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Acute diarrhea in children 

Updated 2013 May 16 11:33:00 AM: INSN/HEP/SPP/SPEIT 2011 clinical practice guideline on diagnosis and treatment of pediatric acute infectious diarrhea in Peru (Rev Gastroenterol Peru 2012 Jan-Mar) view updateShow more updates

Related Summaries:      

Dehydration and hypovolemia Rehydration therapy in children Rotavirus gastroenteritis Traveler's diarrhea Acute diarrhea in adults Prevention of acute diarrhea

Overview:  

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assess hydration status initiate rehydration therapy o oral rehydration therapy (ORT) adequate in most children with acute diarrhea  if no clinical signs of dehydration, encourage home-based ORT and other fluids to prevent dehydration  if mild-to-moderate dehydration, provide ORT in health facility to rapidly replace fluids and ongoing losses o IV rehydration therapy (Ringer's lactate 10-20 mL/kg) indicated if  severe dehydration  signs of clinical deterioration or shock  decreased consciousness  no response to oral rehydration continue to feed children with acute diarrhea; feeding immediately does not appear to increase risk of unscheduled use of IV fluids, vomiting, or persistent or increased diarrhea in children with acute diarrhea (level 2 [mid-level] evidence) consider serious and life-threatening causes if bloody stools, abdominal pain or distention, bilious vomiting, recent antibiotic use, or clinical shock laboratory tests usually not needed in cases of acute uncomplicated, transient gastroenteritis with watery diarrhea o perform microbiological stool studies if bloody diarrhea or severe illness stool cultures, Shiga toxin assay, Clostridium difficile toxin assay if recent antibiotics o additional testing to consider in severe illness or suspected causes other than gastroenteritis - electrolytes, complete blood count, blood cultures, abdominal x-ray antimicrobial medications


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NOT recommended routinely in most children with acute watery diarrhea consider use if premature infant, bloody diarrhea, fever, confirmed pathogen responsive to antimicrobials, traveler's diarrhea, malnourishment, or nonintestinal factors warranting antibiotics antidiarrheal medications not recommended in children, especially younger children if severe malnutrition, admit to hospital, use slow modified oral rehydration approach, feed every 2-3 hours, and give broad-spectrum antibiotics other therapies to consider o zinc supplementation in children < 5 years old may reduce duration of diarrhea but may increase risk for vomiting (level 2 [mid-level] evidence); World Health Organization recommends zinc 10-20 mg/day for 10-14 days o probiotics may reduce duration of acute infectious diarrhea (level 2 [midlevel] evidence); probiotics with efficacy data include Lactobacillus casei strain GG, Enterococcus LAB SF68, Saccharomyces boulardii and Escherichia coli strain Nissle 1917 in children with gastroenteritis, diarrhea typically lasts 5-7 days

Updated 2013 May 16 11:33:00 AM: INSN/HEP/SPP/SPEIT 2011 clinical practice guideline on diagnosis and treatment of pediatric acute infectious diarrhea in Peru (Rev Gastroenterol Peru 2012 Jan-Mar) view updateShow more updates

Related Summaries:      

Dehydration and hypovolemia Rehydration therapy in children Rotavirus gastroenteritis Traveler's diarrhea Acute diarrhea in adults Prevention of acute diarrhea

Overview:  

assess hydration status initiate rehydration therapy o oral rehydration therapy (ORT) adequate in most children with acute diarrhea  if no clinical signs of dehydration, encourage home-based ORT and other fluids to prevent dehydration  if mild-to-moderate dehydration, provide ORT in health facility to rapidly replace fluids and ongoing losses o IV rehydration therapy (Ringer's lactate 10-20 mL/kg) indicated if  severe dehydration  signs of clinical deterioration or shock  decreased consciousness


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 no response to oral rehydration continue to feed children with acute diarrhea; feeding immediately does not appear to increase risk of unscheduled use of IV fluids, vomiting, or persistent or increased diarrhea in children with acute diarrhea (level 2 [mid-level] evidence) consider serious and life-threatening causes if bloody stools, abdominal pain or distention, bilious vomiting, recent antibiotic use, or clinical shock laboratory tests usually not needed in cases of acute uncomplicated, transient gastroenteritis with watery diarrhea o perform microbiological stool studies if bloody diarrhea or severe illness - stool cultures, Shiga toxin assay, Clostridium difficile toxin assay if recent antibiotics o additional testing to consider in severe illness or suspected causes other than gastroenteritis - electrolytes, complete blood count, blood cultures, abdominal xray antimicrobial medications o NOT recommended routinely in most children with acute watery diarrhea o consider use if premature infant, bloody diarrhea, fever, confirmed pathogen responsive to antimicrobials, traveler's diarrhea, malnourishment, or nonintestinal factors warranting antibiotics antidiarrheal medications not recommended in children, especially younger children if severe malnutrition, admit to hospital, use slow modified oral rehydration approach, feed every 2-3 hours, and give broad-spectrum antibiotics other therapies to consider o zinc supplementation in children < 5 years old may reduce duration of diarrhea but may increase risk for vomiting (level 2 [mid-level] evidence); World Health Organization recommends zinc 10-20 mg/day for 10-14 days o probiotics may reduce duration of acute infectious diarrhea (level 2 [mid-level] evidence); probiotics with efficacy data include Lactobacillus casei strain GG, Enterococcus LAB SF68, Saccharomyces boulardii and Escherichia coli strain Nissle 1917 in children with gastroenteritis, diarrhea typically lasts 5-7 days

General InformationDifferential DiagnosisHistory and PhysicalDiagnostic TestingManagement

Rehydration: 

for children with no or minimal signs of dehydration - home-based fluid management recommended o increase fluid intake to compensate for losses and prevent development of dehydration o if possible, replace fluid after each episode of diarrhea or vomiting  50-120 mL (2-4 fluid ounces) in children < 2 years old or < 10 kg (22 lbs)  100-240 mL (4-8 fluid ounces) in children aged 2-10 years or > 10 kg (22 lbs) o encourage oral rehydration solution (ORS) o avoid commercial juices and carbonated beverages o continue usual feeding


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encourage caretakers to bring child to healthcare facility if signs of dehydration arise for children with mild or moderate dehydration - rapid fluid replacement with oral rehydration therapy at health facility recommended o provide 50-100 mL/kg ORS over first 4 hours - give frequently in small amounts (like teaspoonful every 1-2 minutes or frequent small sips) and provide additional ORS to replace ongoing losses, if tolerated o considerations for oral rehydration therapy (ORT)  World Health Organization (WHO) estimated amounts of ORS to give within first 4 hours is 75 mL/kg body weight or by age if weight unknown Approximate Amount of ORS by Age in First 4 Hours: Age

ORS Volume

< 4 months

200-400 mL

4-11 months

400-600 mL

12-23 months

600-800 mL

2-4 years

800-1,200 mL

5-14 years

1,200-2,200 mL

≥ 15 years

2,200-4,000 mL

Abbreviation: ORS, oral rehydration solution.

