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Guidelines on the management of
2011
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COLLEGE OF PAEDIATRICS, ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION
Committee Members
The following are members of the Guidelines Committee:
Professor Lee Way Seah (Chair)– Professor of Paediatrics and Consultant Paediatric Gastroenterologist and
Hepatologist, University of Malaya Medical Centre, Kuala Lumpur;President, College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP)
Datuk Dr. Zulkifli Ismail – Consultant Paediatrian and Paediatric Cardiologist, KPJ Selangor Specialist
Hospital, Shah Alam;President Elect, Asia Pacific Pediatric Association (APPA);Past President, Malaysian Paediatric Association (MPA)
Dr. Nur Atiqah Ng Abdullah– Consultant Paediatrician and Paediatric Gastroenterologist,
Pantai Hospital, Bukit Pantai, Kuala Lumpur
Dr. Oon Meng Kar – Consultant Paediatrician, Klinik Kanak-kanak Oon, Cheras, Kuala Lumpur
Dr. Chai Pei Fan – Consultant Paediatrician and Paediatric Gastroenterologist and Hepatologist,
Pantai Hospital, Bukit Pantai, Kuala Lumpur
©2011 College of Paediatrics, Academy of Medicine of Malaysia and Malaysian Paediatric Association
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
Terms o Reerence
Target audience:
This guidelines aim to cater mainly for paediatricians, primary care physicians and otherfrontline healthcare providers involved in providing care for children.
Format:
This guidelines consist of easy-to-read information with appropriate flow charts. All facts areevidence-based as far as possible. Where evidence is not currently available, the combined and
consensus opinion of the members with adequate consultation with senior colleagues prevailed.
1. The full guidelines on the management of acute diarrhoea in children may be obtainedfrom the following websites:
• CollegeofPaediatrics,AcademyofMedicineofMalaysia(AMMCOP)
http://www.acadmed.org.my/
• MalaysianPaediatricAssociation(MPA)
http://www.mpaweb.org.my/
• MeadJohnsonNutritionMalaysia
http://www.meadjohnsonasia.com.my/home.aspx
2. A pocket reference guide which is a summary of the recommendations for themanagement of acute diarrhoea in children may be obtained from AMMCOP, MPA orMead Johnson Nutrition Malaysia.
3. A wall poster consisting of a flow chart on the management of acute diarrhoea inchildren may be obtained from AMMCOP, MPA or Mead Johnson Nutrition Malaysia.
Content:
The committee members have the sole right to determine the content of the suggestedguidelines. The sponsor did not influence any part of the content at any time.
Disclosure:
No conflict of interest declared by any of the committee members.
Sourceoffunding:
This guidelines was made possible by an unrestricted educational grant from Mead JohnsonNutrition Malaysia.
Disclaimer:
The content / guidelines is based solely on currently available scientific evidence or best clinicalpractice. Healthcare professionals are expected to utilise the information contained withinthis guidelines when exercising their clinical judgement. However, this guidelines shouldnot replace the individual responsibility of the user to make decisions appropriate to thecircumstances of the individual patient and informed by the current indications and accuracyof the drug they are considering.
Copyrightownership:Copyright of the document remains with the College of Paediatrics, Academy of Medicine ofMalaysia (AMMCOP) and Malaysian Paediatric Association (MPA). No part of this publicationmay be reproduced in any form without the prior written permission of the authors.
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COLLEGE OF PAEDIATRICS, ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION
Contents
01 Introduction 1
02 Summary o the Guidelines 2
03 Scope o the Guidelines 3
04 Defnition o Diarrhoea 3
05 Clinical Types o Diarrhoeal Diseases 4
06 Important Causative Agents o Gastroenteritis 5
07 Assessment o Acute Diarrhoea 7
08 Management o Childhood Acute Diarrhoea 11
09 Prevention o Childhood AGE 23
10 Special Considerations 25
11 Part I: Algorithm or Managing Acute Gastroenteritis in Children 26
12 Par t II: Algorithm or Managing Acute Gastroenteritis in Children 27
13 Summary o Established Guidelines 28
Reerences 29
Appendix A 34
Appendix B 35
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
01 Introduction
The first Guidelines on Childhood Acute Gastroenteritis (AGE) in Malaysia were published
in 2001 by the College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP).Since then there has been a proliferation of publications and new findings in this area inthe literature.
Over the last few years, there has been publication of a few guidelines on the managementof childhood AGE. The new WHO Guidelines on the ‘Treatment of Diarrhoea’ (2005)caters mainly for the need of developing countries with a limited health care resources,1
while other guidelines such as those from the Center for Disease Control (CDC) and theEuropean Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)cater mainly for North America and the European countries, respectively.2-5 Therefore
there is an urgent need to have a local guidelines catering to the specific need for Malaysia.
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02 Summary o the Guidelines
Acute diarrhoea is the second most important cause of childhood mortality worldwide. 6
It is estimated that each year, approximately 1.9 million children younger than 5 years
of age dies of acute diarrhoea.7 At present, there is no detailed epidemiological studyon the burden of acute diarrhoea in children from Malaysia. However, it was estimatedthat 1.3% of all medically certified and uncertified deaths (or 69 deaths per year) amongchildren younger than 5 years of age were due to acute gastroenteritis.8
There are four clinical types of diarrhoea, namely acute watery diarrhoea, acute bloodydiarrhoea, persistent diarrhoea and diarrhoea with severe malnutrition.1 The maincauses of childhood AGE are various enteric viruses and bacteria, although parasites areimportant in certain specific setting.9 Various studies, based mainly on hospital admissionstudies, showed that rotavirus is the most common cause of dehydrating diarrhoea in
young children requiring hospital care in Malaysia.10-20 Important bacterial pathogensinclude non-typhoidal Salmonella and E. coli .21
Proper clinical assessment is required to correctly diagnose the condition, in particularthe severity of dehydration of the child, to provide the appropriate management. Everychild with AGE should be carefully assessed for dehydration and other complications.Criteria for hospital care include moderate-to-severe dehydration, persistent vomiting orworsening diarrhoea even in the absence of dehydration, uncertainty about diagnosis,presence of unfavourable socio-economic factors, or presence of other complications.
In most cases of uncomplicated acute diarrhoea with no significant dehydration, nolaboratory investigation is necessary. A careful history and detailed physical examinationto assess the state of hydration is often all that is necessary.
In most instances with uncomplicated AGE, oral rehydration therapy is the treatment ofchoice and is sufficient in a majority of cases. Drug therapy is unnecessary in most cases,and may even be contraindicated or dangerous.
