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COLLEGE OF PAEDIATRICS, ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION
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
THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011
Terms of Reference
This guidelines aim to cater mainly for paediatricians, primary care physicians and other frontline healthcare providers involved in providing care for children.
This guidelines consist of easy-to-read information with appropriate flow charts. All facts are evidence-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 obtained from the following websites:
• College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP) http://www.acadmed.org.my/ • Malaysian Paediatric Association (MPA) http://www.mpaweb.org.my/ • Mead Johnson Nutrition Malaysia http://www.meadjohnsonasia.com.my/home.aspx
A pocket reference guide which is a summary of the recommendations for the management of acute diarrhoea in children may be obtained from AMMCOP, MPA or Mead Johnson Nutrition Malaysia. A wall poster consisting of a flow chart on the management of acute diarrhoea in children may be obtained from AMMCOP, MPA or Mead Johnson Nutrition Malaysia.
The committee members have the sole right to determine the content of the suggested guidelines. The sponsor did not influence any part of the content at any time.
No conflict of interest declared by any of the committee members.
Source of funding:
This guidelines was made possible by an unrestricted educational grant from Mead Johnson Nutrition Malaysia.
The content / guidelines is based solely on currently available scientific evidence or best clinical practice. Healthcare professionals are expected to utilise the information contained within this guidelines when exercising their clinical judgement. However, this guidelines should not replace the individual responsibility of the user to make decisions appropriate to the circumstances of the individual patient and informed by the current indications and accuracy of the drug they are considering.
Copyright of the document remains with the College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP) and Malaysian Paediatric Association (MPA). No part of this publication may be reproduced in any form without the prior written permission of the authors.
COLLEGE OF PAEDIATRICS, ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION
01 Introduction 02 Summary of the Guidelines 03 Scope of the Guidelines 04 Definition of Diarrhoea 05 Clinical Types of Diarrhoeal Diseases 06 Important Causative Agents of Gastroenteritis 07 Assessment of Acute Diarrhoea 08 Management of Childhood Acute Diarrhoea 09 Prevention of Childhood AGE 10 Special Considerations 11 Part I: Algorithm for Managing Acute Gastroenteritis in Children 12 Part II: Algorithm for Managing Acute Gastroenteritis in Children 13 Summary of Established Guidelines References Appendix A Appendix B 1 2 3 3 4 5 7 11 23 25 26 27 28 29 34 35
2-5 Therefore there is an urgent need to have a local guidelines catering to the specific need for Malaysia. Hepatology and Nutrition (ESPGHAN) cater mainly for North America and the European countries. Since then there has been a proliferation of publications and new findings in this area in the literature. 1 .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. The new WHO Guidelines on the ‘Treatment of Diarrhoea’ (2005) caters mainly for the need of developing countries with a limited health care resources. there has been publication of a few guidelines on the management of childhood AGE. Academy of Medicine of Malaysia (AMMCOP). respectively. Over the last few years.1 while other guidelines such as those from the Center for Disease Control (CDC) and the European Society for Pediatric Gastroenterology.
For children who are formula-fed.8 There are four clinical types of diarrhoea.1 The main causes of childhood AGE are various enteric viruses and bacteria.3% of all medically certified and uncertified deaths (or 69 deaths per year) among children younger than 5 years of age were due to acute gastroenteritis. Food should not be withdrawn for longer than 4 – 6 hours after the onset of rehydration.9 Various studies. to provide the appropriate management. there is no detailed epidemiological study on the burden of acute diarrhoea in children from Malaysia. although parasites are important in certain specific setting. In most instances with uncomplicated AGE. and may even be contraindicated or dangerous. consultation with or referral to a specialist with expertise in this area should be considered. lactose intolerance and food protein allergy (most commonly cow milk or soy protein) complicating AGE. no laboratory investigation is necessary. based mainly on hospital admission studies.6 It is estimated that each year.10-20 Important bacterial pathogens include non-typhoidal Salmonella and E. Drug therapy is unnecessary in most cases.9 million children younger than 5 years of age dies of acute diarrhoea. in particular the severity of dehydration of the child. However.COLLEGE OF PAEDIATRICS. persistent vomiting or worsening diarrhoea even in the absence of dehydration. uncertainty about diagnosis. Both are safe and highly effective in preventing severe dehydrating diarrhoea. gradual reintroduction of feeding and switching to lactose-free. oral rehydration therapy is the treatment of choice and is sufficient in a majority of cases. Rotavirus is the commonest viral pathogen causing severe dehydrating diarrhoea in the world over.7 At present. namely acute watery diarrhoea. persistent diarrhoea and diarrhoea with severe malnutrition. repeated or persistent bacterial or parasitic infections should be excluded. or presence of other complications. Children who require rehydration should continue to be breastfed or formula-fed. Every child with AGE should be carefully assessed for dehydration and other complications. In most cases of uncomplicated acute diarrhoea with no significant dehydration. presence of unfavourable socio-economic factors. Rotavirus vaccines are not part of the national immunisation schedule in Malaysia. Breastfeeding is the best measure for the prevention of AGE in young infants. approximately 1. acute bloody diarrhoea. it is recommended that vaccination should be considered as part of prevention of rotavirus diarrhoea. However. showed that rotavirus is the most common cause of dehydrating diarrhoea in young children requiring hospital care in Malaysia. soy or hydrolysate formulae are not recommended. 2 . formula dilution. A careful history and detailed physical examination to assess the state of hydration is often all that is necessary.21 Proper clinical assessment is required to correctly diagnose the condition. Currently there are two rotavirus vaccines available in Malaysia. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 02 Summary of the Guidelines Acute diarrhoea is the second most important cause of childhood mortality worldwide.22 When the duration of diarrhoea persists for more than 14 days following an episode of AGE. coli. it was estimated that 1. Criteria for hospital care include moderate-to-severe dehydration. In these cases.
