WGO GUIDELINE

Acute Diarrhea in Adults and Children
A Global Perspective

Review team: Michael Farthing, MD (Chair, UK), Mohammed A. Salam, MD (Special Advisor,
Bangladesh), Greger Lindberg, MD (Sweden), Petr Dite, MD (Czech Republic), Igor Khalif, MD
(Russia), Eduardo Salazar-Lindo, MD (Peru), Balakrishnan S. Ramakrishna, MD
(India), Khean-Lee Goh, MD (Malaysia), Alan Thomson, MD (Canada), Aamir G. Khan, MD
(Pakistan), Justus Krabshuis, (France), and Anton LeMair, MD (Netherlands)

CONTENTS
1. Introduction and epidemiologic features
2. Clinical manifestations and diagnosis
3. Treatment options and prevention
4. Clinical practice

List of Tables
Table 1 Clinical features of infection with selected diarrheal pathogens
Table 2 Assessment of dehydration using the “Dhaka method”
Table 3 Nonspecific antidiarrheal agents
Table 4 Antimicrobial agents for the treatment of specific causes of diarrhea

List of Figures
Figure 1 Therapeutic approach to acute bloody diarrhea in children
Figure 2 Cascade for acute, severe, watery diarrhea—cholera-like, with severe dehydration. See above for the recipe for
home-made oral fluid
Figure 3 Cascade for acute, mild/moderate, watery diarrhea—with mild/moderate dehydration. See above for the recipe
for home-made oral fluid
Figure 4 Cascade for acute bloody diarrhea—with mild/moderate dehydration

From the University of Sussex, Vice-Chancellor’s Office.
The authors declare that they have nothing to disclose.
Reprints: Michael Farthing, MD, University of Sussex, Vice-Chancellor’s Office, Sussex House, Brighton BN1 9RH, UK (e-mail: m.farthing@
sussex.ac.uk).
Copyright r 2013 by Lippincott Williams & Wilkins