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ORT by mouth or nasogastric tube may have similar overall safety and efficacy as IV rehydration therapy for first-line treatment of dehydration due to acute gastroenteritis in children (level 2 [mid-level] evidence)  reduced osmolarity ORS reduces unscheduled IV infusions and vomiting compared to conventional ORS in children hospitalized with diarrhea (level 1 [likely reliable] evidence)  contraindications to ORT include impairment of airway protective reflexes, abdominal ileus, intussusception, or carbohydrate malabsorption  continue with usual fluids (including milk feeds) during ORS administration consider nasogastric (NG) administration of ORS in child with normal mental status who is unable to drink or who vomits persistently with oral ORS consider IV therapy in child with decreased consciousness or if unresponsive to oral or NG administration of ORS start IV therapy immediately if child shows signs of severe dehydration or clinical deterioration encourage home fluid management after dehydration corrected


for children with severe dehydration (including suspected or confirmed shock) immediate and rapid IV rehydration recommended o start rapid IV infusion with Ringer's lactate solution (or normal saline or similar solution) 10-20 mL/kg until shock resolves or pulse, perfusion and mental status return to normal o WHO recommends Ringer's lactate solution (alternatively, normal saline)  100 mL/kg divided as follows  for infants (< 12 months old)  30 mL/kg in first hour (repeat if radial pulse very weak or not detectable)  70 mL/kg over next 5 hours  for children > 12 months old  30 mL/kg for first 30 minutes (repeat if radial pulse very weak or not detectable)  70 mL/kg over next 2.5 hours  for severely dehydrated children who are able to drink, give oral ORS (about 5 mL/kg per hour) until fluid delivery by IV available o multiple rapid IV infusions may be necessary, especially if child continues to pass large, watery stools during rehydration (rare, but possible) o consider other possible causes or conditions if dehydration does not resolve (such as septic shock or metabolic, cardiac, and neurologic disorders) o edema of eyelids and extremities may indicate overhydration - do not give diuretics, reassess patient for continued therapy after edema subsides o introduce ORT when child's status improves and oral fluids are tolerated

see Rehydration therapy in children for details

Diet: 

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children having semisolid or solid foods should continue usual diet during diarrhea episodes(2) o withholding food ≥ 24 hours not appropriate o avoid foods high in simple sugars (may worsen diarrhea) o BRAT diet (bananas, rice, applesauce [not juice], toast) commonly suggested, but may provide suboptimal nutrition offer child food every 3-4 hours (6 times/day); small frequent feedings tolerated better than large, less frequent meals(1) feeding considerations in infants o breastfed infants should continue to nurse on demand(2) o formula-fed infants should continue usual formula upon rehydration (2) (1) o infants should continue usual diet during diarrhea and increase diet afterwards  food should never be withheld  food should not be diluted  breastfeeding should always be continued o in formula-fed infants, small frequent feedings may reduce duration of diarrhea (level 2 [mid-level] evidence)  based on randomized trial without blinding


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262 hospitalized male infants aged 3-12 months with acute diarrhea were randomized to cows' milk 0.452 MJ/kg/day as 6 feeds (18 mL/kg every 3 hours over 18 waking hours) vs. 12 feeds (9 mL/kg every 1.5 hours over 18 waking hours) for 14 days  frequently fed group had significantly shorter duration of diarrhea  Reference - Arch Dis Child 1999 Dec;81(6):487 PDF addition of soy fiber to infant formula may shorten duration of antibioticassociated diarrhea (level 2 [mid-level] evidence)  based on randomized trial with high dropout rate  63 children aged 5-18 months with acute diarrhea from antibiotic use randomized to regular soy formula vs. soy formula with added soy fiber (Isomil DF) for 10 days  45 children (71%) completed trial  mean duration of diarrhea 25.1 hours with added soy fiber vs. 51.6 hours with regular soy formula (p = 0.0013)  Reference - J Pediatr 2001 Oct;139(4):578 fiber supplementation of soy formula may reduce duration of acute diarrhea in otherwise well infants > 6 months old (level 2 [mid-level] evidence)  based on subgroup analysis of randomized trial  74 babies < 24 months old with acute diarrhea randomized to soy formula with fiber (Isomil DF) vs. soy formula without fiber (Isomil) for 24 days  most common cause of diarrhea was rotavirus  55 babies (74%) completed trial  median duration of diarrhea comparing soy formula with fiber vs. without fiber  12.2 hours vs. 16.9 hours in overall analysis of 67 infants (not significant)  9.7 hours vs. 23.1 hours in analysis of 44 infants > 6 months old (p ≤ 0.05)  17.5 hours vs. 8.1 hours in analysis of 23 infants < 6 months old (not significant)  Reference - Clin Pediatr (Phila) 1997 Mar;36(3):135 soy-based formula with sucrose may shorten acute diarrhea by almost 1 day compared to soy formula with lactose (level 2 [mid-level] evidence)  based on randomized trial with allocation concealment not stated  200 boys aged 3-18 months (mainly formula fed) in Egypt hospitalized with acute diarrhea and dehydration were randomized to soy-based formula containing sucrose (Nursoy ready-to-feed) vs. soy-based formula containing lactose (Nursoy powder)  assigned formula given as 150 mL/kg/day in 8 equal feedings until resolution of diarrhea for 15 hours or 7 days into study  exclusion criteria were visible blood in stool, evidence of systemic infection or severe malnutrition  all children initially stabilized prior to randomization with IV hydration for severe dehydration or World Health Organization (WHO) oral rehydration solution for mild-moderate dehydration  comparing formulas containing sucrose vs. lactose  mean duration of diarrhea 23 hours vs. 39 hours (p < 0.001)