Children who require rehydration should continue to be breastfed or formula-fed. Foodshould not be withdrawn for longer than 4 – 6 hours after the onset of rehydration. For
children who are formula-fed; formula dilution, gradual reintroduction of feeding andswitching to lactose-free, soy or hydrolysate formulae are not recommended.
Breastfeeding is the best measure for the prevention of AGE in young infants. Rotavirusis the commonest viral pathogen causing severe dehydrating diarrhoea in the worldover. Rotavirus vaccines are not part of the national immunisation schedule in Malaysia.However, it is recommended that vaccination should be considered as part of preventionof rotavirus diarrhoea. Currently there are two rotavirus vaccines available in Malaysia.Both are safe and highly effective in preventing severe dehydrating diarrhoea. 22
When the duration of diarrhoea persists for more than 14 days following an episodeof AGE, lactose intolerance and food protein allergy (most commonly cow milk or soyprotein) complicating AGE, repeated or persistent bacterial or parasitic infections shouldbe excluded. In these cases, consultation with or referral to a specialist with expertise inthis area should be considered.
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
03 Scope o the Guidelines
The present guidelines are intended to be used in the following settings in Malaysia:
• Primary care settings (out-patient clinic, emergency room)• In-patient care
The guidelines focus mainly on acute diarrhoea in children. It will include variousmanagement aspects including office management of AGE such as:
• Clinical assessment• Rehydration management• Drugs (antibiotics, anti-diarrhoeal, and anti-emetics)
• Probiotics and prebiotics• Nutrition management (manipulation of feeding practices, special formulae)• Vaccines (rotavirus vaccines)
04 Defnition o Diarrhoea
Diarrhoea is defined as the passage of unusually loose or watery stools, usually at least 3times in a 24-hour period. It is the consistency of the stools that is most important, ratherthan the frequency. Frequent passing of formed stools is not considered as diarrhoea.Similarly, breastfed babies pass loose, 'pasty' stools sometimes up to 6 to 7 times a daywhich should not be considered as diarrhoea.1
The main problem with acute diarrhoea is its ability to cause rapid fluid loss throughstools in addition to electrolytes loss. The volume of fluid loss can vary from 5ml/kg
body weight/day to≥
200 ml/kg body weight/day. Dehydration and electrolyte lossesassociated with untreated diarrhoea are the main causes of morbidity and mortality ofchildhood AGE.
Diarrhoea can also be the initial signs of non-gastrointestinal tract illness, includingmeningitis, bacterial pneumonia, otitis media, intussusception and urinary tract infection.In addition, vomiting without diarrhoea can be the first symptom of a host of diversesurgical and metabolic conditions as well.2
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05 Clinical Types o Diarrhoeal Diseases 1
Acute Watery Diarrhoea
Acute Bloody Diarrhoea
(dysentery)
Persistent diarrhoea
Diarrhoea with
severe malnutrition
Lasts for several hours or days. The main concern
is dehydration. Weight loss can also occur if
feeding is being withheld for too long.
Should be considered when blood and mucous are
present in the stools. The main dangers are damage
to the intestinal mucosa, sepsis and malnutrition.
Dehydration, although not as common as in acute
watery diarrhoea, may also occur.
Defined as diarrhoea that lasts 14 days or longer.
It may lead to malnutrition and serious infection
with or without dehydration.
A serious condition and warrants special attention to
exclude severe systemic infection, dehydration, severe
electrolytes imbalance, heart failure, and vitamin andmineral deficiencies.
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
06 Important Causative Agents o Gastroenteritis
Rotavirus is the main cause of virus-induced gastroenteritis in both developed and
developing countries. Other enteric viruses include norovirus, adenovirus, astrovirus andcalicivirus.9
In developed countries, enteric viruses are more important than bacterial pathogens incausing childhood diarrhoea.9 In the developing countries, on the other hand, bacterialpathogens, such as E. coli , non-typhoidal Salmonella, Shigella species, and Campylobacter species are important pathogens, in addition to enteric viruses.9
Developed Countries Developing Countries
Rotavirus
Unknown
Parasites
Bacteria
Adenovirus
Astrovirus
Calicivirus
Other Bacteria
Toxigenic
Escherichia coli
Adapted from Estes MK and Kapikian AZ . In: Fields Virology. 5th ed. Philadelphia: Lippincott, Williams, and Wilkins; 2007:Page 1917-19749
It is also useful to classify important aetiological agents according to age group andnature of stools (Table 1):
Table 1: Important causative agents o gastroenteritis by age group and natureo stool worldwide 4
Rotavirus, astrovirus, calicivirus, enteric adenovirus,enteropathogenic Escherichia coli (EPEC), enterotoxigenicEscherichia coli (ETEC), Vibrio cholerae
≤ 2 years
Enterotoxigenic Escherichia coli (ETEC), rotavirus, Shigella,Vibrio cholerae
2-5 years
Watery
Shigella, shiga-toxin producing Escherichia coli (STEC),
Campylobacter jejuni
≤ 2 years
Shigella, shiga-toxin producing Escherichia coli (STEC),non-typhoidal Salmonella, E. histolytica
2-5 years
Mucousy / bloody
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Table 2: Important causative agents o childhood acute gastroenteritis
in Malaysia 10, 12, 14, 19, 20, 23
a includes enteropathogenic and enterotoxigenic E. coli b as a mixed infection
NT Not tested
In Malaysia, major enteric viruses causing childhood AGE are rotavirus, norovirus, andenteric adenovirus (Table 2). For bacterial gastroenteritis, the most important causative
agent is the non-typhoidal Salmonella, followed by Campylobacter , Shigella and E.coli .21
Among the hospitalised children, 40 to 50% of cases are caused by rotavirus and patientsdemonstrated severe vomiting and diarrhoea and severe dehydration.
As for outpatient, the main causative agent is non-typhoidal Salmonella. Only 10% ofthe cases are caused by rotavirus.12 However, the above figure was based on only onestudy in Malaysia which was performed in a private outpatient clinic in Klang Valley witha relatively small number of patients.