Diarrhoea can also be the initial signs of non-gastrointestinal tract illness. 'pasty' stools sometimes up to 6 to 7 times a day which should not be considered as diarrhoea. It is the consistency of the stools that is most important. breastfed babies pass loose. intussusception and urinary tract infection. The volume of fluid loss can vary from 5ml/kg body weight/day to ≥ 200 ml/kg body weight/day. 2 3 . Similarly. and anti-emetics) Probiotics and prebiotics Nutrition management (manipulation of feeding practices. bacterial pneumonia. special formulae) Vaccines (rotavirus vaccines) 04 Definition of Diarrhoea Diarrhoea is defined as the passage of unusually loose or watery stools. rather than the frequency.1 The main problem with acute diarrhoea is its ability to cause rapid fluid loss through stools in addition to electrolytes loss. otitis media. usually at least 3 times in a 24-hour period.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 03 Scope of the Guidelines The present guidelines are intended to be used in the following settings in Malaysia: • • Primary care settings (out-patient clinic. It will include various management aspects including office management of AGE such as: • • • • • • Clinical assessment Rehydration management Drugs (antibiotics. including meningitis. emergency room) In-patient care The guidelines focus mainly on acute diarrhoea in children. In addition. Dehydration and electrolyte losses associated with untreated diarrhoea are the main causes of morbidity and mortality of childhood AGE. Frequent passing of formed stools is not considered as diarrhoea. vomiting without diarrhoea can be the first symptom of a host of diverse surgical and metabolic conditions as well. anti-diarrhoeal.
4 . dehydration. although not as common as in acute watery diarrhoea. may also occur. It may lead to malnutrition and serious infection with or without dehydration. Persistent diarrhoea Deﬁned as diarrhoea that lasts 14 days or longer. Acute Bloody Diarrhoea (dysentery) Should be considered when blood and mucous are present in the stools. The main concern is dehydration. heart failure. severe electrolytes imbalance. and vitamin and mineral deﬁciencies. Weight loss can also occur if feeding is being withheld for too long. The main dangers are damage to the intestinal mucosa. Dehydration.COLLEGE OF PAEDIATRICS. Diarrhoea with severe malnutrition A serious condition and warrants special attention to exclude severe systemic infection. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 05 Clinical Types of Diarrhoeal Diseases 1 Acute Watery Diarrhoea Lasts for several hours or days. sepsis and malnutrition.
9 In the developing countries. enteropathogenic Escherichia coli (EPEC). coli. shiga-toxin producing Escherichia coli (STEC). enteric viruses are more important than bacterial pathogens in causing childhood diarrhoea. calicivirus. Other enteric viruses include norovirus. Campylobacter jejuni Shigella. astrovirus.9 In developed countries. Philadelphia: Lippincott. enteric adenovirus. non-typhoidal Salmonella. astrovirus and calicivirus. 2007:Page 1917-19749 It is also useful to classify important aetiological agents according to age group and nature of stools (Table 1): Table 1: Important causative agents of gastroenteritis by age group and nature of stool worldwide 4 Watery ≤ 2 years Rotavirus. adenovirus.9 Developed Countries Developing Countries Rotavirus Unknown Parasites Bacteria Adenovirus Astrovirus Calicivirus Other Bacteria Toxigenic Escherichia coli Adapted from Estes MK and Kapikian AZ . such as E. Vibrio cholerae Enterotoxigenic Escherichia coli (ETEC). 5th ed. enterotoxigenic Escherichia coli (ETEC). Vibrio cholerae 2-5 years Mucousy / bloody ≤ 2 years 2-5 years Shigella. Williams. Shigella species. shiga-toxin producing Escherichia coli (STEC).THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 06 Important Causative Agents of Gastroenteritis Rotavirus is the main cause of virus-induced gastroenteritis in both developed and developing countries. and Wilkins. and Campylobacter species are important pathogens. histolytica 5 . Shigella. E. non-typhoidal Salmonella. on the other hand. In: Fields Virology. in addition to enteric viruses. rotavirus. bacterial pathogens.
ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION Table 2: Important causative agents of childhood acute gastroenteritis in Malaysia 10.4 0 3 0 0 0 No organism 50 59 56 60 39 49 a includes enteropathogenic and enterotoxigenic E. Shigella and E. 6 . Coli a Campylovirus bacter jejuni 4 NT 4 NT NT 2 11 26 10 9 6 6 2 0. coli as a mixed infection NT Not tested b In Malaysia.4 1 0. the main causative agent is non-typhoidal Salmonella.Salmonella Shigella E.4 10 1 0. 14. 23 Percentage of aetiological agent (%) Author Iyngkaran et al 10 Koe et al 12 Lee et al 14 Poo and Lee 19 Tan 20 Kahar-Bador & Lee 23 Number Rota.4b 0 0. Only 10% of the cases are caused by rotavirus. and enteric adenovirus (Table 2).COLLEGE OF PAEDIATRICS.coli.12 However. the most important causative agent is the non-typhoidal Salmonella.21 Among the hospitalised children.NoroTested virus virus 300 97 228 288 261 568 19 9 29 30 54 28 9 Adeno. 40 to 50% of cases are caused by rotavirus and patients demonstrated severe vomiting and diarrhoea and severe dehydration. norovirus. For bacterial gastroenteritis. 20. major enteric viruses causing childhood AGE are rotavirus. the above figure was based on only one study in Malaysia which was performed in a private outpatient clinic in Klang Valley with a relatively small number of patients. 12. As for outpatient. followed by Campylobacter. 19.
