SYMPOSIUM ON PGIMER MANAGEMENT PROTOCOLS IN GASTROINTESTINAL EMERGENCIES

Management of Acute Diarrhea in Emergency Room

Parag Dekate & M. Jayashree &

Sunit C. Singhi

Received: 3 July 2012 /Accepted: 8 October 2012# Dr. K C Chaudhuri Foundation 2012

Abstract Acute diarrhea is the second leading cause ofunder-five mortality in India. It is defined as the passageof frequent watery stools (>3/24 h). Recent change in con-sistency of stools is more important than frequency. Acutediarrhea is caused by variety of viral, bacterial and parasiticagents. The common ones are: Rotavirus, E. coli, Shigella,Cholera, and Salmonella. Campylobacter jejuni, Giardiaand E. histolytica are also not uncommon. The most impor-tant concern in management of acute diarrhea in Emergencyroom (ER) is fluid and electrolyte imbalances and treatmentof underlying infection, wherever applicable. It includes,initial stabilization (identification and treatment of shock),assessment of hydration and rehydration therapy, recogni-tion and treatment of electrolyte imbalance, and use ofappropriate antimicrobials wherever indicated. For assess-ment of hydration clinical signs are generally reliable; how-ever, in severely malnourished children sunken eyes andskin turgor are unreliable. Oral Rehydration Therapy is thecornerstone of management of dehydration. Intravenousfluids are not routinely recommended except in cases ofpersistent vomiting and/or shock. Majority of cases can bemanaged in ER and at home. Hospitalization is indicated ininfants <3 mo, children with severe dehydration, severemalnutrition, toxic look, persistent vomiting and suspectedsurgical abdomen. Supplementations with zinc and probiot-ics have been shown to reduce severity and duration ofdiarrhea; however evidence does not support the use ofantisecretary, antimotility and binding agents. Education ofparents about hand hygiene, safe weaning and safe drinkingwater etc., can help in reducing incidence of this importanthealth problem in the country.

Keywords Children . Acute diarrhea . Oral rehydrationtherapy . Severe dehydration

Introduction

Diarrhea remains second commonest cause of death in chil-dren under 5 y in developing countries despite improvingtrends in diarrhea mortality; it accounts for 15 % of alldeaths of children less than 5 y in developing countries[1, 2]. On average, children < 5 y in developing countries,suffer a median of 3.2 episodes of diarrhea/child/year and upto 4.9 children/1000/year die because of diarrhea. Most of thedeaths are because of fluid and electrolytes imbalance. Themost common concern in Emergency management is acutefluid and electrolytes imbalances and treatment of underlyinginfection wherever indicated.

Definition

Diarrhea Diarrhea is defined as passage of unusually loose orwatery stools with an increase in the frequency, usually at leastthree times in 24 h period. However, it is the consistency of thestools rather than the number that is most important. Breastfed babies may normally pass 5–7 stools a day. Diarrhealasting longer than 14 d is labeled as ‘persistent diarrhea’.

Dysentery Presence of gross blood in the stool is the hall-mark of dysentery and may be accompanied by abdominalcramps and fever.

What is Not Diarrhea?

& Passage of frequently formed stools.& Passage of pasty stools in breast fed infants.

P. Dekate :M. Jayashree : S. C. Singhi (*)Department of Pediatrics, Advanced Pediatrics Centre,Post Graduate Institute of Medical Education and Research,Chandigarh 160012, Indiae-mail: sunit.singhi@gmail.com

Indian J PediatrDOI 10.1007/s12098-012-0909-3

& Passage of stool during or immediately after feeding dueto gastrocolic reflex.

& Passage of frequent loose greenish yellow stools on the3rd and 4th day of life called as transitional stools.

Etiology

Common organisms causing diarrhea, their incidence andpathogenesis are given in Table 1.

Viral diarrhea infects small intestinal epithelium. Theonset is generally abrupt, patient is likely to be afebrileand may have associated vomiting or respiratory symptoms.Toxigenic bacteria also involves small bowels and causessecretary diarrhea (Table 2)

Invasive bacterial and protozoal diarrhea involves colon.Diarrhea is bloody or mucoid and may have associated col-icky abdominal pain, fever and tenesmus. Food poisoning iscaused by preformed bacterial toxins. Onset is abrupt withvomiting followed by diarrhea (Table 3).

Clinical Evaluation [2–4, 8–10]

The objectives of initial clinical evaluation of the patient inemergency department are:

1. Assessment of the severity of the illness, grade of de-hydration and rehydration needs.

2. Identification of likely causes on the basis of the historyand clinical findings.

A rapid assessment of airway, breathing and circulationshould be done in all children at presentation. Tachycardia,prolonged capillary refill time, decreased urine output, al-tered mental status and hypotension indicates presence ofshock and calls for oxygen, and fluid resuscitation with20 ml/kg normal saline bolus.

