Therapeutic methods for diarrhea in children

DEFINITION

Acute diarrhoea is defined as passage of loose or watery stools at least threet imes in a 24 h period. When loose stools contain blood, it is called bloody diarrhoea (dysentery). It is the consistency of the stools which is most important rather than the frequency. Breast-fed babies often pass “pasty” stools fr equently which is not diarrhoea. The mother can often tell accurately whether child has diarrhoea or not.

MAGNITUDE OF THE PROBLEM

Acute diarrhoea is an important cause of mortality and morbidity particularly in young children in the developing countries. Of the 11.6 million deaths among ch ildren less than five years old in all developing countries (1995) due to infect ious diseases, 19% deaths are attributed to diarrhoea[1]. In 1993, an estimated 3.2 million children below five years of age died from diarrhoea alone; 80% of these deaths occurred in the first two years of life[2].

AETIOLOGY

Acute diarrhoea is usually caused by different infectious agents. The microbial agents causing diarrhoea may be classified as bacterial (Vibrio cholerae O1 and O139, Vibrio parahaemolyticus, enterotoxigenic E.coli, Shigella, Salmonella, Campylobacter jejuni, Aeromonous etc.), viral (Rotavirus, Norwalkv i rus etc.), parasites (E. histolytica, Giardia lamblia, Cryptosporidium etc.). The various agents produce diarrhoea either by production of toxin(s) or by inv asion of the gut mucosa. Those organisms which produce diarrhoea by production of toxin(s) produce watery diarrhoea. Vibrio cholerae and enterotoxigenic E .coli are the prototype organisms producing watery (also called secretory) dia rrhoea. Those organisms which invade the gut mucosa usually produce bloody diarr hoea (dysentery). Shigella and E.histolytica are the prototype organisms producing bloody diarrhoea (also called invasive diarrhoea).

In watery diarrhoea usually there is loss of lots of fluid and electrolytes from the body which results in dehydration which is a conspicuous clinical feature in watery diarrhoea. In contrast, in invasive diarrhoea not much fluid and electr olytes are lost in the stool. Therefore, dehydration is not a major feature. It is most practical to base treatment of acute diarrhoea on the clinical type of illness (watery or bloody). Laboratory studies are usually not needed.

DEHYDRATION

Management of acute watery diarrhoea includes replacement of fluid and electroly tes losses, proper feeding and use of appropriate antibiotic in selected cases. It has been mentioned that dehydration occurs due to loss of fluid and electroly tes from the body. Dehydration is now clinically assessed as diarrhoea with “no signs of dehydration”, diarrhoea with “some dehydration” and diarrhoea wit h “severe dehydration”. Table 1 describes how to determine the degree of dehy dration clinically. The signs typical of children with no signs of dehydration are shown in column A, signs of some dehydration in column B and those with sever e dehydration in column C. The sign in bold print with asterisks (*) are the mos t valuable signs for assessing dehydration and are called “key signs”. If two or more of the signs in column C are present including at least one key sign the child has severe dehydration. If this is not the case, but two or more signs from column B (and C) are present, including at least one key sign, the child has some dehydration. If this also is not the case, the child is classified as havi ng no signs of dehydration.

Table 1.

Assessment of diarrhoea patients for dehydration

1. Look at:	Conditiona	Well, alert	Restless, irritable	*Lethargic or unconscious; floppy*
	Eyesb	Normal	Sunken	Very sunken and dry
	Tears	Present	Absent	Absent
	Mouth and tonguec	Moist	Dry	Very dry
	Thirst	Drinks normally, not thristy	*Thirsty, drinks eagerly*	*Drinks poorly, or not able to drink*
2. Feel:	Skin pinchd	Goes back quickly	*Goes back slowly	**Goes back very slowly*
3. Decide:		The patient has no signs of	If the patient has two or more signs, including	If the patient has two or more signs,
		dehydration	at least one *sign*, there is some dehydration	including at least one *sign* , there is
			severe dehydration
4. Treat:		Use Treatment Plan A	Weigh the patient, if possible, and use	Weigh the patient and use Treatment
			Treatment Plan B	Plan C urgently

^aBeing lethargic and sleepy are not the same. A lethargic child is not simply asleep: the child’s mental state is dull and the child cannot be fully awa kened; the child may appear to be drifting into unconsciousness.