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stool output in first 24 hours 57 g/kg vs. 103 g/kg (p < 0.001) recurrent dehydration in 6% vs 17% (p < 0.01, NNT 9)  Reference - Arch Pediatr Adolesc Med 1999 Jul;153(7):675  DynaMed commentary -- results may not apply to breastfed infants or to girls o addition of indigestible starches (green banana or pectin) to rice-based diet associated with reduced diarrhea in Bangladeshi infants (level 2 [mid-level] evidence)  based on small randomized trial  62 boys aged 5-12 months in Bangladesh with > 3 loose stools per day for at least 14 consecutive days were randomized to 1 of 3 diets for 7 days  rice-based diet (control)  rice-based banana diet (cooked green bananas)  rice-based pectin diet  at day 3, 55% in banana and 59% in pectin groups had recovered from diarrhea compared to 15% of rice-alone group (p < 0.001)  Reference - Gastroenterology 2001 Sep;121(3):554 commentary can be found in ACP J Club 2002 Mar-Apr;136(2):67 o lactose-free milk or infant formula does not appear to improve outcomes in most young children with acute diarrhea (level 2 [mid-level] evidence)  based on systematic review with heterogeneity  systematic review of 29 randomized trials comparing lactose-free vs. lactose-containing milk or formula diets in 2,215 young children with acute diarrhea  lactose-free diet associated with lower treatment failure rates (12% vs. 22%, p < 0.001, NNT 10) in overall meta-analysis  differences in treatment failure rates limited to studies in children with severe dehydration and published before 1985 (before diarrhea treatment protocols were widely accepted)  no significant differences in treatment failure rates (15% vs. 13%) in metaanalysis of studies in children with mild diarrhea  Reference - Pediatrics 1994 Jan;93(1):17 dietary considerations for children in developing countries (1, 2) o multiple diarrheal episodes per year may result in suboptimal nutrition, which may increase likelihood and severity of further episodes o maintain caloric intake during acute episodes o increase nutrient intake after each diarrheal episode o appropriate nourishment includes age-appropriate, unrestricted diets including complex carbohydrates, meat, yogurt, fruit and vegetables feeding immediately does not appear to increase risk of unscheduled use of IV fluids, vomiting, or persistent or increased diarrhea in children with acute diarrhea (level 2 [mid-level] evidence) o based on Cochrane review of trials with methodologic limitations o systematic review of 12 randomized trials comparing early vs. late reintroduction of feeding in 1,283 children with acute diarrhea o methodologic limitations included  10 trials had unclear allocation concealment


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 no trials had clear blinding of outcome assessors early refeeding defined as intake during or immediately after start of rehydration late refeeding defined as intake 20-48 hours after start of rehydration no significant differences in  total stool output during first 24 hours after start of rehydration in analysis of 3 trials with 394 patients, results limited by heterogeneity (p = 0.001)  total stool output during first 48 hours after start of rehydration in analysis of 3 trials with 262 patients, results limited by heterogeneity (p = 0.0005)  percentage weight gain at 24 hours in analysis of 3 trials with 212 patients  unscheduled IV fluid therapy in analysis of 6 trials with 813 patients  cases of vomiting in analysis of 5 trials with 456 patients  development of persistent diarrhea (> 14 days duration) in analysis of 4 trials with 522 patients  development of hyponatremia in analysis of 2 trials with 287 patients  mean length of hospital stay in analysis of 2 trials with 246 patients Reference - Cochrane Database Syst Rev 2011 Jul 6;(7):CD007296

National Institute for Health and Clinical Excellence (NICE) recommendations for diarrhea and vomiting caused by gastroenteritis in children < 5 years old recommend "give fullstrength milk straight away" after rehydration, based on no evidence of harm (3) World Health Organization (WHO) manual for treatment of diarrhea recommends diet "with a limited content of lactose" should be given to children with persistent diarrhea, initially with diet containing reduced lactose (such as substituting yogurt for milk), and subsequently with lactose-free diet for children who do not improve(1) high-energy diet in malnourished children with acute shigellosis may improve weight gain and rectal prolapse but cause vomiting (level 2 [mid-level] evidence) o based on randomized trial without blinding o 75 malnourished children ages 12-48 months with acute dysentery due to shigellosis randomized to milk-cereal formula with energy density 4,960 kJ/L vs. milk-cereal formula with energy density 2,480 kJ/L for 10 days in hospital o all children treated with antibiotics for 5 days and standard hospital diet o no significant differences in times to resolution of fever, dysenteric stools, stool frequency or tenesmus o comparing high-energy vs. control formula  67% vs. 41% had vomiting in first 5 days (NNH 3)  mean weight-for-age at 10 days increased by 6.2% vs. 2.7%  resolution of rectal prolapse reported in 26% vs. 8% at 5 days (NNT 6) and 13% vs. 6% at 10 days (NNT 15) o Reference - Br J Nutr 2000 Nov;84(5):775

Management of diarrhea with severe malnutrition: 

assessment of hydration status is difficult(1) o skin turgor poor in children with marasmus due to absence of subcutaneous fat and masked in children with kwashiorkor due to edema


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signs of dehydration that remain useful include eagerness to drink, lethargy, cool moist extremities, weak or absent radial pulse, reduced or absent urine flow o distinguishing some dehydration, severe dehydration and septic shock may be difficult management should take place in hospital(1) rehydration should be orally if possible(1) o nasogastric tube may be used if poor drinking o IV rehydration should be limited to treatment of shock because of risk for overhydration and heart failure o oral rehydration should be slow  start with 10 mL/kg/hour for first 2 hours  give 70-100 mL/kg over 12 hours o do not use full-strength oral rehydration solution, risk for hypernatremia and hypokalemia o preparation of modified oral rehydration solution  if using oral rehydration solution containing sodium 75 mEq/L  dissolve 1 packet into 2 L of water (instead of 1 L)  add 45 mL of potassium chloride (100 g KCl/L) solution  add and dissolve sucrose 50 g  modified solution should contain  sodium 37.5 mEq/L (37.5 mmol/L)  potassium 40 mEq/L (40 mmol/L)  sucrose 25 g/L feed child every 2-3 hours, day and night(1) initial diet (until return of normal appetite) can be based on 130 mL/kg/day of combination of(1) o water 1 L o skimmed milk powder 25 g o vegetable oil 20 g o sugar 60 g o rice powder or other cereal powder 60 g o salt mixture (see WHO 2005 PDF) multivitamin mixture providing at least 2 recommended dietary allowances (RDAs) of all vitamins should be given(1) broad spectrum antibiotics (such as gentamicin and ampicillin) for several days should be given to all severely malnourished children(1)

Antidiarrheal medications: 

antidiarrheal agents NOT recommended o World Health Organization (WHO) advises against use of antidiarrheal drugs in children due to potentially dangerous side effects (1) o Centers for Disease Control and Prevention (CDC) guidance includes warning about potentially serious side effects and reports limited efficacy (2) o National Institute for Health and Clinical Excellence (NICE) advises against use of antidiarrheal medications in children < 5 years old(3)


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Infectious Diseases Society of America (IDSA) recommends avoiding antimotility agents in patients with bloody diarrhea or documented Shiga toxin-producing E. coli (STEC) infections (IDSA Grade E-II)(5) antidiarrheal agents which have been used (but not recommended by NICE) include(3) o adsorbent agents - clay minerals (kaolin, smectite), charcoal o antisecretory agents - racecadotril, bismuth subsalicylate o antimotility agents - loperamide

