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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 > Complications of diarrhoea Complications of diarrhoea Electrolyte disturbances Knowing the serum electrolyte concentrations rarely changes the management of patients dehydrated due to diarrhoea. In most cases, hypernatraemia, hyponatraemia, and hypokalaemia are all adequately treated by oral rehydration with ORS or IV rehydration with Ringer’s lactate. In severe dehydration, however, plasma sodium concentrations may reach extremes and hypokalaemia may produce muscular weakness, dangerous cardiac arrhythmias, and paralytic ileus. Fever Fever in a patient with diarrhoea may be due to the organism causing the diarrhoea or, particularly in children, a 2° infection (e.g. pneumonia or otitis media). The presence of fever should prompt a search for other infections, particularly if it persists after the patient is fully hydrated. In an area where P. falciparum malaria is prevalent, children with a fever of 38-C or above should be treated with an appropriate antimalarial. High fevers (>39-C) in children should be brought down with an antipyretic drug such as paracetamol. This will reduce irritability and prevent febrile convulsions. Convulsions In a child with diarrhoea and convulsions during the illness, the following diagnoses should be considered:

  • Febrile convulsion: this usually occurs in children <8 yrs old when their temperature exceeds 40°C or rises very rapidly. Treat with paracetamol and tepid water sponging.
  • Meningitis: needs to be considered in any child or adult following a convulsion. Look for neck rigidity and Kernig’s sign. Do a lumbar puncture after checking the retinae for papilloedema (raised ICP) and looking for focal neurological signs.
  • Hypoglycaemia: this occasionally occurs in children with diarrhoea, due to their small hepatic glycogen reserves and insufficient gluconeogenesis. If suspected, give 1.0 ml/kg of 50% glucose solution or 2.5 ml/kg of a 20% glucose solution IV over 5 mins. If hypoglycaemia is the cause, recovery will usually be rapid. In such cases, Ringer’s lactate with dextrose should be given to the child for IV rehydration.

Vitamin A deficiency Diarrhoea reduces the absorption of and increases the need for vitamin A. In areas where vitamin A deficiency is already prevalent, young children with diarrhoea have an increased risk of developing eye problems. Doses: 50,000 iu for children <6 months; 100,000 iu for children 6–12 months; 200,000 iu for children >12 months. Give dose on day 1, day 2, and 14 days later or at discharge. Metabolic acidosis During episodes of diarrhoea, a large amount of bicarbonate may be lost from the stool. If renal function is normal, this will be replaced. However, renal impairment due to hypovolaemia may result in the rapid development of a base deficit and acidosis. Excess lactate production may also occur. Features of metabolic acidosis are: serum bicarbonate (<10 mmol/l); acidaemia (pH <7.3); with respiratory compensation (look for rapid and deep breathing); vomiting. P.165
Antidiarrhoeal drugs These agents, though commonly used, have no practical benefit and are never indicated for the treatment of acute diarrhoea in children. Some of them are dangerous. Adsorbents: (e.g. kaolin, attapulgite, smectite, activated charcoal, cholestyramine) are of no proven value in the treatment of diarrhoea. Antimotility drugs: (e.g. loperamide, diphenoxylate with atropine, tincture of opium, paregoric, codeine). These drugs reduce the frequency of stool passage in adults, but do not do so appreciably in children. Moreover, they may cause severe paralytic ileus and prolong infection by delaying the elimination of the causative organism/toxin. They may be used cautiously in adults in exceptional circumstances (e.g. required to travel) but should never be used in children or infants. Other drugs:

  • Antiemetics (e.g. prochlorperazine, chlorpromazine, metaclopramide). Such drugs should not be given since they often cause sedation and may interfere with ORS treatment. Vomiting will cease as the patient becomes hydrated.
  • Cardiac stimulants should never be used to overcome shock and hypotension which may occur in severe dehydration with hypovolaemia. Cardiac output will be restored as rehydration fluid is infused IV.
  • Blood or plasma is only indicated if there is proven shock.
  • Steroids and purgatives are of no benefit and should never be used.

Dietary management of diarrhoea and zinc supplementation Diarrhoeal illness is associated with growth faltering and malnutrition. Diarrhoeal infections may cause malabsorption, with increased faecal loss of nutrients, and reduced dietary intake due to anorexia and food restrictions. These adverse consequences can be minimized by correct dietary management. Children should be encouraged to eat normally if they want to. More frequent ‘nutrient dense’ (i.e. high energy in small volume) foods such as purees should be offered. If the child is anorexic, food should be offered more frequently and increased food offered as soon as the child will eat. Breastfeeding should continue. High-sugar fruit juices and soft drinks should be avoided as the high osmolar load may exacerbate the diarrhoea. Most children with mild diarrhoea can continue to drink cow’s milk. If lactose intolerance occurs reduce the lactose load by mixing milk with cereal such as rice, or using yogurt, and give in small amounts frequently. Give additional food when the child recovers. Zinc deficiency is common in developing countries and in any population in which there is limited consumption of foods of animal origin, especially red meat or offal. Zinc supplements have been shown to reduce the duration and severity of diarrhoea. Zinc sulfate or gluconate (20 mg elemental zinc) is recommended for 7-14 days. ORS should also be given. Formulations of ORS containing zinc are under trial but it is difficult to ensure a standard dose of zinc. No other micronutrient supplement has shown such consistent and important benefits in diarrhoeal disease as zinc but multivitamin mineral supplements are recommended for children with persistent diarrhoea and/or malnutrition who are especially likely to have multiple nutrient deficiencies.

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