Author
Iyngkaran et al 10
Koe et al 12
Lee et al 14
Poo and Lee19
Tan 20
Kahar-Bador& Lee 23
Number
Tested
300
97
228
288
261
568
Rota-
virus
19
9
29
30
54
28
Noro-
virus
9
Adeno-
virus
4
NT
4
NT
NT
2
Salmonella
11
26
10
9
6
Shigella
6
2
0.4b
0
0.4
E. Coli a
10
1
0.4
1
0.4
Campylo-
bacter jejuni
0
3
0
0
0
No
organism
50
59
56
60
39
49
Percentage of aetiological agent (%)
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
07 Assessment o Acute Diarrhoea 1-5
• Identify the presence of, the degree of, and type
of dehydration• Identify the aetiological agent, if indicated and possible
• Identify co-morbidity and complications
• To assess nutritional status
• To ascertain the most appropriate mode of treatment
The following aspects should be covered:
• Assess the onset, frequency, quantity and character
of both vomiting (presence of bile, blood) and diarrhoea
(presence of blood or mucous)
• Recent oral intake (including breast milk and otherfluids and food)
• Urine output
• Weight before illness (if available)
• Associated symptoms (fever, change in mental status)
• Past medical history (underlying medical problems,
history of other recent infections, medications, immune
compromised states)
• Social history
7.1 Assessment:
History
The following aspects should be covered:
• Accurate body weight• Vital signs (temperature, heart rate, respiratory rate,
blood pressure)
• General conditions
• Eyes: sunken eyes, presence / absence of tears
• Mucous membrane – moist or dry
• Respiratory pattern
• Bowel sounds
• Extremities (perfusion, capillary filling time)
• Skin turgor (anterior abdominal wall)
• Inspection of stool (presence of blood or mucous)
7.2 Assessment:
Physical Examination(see Appendix A)
Classification into severity of dehydration is essential for
appropriate fluid management. The best measure of
dehydration is by the percentage loss of body weight.1
However, the actual weight is often not available. It
should also be emphasised that clinical signs for
dehydration are imprecise.4, 24 Therefore, repeated
assessment is often necessary.
Most useful signs for significant dehydration are: 4, 25
• Prolonged capillary refill time (normal < 2 seconds)
• Reduced skin turgor
• Abnormal respiratory pattern
7.3 Assessment:
Dehydration
Aims of assessment
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Table 3: Simplied ways o classiying the degree o dehydration
This is generally defined as a serum sodium concentration
of ≥ 150 mmol/L. Important causes of hypernatraemic
dehydration in childhood acute diarrhoea include young
infants who were predominantly breastfed and were given
inadequate breastfeeding, or given inappropriatelyprepared infant formula. Very little evidence-based
guidelines on this condition have been published recently.
An excellent review on this topic can be found elsewhere.26
Signs and symptoms of hypernatremia largely reflect
central nervous system dysfunction and are prominent
when the increase in the serum sodium concentration is
large or occurs rapidly (i.e., over a period of hours).
Common symptoms in infants include:26
• hyperpnoea
• muscle weakness
• restlessness
• a characteristic high-pitched cry
• insomnia
• lethargy
• and even coma
• convulsions are typically absent except in cases of
inadvertent sodium loading or aggressive rehydration
Hypernatraemic dehydration complicating AGE is
uncommon nowadays. In a one-year prospective studyon 393 children admitted with AGE to a teaching hospital,
the incidence of hypernatraemia was 1.2%, while that of
hyponatraemia was 1.0%.19
7.4 HypernatraemicDehydration
Classification
No signs of dehydration
Some signs of dehydration
Severe dehydration
Fluid deficit as % of body weight
< 3%
3-9%
>9%
Fluid deficit in ml/kg of body weight
< 30 ml/kg
30 – 90 ml/kg
> 90 ml/kg
Adapted from: WHO 2005 1
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
Generally, in patients with high fever (>39°C), overt
faecal blood, abdominal pain, central nervous
system involvement such as irritability, apathy,
seizures or coma suggest bacterial aetiology.27, 28
Patients presenting with more significant vomiting
and respiratory symptoms suggest viral aetiology.29
Rotavirus causes more severe vomiting and
dehydration. However, it should be emphasised
that the clinical features of both viral and bacterialaetiology overlap considerably.27
7.6Bacterial or Viral Cause?
It is always useful to keep in mind the possibility
that the diagnosis of AGE may be incorrect. Although
gastroenteritis consists of the triad of vomiting, diarrhoea
and fever, other conditions can present with the above
symptoms as well. These include:• Acute appendicitis
• Strangulated hernia
• Intussusception or other causes of bowel obstruction
• Urinary tract infection
• Meningitis and other types of sepsis
• Any cause of raised intracranial pressure
• Diabetic ketoacidosis
• Inborn error of metabolism
• Haemolytic uraemic syndrome
• Inflammatory bowel disease
Always consider another diagnosis in the presence
of any of the following warning signs:23
• Abdominal distension
• Bile-stained vomiting
• Blood in vomitus or stool
(in appropriate clinical setting)
• Severe abdominal pain
• Vomiting in the absence of diarrhoea
• Headache
7.5DifferentialDiagnoses 23
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In the majority of children with uncomplicated AGE withno signs of dehydration, laboratory investigations areunnecessary.4
It should also be noted that laboratory assessment for
severity of dehydration are imprecise. The onlylaboratory measurement that appears to be useful indecreasing the likelihood of > 5% dehydration is serumbicarbonate (presence of a normal serum bicarbonate).23 Electrolytes should be measured in moderatelydehydrated children whose history and physicalexamination findings are inconsistent with astraight-forward diarrhoeal illness, and in all severelydehydrated children.4 Electrolytes should also bemeasured in all children requiring intravenous therapy,and during therapy to monitor the presence of hyper-and hyponatraemia, and other electrolyte imbalances.4
• Routine stool culture is not indicated as it is expensiveand does not alter the management in the vast majorityof patients4
• Stools culture is mandatory if profuse watery stools(cholera), blood and mucous in stool (bacterial dysentery)
• Virus – usually not indicated• Parasites – only if clinically indicated• Reducing substances (only in watery stool)
Indications for stool culture are shown in Table 4.