^bIn some infants and children the eyes normally appear somewhat sunken. It is helpful to ask the mother if the child’s eyes are normal or more sunken th an usual.

^cIt is necessary to look inside the child’s mouth. The mouth may be dry in a child who habitually breaths through the mouth. The mouth may be wet in a dehydrated child owing to recent vomiting or drinking.

^dThe skin pinch is less useful in infants or children with marasmus or kw ashiorkor, or obese children.

PREVENTION OF DEHYDRATION (PLAN A)

Diarrhoea with no signs of dehydration may be managed safely and effectively at home with the administration of extra fluid, proper feeding and watching for dan ger signs. The mother may be educated to give her child extra fluid in the form of coconut water, salt and sugar solution, rice water with salt, mild tea (these fluids are called “home available fluid”-HAF) or oral dehydration salt solution (ORS). At any stage if the child becomes either very thirsty, passes many watery stools, vomits repeatedly, or has fever, or blood in stool, the mother s hould be alerted to take the child to a doctor for further management.

TREATMENT OF DEHYDRATION (PLAN B AND C)

Studies have shown that 90% of cases of watery diarrhoea with some dehydration can be safely and effectively managed with ORS solution alone[3]. WHO/UNI CEF recommended ORS contains sodium chloride 3.5 g, 85 mm potassium chloride 1.5 g, sodium bicarbonate 2.5 g, or trisodium citrate, dihydrate 2.9 g and glucose 20 g dissolved in 1 L of water. For the treatment of some dehydration ORS should be administered (50-100 mL per kg). Table 2 gives the guidelines for treating c hildren and adults with some dehydration. The mother should be taught to prepare and give ORS solution. The solution should be given to infants and young childr en using a clean spoon or cup. Use of a feeding bottle is strongly discouraged. If vomiting occurs (usually during the first hour of treatment) the mother should wait for 5-10 min and then start giving ORS solution again but more slow ly. The disadvantages of WHO/UNICEF ORS are that it does not reduce the stool vo lume or duration of diarrhoea and thus are sometimes not acceptable to the mothe rs. Several clinical trials have shown that an ORS solution containing cooked rice powder in place of glucose substantially reduces the rate of stool loss due to acute diarrhoea. Rice based ORS solution significantly reduces the rate of stool output during the first 24 h of treatment by 36% in adults with cholera and by 32% in children with cholera. In contrast, the rate of stool loss in infants and children with acute non-cholera diarrhoea treated with rice ORS solution was only recuded by 18%[4]. A small but significant proportion of dehyd rated patients might benefit from using a low osmolarity solution in which glucose concentration has been slightly reduced[5]. However, the real benefit of using sucha solution as well as their exact composition remains to be determined.

Table 2.

Guidelines for treating children and adults with some dehydration

Approximate amount of ORS solution to give in the first 4 h
Agea	Less than 4 months	4-11 months	12-23 months	2-4 years	5-14 years
Weight:	Less than 5 kg	5-7.9 kg	8-10.9 kg	11-15.9 kg	16-29.9 kg
In mL	200-400	400-600	600-800	800-1200	1200-2200
In local measure

^aUse the patient’s age only when you do not know the weight. The ap proximate amount of ORS required (in mL) can also be calculated by multiplying the patient’s weight in kg by 75. ·If the patient wants more ORS than shown, give more. ·Encourage the mother to continue breastfeeding her child. ·For infants under 6 months who are not breast fed, also give 100-200 mL clean water during this period.NOTE: During the initial stages of therapy, while still dehydrated, adults can consume up to 750 mL per h, if necessary, and children up to 20 mL per kg body weight per h.

The preferred treatment for children with severe dehydration is rapid intravenous rehydration. Such treatment should preferably be carried out by admitting the patient to the hospital. Guidelines for intravenous rehydration are given in Table 3. The preferred solution is Ringer’s Lactate.

Table 3.