History and Examination

Further history and examination [2–4, 8–10] should includeinformation as shown in Table 4.

Hydration status is assessed from stool frequency, heartrate, pulse volume, capillary refill time, skin turgor, sunkeneyes or fontanelle and activity level, or change in weightfrom the previous weight. Grading of hydration status basedon clinical signs is shown in Table 5 and that based onchange in weight in Table 6. Some of the typical signs ofdehydration may not be reliable in malnourished children.Marasmic children may have sunken eyes, and diminishedskin turgor without dehydration. Skin turgor may be maskedby edema in children with Kwashiorkor; irritability and

apathy may be present in both the types of malnutrition. Insuch children thirst, dry tongue and mouth (inner side ofcheek), and signs of hemodynamic compromise (fast threadpulse, delayed capillary refill time and orthostaticchanges in BP, and hypotension) are most reliable indicatorsof dehydration [4].

On abdominal examination children with uncomplicateddiarrhea generally tend to have diffuse abdominal tendernessand loud bowel sounds. Presence of localized tenderness,rebound tenderness to absent bowel sounds indicates a possi-ble surgical cause. Palpation of a loop of bowel or a masssuggests intussusception, enterocolitis or inflammatory boweldisease.

Laboratory Investigations

Laboratory investigations are not required routinely in major-ity of cases of acute diarrhea. Indications for selective use oflaboratory investigations are as summarized in Table 7.

Differential Diagnosis of Acute Diarrhea [3, 9]

Systemic Disease with Acute Diarrhea

Infants and young children with systemic disease can some-times present with acute diarrhea. They generally have sys-temic signs of sepsis and sick look, but not necessarily. In suchchildren following clinical diagnosis should be kept in mind.

& Otitis media, bacterial pharyngitis& Urinary tract infection& Pneumonia& Meningitis& Bacterial sepsis

Diarrhea with Surgical Acute Abdomen

When symptoms of colicky abdominal pain, vomiting andlethargy accompany bloody diarrhea, and abdominal palpa-tion reveals a mass, intussusception, malrotation, and sub-acute intestinal obstruction should be ruled out.

Sometimes because of ingested food stools may appearred (e.g., From beet, red candies, popsicles, cranberries etc.)or tarry (bismuth containing anti-diarrhea, Iron-spinach,chocolate etc.) mimicking blood in stools.

Management [2, 4]

Majority of the patients with diarrhea having mild or nodehydration can be treated on ambulatory basis at home. Somepatients may need a brief period of observation while patients

Indian J Pediatr

Tab

le1

Etio

logicalcauses

ofdiarrhea

with

incidenceandpathog

enesis[3–6]

Category

Agent

Incidence

Patho

genesis

Viruses

Rotavirus

Causes15

–20

%of

diarrhea

Cytop

athicto

smallintestinal

epith

elialcells

Respo

nsible

forup

to50

%of

diarrhea

associated

with

clinical

dehy

drationin

child

renaged

6–24

mo.

Enterov

irus

Virus

replicationandcytopathic

effect

onsm

allintestinal

cells

Adeno

virus

2–5%

Cytolysis,cytokine

prod

uctio

n,andindu

ctionof

hostinflam

matoryrespon

se

Bacteria

Enterotox

igenic

E.coli(ETEC)

Causesup

to25

%diarrhea

inallagegrou

psProdu

cesheat

labile

(LT)and/or

heat

stable

(ST)

enterotoxins

causingsecretorydiarrhea

ofsm

allintestine

Shigella

Causesup

to5–10

%of

acutediarrhea

inallagegroups

Dysentery

syndromeby

invasion

oflargebowel

andenterotoxin

mediatedsm

allbo

wel

diarrhea

Vibrio

cholera

Frequ

entcauseof

diarrhea

inendemic

areasin

child

ren2–

10y

ofage.Accou

ntsfor5–10

%ho

spitalizationin

nonendemic

areas.

Tox

inmediatedsecretorydiarrhea

Non

typh

oidalsalm

onella

Causes2–

10%

ofdiarrhea

indeveloping

coun

tries

Intracellularinvasion

ofileal

epith

elium

Cam

pyloba

cter

jejuni

Causes5–

15%

ofalldiarrhea.Itisazoon

osis

Invasive

andtoxigenicdiarrhea

Protozoal

Giardia

duod

enalis[5]

Mostcommon

protozoalinfectioncausingdiarrhea

Dam

ageto

theendo

thelialbrushbo

rder,enterotoxins,

immun

olog

icreactio

ns,andalteredgu

tmotility

and

fluidhy

persecretio

n

Entam

oeba

histolytica[6]

Ann

ually

0.09

episod

es/child

ofE.histolytica-associated

diarrhea

and0.03

episod

es/child

ofE.histolytica-associated

dysentery

Excystatio

nin

thesm

allbo

wel

andinvasion

ofthecolon

bythetrop

hozoites

Cryptospo

ridium

[7]

Causesaself-lim

iteddiarrhealillness

inhealthyindividu

als

andpersistent

diarrhea

inim

mun

ocop

romised

child

ren

Infectsdistal

smallintestineandprox

imal

colon,

nocytopathic

effect.Causesvillo

usatroph

y,lymph

ocytic

infiltrationetc.

