DIARRHEA IN CHILDREN: MAIN CAUSES AND WAYS OF TREATMENT

ABSTRACT

The article discusses main questions of diagnostics of diarrhea in children. Main cause of acute diarrhea is infection, mainly viral (rotavirus, etc.). Chronic diarrhea frequently has non-infectious origin. The need of multi-aspect diagnostics of diarrhea cause in children is related to the significance of treatment of main disease. Besides, treatment of chronic and acute diarrhea include major component: adsorbents based on smectite. In total treatment of diarrhea has to be complex with the use of dietotherapy and medications: mucocytoprotectors, regulators of motoric, pre- and probiotics.

Keywords: children, diarrhea, infection, traveler's diarrhea, irritable bowel syndrome, nervous regulation, intestinal microbiocenosis, treatment.

Diarrhea is a symptom often encountered in pediatric practice. Normally, in a child over the age of 1 year, the frequency of stools is 1-2 times a day; feces are formed, brown, moderately hard, without impurities of blood, greenery, mucus or other pathological signs. With diarrhea, the frequency of the stool increases, it becomes unformed and even liquid, and impurities may appear in its composition. Thus, diarrhea is not only an increase in the frequency of stools, but a complex change in its nature. In international practice, in the last 10–15 years, the Bristol stool scale has become widely used to identify constipation and diarrhea. This scale implies 7 options for the shape of feces - from solid lumps to a liquid consistency. Types (gradations) 1-2 correspond to constipation, 3-4 to normal stools, and 5-7 to diarrhea. Characteristics of type 5 stool - in the form of soft small balls with smooth edges; type 6 - loose particles with uneven edges, mushy stools; type 7 - watery, without solid particles [1]. Diarrhea is a serious problem for people of all ages, but especially for children, primarily due to the threat of severe hypohydration of the body and metabolic disorders, sometimes life-threatening for the patient. In any person, episodes of diarrhea of ​​varying duration and severity develop repeatedly. Thus, a child under the age of 5 years has an average of 2-3 cases of diarrhea per year. The number of episodes of diarrhea is incalculable, but every year in the world, according to international organizations associated with the health system, about 5 million children die from diarrhea. Most of these cases are primarily associated with infectious diseases, in connection with which WHO pays the closest attention to this problem. According to the nature of the course, diarrhea is divided into acute and chronic. Their reasons are different. Although the infectious factor may be important for the development of any diarrhea, it is more characteristic of acute diarrhea. In chronic diarrhea, congenital or acquired pathologies of the digestive organs are more often detected, including congenital intolerance to certain food components.

The main cause of diarrhea is infection. Viral infections are currently the most relevant, primarily rotavirus, perhaps as the most studied. Among bacterial infections in the world there are cases of cholera, but much more often - dysentery and salmonellosis. However, diarrhea can be a symptom not only of intestinal infections, in which the microorganism affects the gastrointestinal tract, but also of other infections, such as respiratory infections. In this case, diarrhea becomes a manifestation of the general reaction of the body to the virus and its toxins.

