"We can notguaranteecure, but what wecan guarantee isan

honest and transparent effort".

Evidence based
Medicine on
Acute Diarrhea in
Children

Dr.H.K.Takvani, MD Ped., FIAP

IPP, NNF, Gujarat State Chapter 2009-2010

National Executive Board Member. IAP 4 terms
President IAP, Gujarat State Branch, 2001
President IMA Jamnagar City Branch 2008-09

Children Hospital and Neonatal Care Centre

JAMNAGAR-361008, Gujarat, India
drtakvani@gmail.com
drtakvani@rediffmail.com
www.takvanidr.multiply.com
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Takvani

Why to talk on diarrhea?

Prescription Surveys says..

No ORS. IVF where ORS works well or better

No advice on continuing, increasing BF,

(unnecessary stoppage of BF), diet or

hygiene
No zinc.
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Why to talk on diarrhea?

Use of antiemetics
Antibiotics often- Nor-metro, Oflo-ornid
a, Inj.Amikacin.
Un-necessary probiotics
Racecadotril.
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IAP Consensus
Statement

Highlights several important

developments.

Aims that benefits of new knowledge

reach affected.
Wants that new products are not
inappropriately used.
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ORS in diarrhea
ORS for all ages and all types of
diarrhea.
Low osmolarity ORS recommended,
WHO
Sodium 75 mmol/L and glucose 75
mmol/l, osmolarity 245 mosmol/L
Continue Breast feeding and routine
normal diet and energy dense feeds.

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Why Reduced osmolarity

ORS?
39% reduction in need for IVF
19% reduction in stool output
29% lower incidence of vomiting
Risk of hyponatremia not significant
in any type of diarrhea.
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Zinc in Diarrhea
Based on studies in India and other
developing countries there is
sufficient evidence to recommend
zinc in the treatment of acute
diarrhea as
adjunct to oral
rehydration.
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Zinc in Diarrhea
Zinc has an additional modest benefit
Reduces stool volume.
Reduces duration of diarrhea.
Oral rehydration therapy must remain
the main stay of treatment.
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Zinc in Diarrhea
Dose: Elemental Zinc

20 mg/day for 6months and older for 14

days

10 mg/day Between 2-6

months.
Any of zinc salts e.g., sulphate, gluconate

or acetate may beTakvani

used.

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Recommendations of the IAP

National Task Force for Use of
Probiotics

The group recommended that based

on analysis of studies there is
presently insufficient evidence to
recommend probiotics in the
treatment of acute diarrhea in our
settings

Recommendations of the IAP

National Task Force for Use of
Probiotics

Almost all the studies till now were

done in developed countries except
for one very small study from
Pakistan. It may not be possible to
extrapolate the findings of these
studies to our setting where the
breast feeding rates are high and the
microbial colonization of the gut is

Recommendations of the IAP

National Task Force for Use of
Probiotics
The effect of probiotics is strain
related and there is paucity of data to
establish the efficacy of the probiotic
species (namelyL. acidophilus, Lactic
Acid Bacteria) available in the Indian
market. To recommend a particular
species it will have to be first
evaluated in randomized controlled

Recommendations of the IAP

National Task Force for Use of
Probiotics

The earlier studies have documented

a beneficial effect on rotavirus
diarrhea which was present in >75%
of cases in studies from the west.
Rotavirus constitutes about 15% to
25% in India.

Recommendations of the IAP

National Task Force for Use of
Probiotics

The primary outcome analyzed in all

the studies was the duration of
diarrhea. The more objective
parameter of stool output was not
evaluated.

What are Probiotics ??

Nonpathogenic micro-organisms.
Exert a positive influence on the
health or physiology of the host.
They consist of either yeast or
bacteria,
bacillus.

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Sacc. Bul. and LactoTakvani

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Probiotics in the Treatment of

Diarrhea
Mechanisms:
1.Protect the intestine by competing with
pathogens for attachment.
2.Strengthening tight junctions between
enterocytes
3. Enhancing the mucosal immune
response to pathogens.
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Racecadotril
Not enough evidence:
Safety.
Efficacy.
There is no data from our settings.
Methodology of studies questionable.
No routine use
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Acute Diarrhea in the Young

Infant (< 2 mth)

For assessment, recommendations by

the IMNCI which is an adapted version
of IMCI for India, should be followed.
See if child is sick or well child.
Management is different for sick and
well.

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Acute Diarrhea in the Young

Infant (< 2 mth)
Infants who are breastfed and have
no dehydration do not need ORS and
mothers should be advised to
increase breast feeds more often and
for longer duration.
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Acute Diarrhea in the Young

Infant (< 2 mth)

Young infants with dehydration

should be treated as has been
recommended for other children with
dehydration by ORS or IVF as per
dehydration.

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Acute Diarrhea in the Young

Infant (< 2 mth)
Third generation cephalosporins, intravenous ceftriaxone and amikacin if the
child is sick looking, ?septicemia.
Where hospitalization is not possible,
Oral Cefixime with Inj. Amikacin may
be tried after explaining the nature of
disease and risk.
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Acute Diarrhea in the Young

Infant
(> No,
2 mth)
For assessment,
IMNCI,
some,sever dehy.
Management is as per grades of dehydration.
In cases of No & some dehydration when
orally acceptable ORS- ZINC- home available
fluids- increase BF. IVF in Severe Dehydration.