Loperamide: 

loperamide may improve diarrhea in children, but associated with increased adverse effects in children < 3 years old (level 2 [mid-level] evidence) o based on systematic review with heterogeneity o systematic review of 13 randomized trials comparing loperamide to controls in 1,788 children < 12 years old with mostly mild acute diarrhea o 7 trials reported adequate randomization, 6 trials reported allocation concealment, 9 trials were double-blind, 11 trials included > 90% participants in analyses, 4 trials met all key quality criteria o definitions of diarrhea resolution differed across trials o loperamide associated with  decreased prevalence of continued diarrhea at  24 hours (risk ratio [RR] 0.66, 95% CI 0.57-0.78) in analysis of 4 trials  48 hours (RR 0.59, 95% CI 0.45-0.78) in analysis of 4 trials  shorter mean duration of diarrhea (weighted mean difference -0.8 days, 95% CI -0.87 to -0.74 days) in analysis of 6 trials limited by statistical heterogeneity  lower stool count in first 24 hours in analysis of 4 trials limited by statistical heterogeneity o adverse events reported in 10.1% with loperamide vs. 2.1% with controls (p < 0.05, NNH 12) o serious adverse events (ileus, lethargy or death) occurred in children < 3 years old (0.9% with loperamide vs. 0 controls, NNH 111) o Reference - PLoS Med 2007 Mar 27;4(3):e98

Racecadotril: 

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racecadotril is an enkephalinase inhibitor with antisecretory actions o also called acetorphan o available in parts of Europe, South America, and Asia o brand names include Hidrasec, Tiorfan, and Tiorfix conflicting evidence to support racecadotril (level 2 [mid-level] evidence) racecadotril may not improve symptoms of diarrhea more rapidly than standard rehydration therapy (level 2 [mid-level] evidence) o based on randomized trial without blinding o 189 children aged 3-36 months with acute gastroenteritis were randomized to oral rehydration solution (ORS) plus racecadotril vs. ORS and were followed for ≤ 7 days


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racecadotril doses  10 mg every 8 hours for children weighing < 9 kg (19.84 lbs.)  20 mg every 8 hours for children weighing 9-13 kg (19.84-28.66 lbs.)  30 mg every 8 hours for children weighing > 13 kg (28.66 lbs.) o comparing ORS plus racecadotril vs. ORS  number of bowel movements 48 hours after initiating treatment 3.8 vs. 4.1 (not significant)  average duration of gastroenteritis 4.0 days vs. 4.7 days (not significant)  incidence of adverse events 19.1 vs. 20.2 (not significant) o Reference - J Pediatr 2009 Jul;155(1):62 racecadotril may reduce stool volume at 48 hours in children with acute diarrhea (level 2 [mid-level] evidence) o based on systematic review of trials with methodologic limitations o systematic review and meta-analysis of 3 randomized trials comparing racecadotril vs. placebo in 471 children aged 3-48 months with acute diarrhea o inadequate or unclear allocation concealment in 2 trials, trial with adequate allocation concealment described below and allocation concealment not confirmed in full-text report o significant reduction in stool volume in 2 trials for racecadotril vs. placebo for all children (301 patients) and for subgroup of rotavirus-positive children (128 patients) in 2 trials o no significant difference in cure rate at 5 days (84% for racecadotril vs. 77% for placebo) in 2 trials with 307 patients o Reference - Aliment Pharmacol Ther 2007 Sep 15;26(6):807 racecadotril appears effective in young boys hospitalized for acute watery diarrhea (level 2 [mid-level] evidence) o based on randomized trial with allocation concealment not stated o 135 boys aged 3-35 months hospitalized for dehydration with watery diarrhea for 5 days or less were studied  boys with blood in the stool or inability to drink due to drowsiness were excluded  ORS given to correct dehydration over 4-6 hours o 135 patients were then randomized to racecadotril 1.5 mg/kg vs. placebo orally every 8 hours for up to 5 days o all patients continued to get ORS as needed to replace fecal fluid losses o comparing racecadotril vs. placebo  mean stool output at 48 hours was 92 g/kg vs. 170 g/kg (p < 0.001)  mean total stool output before recovery was 157 g/kg vs. 331 g/kg  median duration of diarrhea 28 hours vs. 72 hours in rotavirus-positive and 28 hours vs. 52 hours in rotavirus-negative patients (p < 0.001)  5-day cure rates 84% vs. 66% (NNT 6)  cure rates were about 44% vs. 17% at 24 hours (NNT 4) and 63% vs. 24% at 48 hours (NNT 3)  adverse effects in 10% vs. 7% o study funded by manufacturer of racecadotril o Reference - N Engl J Med 2000 Aug 17;343(7):463, commentary can be found in ACP J Club 2001 May-Jun;134(3):110


Smectite: 

dioctahedral smectite (smectite) a natural clay (hydrated aluminomagnesium silicate) binds digestive mucus and can absorb toxins, bacteria and rotavirus and mainly used in Europe, Asia and Africa smectite may reduce duration of acute diarrhea in children (level 2 [mid-level] evidence) o based on systematic review of trials with methodologic limitations o systematic review of 9 randomized and quasi-randomized trials comparing smectite with placebo or no additional intervention in 1,238 children with acute gastroenteritis o duration of smectite treatment 2-6 days o 4 trials were placebo-controlled, allocation concealment adequate in only 1 trial o duration of diarrhea reduced by 22.7 hours (95% CI 20.6-24.8 hours) with smectite based on meta-analysis of 6 trials with 1,076 patients o cure rate on day 3 was 83% with smectite vs. 51% with control (NNT 3) in metaanalysis of 4 trials with 254 patients, cure rate on day 5 was 95% vs. 84% (not statistically significant) o other effects of smectite based on 2-4 trials for each analysis  effect on stool volume inconsistent in 2 trials  frequency of diarrhea significantly reduced after 48 hours based on 2 trials  no effect on vomiting based on 4 trials  nonsignificant trend toward constipation based on 2 trials o Reference - Aliment Pharmacol Ther 2006 Jan 15;23(2):217 addition of smectite to L. rhamnosus GG may not reduce duration of diarrhea or hospitalization in children (level 2 [mid-level] evidence) o based on randomized trial without intention-to-treat analysis o 88 children aged 4-60 months with acute gastroenteritis treated with Lactobacillus rhamnosus 6 x 109 colony-forming units once daily for 7 days and randomized to smectite 3 g once daily until diarrhea stopped vs. placebo o 81 children (92%) included in analysis o no significant differences in duration of diarrhea or hospitalization o L. rhamnosus plus smectite associated with shorter duration of IV fluids after randomization (p = 0.02) o Reference - Eur J Pediatr 2013 Feb;172(2):247

