Comprehensive Guide to Acute Diarrheal Disorders in Children

of the gastrointestinal tract. So gastro means the stomach and entritis means the intestine. So basically the stomach and

intestinal infections that is your itis. So how does this happen? either by viral infection,

bacterial infection, common cause uh presentation being either vomiting or loose stools. Now you

should understand that the term diarrhea disorder is generally talking about the infectious causes of diarrhea. In the

next classes we'll see about the non-infectious causes which is also called as chronic diarrhea. Okay. Now

what is diarrhea? and diarrhea just means that there is frequent passage of water stools more than the frequency of

the stool. It is the consistency that matters. So the recent change in consistency is more significant than the

frequency of the stool. So why why this topic has been of so much importance across the world because this is the

second most common cause of death in under five children. So in your under five causes of death this is the second

most common cause. Then it is more commonly seen because of the hygiene the footborn and you know waterborn causes.

It is mostly common in African and Asian countries. Now how did we tackle with this the discovery of OS. OS is also

called as discovery of the 21st century because it saved lacks and lacks of lives. After the introduction of OS

which was the most cheapest drug many lacks of lives were saved across the world and the preparation is also

very simple. We'll go in detail with the preparation also. So that is why oras has been a discovery of mankind for this

century. Then coming to the vaccination now the most common cause of gastroenteritis leading to diarrhea is

virus. In that 90% of the causes were rotiral. So in fact the discovery of ORS you know the composition of OS also was

changed based on the diarrhea caused by the rot virus. So based on that only they formulated the osmolarity of the

OS. So that's how we understood that roa virus is the single most common cause of diarrhea. So that is why roto virus

vaccination came into play and with vaccination definitely morbidity as well as mortality has reduced. Now why are we

so much concerned about diarrhea? Because not just an acute effect, it gives rise to a long-term advance

adverse outcome also. Now what is it? Every episode of diarrhea leads to some amount of weight loss in the child.

There's loss of appetite in the child leading to micronutrient deficiencies. Now micronutrient deficiencies we have

dealt in detail and we know that the immunity gets depressed. Once the immunity is depressed, repeated

infection happens. Repeated such cycles happen leading to loss of weight and in many other problems in the child

ultimately leading to malnourishment. So the child is thrown into this vicious cycle of malnourishment and

micronutrient deficiencies post even one episode of diarrhea. That is why this topic is of prime importance as a public

health problem. Coming to eeology now we know 70% of the causes are because of virus in that 90% is again because of

cora virus. Now we have a vaccine for it. The other causes are norovirus, entricadinoirus,

antioiruses, astroirus and calcifus. The second cause is bacteria. Now in bacteria you can remember it as

salmonella shigela eoli. So salmonella salmonella ty and nonifyer salmonella in chigela species chigela and its friend

that isia entropy in e.oli entropathogenic e.coli Eoline and Shikat toxin producing E.oli. Then we have

Vibrio and Vibrio's friend that is campobacttor Jen because both have the same comma shape uh shape in the

bacteria. Correct. Followed by protozone that is the third common cause. So protozoa causing diarrhea is very rare

and generally requires imunosuppression. So that means if a child comes with protoal diarrhea the child will have

problems in immunity. Either it is a child with HIV or it has some congenital immuno deficiency symptoms that is when

you get diarrhea due to protoal infection. The last less common cause is helman that is strong.

So this is your ideology table for diarrhea. Now coming to pathogenesis. So depending on what is the organism there

are three mechanisms you can have diarrhea. So that means either you have toxins. So it is preformed toxins or

secrettory toxins. Pre-formed toxins as in berious which is generally spread through fried rice. So the history of

eating fried rice outside is there or a staff orius where the toxin is already in the substance. The moment it is

ingested the toxin gets absorbed into the body leading to diarrhea. Okay. Next is secrettory toxins. Secrettory toxins

mean there is actively dividing bacteria which lead to release of the toxins in the git system leading to increased

secretion across the epithelium. So that is your secretary toxins. Next coming to the second mechanism the cytotoxic

toxin. Cytotoxic toxin means these are also actively dividing bacteria leading to release of substances which can kill

the intestinal epithelium. Hence the word cytotoxic. So it kills the intestinal epithelium thereby causing

elux of all the fluid and water and electrolytes leading to diarrhea as a complaint. Next is invasion. If you want

to invade the best example is salmonella typey. So what does salmonella typey do? First it will invade the intestinal cell