It should also be emphasised that clinical signs for dehydration are imprecise. presence / absence of tears • Mucous membrane – moist or dry • Respiratory pattern • Bowel sounds • Extremities (perfusion.3 Assessment: Dehydration 7 . immune compromised states) • Social history The following aspects should be covered: • Accurate body weight • Vital signs (temperature. blood pressure) • General conditions • Eyes: sunken eyes. medications. the degree of. 25 • Prolonged capillary reﬁll time (normal < 2 seconds) • Reduced skin turgor • Abnormal respiratory pattern 7. change in mental status) • Past medical history (underlying medical problems. capillary ﬁlling time) • Skin turgor (anterior abdominal wall) • Inspection of stool (presence of blood or mucous) Classiﬁcation into severity of dehydration is essential for appropriate ﬂuid management. respiratory rate. Most useful signs for signiﬁcant dehydration are: 4. quantity and character of both vomiting (presence of bile. frequency. 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. and type of dehydration • Identify the aetiological agent. 24 Therefore.2 Assessment: (see Appendix A) Physical Examination 7. history of other recent infections. The best measure of dehydration is by the percentage loss of body weight. the actual weight is often not available.1 However.1 Assessment: History 7. repeated assessment is often necessary. blood) and diarrhoea (presence of blood or mucous) • Recent oral intake (including breast milk and other ﬂuids and food) • Urine output • Weight before illness (if available) • Associated symptoms (fever.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 07 Assessment of Acute Diarrhoea 1-5 Aims of assessment • Identify the presence of. heart rate.4.
ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 7.e. Very little evidence-based guidelines on this condition have been published recently..COLLEGE OF PAEDIATRICS. Important causes of hypernatraemic dehydration in childhood acute diarrhoea include young infants who were predominantly breastfed and were given inadequate breastfeeding. while that of hyponatraemia was 1.0%. In a one-year prospective study on 393 children admitted with AGE to a teaching hospital.4 Hypernatraemic Dehydration This is generally deﬁned as a serum sodium concentration of ≥ 150 mmol/L. An excellent review on this topic can be found elsewhere.2%. or given inappropriately prepared infant formula.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. the incidence of hypernatraemia was 1.19 Table 3: Simplified ways of classifying the degree of dehydration Classiﬁcation Fluid deﬁcit as % of body weight Fluid deﬁcit in ml/kg of body weight No signs of dehydration Some signs of dehydration Severe dehydration < 3% 3-9% >9% < 30 ml/kg 30 – 90 ml/kg > 90 ml/kg Adapted from: WHO 2005 1 8 . 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 patients with high fever (>39°C). other conditions can present with the above symptoms as well. apathy. diarrhoea and fever.27 9 . it should be emphasised that the clinical features of both viral and bacterial aetiology overlap considerably.27. overt faecal blood. seizures or coma suggest bacterial aetiology. central nervous system involvement such as irritability.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 7. However. 28 Patients presenting with more signiﬁcant vomiting and respiratory symptoms suggest viral aetiology.29 Rotavirus causes more severe vomiting and dehydration.6 Bacterial or Viral Cause? Generally. abdominal pain. Although gastroenteritis consists of the triad of vomiting. 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 7.5 Differential Diagnoses 23 It is always useful to keep in mind the possibility that the diagnosis of AGE may be incorrect.
and frequent vomiting. The only laboratory measurement that appears to be useful in decreasing the likelihood of > 5% dehydration is serum bicarbonate (presence of a normal serum bicarbonate).3 Blood: The incidence of hypoglycaemia in children with AGE has been estimated to be between 1. 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 4.4 7. Mg2+ in young infants) 7.4 Electrolytes should also be measured in all children requiring intravenous therapy. Na+. laboratory investigations are unnecessary. 4 In the majority of children with uncomplicated AGE with no signs of dehydration.23 Electrolytes should be measured in moderately dehydrated children whose history and physical examination ﬁndings are inconsistent with a straight-forward diarrhoeal illness.4 It should also be noted that laboratory assessment for severity of dehydration are imprecise.2%.7.7 Diagnostic Workup 1. K+. Table 4: Indications for stool culture and sensitivity 4 • • • • Bloody diarrhoea (consider dysentery) Severe watery stools (consider cholera) Severe and prolonged diarrhoea Immune-compromised child 7.COLLEGE OF PAEDIATRICS.9 – 9. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 7.7.30-32 The risk factors for developing hypoglycaemia are female gender. pH. and other electrolyte imbalances. HCO3 • Complete blood count– if bacterial sepsis is suspected • Consider glucose monitoring (girls younger than 5 years with vomiting) • (± Ca 2+.32 10 . signs of neuroglycopenia.2 Urine: • 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 • Urea.7. and during therapy to monitor the presence of hyperand hyponatraemia.1 Stool: • Routine stool culture is not indicated as it is expensive and does not alter the management in the vast majority of patients 4 • Stools culture is mandatory if profuse watery stools (cholera). and in all severely dehydrated children.
malnutrition Drug(s) treatment.4 11 . 5 The presence of the following warning signs is helpful in deciding whether the child needs further assessment and possible hospital care: Table 5: Criteria for Hospital Care 4 • • • • • • • • • Severe dehydration (> 9% of body weight). there are no established. uncertain about diagnosis Uncertain about degree of dehydration (obese children) However. 4. toxic looking) Underlying medical conditions (heart failure.1. significant neurodevelopment disabilities) Caregivers unable to provide adequate care at home or other social/logistic concerns Suspected surgical condition. it should be emphasised that at present. metabolic and other complications. severe electrolyte imbalance. shock Neurological abnormalities (lethargy.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 08 Management of Childhood Acute Diarrhoea 1-5 Important points to be considered: • • • • • Identification of children at risk of severe disease or at risk of developing complications Prevention / correction of dehydration and electrolyte imbalance Prevention and treatment of complications such as invasive disease. evidence-based criteria for the hospital admission of childhood AGE. etc. seizures.) Persistent or bilious vomiting (even if no dehydration) Treatment failure with oral rehydration salts (ORS) Presence of systemic illness (high fever.1 Referral for Hospital Care In the majority of cases of uncomplicated childhood AGE with no significant dehydration. which may have a supplementary role Provision of adequate and appropriate nutrition 8. outpatient assessment and subsequent home management is all that is necessary.