Antimicrobial medications: 

universal routine antimicrobial use NOT recommended o ineffective against viruses (considered predominant cause of acute diarrhea especially in winter)(1, 2, 3, 4) o bacterial gastroenteritis usually self-limiting and course may not be shortened by antimicrobials(2) o inappropriate use may lead to antimicrobial resistance, superinfection or induction of disease-producing phage by antibiotics (such as Shiga-toxin phage induced by quinolone antibiotics)(5) o treating shiga toxin-producing E. coli (STEC) O157 with antimicrobials may increase risk of hemolytic-uremic syndrome (HUS) development(5)


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routine antimicrobial use recommended in certain cases, including(4) o severe cholera, shigellosis, typhoid, and paratyphoid fever o severe dysenteric presentation of Campylobacter enterocolitis or Salmonella ileocolitis in immunocompromised patients o severe invasive amebiasis o severe symptomatic giardiasis consider selective use of antimicrobials in certain cases, including o premature infants(2) o bloody diarrhea(1, 3) o parasitic infections(4) o sepsis or septicemia(3) o infections with known pathogens such as(3, 4) (5)  shigellosis (IDSA Grade A-I)  Salmonella ileocolitis  Campylobacter enterocolitis (IDSA Grade B-II)(5)  Clostridium difficile infection  giardiasis  amebiasis  cholera (especially with severe dehydration) o suspected traveler's diarrhea (enterotoxigenic E. coli or other bacterial pathogens may be likely cause) (IDSA Grade A-I)(4, 5) o serious nonintestinal infections (such as pneumonia) (1, 3, 4) o immunodeficiency or underlying disorders (2, 3) o diarrhea lasting > 10-14 days(5) o malnourishment(3) o prosthesis(3) empiric antimicrobial treatment not generally recommended, except perhaps in traveler's diarrhea(5) Centers for Disease Control and Prevention (CDC) advises against empiric antimicrobial use while waiting for culture results(2)

Zinc supplementation:  

World Health Organization (WHO) recommends giving zinc 10-20 mg/day for 10-14 days to all children with diarrhea(1) Centers for Disease Control and Prevention (CDC) states many trials support zinc supplementation for treating acute diarrhea, but further research necessary to identify mechanism of action and optimal delivery(2) zinc supplementation in children < 5 years old with diarrhea appears to reduce duration of diarrhea but may increase risk for vomiting (level 2 [mid-level] evidence) o based on multiple systematic reviews with unexplained heterogeneity o systematic review of 7 meta-analyses and total 26 trials for acute diarrhea and 6 trials for persistent diarrhea  zinc supplementation associated with reduction in mean diarrheal duration in meta-analysis of 19 trials with 8,957 children  standardized mean difference -0.25 (95% CI -0.35% to -0.15)


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results correspond to reduction in mean diarrheal duration by 19.7% (95% CI 11.9%-27.4%)  analysis limited by heterogeneity  dose of zinc only variable which was significantly associated with diarrhea duration (largest effect of zinc supplementation with higher doses)  no other variables found to explain heterogeneity of results  zinc supplementation associated with increased risk for vomiting in metaanalysis of 10 trials with 6,779 children  summary odds ratio 2.13 (95% CI 1.37-3.31)  overall risk of vomiting 19.2% with zinc vs. 9.2% with control  analysis limited by heterogeneity  Reference - PLoS One 2010 Apr 28;5(4):e10386 Cochrane review of 24 randomized trials comparing oral zinc supplementation (≥ 5 mg/day for any duration) vs. placebo in 9,128 children aged 1-60 months with acute or persistent diarrhea, including dysentery  all but 5 trials were conducted in countries with high risk for zinc deficiency  in children with acute diarrhea, zinc associated with  shorter duration of diarrhea (mean difference [MD] -12.63 hours, 95% CI -21.05 to -4.21 hours) in analysis of 19 trials with 4,446 children, results limited by significant heterogeneity  reduced diarrhea at day 3 in analysis of 3 trials with 1,568 children, results limited by heterogeneity  risk ratio (RR) 0.77 (95% CI 0.67-0.89)  NNT 9-25 with diarrhea at day 3 in 37% of placebo group  results not significant in subgroup analysis of 2 trials with 1,334 children < 6 months old and borderline significant (p = 0.06) in analysis of 6 trials with 2,175 children > 6 months old  reduced diarrhea at day 5 in analysis of 5 trials with 1,730 children, results limited by heterogeneity  RR 0.67 (95% CI 0.51-0.89)  NNT 17-76 with diarrhea at day 5 in 12% of placebo group  reduced diarrhea at day 7 in analysis of 10 trials with 5,528 children, results limited by heterogeneity  RR 0.82 (95% CI 0.72-0.94)  NNT 24-112 with diarrhea at day 7 in 15% of placebo group  increased vomiting in analysis of 10 trials with 5,189 children, results limited by heterogeneity  RR 1.59 (95% CI 1.27-1.99)  NNH 7-28 with vomiting in 13% of placebo group  in children with persistent diarrhea, zinc associated with  shorter duration of diarrhea (MD -15.84 hours, 95% CI -25.43 to 6.24 hours) in analysis of 5 trials with 529 children  trend toward reduced diarrhea at day 7 (RR 0.52, 95% CI 0.271.02) in analysis of 2 trials with 221 children > 6 months old


no significant differences in  diarrhea at days 3 and 5 in 1 trial with 173 children > 6 months old  vomiting in analysis of 4 trials with 505 children (vomiting in 6 children overall)  Reference - Cochrane Database Syst Rev 2012 Jun 13;(6):CD005436 o systematic review of randomized placebo-controlled trials of oral zinc ≥ 5 mg/day in children aged 1-60 months with diarrhea  16 trials included 15,231 children with acute diarrhea (up to 14 days duration), 9 inpatient and 7 outpatient trials  6 trials included 2,968 children with persistent diarrhea (duration > 14 days), 4 inpatient and 2 outpatient trials  comparing zinc vs. placebo in acute diarrhea  weighted mean difference in duration of diarrhea -0.24 days (p < 0.001) but analysis limited by heterogeneity (p < 0.001)  no significant difference in rate of diarrhea at day 1 (RR 1.01) in analysis of 5 trials with 3,100 children  no significant difference in rate of diarrhea at day 3 (RR 0.97) or at day 5 (RR 0.94) in analysis of 6 trials  mean reduction in stool frequency 22.1% in 7 trials, but increase of 5% in 1 trial  12.7% vs. 7.6% vomiting (p < 0.001, NNH 19) in analysis of 11 trials with 4,438 children  comparing zinc vs. placebo in persistent diarrhea  weighted mean difference in duration of diarrhea -0.3 days (p < 0.001) in analysis of 5 trials with 489 children  no significant difference in rate of diarrhea at day 1 (RR 1) in analysis of 2 trials with 221 children  mean reduction in stool frequency 9.8% in 4 trials  2.8% vs. 0.001% vomiting (p = 0.047, NNH 35) in analysis of 4 trials with 2,969 children  Reference - Pediatrics 2008 Feb;121(2):326 most trials evaluating zinc supplementation for children < 5 years old with diarrhea due to acute gastroenteritis were conducted in developing countries; insufficient evidence regarding use of zinc supplementation in developed countries o based on systematic review of 18 randomized trials of zinc supplementation for children < 5 years old with diarrhea due to acute gastroenteritis o Reference - Aliment Pharmacol Ther 2008 Sep 15;28(6):713 o suspension form of zinc supplementation associated with better compliance than tablet form, with similar efficacy (level 2 [mid-level] evidence)  based on cohort study of 200 children with diarrhea in emergency setting of earthquake-affected region of Pakistan  Reference - J Coll Physicians Surg Pak 2010 Dec;20(12):837 zinc supplementation 2 mg/kg/day with or without copper may not reduce frequency or duration of acute diarrhea episodes in children in India (level 2 [mid-level] evidence) o based on randomized trial with baseline differences


