MANAGEMENT OF ADD AND
CASE STUDY
Sivasri S
CRMI
2020 BATCH
Introduction
What is ADD ?
Diarrhoea is defined as the
passage of loose, liquid or
watery stools. These liquid
stools are usually passed more
than three times a day.
MANAGEMENT OF ADD – IMNCI
Integrated Management of
Neonatal and Childhood Illness
guidelines
IMNCI stands for Integrated Management of Newborn and Childhood Illness
Rehydration and maintaining hydration
SGLT REMAINS INTACT
One molecule of glucose
facilitates the entry of one
molecule of sodium into the
enterocytes along with one
molecule of water
Forms the basis of 1:1 ratio of sodium and glucose in
ORS
Usage of low osmolarity ORS helps to
1) Reduce stool output
2) Decrease vomiting
3) Decrease the use of unnecessary IV without
increasing the risk of hyponatremia
Alternatives to ORS
Preferable solutions (that contain Acceptable solutions (that don't
salt) contain salt)
Salted rice water (add 3g/l ) Unsalted rice water
Salted yoghurt drink Coconut water
Vegetable/chicken soup with salt
Unsalted soup, yoghurt drinks
Homemade : one teaspoon
without salt
tablesalt and 6 teaspoons sugar
PLAN A
• No dehydration
• The child can be treated at
home after explaining the
method of feeding and the
danger signs to the mother.
• Replacement of ongoing
loss – with WHO ORS
Plan B
• Some dehydration
• REHYDRATION : Deficit replacement with ORS
75 ml/kg body weight should be given orally in 4
hours
Maintainence : Holliday segar formula
• PLAN C
When severe dehydration is present.
• IV fluids should be started immediately – Ringer lactate
with 5% dextrose – 100 ml/kg body weight
◦ The solutions recommended by WHO for intravenous infusion are:
◦ (a) Ringer's lactate solution (also called Hartmann's solution for injection) : It is
the best commercially available solution.
◦ (b) Diarrhoea Treatment Solution (DTS): Also recommended by WHO as an ideal
polyelectrolyte solution for intravenous infusion. It contains in one litre, sodium chloride
4 g, sodium acetate 6.5 g, potassium chloride 1g and glucose 10g .
◦ If nothing else is available, normal saline can be given.
◦
Zinc supplementation
When a zinc supplement is given during an episode of acute diarrhoea, it
reduces the episode's duration and severity. In addition, zinc supplements
given for 10 to 14 days lower the incidence of diarrhoea in the following 2
to 3 months ..
CHEMOTHERAPY : Unnecessary prescription of antibiotics and other drugs will do more harm
than good in the treatment of diarrhoea.
For diarrhoea due to cholera the drug of choice is doxycycline, tetracycline, TMP-SMX and
erythromycin. For diarrhoea due to shigella, the drug of choice is ciprofloxacin as shigella is
usually resistant to ampicillin and TMP-SMX.
Better MCH care practices
(a) MATERNAL NUTRITION:
Improving prenatal nutrition will reduce the low birth weight problem. Prenatal and postnatal nutrition will improve the quality
of breast milk.
(b) CHILD NUTRITION:
(i) Promotion of breast-feeding : Any measures to promote breast-feeding are likely to reduce the diarrhoeal diseases in
infants
(ii) Appropriate weaning practices : Poor weaning practices are a major risk factor for diarrhoea. The child should be weaned
neither too soon, nor too late, in any case not earlier than the sixth month of life using nutritious and locally available foods,
and the foods should be hygienically prepared and given.
(ili) Supplementary feeding : This is necessary to improve the nutritional status of children aged 6-59 months. As soon as the
supplementary food is introduced, the child enters the high-risk category.
(iv) Vitamin A supplementation:
.It also reduces the duration, severity and complications associated with diarrhoea
PREVENTIVE STRATEGIES
c.
◦ (i) SANITATION improved water supply, improved excreta disposal and improved domestic
and food hygiene.
