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Acute Diarrhoeal Disease — Paediatrics (OP Ghai Framework)

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Definition

• Acute diarrhoea: < 14 days duration
• Persistent diarrhoea: ≥ 14 days
• Dysentery: diarrhoea with visible blood in stool

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Epidemiology

• One of the leading causes of morbidity and mortality in children under 5 years in developing countries
• ~1.7 billion episodes of childhood diarrhoea annually worldwide
• Kills ~525,000 children < 5 years/year (mostly from dehydration)
• Each child in a developing country has 3–5 episodes/year
• Peak incidence: 6 months to 2 years (weaning age)

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Aetiology / Causative Agents

Viral (most common, ~70–80% of cases)

Bacterial

Parasitic

• Entamoeba histolytica — dysentery
• Giardia lamblia — watery, malabsorption
• Cryptosporidium — especially in immunocompromised

Non-Infectious Causes

• Antibiotic-associated diarrhoea
• Dietary indiscretion
• Food allergy
• Intussusception (early bloody mucoid stools)
• First presentation of chronic diarrhoea (coeliac, IBD)

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Pathophysiology

1. Secretory Diarrhoea

• Organisms (V. cholerae, ETEC) produce enterotoxins → activate adenylyl/guanylyl cyclase → ↑cAMP/cGMP → ↑Cl⁻ secretion, ↓Na⁺ absorption
• Isotonic, large volume, no osmotic gap
• Persists with fasting

2. Osmotic Diarrhoea

• Unabsorbed solutes (viral-induced brush border damage, lactase deficiency) draw water into lumen
• Stops with fasting; large osmotic gap

3. Invasive/Inflammatory Diarrhoea

• Shigella, Salmonella, Campylobacter, Entamoeba invade mucosa → cytokine release, mucosal ulceration → blood + mucus (dysentery)

4. Altered Motility

• Shortened transit time → reduced absorption

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Clinical Assessment

History

• Duration, frequency, consistency of stools
• Blood/mucus in stools
• Vomiting, fever, abdominal pain
• Feeding (breast vs bottle)
• Recent antibiotics, travel, food history
• Urine output (last void — key indicator of dehydration)

Dehydration Assessment (WHO/IAP Classification)

Other Clinical Signs

• Sunken fontanelle in infants
• Decreased skin turgor
• Capillary refill time > 2 seconds
• Weight loss (most accurate measure of fluid deficit)

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WHO Dehydration Treatment Plans

Plan A — No Dehydration (Home Therapy)

1. Increased fluids: ORS 50–100 mL after each loose stool
   • < 2 years: 50–100 mL per loose stool
   • 2–10 years: 100–200 mL per loose stool

   • 10 years: as much as tolerated

2. Zinc supplementation: 20 mg/day × 10–14 days (10 mg/day if < 6 months)
3. Continue feeding: breastfeed frequently; do not withhold food
4. Counsel on warning signs to return

Plan B — Some Dehydration (ORS in health facility)

• ORS 75 mL/kg over 4 hours
• Reassess every hour
• If vomiting: wait 10 min, then restart slowly
• Nasogastric ORS if unable to drink
• After rehydration → go to Plan A

Plan C — Severe Dehydration (IV rehydration)

• Ringer's Lactate (preferred) or Normal Saline:
  • < 12 months: 30 mL/kg over 1 hour, then 70 mL/kg over 5 hours
  • ≥ 12 months: 30 mL/kg over 30 min, then 70 mL/kg over 2.5 hours
• Reassess every 15–30 minutes
• Once able to drink → switch to ORS

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ORS Composition

Reduced osmolarity ORS (245 vs old 311 mOsm/L) reduces stool output and vomiting without increasing hyponatraemia risk.

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Zinc Supplementation

• Recommended by WHO/UNICEF for all children with diarrhoea
• < 6 months: 10 mg elemental zinc/day
• ≥ 6 months: 20 mg elemental zinc/day
• Duration: 10–14 days
• Reduces duration and severity by ~25%, reduces recurrences

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Dietary Management

• Do NOT withhold food or starve the child
• Breastfeeding: continue throughout illness
• Age-appropriate soft diet: bananas, rice, curd, khichdi (BRAT-like)
• Lactose avoidance usually unnecessary unless prolonged illness with post-enteritis syndrome
• Avoid: high-sugar drinks, fruit juices (osmotic load), carbonated drinks