o

o o o o

808 children living in India aged 6-59 months with acute diarrhea for < 72 hours randomized to 1 of 3 groups for 2 weeks and followed for 3 months  zinc 2 mg/kg/day orally  zinc 2 mg/kg/day plus copper 0.2 mg/kg/day orally  placebo baseline differences included dehydration status, receipt of oral rehydration solution, and serum zinc levels 9% did not complete trial and were excluded from analyses no significant differences among groups in frequency or duration of diarrhea episodes, duration of acute respiratory episodes or fever, or growth outcomes Reference - Pediatr Infect Dis J 2013 Jan;32(1):91

addition of vitamin A and micronutrient supplementation to zinc therapy may not improve diarrhea resolution in children (level 2 [mid-level] evidence) o based on randomized trial with inadequate statistical power o 167 children aged 6-24 months with diarrhea and moderate dehydration were given oral rehydration then randomized to 1 of 4 groups for 14 days  zinc plus placebo vitamin A  zinc plus other micronutrients plus vitamin A  zinc plus vitamin A  placebo o 6% fewer patients enrolled than planned due to dropouts before randomization o all 3 supplemented groups had significantly greater reduction in duration and volume of diarrhea compared to placebo (p < 0.0001 for each) o no significant difference in diarrhea outcomes among supplemented groups o Reference - J Pediatr 2011 Oct;159(4):633

oral zinc may not reduce duration of diarrhea in young children with acute gastroenteritis living in Poland (level 2 [mid-level] evidence) o based on randomized trial without intention-to-treat analysis o 160 children aged 3-48 months with acute gastroenteritis randomized to zinc sulfate (10 or 20 mg/day depending on age) vs. placebo for 10 days in 2 pediatric hospitals in Poland o 12% not included in analysis o no significant differences in duration of diarrhea, stool frequency on days 1-3, vomiting frequency, IV fluid intake and number of children with diarrhea lasting > 7 days o Reference - J Pediatr 2010 Dec;157(6):984 zinc supplementation may reduce hospital admissions and mortality in children aged 359 months with diarrhea in Bangladesh (level 2 [mid-level] evidence) o based on cluster randomized trial without intention-to-treat analysis o 8,070 children aged 3-59 months in Bangladesh were treated with oral rehydration therapy and were cluster-randomized to zinc intervention vs. control o intervention included zinc 20 mg/day for 14 days  rates of zinc supplementation in intervention cohort increased from 40% to > 80% during study  zinc given for about 7 days on average


o

15.5% children were lost to follow-up, mostly due to aging out (> 60 months old); 2.5% children not included in analysis due to moving away o significantly more boys included in intervention clusters o zinc associated with reductions in  duration of diarrhea (hazard ratio 0.76, 95% CI 0.65-0.9)  hospital admissions for diarrhea (rate ratio 0.76, 95% CI 0.59-0.98)  non-injury mortality  rate ratio 0.49 (95% CI 0.25-0.94)  2.22 vs. 4.49 per 1,000 child-years with placebo o Reference - BMJ 2002 Nov 9;325(7372):1059 zinc supplementation of 3 mg/kg/day may not improve weight gain or accelerate recovery from diarrhea in malnourished children (level 2 [mid-level] evidence) o based on randomized trial with allocation concealment inadequately described o 87 malnourished children aged 6-36 months with persistent diarrhea for 14 days in Pakistan who were admitted for 14 days of inpatient supervised rehabilitation were randomized to zinc supplementation vs. placebo o all children given rice-lentil (Khichdi) and yogurt diet o no significant difference between groups at day 14 for overall weight gain, stool volume or stool frequency o Reference - Pediatrics 1999 Apr;103(4):e42

Probiotics: 

probiotics may reduce duration of acute infectious diarrhea (level 2 [mid-level] evidence) o based on Cochrane review with unexplained heterogeneity o systematic review of 63 randomized and quasi-randomized trials evaluating probiotics in 8,014 patients with acute diarrhea proven or suspected to be of infectious origin o 56 trials recruited infants or young children o in overall analyses probiotics reduced  duration of diarrhea (mean difference -24.76 hours, 95% CI -33.61 to 15.91 hours) in analysis of 25 trials with 4,555 patients  diarrhea lasting ≥ 4 days in analysis of 29 trials with 2,853 patients  risk ratio (RR) 0.41 (95% CI 0.32-0.53)  NNT 4-5 assuming diarrhea for ≥ 4 days in 45% of controls o all results limited by significant heterogeneity o effect size differences among trials could not be explained by trial quality, location, probiotic strain, number of different strains, organism viability, dosage, causes or severity of diarrhea o among 10 high-quality trials, 7 found significant benefit with probiotics and 3 found no significant benefit o in subgroup analyses by probiotic strains (where > 3 trials provided data for key outcomes)  for live Lactobacillus casei strain GG  reduced duration of diarrhea (mean difference -26.69 hours, 95% CI -40.5 to -12.88 hours) in analysis of 11 trials with 2,072