12 | www.jcge.com J Clin Gastroenterol  Volume 47, Number 1, January 2013

Globally in this age CLINICAL MANIFESTATIONS AND DIAGNOSIS group. and impaired cognitive development in  Assessing the severity of the illness and the magnitude resource-limited countries. rhea. epidemics (also to determine antimicrobial susceptibility) In industrialized countries. Presence of visible blood in febrile patients generally Interventions such as exclusive breastfeeding (which prevents indicates infection due to invasive pathogens. clinical findings. 78% occur in lines provide a resource-sensitive approach. and improved complementary feeding (by way of histolytica. This amounts to 18% of all medical treatment options are available. continuation of breastfeeding until 24 months of Shigella. particularly during infancy— Clinical Evaluation thereafter. relatively few patients die and to identify the pathogen causing dysentery. agent. or personal hygiene.  Determining likely causes on the basis of the history and sanitation. including stool characteristics tributed to a decline in the mortality rate in developing countries. cholera. the WGO guide- diseases. Not common. history of recent travel costs. (degree) of dehydration (Table 2) During the past 3 decades. common. but may be necessary to identify Vibrio cholerae when The recommended routine use of zinc in the management of there is a clinical and/or epidemiological suspicion of childhood diarrhea. Number 1. and 1. but it continues to be an important cause of Epidemiologic clues to infectious diarrhea can be found morbidity that is associated with substantial health care by evaluating the incubation period.jcge. the African and Southeast Asian regions. ++ . Stool cultures are usually unnecessary for improved nutrition). According to the World Health Organization (WHO) and UNICEF. countries in which the full scale of diagnostic tests and mostly in developing countries. acute diarrhea is the second leading cause of death Although there may be clinical clues. not currently practiced in many coun. The initial clinical evaluation of the patient should sequences of diarrhea in children include growth faltering. Of all child deaths from diarrhea. However. mortality from diarrheal diseases are greatest among chil- dren in this age group. such as diarrhea). the morbidity from diarrheal diseases has in relation to the regional prevalence of different pathogens. there are about 2 billion cases of diarrheal Cascades—a Resource-sensitive Approach disease worldwide every year. remained relatively constant during the past 2 decades. maintaining adequate supply. rather than changes in water For acute enteritis and colitis. + . TABLE 1.9 million children A gold standard approach is feasible for regions and younger than 5 years of age perish from diarrhea each year. from diarrhea. Clinical Features of Infection With Selected Diarrheal Pathogens Clinical Features Abdominal Fecal Evidence of Vomiting. and both the incidence and the risk of etiological diagnosis is not possible clinically (Table 1). focus on: malnutrition. along with improved sanitation. r 2013 Lippincott Williams & Wilkins www. With >5000 children are dying every day as a result of diarrheal their diagnostic and treatment cascades. variable. and personal hygiene are believed to have con. atypical/often not present. a definitive (after pneumonia). Heme. +/ . specific pediatric details are provided FEATURES in each section as appropriate.com | 13 . are immune-competent patients who present with watery diar- expected to affect mortality and morbidity simultaneously. Bloody Pathogens Pain Fever Inflammation Nausea positive Stool Stool Shigella ++ ++ ++ ++ +/ + Salmonella ++ ++ ++ + +/ + Campylobacter ++ ++ ++ + +/ + Yersinia ++ ++ + + + + Norovirus ++ +/ ++ Vibrio +/ +/ +/ +/ +/ +/ Cyclospora +/ +/ + Cryptosporidium +/ +/ + + Giardia ++ + Entamoeba histolytica + + +/ +/ ++ +/ Clostridium difficile + + ++ + + Shiga toxin-producing ++ 0 0 + ++ ++ Escherichia coli (including O157:H7) . Campylobacter jejuni. particularly during the early days of outbreaks/ tries. sanitation. Salmonella. changes in water supply. 0. Each child below 5 years of age experiences an average of 3 annual episodes of acute diarrhea. Oral rehydration salts intravascular volume and correcting fluid and electrolyte (ORS) and nutritional improvements probably have a greater disturbances take priority over identifying the causative impact on mortality rates than the incidence of diarrhea.J Clin Gastroenterol  Volume 47. In some countries. such the deaths of children below the age of 5 and means that resources are not available in large parts of the world. rates decline incrementally. occurs. However. Other direct con. January 2013 WGO Global Guideline Acute Diarrhea INTRODUCTION AND EPIDEMIOLOGIC In this guideline. or Entamoeba age. professional risks. the reduction in the case fatality rate can be attributed largely to Laboratory Evaluation improved case management. is expected to reduce disease incidence. unusual food or eating circumstances. such as Bangladesh.

