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Evidence based Medicine on Acute Diarrhea in Children
Dr.H.K.Takvani, MD Ped., FIAP IPP, NNF, Gujarat State Chapter
2009-2010 National Executive Board Member. IAP 4 terms President
IAP, Gujarat State Branch, 2001 President IMA Jamnagar City Branch
2008-09 Children Hospital and Neonatal Care CentreJAMNAGAR-361008,
Gujarat, India [email protected] [email protected]
www.takvanidr.multiply.com*23 June, 2010Takvani*"We can
notguaranteecure, but what wecan guarantee isan honest and
transparent effort".
Takvani
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Why to talk on diarrhea?
Prescription Surveys says..No ORS. IVF where ORS works well or
betterNo advice on continuing, increasing BF, (unnecessary stoppage
of BF), diet or hygieneNo zinc.
*Takvani*
Takvani
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Why to talk on diarrhea? Use of antiemeticsAntibiotics often-
Nor-metro, Oflo-ornida, Inj.Amikacin. Un-necessary probiotics
Racecadotril.*Takvani*
Takvani
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IAP Consensus Statement Highlights several important
developments.Aims that benefits of new knowledge reach
affected.Wants that new products are not inappropriately used.
next*Takvani*
Takvani
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ORS in diarrhea ORS for all ages and all types of diarrhea.Low
osmolarity ORS recommended, WHOSodium 75 mmol/L and glucose 75
mmol/l, osmolarity 245 mosmol/LContinue Breast feeding and routine
normal diet and energy dense feeds. *Takvani*
Takvani
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Why Reduced osmolarity ORS? 39% reduction in need for IVF19%
reduction in stool output29% lower incidence of vomitingRisk of
hyponatremia not significant in any type of diarrhea.
back*Takvani*
Takvani
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Zinc in Diarrhea Based on studies in India and other developing
countries there is sufficient evidence to recommend zinc in the
treatment of acute diarrhea as adjunct to oral
rehydration.*Takvani*
Takvani
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Zinc in Diarrhea Zinc has an additional modest benefitReduces
stool volume.Reduces duration of diarrhea.Oral rehydration therapy
must remain the main stay of treatment.*Takvani*
Takvani
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Zinc in DiarrheaDose: Elemental Zinc 20 mg/day for 6months and
older for 14 days 10 mg/day Between 2-6 months. Any of zinc salts
e.g., sulphate, gluconate or acetate may be used. back*Takvani*
Takvani
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Recommendations of the IAP National Task Force for Use of
Probiotics
The group recommended that based on analysis of studies there is
presently insufficient evidence to recommend probiotics in the
treatment of acute diarrhea in our settings
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Recommendations of the IAP National Task Force for Use of
ProbioticsAlmost all the studies till now were done in developed
countries except for one very small study from Pakistan. It may not
be possible to extrapolate the findings of these studies to our
setting where the breast feeding rates are high and the microbial
colonization of the gut is different.
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Recommendations of the IAP National Task Force for Use of
ProbioticsThe effect of probiotics is strain related and there is
paucity of data to establish the efficacy of the probiotic species
(namelyL. 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.
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Recommendations of the IAP National Task Force for Use of
ProbioticsThe earlier studies have documented a beneficial effect
on rotavirus diarrhea which was present in >75% of cases in
studies from the west. Rotavirus constitutes about 15% to 25% in
India.
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Recommendations of the IAP National Task Force for Use of
ProbioticsThe primary outcome analyzed in all the studies was the
duration of diarrhea. The more objective parameter of stool output
was not evaluated.
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What are Probiotics ??Nonpathogenic micro-organisms.Exert a
positive influence on the health or physiology of the host. They
consist of either yeast or bacteria, Sacc. Bul. and Lacto-bacillus.
