Management of acute diarrhea in children

The Indian Academy of Pediatrics Committee for Framing Guidelines on the Management of Diarrhea in children convened a meeting in August 2003 to revise the guidelines for management of diarrhea in children. The Consensus Statement has been published in the April 2004 issue of Indian Pediatrics. The salient features of the guidelines with some additional inputs have been presented in the article.
Despite wide spread use of oral rehydration therapy, diarrheal diseases continue to pose a formidable challenge in pediatric practice. Diarrheal diseases still constitute a major component of practitioners day to day work. In the absence of practical guidelines, an average practitioner finds himself/herself greatly constrained in planning a rational management as he/she is unable to get many investigations which most texts continue to advocate.

What is diarrhea? Diarrhea is the passage of three or more liquid or watery stools in a day. However, it is the recent change in the consistency and character of the stools rather than the number of stools that is more important.

Drugs, Diet and Fluids in Diarrhea. The issue of indiscriminate use of antibiotics, as well as the increasing incidence of antibiotic resistance is causing great concern.
1. Antibiotics are indicated only for acute bloody diarrhea.
2. Antibiotics are not indicated for children with acute diarrhea and no visible blood in stools, with pus cells on  stool microscopy because of poor specificity of the test.                 
The national diarrheal disease control program currently recommends the use of cotrimoxazole as the first line drug for the management of acute bloody diarrhea. In areas where resistance rates to cotrimoxazole exceed 30% nalidixic acid should be used as the first line drug for the treatment of acute bloody diarrhea. In case of poor response, norfloxacin, ciprofloxacin or a third generation cephalosporin must be used as second and third line drugs. For high-risk cases which include infants who have not been breastfed and severaly malnourished children, nalidixic acid or norfloxacin should be the first line durg. Entamoeba histolytica and helminths rarely ever cause acute diarrhea in children. Metronidazole and antihelminthics therefore have no role in the routine management of acute bloody diarrhoea. Metronidazole should be used when cases of acute dysentry fail to respond to second line drugs for dysentry such as norfloxacin or when a stool examination has confirmed trophozoites of Entamoeba hystolitica.
Aminoglycosides like gentamicin and amikacin have a poor spectrum of activity against shigella species and therefore they are ineffective in the management of acute bloody diarrhea.

Antiemetics in Acute Diarrhea. Vomiting is the commonest symptom associated with acute diarrhea in children and is particularly distressing to the parents and therefore antiemetics are frequently prescribed. Low osmolarity ORS taken as frequent small sips is expected to reduce the incidence of vomiting in children with acute gastroenteritis. Antiemetics should be reserved for children in whom the vomiting is severe, recurrent and interferes with ORS intake.
Domperidone is the safest with no central nervous system side effects. Continued use is not recommended. Domperidone should be used at a dose of 0.1-0.3 mg/Kg/dose.
Zinc supplementation in Acute Diarrhea. The therapeutic benefits in acute diarrhea may be attributed to effects of zinc on various components of the immune system and its direct gastrointestinal effects. Zinc deficiency is associated with lymphoid atrophy, decreased cutaneous delayed hypersensitivity responses, lower thymic hormone activity, a decreased number of antibody forming cells and impaired T killer cell activity. Zinc deficiency has also been recently shown to affect the differentiation of CD4 response towards Th1 rather than Th2 pathway. The direct intestinal effects of zinc deficiency include decreased brush border activity, enhanced secretory response to cholera toxin and altered intestinal permeability which is reversed by supplementation. Treatment of acute diarrhea with zinc may have benefits on morbidity and mortality from other childhood infections. A uniform dose of 20 mg of elemental zinc should be given during the period of diarrhea and for 7 days after cessation of diarrhea to children older than 3 months.

Probiotics in the treatment of Diarrhea. Probiotics in the form of fermented milk products (yoghourt and curd) have been consumed for centuries. In 1965, Lilly and Stillwell introduced the term probiotic, derived from Greek “for life”. It was used to explicate growth promoting factors produced by microorganisms. Probiotics are non-pathogenic microorganisms that, when ingested exert a positive influence on the health or physiology of the host.. These consist of either yeast or bacteria, predominantly Bifidobacterium and Lactobacillus. There is some preliminary evidence that ingestion of probiotic offers therapeutic benefit in the treatment of acute gastroenteritis in children. There are several possible mechanisms by which probiotics may exert their clinical effects. They can protect the intestine by competing with pathogens for attachment, strengthening tight junctions between enterocytes and enhancing the mucosal immune response to pathogens. The IAP National Task Force 2003 recommended that there is presently insufficient evidence to recommend probiotics in the treatment of acute diarrhea.
The Committee observed: “Both Lactobacillus GG and Lactobacillus reuteri significantly reduced the duration of diarrhea as compared to the placebo. There was only one study with Lactabacillus acidophilus which reported a trend in the reduction of diarrheal duration but, this was not statistically significant.” This study was from Pakistan which had entrolled only 36 subjects. Other strains of probiotics which had not shown any positive effect on duration of diarrhea were Saccharomyces boulardii,
Streptococcus thermophillus lactis, Lactobacillus bulgaricus. The Committee also observed: “The effect of probiotics is strain related and there is paucity of data to establish the efficacy of the probiotic species (namely L. acidophilus, Lactic Acid Bacteria) available in the Indian Market. To recommend a particular species it will have to be first evaluated in randomized controlled trials in Indian children.” Lactobacillus acidophilus has been available in India as “sporlac” for more than three decades, its clinical evaluation has not been done in India. The doctors in India have the following options:
1.Wait for Lactobacillus GG or Lactobacillus reuteri to be made available in India.
2.Wait for evaluation of the probiotic strains available in India, and
3.Continue to use the probiotics available till evaluations are done, to stop their use if found ineffective (useless) or harmful.
Regarding probiotics or minerals provided along with ORS by some manufacturers the Committee observed: “The group did not currently recommend marketing of ORS with additives (probiotics, minerals). They should only be permitted after demonstrating benefit in studies carried out in Indian patients as breast feeding rates, dietary habits and intestinal flora varies from European and North American children.” The manufacturers should provide the evidence of the beneficial effects.