severe dehydration and also in children with paralytic ileus. increased thirst dis. and human ORT consists of: immunodeficiency virus infection risks. more common in well-nourished children and those infected with rotavirus and features irritability. doses reduces the incidence of diarrhea during the following Global ORS coverage rates are still <50%. mercial preparations are often suitable.com r 2013 Lippincott Williams & Wilkins . as is recommended to pre- clinical history or findings. It is more important in the management of diarrhea ORS. and a reduced need for magnesium. 50%.  Rehydration—water and electrolytes are administered to Stool analysis and culture costs can be reduced by replace losses. Zinc deficiency is widespread among children in developing countries. nasogastric admin- diagnostic tests may be considered for quick cholera testing istration of ORS solution is potentially lifesaving when at the patient’s bedside. used in ORT. However. appropriate solutions by mouth to prevent or correct diar. or Rice-based ORS is superior to standard ORS for parasite in a stool specimen from a child with diarrhea does adults and children with cholera and can be used to treat not indicate in all cases that it is the cause of illness. However. and a doughy feel to Minerals in Children the skin. The recommendation for all children Oral rehydration therapy (ORT) is the administration of with diarrhea is 20 mg of zinc per day for 10 days. including at least 1 Signs of “some dehydration” plus at key sign (*) are present least 1 key sign (*) are present Treatment Prevent dehydration Rehydrate with ORS solution Rehydrate with intravenous fluids unless unable to drink and ORS Reassess periodically Frequent reassessment More frequent reassessment *Key signs.  Maintenance fluid therapy to take care of ongoing losses mitted on the basis of interpreting the case information— once rehydration is achieved (along with appropriate such as patient history. rapid thrush (oral candidiasis). All children with persistent diarrhea should receive cose and is associated with less vomiting. contain specific amounts of in malnourished children and in persistent diarrhea. including lesser chance of hypernatremia. Where applicable. ORT is contraindicated in the initial management of Screening usually refers to noninvasive fecal tests. and proportionate to clinical dehydration.Farthing et al J Clin Gastroenterol  Volume 47. inspection. Locally available com- intravenous infusions in comparison with standard ORS. each day for 2 weeks. Certain laboratory studies may be important when the frequent and persistent vomiting (> 4 episodes per hour). infants aged 2 months or younger should receive 10 mg/d rheal dehydration. Routine zinc therapy as an adjunct to TREATMENT OPTIONS AND PREVENTION ORT is useful for modest reduction of the severity but more importantly to reduce diarrhea episodes in children in Rehydration in Adults and Children developing countries. January 2013 TABLE 2. improving the selection and testing of the specimens sub. ORS indicates oral rehydration salts. tablets that can be This formulation is recommended irrespective of age and crushed and given with food are least costly. including cholera. with acute noncholera diarrhea. visual stool nutrition). and efforts 3 months and reduces nonaccidental deaths by as much as must be made to improve coverage. This requires specific rehydration methods. recent use of antimicrobials. supplementary multivitamins and minerals. particularly with an atypical given shortly after rehydration. Assessment of Dehydration Using the “Dhaka Method” Assessment Plan A Plan B Plan C General condition Normal Irritable/less active* Lethargic/comatose* Eyes Normal Sunken — Mucosa Normal Dry — Thirst Normal Thirsty Unable to drink* Radial pulse Normal Low volume* Absent/uncountable* Skin turgor Normal Reduced* — Diagnosis No dehydration Some dehydration Severe dehydration At least 2 signs. institutionalization. The new WHO and UNICEF recommend routine zinc therapy for lower-osmolarity ORS (recommended by the WHO and children with diarrhea. such patients wherever its preparation is convenient. Supplemental Zinc Therapy. The important salts that are lost in diarrhea stool. clinical aspects. virus. These should the type of diarrhea. intravenous rehydration is not possible and the patient is being transported to a facility where such therapy can be Pediatric Details administered. It is Measurement of serum electrolytes may be required in not superior to standard ORS in the treatment of children some children with a longer duration of diarrhea with mod. aging acute gastroenteritis and it reduces hospitalization Supplementation with zinc sulfate in recommended requirements in both developed and developing countries. Identification of a pathogenic bacterium. UNICEF) has reduced concentrations of sodium and glu. and estimated incubation period. irrespective of the type. especially when food is erate or severe dehydration. less stool output. Number 1. underlying diagnosis is unclear or diagnoses other than and painful oral conditions such as moderate to severe acute gastroenteritis are possible. Hypernatremic dehydration is vent malnutrition. for 10 days. provide as broad a range of vitamins and minerals as 14 | www. Multivitamins.jcge. ORT is a cost-effective method of man.