Indian J Pediatr

having severe dehydration and a selective group of veryyoung, malnourished, toxic-sick looking patients need hospi-talization as shown below.

Indications for Observation in Emergency Department

& Stable newborns and infants with diarrhea without fea-tures of toxicity and dehydration.

& Patient with moderate dehydration accepting orally well.& Malnourished children with mild dehydration.& Patients with diarrhea without dehydration with de-

creased oral intake.

Indications for Hospitalization [2–4, 10]

& Severe dehydration requiring intravenous hydration.& Newborns and infants <3 mo of age with dehydration.& Malnourished children with dehydration.& Toxic appearance, changing mental status (GCS<11) or

seizures.& Fever >38.5 °C for infants > 3 mo or >39 °C for children

6–36 mo-old.& Suspected surgical cause: localizing findings and entero-

colitis need surgical consult.& High output diarrhea (>10 large volume stool/day).& Persistent vomiting, or diminished or no oral intake .& Suboptimal or no response to oral rehydration therapy

(ORT) or further deterioration.& Inability of caregivers to administer ORT.& History of premature birth, chronic medical conditions

or concurrent illness.

Treatment of a Child with Diarrhea Presenting in Shock

It is difficult to distinguish between hypovolemic shockcaused by severe dehydration and septic shock initially. Allchildren in shock should be given 20 ml/kg of rapid fluidbolus in first hour with continuous monitoring of pulse rate,pulse volume, respiratory rate, capillary refill time and urineoutput. If shock improves at the end of the bolus (reflected bydecrease in pulse rate, respiratory rate, improved pulsevolume, capillary refill time and urine output), a diagnosisof hypovolemic shock (severe dehydration) should be con-sidered and oral rehydration therapy should be started asdetailed later. If there is worsening or no improvement atend of initial fluid bolus, septic shock should be consideredand appropriately managed as per the septic shock guidelines(management of septic shock is beyond the scope of thisprotocol, please refer to septic shock guidelines elsewhere).

Oral Rehydration Therapy (ORT)

Oral rehydration therapy (ORT) is the administration offluid by mouth to prevent or correct dehydration thatoccurs as a consequence of diarrhea. ORT is the stan-dard for efficacious and cost-effective management ofacute gastroenteritis, both in developing and developedcountries.

Oral rehydration solution (ORS) is the fluid specificallydeveloped for ORT. Composition of standard ORS is shownin Table 8. A more effective, lower-osmolarity ORS (withreduced concentrations of sodium and glucose, associatedwith less vomiting, less stool output, and a reduced need forintravenous infusions in comparison with standard ORS)has been developed for global use [2, 8, 10].

Table 3 Incubation period and likely causes of toxogenic diarrhea/food poisoning [3, 4]

Incubation period Likely causes of diarrhea

<6 h Preformed toxins of B. cereus and S. aureus

6 – 24 h Preformed toxin of C. perfringes and B. cereus

16 – 72 h Vibrio, Salmonella, ETEC, Shigella,Campylobacter, Yersinia, Shiga toxinproducing E.coli, Giardia, Cyclospora,Cryptosporidium

Table 4 History and clinical evaluation of diarrhea patient [2, 4, 8, 9]

History Assessment of dehydration

Onset, frequency, quantity General appearance, alertness

Character: bile, blood and mucus Temperature

Vomiting (color and frequency) Pulse rate, volume

Fever Respiratory rate (acidotic breathing)

Oral acceptance Blood pressure

Abdominal distension Capillary refill time

Level of consciousness,abnormal movements

Mucus membrane(tongue, inner cheek)

Urine output (passageof urine in last 6 h)

Sunken fontanels, sunken eyes

Perianal excoriation or rednessSkin turgor

Underlying medical conditionGlasgow coma score (GCS)

Past medical historySigns of malnutrition

Epidemiological historyChange in body weight(if previous body weight known)

Table 2 Etiologic agents and and pattern of small vs. large boweldiarrhea [3, 4]

Site Organisms Characteristics

Small boweldiarrhea

Rotavirus, Salmonella,V. cholera, Giardia,Cryptosporidium

Frequent, largequantity, watery,greenish to whitestools

Large boweldiarrhea

Shigella, Enteroviruses,E. coli, C. jejuni,E. histolytica

Semi-loose, smallquantity, with orwithout blood inthe stool

Indian J Pediatr

ORT consists of

& Rehydration& Maintenance therapy& Prevention of ongoing losses

ORT may be contraindicated in children who are in hemo-dynamic shock or with ileus. For children who are unable totolerate ORS via oral route (with persistent vomiting),naso-gastric feeding can be used to administer ORS.