Table 6: Mean Stool Na+ and K+ (mmol/L) According to Duration of Diarrhoea Before Admission Cholera Duration (h) (mmol/L) EPEC K (mmol/L) Rotavirus (mmol/L) Na 98 83 63 46 (mmol/L) Na 67 55 44 44 K (mmol/L) Na 53 42 32 34 (mmol/L) K 0 – 12 13 – 24 25 – 48 48+ 29 37 28 65 37 38 26 37 46 42 28 43 12 Adapted from Molla AM et al. worsening dehydration despite adequate therapy • Resuscitation (normal saline / Ringer’s lactate) • Frequent monitoring • Immediate referral to hospital for admission 8. continue usual feeding and offer extra water • For older children: continue normal diet with extra ﬂuids • If no excessive vomiting and in the absence of adverse social circumstances. rotavirus and enteropathogenic Escherichia coli. enteral rehydration via the naso-gastric route is as effective if not better than intravenous rehydration.1-5 When oral rehydration is not feasible. It is more appropriate to use the original WHO ORS in situations where cholera is likely. 33 Oral or enteral rehydration is associated with significantly fewer major complications and a shorter hospital stay compared with intravenous therapy and is successful in most children. In other situations.2 Some signs of dehydration (3-9%) 8. 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.COLLEGE OF PAEDIATRICS. a reduced osmolality ORS is preferred. 8. oral rehydration should be used as first-line therapy for the management of children with AGE.2.4 Selection of oral rehydration salts (ORS) Table 6 shows the electrolyte content of stool samples obtained from patients with cholera.1 No signs of dehydration (< 3%) • If no excessive vomiting.1-5.2. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 8. home management is usually sufﬁcient • If breastfeeding. 199134 .2. continue breastfeeding • If formula-fed.3 Severe dehydration (> 9%) 8.2 Rehydration in Acute Diarrhoea General principles: Generally.2.
2009 36 # 1 molecule of citrate is metabolised into 3 molecules of bicarbonate in the body.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 Table 7 shows the electrolyte content of various ORS preparations available in Malaysia.5 75 75 110 10 10 10 311 245 290 245 245 312 Adapted from Santosham M.5 250 0 21 260 330 Adapted from Santosham M. Fluids that are not suitable as substitute for ORS include 100 Plus (Table 8). Osmolality of Various ORS Preparations (mmol/L) Na 90 75 56 75 75 90 (mmol/L) K (mmol/L) Cl (mmol/L) HCO3 30 30 20 Glucose (mmol/L) Citrate # (mmol/L) Osmolality (mmol/kg) Standard WHO (1975) Reduced-Osmolality WHO (2002) Ministry of Health ORS Plus (per sachet) Upha E-Lyte (per sachet) Weewa ORS (per sachet) 20 20 20 20 20 21 80 65 56 65 65 81 111 75 137. Table 8: Fluids Not Appropriate to be Used in Rehydration Therapy (mmol/L) Na 2 3 (mmol/L) K 0 (mmol/L) Cl (mmol/L) HCO3 NA 0 0 0 3 Glucose (mmol/L) Osmolality (mmol/kg) Coca cola Apple juice Chicken broth Tea 100 Plus NA NA NA NA 20 616 600 – 900 0 0 NA 618 20 8 0 3. 1997 35. Lee WS. Lee WS. Table 7: Electrolytes Composition. 2009 36 NA Not available 13 . 1997 35.
COLLEGE OF PAEDIATRICS. immuno-suppressed. i. immune-compromised.3. Thus. over 48 hours. Subsequent rehydration can also be achieved with ORS.1 Special Consideration Hypernatraemic dehydration Hypernatraemic dehydration is defined as serum sodium concentration of more than 145 mEq/L.3 8. Generally patients with hypernatraemic dehydration respond well to oral rehydration therapy. ORS might be safer than intravenous fluid because it is less likely to lead to a precipitous increase in intracellular water associated with seizures and raised intracranial pressure. achlorhydia 14 . adenovirus). Such therapy is ineffective and may be harmful. antibiotic therapy should not be given routinely to children with diarrhoea.e. systemically ill. antibiotics are only needed for specific pathogens or defined clinical settings.4 8.2 Those with severe dehydration should first receive intravenous fluid therapy for resuscitation. Recommendations: Antibiotics are indicated in the following situations: • • • • Shigella dysentery . these should be treated 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).1-5 Majority of gastroenteritis cases in children are viral in origin (rotavirus. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 8.4. 2 8.in cases presenting as bloody diarrhoea. norovirus. The principal of subsequent rehydration should be the use of isotonic solution (normal saline) administered at a slower rate.1 Adjunctive Therapy for Acute Diarrhoea Antibiotics 1-5 With only a few exceptions.