• Bloody diarrhoea (consider dysentery)• Severe watery stools (consider cholera)• Severe and prolonged diarrhoea• Immune-compromised child
7.7 DiagnosticWorkup 1, 4
7.7.1 Stool:
• Specific gravity – may be helpful in the monitoring of
response to therapy in children with severe
dehydration undergoing rehydration therapy
• Urine microscopy – should not be performed
routinely because of possibility of contamination
of urine samples during acute diarrhoea
7.7.2 Urine:
• Urea, Na+, K+, pH, HCO3-
• Complete blood count– if bacterial sepsis is suspected
• Consider glucose monitoring (girls younger
than 5 years with vomiting)
• (± Ca2+, Mg2+ in young infants)
7.7.3 Blood:
Table 4: Indications or stool culture and sensitivity 4
The incidence of hypoglycaemia in children with AGE has been estimated to be between1.9 – 9.2%.30-32 The risk factors for developing hypoglycaemia are female gender, signs ofneuroglycopenia, and frequent vomiting.32
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
08 Management o Childhood Acute Diarrhoea 1-5
Important points to be considered:
• Identification of children at risk of severe disease or at risk of developingcomplications
• Prevention / correction of dehydration and electrolyte imbalance• Prevention and treatment of complications such as invasive disease, severe
electrolyte imbalance, metabolic and other complications, malnutrition• Drug(s) treatment, which may have a supplementary role• Provision of adequate and appropriate nutrition
8.1 ReferralforHospitalCare
In the majority of cases of uncomplicated childhood AGE with no significant dehydration,outpatient assessment and subsequent home management is all that is necessary.1, 4, 5 Thepresence of the following warning signs is helpful in deciding whether the child needsfurther assessment and possible hospital care:
Table 5: Criteria or Hospital Care 4
• Severe dehydration (> 9% of body weight), shock• Neurological abnormalities (lethargy, seizures, etc.)• Persistent or bilious vomiting (even if no dehydration)• Treatment failure with oral rehydration salts (ORS)• Presence of systemic illness (high fever, toxic looking)• Underlying medical conditions (heart failure, significant
neurodevelopment disabilities)• Caregivers unable to provide adequate care at home or
other social/logistic concerns• Suspected surgical condition, uncertain about diagnosis• Uncertain about degree of dehydration (obese children)
However, it should be emphasised that at present, there are no established,
evidence-based criteria for the hospital admission of childhood AGE.4
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8.2 RehydrationinAcuteDiarrhoea
Generalprinciples: Generally, oral rehydration should be used as first-line therapy for themanagement of children with AGE.1-5 When oral rehydration is not feasible, enteral rehydrationvia the naso-gastric route is as effective if not better than intravenous rehydration.1-5, 33 Oral
or enteral rehydration is associated with significantly fewer major complications and a shorterhospital stay compared with intravenous therapy and is successful in most children.
• If no excessive vomiting, home management is
usually sufficient
• If breastfeeding, continue breastfeeding
• If formula-fed, continue usual feeding and offer
extra water
• For older children: continue normal diet with extra fluids
8.2.1 No signs ofdehydration(< 3%)
• If no excessive vomiting and in the absence of
adverse social circumstances, may still consider
outpatient therapy
• ORS 30-90ml/kg within 2-3 hours
• After every diarrhoea episode: ORS 10ml/kg
• Small and frequent feeds with regular assessment
• Hospital referral for admission for IV fluid if there is
persistent vomiting, worsening dehydration despite
adequate therapy
8.2.2 Some signs ofdehydration(3-9%)
• Resuscitation (normal saline / Ringer’s lactate)
• Frequent monitoring
• Immediate referral to hospital for admission
8.2.3 Severe dehydration(> 9%)
8.2.4 Selection of oral rehydration salts (ORS) Table 6 shows the electrolyte content of stool samples obtained from patients with cholera,rotavirus and enteropathogenic Escherichia coli. It is more appropriate to use the original WHOORS in situations where cholera is likely. In other situations, a reduced osmolality ORS is preferred.
Table 6: Mean Stool Na+ and K+ (mmol/L) According to Duration o Diarrhoea
Beore Admission
Adapted from Molla AM et al, 1991 34
Duration(h)
0 – 12
13 – 24
25 – 48
48+
Na(mmol/L)
98
83
63
46
K(mmol/L)
29
37
28
65
EPEC
Na(mmol/L)
67
55
44
44
K(mmol/L)
37
38
26
37
Rotavirus
Na(mmol/L)
53
42
32
34
K(mmol/L)
46
42
28
43
Cholera
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
Table 7 shows the electrolyte content of various ORS preparations available in Malaysia.Fluids that are not suitable as substitute for ORS include 100 Plus (Table 8).
Table 7: Electrolytes Composition, Osmolality o Various ORS Preparations
Adapted from Santosham M, 1997 35 ; Lee WS, 2009 36
# 1 molecule of citrate is metabolised into 3 molecules of bicarbonate in the body.
Table 8: Fluids Not Appropriate to be Used in Rehydration Therapy
Adapted from Santosham M, 1997 35 ; Lee WS, 2009 36
NA Not available
Standard WHO (1975)
Reduced-Osmolality WHO (2002)
Ministry of Health
ORS Plus (per sachet)
Upha E-Lyte (per sachet)
Weewa ORS (per sachet)
Na(mmol/L)
90
75
56
75
75
90
K(mmol/L)
20
20
20
20
20
21
Cl(mmol/L)
80
65
56
65
65
81
HCO3
(mmol/L)
30
30
20
Glucose(mmol/L)
111
75
137.5
75
75
110
Citrate #
(mmol/L)
10
10
10
Osmolality(mmol/kg)
311
245
290
245
245
312
Coca cola
Apple juice
Chicken broth
Tea
100 Plus
Na(mmol/L)
2
3
250
0
21
K(mmol/L)
0
20
8
0
3.5
Cl(mmol/L)
NA
NA
NA
NA
20
HCO3
(mmol/L)
NA
0
0
0
3
Glucose(mmol/L)
616
600 – 900
0
0
NA
Osmolality(mmol/kg)
618
260
330
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8.3 SpecialConsideration
8.3.1 Hypernatraemic dehydration
Hypernatraemic dehydration is defined as serum sodium concentration of more than145 mEq/L. Generally patients with hypernatraemic dehydration respond well to oralrehydration therapy.2 Those with severe dehydration should first receive intravenousfluid therapy for resuscitation. The principal of subsequent rehydration should be theuse of isotonic solution (normal saline) administered at a slower rate, i.e. over 48 hours.Subsequent rehydration can also be achieved with ORS. ORS might be safer thanintravenous fluid because it is less likely to lead to a precipitous increase in intracellularwater associated with seizures and raised intracranial pressure.2
8.4 AdjunctiveTherapyforAcuteDiarrhoea
8.4.1 Antibiotics 1-5
With only a few exceptions, antibiotic therapy should not be given routinely to childrenwith diarrhoea. Such therapy is ineffective and may be harmful.1-5 Majority of gastroenteritiscases in children are viral in origin (rotavirus, norovirus, adenovirus). Thus, antibiotics areonly needed for specific pathogens or defined clinical settings.
