Pediatric diarrhea, or diarrheal disease, is a group of multi-pathogenic, multi-factor-induced gastrointestinal syndrome characterized by an increase in the number of stools and changes in stool characteristics, and is one of the most common diseases in infants and young children in China. 6 months-2 years old infants and young children have a high incidence, and about half of them are within one year of age, and is one of the main causes of malnutrition and impaired growth and development in children.
I. Susceptibility factors of pediatric diarrhea
1, infants and young children’s digestive system is not yet mature, gastric acid and digestive enzyme secretion less, enzyme activity is low, can not adapt to the large changes in food quality and quantity; infants and young children water metabolism is vigorous, within one year of daily intake and discharge of water accounted for 1/2 of the total amount of body fluids (1/7 for adults), poor tolerance to water shortage, once the loss of water is prone to fluid disorders; infant period neurological, endocrine, circulatory, liver, kidney function Developmental immaturity, prone to digestive tract dysfunction.
2.Fast growth and development, relatively more nutrients required, and infant food is mainly liquid, the amount of entry is high, the gastrointestinal tract burden.
3, poor defense function of the body
(1) Infants have low gastric acid, faster gastric emptying, and weaker ability to kill bacteria that enter the stomach.
(2) Serum immunoglobulin and gastrointestinal secretory IgA are low.
4, intestinal flora dysbiosis normal intestinal flora has an antagonistic effect on invasive pathogenic microorganisms, newborns have not yet established a normal intestinal flora after birth, change the diet to change the intestinal environment, or abuse of broad-spectrum antibiotics, can make the balance of the normal intestinal flora is out of balance, and suffer from intestinal infections.
5, artificial feeding breast milk contains a large number of humoral factors, macrophages and granulocytes, lysozyme, lysosomes, has a strong anti-intestinal infection effect. Although there are some of the above components in domestic animal milk, but in the heating process is destroyed, and artificial feeding of food and eating utensils are extremely vulnerable to contamination, so the incidence of intestinal infections in artificially fed children is significantly higher than that of breast-fed children.
Second, the etiology of pediatric diarrhea
1, dietary factors
(1) Improper feeding can cause diarrhea, mostly for artificially fed children, because: feeding irregularities, improper diet, sudden changes in food varieties, or premature feeding of large amounts of starchy or fatty foods; fruit juices, especially those containing high fructose or sorbitol, can produce hyperosmolar diarrhea; intestinal irritants (seasonings, fiber-rich foods) can also cause diarrhea.
(2) Allergic diarrhea, such as diarrhea caused by allergy to milk or soy (soy milk).
(3) primary or secondary disaccharidase (mainly lactase) deficiency or reduced activity, intestinal digestion and absorption of sugar and cause diarrhea.
2, climate factors: sudden climate change, abdominal cold to increase intestinal peristalsis; weather too hot digestive juice secretion reduced or due to thirsty drinking too much milk, etc. may induce digestive disorders caused by diarrhea.
3, infection factors: intestinal infection can be caused by viruses, bacteria, fungi, parasites, the first two are more common, especially viruses. Infant diarrhea in the cold season 80% caused by viral infections, viral enteritis main pathogen for rotavirus, followed by stellate and cup-shaped virus, enterovirus (including coxsackievirus, echovirus, enteric adenovirus), norovirus, coronavirus, etc..
4, systemic diseases: can affect the function of the gastrointestinal tract and lead to diarrhea symptoms, commonly infectious diseases outside the intestinal tract. For example, when children suffer from otitis media, upper respiratory tract infection, pneumonia, urinary tract infection, skin infection or acute infectious disease, diarrhea can be complicated by fever, toxins released by the infectious agent, antibiotic treatment, and local irritation of the rectum (bladder infection). Sometimes pathogens (mainly viruses) can simultaneously infect the intestinal tract.
5, abuse of antibiotics can also cause diarrhea, in addition to some antibiotics can reduce carbohydrate transport and lactase levels, extraintestinal infections when long-term, extensive use of broad-spectrum antibiotics can cause intestinal flora disorders, the normal intestinal flora is reduced, drug-resistant Staphylococcus aureus, Aspergillus, Pseudomonas aeruginosa, Clostridium difficile or Candida albicans, etc. can multiply, causing drugs more difficult to control Enteritis, some scholars call it antibiotic-associated diarrhea.
