TREATMENT

IN P E D I A T R I C

PRACTICE

TREATMENT OF ACUTE DIARRH(EA IN INFANTS*

K. C. CItAUDHURI, M.B. Calcutta It is necessary to investigate carefully the nature af diarrhoea and to assess correctly its relationship to the general nutrition condition of the patient before any rational treatment is possible. The factors producing diarrhoea may be such that they do not and can not cause anything more than a mild gastro-intestinal upset. On the other hand, they may be so virulent that they lead to severe local and constitutional disturbances such as intense diarrhoea, vomiting, loss of weight, high fever, and even signs of acute dehydration and collapse. Apart from the aetiological factors, the general nutrition condition of the patient may also modify the course af illness. The reactions produced in a previously well-nourished child are different from those in a dystrophic or marasmic one. Even a severe diarrhoea may remain confined to the gastro-intestinal tract in a well-nourished child but a mild infection may cause intense constitutional disturbances in a marasmic patient. Naturally therefore the methods of treatment will vary with the cause and nutrition condition. The real difficulty of treatment lies in the absence of a n y objective method to distinguish between these groups of diarrhoeal diseases and to foresee what reactions they may produce in the child. For the purpose of successflfl treatment diarrhoea is clinically divided into two major groups: (I) Mono-symptomatic diarrhoea, that is, diarrhoea is the only symptom present without any associated general disturbance. (2) Poly-symptomatic diarrhoea in which diarrh{e.a is attended with more or less severe constitutional disturbance. 9The nutrition condition is also divided into three classes (I) normal (2) dystrophic--body-weight is flnctuating, musculature and subcutaneous fat are fairly dew,loped and turgor is not normal (3) marasmic--bodyweight is lost, musculature and subcutaneous fat have disappeared and turgor is bad as evidenced by wrinkled skin. It is not difficult to understand that different methods .of treatment must be practised in dealing with these two clinical types o.f diarrhoea *From the Chittaranjan Sishu-Sadan, Calcutta. Submitted for publication, December 2o, I936. 4

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in relation to the three stages of nutrition. B u t the primary object of treatment is always the same--to gain permanent control over the disturbances and disease processes localised in the gastro-intestinal tract and overcome quickly the constitutional reactions, if any. It is not the control of diarrhoea which is important but efforts should be directed to bring about a rapid return of appetite, normal activity,, gain in weight and satisfactory general condition. And if toxa~mia is present, energetic attempts must be made for the detoxication of the patient. The treatment of local gastro-intestinal conditions under such circumstances is of secondary importance. The first favourable signs of treatment are steadying of or gain in body-weight, disappearance of vomiting, reduction af temperature, change in facial expression, an awakening from cloudy consciousness, improvement of circulation, and establishment of diuresis and normal respiration. The stool may remain green, loose and sometimes frequent. Gradually the frequency of stool diminishes and its character changes. DIETARY TREATMENT The treatment of diarrhoea is principally dietetic and drugs play a very secondary r61e. Dietetic formukr have not only marked therapeutic effect but also maintain the body functions. They have some special features which are as follows: (I) Low fat content because fat promotes the growth of bacteria in tl~e int:estinal tract and delays emptying of the stomach. (2) High protein content because it inhibits fermentation and does not upset the digestion even if given in large quantity. (3) Restriction of tile carbohydrate content because it leads to fermentation, and (4) Acidification of milk modifications by adding lactic acid, citric acid or otherwise as it improves digestion and absorption. A wide choice is possible in the selection of such a therapeutic dietary as many milk modifications can be prepared which have one or all ot these features. ]:or example, I.

Simple milk modifications: (a)

~ Milk: Cow's mi~k Rice or ()at water Sugar

(b)

4 oz. 4 oz. 2 teaspoonful

~- Milk: Cow's milk

5 oz.

Rice or oat water Sugar

3 oz. 2--3 teaspoonful

CttAUDHURI--TREATMENT

87

OF D1ARRHCF.A

As a d i l u e n t it is a d v i s a b l e to use rice or p r e p a r e d as follows:

oat

water

which

is

9 Rice water: Wash i oz. of rice clean ; mix u ith one pint of water and boil over slow fire for 3o---45 minutes, strain. Oat water : Mix i oz. of quaker oat in one pint of water and boil ow~r slow fire for ~o--J5 miimtes, strain. When properly pret)ared both should have the consistency of lhin treacle. 2.

Acid milk:

(a) W h o l e lactic a c i d m i l k : Boil 8 oz. of cow's milk, cool. Add drop by drop one teaspoonful of mc}o lactic acid solution whilst stirring. Milk will be curdled into fine floccules. Acid 2--. I teaspoonful of sugar. (b) S k i m m e d lactic a c i d m i l k : Skim cow's milk by means of a separator or putting on ice ; take skimmed milk, boil and cool and add lactic acid solution as abow~. Add 2 - - 4 teas-lxx~nlul of sugar. 3.