Recommendations:
Antibiotics are indicated in the following situations:
• Shigella dysentery - in cases presenting as bloody diarrhoea, these should betreated with an antimicrobial effective for Shigella
• When cholera is suspected• When diarrhoea is associated with another acute infection such as pneumonia
and urinary tract infection• May be indicated for Salmonella gastroenteritis in very young babies
(< 3 months), immune-compromised, immuno-suppressed, systemically ill,achlorhydia
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
Table 9: Recommended Antibiotics or Acute Diarrhoea 4
Pathogen
Shigellosis 4
Salmonella
Gastroenteritis
(in high risk children) A
Campylobacter
dysentery
Cholera
Antibiotics
Azithromycin
Ceftriaxone
Trimethoprim-
sulfamethoxazole
Amoxicillin
Ceftriaxone
Trimethoprim
-sulfamethoxazole
Ciprofloxacin
Erythromycin
Azithromycin
Doxycycline B
Azithromycin
Total daily doses
Day 1: 12 mg/kgDay 2-5: 6 mg/kg
50 mg/kg
10/50 mg/kg
( TM/SMZ )
40-50 mg/kg
50 mg/kg
10/50 mg/kg
5-10 mg/kg PO
4-7 mg/kg IV
30-50 mg/kg
4-7 mg/kg IV
>8 kg: 4.4 mg/kg
(300 mg as a single
dose in adult)
Day 1: 12 mg/kg
Day 2-5: 6 mg/kg
No. of Doses/day
1
1
2
3
1
2
2
2
2
2
1
1
Duration
5 days
2-5 days
5 days
5 days
2-5 days
5 days
5 days
5 days
5 days
5 days
Single dose
3 days
Note:
A: High risk children include those with underlying immune deficiency, anatomical and functional asplenia, corticosteroid or
immunosuppressive therapy, inflammatory bowel disease, achlorhydria, and neonates and young infants.4
B: World Health Organization (WHO) does not recommend the use of doxycycline in children with cholera.
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8.4.2 Anti-emetics
Anti-emetics include drugs such as dimenhydrinate, metoclopromide, domperidone andpromethazine. These may cause sedation that can interfere with oral rehydration therapy.
Due to this reason, anti-emetics are not routinely indicated in children with diarrhoea.
1-5
In addition, anti-emetics may decrease vomiting but increase frequency of diarrhoea.This will lead to retention of fluid and toxin that would have been eliminated throughvomiting.4, 37 Therefore, it is recommended that children with persistent vomiting be givensmall frequent feeds.
Recommendations:
• Not recommended
8.4.3 Anti-diarrhoeal agents and other therapies
Anti-diarrhoeal agents are generally not indicated in childhood AGE.
Various anti-diarrhoeal agents and other therapies are available in the market, and theycan be divided into the following categories:
Table 10: Anti-diarrhoeal Agents and Other Therapies Commonly Used in Childhood
Acute Diarrhoea, According to Efcacy on Diarrhoea and Saety Prole
No. Categories Examples
1 No e ect on diarrhoea or not sae in young children Loperamide
Activated charcoal
2 Possible eects on diarrhoea but not licensed to be
used in young children
Kaolin-pectin
CholestyramineBismuth-salt
3 Uncertain or some eects, but generally sae Diosmectite
Certain probiotics
4 Sae and licensed in children with useul / positive
eects in childhood diarrhoea
Zinc
Certain probiotics
Racecadotril
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
8.4.3.1 Anti-motility(intestinaltransitinhibitor;opiateagonists)
(i) Loperamide (Imodium® )
• decrease frequency and duration of diarrhoea but have serious side effects(lethargy and death) especially in young children (< 3 years).38 In this meta-analysis, 8 out of 972 children with loperamide had lethargy/death compared tonone from the placebo group.38
Recommendations:
• Not recommended 38
(ii) Diphenoxylate HCl (Lomotil ® )
• anti-peristaltic, mask water loss, prolong intestinal transit time• increases direct contact between intestinal epithelium and noxious agents• usage in Shigella – invasive illness, prolonged fever, prolonged excretion of
Shigella• has narrow therapeutic range, hence risk of overdose and severe side effects
Recommendations:
• Not recommended
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8.4.3.2 Intraluminal agents(adsorbents,bulk-forming,etc.)
(i) Silicates - kaolin/pectin39
• binds microorganisms or their products• increase stool consistency but not losses of water and electrolytes• not very effective• may decrease intestinal nutrient or drug absorption
Recommendations:
• Not recommended 39
(i) Silicates – diosmectite (Smecta® )
• binds selected bacterial pathogens and rotavirus• restore integrity of damaged intestinal epithelium• reduce stool output and duration of diarrhoea• shown to be effective in rotavirus diarrhoea• maybe used as adjunctive to ORS• A meta-analysis published in 2006 showed that diosmectite is a useful adjunctive
therapy to childhood acute gastroenteritis.40
A total of six randomised-controlledtrials showed that as compared to placebo, diosmectite significantly reduced theduration of diarrhoea by approximately 22.7 hours, and the chance of a cureon intervention day 3 was significantly increased in diosmectite vs. the controlgroup (RR 1.64, 95% CI: 1.36-1.98).40 A more recent randomised controlledtrial showed that diosmectite reduced stool output in children with acute waterydiarrhoea, especially those who were rotavirus-positive.41
• No side effects 4, 40
Recommendations:• Can be considered as an adjunctive therapy4, 40
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
8.4.3.3 Anti-secretory
(i) Enkephalinaseinhibitors(racecadotril*)
• enkephalinase-inhibitor, preserving endogenous enkephalinase• significantly reduces stool output (~50%) by 48 hour• well tolerated• no side effects42, 43
One of the major drawbacks on racecadotril is that most randomised-controlled trials
previously were mainly industry-sponsored.42, 43
Recommendations:
• Can be considered as an adjunctive therapy42, 43
* Not commercially available in Malaysia at the time of publication of this guideline.
Table 11: Recommendation on The Use o Anti-emetics and Anti-diarrhoeal Agents on
Childhood Acute Gastroenteritis 4
Agents Recom
Anti-emetics
Dimenhydrinate, Metoclopromide,
Domperidone, Promethazine
Not recommended
Anti-motility
Loperamide
Diphenoxylate HCl
Not recommended
Not recommended
Intramural agents
Silicates-kaolin / pectin
Diosmectite
Not recommended
Can be considered as adjunctive Anti-secretory
Racecadotril
Can be considered as adjunctive
Though commonly used, most of the anti-diarrhoeal agents and other therapies have nopractical benefits and are never indicated for the treatment of acute diarrhoea in children.In fact, some are harmful to children.1-5
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8.4.4 Probiotics and prebiotics
Certain strains of probiotics may be an effective adjunct to the management of diarrhoea.4
The effects of probiotics are strain-specific and dose specific. Not all probiotics are
equivalent in terms of efficacy and the efficacy of a specific strain cannot be generalised.Even the most studied strain like Lactobacillus GG show efficacy results that are notalways consistent. In fact, there is no evidence of efficacy for many available commercialpreparations. Products with multiple strains should also have efficacy studies. Addingadditional strains to an effective strain may not necessarily have a synergistic effect orincrease in efficacy.
Recommendations:
• probiotic strain or strains with proven efficacy and in appropriate doses• commercial probiotic products with viability studies
Several meta-analyses and systemic reviews have shown a statistically significant effectand moderate clinical benefit of selected probiotic strains in the treatment of acutewatery diarrhoea.44, 45, 46
The most studied probiotic strains are Lactobacillus GG, lactobacillus acidophilus and Saccharomyces boulardii . The designs of the studies are different, using different strainsand some a combination of different strains. The studies also have different aims andmeasured different end points.