Third, the clinical manifestations of pediatric diarrhea
1, different causes of diarrhea standing with clinical characteristics and different clinical course. Therefore, the clinical diagnosis often includes the course of the disease, the severity and the estimated possible etiology.
2, clinical staging continuous course of diarrhea within 2 weeks for acute diarrhea, 2 weeks to 2 months for prolonged diarrhea, and more than 2 months for chronic diarrhea.
3, the clinical manifestations of light acute diarrhea are often caused by dietary factors and extra-intestinal infections can be acute or slow, mainly gastrointestinal symptoms, loss of appetite, occasional overflow or vomiting, the number of stools increases, but each stool volume is not much, thin or with water, yellow or yellow-green, acidic, common white or yellow-white milk flaps and foam. No dehydration and systemic toxicity symptoms, mostly in a few days to heal.
4, the clinical manifestations of heavy acute diarrhea are mostly caused by intestinal infections. Often acute onset, can also be gradually aggravated by light, transformation, in addition to heavy gastrointestinal symptoms, there are more obvious dehydration, electrolyte disorders and systemic symptoms of infection poisoning, such as fever, mental agitation or depression, drowsiness, and even coma, shock.
(1) Gastrointestinal symptoms: low appetite, vomiting, or coffee-colored liquid in severe cases; frequent diarrhea, 10 to several 10 times a day, mostly yellow watery or egg-like stools, containing a small amount of mucus, and a small amount of blood in a few children.
(2) water, electrolytes and acid-base balance disorders.
Fourth, the diagnosis of pediatric diarrhea
1, according to the season of onset, medical history (including feeding history and epidemiological data), clinical manifestations and stool properties can make a clinical diagnosis. The presence or absence of dehydration (degree and nature), electrolyte disturbance and acid-base imbalance must be determined. Pay attention to the search for the etiology, and consider from the clinical diagnosis and treatment needs. Diarrhea can be first divided into two groups according to the presence or absence of white blood cells in the stool routine.
2, stool without or occasionally see a small number of white blood cells for invasive bacteria other than the cause of diarrhea (such as viruses, non-invasive bacteria, parasites, such as intestinal and external infections or improper feeding) caused by diarrhea, mostly watery diarrhea, sometimes with dehydration symptoms, should be distinguished from “physiological diarrhea” and lactase deficiency and other digestive dysfunctional diseases.
3, the stool has more white blood cells indicate that the colon and ileum end of invasive inflammatory lesions, often caused by a variety of invasive bacterial infection, based only on clinical performance is difficult to distinguish, when necessary, stool bacterial culture, bacterial serotype and toxicity detection, also need to be distinguished from bacterial dysentery and necrotizing enterocolitis and other diseases.
4, “physiological diarrhea” mostly seen in infants within 6 months of age, the appearance of fat, often eczema, soon after birth, diarrhea, in addition to an increase in the number of stools, no other symptoms, good appetite, does not affect growth and development. In recent years, it has been found that this kind of diarrhea may be a special type of lactose intolerance, and after the addition of complementary foods, the stool will gradually turn to normal.
5, leading to various diseases of small intestine digestion and absorption dysfunction, such as lactase deficiency, glucose-galactose malabsorption, loss of chlorine diarrhea, primary bile acid malabsorption, allergic diarrhea, etc., can be identified according to the characteristics of each disease fecal acidity, reducing sugar test and other examination methods.
6, bacteriophageal dysentery often has a history of epidemiology, the onset of acute, systemic symptoms heavy. Stool more, the amount is small, discharge pus and blood stool with urgency, stool microscopy has more pus cells, red blood cells and phagocytosis, stool bacterial culture with Shigella dysenteriae growth can confirm the diagnosis.
7, necrotizing enterocolitis poisoning symptoms are more serious, abdominal pain, abdominal distension, frequent vomiting, high fever, dark red paste stool, gradual widening of the gap, intestinal wall gas accumulation, etc..
