Good morning

Diarrhea is best defined as excessive loss of

fluid and electrolyte in the stool. Acute
diarrhea is defined as sudden onset of
excessively loose stools of >10 mL/kg/day in
infants and >200 g/24 hr in older children,
which lasts <14 days. When the episode lasts
>14 days, it is called chronic or persistent
diarrhea.
The most common manifestation of GI tract
infection in children is diarrhea, abdominal
cramps, and vomiting. Systemic manifestations
are varied and associated with a variety of
causes. The evaluation of a child with acute
diarrhea includes:
*Assess the degree of dehydration and acidosis
and provide rapid resuscitation and rehydration
with oral or intravenous fluids as required
*Obtain appropriate contact, travel, or exposure
history. This includes information on exposure
to contacts with similar symptoms, intake of
contaminated foods or water, child-care center
attendance, recent travel of patient or contact
with a person who traveled to a diarrhea-
endemic area, and use of antimicrobial agents.
*Clinically determine the etiology of diarrhea
for institution of prompt antibiotic therapy, if
indicated.
Treatment
The broad principles of management of
acute gastroenteritis in children include
oral rehydration therapy, enteral feeding
and diet selection, zinc supplementation,
and additional therapies such as
probiotics.
SUMMARY OF TREATMENT BASED ON DEGREE OF DEHYDRATION
DEGREE OF
REHYDRATION THERAPY
DEHYDRATION
Minimal or no
Not applicable
dehydration
Mild to moderate ORS, 50-100 mL/kg body
dehydration weight over 3-4 hr
Lactated Ringer solution or
normal saline in 20 mL/kg body
weight IV until perfusion and
Severe mental status improve; then
dehydration administer 100 mL/kg body
weight ORS over 4 hr or 5%
dextrose 1/2 normal saline IV
at twice maintenance fluid rates
REPLACEMENT OF LOSSES NUTRITION
Continue breast-
<10 kg body weight: 60- feeding, or resume
120 mL ORS for each diarrheal age-appropriate
stool or vomiting episode normal diet after
>10 kg body weight: 120- initial hydration,
240 mL ORS for each diarrheal including adequate
stool or vomiting episode caloric intake for
maintenance*
Same Same
Same; if unable to drink,
administer through nasogastric
tube or administer 5% dextrose
Same
in 1/4 normal saline with
20 mEq/L potassium chloride
IV
*Oral Rehydration Therapy
Children, especially infants, are more susceptible than
adults to dehydration because of the greater basal fluid
and electrolyte requirements per kg and because they are
dependent on others to meet these demands. Dehydration
must be evaluated rapidly and corrected in 4-6 hr according
to the degree of dehydration and estimated daily
requirements. A small minority of children, especially
those in shock or unable to tolerate oral fluids, require
initial intravenous rehydration, but oral rehydration is the
preferred mode of rehydration and replacement of
ongoing losses .
Risks associated with severe dehydration that might
necessitate intravenous resuscitation include:
age <6 mo, prematurity, chronic illness, fever >38C
if <3 mo or >39C if 3-36 mo, bloody diarrhea,
persistent emesis, poor urine output, sunken eyes,
and a depressed level of consciousness.
The low-osmolality WHO oral rehydration solution (ORS)
containing 75 mEq of sodium and 75 mmol of glucose per
liter ,K 20mmol/L, Cl 65mmol/L, Carbohydrate 13.5g/l , with
total osmolarity of 245 mOsm per liter, is more effective than
other formulations in reducing stool output without the risk of
hyponatremia, and it is now the global standard of care.
Cereal-based oral rehydration fluids can also be
advantageous in malnourished children and can be prepared
at home. Home remedies including decarbonated soda
beverages, fruit juices, and tea are not suitable for
rehydration or maintenance therapy because they have
inappropriately high osmolalities and low sodium
concentrations.
Oral rehydration should be given to infants and children
slowly, especially if they have emesis. It can be given
initially by a dropper, teaspoon, or syringe, beginning with as
little as 5 mL at a time. The volume is increased as tolerated.
