Vomiting and Diarrhoea in Children
Edited by : Sutikno
Vomiting in Childhood
Vomiting is a frequent manifestation of disease in childhood, even in the new born it may be the first sign or an early symptom of illness. Vomiting may seem unimportant, but it can be serious and should not be taken lightly. Parent may become alarmed, but usually only when vomiting is repeated or distressing. Close observation and immediate attention are imperative, particulary in new borns, as they readily become dehydrated and may deteriorate rapidly.
Vomiting is defined as the forceful expulsion of the contents of the stomach through the oesophagus. It may be difficult to differentiate vomiting from regurgitation often called ‘spitting up’ or gastroenteric reflux. In regurgitation, the return of swallowed substances usualy occurs in small amounts and almost without efforts.
Vomiting may be preceded by nousea and salivation, in more severe cases retching occurs. The sequence is described as a downward movement of the diaphragm with the glotis and mouth closed followed by contraction of the phylorus and relaxed antrum. The abdominal muscles contract and the cardia rises and open, allowing expulsion of the vomitus. A vomiting centre on the floor of the ventricle receives and coordinates impulses from the visceral afferents and chemoreceptor zone.
In seeking the causes of vomiting the following should be considered :
1. Age of the child
2. History of change in milk or other food stuffs
3. Dietary indiscretion
4. Character of the vomitus, e.g. bile-stained in deudenal stenosis, resembling coffe-grounds in peptic ulser, blood-streaked in gastric erosion, fresh blood in oesophageal varices, faecaloid in peritonitis or lower intestinal obstruction
5. Frequency and time of vomiting, e.g. soon after ingesting food as in pylorospasm or some time latter as in intestinal obstruction
6. Other accompanying manifestations, e.g. fever in acute urinary tract or respiratory infections, headache in meningitis, a lot of drooling in tracheo-oesophageal fistulas, and abdominal pain in appendicitis
7. Projectile vomiting in pyloric stenosis and increased intracranial pressure
8. Other sibling or companions presenting with the same symptom, as in food poisoning
Aetiology of Vomiting
In the newborn period non-pathological causes are gastric irritation, intolerance to artificial milk and faulty feeding technique.
Phatological and more serious causes are :
1. Congenital defects of the gastrointestinal tract, e.g. in the oesophagus (oesophageal atresia with tracheo-oesophageal fistula, oesophageal stenosis, hiatus hernia, compression on the oesophagus)
Defects in other parts of the gastrointestinal tracts may manifest as atresia, stenosis, meconium ileus, hirsprung’s disease, or congenital bands
2. Infections
3. Increased intracranial pressure
4. Metabolic disorders
In infancy and later childhood common causes of vomiting are :
1. Dietary indiscretion
2. Infections, e.g. sepsis, acute upper and lower respiratory infections, urinary infections and peritonitis.
3. Gastrointestinal disorders, e.g. obstruction and pressure
4. Neurological disorders, e.g. meningitis, brain tumour, abscess, intracranial haemorrhage and concussion
5. Endocrine disorders, e.g. galactosemia and adrenocortical insufficiency
6. Drugs and toxins
7. other conditions, e.g. allergy, habit vomiting mainly due to feeding problems and parental attitude, and cyclic vomiting (recurrent, period or acetonaemic vomiting)
Management of Vomiting
Management of vomiting varies according to the cause, frequency and severity. The cause must be determined as soon as possible – at the times this is complicated and time consuming. In the meantime, hydration of the patient must be attended to. Intravenous fluid and electrolyte therapy may be an urgent non specific therapy. The patient’s nutrition must not be over looked.
Temporary measures include giving ice chips, hard candies and small sips of sweet cold juices or carbonates sodas. Antispasmodics and antiemetics are often prescribed, but their beneficial effect are usually temporary. Care must be taken with the use of phenothiazine derivates as they may cause extrapyramidal reactions. Surgery when indicated may be a live-saving procedure.
Diarrhoea in Childhood
Despite remarkable advances in medicine and public health, diarrhoeal diseases continue to be major cause of morbidity and mortality in childhood throughout the world, but particularly in developing countries. In infancy diarrhoea is estimated to cause higher mortality than all other infections combined. The consensus is that, for years to come, diarrhoeal diseases will remain a scourge to populations in developing countries. In view of this there has been increasing interest in an concern for diarrhoeas. The World Health Organization (WHO) has led in undertaking studies to provide measures to control and prevent these disorders. Research on different aspects of diarrhoeal diseases has result in increased knowledge and information.
Complications of diarrhoea are common in infant who are malnourished, sickly or have a chronic infection such as tuberculosis or a parasitic infection.
Epidemiology of Diarrhoea
Epidemiologically, Diarrhoeal diseasaes are closely associated with factors such as poverty, poor sanitation, malnutrition, contaminated water, lack of health education and overcrowding. Diarrhoea may occur at any age, but the incidence is highest in infancy. Alarming epidemic diarrhoeas have been reported in nurseries, while in different areas seasonal epidemics have been noted.
Aetiology of Diarrhoea
Specific causes of diarrhoea in childhood may not be determined readily, although with appropriate technology now available, the aetiology of acute watery diarrhoea can be confirmed more accurately than in the past. Investigation may include a dietary history, close observation and knowledge of epodemiological factors. A number of examinations are helpful, e.g. routine microscopic stool examination, stool culture for bacteria when leucocytes are present, the use of clinitest for disaccharide intolerance, viral cultures, serological determinations, etc.
