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Evidence based Medicine on Acute Diarrhea in Children
Dr.H.K.Takvani, MD Ped., FIAP
IPP, NNF, Gujarat State Chapter 2009-2010National Executive Board Member. IAP 4 termsPresident IAP, Gujarat State Branch, 2001 President IMA Jamnagar City Branch 2008-09 Children Hospital and Neonatal Care CentreJAMNAGAR-361008, Gujarat, [email protected] [email protected] www.takvanidr.multiply.com
19/04/2323 June, 2010 Takvani 1
"We can not guarantee cure, but what we can guarantee is an honest and transparent effort".
Why to talk on diarrhea?
Prescription Surveys says…..
• No ORS. IVF where ORS works well or better
• No advice on continuing, increasing BF,
(unnecessary stoppage of BF), diet or hygiene
• No zinc. 19/04/23 Takvani 2
Why to talk on diarrhea?
• Use of antiemetics
• Antibiotics often- Nor-metro, Oflo-ornida, Inj.A
mikacin.
• Un-necessary probiotics
• Racecadotril.19/04/23 Takvani 3
IAP Consensus Statement
• Highlights several important developments.
• Aims that benefits of new knowledge reach
affected.
• Wants that new products are not
inappropriately used. next19/04/23 Takvani 4
ORS in diarrhea
• ORS for all ages and all types of diarrhea.• Low osmolarity ORS recommended, WHO• Sodium 75 mmol/L and glucose 75 mmol/l,
osmolarity 245 mosmol/L• Continue Breast feeding and routine normal
diet and energy dense feeds.
19/04/23 Takvani 5
Why Reduced osmolarity ORS?
• 39% reduction in need for IVF
• 19% reduction in stool output
• 29% lower incidence of vomiting
• Risk of hyponatremia not significant in any
type of diarrhea. back19/04/23 Takvani 6
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.
19/04/23 Takvani 7
Zinc in Diarrhea • Zinc has an additional modest benefit
• Reduces stool volume.
• Reduces duration of diarrhea.
• Oral rehydration therapy must remain the
main stay of treatment.19/04/23 Takvani 8
Zinc in Diarrhea
• Dose: 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. back19/04/23 Takvani 9
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
Recommendations of the IAP National Task Force for Use of Probiotics
• Almost 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.
Recommendations of the IAP National Task Force for Use of Probiotics
• The effect of probiotics is strain related and there is paucity of data to establish the efficacy of the probiotic species (namely L. acidophilus, Lactic Acid Bacteria) available in the Indian market. To recommend a particular species it will have to be first evaluated in randomized controlled trials in Indian children.
Recommendations of the IAP National Task Force for Use of Probiotics
• The 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.
Recommendations of the IAP National Task Force for Use of Probiotics
• The primary outcome analyzed in all the studies was the duration of diarrhea. The more objective parameter of stool output was not evaluated.
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. 19/04/23 Takvani 15
Probiotics in the Treatment of Diarrhea
Mechanisms: 1.Protect the intestine by competing with
pathogens for attachment. 2.Strengthening tight junctions between
enterocytes3. Enhancing the mucosal immune
response to pathogens.19/04/23 Takvani 16
RacecadotrilNot enough evidence:Not enough evidence:• Safety.• Efficacy.• There is no data from our settings.• Methodology of studies questionable.• No routine use back
19/04/23 Takvani 17
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. 19/04/23 Takvani 18
• 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.
19/04/23 Takvani 19
Acute Diarrhea in the Young Infant (< 2 mth)
• Young infants with dehydration should be treated as has been recommended for other children with dehydration by ORS or IVF as per dehydration.
19/04/23 Takvani 20
Acute Diarrhea in the Young Infant (< 2 mth)
• 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.
19/04/23 Takvani 21
Acute Diarrhea in the Young Infant (< 2 mth)
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. 19/04/23 Takvani 22
19/04/23Takvani
23
hom
e av
aila
ble
fluid
sacceptable unacceptable
Plain water coffee
coconut water aerated cold drinks
plain buttermilk fruit juice(with sugar
milk Lassi(with sugar)
thin dal
fruit juice(without sugar)
Lassi(without sugar) NEXT
Antibiotic in Acute Diarrhoea
Indicated only for : • Acute bloody diarrhea with gross blood• Shigella positive culture, • Cholera, • Associated systemic infection• Severe malnutrition. (Septicemia)19/04/23 Takvani 24
Antibiotic in Acute Dysentery
• Indiscriminate 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 cotrimoxazole19/04/23 Takvani 25
Antibiotic in Acute Dysentery• Resistance 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.19/04/23 Takvani 26
Antibiotic in Acute Dysentery
Antibiotics are not not indicated if• No visible blood in stools• Pus 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)
19/04/23 Takvani 27
Antibiotic in Acute Dysentery
• Entamoeba histolytica and helminths rarely
ever cause acute diarrhea in children.
• Metronidazole and antihelminthics therefore
have no role in the routine management of
acute bloody diarrhea.19/04/23 Takvani 28
Antibiotic in Acute Dysentery
• Metronidazole/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.
19/04/23 Takvani 29
Antibiotics in Acute Dysentery
• Aminoglycosides like gentamicin and amikacin
have a poor spectrum of activity against
shigella species and therefore they are
ineffective in the management of acute
bloody diarrhea. back 19/04/23 Takvani 30
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.
19/04/23 Takvani 31
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.
19/04/23 Takvani 32
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).
19/04/23 Takvani 33
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
19/04/23 Takvani 34
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
19/04/23 Takvani 35
I conclude ….
• Prescribe ORS for all ages.
• Continue Breast feeding and diet.
• Explain danger signals.
• 20 mg/10 mg of elemental zinc
19/04/23 Takvani 36
I conclude….
No probiotics, may be as a placebo Causious approach infants <2 mo/PEM as it
can be a part of Septicemia. Judicious use of antibiotics for dysentery and
systemic infections No antimotility agents….strictly. (seen deaths)
19/04/23 Takvani 37
If interested… Indian Pediatrics• 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 - 348
• Statement National seminar on importance of zinc in human health Ms. Rekha Sinha. Indian Pediatrics : Dec 2004;41:1213 - 1217
• Editorial 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 - 433
• Brief Reports Outcome of Nutritional Rehabilitation with and without Zinc SupplementationK.E. Elizabeth, P. Sreedevi and S. Noel Narayanan. Indian Pediatrics : Jun 2000;37:650 – 655
• Management 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
19/04/23 Takvani 38
19/04/23 Takvani 39
[email protected] www.takvanidr.multiply.com
Dr.H.K.Takvani MD (Pediatrics), FIAPChildren Hospital and Neonatal Care Centre
Valkeshwari NagariIndira Marg
JAMNAGAR-361008, Gujarat, India
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