then go and be in the m tissue. So the mucosal associated lymphoid tissue it will go form flask shaped ulcers. If at

this time also the patient doesn't come to you or you don't read it then there will be a disseminated blood infection

leading to typhoid fever correct. So there will be bacteria then if it is not still treated then

this can lead to septicia. So this is the third mechanism by which acute diarrhea can happen. So this the

mechanism here is invasion of the mucosal tissue leading to diarrhea. So these are the three main mechanisms by

which diarrhea can happen. So either it is preformed or secretary toxins, cytotoxic toxins or invasion of the

cell. The same thing is again divided into non-inflammatory, inflammatory and penetrating. So invasive is all

penetrative. That means the organism penetrates the bubble goes into the bloodstream also. Okay. In the second

that is inflammatory this is cytotoxic group where the cell of the intestinal epithelm is also killed. So here it is

more of secrettory toxin or the preformed toxin which will lead to a watery diarrhea but less inflammation in

the gut. So that is why when you do a stool examination stool examination is generally not done for acute diarrhea. I

want you to remember that for the first 7 days generally we don't do a stool examination but if it persists that

means the diarrhea is not settling in 7 days then we think of stool examination where if there is fetal luccoytes that

means there is inflammation so that will go to the second and third category correct so if there are no luccoytes and

no increase in lactopherin then it is probably the first type which will generally settle within 7 days okay but

the other two varieties will increased gluccoytes in the stool routine. So the respective examples we have already

dealt with. So how do we classify diarrheal disorders? We classify them into acute, persistent and then there is

one category called chronic. Now chronic and persistent are both more than 14 days. Okay. So acute diarrhea is

generally infective settles in 7 days. Persistent diarrhea is it starts like acute. It looks like a infective

diarrhea. The infection is treated but the diarrhea still persists and goes beyond 14 days. So that is persistent

diarrhea. Now what is chronic diarrhea? Chronic diarrhea is not infective at all. It has many other causes which

leads to diarrhea which uh which remains for more than 14 days but it was never infective to start with. Whereas

persistent was infective to start with. Okay. Anyways we'll deal about this in the next class in detail. Okay. Coming

to clinical features of acute diary disorder. So what is the most common feature? Definitely there should be

loose roots. So in that you should remember recent change in consistency is more important than the frequency. Then

you have second complaint being vomiting. Then you can have depending on the organism you can have blood and

mucus. Sometimes when we label this as dentry also. Okay. Then you can have pain abdomen, you can have fever, when

you you can have tennis mas and you can have complications due to dehydration. Okay. Now coming to assessment of

dehydration. So whenever this kind of complaint comes what is that you have to see in the child. So the best way to

remember this is remember this pneumonic as set four. So S is for sensorium. You see the child. So you categorize the

dehydration into three things. No dehydration, some dehydration, severe dehydration. Remember these, it is not

mild, moderate, severe. It is no dehydration. It is some and it is severe. It is renamed already. No

dehydration generally we have 3% water loss from the body weight. So some dehydration up to 6% of water loss from

your body weight. Severe dehydration is more than 9% or you remember it as more than 10% of body weight loss. Okay. Now,

how do we remember the categories of dehydration? You remember the pneumonic set four. Now, what is S? S is for

sensorium. You see the child whether the child is active, alert or is it excessively crying and just irritable or

is he very lethargic and not responding much. So, if he's a well alert child, he'll be no dehydration. If he's a

restless and irritable child, he some dehydration. If he's a lethargic or unconscious child, he's a severe

dehydration. Next is E. E is for eyes. You see the eyes, whether it is a normal eye or is it a sunken eye or a very

sunken and dry eye. So now sunken is a little subjective finding. So you have to ask mother here. How does this eye

look to you? Does it look sunken to you? That is what you have to ask the mother. And if she says yes, then it fits into

your some dehydration and then your very sunken will fit into your severe dehydration. Next is P4. That means

there are four T's. First T is tears. You see the eyes of the child when the child is crying. If tears are present,

it is no dehydration. If it is absent, either it is some or it is severe. Next is tongue. So you see the mouth and

tongue. If it is moist, it is no dehydration. If it is dry, it is some dehydration. If it is a very dry, it is

a severe dehydration. Now, how do you check this? You can actually swipe the finger inside the mouth with a loud hand

and you can see whether it is actually dry. Okay. Or sometimes visual examination itself will be enough. Next