Treatment of Mild and Moderate Dehydration

1. Oral Rehydration Therapy (ORT) [2, 4, 10]

& Determine amount of ORS to be given during first4 h (Table 9)

& Show the mother how to mix and give ORS solution.Give frequent small sips from a cup. If the child vomits,wait for 10 min. Then continue, but more slowly. Con-tinue breastfeeding whenever the child wants.

& Give recommended amount of ORS over 4–h period asmentioned in Table 9 according to the degree ofdehydration.

& Reassess for the degree of dehydration after 2–4 h andselect the appropriate plan for further rehydration.

2. Give Extra Fluids [2, 4, 11]

& If breast fed, breastfeed frequently and for longer ateach feed.

& If the child is not exclusively breastfed, give one ormore of the following home made food-based fluids(such as soup, rice water, and yoghurt drinks), orclean water.

& If the child wants more ORS than shown, give more.& For infants less than 6 mo who are not breastfed, also

give 100–200 ml clean water during this period.& Show the mother how much fluid to give in addition

to the usual:

Up to 2 y: 50 to 100 ml after each loose stool and inbetween them.2 y or more: 100 to 200 ml after each loose stooland in between them.

3. Continue Feeding [2, 10]

Begin feeding the child in emergency itself withwhatever is appropriate for the age of the child. Avoidhigh fiber and bulky food, very dilute soups and foodwith lot of sugar.

Points to be Kept in Mind During Rehydration [4]

& Rehydration must be assessed by clinical examinationand not by fluid volume given.

& The volumes can be increased to achieve rehydration.& Puffiness around the eyes suggests over hydration.

Table 5 Assessmentof dehydration [2–4, 8, 9] Characteristics Mild

dehydrationModerate dehydration(≥2 signs)

Severe dehydration (>2signs)

Watery stools < 4/d 4–10/d >10/d

Vomiting Some/none Some/none Very frequent

Condition Well alert Restless, irritable Lethargic, dry, floppy

Eyes Normal Sunken Very sunken and dry

Tears Present Absent Absent

Tongue Moist Dry Very dry

Thirst Drinks normally Thirsty, drinks eagerly Unable to drink

Skin turgor Normal Delayed (slow return) Very delayed (>2 s)

CRT Normal Prolonged Prolonged

Extremities Warm Cold Mottled, cynotic

Heart rate Normal Increased Increased or decreased in severe cases

Pulse quality Normal Normal to decreased Weak, thread, impalpable

Urine output Normal Decreased and high colored Very scanty/anuria for 6 h

Table 6 Assessment of severity of dehydration as per body weight loss [2– 4]

Age Mild dehydration Moderate dehydration Severe dehydration

Infants (EWL) 0–5 % of body wt. loss 5–10 % of body wt. loss >10 % of body wt. loss

Children and adolescents(EWL) <3 % of body wt. loss 3–9 % of body wt. loss >9 % of body wt. loss

EWL Estimated weight loss

Indian J Pediatr

Maintenance therapy should be started as soon as the signs ofdehydration have gone, but not before it. A simplified algorithmfor rehydration therapy of acute diarrhea is shown in Fig. 1.

When to Return

Mother/caretaker should be advised to return to healthcare facility immediately if any of the following symp-toms are noticed.

& Passes many stools (>10 times/d)& Is very thirsty

& Has sunken eyes& Has fever& Does not eat or drink normally& Not passing urine for 6 h& Having altered mentation& Not getting better after 2 d

Treatment of Severely Dehydrated Children(Replacement Therapy) [2, 4, 10]

Start IV fluid immediately. If the child can drink, giveORS by mouth while the drip is set up. Give 100 ml/kgRinger’s Lactate Solution (or, if not available, normalsaline) divided as follows: 20 ml/kg body weight intra-venously till perfusion and mental status improve; thenadminister 100 ml/kg ORS over 4 h or 5 % dextrose ½saline IV at twice maintenance fluid rate (Table 9).

& Reassess the child every 1–2 h. If hydration status is notimproving; give IV drip more rapidly. Also give ORS(about 5 ml/kg/h) as soon as the child can drink; usuallyafter 3–4 h (infants) or 1–2 h (children).

