spoon of sugar). Diarrhoea case fatality rate has decreased a lot after the introduction of the ORS, due to the prevention of dehydration.Management of Chronic (Persistent) Diarrhoea
If the child is under 6 months or is also dehydrated, refer to the hospital, where dehydration is corrected and the case is fully assessed.Management of Chronic (Persistent) Diarrhoea
If the child is over 6 months and not dehydrated, then the management is mainly dietary. Teach the mother to: Dilute any animal milk given to the child with an equal volume of water or replace with fermented milk products such as yogurt. Increase energy intake: 6 meals per day of thick cereals, added oils or fat, vegetables, pulses and fish or meat. Reassess in 5 days. If diarrhoea persists refer to hospital. If diarrhoea has stopped, teach the mother to use the regular diet, resume the usual animal milk & give an extra meal every day for one month, use growth charts.Management of Blood in Stool
If Bacillary dysentery (Shigella) is prevalent in the area, The clinical picture is severe, and There are no amoebic trophozoites in the general stool examination, give Co-trimoxazol or the antibacterial of choice If Amoebic dysentery is prevalent in the area, Symptoms are less severe, and Amoebic trophozoites are seen in the general stool examination, give metronidazole (Flagyl)Drugs not to be used for diarrhoea
Anti-bacterials: Most cases are viral. Antibacterials are only used when there is lab evidence of bacterial infections (mainly cholera and bacillary dysentery). They will eventually lead to secondary infection due to the inhibition of the growth of the normal flora. Anti-protozoal: Used only when there is lab evidence of amoebic dysentery or giardiasis. Mycostatin: Monilia is a normal inhabitant of the GIT. Mycostatin is only given when there is oral thrush or anal moniliasis. Anti-motility agents and anti-spasmodics: As they may cause paralytic ileus in children. Pectocaolines: Will coat the GIT, allow colonization of the GIT bacteria with bacteria and lead to persistent diarrhoea. Anti-emetics: May cause CNS symptoms.Control of Acute Respiratory Infections Programs
(ARI)Acute Respiratory Infections (ARI)
ARIs are a worldwide problem. In addition to diarrhoea & malnutrition, ARIs form a main cause of morbidity & mortality among children in developing countries. ARIs contribute to 30-60% of all children attending outpatient department of health facilities, 70% of which are upper ARIs.
Acute Respiratory Infections (ARI)
Although the overall incidence of ARIs among children in developing & developed countries is within the same range, the annual incidence of pneumonia is 3-4 % in children <5 years of age in developed countries compared to 10-20% in developing countries. This shows that the majority of these infections are mild & can be treated at home without the use of antibiotics.Acute Respiratory Infections (ARI)
One of the objectives of ARI control program is To identify the few serious cases of ARI, and To follow the standard case management guidelines for ARI cases. On average, a child living in an urban area gets 5-8 attacks of ARI/year, & each attack lasts for 7-9 days (35-72 days of illness/year).Acute Respiratory Infections (ARI)
The primary offenders are usually viruses, which are responsible for a high proportion of the primary infections, while bacteria may be primary or secondary offenders. Streptococcus pneumonia & Haemophilus influenzae are the most frequent causes of pneumonia & account to 2-4% of cases in developed countries and 20% of cases in developing countries.Acute Respiratory Infections (ARI)
The Standard Case Management of ARI Cases includes: Assessment. Classification . Management.
Assessment a) Ask:
1. How old is the child? a. 2 months - 5 years: Is the child able to drink? b. Less than 2 months: Has the child stopped feeding well (less than half the amount he normally takes) 2. Is the child coughing? For how long? (< 30 days: acute, > 3o days: chronic) 3. Does the child have fever? For how long? 4. Did the child have convulsions during the current illness?Assessment b) Look & listen:
The child has to be calm Chest indrawing: When the child breathes in, if the lower chest wall goes in this is called chest indrawing. This occurs because the effort required to breathe in is much greater than normal, due to the loss of elasticity of the lung tissue. Stridor: Is a harsh sound made when the child breathes in, due to narrowing of the upper respiratory tract (larynx, trachea or epiglottis) & is usually called croup. Wheeze: Is a soft musical sound made when the child breathes out, due to narrowing of the lower air passages in the lungs, & requires effort.Assessment c) Count:
The number of breaths in one minute, to detect fast breathing. The cut off point is determined according to the age of the child: Age RR/minute < 2 months 60 + 2 months up to 12 months 50 + 12 months up to 5 years 40 +
Assessment d) see:
If the child is abnormally sleepy or difficult to wake Drowsy child; - Who does not look at his mother, - May not watch the doctor when he talks or moves, - Stares blankly & does not appear to see anything).Assessment e) Feel:
Assessment f) Check:For severe under-nutrition which may either be severe marasmus (extreme wasting of fat & muscles) or kwashiorkor (generalized oedema & thin, sparse hair).
