Chapter 5
Diarrhoea
Case I
Case study: Sarah
Sarah, 9 months old, was brought to the hospital with 5
day history of watery stools. She was restless and
irritable.
What are the stages in the
management of Sarah?
Stages in the management of a sick
child (Ref. Chart 1, p. xxii)
1. Triage
2. Emergency treatment
3. History and examination
4. Laboratory investigations, if required
5. Main diagnosis and other diagnoses
6. Treatment
7. Supportive care
8. Monitoring
9. Discharge planning
10. Follow-up
Have you noticed any emergency or priority
signs?
Temperature: 36,80C, pulse: 130/min, RR: 40/min,
capillary refill time: below 2 seconds, weight: 8
kg, sunken eyes, normal skin turgor
Triage
Emergency signs (Ref. p. Priority signs (Ref. p. 6)
2, 6) • Tiny baby
• Obstructed breathing • Temperature
• Severe respiratory distress • Trauma
• Central cyanosis • Pallor
• Signs of shock • Poisoning
• Pain (severe)
• Coma
• Respiratory distress
• Convulsions
• Restless, irritable
• Severe dehydration • Referral
• Malnutrition
• Oedema of both feet
• Burns
History
Sarah had been well 5 days ago, but then she began
to have loose watery stools 8-10 times a day. There
was no blood or pus in the stool.
• Past medical history: previously well, no significant
past history
• Immunization: completed according to Expanded
Programme on Immunization schedule, measles due
• Social history: lives with her mother and sister, 4
years old
• Medications: none
• Allergies: not known
Examination
Sarah was crying continuously, she only stopped briefly
when her mother put her to her breast. When she was
offered ORS she drank eagerly.
Vital signs: temperature: 36.8 °C, pulse: 130/min,
RR: 40/min
Weight: 8 kg
Eyes: sunken
Skin: normal skin turgor (skin pinch goes back
immediately)
Chest: air entry was good bilaterally and there
were no added sounds
Cardiovascular: both heart sounds were audible
and there was no murmur
Abdomen: bowel sounds were active and there was
no organomegaly
Neurology: restless and irritable; no neck stiffness
and no other focal signs
Differential diagnoses
• List possible causes of the illness
• Main diagnosis
• Secondary diagnoses
• Use references to confirm (Ref. p.
127)
Differential diagnoses
(continued)
• Acute (watery) diarrhoea
• Cholera
• Dysentery
• Persistent diarrhoea
• Diarrhoea with severe malnutrition
• Diarrhoea associated with recent antibiotic
use
• Intussusception
Additional questions on history
• Diarrhoea
– frequency of stools
– number of days
– blood in stools
• Local reports of cholera outbreak
• Recent antibiotic or other drug treatment
• Attacks of crying with pallor in an infant
Further examination based on
differential diagnoses
Look for:
• Signs of dehydration such as:
restlessness, irritability, lethargy, sunken
eyes, skin pinch returns slowly
• Blood in stool
• Severe malnutrition
• Abdominal mass
• Abdominal distension
Further examination based on
differential diagnoses
Sunken eyes
(Ref. p. 127)
Classification of the severity of
dehydration in children with diarrhoea
• Rapid assessment of hydration status and classification of
severity of dehydration in children with diarrhoea:
Classification Signs or symptoms
Severe Two or more of the following signs:
dehydration • lethargy/unconsciousness
• sunken eyes
• unable to drink or drinking poorly
• skin pinch goes back very slowly (>2 seconds)
Some Two or more of the following signs:
dehydration • restlessness, irritability
• sunken eyes
• drinks eagerly, thirsty
• skin pinch goes back slowly
No Not enough signs to classify as some or severe
dehydration dehydration
(Ref. Table 12, p. 128)
Please summarize the signs of
dehydration you noticed in
Sarah
Classification of the severity of dehydration
in children with diarrhoea
Classification Signs or symptoms
Severe Two or more of the following signs:
dehydration • lethargy/unconsciousness
• sunken eyes
• unable to drink or drinking poorly
• skin pinch goes back very slowly (>2
seconds)
Some Two or more of the following signs:
dehydration • restlessness, irritability
• sunken eyes
• drinks eagerly, thirsty
• skin pinch goes back slowly
No Not enough signs to classify as some or
dehydration severe dehydration
(Ref. Table 12, p.
What investigations would you
like to do to make your
diagnosis ?
At this stage no additional
investigations are necessary
Diagnosis
Summary of findings:
Examination: restlessness,
irritability, sunken eyes, drinks
eagerly, thirsty
Acute diarrhoea with some
dehydration
How would you treat Sarah?
Treatment Plan B
(Ref. Chart 14, p.
135)
In the first 4 hours give 75 ml per kg of ORS as shown
in table below
Show the mother how to give the child ORS solution, a
teaspoonful every 1-2 minutes if the child is under 2
years; frequent sips from a cup for an older child
Treatment (continued)
• After 4 hours:
- Reassess the child and check the signs of
dehydration
- Select the appropriate plan to continue (discharge
if necessary to Treatment Plan A or C)
- Begin feeding the child in clinic
• If the mother must leave before completing
treatment:
- Show her how to prepare ORS at home
- Give her enough ORS packets to complete
rehydration
- Explain the 4 Rules of Home Treatment:
1.Give extra fluid
2.Give zinc supplements
3.Continue feeding
Treatment (drugs)
• Antibiotic treatment is rarely necessary
(Ref. p. 126)
Only for:
Dysentery (mostly Shigella)
Cholera
Neonates with diarrhoea and fever
• Anti-diarrhoeal agents
Never necessary and often harmful!
What supportive care and
monitoring are required?
Supportive Care
•Check regularly to see if there are problems
(Ref. p. 132-136 )
–If the child vomits, wait 10 minutes, then, resume
giving ORS solution more slowly
–If the child's eyelids become puff, stop ORS solution
and give plain water or breast milk
•Advise breastfeeding mothers to continue to
breastfeed whenever the child wants
•Infection control: hand washing in clinic and
hospital
Monitoring
• The child should be checked by nurses
frequently
• Use a Monitoring chart (Ref. p. 320, 413)
• Pay special attention to signs of dehydration
such as:
lethargy/unconsciousness
sunken eyes
unable to drink or drinking poorly
skin pinch goes back slowly or very slowly
(>2
seconds)
restlessness, irritability
drinks eagerly, thirsty
Summary
• Sarah was rehydrated with oral rehydration solution.
• She was discharged on the same day when she was
alert, able to drink and eat.
• Before discharge home Sarah was given zinc
supplements.
• At the time of discharge her mother was given advice on
how to give extra fluid, to continue feeding and when to
return.
• She was also given a Mother’s card containing this
information and two packets of oral rehydration solution.