Oral rehydration can also be given by a nasogastric tube if
needed; this is not the usual route.
Limitations to oral rehydration therapy
include shock, an ileus, intussusception,
carbohydrate intolerance (rare), severe emesis,
and high stool output (>10 mL/kg/hr).
(oral mucosal absorption
preparation) reduces the incidence of emesis,
thus permitting more effective oral
rehydration.
*Enteral Feeding and Diet Selection
Continued enteral feeding in diarrhea aids in recovery from
the episode, and a continued age-appropriate diet after
rehydration is the norm. Although intestinal brush border
surface and luminal enzymes can be affected in children with
prolonged diarrhea, there is evidence that satisfactory
carbohydrate, protein, and fat absorption can take place on a
variety of diets.
Once rehydration is complete, food should be reintroduced
while oral rehydration can be continued to replace ongoing
losses from emesis or stools and for maintenance.
Breast-feeding or nondiluted regular formula should be
resumed as soon as possible. Foods with complex
carbohydrates (rice, wheat, potatoes, bread, and cereals),
lean meats, yogurt, fruits, and vegetables are also tolerated.
Fatty foods or foods high in simple sugars (juices,
carbonated sodas) should be avoided. The usual energy
density of any diet used for the therapy of diarrhea should
be around 1 kcal/g, aiming to provide an energy intake of a
minimum of 100 kcal/kg/day and a protein intake of 2-3
g/kg/day. In selected circumstances when adequate intake of
energy-dense food is problematic, the addition of amylase
to the diet through germination techniques can also be
helpful.
With the exception of acute lactose intolerance in a small
subgroup, most children with diarrhea are able to tolerate
milk and lactose-containing diets. Withdrawal of milk and
replacement with specialized (and expensive) lactose-free
formulations are unnecessary. Although children with
persistent diarrhea are not lactose intolerant, administration
of a lactose load exceeding 5 g/kg/day may be associated
with higher purging rates and treatment failure. Alternative
strategies for reducing the lactose load while feeding
malnourished children who have prolonged diarrhea include
addition of milk to cereals and replacement of milk with
fermented milk products such as yogurt.
Rarely, when dietary intolerance precludes the
administration of cow's milk–based formulations or
milk it may be necessary to administer specialized
milk-free diets such as a comminuted or blenderized
chicken-based diet or an elemental formulation.
Although effective in some settings, the latter are
unaffordable in most developing countries. In addition
to rice-lentil formulations, the addition of green
banana or pectin to the diet has also been shown to be
effective in the treatment of persistent diarrhea.
Zinc Supplementation
There is strong evidence that zinc supplementation in children
with diarrhea in developing countries leads to reduced
duration and severity of diarrhea and could potentially
prevent a large proportion of cases from recurring. In addition
to improving diarrhea recovery rates, administration of zinc in
community settings leads to increased use of ORS and
reduction in the inappropriate use of antimicrobials. Although
some studies have failed to demonstrate beneficial effects of
zinc supplementation in young infants <6 mo of age, WHO
and UNICEF recommend that all children with acute
diarrhea in at-risk areas should receive oral zinc in some
form for 10-14 days during and after diarrhea (10 mg/day
Additional Therapies
The use of probiotic nonpathogenic bacteria for prevention and
therapy of diarrhea has been successful in developing countries. In
addition to restoring beneficial intestinal flora, probiotics can enhance
host protective immunity such as down-regulation of pro-
inflammatory cytokines and up-regulation of anti-inflammatory
cytokines. A variety of organisms (Lactobacillus, Bifidobacterium)
have a good safety record; therapy has not been standardized and the
most effective (and safe) organism has not been identified.
Saccharomyces boulardii has been shown to be effective in antibiotic-
associated and in C. difficile diarrhea, and there is some evidence that
it might prevent diarrhea in daycare centers. Lactobacillus rhamnosus
GG was associated with reduced diarrheal duration and severity, more
evident in case of childhood rotavirus diarrhea. Similar, although
weaker, evidence was obtained with S. boulardii.