The timing of administration is also of importance. 2005). boulardii or L. reuteri ATCC 55730) and for S. and severe dehydration. Lactobacillus plantarum. January 2013 WGO Global Guideline Acute Diarrhea possible. which usually takes 2 to 4 hours. adds to the costs. zinc. Several meta-analyses of controlled clinical trials have been published that show consistent results in systematic Diet reviews. Nonspecific Antidiarrheal Agents Antimotility agents Should be used mostly for mild to moderate traveler’s diarrhea (without clinical signs of invasive diarrhea) Loperamide (4-6 mg/d) is the agent of choice Inhibits intestinal peristalsis and has mild antisecretory properties for adults Should be avoided in bloody or suspected inflammatory diarrhea (febrile patients) Significant abdominal pain also suggests inflammatory diarrhea (this is a contraindication for loperamide use) Pediatric details: Not recommended for use in children—has been demonstrated to increase disease severity and complications. receive food.org/ 2 to 4 hours. the effects are strain specific adults or children who are receiving antibiotic therapy. rhamnosus GG in effects in humans. Bifidobacterium infantis. Breastfed infants and children should continue to there is only suggestive evidence that Lactobacillus GG. electrolytes. casei. L. suggesting that probiotics are safe and effective. and food should be infections. probiotics-prebiotics. may make ORT difficult. and Saccharomyces cerevisiae (boulardii) are useful in Pediatric Details reducing the severity and duration of acute infectious In general. One and need to be verified for each strain in human studies. with demonstrated beneficial health dence of efficacy for S. There is inadequate research evidence to be certain that VSL#3 (L. Nonspecific Antidiarrheal Treatment Probiotics for the Treatment of Acute Diarrhea None of these drugs addresses the underlying causes or It has been confirmed that different probiotic strains effects of diarrhea (loss of water. particularly in children with invasive diarrhea Antisecretory agents Not useful in adults with cholera Racecadotril is an enkephalinase inhibitor Pediatric details: It has been found useful in children with diarrhea. including at least 2 recommended daily allowances shortens the duration of acute diarrheal illness in children of folate. Probiotics Antibiotic-associated Diarrhea Probiotics are live microorganisms. diarrhea in infants.worldgastroenterology.html). and (see tables 8 and 9 in WGO’s Guideline on probiotics at nutrients).J Clin Gastroenterol  Volume 47. mostly in develop.jcge. Lactobacillus Pediatric Details acidophilus. vitamin A. have been reported. boulardii are effective in some for nonbreastfed. even during the rehydration phase. Bifidobacterium lon- Controlled clinical intervention studies and meta. However. Mechanisms of action are strain specific: there is started immediately after correction of some (moderate) evidence for efficacy of some strains of lactobacilli (eg. The oral administration of probiotics children with acute or persistent diarrhea (Table 3). and S. Radiation-induced Diarrhea ing countries. and significantly different effects ciated diarrhea and Clostridium difficile diarrhea. there is strong evi- GG (ATCC 53103).worldgastroenterology. activated charcoal. Prevention of Acute Diarrhea Pediatric Details In the prevention of adult and childhood diarrhea. study indicated that L. Lactobacillus casei DN-114 001. casei DN-114 001 is effective in Extrapolation from the results of even closely related hospitalized adult patients for preventing antibiotic-asso- strains is not possible. Number 1. Bifidobacterium breve. boulardii. Use of probiotics may not be appro- priate in resource-constrained settings. using ORT or intravenous rehydration. antidiarrheals have no practical benefits for diarrhea in children. Antiemetics are usually unnecessary in acute http://www. Lactobacillus delbrueckii.com | 15 . casei DN-114 001. magnesium. and thus should not be used r 2013 Lippincott Williams & Wilkins www.org/probiotics-prebiotics. However. attapulgite Inadequate proof of efficacy in acute adult diarrhea. diarrhea management. L. specific settings (see tables 8 and 9 in WGO’s Guideline rehydration is the first priority and can be accomplished in on probiotics at http://www. such as Lactobacillus In antibiotic-associated diarrhea. The practice of withholding food for >4 hours is The evidence from studies on viral gastroenteritis is more inappropriate—normal feeding should be continued for convincing than the evidence on bacterial or parasitic those with no signs of dehydration. dehydrated children and for adults. Lactobacillus rhamnosus GG. and some that have sedative effects html) including Lactobacillus reuteri ATCC 55730. (nonopiate) with antisecretory activity and is now licensed in many countries in the world for use in children Adsorbents Kaolin-pectin. gum. and copper (WHO by approximately 1 day. casei GG and L. TABLE 3. and analyses support the use of specific probiotic strains and Streptococcus thermophilus) is effective in the treatment of products in the treatment and prevention of rotavirus radiation-induced diarrhea.