T is thirst. How does the child drink water? Does it drink normally? That is that is when you force and you make the

child drink then it is no dehydration. If the child is thirsty and he's asking for water and drinking eagerly then it

is some dehydration. If he doesn't drink at all and is almost like lethargic then it fits into severe dehydration. So the

last T is tur. So skin tar you see. So T4 tears thirst tongue and tur. So if in the tongue tur what do you do is you

pinch the abdominal skin for 2 seconds,0001,0002 and you leave it. And if it goes back

immediately then it is no dehydration. If it goes back slowly but less than 2 seconds then it is summed. If it goes

back very slowly but more than 2 seconds that is 1,000 1,0002 you leave and say 1,0001,0002,0003.

So it is crossing,0002 then it is severe dehydration. The place where you check you generally check it in the flank

area. Okay. So this is how you decide on the uh severity of the dehydration. So if there are no signs of dehydration. If

two or more signs in this set four then it is some dehydration. In severe category also two or more signs you take

it as severe dehydration. How do we treat this? We have plan A, plan B and plan C. We'll deal about in detail

second. So what are the um K weights that you should be worried

when you are assessing the dehydration. So in some children like I told the eyes might be a little deep set eyes where

you have to ask the mother and in the skin pinch test you can't do it on marasmic child

and obesity child because this can be misleading in obesity it may be normal in spite of having a dehydrated child in

quashier and marasmas in a no dehydration child also you might get prolonged skin. So this is a little

difficult to assess. So these are the uh false things false positives that you can get in your examination. Correct? So

these are your signs of dehydration. So you have a flat or a sunken AF in case of a child below one year. There are no

tears. There is dry and sticky mouth. You can have fast breathing also. Now why is this? If the dehydration is

severe, there is acidosis or the metabolic esttois that sets in leading to acidotic breathing. Okay? There can

be belly ache and generally no wet diaper or no urination for six and more hours. So you always remember urine

output is the best method to tell how the circulation of your body is. If there is urine output, it's a very good

sign saying that the circulation in the body is very good. Okay. So how do we describe like I told you 3%, 6% and 10%.

Same thing you can remember it as no dehydration, fluid losses less than 50 ml per kg. this 50 to 100 ml per kg and

severe dehydration it is more than 100 ml per kg. What are the investigations to do? Like I told diarrhea but no need

of investigation at least for first 5 to 7 days because most common cause is virus. There's no antiviral that we use.

There's no specific treatment that we use. So don't unnecessarily waste investigation or prick the child for

investigations. If required in cases as as in severe acute malnutrition a child looks malnourished or there is any

suspected immuno deficiency or say that the child is looking toxic that means very high grade of fever there is a

doubt that this can be a bacterial infection also that is when we tell CBC CRP okay and electrolytes uria creatins

specifically in severe dehydration to see how much our kidneys are getting perfused and if there is low urine

output it tells that the kidneys are getting compromised and for that purpose we send electrolytes as well as ura

stool routine and microscopy we wait unless the diarrhea is more than 7 days we wait for it it is not a great

investigation to do and waste money okay so in most cases there's no need of any diagnostic workup in severe conditions

in hospital settings it may be individualized especially in Children with chronic condition, severe sepsis,

prolonged symptoms during outbreaks. Yes. During outbreaks like a coler outbreak. Yes. Where we have to confirm

the diagnosis that there's a outbreak in one area where more than expected numbers of diaries have come and if

there is child with high fever and if there is history of travel to high risk areas depending on that local

epidemiology we might have to do a sto okay in severe dehydration is sent. So what is the management? So how do we

manage the child? There are four major components that we have that is de rehydration. Whatever the child has

lost, first you rehydrate the child and then give maintenance fluid to maintain the hydration. Ensure adequate feeding.

Zinc is the main cornerstone of treating diarrhea. Then early recognition of danger signs and treatment of

complications. Okay. So this is the cornerstone of treatment of diarrhea. Okay. So next

coming to OS. So how do we uh treat this low osmarity OS is what we use. So the satchets that you see in the market if

it has a WH label on it then it is a low osmarity OS. So this is the content of it. You need not remember this entirely

but you should remember that the total osmolarity is 245 and sodium content is equal to glucose content and it is 75 m

per liter. Now why this is important? You should understand that the OS works on the principle of glucose dependent

sodium pump. Now because of the viral infection like I told you in the beginning there can be cytotoxic effect

because of which the act the sodium and chloride from the gut mucosa can be actively secreted into the rumin that

means there is a mucosal tissue mucosal cell the mucosal cell is disrupted leading to easy secretion of sodium and

chloride into the gut increasing the diarrhea. Now whenever you give OS OS depends on glucose dependent sodium

pump. So whatever glucose is there the 75 m in the OS gets absorbed through this intact and functional pump.