Kaopectate 1-D (loperamide) Oral Uses
This medication is used to treat sudden diarrhea
(including traveler's diarrhea). It works by
slowing down the movement of the gut. This
decreases the number of bowel movements and
makes the stool less watery. Loperamide is also
used to reduce the amount of discharge in
patients who have undergone an ileostomy.
It is also used to treat on-going diarrhea in people
with inflammatory bowel disease.
Loperamide treats only the symptoms, not the cause
of the diarrhea (e.g., infection). Treatment of other
symptoms and the cause of the diarrhea should be
determined by the doctor.
It not used in children younger than 6 years unless
directed by your doctor. This medication should not
be used in infants younger than 24 months.
Similarly, antiemetic agents such as the
phenothiazines are of little value and are
associated with potentially serious side effects
(lethargy, dystonia, malignant hyperpyrexia).
Nonetheless, ondansetron is an effective and
less-toxic antiemetic agent. Because persistent
vomiting can limit oral rehydration therapy, a
single sublingual dose of an oral dissolvable
tablet of ondansetron (4 mg 4-11 yr and 8 mg for
children >11 yr [generally 0.2 mg/kg]) may be
given.
.
Racecadotril, also known as acetorphan, is an
antidiarrheal drug which acts as a peripherally
acting enkephalinase inhibitor. Unlike other
medications used to treat diarrhea, which reduce
intestinal motility, racecadotril has an
antisecretory effect—it reduces the secretion of
water and electrolytes into the intestine. It is
available in France (where it was first
introduced in 1993 and is widely used) and other
European countries, as well as most of South
America and some South East Asian countries,
but not in the United States.
It is sold under the tradenames Hidrasec or, in
France, Tiorfan. In Italy it is sold under the
tradename Tiorfix.
A small randomized controlled trial found
racecadotril to significantly reduce the duration
and volume of watery diarrhea in children when
given as an adjunct to oral rehydration therapy.
Nitazoxanide
Mechanism of action
The anti-protozoal activity of nitazoxanide is believed to be
due to interference with the pyruvate:ferredoxin
oxidoreductase (PFOR) enzyme dependent electron transfer
reaction which is essential to anaerobic energy metabolism.
It has also been shown to have activity against influenza A
virus in vitro. The mechanism appears to be by selectively
blocking the maturation of the viral hemagglutinin at a stage
preceding resistance to endoglycosidase H digestion. This
impairs hemagglutinin intracellular trafficking and insertion
of the protein into the host plasma membrane.
Nitazoxanide is a first-line choice for the treatment of
illness caused by Cryptosporidium parvum or Giardia
lamblia infection in immunocompetent adults and
children, and is an option to be considered in the
treatment of illness caused by other protozoa and/or
helminths.
It is used for the treatment of infectious diarrhea
caused by Cryptosporidium parvum and Giardia
lamblia in patients 1 year of age and older.
Nitazoxanide is currently in Phase II clinical trials for the
treatment of hepatitis C, in combination with peginterferon
alfa-2a and ribavirin.
A randomised double-blind placebo-controlled study
published in 2006, with a group of 38 young children
concluded that a 3-day course of nitazoxanide significantly
reduced the duration of rotavirus disease in hospitalized
pediatric patients. Dose given was "7.5 mg/kg twice daily" and
the time of resolution was "31 hours for those given
nitazoxanide compared with 75 hours for those in the placebo
group." Rotavirus is the most common infectious agent
associated with diarrhea in the pediatric age group worldwide.
Rotavirus Immunization
Most infants acquire rotavirus diarrhea early in life; an effective
rotavirus vaccine would have a major effect on reducing diarrhea
mortality in developing countries. In 1998, a quadrivalent Rhesus
rotavirus-derived vaccine was licensed in the United States but
subsequently withdrawn due to an increased risk of
intussusception. Subsequent development and testing of newer
rotavirus vaccines have led to their introduction in most developed
countries and approval by the WHO in 2009 for widespread use in
developing countries. Emerging evidence indicates that the
introduction of these vaccines is associated with a significant
reduction in severe diarrhea and associated mortality.
Thank You