Chronic or Persistent Diarrhoea (PD)

Definition

• Diarrhoea with or without blood that persists for at least 14 days or more
• Usually follows an episode of acute gastroenteritis
• SEVERE persistent diarrhoea = PD + some or severe dehydration

Important points in history

• Duration of diarrhoea
• Presence of blood in stool
• Use of antibiotics and other drugs
• Usual feeding practices
• Recent gastrointestinal illness - post-diarrhoeal lactose intolerance?
• Previous stool consistency - is this constipation with overflow?
• Weight loss, night sweats, fevers, TB contact

Important points on examination

Determine whether

• Signs of dehydration Acute Gastroenteritis
• Signs of malnutrition
• Look for markers of immune deficiency - oral thrush
• Evidence of non intestinal infections such as pneumonia, sepsis
• Evidence of malignancy or TB - lymphadenopathy, abdominal masses

Who to admit?

• PD + some or severe dehydration
• PD + severe malnutrition
• Suspicion of underlying systemic illness

Investigations

(a) Assessment, resuscitation and early stabilisation as for Acute diarrhoea -PLAN A, B or C Acute Gastroenteritis

• Screen and treat associated secondary infections
• Treat persistent bloody diarrhoea as per acute bloody diarrhoea/dysentery protocol Dysentery
• Treat amoebiasis with metronidazole 10 mg/kg (maximum 750 mg) three times a day for 5 days
• If Giardia seen/ suspected, give metronidazole 7.5mg/kg 3 times a day for 7 days
• If HIV+ consider treatment for isospora (high dose cotrimoxazole) and helminthiasis (stat albendazole) HIV guidelines

(b) Feeding

• Many children will have poor appetite until diarrhoea lessens and serious infection has been treated. Special diets are therefore required. Besides giving child energy and nutrition, feeding will also speed up gut recovery.

Infants under 6 months

• Mothers must be encouraged to breastfeed exclusively. Breastfeeding must never be stopped under any circumstances
• For non breastfeeding infants, encourage use of breast milk substitutes that are low in lactose e.g. yoghurt

Children aged 6 months or more

• Encourage mothers/ guardians to start feeding their children as soon as they are able
• Consider nasogastric feeding for children not able to feed orally
• Goal is to give daily intake of at least 110kcalories/kg of a diet low in lactose
• Use of Moyo feeds (F75, F100) - discuss with Moyo staff

(c) Micronutrient supplementation

All children with PD and malnutrition should have an initial dose of Vitamin A

A 2 week daily intake at least two times the recommended daily allowance for (see Formulary for dosages)

• multivitamins (vitamin A, 800 μg)
• folate (100 μg)
• minerals (not necessary if using F75, F100)
• zinc
  • up to 6 months 1/2 tablet (10 mg) per day
  • 6 months and more 1 tablet (20 mg) per day
• iron (should not be started until recovery from diarrhoea has started)

Monitoring

• Body weight
• Temperature
• Food/ fluid intake
• Number of diarrhoeal stools

Children should resume appropriate diet for their age as soon as treatment successful

Discharge when

• Steady weight gain (at least 3 days of successive weight gain)
• Fewer diarrhoeal stools
• Absence of fever

Follow up and Rehabilitation

• Discuss and address underlying risk factors with guardian - appropriate feeding (breast feeding, supplementary feeding); environmental hygiene and sanitation; HIV
• Consider referral to community supplementary feeding program

Reference:
WHO Pocket Book of Hospital Care for Children 1st Malawi Edition (2013)