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Universal Recommendations for the Management of Acute Diarrhea in Nonmalnourished Children

Guarino, Alfredo*; Lo Vecchio, Andrea*; Dias, Jorge Amil; Berkley, James A.; Boey, Chris§; Bruzzese, Dario||; Cohen, Mitchell B.; Cruchet, Sylvia#; Liguoro, Ilaria**; Salazar-Lindo, Eduardo††; Sandhu, Bhupinder‡‡; Sherman, Philip M.§§; Shimizu, Toshiaki||||

Journal of Pediatric Gastroenterology and Nutrition: November 2018 - Volume 67 - Issue 5 - p 586–593
doi: 10.1097/MPG.0000000000002053
Clinical Guidelines: Gastroenterology

Objective: Despite a substantial consistency in recommendations for the management of children with acute gastroenteritis (AGE), a high variability in clinical practice and a high rate of inappropriate medical interventions persist in both developing and developed countries.

The aim of this study was to develop a set of clinical recommendations for the management of nonseverely malnourished children with AGE to be applied worldwide.

Methods: The Federation of International Societies of Pediatric Gastroenterology, Hepatology, and Nutrition (FISPGHAN) Working Group (WG) selected care protocols on the management of acute diarrhea in infants and children aged between 1 month and 18 years. The WG used a 3-step approach consisting of: systematic review and comparison of published guidelines, agreement on draft recommendations using Delphi methodology, and external peer-review and validation of recommendations.

Results: A core of recommendations including definition, diagnosis, nutritional management, and active treatment of AGE was developed with an overall agreement of 91% (range 80%–96%). A total of 28 world experts in pediatric gastroenterology and emergency medicine successively validated the set of 23 recommendations with an agreement of 87% (range 83%–95%). Recommendations on the use of antidiarrheal drugs and antiemetics received the lowest level of agreement and need to be tailored at local level. Oral rehydration and probiotics were the only treatments recommended.

Conclusions: Universal recommendations to assist health care practitioners in managing children with AGE may improve practitioners’ compliance with guidelines, reduce inappropriate interventions, and significantly impact clinical outcome and health care-associated costs.

*Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples, Italy

Departamento de Pediatria Médica, Hospital de São João, Porto, Portugal

KEMRI/Welcome Trust Research Programme, Kilifi, Kenya

§Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

||Department of Public health, Univeristy of Naples Federico II, Naples, Italy

Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL

#Instituto de nutrición y tecnología de los alimentos de la Universidad de Chile (INTA), Santiago, Chile

**Pediatric Clinic, Department of Maternal and Child Health, ASUIUD S, Maria della Misericordia, University of Udine, Italy

††Department of Pediatrics, Universidad Peruana Cayetano Heredia, Lima, Peru

‡‡Department of Paediatric Gastroenterology Bristol Royal Hospital for Children, Bristol, UK

§§Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada

||||Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.

Address correspondence and reprint requests to Alfredo Guarino, MD, Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy (e-mail:

Received 5 March, 2018

Accepted 22 May, 2018

P.M.S. has received honoraria for CME presentations from Nestle Nutrition, Abbott Nutrition, and Mead Johnson Nutrition, and collaborates on research grants related to probiotics awarded from the Canadian Institutes of Health Research, Lallemand Human Nutrition, and BIoKPlus.

The authors report no conflicts of interest.

© 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,