Table 7 Indications for various investigations in a patient with acute diarrhea and their importance [4, 10]

Investigations Indications Important points

Stool routine 1. Mucoid and bloody diarrhea Presence of leukocytes, protozoa, RBC’s and bacteria.

2. Suspected cholera (hanging drop preparation) Presence of polymorphs suggest infection by invasive bacteria

Stool culture 1. Toxic looking infants <1 y havingpolymorphs in stool

Available after 2–3d

2. Suspected cholera

Start/change antibiotic as per sensitivity pattern

3. Immunocompromised children

4. Children with hemoglobinopathies

Blood counts, bloodculture, CRP

1. Newborns with diarrhea Distinguishes Salmonella and Shigella infection -Shigella having a marked shift to left.2. Toxic infants and children’s

Start/change antibiotic as per sensitivity pattern3. Infants <3 mo, with fever >38.5°C

Monitoring of systemic inflammation4. Older children with sepsis, fever, seizuresand altered sensorium

Blood biochemistry (Na, K,urea, creatinine, glucose)

1. All those requiring hospitalization These parameters will guide the treatment plan andguide the response to treatment. Some abnormalitiesneed urgent treatments (hypo kalemia, hypoglycemia,hyponatremic seizures etc. )

2. Seriously ill toxic patients3. Severe dehydration/shock

4. Malnourished patients with dehydration

5. Newborns and infants <3 mo

6. Children with altered sensorium

Blood gas analysis 1. All seriously ill patients Will tell about metabolic acidosis, bicarbonatelosses from the body, body compensation andimprovement with treatment

2. Patients with acidotic breathing

3. Patients with severe dehydration or shock

4. Malnourished patients with dehydration

ECG 1. Malnourished patients Will tell about the K+ status

2. Severely dehydrated patients

3. Patients with high output diarrhea

4. Patients having acidosis

Table 8 Composition of WHO ORS [2]

Components g/L Constituents(ionic form)

Concentration(mmol/L)

Sodium chloride 2.6 Sodium 75

Anhydrous glucose 13.5 Chloride 65

Potassium chloride 1.5 Glucose 75

Trisodium citrate, dihydrate 2.9 Potassium 20

- - Citrate 10

Total osmolality 245

Indian J Pediatr

& Reassess an infant after 6 h and a child after 3 h.Classify dehydration. Then choose the plan to con-tinue treatment

& If ORT is not possible or feasible, same amount of fluidcan be given intravenously. Type of fluid used is Ringerlactate or N/2 in 5 % dextrose (Fig. 1).

Therapeutic End Points in Intravenous Rehydration Therapy

1. Adequate urine output2. Urine specific gravity (1.010–1.015)3. Normal serum electrolytes4. BUN decreased by one half every 15–20 h till normalized

Table 9 Guidelines forrehydration therapy [2, 4, 10]

a Use the child’s age only whenthe weight is not known. Theapproximate amount of ORS re-quired (in ml) in case of moder-ate dehydration can becalculated as 50– 100 (75) ml/kgof child’s body weight [2]b Repeat if radial pulse is stillvery weak or not detectable andconsider probable septic shock

Degree of dehydration Age group Type of fluid Volume of fluid Rate of administration

Mild All ORS 50 ml/kg Within 4 h

Moderate < 4 moa (< 6 kg) ORS 200 – 400 ml Within 4 h

4 –12 mo ORS 400 – 700 ml Within 4 h(6 – 10 kg)

12 – 24 mo ORS 700 – 900 ml Within 4 h(10 – 12 kg)

24 – 60 mo ORS 900 – 1400 ml Within 4 h(12 – 19 kg)

Severe < 12 mo RL First 30 ml/kg Within 1 hb

RL Then 70 ml/kg Within 5 h

1 – 5 y RL First 30 ml/kg Within 30 min

RL Then 70 ml/kg Within 2.5 h

If signs of dehydration are still present follow by: ORS 20 ml/kg every hour

Fig. 1 A simplified algorithmfor rehydration therapyof acute diarrhea

Indian J Pediatr

5. Normal acid base status6. Urinary K+> 40 mEq/L

Antimicrobial Therapy [2, 3, 8, 10]

The decision to treat with antimicrobial therapy shouldbe made on a patient-by-patient basis, and may differaccording to the age group. Antimicrobials are notneeded for small bowel diarrhea and food poisoningexcept cholera. Large bowel diarrhea is invasive. Sal-monella can cause bacteremia in about 10–45 % ofinfected infants and neonates, while shigella and inva-sive E. coli can cause high fever and toxemia. Inshigellosis,therapy is required in severely ill childrenor children with persistent symptoms. Yersinia needstreatment when there is severe disease, bacteremia orunderlying illness. Timely antibiotic therapy in selectedcases of diarrhea may reduce the duration and severityof diarrhea and prevent complications. While theseagents are important to use in specific cases, theirwidespread and indiscriminate use leads to developmentof anitmicrobial resistance. Use of antimicrobials is rec-ommended in the treatment of acute diarrhea when there

are signs of systemic infections, recognizable bloodydiarrhea and in immunocompromised hosts as follows:

1. Diarrhea with clinical signs of sepsis: (toxic look,leukocytosis, fever > 38.5° C, septic shock): Ceftriaxone50 –100 mg/kg/d IV/IM divided 12 hourly for 7–10 d.