4 mg/kg (300 mg as a single dose in adult) Day 1: 12 mg/kg Day 2-5: 6 mg/kg Cholera Doxycycline B Azithromycin 1 3 days Note: A: High risk children include those with underlying immune deficiency. 15 . inflammatory bowel disease.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 Table 9: Recommended Antibiotics for Acute Diarrhoea 4 Pathogen Shigellosis 4 Antibiotics Azithromycin Ceftriaxone Trimethoprimsulfamethoxazole Total daily doses Day 1: 12 mg/kg Day 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 No. and neonates and young infants. corticosteroid or immunosuppressive therapy. of Doses/day 1 1 2 Duration 5 days 2-5 days 5 days Salmonella Gastroenteritis (in high risk children) A Amoxicillin Ceftriaxone Trimethoprim -sulfamethoxazole Ciproﬂoxacin 3 1 2 2 2 2 2 1 5 days 2-5 days 5 days 5 days 5 days 5 days 5 days Single dose Campylobacter dysentery Erythromycin Azithromycin 30-50 mg/kg 4-7 mg/kg IV >8 kg: 4. achlorhydria.4 B: World Health Organization (WHO) does not recommend the use of doxycycline in children with cholera. anatomical and functional asplenia.
These may cause sedation that can interfere with oral rehydration therapy. 37 Therefore. 1 2 Categories No effect on diarrhoea or not safe in young children Possible effects on diarrhoea but not licensed to be used in young children Uncertain or some effects. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 8.4. Due to this reason. it is recommended that children with persistent vomiting be given small frequent feeds.COLLEGE OF PAEDIATRICS. and they can be divided into the following categories: Table 10: Anti-diarrhoeal Agents and Other Therapies Commonly Used in Childhood Acute Diarrhoea. but generally safe Safe and licensed in children with useful / positive effects in childhood diarrhoea Examples Loperamide Activated charcoal Kaolin-pectin Cholestyramine Bismuth-salt Diosmectite Certain probiotics Zinc Certain probiotics Racecadotril 3 4 16 .4. This will lead to retention of fluid and toxin that would have been eliminated through vomiting. metoclopromide. anti-emetics are not routinely indicated in children with diarrhoea. anti-emetics may decrease vomiting but increase frequency of diarrhoea.3 Anti-diarrhoeal agents and other therapies Anti-diarrhoeal agents are generally not indicated in childhood AGE.2 Anti-emetics Anti-emetics include drugs such as dimenhydrinate. Various anti-diarrhoeal agents and other therapies are available in the market.1-5 In addition. According to Efficacy on Diarrhoea and Safety Profile No. • Recommendations: Not recommended 8.4. domperidone and promethazine.
38 In this metaanalysis. prolonged excretion of Shigella has narrow therapeutic range. prolong intestinal transit time increases direct contact between intestinal epithelium and noxious agents usage in Shigella – invasive illness. 8 out of 972 children with loperamide had lethargy/death compared to none from the placebo group.3.38 Recommendations: • Not recommended 38 (ii) • • • • • Diphenoxylate HCl (Lomotil®) anti-peristaltic. hence risk of overdose and severe side effects Recommendations: Not recommended 17 .1 Anti-motility (intestinal transit inhibitor. prolonged fever. mask water loss. opiate agonists) (i) • Loperamide (Imodium®) decrease frequency and duration of diarrhoea but have serious side effects (lethargy and death) especially in young children (< 3 years).THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 8.4.
) (i) • • • • • Silicates . bulk-forming.40 A total of six randomised-controlled trials showed that as compared to placebo. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 8.4.40 A more recent randomised controlled trial showed that diosmectite reduced stool output in children with acute watery diarrhoea.64.3.98).36-1.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. the control group (RR 1. 40 Recommendations: • Can be considered as an adjunctive therapy 4.COLLEGE OF PAEDIATRICS.7 hours. 95% CI: 1. etc.41 No side effects 4. especially those who were rotavirus-positive. 40 • 18 .2 Intraluminal agents (adsorbents. diosmectite significantly reduced the duration of diarrhoea by approximately 22. and the chance of a cure on intervention day 3 was significantly increased in diosmectite vs.
THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 8. 43 • * Recommendations: Can be considered as an adjunctive therapy 42.4. Table 11: Recommendation on The Use of Anti-emetics and Anti-diarrhoeal Agents on Childhood Acute Gastroenteritis 4 Agents Anti-emetics Dimenhydrinate. preserving endogenous enkephalinase significantly reduces stool output (~50%) by 48 hour well tolerated no side effects42.3 Anti-secretory (i) • • • • Enkephalinase inhibitors (racecadotril*) enkephalinase-inhibitor. Metoclopromide. In fact. 43 Not commercially available in Malaysia at the time of publication of this guideline.1-5 19 . most of the anti-diarrhoeal agents and other therapies have no practical benefits and are never indicated for the treatment of acute diarrhoea in children. some are harmful to children. 43 One of the major drawbacks on racecadotril is that most randomised-controlled trials previously were mainly industry-sponsored.3. Domperidone.42. Promethazine Anti-motility Loperamide Diphenoxylate HCl Intramural agents Silicates-kaolin / pectin Diosmectite Anti-secretory Racecadotril Recommendation Not recommended Not recommended Not recommended Not recommended Can be considered as adjunctive Can be considered as adjunctive Though commonly used.
ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 8. 20 .4. • • 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 effect and moderate clinical benefit of selected probiotic strains in the treatment of acute watery diarrhoea.4 The effects of probiotics are strain-specific and dose specific. The studies also have different aims and measured different end points. Even the most studied strain like Lactobacillus GG show efficacy results that are not always consistent. Products with multiple strains should also have efficacy studies. Adding additional strains to an effective strain may not necessarily have a synergistic effect or increase in efficacy. In fact. Not all probiotics are equivalent in terms of efficacy and the efficacy of a specific strain cannot be generalised. 45. lactobacillus acidophilus and Saccharomyces boulardii.44.4 Probiotics and prebiotics Certain strains of probiotics may be an effective adjunct to the management of diarrhoea. there is no evidence of efficacy for many available commercial preparations. 46 The most studied probiotic strains are Lactobacillus GG. using different strains and some a combination of different strains.COLLEGE OF PAEDIATRICS. The designs of the studies are different.