patients, analysis limited by heterogeneity with 8 trials finding benefit and 3 trials finding no effect  reduced rate of diarrhea lasting ≥ 4 days in analysis of 4 trials with 572 patients  RR 0.59 (95% CI 0.4-0.87)  NNT 4-15 assuming diarrhea for ≥ 4 days in 53% of controls  analysis limited by heterogeneity with 3 trials finding benefit and 1 trial finding no effect  reduced mean stool frequency on day 2 in analysis of 6 trials with 1,135 patients, analysis limited by heterogeneity with 3 trials finding benefit and 3 trials finding no effect  for Enterococcus LAB SF68  reduced rate of diarrhea lasting ≥ 4 days in analysis of 4 trials with 333 patients  RR 0.21 (95% CI 0.08-0.52)  NNT 2-4 assuming diarrhea for ≥ 4 days in 62% of controls  analysis limited by heterogeneity but all 4 trials suggested benefit  for Saccharomyces boulardii  reduced rate of diarrhea lasting ≥ 4 days in analysis of 6 trials with 606 patients  RR 0.37 (95% CI 0.21-0.65)  NNT 4-8 assuming diarrhea for ≥ 4 days in 40% of controls  analysis limited by heterogeneity but all 6 trials suggested benefit  none of these 6 trials met all quality criteria o Reference - Cochrane Database Syst Rev 2010 Dec 8;(12):CD003048 some probiotics but not others may reduce duration of acute diarrhea in young children (level 2 [mid-level] evidence) o based on randomized trial without blinding of parents o 571 children aged 3-36 months with diarrhea (3 or more loose or liquid stools/day) for < 48 hours were treated with oral rehydration solution for 3-6 hours, then fed with full-strength formula, and were also randomized to 1 of 6 groups  oral rehydration alone  L. casei subspecies rhamnosus GG (Dicoflor 60) twice daily for 5 days  S. boulardii (Codex) twice daily for 5 days  Bacillus clausii (Enterogermina) twice daily for 5 days  Enterococcus faecium SF 68 (Bioflorin) twice daily for 5 days  mixture of L. delbrueckii var bulgaricus, L. acidophilus, Streptococcus thermophilus and B. bifidum (Lactogermina) twice daily for 5 days o median duration of diarrhea  115.5 hours with oral rehydration solution alone  118 hours with Enterogermina (not significant)  115 hours with Bioflorin (not significant)  105 hours with Codex (not significant)  78.5 hours with Dicoflor 60 (p < 0.001)  70 hours with Lactogermina (p < 0.001) o study not funded by industry, authors declare no competing interests


o

Reference - BMJ 2007 Aug 18;335(7615):340 , commentary can be found in BMJ 2007 Sep 1;335(7617):414 Lactobacillus preparations o Lactobacillus therapy may reduce duration and frequency of acute infectious diarrhea in children (level 2 [mid-level] evidence)  based on systematic review without trial quality assessment  systematic review and meta-analysis of 9 randomized placebo-controlled trials of Lactobacillus  at least 3 different Lactobacillus strains evaluated  summary point estimates show  reduction in diarrhea duration of 0.7 days (95% CI 0.3-1.2 days, based on 7 trials)  reduction in diarrhea frequency of 1.6 stools on day 2 of treatment (95% CI 0.7-2.6 fewer stools, based on 3 trials)  preplanned subanalysis suggests dose-effect relationship  Reference - Pediatrics 2002 Apr;109(4):678 , commentary can be found in ACP J Club 2002 Nov-Dec;137(3):96 o Lactobacillus therapy may reduce length of hospital stay in children admitted for acute diarrhea (level 2 [mid-level] evidence)  based on randomized trial with allocation concealment not stated  69 children hospitalized for acute diarrhea were randomized to Lactobacillus (L. rhamnosus 19070-2 [1,010 CFU] and L. reuteri DSM 12246 [1,010 CFU]) vs. placebo orally twice daily for 5 days  comparing Lactobacillus vs. placebo  duration of diarrhea 82 vs. 101 hours (p = 0.07)  10% vs. 33% had loose stools at end of study (p = 0.03, NNT 5)  comparing Lactobacillus vs. placebo among patients treated within 60 hours of onset of diarrhea  duration of diarrhea 80 vs. 130 hours  duration of hospitalization 1.7 vs. 3.5 days  Reference - Pediatr Dis Infect J 2002 May;21(5):411 in Altern Ther Health Med 2002 Nov-Dec;8(6):102 o live L. casei strain GG may reduce duration of acute diarrhea (level 2 [mid-level] evidence)  based on meta-analysis of 11 randomized trials with heterogeneity  Reference - see Cochrane review CD003048 summarized above o Lactobacillus reuteri may reduce duration and relapse of acute diarrhea in children (level 2 [mid-level] evidence)  based on randomized trial without intention-to-treat analysis  74 children aged 6-36 months hospitalized for acute diarrhea with clinical signs of mild to moderate dehydration randomized to Lactobacillus reuteri DSM 17938 (4 × 108 colony-forming units) orally once daily vs. placebo for 7 days  oral rehydration solution given during first 4 hours, then subsequent fecal losses replaced as needed  69 children (93%) included in analysis  comparing L. reuteri vs. placebo  diarrhea on day 3 in 73% vs. 46% (p < 0.03, NNT 4)


  

mean duration of diarrhea 2.1 days vs. 3.3 days (p < 0.03) relapse of diarrhea in 15% vs. 42% (p < 0.03, NNT 4) vomiting in 35% vs. 55% (not significant)  Reference - Aliment Pharmacol Ther 2012 Aug;36(4):363 o Lactobacillus paracasei strain ST11 (ST11) does not improve rotaviral diarrhea (level 1 [likely reliable] evidence) but may reduce duration of nonrotaviral diarrhea in children (level 2 [mid-level] evidence)  based on randomized trial  230 boys ages 4-24 months with acute watery diarrhea (4 or more liquid stools within 24 hours) for < 2 days in Bangladesh admitted to metabolic research unit and randomized to ST11 (5 billion colony-forming units) vs. placebo twice daily for 5 days  24 children with vibrios subsequently excluded, 3 children did not have rotavirus testing  in overall cohort, no significant differences in daily or cumulative stool output, stool frequency, oral rehydration solution intake or cessation of diarrhea  among 140 boys with positive rotaviral testing, no significant differences in daily or cumulative stool output, stool frequency, oral rehydration solution intake or cessation of diarrhea  among 63 boys with negative rotaviral testing, ST11 associated with lower cumulative oral rehydration solution intake (mean 180 vs. 331 mL/kg over 6 days), lower cumulative stool output (mean 225 vs. 381 g/kg over 6 days), higher rate of diarrhea cessation within 6 days (70% vs. 47%, NNT 5)  Reference - Pediatrics 2005 Aug;116(2):e221 o Lactobacillus GG probiotic may not reduce duration of diarrhea in infants and children < 2 years old hospitalized for acute diarrhea (level 2 [mid-level] evidence)  based on randomized trial with inadequate statistical power  64 Australian Aboriginal infants and young children (aged 4 months to 2 years) admitted to hospital with acute diarrhea were randomized to Lactobacillus GG (5 x 109 colony-forming units) vs. placebo orally 3 times daily for 3 days  no significant differences in duration of diarrhea or total diarrheal stools  Reference - J Pediatr Gastroenterol Nutr 2010 Jun;50(6):619 o Lactobacillus acidophilus reduced mean duration of diarrhea (from 63.4 hours to 39.5 hours, p < 0.01) in randomized trial in 80 children (mean age 10 months) (Pediatrics 2007 Oct;120(4):e795) S. boulardii o live S. boulardii may reduce rate of diarrhea lasting ≥ 4 days (level 2 [mid-level] evidence)  based on meta-analysis of 6 randomized trials with methodologic limitations  Reference - see Cochrane review CD003048 summarized above o S. boulardii may reduce duration of diarrhea in infants and children  based on systematic review and small randomized trial  systematic review of 5 randomized trials of S. boulardii with 619 children with acute infectious diarrhea