The causes of diarrhoea in childhood are varied and may rang from a trivial dietary indiscretion to severe or intractable condition such as cholera or mal absorption syndromes. Frequently, diarrhoeas, in children is associated with intestinal bacterial infections and therefore are managed readily as such. Research has shown that patogenic organism may account for only 15 to 30 %
TABLE I. Common aetiological factors in diarrhoeal disease of childhood
Non-infectius
Dietary error
Allergy
Drugs
Poisons
Mal-absorption syndromes
Endocrine disorders
Metabolic disorders
Infectious
Bacterial
Escherichia coli
enteropathogen
enterotoxin
enteroinvasive
Shigella
Salmonela
Staphylococcus
Cholera
Pseudomonas
Klebsiella
Enterobacteriaceae
Viral
Retrovirus
Enterovirus
Adenovirus
Parasitic
Entamoba histolytica
Strongiloides stercoralis
Capillaria
Fungel
Monilia
Miscellaneous, e.g. excess food intake, laxative food stuff
of case. The table summarises common causes of diarrhoea in paediatric age groups.
Pathogenesis of Diarrhoea
An extensive study over the past four decades on pathogenic Escherichia coli as a frequent cause of infantile dirrhoea, has resulted in detailed information on the pathogenesis of 3 types of this organism; enteropathogenic, enterotoxic, enteroinvasive.
The enteropathogenic type is characterized by specific cell wall antigen. Recurrences of diarrhoea in infant have been causes by this group. The organism invade the intestinal mucosea and may even cause septicemia.
In the enterotoxic type, a special antigen cases the bacteria to attach the intestinal epithelium with the prompt multiplication of the organism, facilitating interaction between released toxin and the epithelium. The toxin are heat-stable, and have been detected by detailed and complicated procedures. The enterotoxin works through a second messenger system (cyclic nucleid system) and induces an excessive response of the normal function of the intestinal tract.
In the enteroinvasive group, the organism invade and multiply within epithelial cells.
In severe cases signs of dehydration, diminished circulation and acidosis become evident
Clinical Manifestation of Diarrhoea
Diarrhoea is defined as an increase in frequency and liquidity of faecal discharges. The number of stools may vary from about 3 per day to hourly or may be a continuous flow of the watery stools. In quantity, the stool may be scanty or copious. Diarrhoea may also be classified according to duration as acute
Or chronic, and according to severity as mild, moderate or severe.
In mild cases, appetite may be impaired, and the child irritable or anorexic. Vomiting may precede changes in stools, which at first be soft, then increasing loose. Abdominal pain may be mild or distressing. Fever may be an early manifestation; occasionally the disease is ushered in by hyperpyrexia with convulsions.
In severe cases sign of dehydration, diminished circulation and acidosis become increasingly evident. Progressively there may be thirst, sunken eyes and fontanelles, weak thready pulse with cold extremities and rapid respiration, followed by apathy and weakness, then coma. Seizure may be due to hyperpyrexia, hepernatremia, shigela infection or severe hypoglicaemia, especially in malnourished patients.
In chronic and intractable diarrhoea, loose stool occur two or more times daily for 2 weeks or more. Dehydration and malnutrition set in readily. A common cause is disaccharide mal-absorption due to enzyme deficiency. Secondary deficiency may occur in patients with severe malnutrition or those with marked damage of the intestinal mucosa. Other conditions leading to chronic diarrhoeas are irritable colon syndrome, regional enteritis, ulcerative colitis, shigellosis, parasitism and dietary allergy.
Complications of Diarrhoea
Complications are common in infants who are malnourished, sickly or have some chronic infection like tuberculosis or a parasitic infection. Among the unfavourable developments in the course of diarrhoea are anuria, acute tubular necrosis (ATN), pulmonary oedema, and venous thrombosis.
Management of Diarrhoea
The primary measure in the management of diarrhoea, even whilst the specific aetiology is being determined, is paying close attention to the course of disease, and in particular the child’s state of dehydration. The first step should be to replace all fluid looses (dehydration). Mortality from diarrhoeal diseases is significantly reduced by prompt and adequate management of dehydration.
In recent years the usefulness of oral glucose-electrolyte solution for rehydration has been emphasised. However, severe dehydration and very weak, lethargic stuporous condition require vigorous treatment with intravenous fluid to restore circulation and renal function.
Drug treatment is if no value in viral diarrhoeas. In bacterial infection, the drug used depends on the specific organism, but since identification is often difficult or impossible, selection of an antimicrobacterial drug may depend on experience or research regarding the usual organism and drug resistance in a given area.
A WHO guide for primary drug use emphasised that a number of commonly used antidiarrhoeal drugs have been found to be of no value and may be harmful. Among such drugs are purgatives, tincture of opium, atropine, cardiotonics such as adrenaline, corticosteroids, oxigen, charcoal and kaolin, pectin and bismuth, diphenoxilate hydrochloride and atropine sulphate and streptomicyn.
Prevention and Control
Important preventive measure of diarrhoeal diseases are attention to housing conditions, sanitation, hygiene precautions, and availablility of uncontaminated water supply. Adequate and proper nutrition are basic precautions, as are periodic health examinations in infants and children. Vaccination against specific diarrhoeal diseases may become an effective method of control.
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