Butter milk:

Add one teaspoonful of sour milk or B. Acidi Lactici culture in J6 oz. of t,,w's milk, lei it get sour for 3--12 hours in a warm place. Skim the butter off. Add 2 - - 4 teaspoonful of sugar. 4.

Protein milk:

Add 3o grains of calcium lactate in i6 oz. of cow's milk and boil. Casein will be precipitated. Take the casein on a piece of muslin and hang for an hour without pressing. Add this dried casein by slowly rubbing over a fine 'deve to 8 oz. of butter milk, add 8 oz. of water, add 2--, I teaspoonful of sugar and boil. B o t h b u t t e r m i l k a n d p r o t e i n m i l k are difficult to p r e p a r e in a h o l d a n d for t h i s r e a s o n it m a y b e n e c e s s a r y to u s e p r o p r i e t o r y m i l k (ELEDO,~;) a n d p r o t e i n m i l k (EDELWEISS) powder. If g r a d e of a c i d i t y is n o t r e a c h e d a n d m a i n t a i n e d , n o t h e r a p e u t i c is p r o d u c e d .

housebutter proper effect

As r e g a r d s t h e c h o i c e of s u g a r , lactose h a s n o a d v a n t a g e over ordinary sugar. O n t h e c o n t r a r y it h a s s o m e d i s a d v a n t a g e s . S u g a r o.f m i l k f e r m e n t s easily, h a s a l a x a t i v e a c t i o n , u p s e t s t h e d i g e s t i o n a n d gets a b s o r b e d w i t h difficulty. I t is a d v i s e d to use o r d i n a r y c a n e - s u g a r . T H E F O U R PHASE D I E T T h e a d m i n i s t r a t i o n of t h e d i e t is a d j u s t e d to t h e clinical c o n d i t i o n of t h e p a t i e n t a n d is g e n e r a l l y g i v e n in stages. T h e f o l l o w i n g a r e t h e stages : T h e First P h a s e : W i t h t h e a p p e a r a n c e of t h e first sign of illness all feeds a r e w i t h d r a w n . Water, sweetened water, fennel or weak tea

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INDIAN JOURNAL OF PEDIATRICS

are only given with a view to supply only the fluid requirement. Salt solutions are not advised as they may cause pathological retention of tluid in the tissues specially because in diarrhoeas there is considerable disturbance of water and mineral metabolism. The fluid requirement is known to be one-sixth of the body-weight, that is, 2--289 oz. per lb. of body-weight. For example, a child weighing 12 lbs. would require 24 oz. of fluid in 24 hours. This quantity must be supplied. And m a y be given in 5 or 6 meals with a night pause of 8 hours between IO p.m., and 6 a.m. It is evident that during this phase the diet is quite inadequate both qualitatively and quantitatively and it should not be continued for more than is absolutely necessary. The usual period is 12 to 24 hours. If the diet is restricted and the fasting continued, it m a y cause a disappearance of the stored reserve of the body, lower the tolerance for food and lead to a state of dystrophy or marasmus, a possibility which must be carefully avoided and guarded. Unnecessary starvation is more harmful than the disease itself. The favourable effect of withdrawal of food is shown by an improvement of the general condition on the very next day but in some infectious diarrhoeas and in marasmic or hydrolabile children it may be delayed but this is no indication to continue the starvation period. On the contrary, it is advisable to attempt to re-establish the body functions by prescribing a diet adequate to supply the caloric requirement. The Second Phase: During this phase attempt is made to go from starvation diet to milk-free transition diet. Rice-water, oat-water or barley water with 3 - - 5 % sugar is generally advised. The quantity is the same as in case of fluid (~th of the body-weight) and the total amount is given in 5 or 6 meals with a night pause of 8 hours. This is done within 48 hours of the onset of illness and the appearance of dark yellow or brownish hunger stool marks the beginning o.f the improvement. The Third Phase: This is the stage of therapeutic dietary and its administration requires considerable skill and clinical experience. In mono-symptomatic diarrhoea simple addition of 1 - - 2 % protein either in the form of butter-milk powder, plasmon or lactana will bring about the desired improvement. But in poly-symptomatic diarrhoeas careflll dieteting with butter-milk, protein milk or lactic acid milk may be necessary. However, the most dependable and most rapidly effective therapeutic nutrition is breast-milk combined with acid feeding. First, one meal of butter milk with 3 - - 5 % sugar is given and on each s u b ~ quent day it is increased in such a way that all the cereal feeds of the second stage are replaced in a week or so. Some childern take buttermilk poorly and in others it: aggravates diarrhoea. Under such circum-