2. Diarrhea in a child with severe malnutrition: Ampicillin200 mg/kg/d IV/IM divided 6 hourly along with genta-micin 5 mg/kg/d IV/IM 8 hourly for 7–10 d.

3. Neonates and very young infants (< 3 mo) with fever(> 38.5°C): Cefotaxime 150 mg/kg/d IV/IM divided8 hourly along with amikacin 15 mg/kg/d IV/IM OD for7–10 d

4. Dysentry (bloody stools) and diarrhea during outbreakof shigellosis: Ceftriaxone IV/IM 50–100 mg/kg/d for7 d or Ciprofloxacin orally 20–30 mg/kg/d divided12 hourly for 7–10 d.

5. Suspected Cholera (‘Rice water stools’ with highpurge rate i.e., > 10 large volume stools/d): Doxy-cycline 300 mg OD for 3 d or Azithromycin 20 mg/kg single dose. Treatment of cholera decreases du-ration of disease and mortality, and controls thetransmission.

Table 10 Antibiotics used in acute diarrhea as per causative agent[2–4, 7, 9, 10]

Organism Drug of choice Doses

Shigella (severe dysenteryand EIEC dysentery)

Ciprofloxacin, ampicillin, ceftriaxone, ortrimethoprim-sulfamethoxazole (TMP-SMX).

Ceftriaxone IV IM 50–100mg/kg/d qd, bid × 7 d

Most strains are resistant to many antimicrobials Ciprofloxacin PO 20–30 mg/kg/d bid × 7–10 d

10 mg/kg/d of TMP and 50 mg/kg/d of SMX bid × 5 d

V. cholera Doxycycline, azithromycinor ciprofloxacin

Doxycycline 300 mg OD for 3 d

Azithromycin 20 mg/kg single dose

Ciprofloxacin PO 20–30 mg/kg/d qid for 5–10 d

EPEC, ETEC, EIEC TMP-SMX or ciprofloxacin 10 mg/kg/d of TMP and 50 mg/kg/d of SMX bid × 5 d

Ciprofloxacin PO 20–30 mg/kg/d qid for 5–10 d

Salmonella No antimicrobials for uncomplicatedgastroenteritis in normal hosts causedby non-typhoidal species.

See treatment of Shigella

Treatment is indicated in infants <3 mo,patients <1 y with toxic look, severe colitis,immuno-incompetent state (malignancy,chronic GI disease, hemoglobinopathies, or HIV infection)

Clostridium difficile Discontinue offending antibiotic

Metronidazole (first line) PO 30 mg/kg/d divided tid × 5 d

Vancomycin (2nd line) PO 40 mg/kg/d qid × 7 d

Entamoeba histolytica Metronidazole PO 30–40 mg/kg/d tid × 7–10 d

Giardia lamblia Furazolidone or metronidazole or albendazoleor quinacrine

Furazolidone PO 25 mg/kg/d qid for 5–7 d

Metronidazole PO 30–40 mg/kg/d tid × 7 d

Albendazole PO 200 mg bid × 10 d

Campylobacter jejuni Erythromycin or azithromycin Erythromycin 50 mg/kg q8h, 5 d

Azithromycin 5–10 mg/kg qid, 5 d

Indian J Pediatr

6. Suspected amebiasis, or giardiasis (colitic stools,anorexia and weight loss, persistent diarrhea, failureto thrive): Metroinidazole oral 30–40 mg/kg/d divid-ed 8 hourly for 7–10 d, and cryptosporidium(nitazoxamide).

7. Diarrhea in an immunocompromized child (HIV infec-tion, lymphoreticular malignancy, receiving chemother-apy, underwent organ transplantation)

Antimicrobials to be given in acute diarrhea when thepathogen is known are given in detail in Table 10.

Other Ways of Management

Significant abnormalities in serum sodium concentrationcan to occur in acute diarrhea. In patients receiving intrave-nous rehydration further management of fluid and electro-lyte therapy with respect to serum sodium concentration isgiven in Table 11.