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.2x1010 to 2x1013 CFU 3 to 7 days Lactobacillus Rhamnosus GG 47-56 Lactobacillus acidophilus 57-62 6 • Reduce duration of diarrhoea (5/6) • Reduce by 6. 69. • Recommendations: Not recommended 21 .THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 Table 12: Summary of Randomised Controlled Trials (RCT) of The Four Commonest Strains on Acute Gastroenteritis in Children Strain Total number of RCT 10 • • • • Efficacy (number of studies) 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) Efficacy (number of studies) 1.6 to 31 hours • Reduce stool frequency (1/6) • Reduce duration of diarrhoea (4/5) • Reduce by 24 to 38 hours 1x10 9 to 6x109 CFU 3 to 5 days Saccharomyces boulardii 63-67 5 3 x 109 CFU 5 to 6 days Lactobacillus reuteri 68.
Food should not be withdrawn for longer than 4 – 6 hours after the onset of rehydration.COLLEGE OF PAEDIATRICS. 4. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 8. Children fed with undiluted formula resulted in a significant body weight catch-up (p = 0. For children who are formula-fed.002) as compared to those fed with diluted formula.72 • Recommendations: In children who are on infant formula.5 Nutritional Therapy / Special Infant Formula Children who require rehydration should continue to be fed.046) as compared to those fed with diluted formula.5. 72 8. diluted formula A meta-analysis (1994) identified 16 studies (9 randomised controlled trials) that investigated the practice of diluting formula 2.1 Undiluted vs. 71. formula dilution and gradual reintroduction of feeding are not recommended.to 6-fold for periods ranging from 1 to 6 days.3. but there was no difference in the duration of diarrhoea. no dilution of formula is recommended 22 . Breastfeeding should be continued during acute gastroenteritis.72 Children given undiluted formula has a slight increase in stool frequency (p = 0.
only 4 out of 14 trials provided information on stool frequency and outputs. about 3% (see section 10.74.2 Soy-based or cow milk-based lactose-free formula The vast majority of young children with acute gastroenteritis can safely continue to receive lactose-containing milk formula because the number of treatment failures is negligible compared to children with acute diarrhoea on a lactose-free diet.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 8.72 The effects on weight gain cannot be reliably assessed as very few studies reported data on weight gain. evidence-based data to support the routine need to switch from a cow milk-based formula to a soy or hydrolysate formula in a baby with acute gastroenteritis. the results were widely heterogeneous.15%) in children who did not. 75 In addition.1). the incidence of secondary lactose intolerance after AGE in Malaysian infants is generally low.72 Thus. duration of hospitalisation. Pooled results were widely heterogeneous. there is at present no sufficient. 73 In a meta-analysis on randomised controlled trials comparing lactose-free versus lactosecontaining formula after AGE. 71. 72. • Recommendations: In the absence of clinical evidence suggestive of lactose intolerance (please refer to 10. Lactose-containing formula caused marginally greater stool outputs than lactose-free formula.72 However. overall. 23 . 22% (95% CI 18-27%) of children who consumed lactose had therapeutic failure compared to 12% (95% CI 9% .4 There is also no advantage for soy formula over cow milk formula over severity and duration of diarrhoea.5. a routine change to lactose-free formula (either soy-based or cow milk-based) after an episode of acute diarrhoea is not recommended. or treatment failure.72 Nine trials reported data on the duration of diarrhoea after the initiation of therapy. However.4.2).
77 Thus.4 Zinc UNICEF and WHO recommend zinc supplementation (10mg below 6 months of age.4 24 .5.5 Others Homeopathy: Although homeopathy continues to be widely used. there is insufficient evidence to recommend its use for the treatment of acute gastroenteritis in children.4 • Recommendations: Zinc can be considered to be given to malnourished children with acute diarrhoea 8. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION Table 12: Locally Available Soy-based and Lactose-free Formulae (in Alphabetical Order) Nature Cow milkbased lactose-free Locally available brand • Dulac® Lactose Free • Enfalac A+ LactoFree ® • Mamex Gold Lactose Free ® Age range 0 – 12 months Infancy and beyond Infancy and beyond Infancy and beyond Infancy and beyond Infancy and beyond 0 – 12 months Infancy and beyond 0 – 12 months > 12 months 0 – 6 months 7 months and beyond Infancy and beyond Manufacturer Danone Dumex Mead Johnson Danone Dumex Nestle Morinaga UP International Abbott Nutrition Mead Johnson Abbott Nutrition Abbott Nutrition Danone Dumex Danone Dumex Pfizer • Nan AL 110 • NL33 • Novalac AD • Similac LF ® Soy-based • Enfalac A+ ProSobee ® • Isomil ® • Isomil® Plus • Mamex Gold Soya Step 1 ® • Mamex® Gold Soya Step 2 • Nursoy ® 8.76 There is no proven benefit of the use of zinc in children without severe malnutrition.4 Herbal Medicine: There is insufficient evidence to recommend in favour or against the use of herbal medicine for the treatment of acute gastroenteritis in children. with acute gastroenteritis.5.COLLEGE OF PAEDIATRICS. zinc should only be given to malnourished children. 20mg in older infants and children for 10-14 days) as a universal treatment for children with diarrhoea.