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stances, protein milk or lactic acid milk m a y be given. Protein milk. has this advantage that it m a y be given almost schematically and the quantity of sugar increased to IO~o without upsetting the digestion. Thus the caloric value of the diet may be increased to a high level without increasing the total volume. BESSAU prescribes thickened ricewater alternating with butter-milk with satisfactory results. His plan is as follows: First d a y - - a l l feeds IO~o rice-water. Second day--all feed~-IO~o rice-water with 5--6~o sugar. Third day--first feed-IO~o rice-water with 5~o sugar--alternating with a .feed of butter-milk with 5--IO~o sugar. The quantity of food is calculated on the basis of body-weight as above and the meals number 5 or 6 in a day. During this stage constant effort is made to supply a quantitatively adequate diet so that the weight gain is possible. The persistence of green or even loose stool is not a contra-indication to ~eeding so long the weight gain continues and the general condition is satisfactory. The Fourth or last Phase: Is the period of return to optimal e9nvalescent or maintenance diet. As the therapeutic diet contains a disproportionate amount of various proximate principles, it should be changed as soon as it is possible. Otherwise nutritional disturbances may result due to one-sided diet. First, one meal replaced by the usual diet for the age (say ~ milk 4--5 oz. with sugar) and then other feeds are replaced gradually; later cereals and vitamin containing food are given.

These four phases a r e the most essential steps in the dietetic management of diarrhoea but in actual practice one or more of the steps may be dropped according to the severity of the clinical 'condition. The usual duration of treatment in well-nourished children extends over lO--14 days and in dystrophic or marasmic children 6--8 weeks. The physicians should not expect quicker results, and should not deviate from the planned dietary so long satisfactory progress is maintained. In some cases diarrhoea persists despite satisfactory weight gain and general improvement. In such cases mild astringents like creta prep. or eldoform may be prescribed. In others slight rise of temperature occurs and the weight sh'ows wild "Jagaries of gain and loss. The remedy is to a d d fatty.food to restore the normal body resistance and to make the weight stable. If the weight remains stationary, this is often caused by insufficiency of calories. The food should be increased to raise the caloric value: TREATMENT OF FLUID LOSS If signs of dehydration or collapse are present as in alimentary toxicosis, these must be energetically treated in preference to the local gastro-intestinal symptoms. The most effective method is of course the

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INDIAN JOURNAL OF PEDIATRICS

adminisffation of fluid by mouth but this is often impossible, . because of vomiting and therefore parenteral route is chosen. It rfiay be'gi~eta per rectum, subcutaneously, intramuscularly, intra-peritoneally or intt:avenously according to the urgency of the symptoms. Rectal administration is very often unsuitable as the fluid is not retained and the quantity cannot be estimated. Also the absorption is ve.ry slow. Subcutaneous and intraperitoneal methods are easy but intraperitoneal route is riot selected if any tympanites is present. Large quantity of fluid cannot be given b y intramuscular or subcutaneous method. Intravenous method should be selected whenever possible. I n young infants there is no difficulty because it m a y be given by intrasinous puncture. A nurse or an assistant sits on a chair with the patient on his or her lap facing the operator. The operator sits facing his assistant. The part imme,liately in front of the posterior angle of the anterior fontanelle is cleaned with al. solute alcohol and "Fine. Iodine as usual and the needle is put at 3o~ angle and then straightened. Blood is drawn into the syringe showing the correct postIron. of lhe needle. The required volume of fluid may then be given. Normal saline, Ringer's solution or 5 - - 1 2 % solution of glucose are generally used. Five per cent solution is used for hypodermic injections and I2~% for intravenous. The total quantity varies with the urgency of the case but the usual dose, is 5 o - - 1 2 o c.c. repeated every day until the dehydration is completely controlled. DI'r UG T H E R A P y

Drugs play a very subordinate r61e in the treatment of diarrhoeas. Cardiac stimulants such as caffein sodii benzoas gr. ~ - - ] twice daily m a y be necessary. Mild astringent,~-osmo-kaolin, eldoform, creta prep. etc., are prescribed, if diarrhoea persists despite favourable effect on general condition. Sedatives--Peacock's bromide or luminal m a y have to be given if convulsions are present. In case of intractable vomiting gastric lavage is done. Purgatives are generally contra-indicated and castor oil and calomel should be avoided. NURSING CARE

Nursing ('are is of utmost importance. Meticulous care of the skin, prevention of excoriation of buttocks, sore mouth, regular sponging, etc., should be carefully done. The patient should be kept warm and forced feeding must not be undertaken. REFERENCES

*.

CrtAUl)HURI, K. C.--Ind, Jour. Ped. 3: 76, I93(5. MEYER, L. F. & NASSAU, E.--Die' Sduglingsernf:heung, Bergmann, Miinchen, I93o. I'FAUNDLER, M. & SCHLOSSMANN, A.--Diseases of Clfildren, Vol. 4. Eng. Ed.

Lippincot, Philadelphia, I935.