Enteral Feeding and Diet Selection [2]

Give an age- appropriate diet-regardless of the fluid usedfor ORT/maintenance. Infants require more frequentbreastfeedings. Older children need appropriately morefluids and energy and micronutrient – rich foods (Energydensity 1 kcal/g). Give appropriate food (grains, dals,bananas and vegetables) as frequent, small mealsthroughout the day (six meals/day); avoid high fibre,bulky diet. Gradually increase energy intake as tolerated toreach an energy intake of 100 kcal/kg/d and protein intake2–3 g/kg/d.

A lactose free diet is often recommended, but is neededin malnourished patients or after severe enteritis.

Zinc Therapy (Zinc supplementation) [2, 4, 10]

Zinc deficiency is widespread among children in devel-oping countries. Supplementation treatment with zinc(20 mg per day until diarrhea ceases) reduces the dura-tion and severity of diarrheal episode in children indeveloping countries. Zinc supplements are given for10–14 d during and after diarrhea in the doses of10 mg/kg for infants < 6 mo of age and 20 mg/d forthe children >6 mo of age. In addition to improvingdiarrhea, administration of zinc in community settingsleads to increased use of ORS and reduction in the useof antimicrobials.

Probiotics [11, 12]

Used alongside rehydration therapy, probiotics appear to besafe and have clinically beneficial effects in shortening the T

able

11Classificationof

dehy

drationdepend

ingup

onsodium

concentrationandits

managem

ent[4]

Total

body

water

Decreased

Serum

Sod

ium

concentration

Decreased

(<13

5mEq/L)

Normal

(135–14

5meq/L)

Increased(>14

5mEq/L)

Phy

siolog

ical

derang

ement

Hyp

oton

icdehy

dration

Isoton

icdehy

dration

Hyp

ertonicdehy

dration

Urine

sodium

<10

mEq/L

Variable

<10

mEq/L

Treatment

Isoton

icsalin

e½

norm

alsalin

e1/3no

rmal

salin

e

Level

ofdehy

dration

Mild

<5%

<5%

10%

Mod

erate

5%

10%

12–15

%

Severe

10%

15%

>15

%

Deficitestim

ation

Weigh

tin

kg×vo

lumedeficit

Total

volumerequ

irem

ent

Maintenance

fluids

(Holiday

Segar

form

ula)

+Deficitvo

lume

Na+

concentrationof

repairsolutio

n80–10

0mEq/L

50–80

mEq/L

30–40

mEq/L

Rateof

replacem

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Indian J Pediatr

duration and reducing stool frequency in acute infectiousdiarrhea [11, 12]. There are varieties of microorganisms(Lactobacillus, Bifidobacterium) that have good safety re-cord; therapy has not been standardized and most effectiveand safe organisms and regimens for specific groups havenot been identified. The authors give their patients probi-otics for 5 d.

Antimotility Agents [2, 4, 10]

Gut stasis following use of antimotility agents may lead toinvasion of the bowel wall by infecting organisms leading toworsening of the condition. These agents are contra-indicatedin childrenwith dysentery and probably should not be given toinfants and young children.

Antiemetic Agents [2, 4, 10]

Phenothiazines are of little value and are associatedwith potentially serious side effects. Ondensetron is aneffective and less toxic antiemetic agent (Dose: 2 mg inchildren 8–15 kg, 4 mg in children >15–30 kg, 8 mg inchildren >30 kg). A comprehensive approach to man-agement of acute diarrhea is shown in Fig. 2.

Specific Aspects of Management of Acute Diarrheain Children with Severe Malnutrition

Diarrhea is a serious and often fatal event in childrenwith severe malnutrition [13, 14]. Management of acutediarrhea in these children presents unique challenges as

Fig. 2 Algorithm formanagement of a patientwith diarrhea

Indian J Pediatr

malnutrition predisposes to severe and prolonged diar-rhea due to underlying micronutrient deficiency (partic-ularly zinc) that causes suppressed immune function.Care of these children, in addition to correction of dehydra-tion, must focus on management of malnutrition, con-tinuation of feeding which lessens weight loss and earlydetection and treatment of underlying infections and probablesepsis [14].

Assessment of Dehydration

As mentioned earlier, typical signs of dehydration suchas skin turgor, sunken eyes, mental status and peripheraltemperature are unreliable for assessment of hydrationstatus in a malnourished child. In such children thirst,dry tongue and inner side of cheek, and signs of hemo-dynamic compromise (fast weak or absent pulses,delayed capillary refill time and orthostatic changes inBP, and hypotension) and reduced or absent urine flowindicates severe dehydration [4].

Principles of Treatment

Malnourished children in shock should be treated as perdetails given in the section earlier.