Guidelines for intravenous treatment of children and adults with sever e dehydration

·Start IV fluids immediately. If the patient can drink, give ORS by mouth until the drip is set up. Give 100 mL/kg Ringer’s Lactate Solutiona divided as follows:
Age	Fisst give 30 mL/kg in:	Then give 70 mL/kg in:
Infants (under 12 months)	1 hb	5 h
Older	30 minb	2.5 h
·Reassess the patient every hour. If hydration is not improving, give the IV drip more rapidly.
·After 6 h (infants) or three hours (older patients), evaluate the patient using the assessment chart. Then choose the appropriate Treatment Plan (A,B or C) to continue treatment.

^aIf Ringer’s Lactate Solution is not available, normal saline may be used.

^bRepeat once if radial pulse is still very weak or not detectable.

FEEDING DURING DIARRHOEA

During diarrhoea the child should be fed properly. Previously it was thought tha t during diarrhoea, nutrients are not absorbed adequately and hence the bowel sh ould be given a rest. Recent studies indicate that during and after diarrhoea most of the nutrients are sufficiently absorbed. In fact, proper feeding during diarrhoea has been shown to be beneficial and prevents malnutrition. Breast feeding should be continued throughout the duration of diarrhoea. Easily digestable, energy-rich, high potassium containing, non-fibrous food should be given to the child. During convalescence at least one extra feed daily for several weeks is recommended. Locally available and culturally acceptable foods are preferred.

ROLE OF DRUGS

All cases of bloody diarrhoea where dehydration is present should be managed wit h rehydration therapy as detailed for the acute watery diarrhoea. In addition, a ll the cases of bloody diarrhoea in children below 5 years of age should be trea ted with an appropriate antibiotic assuming that the child is suffering from shi gellosis. Studies have shown that antibiotic therapy definitely hastens recovery[6]. The drug of choice for shigellosis is nalidixic acid[7]. Ot her drugs (ampicillin[8] or cotrimoxazole[9]) may be used depend ing upon the drug resistance pattern of the circulating shigella strains in the area. It has been shown that norfloxacin[10] or ciprofloxacin[11] are also highly effective in the treatment of shigellosis. These drugs are co ntraindicated for young children because of the potential cartilage toxicity rep orted in experimental animals[12]. However, more and more information is coming that these drugs may turn out to be safe even in children for such short term use[13]. Amebiasis rarely occurs in children below 5 years of age and therefore random use of antiamoebic drugs for childhood diarrhoea is not recommended. However, if antibiotic therapy fails and E.histolytica trophozoites are seen by microscopic examination of stool, metronidozole or tini dazole may be used in the recommended doses.

Routine use of antibiotic(s) in acute watery diarrhoea is not recommended and is actually harmful. The only indication for use of antibiotics is for the treatme nt of suspected severe cholera cases as an adjunct to rehydration therapy. Chole ra should be suspected when a child of more than two years of age suffers from acute watery diarrhoea with severe dehydration in an endemic area. The drugs of c hoice for the treatment of cholera are tetracycline and doxycycline. Norfloxacin [14]and ciprofloxacin[15] have been shown to be also highly eff ective. Antibiotic therapy shortens the volume and duration of diarrhoea thereby reducing the fluid requirement, and duration of hospitalisation and excretion o f Vibrio cholerae in stool. Other drugs, as for example, antiemetics, antich olinergics, antidiarrhoeals like opium, charcoal, kaoline and pectin, steroid an d cariotonics are not required for the treatment of diarrhoea. In fact some of t hem are not only useless but may also be harmful. Antiemetics produce sedation a nd therefore, interfere with oral rehydration therapy and may produce or aggrava te hypotension thereby interfering with the renal circulation. Anti-cholinerg ics may produce paralytic ileals.

Recently, supplementation with micronutrients especially zinc as an adjunct to r ehydration therapy for the treatment of acute diarrhoea has been suggested[16].

ACKNOWLEDGEMENTS

Tables 1, 2 and 3 have been reproduced from the WHO manual The treatment of diarrhoea-a manual for physicians and other senior health workers (WHO/CDR/9 5.3)