both safe and highly efficacious. Subsequent 2 doses administered at 4-10 weeks’ interval. Interval between 2 doses should not be < 4 weeks.80 Both have been proven to be very safe and are highly effective in preventing severe dehydrating diarrhoea. However.80 Rotavirus vaccines are not part of the National Immunisation Program (NIP) in Malaysia. Rotarix® (Monovalent human attenuated Rotavirus vaccine) PO x 2 doses up to age 24 weeks 25 . First dose of primary vaccination should be given between the age of 6 and 12 weeks. Table 13: Rotavirus Vaccines Available in Malaysia Drug Rotateq (Pentavalent Rotavirus vaccine) ® Dosage PO x 3 doses up to age 32 weeks Dosing interval 1st dose administered at 6-12 weeks of age. 1st dose between 6-14 weeks of age. while others include the use of safe drinking water. RotaTeq® and Rotarix®. Two rotavirus vaccines.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 09 Prevention of Childhood AGE 9. 79 Vaccines for other enteric pathogens are currently not available on a routine basis.4 The best measure is the promotion of breastfeeding.78.2 Vaccines Rotavirus is the commonest viral pathogen causing severe dehydrating diarrhoea in the world over. and the full schedule (RotaTeq® 3 doses and Rotarix® 2 doses) should be completed by the age of 8 months for RotaTeq® and 6 months for Rotarix®. 3rd dose should be completed before 32 weeks of age.1 General Measures General measures of preventing childhood AGE are effective in certain circumstances. • Recommendations: Rotavirus vaccine should be considered as a part of prevention of rotavirus diarrhoea in Malaysian children. 2nd dose between 14-24 weeks of age. it is recommended that vaccination should be considered as part of prevention of rotavirus diarrhoea. and an improvement of environmental hygiene. 9. are available in Malaysia. Rotavirus vaccines are part of routine universal vaccination programme in many countries in the world.
There is very little evidence that prebiotics may be used as a preventive measure to the management of diarrhoea.88.90.85 There are also studies that looked at using probiotics supplements to prevent acute diarrhoea in children or use of formula with added probiotics with or without prebiotics to prevent acute diarrhoea in children. 82.3 Probiotics and prebiotics There are studies on the use of probiotics in preventing antibiotic associated diarrhoea (AAD) in children and adults. 91 26 . thereby improving the health of the host. 87 Not all studies showed beneficial effects.86. Not all types of prebiotics are the same or have similar effect. Studies in children have shown certain strains like Bifidobacterium lactis.84 Another meta-analysis noted that the potential protective effects of probiotics to prevent AAD in children did not withstand intention-to-treat analysis. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 9.45).COLLEGE OF PAEDIATRICS. Saccharomyces boulardii.81. 89 Prebiotics are defined as non-digestible food compounds that beneficially affect the host by selectively stimulating the growth and/or activity of one or of a limited number of bacteria in the large intestine.3 to 0. Lactobacillus rhamnosus are able to reduce the risk of AAD (relative risk [RR] between 0. 83 A meta-analysis on use the use of probiotics to prevent AAD concluded that treating 7 children at risk of developing AAD will only prevent 1 case of AAD. Streptococcus thermophilus.
1 Persistent Diarrhoea Approximately 3-14% of children with acute gastroenteritis developed persistent diarrhoea.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 10 Special Considerations 10. In malnourished children with persistent diarrhoea. 22. a temporary change to lactose-free formula. 92 Bacterial infections. A change to either extensively hydrolysed formula or elemental formula is unnecessary. 92 10. 92 In Malaysia. consultation with or referral to an appropriate expert is indicated. is often adequate. lactose intolerance and food protein allergy (cow milk and soy protein) are the three most important causes of persistent diarrhoea following AGE in Malaysia. 27 .22. approximately 3% of children with AGE developed persistent diarrhoea (duration > 14 days). In children with lactose intolerance without malnutrition.2 Lactose Intolerance 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 resolve with the presence of the above clinical features.22. either cow milk-based or soy protein-based.
consultation with or referral to a specialist with expertise in this area is advisable. either cow milk-based or soy protein-based. consultation with or referral to a specialist with special expertise in this area is advisable. Soy formula is generally not recommended in infants younger than 6 months of age. • • 28 . In a child with persistent diarrhoea where food protein allergy is suspected.COLLEGE OF PAEDIATRICS. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 10. A change to either extensively hydrolysed formula or elemental formula is not indicated. is adequate. a temporary change to lactose-free formula. Children suspected with cow milk protein allergy should be referred to a specialist with expertise in this area. • Recommendations: In children with lactose intolerance with normal nutritional status.3 Cow Milk Protein Allergy Food protein allergy is a potentially serious complication following acute gastroenteritis. In a malnourished child with persistent diarrhoea.
seizures. Campylobacter jejuni. Differential diagnoses: Watery without blood and mucous • 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 Blood and mucous Consider the following: 1. Assess if stools are watery and if blood and mucous are present 4. it is impossible to differentiate with certainty viral from bacterial gastroenteritis 5. Exclude bacterial pathogens 2. History and physical examination 2. It should be emphasised that by just inspecting the appearance of the stool. toxic looking) underlying medical conditions (heart failure. Always consider differential diagnosesb a.) persistent or bilious vomiting (even if no dehydration) treatment failure with oral rehydration salts (ORS) presence of systemic illness (high fever. Treatment with antibiotic for the speciﬁc pathogen (see Guideline above) 4. Rehydrate as necessary Consider the following: 1.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 11 Part I: Algorithm for Managing Acute Gastroenteritis in Children Child with diarrhoea (> 3 times in a 24 hour period) Do the following: 1. histolytica) 3. should consider cholera as a possibility 2. etc. Consider other diagnoses in the presence of warning signsa 7. uncertain about diagnosis • uncertain about degree of dehydration (obese children) Continue and refer to part II: Algorithm for Managing Acute Gastroenteritis in Children 29 . E. Rehydrate as necessary Criteria for hospital admission: • • • • • • severe dehydration (> 9% of body weight). degree and type of dehydration 3. Assess presence. Stool hanging drop test for V. cholerae or culture if the diarrhoea is profuse and watery in nature or ﬁshy odour. Stool studies for dysentery (Shigella. shock neurological abnormalities (lethargy. signiﬁcant neurodevelopment disabilities) • caregivers unable to provide adequate care at home or other social/logistic concerns • suspected surgical condition. STEC. non-typhoidal Salmonella. Warning signs: • • • • • Abdominal distension Bile-stained vomiting Blood in vomitus or stool Severe abdominal pain Vomiting in the absence of diarrhoea • Headache b. Assess nutritional status 6.