Following glucose sodium also goes and following sodium water molecule also goes leading to rehydration.

Okay. Now how much goes? So for one molecule of glucose, one molecule of sodium and one molecule of water. So

this is called as 1 is to1 molar ratio. So so much OS will do a effect. So that means if there is um you know good

amount of rehydration that is happening, it is not because of sodium and chloride reabsorption. It is glucose dependent

sodium and water reabsorption that happens when OS is given. So there is a single universal OS means what? It is

the same OS across all the age groups. There is no different ORS for kids or adults or old age people. No, it is same

single OS satchet available across the age groups. And what you have to see this WH label in any OS satchet that you

see should be seen and you should counsel parents also that not to use the tetra packs but stick to satchets. So

there are two types of satchets that we get. One satchet for one liter water bottle. The other one for 200 ml of

water bottle or 200 ml of water. So how do we prepare this? We'll come to this. So low or osmarity. It reduces the stool

output. It decreases vomiting also and reduces the chance of IV rehydration. IV therapy always has its own risk with

infection hyponetriia. So that also can be avoided. Okay. Now what are home available foods that are okay to give

during diarrhea. So one is best iss in your home prepare it in and start using it or use salted drinks like salted rice

water, salted yogurt drink. You can even use vegetable and chicken soup with a pinch of salt in it. Those that do not

contain salt are also acceptable because that leads to some amount of hydration. Those are unsalted soup, unsalted

yogurt, coconut water. Okay, tea is not preferred. This is wrong. Tea is not preferred. Fresh fruit juice also are

not preferred. Fruit is preferred than giving fruit juice. What is not acceptable is carbonated drinks,

commercial fruit juices and something which has excess of glucose. Although the mechanism was glucose dependent

sodium pump, you should make sure that sodium is there in the drink. You can't give plain glucose and let the child

improve. So what does plain glucose do? Increased sweetening agent will cause hyperosmolarity

leading to hyperosmotic diarrhea increasing the chances of having watery stools further. So strictly no sweetened

juices. Okay. So how do we prepare OS if there is a patient who is living in a very remote area and not accessible to

sachets nearby. This is how ORS can be prepared even at home. So in a one liter of water which is five cup each cup

roughly around 200 ml boiled and cooled water you put six teaspoons of sugar leveled teaspoons

that means if there is a teaspoon you don't make a hill on it you make it leveled so leveled teaspoon so 1

teaspoon is generally 5 ml in quantity so 6 tepoon of sugar and half teaspoon of salt

and mix it and this becomes your homemade ORS. This also can be prepared otherwise in one liter of water bottle

you have to mix the entire ORS saget and this can be used for 24 hours in room temperature. Okay. Now coming to

individual plans that is plan A, plan B plans. Now what is plan A? Plan A means we are dealing with a child who has no

dehydration but he has ongoing stool losses. So what do you tell the mother? We can treat at home. You'll tell that

we'll give you OS. We will give you few things, few medicines. You continue to treat at home and come back to us if any

of these danger signs come up. That is diarrhea persist for more than 3 days. The you feel the loose tools are

worsening. The baby is not able to drink OS and starts vomiting it out or there is fever. the child is becoming more

lethargic and slipping into the other categories of dehydration some and severe dehydration or if there is blood

in stools counseling these danger signs you send the mother home with OS you send the mother home with zinc and

probiotics okay even if you don't give probiotics you can give just and zinc for plant

okay so how much to give the best way to remember is give 10 ml per kg G for each R2.