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
Table 12: Summary o Randomised Controlled Trials (RCT) o The Four Commonest
Strains on Acute Gastroenteritis in Children
Strain Total
numbero RCT
Efcacy
(number o studies)
Efcacy
(number o studies)
Lactobacillus
Rhamnosus GG 47-56
10 • Reduce duration of diarrhoea (5/10)
• Reduce by 8 to 37 hours
• Reduce stool frequency (5/10)
• Effective only for rotavirus positive
patients (2/10)
1.2x1010 to 2x1013 CFU
3 to 7 days
Lactobacillus
acidophilus 57-62
6 • Reduce duration of diarrhoea (5/6)
• Reduce by 6.6 to 31 hours
• Reduce stool frequency (1/6)
1x109 to 6x109 CFU
3 to 5 days
Saccharomyces
boulardii 63-67
5 • Reduce duration of diarrhoea (4/5)
• Reduce by 24 to 38 hours
3 x 109 CFU
5 to 6 days
Lactobacillus
reuteri 68, 69, 70
3* • Reduce duration of diarrhoea (2/3)
• Reduce by 30 to 40 hours
1x1010 CFU
5 days
* 2 studies with added Lactobacillus rhamnosus
Currently there is no role for prebiotics in the treatment of AGE.
Recommendations:
• Not recommended
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8.5 NutritionalTherapy/SpecialInfantFormula
Children who require rehydration should continue to be fed. Food should not bewithdrawn for longer than 4 – 6 hours after the onset of rehydration. Breastfeedingshould be continued during acute gastroenteritis. For children who are formula-fed,
formula dilution and gradual reintroduction of feeding are not recommended.3, 4, 71, 72
8.5.1 Undiluted vs. diluted formula
A meta-analysis (1994) identified 16 studies (9 randomised controlled trials) that investigatedthe practice of diluting formula 2- to 6-fold for periods ranging from 1 to 6 days.72
Children given undiluted formula has a slight increase in stool frequency (p = 0.046) ascompared to those fed with diluted formula, but there was no difference in the durationof diarrhoea. Children fed with undiluted formula resulted in a significant body weightcatch-up (p = 0.002) as compared to those fed with diluted formula.72
Recommendations:
• In children who are on infant formula, no dilution of formula is recommended
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
8.5.2 Soy-based or cow milk-based lactose-free formula
The vast majority of young children with acute gastroenteritis can safely continue toreceive lactose-containing milk formula because the number of treatment failures is
negligible compared to children with acute diarrhoea on a lactose-free diet.4, 71, 72, 73
In a meta-analysis on randomised controlled trials comparing lactose-free versus lactose-containing formula after AGE, overall, 22% (95% CI 18-27%) of children who consumedlactose had therapeutic failure compared to 12% (95% CI 9% - 15%) in children who didnot. However, the results were widely heterogeneous.72
However, only 4 out of 14 trials provided information on stool frequency and outputs.Lactose-containing formula caused marginally greater stool outputs than lactose-freeformula.72 Nine trials reported data on the duration of diarrhoea after the initiation of
therapy. Pooled results were widely heterogeneous.72
The effects on weight gain cannotbe reliably assessed as very few studies reported data on weight gain.72
Thus, there is at present no sufficient, evidence-based data to support the routine needto switch from a cow milk-based formula to a soy or hydrolysate formula in a baby withacute gastroenteritis.4
There is also no advantage for soy formula over cow milk formula over severity andduration of diarrhoea, duration of hospitalisation, or treatment failure.74, 75
In addition, the incidence of secondary lactose intolerance after AGE in Malaysian infantsis generally low, about 3% (see section 10.1).
Recommendations:
• In the absence of clinical evidence suggestive of lactose intolerance (pleaserefer to 10.2), a routine change to lactose-free formula (either soy-based orcow milk-based) after an episode of acute diarrhoea is not recommended.
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Table 12: Locally Available Soy-based and Lactose-ree Formulae (in Alphabetical Order)
Nature Locally available brand Age range Manuacturer
Cow milk-based
lactose-ree
• Dulac® Lactose Free
• Enfalac A+ LactoFree®
• Mamex® Gold Lactose Free
• Nan AL 110
• NL33
• Novalac AD
• Similac® LF
0 – 12 months
Inancy and beyond
Inancy and beyond
Inancy and beyond
Inancy and beyond
Inancy and beyond
0 – 12 months
Danone Dumex
Mead Johnson
Danone Dumex
Nestle
Morinaga
UP International
Abbott Nutrition
Soy-based • Enfalac A+ ProSobee®
• Isomil®
• Isomil® Plus
• Mamex® Gold Soya Step 1
• Mamex® Gold Soya Step 2
• Nursoy®
Inancy and beyond
0 – 12 months
> 12 months
0 – 6 months
7 months and beyond
Inancy and beyond
Mead Johnson
Abbott Nutrition
Abbott Nutrition
Danone Dumex
Danone Dumex
Pfzer
8.5.4 Zinc
UNICEF and WHO recommend zinc supplementation (10mg below 6 months of age, 20mg inolder infants and children for 10-14 days) as a universal treatment for children with diarrhoea.76 There is no proven benefit of the use of zinc in children without severe malnutrition, withacute gastroenteritis.77 Thus, zinc should only be given to malnourished children.4
Recommendations:
• Zinc can be considered to be given to malnourished children with acute diarrhoea
8.5.5 Others
Homeopathy: Although homeopathy continues to be widely used, there is insufficientevidence to recommend its use for the treatment of acute gastroenteritis in children.4
HerbalMedicine: There is insufficient evidence to recommend in favour or against theuse of herbal medicine for the treatment of acute gastroenteritis in children.4
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
09 Prevention o Childhood AGE
9.1 GeneralMeasures
General measures of preventing childhood AGE are effective in certain circumstances. 4
The best measure is the promotion of breastfeeding, while others include the use of safedrinking water, and an improvement of environmental hygiene.
9.2 Vaccines
Rotavirus is the commonest viral pathogen causing severe dehydrating diarrhoea in theworld over. Two rotavirus vaccines, RotaTeq® and Rotarix®, both safe and highly efficacious,are available in Malaysia.78, 79 Vaccines for other enteric pathogens are currently notavailable on a routine basis. Rotavirus vaccines are part of routine universal vaccinationprogramme in many countries in the world. First dose of primary vaccination shouldbe given between the age of 6 and 12 weeks, and the full schedule (RotaTeq® 3 dosesand Rotarix® 2 doses) should be completed by the age of 8 months for RotaTeq ® and 6months for Rotarix®.80 Both have been proven to be very safe and are highly effective inpreventing severe dehydrating diarrhoea.80
Rotavirus vaccines are not part of the National Immunisation Program (NIP) in Malaysia.