 Consider antimicrobial treatment for: Important Notes —Shigella. nontyphoidal salmonellosis when they cause persistent diarrhea. and paratyphoid fevers.Farthing et al J Clin Gastroenterol  Volume 47. 2-g dose Secnidazole For adults (not available in the United States) Campylobacter Azithromycin Adults: 500 mg 1 /d for 3 d Children: single dose of 30 mg/kg early after disease onset Fluoroquinolones such as ciprofloxacin Adults: 500 mg 1 /d for 3 d 16 | www. the doses given. Antimicrobial Agents for the Treatment of Specific Causes of Diarrhea First choice Cause Alternative(s) Cholera Doxycycline Adults: 300 mg once Children: 2 mg/kg (not recommended) Azithromycin Adults: 1.0 g as a single dose. or parasitic infections. chronic liver  If drugs are not available in liquid form for use in young disease. children. TABLE 4. (Table 4) persistent diarrhea.jcge. patients. —Antimicrobials are also indicated for associated health —Dysenteric presentation of campylobacteriosis and problems such as pneumonia. immunocompromised locality/region. January 2013 Antimicrobials in Adults and Children —Symptomatic giardiasis (anorexia and weight loss. failure to thrive). shigellosis. and when host immune status is compromised Pediatric Details for any reason such as severe malnutrition. —Cholera. is recommended in the treatment of severe (clinically —Moderate/severe traveler’s diarrhea or diarrhea with fever recognizable): and/or with bloody stools.0 g as a single dose only once Pivmecillinam Adults: 400 mg 3-4 times/d for 5 d Children: 20 mg/kg 4/d for 5 d Ceftriaxone Adults: 2-4 g as a single daily dose Children: 50-100 mg/kg 1/d intramuscularly for 2-5 d Amebiasis—invasive Metronidazole intestinal Adults: 750 mg 3 /d for 5 d* Children: 10 mg/kg 3/d for 5 d* *10 d for severe disease Giardiasis Metronidazole Adults: 250 mg 3 /d for 5 d Children: 5 mg/kg 3/d for 5 d Tinidazole Can also be given in a single dose—50 mg/kg orally. it may be necessary to use tablets and estimate —Invasive intestinal amebiasis.  All doses shown are for oral administration. maximum dose 2 g Ornidazole Can be used in accordance with the manufacturer’s recommendations—single. infants and elderly. Number 1. typhoid.com r 2013 Lippincott Williams & Wilkins .0 g as a single dose only once Children: 15 mg/kg every 12 h for 3 d *The minimum inhibitory concentration has increased in many countries—multiple-dose therapy over 3d Shigellosis Ciprofloxacin Adults: 500 mg 2 /d for 3 d or 2. and those with liver diseases and lymphoprolifer-  Antimicrobials are reliably helpful and their routine use ative disorders) and in dysenteric presentation. or lymphoproliferative disorders. Campylobacter (dysenteric form).  Selection of an antimicrobial should be based on the —Nontyphoidal salmonellosis among at-risk populations susceptibility patterns of strains of the pathogens in the (malnutrition. Salmonella. only once Children: 20 mg/kg as 1 single dose Ciprofloxacin* Adults: 500 mg 12-hourly for 3 d or 2.

