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Ovid: Oxford Handbook of Tropical Medicine

Editors: Eddleston, Michael; Pierini, Stephen; Wilkinson, Robert; Davidson, Robert Title: Oxford Handbook of Tropical Medicine, 2nd Edition Copyright ©2005 Oxford University Press (Copyright 2005 by M. Eddleston, S. Pierini, R. Wilkinson, and R. Davidson) > Table of Contents > Chapter 2 > Chapter 2D – Diarrhoeal diseases > Management of persistent diarrhoea Management of persistent diarrhoea This is diarrhoea, with or without blood, that begins acutely and lasts at least 14 days. Clinically these episodes cannot be differentiated from sequential episodes of acute diarrhoea over a prolonged period but the management is the same. It is usually associated with weight loss and, often, with serious non-intestinal infections. Many children with persistent diarrhoea are malnourished before the diarrhoea starts. Persistent diarrhoea almost never occurs in infants who are exclusively breastfed. Take a careful history and examine the patient well. The object of treatment is to restore weight gain and normal intestinal function. In most cases, the patient will need to be admitted to hospital for diagnostic tests, treatment, and observation. Treatment of persistent diarrhoea

  • Appropriate fluids to prevent/treat dehydration. (See p. 152.)
  • Appropriate antimicrobial therapy to treat diagnosed infections, in particular non-intestinal infections in children (e.g. pneumonia, otitis media, UTI). If there is persistent bloody diarrhoea, look for evidence of Shigella, Entamoeba, or Giardia infection. (See p. 122.)
  • A nutritious diet that does not cause worsening of the diarrhoea. Children will require a minimum of 110 calories/kg per day, which may have to be given via a NG tube if the child is too weak or refuses to eat. For infants <6 months, encourage exclusive breastfeeding. Help mothers who are not breastfeeding to re-establish lactation. (See Chapter 15.)
  • Where possible, replace animal milk with yoghurt, a lactose-free formula, or a local diet with reduced lactose (<3.5 g/kg body weight/day). For older infants and young children, use standard diets made from local ingredients. Two diets are given in the box: the first contains reduced lactose, the second is lactose-free for the 30% of children who do not improve with the first diet.
  • Supplementary vitamins and minerals. All children with persistent diarrhoea should receive supplementary multivitamins and minerals each day for 2 weeks. Tablets that are crushed and mixed with food are less costly. One should aim to provide at least two recommended daily allowances (RDAs) of folate, vitamin A, iron, zinc, magnesium, and copper. As a guide, the RDAs for a 1-year-old child are:
    • Folate 50 mcg
    • Zinc 10 mg
    • Iron 10 mg
    • Vitamin A 400 mcg
    • Copper 1 mg
    • Magnesium 80 mg

P.163

Diet 1 (low lactose) Diet 2 (lactose-free)
83 calories/100 g 75 calories/100 g
11% of calories as protein 15% of calories as protein
2.7 g lactose in 130 ml/kg body weight/day
Ingredients
Full fat dried milk 11g
(or 85 ml whole milk)
Whole egg (without shell) 36g
Uncooked rice 18g Uncooked rice 10g
Vegetable oil 4g Vegetable oil 5g
Cane sugar 3g Glucose 5g
Water to make up to 200 ml final volume Water to make up to 200 ml final volume
130 ml/kg provides 110 cal/kg 145 ml/kg provides 110 cal/kg
Boil rice to a slurry with some of the water, add other ingredients and rest of water to make up to 200 ml final volume. Boil rice to a slurry with some of the water, add the whole beaten egg and continue to cook for another minute, stirring well. Add the rest of the ingredients and the water to make up to 200 ml final volume.

Malnutrition and diarrhoea Diarrhoea is as much a nutritional disease as one of fluid and electrolyte loss. Children who die from diarrhoea, despite good management, are usually malnourished — often severely so. During diarrhoea, decreased food intake, decreased nutrient absorption, and increased nutrient requirements often combine to cause weight loss and failure to grow. The child’s nutritional status declines and any pre-existing malnutrition is made worse. Malnutrition itself makes diarrhoea worse, prolonging it and making it more frequent. This vicious cycle may be broken by continuing to give nutrient-rich foods during diarrhoea and giving a nutritious diet, appropriate for the child’s age, when the child is well. When these steps are followed, malnutrition can be either prevented or corrected and the risk of death from a future episode of diarrhoea is much reduced. See Chapter 15 for further information.

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