- As soon as the patient can drink, give 5 ml/kg/hour of ORS solution.
- After 6 hours (young children) or 3 hours (older children), re-evaluate the patient using the assessment chart, then choose the appropriate treatment regimen to continue treatment.
- If IV fluids cannot be administered, rehydration can be performed by nasogastric tube with ORS solution 20 ml/kg/hour. Reassess the patient's condition every 1-2 hours. If after 3 hours the patient's condition is still unwell, rehydration should be performed.
The patient did not improve, so he was transferred to a higher level for intravenous fluids.
5- Nutritional treatment of diarrhea:
- In the treatment of diarrhea, in addition to rehydration and electrolyte replacement, feeding is an equally important step in preventing malnutrition. The most effective nutritional approach is to continue feeding the child during diarrhea and to feed the child for two weeks after the diarrhea has stopped.
- Temporarily reduce the amount of animal milk (or lactose) in the diet.
- Provides adequate energy, protein, vitamins and minerals for the body.
- Avoid giving your child foods or drinks that make diarrhea worse.
- Make sure to provide enough food for children during the recovery period to restore the state of malnutrition.
- Many studies show that 60% of nutrients are still absorbed during the acute phase of diarrhea.
5.1. Nutrition during diarrhea :
Foods to eat when your child has diarrhea
Rice (rice flour), potatoes. Lean chicken, lean pork, lean fish. Soy milk, yogurt, low- or lactose-free milk. Vegetable oils. Carrots, sapodilla, bananas, apples.
Depending on the child's age and diet before having diarrhea, use an appropriate diet.
before diarrhea
Nurture0 - 3 months | 4 - 5 months | > 6 months | |
Breastfeeding Animal milk Industrial milk | Continue Continue but dilute 1/2 for 2 days | Continue Continue but dilute 1/2 for 2 days, otherwise give soft food | Continue Continue feeding as usual. |
Soft food or solid food (#) | Are not | Continue if normally fed | Continue or start if not feeding yet |
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(#): These foods should not be given while rehydrating but should be given again immediately afterwards.
Infants under 6 months of age who are breastfeeding :
Continue breastfeeding normally and increase the number of feedings. Because breast milk is still well tolerated when having diarrhea, breastfeeding will help the baby have less diarrhea and recover faster. If the baby does not have breast milk, feed the baby cow's milk or formula that the baby has been eating before, but feed it in small amounts and many times a day.
Children from 6 months old :
In addition to breast milk and milk substitutes as above, children need to be fed more often and in small amounts foods rich in nutrients such as lean meat, fish, eggs, milk... and add a little oil and fat to increase the energy of the diet.
Food needs to be soft, well-cooked, and fed immediately after cooking to ensure hygiene and reduce the risk of secondary infection. If you have to feed your child pre-cooked food, it needs to be reheated before feeding.
Feed your child more ripe fruit or fruit juice such as: banana, orange, mango, papaya, sapodilla... to increase the amount of potassium, beta-carotene, vitamin C...
Foods to avoid when children have diarrhea
+ Industrial soft drinks and foods containing a lot of sugar because these foods can increase diarrhea.
+ Food use: absolutely do not feed children with salt porridge or salt powder, still feed children with normal foods without having to abstain from anything. Note : do not feed them hard foods such as old vegetables, meat with lots of tendons or low in nutrients such as raw vegetables: celery, bamboo shoots, or hard-to-digest whole grain starches such as corn and beans.
Amount of food: Children should be encouraged to eat as much as possible, young children should be fed 6 times/day or more.
Attention:
- If the child eats little or vomits after eating, feed less and increase the number of meals compared to the menu.
- From the 5th day, if the child's diarrhea has subsided, gradually return to a normal diet.
5.2. Nutrition during recovery and monitoring :
Give your child an extra meal each day for 2 weeks after diarrhea. If your child is recovering from malnutrition or persistent diarrhea, the extra meal should be given longer until the malnutrition is corrected.