7. oral cholera infection with Shiga toxin–producing E. traveler’s diarrhea). pitalizations and deaths. and other complications ORS and correct dehydration of a severely dehydrat. and remains controversial. shigellosis. giardiasis. When dehydration is corrected. was licensed in the United States for routine —Perform ORT rapidly.  Notifiable in the United States: cholera. 4. made by Merck for use in children. Campylobacter (dysenteric  Treat symptoms (if necessary. In traveler’s diarrhea. and at the beginning of an outbreak/ countries. Perform initial assessment. RotaTeq. save culture plates and isolates. 1. or persistent personnel but are impractical for use in developing diarrhea. immunization of infants. vaccine. regardless of the etiologic agent. irrespective of recombinant cholera toxin B subunit. countries. take children to a health facility for treatment. be immunized against measles at the recommended age. because the risk of cholera for Approach in Children With Acute Diarrhea the usual traveler is very low. Prevent dehydration in patients with no signs of be educated to recognize signs of dehydration and when to dehydration. Parents/caregivers of children should 3. Since then. outbreaks. 12-hourly for 3 d) and norfloxacin. Use ORS for rehydration:  Rotavirus: in 1998. and in advanced enterotoxigenic E. 1). using home-based fluid or 2. Consider antimicrobial therapy for specific pathogens. ORS as appropriate. 5 mg/kg  Epidemiological clues: food. coli vaccine candidate 2004 recommended routine use of zinc as an adjunct to consists of a killed whole-cell formulation plus a ORT for treatment of childhood diarrhea. In 2002. Other rotavirus vaccines are 3.com | 17 . Home Management of Acute Diarrhea in Adults and Children CLINICAL PRACTICE Milder and uncomplicated cases of nondysenteric Approach in Adults With Acute Diarrhea diarrhea in both adults and children can be treated at home. the rate of ORS usage has dramatically increased. fecal inflammation. Administer additional ORS for ongoing losses through dence and severity of diarrheal diseases. effectiveness) are currently approved for clinical use. and preliminary trials are promising. In 1999. cryptospor- cies such as epidemics.  V. production was —Routine adjunct zinc therapy for children aged 5 stopped after the vaccine was causally linked to years or younger. activity.  Salmonella typhi: 2 typhoid vaccines (with limited cost dysentery. salmonellosis. ated vaccine currently under development in several 6. using home-based fluids or ORS solution. No unnecessary laboratory tests or medications.  In outbreaks. within 3 to 4 hours. Stratify subsequent management: are trimethoprim/sulfamethoxazole (TMP/SMX. coli. oral cholera vaccines are still being investigated. 2 vaccines have been approved: a live oral —Normal food or age-appropriate unrestricted diet. cholerae: the current price and need for multiple doses (at least 2) and shorter protective efficacy are limitations. consider bismuth form) are the only pathogen isolated from children with subsalicylate or loperamide in cases of nondysenteric persistent diarrhea. >40 countries throughout the world currently available for protection against Shiga toxin– have adopted the recommendations. Currently. Obtain a fecal specimen for analysis: immunogenic and protective in field trials.  Measles immunization can substantially reduce the inci. Their use in endemic areas idiosis.jcge.J Clin Gastroenterol  Volume 47. epidemic. malnutrition. 2. laboratories. —Nontyphoidal salmonellosis in infants. Early intervention and administration of home-based fluids/ORS  Rehydration of patients with some dehydration using reduces dehydration. abdominal pain. Manage dehydration. bloody. —Continue breastfeeding. coli infection.  Shigella organisms: 3 vaccines have been shown to be 5. day care attendance. vaccine is only recommended for those working in refugee or relief camps. season. Every infant should diarrhea (Fig. —When Shigella. cheaper killed-cell vaccine is likely to be available fecal specimens and food or water specimens at soon. other illness. More promising is a single-dose live-attenu. both the new ORS and zinc have been introduced. No vaccines are etiology. Salmonella. r 2013 Lippincott Williams & Wilkins www. 701C and their use is recommended only in complex emergen. antibiotics. January 2013 WGO Global Guideline Acute Diarrhea  Consider antimicrobial treatment for:  Maintain hydration using ORS solution. Number 1. In countries where producing E. RotaShield (Wyeth). intussusception in infants. and leads to fewer clinic visits and potentially fewer hos- ing patient with an appropriate intravenous fluid.  Alternative antimicrobials for treating cholera in children 4. and GSK’s Rotarix. Parenteral vaccines may be useful for travelers and military  If there is severe. Prevention of Diarrhea With Vaccines  Clinical clues: bloody diarrhea. The principles of Pediatric Details appropriate treatment for children with diarrhea and  Salmonella typhi: no available vaccine is currently dehydration are: suitable for routine use for children in developing 1. rapid realimentation: being developed. freeze A new. travel. WHO and UNICEF revised their recom-  Enterotoxigenic Escherichia coli vaccines: the most mendations for routine use of hypoosmolar ORS. inflammatory. a rotavirus vaccine. sexual TMP + 25 mg/kg SMX. Report to the public health authorities. wasting.

with severe dehydration.jcge. vomiting Level 5 ORT Level 6 Home-made oral fluid: salt. January 2013 Severely malnourished? Yes: refer to hospital No: give antimicrobial for Shigella Better in 2 days? Yes: complete 3days’ treatment No: see next Initially dehydrated. severe.com r 2013 Lippincott Williams & Wilkins . fluoroquinolone. or other Level 3 High Intravenous fluids + ORT Resources Low Level 4 Nasogastric tube ORS if persistent. Number 1. Therapeutic approach to acute bloody diarrhea in children. and clean water FIGURE 2. Level 1 Intravenous fluids + antibiotics + diagnostic tests: stool microscopy/culture Based on tests: tetracycline. watery diarrhea—cholera-like. ORT indicates oral rehydration therapy. See above for the recipe for home-made oral fluid. or measles in past 6 weeks? Yes: refer to hospital No: change to second antimicrobial for Shigella Better in 2 days? Yes: complete 3days’ treatment No: refer to hospital or treat for amebiasis FIGURE 1. 18 | www. age < 1 y. fluoroquinolone Level 2 Intravenous fluids + antibiotics Empirical: tetracycline. sugar. Cascade for acute.Farthing et al J Clin Gastroenterol  Volume 47.