Children with signs of sepsis or in a state of severemalnutrition should receive systemic broad spectrum anti-biotics. General principles of dehydration correction re-main same as that for any child with diarrhea withfollowing exceptions:

i. Reduced Osmolarity ORS [RO-ORS] with potassiumsupplements should be preferred for rehydration andmaintenance.

ii. Dehydration should be corrected slowly over 12 h.iii. ORT should be given at 10 ml/kg/h for first two hours

followed by at 5–10 ml/kg every hour for next 4–10 h (byoral/nasogastric tube), adjusting it based on the capabilityof child to drink, volume of fluid loss in stools andvomiting.

iv. Careful frequent reassessment is needed for signs ofrehydration and overhydration.

v. Overhydration in a malnourished child is dangerousand can precipitate heart failure because of poorcardiac reserve and pumping capability contributedby underlying nutritional cardiomyopathy, anemiawith volume overloaded state and acute illness re-lated decompensation. An increase in pulse rate withimproved pulse volume, increase in respiratory rate, crepi-tation over basal lung regions, appearance or increase in

edema and appearance of periorbital puffiness indicatesoverhydration.

Prevention [2, 3, 7, 8]

Use this opportunity to educate parents about followingmeasures to prevent further episodes of diarrhea: Safe waterand sanitation, hand hygiene, exclusive breast feeding forinitial 6 mo, appropriate and safe weaning, safe food han-dling habits, Vitamin A supplementation and vaccination-against Rotavirus, Typhoid fever, and Measles.

Conflict of Interest None.

Role of Funding Source None.

References

1. WHO/UNICEF. Joint statement on clinical management ofacute diarrhea. New York: UNICEF; 2004. [cited on 25-09-2011]. Available at: http://www.unicef.org/publications/index_21433.html.

2. Department of Maternal, Child and Adolescent Health, WorldHealth Organization. ‘Diarrhea treatment guidelines includingnew recommendations for the use of ORS and zinc supplemen-tation for clinic-based healthcare Workers’. Arlington: USAID;2005. [cited on 25-09-2011]. Available at: http://www.who.int/maternal_child_adolescent/documents/a85500/en/index.html.

3. Bhutta ZA. Acute gastroenteritis in children. In: Kliegman S, St.Geme Schor B, eds. Nelson textbook of pediatrics. 19th ed.Philadelphia: Elsevier Saunders; 2011. pp. 1323–38.

4. Singhi S. Acute diarrhea. In: Singhi S, Surpure JS, eds. Synopsis ofPediatric Emergency Care. 2nd ed. Delhi: PEEPEE; 2010. pp. 341–7.

5. Haque R, Mondal D, Duggal P, et al. Entamoeba histolytica infec-tion in children and protection from subsequent amebiasis. InfectImmun. 2006;74:904–9.

6. Ajjampur SS, Sankaran P, Kannan A, et al. Giardia duodenalisassemblages associated with diarrhea in children in South Indiaidentified by PCR-RFLP. Am J Trop Med Hyg. 2009;80:16–9.

7. Khan WA, Rogers KA, Karim MM, et al. Cryptosporidiosis amongBangladeshi children with diarrhea: a prospective matched case–control study of clinical features, epidemiology and systemic anti-body responses. Am J Trop Med Hyg. 2004;71:412–9.

8. CDC Disasters. Guidelines for the management of acute diarrheaafter a disaster. Atlanta: Centers for Disease Control and Prevention;2008. [cited on 25-09-2011]. Available at: http://emergency.cdc.gov/disasters/disease/diarrheaguidelines.asp.

9. World Gastroenterology Organization (WGO). WGO practiceguideline: Acute diarrhea. Munich: World GastroenterologyOrganization (WGO); 2008. p. 28. [cited on 25-09-2011].Available at: http://www.dphhs.mt.gov/publichealth/cdepi/documents/WorldGastroenterologyOrganizationPracticeGuideline.pdf.

10. Bhatnagar S, Lodha R, Choudhury P, et al. IAP Guidelines 2006on management of acute diarrhea. Indian Pediatr. 2007;44:380–9.

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11. Allen SJ, Martinez EG, Gregorio GV, Dans LF. Probioticsfor treating acute infectious diarrhoea. Cochrane DatabaseSyst Rev. 2010;11:CD003048. doi:10.1002/14651858.CD003048.pub3.

12. Szajewska H, Mrukowicz JZ. Probiotics in the treatment andprevention of acute infectious diarrhea in infants and chil-dren: a systematic review of published randomized, double-

blind, placebo-controlled trials. J Pediatr Gastroenterol Nutr.2001;33:S17–25.

13. Sachdev HP, Kumar S, Singh KK, Satyanarayana L, Puri RK. Riskfactors for fatal diarrhea in hospitalized children in India. J PediatrGastroenterol Nutr. 1991;12:76–81.

14. Uysal G, Sökmen A, Vidinlisan S. Clinical risk factors for fataldiarrhea in hospitalized children. Indian J Pediatr. 2000;67:329–33.

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