6. Antibiotics and other drugs in diarrhea:
6.1. Antibiotics :
Antibiotics are not routinely given for acute diarrhea. Ninety-five percent of cases of diarrhea in children are successfully treated with oral rehydration and feeding alone. Antibiotics are indicated for shigellosis and cholera.
- Bacillary dysentery: Cotrimoxazole (Bactrim): 50 mg/kg body weight/2 times/day, for 5 - 7 days or Nalidixic Acid (Negram): 50 mg/kg/day for 5 - 7 days.
- Cholera: Tetracycline 30 mg/kg/day for 3 days (not for children < 7 years old) or Erythromycin 30 - 40 mg/kg/day for 3 days.
6.2. Antiparasitic drugs :
In diarrhea, drugs can be used to treat some other infections. Only treat dysentery when shigellosis treatment does not cure or when red blood cell-eating amoeba is found in the stool. Treat Giardia when diarrhea lasts more than 14 days and cysts or flagellate protozoans are found in the stool.
Treatment of flagellates: Metronidazole (Klion, Flagyl): 15 mg/kg/day for 7 - 10 days.
6.3. Drugs that should not be used in diarrhea :
- Anti-peristaltic drugs such as immodium, anti-emetic drugs such as promethazine, absorbent drugs such as actapulgite, smecta, activated charcoal are not useful in treating diarrhea.
7. Diarrhea prevention:
- Proper treatment of a case of diarrhea includes rehydration with oral fluids and
Nutrition can reduce the harmful effects of diarrhea such as dehydration, malnutrition and the risk of death. However, although the frequency of diarrheal episodes has decreased, measures are still needed to reduce the spread of diarrhea-causing bacteria and increase the child's resistance to fight pathogens.
- There are 7 measures identified as propaganda goals.
7.1. Breastfeeding :
The composition of breast milk is the same in nutrients (glucid, protein, fat), micronutrients (vitamins, minerals), enzymes, hormones and growth factors, immune system resistance factors and anti-inflammatory factors.
- Vitamins: breast milk has more vitamin A than cow's milk, helping children prevent dry eyes.
- Minerals: calcium in breast milk is less than in cow's milk but is easily absorbed and meets the needs of children.
- Iron absorption in breast milk is higher than in cow's milk. Therefore, breastfed babies are less likely to be anemic.
- Antibacterial substances in breast milk protect babies from disease:
Some antibodies passed from mother to child through the placenta help newborns have resistance and immunity to some diseases in the first 4-6 months such as measles, flu, whooping cough...
White blood cells: In the first 2 weeks, breast milk contains up to 4,000 white blood cells/ml of milk.
- Breast milk has anti-allergic effects: fully breastfeeding for the first 6 months reduces the rate of illness, death, diarrhea and acute respiratory infections. Exclusive breastfeeding for the first 6 months also reduces the risk of chronic diseases such as diabetes, obesity, and is the basis for breastfeeding for up to 2 years.
- Strengthening mother-child affection: breastfeeding is a condition for mother and child to be close to each other. That natural closeness is an important psychological factor that helps the child develop harmoniously. Breastfeeding creates a close bond between mother and child.
- Protecting mothers' health:
Stimulates early milk secretion, prevents engorgement, blocked milk ducts, and prevents postpartum infections.
. Help mother get pregnant slowly.
Breastfeeding immediately after birth helps the uterus contract and stop bleeding for the mother.
- Breast milk is economical and convenient: Breast milk is available within 24 hours and does not require preparation. Breast milk is convenient for babies, does not require cooking, is cheaper than any other food, saving mothers both money and time.
7.2. Improve weaning practices
+ Weaning is a process of getting children used to the adult diet. Weaning is a dangerous stage because children do not have food with enough nutritional value, food and drinking water can be contaminated by pathogens, many of which cause diarrhea.