Classification
Is done according to age group. Two months up to 5 years: After the assessment is completed, one of the following four classifications is reached: a) Very Severe Disease: is made when any of the following danger signs is detected: Not able to drink* Convulsions Abnormally sleepy or difficult to wake Stridor in a calm child Severe under nutrition* This child is at high risk of dying, so we should act urgently. Note:* means that the sign is peculiar to this age group
Classification
b. Severe Pneumonia: A child with chest indrawing, who may also have nasal flaring, grunting or cyanosis. This child is also at high risk of dying, so we should act urgently. c. Pneumonia: No chest indrawing, but the child has fast breathing: 50+/minute (2-12 months) and 40+/minute (12 months-5 years). d. No Pneumonia (cough or cold): No chest indrawing & no fast breathing.Classification
2. Less than 2 months: Young infants become sick and die very quickly. They frequently have non-specific signs and symptoms such as poor feeding or low body temperature and may normally have mild chest indrawing because of their soft chest wall. After the assessment is completed, one of the following three classifications is reached:Classification
Classificationb. Severe Pneumonia: Fast breathing (60+/minute) or severe chest indrawing. c. No Pneumonia: No fast breathing, no chest indrawing and no danger signs. Note: To act urgently is to give an initial (pre-referral) dose of parenteral antibiotics and to send to hospital immediately.
Management
Very Severe Disease or Severe Pneumonia: The line of management of children with these two classifications are the same for all age groups. It is as follows: Give the first (Pre-referral) dose of paranteral antibiotics. Refer urgently to hospital. Treat fever, if present.Management
Pneumonia: This diagnosis is peculiar to children between 2 months and 5 years. The child is treated at home with antibiotics. One of the following drugs is given for five days: - Cotrimoxazole, amoxicillin (syrup or tablets) - or Procaine Penicillin (daily i.m. injections). The rules are: Give the first dose in the health centre Teach the mother how to give the dose, how much, how many doses per day and for how many days. Advise on home care. Reassess in two days, or sooner if the child gets worse.Management
Reassessment : - If the child is found to be worse, refer urgently to hospital. - If the child is improving, finish the 5 days of antibiotics. - If the condition is the same, check with the mother on how she has been giving the antibiotic. - If she is doing it correctly, change the antibiotic. If not, teach her how to give it correctly.Management
No Pneumonia (Cough or cold): Advice home care. Two months-5 years: No antibiotics Look for other problems such as chronic cough (refer to hospital for further assessment; TB, asthma, whooping cough), ear problem or sore throat (further assessment) Advise mother to give home care (clear the nose, feed the child during the illness, and increase feeding after the illness; give extra fluids to drink and breast feed; soothe the throat and relieve cough with a safe remedy; return quickly if any of the following develops- breathing becomes difficult- breathing becomes fast- the child is not able to drink- the child becomes sicker) Treat fever, if present Treat wheezing, if present
Management
Refer urgently to hospital Give pre-referral antibiotic Treat fever and pain with paracetamolMastoiditis
Yes
Feel: for a tender swelling behind the ear.
Antibiotics for 5 days Dry the ear by wicking Reassess in five days Treat fever and pain with paracetamol
Acute Ear Infection
Yes
Look : for pus draining from the ear, and a red immobile ear drum.
Dry ear by wicking Treat fever and pain with paracetamol If case does not improve, refer
Chronic Ear Infection
> 2 wks
Antibiotics for 5 days Dry the ear by wicking Reassess in five days Treat fever and pain with paracetamol
Acute Ear Infection
b. Does the child have pus draining from the ear? If yes, for how long?
< 2 wks
Ask: a. Does the child have ear pain? Yes
Management
Classification
Assessment
Standard Case Management of Ear Problems
YesFeel the front of the neck for lymph nodes.
Benzathin penicillin or amoxicillin Give a safe soothing remedy Treat fever and pain with paracetamol
Streptococcal Sore Throat
Yes
Look for exudates on the throat.
Soft food and drink Treat fever and pain with paracetamol
Viral Sore Throat
Yes, but with pain
Refer urgently to hospital 2. Give pre-referral antibiotic 3.Treat fever and pain with paracetamol
Throat abscess
No
b. Is the child able to drink?
Ask: a. Does the child have a sore throat?
Management
Classifi-cation
Assessment
Standard Case Management of Sore Throat