◦ Adequate supply of clean water close to their homes.
◦ Simple hygienic measures like hand washing with soap before preparing food, before eating,
before feeding a child, after defecation, after cleaning a child who has defecated, and after
disposing off a child's stool should be promoted.
◦ All families should have a clean and functioning latrine. The latrine should be kept clean by
regular washing of dirty surface.
◦ If there is no latrine, family members should defecate at a distance from the house, paths or
areas where children play and at least 10 metres away from the water supply source.
◦ Contaminated foods of all sorts have been identified as major vehicles for the transmission of
faecal pathogens during early infancy, e.g., diluted milk, cereal gruels, etc.
◦ (il) HEALTH EDUCATION : Environmental sanitation
measures require educational support, to ensure their
proper use and maintenance of such facilities.
◦ (iii) IMMUNIZATION : Immunization against measles
is a potential intervention for diarrhoea control.
◦ Two live, oral, attenuated rotavirus vaccines were
licensed in 2006: the monovalent human rotavirus
vaccine (Rotarix"™) and the pentavalent bovine-
human, reassortant vaccine (Rota Teq™).
◦ Fly control :Flies breeding in association with human
or animal faeces should be controlled.
CASE STUDY
◦ Devdhanik, 3 year old male child from arasipalayam came with complaints of
◦ Watery stools for last 2 days - 5to 6 episodes
◦ 4 to 5 episodes of vomiting since 1 day
◦ History of presenting illness : Watery stools not blood stained, no h/o fever , h/o
vomiting 3 episodes contained food food particles.
Past history : H/o similar episode in the past treated with ORS 6 months back
Antenatal, Natal history – nil significant
Immunization history – Immunized upto date
Diet history – exclusive breastfed upto 6 months. Breastfed till age of 2. Currently on
home meals , no history of outside food intake
◦ Examination
◦ General examination
Conscious , lethargic , irritable
No pallor , icterus , clubbing , cyanosis , lymphadenopathy, pedal edema
Pulse – 110 / min
Respiratory rate – 30 / min
Head to toe examination :
Sunken eyes
Drinks water eagerly and thirsty
Skin pinch goes back in 2 s
ANTHROPOMETRY weight : 22 kg
height : 105 cm
head circumference ; 50 cm
MUAC 13
Systemic examination
CVS S1,S2 heard , no murmur
RS NVBS
ABDOMEN Soft , non tender
CNS NFND
SOCIAL ASPECT
◦ A. FAMILY : JOINT FAMILTY
◦ LITERACY AND OCCUPATION OF FATHER AND MOTHER : LITERATE , TEXTILE INDUSTRY
◦ INCOME : 15000 PER MONTH
◦ MEMBERS AND PER CAPITA INCOME : 3 MEMBERS AND PERCAPITA RS 4500
◦ SES CLASS 2
HOUSING AND ENVIRONMENT :
HOUSE : PUCCA
NO OF ROOMS : 3 , NO OVERCROWDING
SANITARY LATRINE : PRESENT
SOURCE OF DRINKING WATER : CLEAN , BORE WATER
KITCHEN : FOOD ITEMS CLOSED WITH LID NO INSECT BREEDING
SURROUNDINGS: CLEAN
CLINICOSOCIAL DIAGNOSIS:
◦ 3 year old male , from joint family , literate parents ,belonging to SES class 2
( modified BG Prasad ) , pucca house with no overcrowding , sanitary latrine
present , clean source of drinking water and surroundings.
DIAGNOSIS:
Acute diarrheal disorder with some dehydration
MANAGEMENT
◦ Individual level : ORS management according to IMNCI
◦ Family level : awareness and motivating family to maintain hygiene- handwashing
and immunization , diet for child and sanitation
◦ Community level – motivating use of sanitary latrine
, promoting use of ORS
REFERENCES
◦ PARK TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICINE 27 TH EDITION ‘
◦ OP GHAI TEXTBOOK OF PAEDIATRICS