+ Breast milk fully meets the needs of the baby in the first 6 months. From the 6th month, the baby develops rapidly and requires very high nutritional needs. In addition to breast milk, the baby needs to be fed additional foods, called complementary foods. Babies who are artificially fed are also fed the same as breastfed babies.
- 5 months: start feeding baby a thin meal of porridge.
- 6 months: 1 meal of thick porridge.
- 7 - 8 months: 2 meals of thick porridge.
- 9 - 12 months: 3 meals of thick porridge.
- July - August: add other foods such as meat, fish, shrimp, crab, beans, peanuts, sesame...
- From the 9th month: can be fed with all the foods like adults. After 6 months of age, supplementary foods should be given because:
- At this age, children show signs of liking to eat.
- Teeth begin to grow, know how to use tongue to move food and chew.
- The digestive system has gradually improved.
+ Do not give children complementary foods too early or too late .
Starch: noodles, rice
Protein: eggs, meat | ||
Corn, potatoes | Breast milk | Fish, shrimp, beans, peas |
Fat: oil, fat, butter | Vitamins, minerals: vegetables, fruits | |
7.3. Use clean water for hygiene and drinking :
The spread of disease-causing bacteria can be through many ways:
- Direct transmission of bacteria from sick people to healthy people through the following routes: feces
- hands, feet and mouth.
- From vomit, feces of sick people - flies, rats, cockroaches and other insects are brought to food and to healthy people.
- From vomit, feces of sick people - water - food to healthy people.
Environmental and personal hygiene measures:
- Environmental sanitation is first of all controlling the growth of flies, mosquitoes, cockroaches, rats... To limit this, it is necessary to collect waste, treat waste hygienically, and prohibit indiscriminate defecation. Limiting the growth of flies and mosquitoes will contribute greatly to preventing the spread of pathogens.
- Ensuring clean water hygiene and safety is very important.
- Water plants as well as water quality monitoring agencies also have a system of continuous monitoring of water hygiene quality. Drinking water sources must be kept clean. All drinking water must be disinfected with Chloramine B chemical.
- Use safe water : Families need to choose the cleanest water source possible; Do not dump waste, laundry water, patient's utensils or throw dead animals, garbage into ponds, lakes, rivers.
Do not bathe, wash clothes or defecate near water sources; Build latrines at least 10 meters away from water sources on lower ground; Store water in jars or pots that are washed daily and have lids; Use a long-handled ladle to scoop water, do not touch the water with your hands;
Food hygiene : Eat cooked food and drink boiled water, do not eat raw vegetables, ice is made from clean water and ensure hygiene quality.
Avoid foods and dishes that are susceptible to contamination and carry germs, especially foods that attract flies to spread germs.
Do not eat uncooked foods such as rare dishes, salads, raw vegetables and even cooked foods that are not stored hygienically.
7.4. Hand washing :
Regular hand washing
All causes of diarrhea are transmitted by hands contaminated with feces. All family members should wash their hands thoroughly after defecating, after cleaning up a child's defecation, after cleaning up a child's feces, before preparing food, and before eating. Good handwashing requires the use of soap and water.
Hands must be washed with clean water and soap before preparing food and after using the toilet to avoid spreading germs.
7.5 . Using the toilet :
- Personal hygiene in preventing diarrhea should be noted for everyone to be aware of hygiene after defecation, or help sick people clean up waste.
- Strictly manage and handle feces and waste of healthy and sick people. For feces and vomit of diarrhea patients, use Cloramin B and lime powder to disinfect, ensuring that no pathogens are introduced into the environment.
- Human excrement must be handled so that it does not stick to hands and pollute water sources. The best way is for people to regularly use hygienic latrines.
7.6. Safe disposal of baby feces :
In many places, people often think that children's feces are harmless. But in fact, children are often infected with microorganisms that cause intestinal diseases and children's feces are a dangerous source of disease spreading to others. For children with diarrhea or asymptomatic infections,
The more evidence, the more dangerous the child's stool.