Diet in Diarrhea. No child with acute diarrhoea should be starved. Feeding should begin as soon as dehydration has been corrected. Breast feeding can and should be continued in all infants with diarrhea. Easily digestible soft food should be given ad libitum to the child as soon as, and as much as, he/she would like to have. Small frequent feeds would be preferable. The normal dietary intake should be restored as soon as possible. There is no need to start either milk substitutes or lactose free foods during an episode of acute diarrhea. Some parents withhold food as they observe that the child passes motion after taking feed. The parents should be impressed upon that sick child may pass stools soon after taking food because of gastro-colic reflex, so they must continue to offer food without any apprehension. A lesser-known fact about banana is that it is rich in pectin and free from gluten.
Oral and Intravenous Fluid Therapy in Acute Diarrhea. Oral rehydration therapy (ORT) is now recognised as a powerful intervention in the treatment of dehydration due to acute diarrhoea.
The new improved universal ORS recommended by the WHO containing sodium 75 mmol/L and glucose 75 mmol/L. Osmolarity 245 mosmol/L is acceptable for all ages. The IAP National Task Force 2003 proposed that a pediatric ORS containing sodium 60 mmol/L. glucose 84 mmol/L, osmolarity 224 mosmol/L is the most suitable for children. WHO type of ORS is to be used in calculated amounts (50 ml/Kg and 100 ml/kg in 4 hours for mild and moderate dehydration respectively, or 75 ml/kg for “some dehydration”) till dehydration is corrected. If the child is still dehydrated after 4 hours, then the same amounts of ORS may be repeated. The phase of rehydration would usually last 6-8 hours. If the child is still dehydrated after 8 hours, then it would be preferable to use intravenous therapy for some time. WHO protocols recommend intravenous fluids only for severe dehydration and that too only till the peripheral circulatory failure is corrected. Thus, it recommends only 30-50 ml/kg of Ringer’s Lactate in about 2 hours time and then to continue rehydration with ORS. Because of the taste some children do not take ORS, such children may be offered home made sugar-salt water or some other home made fluids like butter milk or lime water with sugar and salt. Aerated drinks should not be given to replace fluid loss.
Starch or Glycine based ORS have been found to be useful in some studies and are referred to as super ORS. However, the reductions in diarrheal stools obtained with the use of these so-called super ORS, has not been very significant.
Conclusions. It is apparent that a careful appraisal of clinical features like age of the child, consistancy and contents of the stools, presence or absence of vomiting; coupled with detailed physical examination can help in formulating appropriate management including rational drug therapy in majority of children with acute diarrhea.
-Dr. Yash Paul, Consultant Pediatrician, A-D-7, Devi Marg, Bani Park, Jaipur-302016 E-mail : dryashpaul2003@yahoo.com
- Dr. Priya, Associate Professor, Department of Pediatrics, M.G.N.I.M.S., Sitapura, Jaipur.

The treatment of acute diarrhea in the third millennium: a pediatrician’s perspective.
Diarrheal diseases continue to be a major cause of morbidity and mortality worldwide. Although new, potentially useful drugs such as acetorphan are appearing at the horizon, the cornerstone of treatment remains a proper oral rehydration (ORT). Yet, the rates at which ORT is used are still disappointingly low. Despite dramatic progresses in the understanding of the pathophysiology of diarrhea, the list of available drugs is indeed short. Recently however, several new options have appeared that may bear a great potential in the near future. The first is a potential improvement of ORS. It was recently shown that the addition of a resistant starch to oral rehydration solution reduces fecal fluid loss and shortens the duration of diarrhea in patients with cholera. Starches that are resistant to hydrolysis by amylase in fact generate in the colon short-chain fatty acids, which are known to enhance sodium absorption. The second development in treating diarrheal disease is acetorphan (racecadotril). This enkephalinase inhibitor has in fact been shown to be effective in reducing by almost half the stool output of 135 young children with acute diarrhea. Finally, probiotics. In the last few years, they have attracted a great deal of renewed interest, particularly focusing on their effects in treating and preventing diarrheal diseases. Lactobacillus GG proved effective in several clinical trials, mostly randomized and placebo-controlled, in the prevention and/or treatment of acute diarrheal disease in children. We have recently shown the safety and efficacy in its administration in the ORS, especially in Rotavirus-induced diarrheas, in a large multicenter, randomized, double blind and placebo-controlled study conducted on behalf of the ESPGHAN Working Group on Acute Diarrhea.
(Guandalini S. In Acta Gastroenterol Belg. 2002 Jan-Mar;65(1):33-6.)

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