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Antimicrobial Therapy

Avoid: antidiarrhoeals (loperamide, codeine), antiemetics routinely in children

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Complications

Immediate

• Dehydration — most common, life-threatening
• Electrolyte imbalance: hypo/hypernatraemia, hypokalaemia, metabolic acidosis
• Hypoglycaemia (especially in malnourished)
• Septicaemia (invasive bacteria)

Delayed / Complications

• Haemolytic Uraemic Syndrome (HUS) — EHEC O157:H7; triad: microangiopathic haemolytic anaemia, thrombocytopaenia, acute renal failure
• Reactive arthritis (Salmonella, Shigella, Campylobacter, Yersinia)
• Guillain-Barré syndrome — Campylobacter
• Toxic megacolon — Shigella
• Post-enteritis syndrome — persistent diarrhoea with lactose intolerance
• Malnutrition — vicious cycle

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Electrolyte Disturbances

Hyponatraemia (Na < 130 mEq/L)

• Due to hypotonic fluid replacement
• Symptoms: lethargy, convulsions

Hypernatraemia (Na > 150 mEq/L)

• Loss of hypotonic fluid + use of high-solute solutions
• Very dangerous: cerebral oedema if corrected too fast
• Correct slowly over 48–72 hours

Hypokalaemia (K < 3.5 mEq/L)

• Faecal K⁺ loss + poor intake
• Signs: weakness, ileus, cardiac arrhythmias
• ORS contains K⁺ (20 mmol/L) — prevents this

Metabolic Acidosis

• Bicarbonate loss in stool + poor tissue perfusion
• Citrate/bicarbonate in ORS corrects mild acidosis

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Rotavirus — Special Note (OP Ghai Emphasis)

• Most important cause of severe dehydrating diarrhoea in children < 5 years
• Peak age: 6 months – 2 years
• Incubation: 1–3 days
• Profuse watery diarrhoea (up to 10–20 episodes/day) + vomiting + fever
• Winter peak (temperate climates); year-round in tropics
• Diagnosis: Rotavirus antigen in stool (ELISA/latex agglutination)
• Vaccines: Rotarix (2-dose), RotaTeq (3-dose) — in India's Universal Immunisation Programme
• No specific antiviral; treatment = ORS/rehydration

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Prevention

1. Exclusive breastfeeding for 6 months (greatest single protective factor)
2. Safe water and sanitation (WASH)
3. Hand hygiene — handwashing with soap before meals and after defecation
4. Food safety — proper storage, cooking
5. Vaccination: Rotavirus, Measles, Typhoid, Cholera (in endemic areas)
6. Zinc and Vitamin A supplementation in at-risk children
7. Improved nutrition → reduces severity

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Key Points / Mnemonics

• "3 Ps" in diarrhoea management: Plain water + Push ORS + Protect feeding
• DOTS (WHO simplified plan): Diagnose, ORS, Treat (zinc), Signpost (warning signs)
• Do NOT use: antidiarrhoeals, antiemetics, antibiotics (unless indicated), formula changes routinely
• Most deaths from diarrhoea are due to dehydration — correctable with ORS
• Zinc reduces duration by ~25% and prevents recurrence for 2–3 months

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Kangaroo Mother Care (KMC) — Paediatrics (OP Ghai Framework)

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Definition

1. Skin-to-skin contact (SSC) — baby placed on mother's chest, prone, between breasts
2. Exclusive breastfeeding/breast milk feeding
3. Early discharge with follow-up

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Historical Background

• Developed in Bogotá, Colombia in 1978 by Dr. Edgar Rey Sanabria and Dr. Héctor Martínez, as a response to incubator shortage and high infection rates
• WHO formally recommended KMC in 2003; updated guidelines in 2022
• Proven to reduce neonatal mortality in LMICs significantly

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Indications

• All preterm neonates (< 37 weeks gestation)
• Low birth weight (LBW < 2500 g) — especially VLBW (< 1500 g) and ELBW (< 1000 g)
• Medically stable neonates not requiring intensive respiratory support
• Can be initiated in NICU once baby is haemodynamically stable (even on oxygen/CPAP — modified KMC)

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Components of KMC

1. Kangaroo Position (Skin-to-Skin Contact)

• Baby placed upright (prone), chest-to-chest with mother (or father/other caregiver)
• Baby's head turned to one side (to keep airway open), slightly extended neck
• Hips flexed and abducted in "frog-leg" position; arms flexed
• Abdomen at level of mother's epigastrium
• Covered with mother's clothing/binder/wrap to maintain position and warmth
• Duration: ideally continuous (24 hours/day) — more the better; minimum recommended 18 hours/day (OP Ghai) for full benefit
• If mother needs rest, father or another family member can provide KMC