Safe disposal of manure
Unsanitary environments spread diarrheal agents. Feces contaminate water sources where children play, where mothers wash clothes and collect water for their families. Families need to pay attention to the quality and hygiene of latrines. If the latrines do not meet standards, they must defecate in the pit and bury the feces immediately after defecation. Children's feces often contain diarrheal agents and must be collected, poured into latrines or buried immediately after defecation.
7.7. Measles vaccination :
Complete vaccination according to the expanded immunization schedule is required. Measles vaccination can reduce the incidence and severity of diarrhea. All children should be vaccinated against measles at the recommended age.
Children who have measles or have recovered from measles within 4 weeks are more likely to have diarrhea or severe dysentery and are more likely to die, due to damage to the immune system after measles or due to damage to the intestinal mucosa that has not fully healed after the illness.
EVALUATION QUESTION.
Choose the correct sentence:
1 - Diarrhea is:
A. Loose or watery stools more than 3 times in 24 hours
B. Loose stools more than 5 times in 24 hours
C. Loose or watery stools more than 4 times a day
D. Breastfed babies have loose stools. 2- Causes of acute diarrhea:
A. Children who are fed cow's milk, powder, and rice water often have diarrhea.
B. Due to nutrition and infection.
C. Due to viral infection.
D. Due to unhygienic eating and drinking. 3- Assess dehydration status:
A. General condition.
B. Eyes.
C. Thirsty, pinched skin. D. All are correct.
4- Treat diarrhea according to treatment regimen A:
A. For oral use only.
B. Oral and intravenous use.
C. Insert a nasogastric tube for the child to drink.
D. Give the child salted rice water to drink.
5- Principles of treating diarrhea at home:
A. Give your child more fluids than usual to prevent dehydration: .
B. Use 3 treatment principles.
C. Feed children plenty of nutritious foods to prevent malnutrition.
D. Apply only one of the three treatment principles.
6- Drugs for treatment of acute diarrhea:
A. Antibiotics.
B. Only use antibiotics when there is a bacterial infection.
C. Antiemetics.
D. Pain reliever.
7- Propaganda for prevention of acute diarrhea:
A. Give oral rehydration solution.
B. There are 7 measures.
C. Give salted rice water to drink and feed.
D. All are correct.
LESSON: 10
RHEUMATIC HEART DISEASE AND RHEUMATIC HEART PREVENTION PROGRAM
Target
1. Describe the causes, mechanisms and symptoms of rheumatic heart disease.
2. Describe the clinical and paraclinical signs of rheumatic heart disease.
3. Describe the treatment and prevention measures for rheumatic heart disease.
1. General
Rheumatic heart disease is an infectious - allergic - immune disease that causes damage to many parts of the body: joints, heart, brain, skin... The damage can be only in one part, but can also be in many parts at the same time during a progression or added in subsequent rheumatic episodes. Damage caused by rheumatic heart disease is only transient (in the skin, in the joints...) but can last long, progress into irreversible damage, leaving serious lifelong sequelae (in the heart ).
2. Causes
The cause of rheumatic heart disease is streptococcus (group A hemolytic streptococcus (LCK)
By specific serological reactions, people have isolated over 80 different types of group A LCK, of which 10 common types are M types 1, 3, 5, 6, 14, 18, 19, 24,
27, 29.
The initial lesions of group A LCK are pharyngitis and tonsillitis, which can cause rheumatic heart disease. The initial skin lesions of LCK do not cause rheumatic heart disease.
3. Epidemiology
Common age: 5 - 15 years old. Rare in children under 5 years old and adults over 25 years old. Gender: men and women are equally affected.
Every year, about 20 million children in the world suffer from rheumatic heart disease, of which 0.5 million die from heart valve and rheumatic heart disease sequelae (Vietnam National Cardiology Association, 2000).