V. Treatment of pediatric diarrhea
1, three basic principles
(1) adjust the diet, prevent and correct dehydration, rational use of drugs, strengthen care and prevent complications.
(2) Different periods of diarrhea disease treatment focus on different priorities, acute diarrhea more attention to maintain water, electrolyte balance and anti-infection, prolonged and chronic diarrhea should pay attention to the problem of intestinal flora imbalance and diet therapy.
(3) Improper treatment often leads to half-measures or counterproductive results.
According to the above principles, when parents complain of abnormal stools and consider diarrhea, the pediatrician should first clarify the cause, assess the degree of diarrhea, the presence of acute problems such as fever and dehydration, and the impact on the child’s growth and development.
2.Dietary therapy
(1) Continue the diet to meet the physiological needs and replenish disease consumption in order to shorten the recovery time after diarrhea. Reasonable adjustments should be made according to the specific pathophysiological condition of the disease, individual digestive and absorption functions and usual dietary habits.
(2) Breastfed infants continue to breastfeed and suspend complementary foods; artificially fed children can be fed with equal amounts of rice soup or diluted milk or other milk substitute crystals, and gradually transition from rice soup, porridge, noodles, etc. to a normal diet. Those with severe vomiting can be temporarily – fasting 4-6 hours (not water), to continue feeding after improvement, from less to more, from thin to thick.
(3) Viral enteritis mostly has secondary disaccharidase (mainly lactase) deficiency. For suspected cases, dairy feeding can be suspended and replaced by soy-based milk substitutes, or fermented milk, or de-lactose formula to reduce diarrhea and shorten the course of the disease.
(4) Gradually resume a nutritious diet after the diarrhea stops, and add meals once a day for 2 weeks.
In conclusion, there are many factors that cause diarrhea in children, such as reduced feeding and absorption during diarrhea, recovery of intestinal mucosal damage, high metabolism during fever, loss of protein during invasive enteritis, etc., all of which increase nutritional needs, such as restricting diet too strictly or fasting for too long often causes malnutrition and complicates acidosis, resulting in prolonged illness affecting growth and development. Therefore, dietary management of pediatric diarrhea is very important, especially for children with prolonged and chronic diarrhea of more than 2 weeks duration.
3, rehydration treatment
(1) Dietary adjustment of small amount and more meals, more feeding of soup and water type is important; dietary adjustment of good feeding can reduce the rate of intravenous rehydration.
(2) Oral rehydration ORS can be used to prevent dehydration and correct mild and moderate dehydration when diarrhea. The amount of oral rehydration fluid is about 50-80ml/kg for mild dehydration and 80-100ml/kg for moderate dehydration, and the accumulated loss will be replenished within 8-12 hours. After the dehydration is corrected, ORS can be diluted with the same amount of water and given orally at will as needed. Because ORS is 2/3 liquid, oral rehydration is not recommended for newborns and children with obvious vomiting, abdominal distension, shock, cardiac and renal insufficiency, etc.
(3) Intravenous rehydration solution is suitable for children with moderate or above dehydration, severe vomiting and diarrhea or abdominal distension. The composition, amount and drip duration of the infused solution must be decided according to the different degrees and nature of dehydration, while paying attention to individualization, combining age, nutritional status, and self-regulatory function with flexibility.
4.Treatment principles of prolonged chronic diarrhea
(1) Actively search for the cause of the prolonged course of the disease, treat the cause, avoid the abuse of antibiotics, and avoid the stubborn intestinal flora dysbiosis.
(2) Prevention and treatment of dehydration, correction of electrolyte and acid-base balance disorders.
(3) Nutritional treatment of such children mostly have nutritional disorders, and continued feeding is a necessary therapeutic measure to promote disease recovery, such as repair of intestinal mucosal damage, recovery of pancreatic function, and production of biosaccharidase in microvillous epithelial cells, etc. Fasting is harmful to the organism.
(4) prolonged, chronic diarrhea is often accompanied by malnutrition and other complications, the condition is more complex, it is necessary to take comprehensive treatment measures.