That means if the child is 100 uh sorry if the child is 10 kg give 100 ml of Q RS for every RTO. So depending on weight

band you can do it or you can stick to holiday cigar formula that we use for fluid calculation right. So holiday

cigar formula what does it tell for the first 10 kg the requirement of the fluid is 100 ml per kg which is nothing but 1

liter. After 10 kg between 10 to 20 kg requirement is 50 ml per kg that means it is 500 ml if it is a 20 kg child. So

10 1 1 liter plus 500 ml is 1.5 liter and if the child is above 20 kg then it is 20 ml per kg about 20 kg correct so

that means if it is a child with 22 kg first 10 kg you will give 1 liter next 10 kg you will give 500 ml so 500 ml for

the next 2 kgs you'll give 20 into 2 that is 40 so the total requirement will be 1540

correct you stick to this and then tell the parent how much OS to provide at home or simple way to remember is 10 ml

per kg okay so this is your planning so how do you tell mother you she can give sips in a cup if it is a older child or

give in teaspoon every 1 to 2 minutes if it's a child below 2 years if the child vomits by chance wait for 10 minutes and

give the os more slowly this is the same preparation that I told okay that is about the planning next coming to plan.

Now what is plan B? That means there is some dehydration that is around 6% of weight loss has already happened. So

this is generally a daycare treatment but it needs to be treated in a hospital setting or a healthcare setting. Now

what is this? What you do here is you replace the 6%. Plus you make sure the hydration is maintained. That means your

maintenance will continue. Okay. So what do what do we do for the replacement? we have something called as

so this is the same holiday cigar formula that I told you so for the replacement what do you do you give 75

ml of k per kg of os over 4 hours so that means say there is a 10 kg child you'll give 750 ml over 4 hours that

roughly comes to 200 ml every hour and at the end of 4 hours you again assess based on our set four criteria correct

Now if the child still falls into moderate dehydration, you repeat plan B. If the child falls into mild

dehydration, you send the child for mildness or no dehydration, some dehydration. So if the child falls

into severe dehydration category, you refer the child or you admit the child. Correct? So after 4 hours, you have to

assess using the same set four criteria that we discussed. So this is a very effective therapy plan B. We have

avoided lot of admissions and unnecessary hospital stay because of this. So plan B works wonders. Okay, you

should just know that you should monitor the child for 4 hours in a health center or a healthcare facility. So when does

this plan B generally is ineffective? If the child is not able to take there is vomiting or if it is a high stool purge

rate or if there is paralytic and if your OS preparation is not appropriate instead of adding for one liter if you

add it for 2 liter water bottle it won't be an adequate preparation. So the preparation of OS is although very

simple needs to be told clearly to the patient and even to our students. So one liter packet in one liter of water

bottle no sharing I'm making half also. So 500 ml bottle that is also not accepted. So complete one liter and one

sit should be followed. So at the end of 4 hours if the child has been shifted to no dehydration category then you send

the child home saying that give 10 ml per kg of replacement um os with every loose tools continue breastfeeding

continue semi-olid food offer plain water also and come for review regularly okay along with zinc and probiotics

again next coming to treatment of severe dehydration or plan C. Now you should understand that plan C may the severe

dehydration you have lost around 10% of body weight. So it is like the child has come to you in shock. So what is the

treatment for this? You have to replace 100 ml. So 10 into 10 100 ml per kg of fluids over 6 hours if it is below one

year child and over 3 hours if it's above one year. So smaller the child more chances of having electrolyte

imbalance with rapid infusion of fluids. So we go slow. So that's how you can remember that below one year is longer

duration that is 6 hours. Above one year it is shorter duration that is 3 hours. And every 15 to 30 minutes you check for

pulses and high duration. So this is it. Below 12 months or 1 year you give 30 ml per kg over 1 hour. Remaining 70 ml per

kg over 5 hours. Sorry this is yeah correct. Over 5 hours. And above 1 year it is half an hour and 2 and 1/2

hours. So this is your plan C. This is 6 hours. This is 3 hours. Okay. So this is how you treat your plan C. So

this is the summary of it. Okay. So the same thing what I've described in detail only is mentioned. So after 4 hours you

decide if it is plan B or plan A. Here also after giving that whether it is 6 hours or 3 hours you see if it is still

in plan C then repeat plan C again. or if it is rehydrated then shift it to plan B or A depending again on your set

for criteria for dehydration. So irrespective of whatever you remember or know you should remember this set for

criteria. Okay. So what are the additional therapies? Zinc. Now zinc the dose is 20 mg per day. It is not kg. It

is age based. It is not weight based uh dose. So 20 mg per day for straight 2 weeks. 10 mg per day if it is below 6

months for 2 weeks. Now what is the benefit of zinc? It reduces the fluid content.

It helps in better water retention. It helps in healing of the gut mucosa and it protects the child for next 3 months.