The incidence of the disease varies by country, in developing countries it is still high, about 1-12%. In Vietnam, the incidence of the disease is from 2 - 4.5%, the mortality rate is 6.7% (National Heart Association, 2000).
Favorable factors:
Poor living conditions: cramped, damp, crowded, unsanitary, poor nutrition.
Climate: cold, humid.
Winter and early spring: The frequency of the disease is higher than other seasons of the year. Allergic constitution.
4. Diagnosis
Diagnosis of rheumatic heart disease based on modified Jones criteria:
4.1. Main standards :
4.1.1. Polyarthritis:
Most common (62 - 85%) with characteristics:
- Swelling, heat, redness, pain, limited movement.
- Inflammation of 2 or more joints.
- Often found in joints: knees, elbows, wrists, ankles...
- Has the property of moving from one joint to another.
- Joint inflammation lasts from 2 to 7 days.
- When healed, there are no sequelae.
4.1.2. Carditis : Can be a solitary manifestation but accompanied by polyarthritis. This is the most common and dangerous manifestation. Early diagnosis and correct treatment can help patients recover and prevent recurrence. Misdiagnosis and late treatment can cause patients to die from acute heart failure or from heart valve sequelae.
If the inflammation is mild, the child will feel nervous, have a rapid heartbeat, rapid breathing, chest pain, and a heart exam will reveal muffled heart sounds, rapid heart rate, and murmurs. If the inflammation is severe, there will be symptoms of difficulty breathing, swelling of the face and legs, enlarged heart, rapid heart rate, murmurs, and an enlarged and painful liver.
4.1.3. Sydenham's chorea:
Due to damage to the central nervous system. Usually appears after group A LCK infection for more than 6 months. Often occurs in girls, pre-pubescent age.
Initially, the child's mental state changes slowly, becoming irritable, anxious, fearful, agitated, and having memory loss. Clumsy movements: difficulty writing, dropping bowls and chopsticks. Then chorea appears with the following characteristics: involuntary, aimless. Abnormal, sudden, decisive, excessive movements, uneven amplitude, and impaired coordination.
Location of chorea: at the base of limbs: head shaking, facial muscle twitching, continuous eye blinking, slurred speech, difficulty speaking. Outside of the attack: decreased muscle tone.
Chorea increases with exertion, emotion, and decreases with sleep. There are no pathological sensory or reflex disturbances.
4.1.4. Subcutaneous nodules (Meynet nodules):
Solid, small, painless, non-red, 10 - 20 mm in diameter.
Not stuck under the skin but stuck on the superficial bone base: knee, elbow, spine. The number of grains ranges from a few to a few dozen grains. Disappears after a few weeks without leaving any sequelae.
4.1.5. Erythema annulare (Besnier's rash): (rare)
The rash is pale pink in the middle, surrounded by dark red, circular or blister-like, of varying sizes. Appears on the trunk and limbs, never on the face. Not itchy, not painful. Disappears after a few days, leaving no sequelae.
4.2. Sub-criteria:
4.2.1. Clinical:
Fever: usually temperature >38 degrees Celsius.
Joint pain: can be pain in one or more joints, pain when examined and moved.
History of rheumatic heart disease or rheumatic heart disease: history of obvious arthritis or valvular heart disease.
4.2.2. Paraclinical:
- Acute inflammatory reactions:
Erythrocyte sedimentation rate: increased in the acute phase, decreased and returned to normal when recovered. First hour VS increased > 30 mm.
Blood formula: increased white blood cells.
C reactive protein (CRP): positive
Prolonged PR interval on electrocardiogram: normal PQ in children is between 0.11 - 0.18s.
4.3. Signs of group A LCK infection :
4.3.1. Antistreptolysine O (ASLO) : increased > 333 Todd units in children. ASLO starts to increase 10 days after group A LCK infection, lasts 3 - 5 weeks and then gradually decreases. Should be done twice.