However, it is recommended that vaccination should be considered as part of preventionof rotavirus diarrhoea.
Recommendations:
• Rotavirus vaccine should be considered as a part of prevention of rotavirus
diarrhoea in Malaysian children.
Table 13: Rotavirus Vaccines Available in Malaysia
Drug Dosage Dosing interval
Rotateq®
(Pentavalent
Rotavirus vaccine)
PO x 3 doses
up to age 32 weeks
1st dose administered at 6-12 weeks o age.
Subsequent 2 doses administered at 4-10
weeks’ interval. 3rd dose should be completed
beore 32 weeks o age.
Rotarix®
(Monovalent
human attenuatedRotavirus vaccine)
PO x 2 doses
up to age 24 weeks
1st dose between 6-14 weeks o age. 2nd dose
between 14-24 weeks o age. Interval between
2 doses should not be < 4 weeks.
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9.3 Probioticsandprebiotics
There are studies on the use of probiotics in preventing antibiotic associated diarrhoea(AAD) in children and adults. Studies in children have shown certain strains likeBifidobacterium lactis, Streptococcus thermophilus, Saccharomyces boulardii ,
Lactobacillus rhamnosus are able to reduce the risk of AAD (relative risk [RR] between 0.3to 0.45).81, 82, 83 A meta-analysis on use the use of probiotics to prevent AAD concludedthat treating 7 children at risk of developing AAD will only prevent 1 case of AAD. 84 Another meta-analysis noted that the potential protective effects of probiotics to preventAAD in children did not withstand intention-to-treat analysis.85
There are also studies that looked at using probiotics supplements to prevent acutediarrhoea in children or use of formula with added probiotics with or without prebioticsto prevent acute diarrhoea in children.86, 87 Not all studies showed beneficial effects.88, 89
Prebiotics are defined as non-digestible food compounds that beneficially affect the hostby selectively stimulating the growth and/or activity of one or of a limited number ofbacteria in the large intestine, thereby improving the health of the host. Not all types ofprebiotics are the same or have similar effect. There is very little evidence that prebioticsmay be used as a preventive measure to the management of diarrhoea.90, 91
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
10 Special Considerations
10.1 PersistentDiarrhoea
Approximately 3-14% of children with acute gastroenteritis developed persistentdiarrhoea.22, 92
In Malaysia, approximately 3% of children with AGE developed persistent diarrhoea(duration > 14 days).22, 92 Bacterial infections, lactose intolerance and food protein allergy(cow milk and soy protein) are the three most important causes of persistent diarrhoeafollowing AGE in Malaysia.22, 92
10.2 LactoseIntolerance
Clinical features of lactose intolerance include:92
• Abdominal pain• Nausea• Persistent diarrhoea• Watery stools• Abdominal distension• ± Perianal excoriation
Secondary lactose intolerance should be suspected when acute diarrhoea fails to resolvewith the presence of the above clinical features.
In children with lactose intolerance without malnutrition, a temporary change tolactose-free formula, either cow milk-based or soy protein-based, is often adequate. Achange to either extensively hydrolysed formula or elemental formula is unnecessary.In malnourished children with persistent diarrhoea, consultation with or referral to anappropriate expert is indicated.
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10.3 CowMilkProteinAllergy
Food protein allergy is a potentially serious complication following acute gastroenteritis.Children suspected with cow milk protein allergy should be referred to a specialist withexpertise in this area.
Recommendations:
• In children with lactose intolerance with normal nutritional status, a temporarychange to lactose-free formula, either cow milk-based or soy protein-based,is adequate. A change to either extensively hydrolysed formula or elementalformula is not indicated. Soy formula is generally not recommended in infantsyounger than 6 months of age.
• In a malnourished child with persistent diarrhoea, consultation with or referral
to a specialist with expertise in this area is advisable.• In a child with persistent diarrhoea where food protein allergy is suspected,
consultation with or referral to a specialist with special expertise in this area isadvisable.
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
11 Part I: Algorithm or Managing Acute
Gastroenteritis in Children
Child with diarrhoea(> 3 times in a 24 hour period)
Watery without
blood and mucous
Do the following:
1. History and physical examination
2. Assess presence, degree and type of dehydration
3. Assess if stools are watery and if blood and mucous
are present
4. It should be emphasised that by just inspecting the
appearance of the stool, it is impossible to differentiate
with certainty viral from bacterial gastroenteritis
5. Assess nutritional status6. Consider other diagnoses in the presence of warning signsa
7. Always consider differential diagnosesb
a. Warning signs:
• Abdominal distension
• Bile-stained vomiting
• Blood in vomitus or stool
• Severe abdominal pain
• Vomiting in the absence
of diarrhoea
• Headache
b. Differential diagnoses:
• Acute appendicitis
• Strangulated hernia
• Intussusception or
other causes of bowel
obstruction
• Urinary tract infection
• Meningitis and other
types of sepsis
• Any cause of raisedintracranial pressure
• Diabetic ketoacidosis
• Inborn error of metabolism
• Haemolytic uraemic
syndrome
• Inflammatory bowel
disease
Consider the following:
1. Stool hanging drop test
for V. cholerae or cultureif the diarrhoea is profuse
and watery in nature or
fishy odour, should
consider cholera as
a possibility
2. Rehydrate as necessary
Blood and mucous
Consider the following:
1. Exclude bacterial pathogens
2. Stool studies for dysentery(Shigella, Campylobacter
jejuni , STEC, non-typhoidal
Salmonella, E. histolytica )
3. Treatment with antibiotic for
the specific pathogen
(see Guideline above)
4. Rehydrate as necessary
Criteria for hospital admission:
• severe dehydration (> 9% of body weight), shock
• neurological abnormalities (lethargy, seizures, etc.)