This is the most important thing. Okay. And then probiotics also can be given. These are the names that you should

remember. Lactobacillus ramnosis, satroyis, bolardi, bifidtoacterium and router. So these are the four

recommended bacterias or probiotics that can be used. So pro O is for organism. Prebiotics

pre is for things that help the organisms to thrive.

Okay, these are the these are the additional therapies. Am I audible?

No, no, no. I think I I was thinking that I'm not audible because the screen started hanging here. Okay, I'm audible,

right? Then I'll continue. Yeah. So the other additional therapies are lopramide which is contraindicated.

Onensetron or antiatic agents can be given. Enkeilan inhibitors like daughter also can be given although there is

limited experience in pediatrics okay so coming to antibiotic use so do we need to give antibiotics now because I told

90% of the causes viral so strictly no antibiotics so these are the only conditions where we give antibiotic if

we are dealing with a child below 3 months because we don't know it may be a septic child if we are dealing with a

child with chronic conditions or immuno deficiency or if we are dealing with a child with severe acute malnutrition or

if we have strong suspicion for chigela or ecoli infection or vibriolia and gcinalitica infections. Okay. So these

are the only conditions where we use antibiotics and generally we use antibiotic that is septrixone or we can

even use oral eithroyc and doxycyc when it comes to a vibrio outbreak. Okay. So coming to the prevention. So we

finished the plan ABC. We talked about the additional therapies and we also talked about the antibiotics.

Correct. So next coming to prevention. So the best way to prevent is exclusive breastfeeding. So exclusive

breastfeeding itself is protective to avoid diarrheal disorders in um kids. Okay. And improved

complimentary feeding. Now improved complimentary feeding practices means maintaining hand hygiene and giving good

protein richch diet and including fruits in the diet so that good amount of antioxidants are also given to the

child. Rotirus immunization has become a norm. Now we give 6 10 and 14 weeks three doses of roirus vaccination

improved water sanitation personal and domestic hygiene. So this was the overall approach how we went through

plan ABC. So this is just a short topic that is diarrhea in SAM. Now diarrhea in SAM you

can't use the set four criteria. No using set four criteria. You have to assess the child clinically. So how do

you assess if the child has cold hands, slow capillary fill and weak and fast pulse. This is child in shock. If these

three things are not there then it is a SAM without shock. Sam with the diarrhea without shock. Okay. So there is nothing

like mild, moderate and severe dehydration in SAM. This is one thing you should remember. There is no

categories of de dehydration in severe acute malnutrition child. Okay. The only thing you can see is eagerness to drink,

sunken eyes and reach change in child's appearance. Okay. So how do we treat it? we use something called as rummol.

So, so rummol is rehydrated solution for malnourished which dilutes one satchet in 2 liter of water. Okay, this is a

separate rumal satchet which is high in potassium and low in sodium. So the if we don't have rumol satchet using our cm

we can make it into reamol by mixing it in 2 liter of water and adding 45 ml of potassium chloride and adding 50 g of

glucose. By doing this a normal who also can be converted tool. Okay. And preferably in SAM we stick to

oral rehydration. We avoid IV only if there is shock making IV. If Subsha, I think we can end the class.

There was a glitch on the other uh PC. Yeah, I think there's one doubt that has popped up.

Uh what about the diarrhea like during antibiotic usage? June should yes see that's what we are telling no that don't

use antibiotics only for uh diarrheal cases at least for the first five to seven days strictly no antibiotics

unless it is a proven thing that it is because of either your chigel basilli or it is because of typhoid that is when we

use um okay no uh augmenting for respiratory cases. Yes, you can use zinc there. Giving zinc doesn't harm the

child. Yeah, it can be seen as a side effect. But here you should remember that you should counsel the parent and

send that we are using antibiotic for respiratory illness. Uh side effect of loose tools can be seen in the child.

Nothing to worry for it. You should just hydrate the child using OS and uh generally these kind of cases don't

require zinc because it is not the gut it is antibiotic induced um diarrhea. But if it remains it becomes a concern

say it remains for more than 3 days. Yes. Giving zinc is safe. You can give zinc. You can even give probiotics.

Yes. I hope the doubt is cleared. Yes. Okay. So any doubts you can drop me

in the mail or in my Insta channel so that we can get back to these doubts in the next class. Okay. Next class is more

interesting. There is lot to talk about the persistent and chronic diarrhea which is which is you know nothing

related to the infection. Those are the non-infectious causes. Okay. Fine.

Okay. See you in the next class then. Bye.