meta-analysis of 4 trials comparing S. boulardii vs. control  significantly reduced duration of diarrhea (weighted mean difference -1.1 days, 95% CI -1.3 to -0.8 days)  significantly reduced risk of diarrhea on days 3, 6 and 7  S. boulardii significantly reduced risk of diarrhea lasting > 7 days in 1 trial with 88 patients (NNT 5, 95% CI 3-20)  Reference - Aliment Pharmacol Ther 2007 Feb 1;25(3):257  small randomized trial without blinding  55 children (mean age 21 months) with acute nonbloody diarrhea randomized to S. boulardii vs. yogurt fluid  diarrhea resolution on day 3 in 48.5% with S. boulardii vs. 25.5% with yogurt fluid (p < 0.05, NNT 5)  no significant differences in  mean duration of diarrhea  hospital stay  Reference - Am J Trop Med Hyg 2010 Mar;82(3):488 o S. boulardii may reduce duration of diarrhea in children (level 2 [mid-level] evidence)  based on randomized trial with unclear method of randomization  186 children aged 6-48 months hospitalized within 72 hours of onset of acute diarrhea randomized to S. boulardii 200 mg orally twice daily for 5 days vs. placebo  S. boulardii associated with reduced duration of diarrhea (p < 0.05)  Reference - J Pediatr Gastroenterol Nutr 2011 Nov;53(5):497 E. coli strain Nissle 1917 reduces acute diarrhea in infants and toddlers (level 1 [likely reliable] evidence) o based on 2 randomized trials by same authors o randomized trial in 113 children  113 children aged 2-47 months with acute diarrhea randomized to E. coli Nissle 1917 vs. placebo suspension 1-3 mL/day orally  response defined as reduction of stool frequency to ≤ 3 watery or loose stools/day for at least 2 consecutive days  comparing E. coli Nissle 1917 vs. placebo  response rate 94.5% vs. 67.2% (NNT 4)  median time to response 2.5 days vs. 4.8 days (p = 0.0007)  Reference - Eur J Pediatr 2007 Apr;166(4):311 o randomized trial in 151 children  151 children aged 1-47 months with nonspecific diarrhea for 4-14 days randomized to E. coli Nissle 1917 vs. placebo suspension 1-3 mL/day orally for 21 days  comparing E. coli Nissle 1917 vs. placebo  7-day response rate 78.7% vs. 59.2% (NNT 6)  14-day response rate 93.3% vs. 65.8% (NNT 4)  21-day response rate 98.7% vs. 71.1% (NNT 4)  median time to response 2.4 days vs. 5.7 days (p < 0.0001)  Reference - Pediatr Infect Dis J 2008 Jun;27(6):494 Bio-three probiotics associated with decreased duration of diarrhea and length of stay among children hospitalized with acute infectious diarrhea (level 2 [mid-level] evidence)


o o

o

o

based on randomized trial with allocation concealment not stated 304 children aged 3 months to 6 years hospitalized for acute diarrhea randomized to Bio-three (mixture of Bacillus mesentericus, Enterococcus faecalis, and Clostridium butyricum) vs. placebo orally 3 times daily for 7 days comparing probiotics vs. placebo  mean duration of diarrhea after therapy was 60.1 vs. 86.3 hours (p = 0.003)  length of hospital stay was 2.9 vs. 4.2 days (p = 0.009) Reference - Pediatr Infect Dis J 2010 Feb;29(2):135

Other therapies: 

glutamine supplementation may reduce duration of diarrhea in infants (level 2 [midlevel] evidence) o based on randomized trial without intention-to-treat analysis o 159 infants with acute diarrhea in Turkey randomized to glutamine 0.3 g/kg/day vs. placebo for 7 days o 19.5% of children not included in analysis  some excluded because of urinary tract infection, detection of Shigella or Entameba histolytica, confirmed cow's milk intolerance  others excluded due to noncompliance or dropout o mean duration of diarrhea 3.4 vs. 4.6 days (p = 0.004) o no differences in weight gain or infectious diseases at 3 months o Reference - J Pediatr Gastroenterol Nutr 2004 May;38(5):494 o DynaMed commentary -- median duration of diarrhea less susceptible to outliers (that is, single cases with prolonged diarrhea) and should also have been reported individualized homeopathic treatment may modestly reduce duration of acute childhood diarrhea (level 2 [mid-level] evidence) o based on meta-analysis without intention-to-treat analysis o meta-analysis of 3 randomized trials comparing individualized homeopathic medicine vs. placebo in 242 children ages 6 months to 5 years with acute diarrhea o duration of diarrhea defined at time until less than 3 unformed stools per day for 2 consecutive days o 7% of children did not complete follow-up and were not included in analysis o duration of diarrhea 3.3 days with homeopathy vs. 4.1 days with placebo (p = 0.008, mean difference 0.66 days) o Reference - Pediatr Infect Dis J 2003 Mar;22(3):229 most commonly used homeopathic remedies for diarrhea are podophyllum in most cases, and Arsenicum album in cases with anxiety, emotional reaction or suspected food poisoning (Alternative Medicine Alert 2006 Feb;9(2):17) goldenseal (active component berberine) has been shown to reduce stool volumes and duration of infectious diarrhea, but not recommended due to possible toxicity and plant's endangered status (Arch Fam Med 1998 Nov-Dec;7(6):523 )

Medications not recommended: 

World Health Organization (WHO) advises against the use of (1) o antiemetics


o o o o

cardiac stimulants blood or plasma - unless hypovolemia due to septic shock steroids purgatives

Follow-up: 

  

fluid management after rehydration(3) o encourage fluid intake (for maintenance and after each large watery stool) o encourage breastfeeding and other milk feeds restart oral rehydration therapy if dehydration occurs after rehydration (3) re-evaluate children treated as outpatients after 7 days (or earlier if diarrhea worsens or if other problems arise)(1) children treated in hospital should be measured daily for(1) o body weight o temperature o food taken o number of diarrhea stools children with bloody diarrhea should be seen again in 2 days if (1) o initially dehydrated o < 1 year old o had measles during past 6 weeks o is not getting better (signs of improvement include absence of fever, less blood in stool, passage of fewer stools, improved appetite and normal activity)

PrognosisGuidelines and ResourcesPatient InformationICD-9/ICD-10 CodesReferences


Acute diarrhea in children