*Takvani*
Takvani
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Probiotics in the Treatment of DiarrheaMechanisms: Protect the
intestine by competing with pathogens for attachment. Strengthening
tight junctions between enterocytes3. Enhancing the mucosal immune
response to pathogens.*Takvani*
Takvani
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RacecadotrilNot enough evidence:Safety.Efficacy.There is no data
from our settings.Methodology of studies questionable.No routine
use back*Takvani*
Takvani
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Acute Diarrhea in the Young Infant (< 2 mth) For assessment,
recommendations by the IMNCI which is an adapted version of IMCI
for India, should be followed. See if child is sick or well
child.Management is different for sick and well. *Takvani*
Takvani
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Infants who are breastfed and have no dehydration do not need
ORS and mothers should be advised to increase breast feeds more
often and for longer duration.*Takvani*Acute Diarrhea in the Young
Infant (< 2 mth)
Takvani
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Young infants with dehydration should be treated as has been
recommended for other children with dehydration by ORS or IVF as
per dehydration. *Takvani*Acute Diarrhea in the Young Infant (<
2 mth)
Takvani
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Third generation cephalosporins, intra-venous ceftriaxone and
amikacin if the child is sick looking, ?septicemia.Where
hospitalization is not possible, Oral Cefixime with Inj. Amikacin
may be tried after explaining the nature of disease and risk.
*Takvani*Acute Diarrhea in the Young Infant (< 2 mth)
Takvani
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Acute Diarrhea in the Young Infant (> 2 mth) For assessment,
IMNCI, No, some,sever dehy.Management is as per grades of
dehydration. In cases of No & some dehydration when orally
acceptable ORS- ZINC- home available fluids- increase BF. IVF in
Severe Dehydration. *Takvani*
Takvani
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*Takvani*home available fluids
acceptableunacceptablePlain watercoffee
coconut wateraerated cold drinks
plain buttermilkfruit juice(with sugarmilkLassi(with sugar)
thin dal
fruit juice(without sugar)Lassi(without sugar)NEXT
Takvani
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Antibiotic in Acute DiarrhoeaIndicated only for : Acute bloody
diarrhea with gross bloodShigellapositive culture, Cholera,
Associated systemic infectionSevere malnutrition.
(Septicemia)*Takvani*
Takvani
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Antibiotic in Acute DysenteryIndiscriminate use of antibiotics
Increasing incidence of resistance.Cotrimoxazole has been
recommended as the first line drug for acute bloody diarrhea. High
resistance of shigella to cotrimoxazole*Takvani*
Takvani
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Antibiotic in Acute DysenteryResistance rates to cotrimoxazole
exceed 30%Cefixime 20mg/kg/day 5-7 days should be used instead of
quinolones looking to safety and medico legal aspects.No response
to cefixime in 3 days Ceftriaxone 50-100mg/kg od for 2-5
days.*Takvani*
Takvani
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Antibiotic in Acute DysenteryAntibiotics are not indicated ifNo
visible blood in stoolsPus cells on stool microscopy because of
poor specificity of the test. Routine stool examination or stool
cultures have no useful role. (except to show that antibiotics are
not required- personal)*Takvani*
Takvani
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Antibiotic in Acute DysenteryEntamoeba histolytica and helminths
rarely ever cause acute diarrhea in children. Metronidazole and
antihelminthics therefore have no role in the routine management of
acute bloody diarrhea.*Takvani*
Takvani
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Antibiotic in Acute DysenteryMetronidazole/Tinidazole should be
used when cases of acute dysentery fail to respond to second line
drugs for dysentery such as cefixime or when a stool examination
has confirmed trophozoites of Entamoeba hystolitica.*Takvani*
Takvani
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Antibiotics in Acute DysenteryAminoglycosides 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. back *Takvani*
Takvani
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Antiemetics in Acute Diarrhea Vomiting, common associated
symptom.Distressing to the parent, antiemetics.Overdose due to
haste/improper preparation like domperidone 10mg/1ml instead of
1mg/1ml in sone (Domstal Baby and Motinorn) and round the clock
prescrition like TDS leads to side effects.*Takvani*
Takvani
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Antiemetics in Acute Diarrhea Low osmolarity ORS reduces
vomiting. Stop for 10 minutes and than restart giving ORS in small
sips.Most can be managed by frequent small sips (5-10 ml) of ORS
with sips of simple water and breast feeding in between without
force feeding ORS. *Takvani*
Takvani
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Antiemetics in Acute Diarrhea Antiemetics should be reserved for
children in whom the vomiting is severe, recurrent and interferes
with ORS intake (more than 3 per hour). *Takvani*
Takvani
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Antiemetics in Acute Diarrhea A single dose of
domperidone/?ondansetron in children with severe vomiting.
Continued use is not recommended. Dose of 0.1-0.3 mg/kg/dose.