lethargic. try spoon feeding or ORS by nasogastric /oralgastric tube feeding • Breastfeed or milk feed normally • Formula dilution not recommended • Children may continue on lactose containing milk formula • Continue normal diet in older children • Small and frequent feeds with regular assessment • Resuscitation (normal saline/Ringer’s lactate) • Frequent monitoring Consider intensive care if not resolved Unresolved Stable Unstable Hospital referral for admission for IV ﬂuid if persistent vomiting/worsening dehydration 30 . mottled and cyanotic extremities • Minimal urine output No admission if no excessive vomiting No admission if no excessive vomiting Immediate referral to hospital for admission • 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. quality of pulse normal to decreased. eyes deeply sunken and capillary reﬁll prolonged and minimal • Tears absent and mouth and tongue are parched • Skin fold recoil in > 2 seconds • Cold. breathing. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION 12 Part II: Algorithm for Managing Acute Gastroenteritis in Children No signs of dehydration (<3% loss of body weight) • Child alert • Drinks normally • Heart rate. breathing normal to fast. quality of pulse weak and thready or impalpable. 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. 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. restless or irritable • Thirsty and eager to drink • Heart rate normal to increased.COLLEGE OF PAEDIATRICS. 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. breathing deep. quality of pulse. unconscious • Drinks poorly and unable to drink • Tachycardia with bradycardia in most severe cases. there is some dehydration Severe dehydration (>9% loss of body weight) • Child apathetic. fatigued.
Only in selected clinical situations ORS Antibiotics Yes Rarely required.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 13 Summary of Established Guidelines CDC 2003 2 WHO 2005 1 ESPGHAN 2008 4 European Countries. NR Prebiotics Should await further clinical trials NR - NR A switch to lactose-free. Lomotil) Adsorbants (Smectite) Adsorbants (Kaolin-pectin) Anti-secretory (Racecodotril) Anti-secretory (Bismuth subsalicylate) NR NR NR NR NR NR NR NR NR - NR May be recommended NR May be recommended NR - May be considered as an adjunctive NR May be considered as an adjunctive* NR NR Need more studies NR NR - NR - NR (Not practical. boulardii) Some benefits. soy or hydrolysate NR NR NR NR NR Not recommended * Not commercially available in Malaysia at the time of publication of this guideline. Consult paediatric or infectious specialist NR NR Antiemetics Antimotility (Loperamide. needs to be given frequently) - NR Probiotics Should await further clinical trials Strain-specific (Lactobacillus GG. with emphasis on US populations Yes Routine use wastes resources & may lead to antimicrobial resistance NR NR Developing countries or communities with scarce health resources Yes Not routinely indicated. S. Can be given when a normal diet is reintroduced - May be considered as an adjunctive. Australia AMMCOP/MPA 2011 Paediatric. Should be strainspecific and dose specific. low diarrhoeal morbidity and mortality Yes Do not recommend routine use in otherwise healthy children New South Wales Health 2010 5 Primary case setting in New South Wales. Only required for specific pathogens or defined clinical settings NR NR Setting Paediatric practice. primary care and frontline healthcare providers in Malaysia Yes Not routinely indicated. 31 . Imodium) Antimotility (Diphenoxylate HCL.
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fast Slightly sunken Decreased Dry Recoil in < 2 seconds Prolonged Cool Decreased Severe dehydration ( > 9% loss of body weight) Mental status Thirst Heart rate Quality of pulse Breathing Eyes Tears Mouth and tongue Skin fold Capillary refill Extremities Urine output Apathetic. might refuse liquids Normal Normal Normal Normal Present Moist Instant recoil Normal Warm Normal to decreased Adapted from WHO 2005 1. lethargic. irritable Thirsty. minimal Cold. fatigue or restless. thready. cyanotic Minimal Drinks N. mottled. alert Mild to moderate dehydration ( 3-9% loss of body weight) N. unable to drink Tachycardia. CDC 2003 2 37 . unconscious Drinks poorly. or impalpable Deep Deeply sunken Absent Parched (very dry) Recoil in > 2 seconds Prolonged.THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011 APPENDIX A Assessment of dehydration in acute diarrhoea Symptom No signs of dehydration ( < 3% loss of body weight) Well. eager to drink Normal to increased Normal to decreased Normal. with bradycardia in most severe cases Weak.
COLLEGE OF PAEDIATRICS. ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION APPENDIX B Anti-Diarrhoeal Drugs Attributes Reduces secretion Prevents virulence Reduce stool output Shorten duration of diarrhoea Fast acting Constipation as a side effect Systemic side effects Does not interfere with ORS Loperamide Yes No No No Bismuth subsalicylate No No Yes No Smectide Yes Yes Yes Yes Racecadotril Yes No Yes Yes Yes No No Yes No Yes No Yes Not tested Potentially Yes No Yes No Yes Adapted from Edelman et al. 2010 94 38 . 198593 and Salazar-Lindo E.
my/ • Mead Johnson Nutrition Malaysia http://www.org.mpaweb.acadmed.my/ • Malaysian Paediatric Association (MPA) http://www.aspx ©2011 College of Paediatrics. Academy of Medicine of Malaysia and Malaysian Paediatric Association .The sponsor of this educational material was not involved in the development of this publication and in no way influenced its content. The full guidelines on the management of acute diarrhoea in children may be obtained from the following websites: • College of Paediatrics. Academy of Medicine of Malaysia (AMMCOP) http://www.my/home.com.org.meadjohnsonasia.
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