• persistent or bilious vomiting (even if no dehydration)
• treatment failure with oral rehydration salts (ORS)
• presence of systemic illness (high fever, toxic looking)
• underlying medical conditions (heart failure, significant
neurodevelopment disabilities)
• caregivers unable to provide adequate care at home or
other social/logistic concerns
• suspected surgical condition, uncertain about diagnosis
• uncertain about degree of dehydration (obese children)
Continue and refer to part II: Algorithm for Managing
Acute Gastroenteritis in Children
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12 Part II: Algorithm or Managing Acute
Gastroenteritis in Children
Stable
Unstable
Unresolved
No signs of dehydration(<3% loss of body weight)
• Child alert
• Drinks normally
• Heart rate, quality of pulse,
breathing, eyes and capillary
refill are normal
• Tears present and mouth
and tongue are moist
• Instant recoil in skin fold
• Warm extremities
• Normal to decreased
urine output
Some signs of dehydration(3-9% loss of body weight)
• Child normal, fatigued,
restless or irritable
• Thirsty and eager to drink
• Heart rate normal to
increased, quality of pulse
normal to decreased,
breathing normal to fast,
eyes slightly sunken and
capillary refill prolonged
• Tears decreased and mouth
and tongue are dry• Skin fold recoil in
< 2 seconds
• Cool extremities
• Decreased urine output
• If patient has 2 or more
signs of the above, there is
some dehydration
• Breastfeed or milk
feed normally
• Formula dilution not
recommended
• Children may continue
on lactose containing
milk formula
• Continue normal diet in
older children
• Encourage lots of fluid intake
• Offer ORS
Advise to seek medical
attention if persist more than
14 days. Consider lactose
intolerance and
food protein allergy
• Trial of ORS 30-90 ml/kg
(75 ml/kg for moderate
cases) within 4 to 6 hours
• Every diarrhoea episode:
ORS 10 ml/kg
• If ORS by mouth is
refused/inadequate, try
spoon feeding or ORS by
nasogastric /oralgastric
tube feeding
• Breastfeed or milk feed
normally
• Formula dilution notrecommended
• Children may continue
on lactose containing
milk formula
• Continue normal diet in
older children
• Small and frequent feeds
with regular assessment
Hospital referral for admissionfor IV fluid if persistent
vomiting/worsening dehydration
Severe dehydration(>9% loss of body weight)
• Child apathetic, lethargic,
unconscious
• Drinks poorly and unable
to drink
• Tachycardia with
bradycardia in most severe
cases, quality of pulse weak
and thready or impalpable,
breathing deep, eyes deeply
sunken and capillary refill
prolonged and minimal• Tears absent and mouth and
tongue are parched
• Skin fold recoil in
> 2 seconds
• Cold, mottled and cyanotic
extremities
• Minimal urine output
• Resuscitation
(normal saline/Ringer’s lactate)
• Frequent monitoring
Consider intensive care
if not resolved
No admission
if no excessive vomiting
No admission
if no excessive vomiting
Immediate referral to hospital
for admission
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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
13 Summary o Established Guidelines
CDC 20032 WHO 20051 ESPGHAN20084
New SouthWales Health
20105
AMMCOP/MPA2011
Setting Paediatricpractice, withemphasison USpopulations
Developingcountries orcommunitieswith scarcehealthresources
EuropeanCountries,low diarrhoealmorbidity andmortality
Primary casesetting in NewSouth Wales, Australia
Paediatric,primary careand rontlinehealthcareproviders inMalaysia
ORS Yes Yes Yes Yes Yes
Antibiotics Routineuse wastesresources &may lead to
antimicrobialresistance
Not routinelyindicated. Onlyin selectedclinical
situations
Do notrecommendroutine use inotherwise healthy
children
Rarelyrequired.Consultpaediatric
or inectiousspecialist
Not routinelyindicated.Only requiredor specifc
pathogens ordefned clinicalsettings
Antiemetics NR NR NR NR NR
Antimotility(Loperamide,Imodium)
NR NR NR NR NR
Antimotility(DiphenoxylateHCL; Lomotil)
NR NR NR NR NR
Adsorbants(Smectite)
- NR May berecommended
- May beconsidered as anadjunctive
Adsorbants(Kaolin-pectin)
NR NR NR NR NR
Anti-secretory(Racecodotril)
Need morestudies
- May berecommended
- May beconsidered as anadjunctive*
Anti-secretory(Bismuthsubsalicylate)
NR NR (Notpractical,needs tobe givenfrequently)
NR NR NR
Probiotics Should awaiturther clinicaltrials
- Strain-specifc(LactobacillusGG, S. boulardii )
Some benefts.Can be givenwhen anormal diet isreintroduced
May beconsidered asan adjunctive.Should be strain-specifc anddose specifc.
Prebiotics Shouldawait urtherclinical trials
- NR - NR
A switch tolactose-ree, soyor hydrolysate
NR NR NR NR NR
NR Not recommended
* Not commercially available in Malaysia at the time of publication of this guideline.
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APPENDIX A
Assessment o dehydration in acute diarrhoea
Symptom No signs o
dehydration
(< 3% loss o
body weight)
Mild to moderate
dehydration
(3-9% loss o
body weight)
Severe dehydration
(> 9% loss o body weight)
Mental status Well, alert N, atigue or restless,
irritable
Apathetic, lethargic,
unconscious
Thirst Drinks N, might
refuse liquids
Thirsty, eager to
drink
Drinks poorly, unable to drink
Heart rate Normal Normal to increased Tachycardia, with bradycardia
in most severe cases
Quality o
pulse
Normal Normal to
decreased
Weak, thready, or impalpable
Breathing Normal Normal, ast Deep
Eyes Normal Slightly sunken Deeply sunken
Tears Present Decreased Absent
Mouth and
tongue
Moist Dry Parched (very dry)
Skin old Instant recoil Recoil in < 2
seconds
Recoil in > 2 seconds
Capillary refll Normal Prolonged Prolonged, minimal
Extremities Warm Cool Cold, mottled, cyanotic
Urine output Normal to
decreased
Decreased Minimal
Adapted from WHO 2005 1 , CDC 20032
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APPENDIX B
Anti-Diarrhoeal Drugs
Attributes Loperamide Bismuth
subsalicylate
Smectide Racecadotril
Reduces
secretion
Yes No Yes Yes
Prevents
virulence
No No Yes No
Reduce stool
output
No Yes Yes Yes
Shorten
duration o
diarrhoea
No No Yes Yes
Fast acting - No Yes Yes
Constipation
as a side
eect
Yes No No No
Systemic
side eects
Yes Potentially No No
Does not
interere
with ORS
Not tested Yes Yes Yes
Adapted from Edelman et al, 1985 93 and Salazar-Lindo E. 201094
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The sponsor of this educational material was not involved in thedevelopment of this publication and in no way influenced its content.
The fullguidelines on the management of acute diarrhoea in childrenmay be obtained from the following websites:
•CollegeofPaediatrics,AcademyofMedicineofMalaysia(AMMCOP) http://www.acadmed.org.my/
•MalaysianPaediatricAssociation(MPA) http://www.mpaweb.org.my/
•MeadJohnsonNutritionMalaysia http://www.meadjohnsonasia.com.my/home.aspx
©2011 College of Paediatrics, Academy of Medicine of Malaysia and Malaysian Paediatric Association