The so-called traveler's diarrhea is one of the most common acute diseases. Traveler's diarrhea affects hundreds of thousands of people moving from one region to another, primarily tourists. According to statistics, almost 20% of those with diarrhea spend at least 1 day in bed, skipping excursions, rest or other activities; about 40% are forced to make adjustments to their plans, and 1% ends up in the hospital. At the same time, travelers' diarrhea is characterized by a favorable course, and most patients recover within a few days. Most often, it develops in people moving from Europe, North America or Japan to Asia and Africa. Traveler's diarrhea is most often associated with the activity of one of the varieties of E. coli, but may be due to some other microorganisms or viruses. In addition to diarrhea itself, with this disease, fever, abdominal pain, nausea, vomiting are possible. Diarrhea of ​​a non-infectious nature is observed with food allergies, intolerance to milk sugar lactose, as well as cereal protein gluten (celiac disease), etc. It may be associated with taking medications, such as laxatives, as well as antibiotics, but this should not be a reason to refuse them applications. We emphasize that antibiotics for bacterial infections have saved millions of lives of children and adults in their relatively short history; it is important to strictly follow the appointments - taking in certain doses and with the proper duration of the course. One of the causes of non-infectious diarrhea is irritable bowel syndrome (IBS). This is a functional intestinal disorder, manifested by abdominal pain syndrome, defecation disorders, flatulence. IBS is one of the most common diseases in the practice of a gastroenterologist (40–70% of patients). The pain syndrome is characterized by a variety of manifestations in combination with constipation, diarrhea, which determines the classification of this disease. Rome criteria II (1999) provided for 3 variants of the disease: with diarrhea, constipation and flatulence; Rome criteria III (2006) subdivide IBS into 4 subtypes: with diarrhea, constipation, mixed and undifferentiated. The subtype of IBS is determined by the nature of the stool in accordance with the Bristol scale of stool forms, as well as the time spent per day for the act of defecation in any type of stool. The latter is important to distinguish between mixed and undifferentiated subtypes of IBS, although from the clinician's point of view, there is no fundamental difference between them. A large number of works have been devoted to the pathogenesis of IBS. For a long time, the entire clinical picture of IBS was explained by impaired motility of the colon. The cause of dyskinesia was considered to be dysbiotic disorders detected in patients. Bacteria present in the large intestine convert carbohydrates undigested in the small intestine into short-chain fatty acids, which are then excreted into the intestinal lumen. These substances are partially absorbed by the intestinal mucosa, and also serve as a substrate for the intestinal microflora, increasing its biomass. In addition, short chain fatty acids lower pH and increase osmotic pressure. Although the pathogenesis of IBS is not fully understood, it is obvious that hypersensitivity of the receptor apparatus of the large intestine, as well as disorders of the nervous regulation of its motility, which are closely associated with disorders of the autonomic nervous system and the mental sphere, are important for the development of the disease. The nature of the course of the disease is affected by disturbances in the intestinal microbiocenosis, leading to a change in the metabolic functions of the microbial community, in particular, to a change in the production of short-chain fatty acids necessary for the normal functioning of the intestine. Numerous studies demonstrate a significant role in the development of IBS from past intestinal infection. Thus, among patients with IBS, markers of intestinal infections in coprofiltrates and blood serum are found in 62% of cases [5–7]. Treatment options for diarrhea depend on its cause. Actually diarrhea is a symptom of some other disease, and it is necessary to treat it. However, in almost all cases, regardless of the cause, it is necessary to replenish the loss of water and salts with the help of special or home-made solutions, as well as prescribe adsorbents, drugs that bind microbes and their toxins in the intestines, preventing them from showing their activity and being absorbed into the intestine. blood. Pro- and prebiotic preparations, preparations of pancreatic enzymes are also used. Currently, in the treatment of acute infectious diarrhea, antibiotics are used much less often than before, but, nevertheless, in some cases they are necessary. Smectite-based adsorbents today occupy a strong place in the treatment of acute and chronic diarrhea. Unlike many other adsorbing agents, dioctahedral smectite in the composition of Smecta (Bofur Ipsen) not only effectively binds microbial toxins in the intestine and blocks their damaging effects, but also forms a protective layer on the surface of the intestinal mucosa, which protects it from damage and promotes the processes recovery, i.e., it has a cytomucoprotective effect.

Smecta is available in powder form and packaged in sachets. Depending on the age of the patient, one or another amount of the drug is dissolved in water and drunk. The dose and frequency of administration are determined by the age of the patient and the severity of the disease. At the same time, there are no age restrictions on the dose: usually it is 1-2 sachets per reception for children aged 1-2 years and 2-3 sachets for children over 2 years old. Smecta tastes good, and most children do not cause displeasure. The duration of therapy is determined by the underlying disease and can range from a single dose to 7-10 days or more. In acute intestinal infections, the average duration of the drug is 5 days and is determined by the clinical picture; in severe intestinal lesions, it exceeds 10 days. In patients with malabsorption syndrome, dioctahedral smectite can be prescribed as an adjuvant against the background of severe diarrheal syndrome - in this case, the duration of the drug intake varies between 3-7 days.

In general, the treatment of diarrhea always requires an integrated approach using diet therapy and drugs of various groups, including both mucocytoprotectors and motility regulators, pre- and probiotics, etc. The prevention of acute diarrhea is based on personal hygiene and rational nutrition. Non-infectious diarrhea often has a chronic course and hereditary nature - in these cases, early diagnosis and adequate therapy are of great importance.

References:

1. O'Donnell L. J., Virjee J., Heaton K. W. Detection of pseudodiarrhoea by simple clinical assessment of intestinal transit rate // Br. Med. J. — 1990; 300: 439–440.
2. Oksanen P. J., Salminen S., Saxelin M. et al. Prevention of travellers’ diarrhoea by Lactobacillus GG // Ann. Med. — 1990; 22: 53–56.
3. McFarland L. V. Meta-analysis of probiotics for the prevention of traveler’s diarrhea // Travel Med. Infect. Dis. — 2007; 5: 97–105.
4. Longstreth G. F., Thompson W. G., Chey W. D. et al. Functional bowel disorders // Gastroenterology. — 2006; 130: 1480–1491.
5. Aube A. C. Short-chain fatty acids. Their role in intestinal pathophysiology and therapeutic potential in gastroenterology // Gastroenterol. Int. — 1995; 8: 167–176.
6. Uchaikin VF, Balikin VF, Shamsheva OV Infectious diseases in children. Textbook. M. GEOTAR-Media 2021.
7. Children's diseases: textbook / ed. A. A. Baranova. - Moscow: GEOTAR-Media, 2007.