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home available fluids

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acceptable

unacceptable

Plain water

coffee

coconut water

aerated cold drinks

plain buttermilk

fruit juice(with sugar

milk

Lassi(with sugar)

thin dal
fruit juice(without
sugar)
Lassi(without sugar)
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Antibiotic in Acute
Diarrhoea
Indicated only for :
Acute bloody diarrhea with gross
blood
Shigellapositive culture,
Cholera,
Associated systemic infection
Severe malnutrition. (Septicemia)

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Antibiotic in Acute
Dysentery

Indiscriminate use of antibiotics

Increasing incidence of resistance.

Cotrimoxazole has been recommended as
the first line drug for acute bloody diarrhea.
High resistance of shigella to cotrimoxazole
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Antibiotic in Acute
Dysentery
Resistance rates
to cotrimoxazole exceed
30%

Cefixime 20mg/kg/day 5-7 days should be

used instead of quinolones looking to
safety and medico legal aspects.
No response to cefixime in 3 days
Ceftriaxone 50-100mg/kg od for 2-5 days.

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Antibiotic in Acute
Dysentery
Antibiotics are not indicated if
No visible blood in stools
Pus cells on stool microscopy because
of poor specificity of the test.
Routine stool examination or stool
cultures have no useful role. (except to
show that antibiotics are not requiredpersonal)

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Antibiotic in Acute
Dysentery
Entamoeba histolytica and helminths
rarely ever cause acute diarrhea in
children.
Metronidazole and antihelminthics
therefore have no role in the routine
management of acute bloody diarrhea.

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Antibiotic in Acute
Dysentery
Metronidazole/Tinidazole should be
used when cases of acute dysentery
fail to respond to second line drugs
for dysentery such as cefixime or
when a stool examination has
confirmed trophozoites of Entamoeba
hystolitica.
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Antibiotics in Acute
Dysentery

Aminoglycosides like gentamicin and

amikacin have a poor spectrum of
activity against shigella species and
therefore they are ineffective in the
management of acute bloody
diarrhea.

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Antiemetics in Acute
Diarrhea

Vomiting, common associated

symptom.
Distressing to the parent, antiemetics.
Overdose due to haste/improper
preparation like domperidone
10mg/1ml instead of 1mg/1ml in sone
(Domstal Baby and Motinorn) and
round the clock prescrition like TDS
leads to side effects.

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Antiemetics in Acute
Diarrhea

Low osmolarity ORS reduces

vomiting.
Stop for 10 minutes and than restart
giving ORS in small sips.
Most can be managed by frequent
small sips (5-10 ml) of ORS with sips
of simple water and breast feeding in
between without force feeding ORS.

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Antiemetics in Acute
Diarrhea
Antiemetics should be reserved for
children in whom the vomiting is
severe, recurrent and interferes with
ORS intake (more than 3 per hour).
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Antiemetics in Acute
Diarrhea
A single dose of domperidone/?
ondansetron in children with severe
vomiting.
Continued use is not recommended.
Dose of 0.1-0.3 mg/kg/dose.
Single dose only
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Antiemetics in Acute
Diarrhea

In view of serious side effects

metoclopramide is not recommended.
Personal experience: Single dose of
Inj.Metoclopramide 0.2mg/kg stops
vomiting and improves ORS intake
and avoids IV fluids in many cases
without a single case of side effect.
Not validated by IAP.
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I conclude .
Prescribe ORS for all ages.
Continue Breast feeding and diet.
Explain danger signals.
20 mg/10 mg of elemental zinc
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I conclude.
No probiotics, may be as a placebo
Causious approach infants <2
mo/PEM as it can be a part of
Septicemia.
Judicious use of antibiotics for
dysentery and systemic infections
No antimotility agents.strictly.
(seen deaths)

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If interested Indian
Pediatrics

Statement Consensus statement of IAP National Task Force:

Status report on management of acute diarrhea Shinjini
Bhatnagar,Nita Bhandari, U.C. Mouli , M.K. Bhan. Indian Pediatrics :
Apr 2004;41:335 - 348
Statement National seminar on importance of zinc in human
health Ms. Rekha Sinha. Indian Pediatrics : Dec 2004;41:1213 1217
Editorial The role of zinc in child health in developing
countries: Taking the science where it matters Zulfiqar A.
Bhutta. Indian Pediatrics : May 2004;41:429 - 433
Brief Reports Outcome of Nutritional Rehabilitation with and
without Zinc SupplementationK.E. Elizabeth, P. Sreedevi and S.
Noel Narayanan. Indian Pediatrics : Jun 2000;37:650 655
Management of Acute Diarrhea: From Evidence to Policy
Shinjini Bhatnagar, Seema Alam* and Piyush Gupta*
National Co-ordinator, and *Joint National Co-ordinators, IAPUNICEF Program on Evidence-based Management of
Diarrhea.http://indianpediatrics.net/mar2010/mar-215-217.htm

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Friends. Please Share your views

Dr.H.K.Takvani

MD (Pediatrics), FIAP
Children Hospital and Neonatal Care Centre
Valkeshwari Nagari
Indira Marg
JAMNAGAR-361008, Gujarat, India

drtakvani@gmail.com
www.takvanidr.multiply.com
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