2. Kangaroo Nutrition

• Exclusive breastfeeding is the goal
• If unable to suckle (too preterm): expressed breast milk by cup/spoon/nasogastric tube
• No prelacteal feeds, no formula if avoidable
• Frequent feeding on demand; monitor weight gain

3. Kangaroo Discharge and Follow-Up

• Early discharge criteria (WHO/OP Ghai):
  • Baby is in full KMC (tolerating well)
  • Weight ≥ 1800–2000 g (or ≥ 2000 g as per some guidelines)
  • Weight gain ≥ 15–20 g/kg/day for at least 3 consecutive days
  • Baby breastfeeding exclusively or feeding well
  • Mother confident and trained
  • No apnoea/bradycardia/hypothermia
  • Social support available at home
• Follow-up at 48 hours, 1 week, 2 weeks, then monthly until 40 weeks corrected gestational age

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Physiological Benefits / Mechanism of Action

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Benefits — Evidence Summary

• Mortality: KMC reduces neonatal mortality in LBW infants by ~40% (WHO evidence)
• Hypothermia: Significantly reduced
• Hospital infections (nosocomial): Reduced by ~50%
• Breastfeeding rates: Higher at discharge and at 1–3 months
• Duration of hospitalisation: Shorter
• Neurodevelopmental outcomes: Better at 12–24 months
• Weight gain: Faster (metabolic rate conserved by warmth)
• Apnoea of prematurity: Reduced frequency and severity
• Pain relief: KMC during painful procedures (heel prick, IV insertion) reduces pain scores

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KMC vs Conventional Care (Incubator)

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Temperature Monitoring in KMC

• Axillary temperature should be 36.5–37.5°C
• Check temperature every 4–6 hours
• If hypothermic (< 36.5°C): increase KMC duration, add extra cover
• If hyperthermic (> 37.5°C): reduce clothing, check for infection

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Criteria to Discontinue KMC

• Baby reaches corrected gestational age of 40 weeks (term equivalent), OR
• Baby weighs ≥ 2500 g and is thriving
• Baby starts to resist or dislike the position (self-regulation emerges)

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Types of KMC

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Practical Steps (Counselling the Mother)

1. Wash hands thoroughly before handling baby
2. Dress baby in hat, diaper/nappy, socks — no vest
3. Place baby upright between breasts, skin-to-skin
4. Secure with binder/wrap/sari around both
5. Mother wears a front-open garment (blouse/shirt)
6. Baby's head slightly extended — avoid flexion (airway compromise)
7. Mother should be semi-reclined at 30–60° (not fully supine)
8. Breastfeed on demand (every 2–3 hours minimum)
9. Monitor for temperature, colour, breathing, feeding

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Contraindications / When to Delay KMC

• Absolute: Baby requiring mechanical ventilation (endotracheal intubation)
• Relative/Delay until stable:
  • Severe respiratory distress
  • Major surgical conditions pre-operatively
  • Severe hypothermia (until initial rewarming)
  • Haemodynamic instability (on vasopressors)

Note: Baby on CPAP or low-flow O₂ can still receive modified KMC — not a contraindication.

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WHO Updated Recommendations (2022)

• Immediate KMC should be initiated as soon as possible after birth, even for unstable neonates (with appropriate monitoring)
• Facility-based continuous KMC before conventional incubator care in stable babies
• Duration of at least 8–24 hours/day
• Applies to all neonates born at < 2000 g or < 33 weeks gestation

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Role in India / IMNCI / National Programmes

• KMC is a core component of India's FBNC (Facility Based Newborn Care) and HBNC (Home Based Newborn Care) programmes
• Promoted under National Health Mission (NHM), Navjaat Shishu Suraksha Karyakram (NSSK)
• KMC rooms/wards established in district hospitals and CHCs
• ASHA workers trained to promote home KMC for LBW babies after discharge
• Part of IMNCI (Integrated Management of Neonatal and Childhood Illnesses) protocol

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Key Points for Exams (OP Ghai Highlights)

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Mnemonic: "KMC = 3 K's"

• Kangaroo position (skin-to-skin)
• Kangaroo nutrition (breast milk/breastfeeding)
• Kangaroo discharge + follow-up (early, with support)

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