Assessing and managing diarrhoea

Diarrhoea in children with palliative care needs

Bowel Chart

By Cabot Health, Bristol Stool Chart –  https://commons.wikimedia.org/w/index.php?curid=84257571

Diarrhoea in children can occur for many reasons but is less common than constipation in children with chronic or terminal illnesses.

Diarrhoea is still a major cause of mortality in under-developed countries.

Adequate management requires taking a thorough history of illness, medications and diet. Many cases can be managed with reassurance, clear fluids and oral rehydration in the short term. Below is a summary of the types of diarrhoea, followed by some approaches to management. In all cases, but particularly pertinent in palliative care, children ought to be treated according to their individual needs and agreed goals of care.

Types of diarrhoea

Acute diarrhoea

Diarrhoea lasting for less than 14 days. Causes dehydration and contributes to malnutrition. High output losses can cause hypovolaemic shock.

Chronic diarrhoea

Diarrhoea lasting more than 14 days. Can lead to malnutrition and weight loss due to malabsorption. Can be non-infectious and non-dehydrating.

Dysentery

Diarrhoea with blood in the stool, with or without mucous. In young children dysentery is generally caused by shigella.

Assessment of diarrhoea

It will be appropriate to determine goals of care in advanced/critical disease. Formulating a care plan in consultation with the child where appropriate and their caregivers can be an opportunity to discuss ways of managing symptoms, determine the social and psychological impact and can provide the time to offer reassurance to the child and family.

1.  Take a full history by determining the following from the parents (and the child if they are old enough):

  • What is the time course of the diarrhoea? (To determine if acute or chronic)

  • Any infectious exposure.

  • Birth and family history, e.g. of Coeliac disease

  • Timing of the diarrhoea i.e. neonatal vs introduction of cows milk protein

  • Use of a bowel chart to determine characteristics of stools according to fluidity, type, consistency, colour and smell

  • What is the contribution from underlying diseases such as HIV, Cystic Fibrosis?

  • Are they taking treatment related medications e.g. ARTs, antibiotics, excess laxatives, radiation and chemotherapy?

  • Constipation – possible faecal impaction with overflow.

  • Neurological features e.g. paraplegia or autonomic dysfunction.

  • Diet or feeding related e.g. lactose intolerance / change in feed / formula mixed correctly / adequate feeding practices.

  • Have cultural practices been used e.g. herbal medications, enemas?

  • Are immunisations up to date?

2. Conduct a physical examination

  • Assess for dehydration and shock. (Check if there is a palliative plan for resuscitation/comfort care and the intervention level status.)
  • Review pain
  • Check for anorectal irritation e.g. candidiasis, faecal incontinence, post radiotherapy

3. Laboratory/radiological investigation if appropriate

  • Venous blood  gas, blood count, electrolytes, haemo-occult test, urine/stool culture, substance reducing screens, and radiological examination of the GIT tract can be performed if clinically indicated.

4. Biopsychosocial assessment

Consider the following:

  • Psychological impact e.g. embarrassment, loss of dependence, anxiety, fear, etc.
  • Social impact on child and family e.g. social isolation due to smell and soled underwear, developmental regression, child being bullied, etc.
  • Spiritual impact e.g. questioning ‘why me?’

Managing constipation in children with palliative care needs

Non-pharmacological strategies for managing diarrhoea

Parents or caregivers should be encouraged to maintain a positive and supportive attitude throughout treatment and expect gradual improvement. Other strategies can include:

  • Change in diet
    In consultation with a dietician, options can include:

    • Continuing and increasing breastfeeding during and after diarrhoeal episode.
    • BRATT diet (Banana, Rice, grated Apple, Tea, Toast) for older children. Avoid spicy, high fibre and greasy foods and caffeinated drinks.
    • Consider a semi-alimental feed (Pepti-K, Alfare) or with no lactose (Standard K) which helps in interim until villi regenerate
    • Lactose free milk. Avoid dairy products or other lactose containing products.
    • Yoghurt and maas to assist with replacement of gut flora
    • Supportive measures including Vitamin A, probiotics and zinc supplementation.
    • Natural products used in astringents or teas such as ginger, turmeric, or cinnamon.
  • Fluid intake
    Small amounts of clear fluids initially, especially if patient is eager to drink, use Oral Rehydration Solution (ORS) in the short term, and continue to assess and reassess hydration status.

  • Lifestyle adaptions

    •  Counselling of carers e.g. household hygiene especially handling of child’s food and water, cross infection risks, disposal of nappies, washing of clothing and soiled linen.
    • Use of waterproof plastic under sheet, absorbent underwear (cotton nappies or liners).
    • Improved water supply quantity and quality, including treatment and safe storage of household water where possible – encourage sanitation and hygiene practices and education.
    • Use barrier creams to prevent excoriation and exposure of affected areas to fresh air to dry it out, treat nappy rashes with gentian violet, egg whites if candidiasis suspected.
    • Carefully plan all outings – carry a change of clothes, know the location of toilets.
    • Introduce pleasant smells in the home e.g. vanilla, lemon, lavender sprigs.