However. where subsalicylate have sufficient evidence of efficacy and safety.com | 19 .  Maintain adequate fluid intake. The ingredients to be mixed are: Cascades  One level teaspoon of salt. See above for the recipe for home- made oral fluid. small. r 2013 Lippincott Williams & Wilkins www. apeutic techniques for the same disease.  Changing mental status  Antidiarrheal medication with loperamide (flexible dose  History of premature birth. ORT/ORS use. and water at home.  Visible blood in stool Where feasible. including frequent and substantial alence of diarrheal diseases should be encouraged to store a volumes few ORS packets and zinc tablets if there are children below  Persistent vomiting. diarrhea requiring specific interventions is more prevalent Family knowledge and people may not be competent in assessing their Family knowledge about diarrhea must be reinforced conditions. this moted as antidiarrheal agents. Antidiarrheal agents It relieves discomfort and social dysfunction. vomiting Resources Level 3 Low ORT Level 4 Home-made oral fluid: salt.  Young age ( less than 6 mo or <8 kg weight)  Antimicrobial treatment is reserved for prescription only  Fever Z381C for infants less than 3 months old or in residents’ diarrhea or for inclusion in travel kits (add Z391C for children aged 3 to 36 months loperamide). and clean water FIGURE 3. families in localities with a high prev. watery diarrhea—with mild/moderate dehydration. A cascade is a hierarchical set of diagnostic or ther-  Eight level teaspoons of sugar. Cascade for acute. severe dehydration. according to loose bowel movements) may diminish or concurrent illness diarrhea and shorten the duration. nutrition. administer ORT  No improvement within 48 hours—symptoms exacer- bate and overall condition gets worse Home-made Oral Fluid Recipe  No urine in the previous 12 hours Preparing 1 L of oral fluid using salt. and when and where to seek care. Cascades for acute diarrhea are shown has been boiled and then cooled. in areas such as prevention. zinc Principles of self-medication: supplementation. only loperamide and bismuth may not be appropriate in developing countries. mild/moderate. sugar. but more frequent meals for children. persistent fever the age of 5 in the family.jcge. sugar. ranked by the  One liter (5 cupfuls) of clean drinking water or water that resources available. Indications for medical consultation or in-patient care are:  Consumption of solid food should be guided by appetite  Caregiver’s report of signs consistent with dehydration in adults. There is Among hundreds of over-the-counter products pro- no evidence that it prolongs the illness. Level 1 Intravenous fluids (consider) + ORT Level 2 High Nasogastric tube ORS—if persistent. in Figures 2–4. ORT indicates oral rehydration therapy. chronic medical conditions.J Clin Gastroenterol  Volume 47. January 2013 WGO Global Guideline Acute Diarrhea Self-medication is safe in otherwise healthy adults. Number 1.  High-output diarrhea. so that home therapy can be  Suboptimal response to ORT or inability of caregiver to initiated as soon as diarrhea starts.

Pediatric details  Levels 5 and 6 must be seen as interim measures and are  Nasogastric feeding is not very feasible for healthy and better than no treatment if no intravenous facilities are active older children. E. needles. patients with  Nasogastric therapy requires skilled staff. histolytica.jcge.com r 2013 Lippincott Williams & Wilkins . it must be ensured  Nasogastric administration (ORS and diet) is especially that disposable sterile syringes.Farthing et al J Clin Gastroenterol  Volume 47. ORT indicates oral rehydration therapy.  When intravenous therapy is used. severe bacterial colitis Level 2 High ORT + antibiotics Empirical antibiotics for moderate/severe illness Resources Low Level 3 ORT Level 4 Home-made oral fluid: salt. and clean water FIGURE 4. January 2013 Level 1 ORT + antibiotics + diagnostic tests: stool microscopy/culture Consider causes: S. but it is suitable for malnourished. sugar. Cascade for acute bloody diarrhea—with mild/moderate dehydration. (anorexia). Cautions Notes  If facilities for referral are available.) dehydration). lethargic children. (Caution: there facility with access to intravenous fluids (levels 5 and 6 is a risk of infection with contaminated intravenous cannot replace the need for referral in case of severe infusion equipment. dysenteriae. to avoid the risk of hepatitis B and C. Number 1. intravenous fluid treatment is more easily death) should be referred to the nearest health care available than nasogastric tube feeding. and drip sets are helpful in long-term severely malnourished children used. 20 | www. severe dehydration (at risk of acute renal failure or  Often. available.