Single dose only*Takvani*
Takvani
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Antiemetics in Acute Diarrhea In view of serious side effects
metoclopramide is not recommended.Personal experience: Single dose
of Inj.Metoclopramide 0.2mg/kg stops vomiting and improves ORS
intake and avoids IV fluids in many cases without a single case of
side effect. Not validated by IAP. back*Takvani*
Takvani
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I conclude .Prescribe ORS for all ages.Continue Breast feeding
and diet.Explain danger signals.20 mg/10 mg of elemental
zinc*Takvani*
Takvani
- I conclude.No probiotics, may be as a placeboCausious approach
infants
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If interested Indian PediatricsStatement Consensus statement of
IAP National Task Force: Status report on management of acute
diarrhea Shinjini Bhatnagar,Nita Bhandari, U.C. Mouli , M.K. Bhan.
Indian Pediatrics : Apr 2004;41:335 - 348Statement National seminar
on importance of zinc in human health Ms. Rekha Sinha. Indian
Pediatrics : Dec 2004;41:1213 - 1217Editorial The role of zinc in
child health in developing countries: Taking the science where it
matters Zulfiqar A. Bhutta. Indian Pediatrics : May 2004;41:429 -
433Brief Reports Outcome of Nutritional Rehabilitation with and
without Zinc SupplementationK.E. Elizabeth, P. Sreedevi and S. Noel
Narayanan. Indian Pediatrics : Jun 2000;37:650 655Management of
Acute Diarrhea: From Evidence to Policy Shinjini Bhatnagar, Seema
Alam* and Piyush Gupta* National Co-ordinator, and *Joint National
Co-ordinators, IAP-UNICEF Program on Evidence-based Management of
Diarrhea.http://indianpediatrics.net/mar2010/mar-215-217.htm
*Takvani*
Takvani
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*Takvani*[email protected]
www.takvanidr.multiply.comDr.H.K.Takvani MD (Pediatrics),
FIAPChildren Hospital and Neonatal Care CentreValkeshwari
NagariIndira MargJAMNAGAR-361008, Gujarat, IndiaFriends. Please
Share your views
Takvani
Takvani, JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani, Jamnagar*[email protected]*Instead of
lactobacillus , can we make it probiotics?Can the bit about feeding
come up as the 2nd point and probiotics and the antisecretory drug
shifted [email protected], JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani, Jamnagar*[email protected]*It should be Low
Osmolarity ORS [email protected], JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani, Jamnagar*[email protected]*The recommendations
as per the revised guidelines from the health ministry are 10 mg
zinc for 2 upto 6 months and 20 mg for children 6 months or
[email protected],
[email protected],
[email protected],
[email protected],
[email protected],
[email protected], JamnagarTakvani,
Jamnagar*[email protected]*What are
[email protected], JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani, Jamnagar*[email protected]*Where is the
recommendation for this different ORS for young infants?I thought
all children including infants had to be given the same low
osmolarity ORS recommended by WHO and govt. of
[email protected], JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani, Jamnagar*[email protected]*WHO recommends
quinolones as the 1st line of drugs for dysentery. We were also
told that quinolones had been approved as the 1st line in India ,
but apparently this issue has been raised again and therefore is
still a grey area. It the circumstances it is best to stick to what
you are [email protected], JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani,
Jamnagar*[email protected]*[email protected],
JamnagarTakvani, Jamnagar*[email protected]*Statement Consensus
statement of IAP National Task Force: Status report on management
of acute diarrhea Shinjini Bhatnagar,Nita Bhandari, U.C. Mouli ,
M.K. Bhan. Indian Pediatrics : Apr 2004;41:335 - 348Statement
National seminar on importance of zinc in human health Ms. Rekha
Sinha. Indian Pediatrics : Dec 2004;41:1213 - 1217Editorial The
role of zinc in child health in developing countries: Taking the
science where it matters Zulfiqar A. Bhutta. Indian Pediatrics :
May 2004;41:429 - 433Brief Reports Outcome of Nutritional
Rehabilitation with and without Zinc SupplementationK.E. Elizabeth,
P. Sreedevi and S. Noel Narayanan. Indian Pediatrics : Jun
2000;37:650 655Management of Acute Diarrhea: From Evidence to
Policy Shinjini Bhatnagar, Seema Alam* and Piyush Gupta* National
Co-ordinator, and *Joint National Co-ordinators, IAP-UNICEF Program
on Evidence-based Management of
Diarrhea.http://indianpediatrics.net/mar2010/mar-215-217.htm
[email protected], JamnagarTakvani,
Jamnagar*[email protected]*www.takvanidr.multiply.com
[email protected]
