Universal Recommendations for the Management of Acute Diarrhea in Children
The management of Acute Gastroenteritis (AGE) is essentially based on 5 steps:
1. Assessment of dehydration by simple, reproducible, and validated parameters and/or clinical score;
2. Prompt rehydration with reduced osmolality ORS;
3. Avoidance of elimination diets and continuing of breast-feeding in infants and regular diet in children;
4. Limiting laboratory investigations to selected circumstances and increased risk for bacterial infection;
5. Consider active treatment of diarrhea with products supported by compelling clinical evidence in children.
Rehydration:
Replacing fluid losses and avoiding dehydration are the primary aims of AGE management.
The oral route is effective in preventing and treating mild-to-moderate dehydration and should be started as soon as possible with appropriate solutions.
Different oral rehydration solutions (ORS) are available worldwide; however, an overall trend in recommending reduced osmolarity solutions (60–75 mmol Na+) has been observed in the last 10 years based on evidence of efficacy and better palatability than the WHO/UNICEF 90 mmol Na+ ORS.
In any case, the use of ORS is the key intervention to reduce AGE-related mortality, and it should be explained to mothers at well-being visits particularly in low-income areas as early as possible.
Recommendation
ORS is the first-line treatment of AGE.
Reduced osmolality ORS (60–75 mmol/L Na+) is recommended as first-line treatment of AGE. In case of cholera, 75 mmol/L Na+ is the standard rehydration regimen.
ReSoMal (Rehydration Solution for Malnutrition) containing 45 mmol/L Na+ and 40 mmol/L K+ may be indicated for malnourished children, although there are no conclusive data on its efficacy compared to standard reduced osmolality ORS.
In children who do not tolerate oral rehydration, administration of rehydration fluids either by nasogastric tube or intravenously (IV) is effective and should be recommended. IV rehydration should be avoided where possible in severely malnourished children. Enteral administration of ORS through a nasogastric tube is effective in rehydrating children with AGE and it is associated with fewer side effects than IV rehydration, especially in malnourished children.
Children with shock should be managed according to guidelines for hypovolemic shock.
In non-shocked children with severe dehydration, moderate quality of evidence supports the use of rapid IV rehydration with 20 mL/kg/h of 0.9% saline solution for 2 to 4 hours.
Nutritional management:
Several nutritional approaches are currently used worldwide according to local habits and beliefs to reduce severity and duration of diarrhea, but only few have been appropriately tested for efficacy.
All international guidelines agree on continuation of breast-feeding throughout the episode, and an age-appropriate scheme should be started during or after initial rehydration (4–6 hours).
Diet modification is usually unnecessary. However, several data support the addition of zinc to malnourished children.
Recommendation
Infants younger than 6 months should neither interrupt breast-feeding nor introduce diluted or modified formula. Where there is not the possibility to breast-feed, routine dilution of milk and routine use of lactose-free milk formula are not usually necessary.
Children should be re-fed early during the course of AGE. Regular oral feeding should be reintroduced no later than 4 to 6 hours after the onset of rehydration.
Lactose-restricted diets may be considered in hospitalized children and in children with prolonged diarrhea (>7 days). Lactose-free formula should be recommended in children with chronic diarrhea (>14 days).
Elimination diet is usually not indicated for children with AGE and it may further impair the child’s nutritional status.
Zinc is recommended as an adjunct to oral rehydration therapy in children older than 6 months living in low-income countries or in settings with medium or high risk of zinc deficiency. In infants younger than 6 months zinc is not effective regardless of the nutritional status.
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Many pharmacological interventions have been proposed in adjunct to ORS to reduce the severity and duration of symptoms. Only some have been specifically and accurately tested in clinical trials, whereas many products are currently available on the market with no proof of efficacy and safety.
Recommendation
Active treatment of diarrhea with the administration of probiotics and/or drugs may be considered where there is solid proof of efficacy in reducing the intensity and duration of symptoms. To maximize efficacy, active treatment should be administered early in the course of the disease.
However, administration of any product should not replace oral rehydration therapy and should be always used as an adjunct to ORS treatment.
Probiotics are effective in reducing the duration and intensity of symptoms of AGE. If available and in agreement with caregivers, selected probiotic strains (including Lactobacillus rhamnosus GG, Saccharomyces boulardii, and also L reuteri) can be considered in children with AGE, as an adjunct to ORS.
Antidiarrheal drugs recommended by several guidelines as adjunct to ORS treatment in children with AGE did not reach sufficient agreement among experts. Specifically, smectite (66.6%) and racecadotril (67.6%) were not endorsed based on stringent criteria.
Loperamide and other anti-motility drugs are not recommended in the treatment of AGE.
Vomiting is a major cause of dehydration (additional fluid losses and impaired oral rehydration). The use of antiemetics has been proposed with the primary aim of reducing vomiting in the first hours after disease onset, allowing effective oral rehydration and avoiding hospital admission. Routine use of antiemetics is still debated, mainly in the outpatients setting.
Metoclopramide, although effective, has significant side effects and is therefore not recommended for children with vomiting owing to AGE.
The efficacy of Domperidone is not supported by randomized controlled trials.
Ondansetron administered either orally or intravenously is effective in reducing vomiting and may avoid hospital admission. A single dose at the dosages used in the available studies may be considered in young children presenting to an emergency department with vomiting to ensure oral rehydration and reduce hospital admission.
However, the use of ondansetron has been associated with QT prolongation and severe cardiac arrhythmias and the drug carries a warning label by both the Food and Drug Administration and the European Medicines Agency that should be taken into account by health care providers.
AGE in otherwise healthy children is usually self-limited regardless of etiology. Even without specific antimicrobial therapy, clinical recovery generally occurs within a few days and the causative organism is cleared in a few days or weeks.
Routine use of antibiotics is not recommended for the treatment of AGE.
The use of antibiotics should be started immediately and may be considered in specific situations, including:
- infants younger than 3 months
- children with underlying chronic conditions, including those with sickle cell anemia or immunodeficiency and those at risk for developing severe or extraintestinal dissemination
- isolation of specific pathogens such as Shigella, enterotoxigenic (but not Shiga-like toxin-producing) Escherichia coli, V cholerae, Yersinia enterocolitica, and Entamoeba histolytica.
- Campylobacter colitis can be treated with antibiotics, but treatment is effective only if administered within the first 2 days from the onset of symptoms.
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