Substantial scientific evidence and consequent general agreement now exists among pediatric gastroenterologists that optimal management of mildly to moderately dehydrated children in Europe should consist of the following “Six Pillars of Good Practice”:
- Use of oral rehydration solution (ORS) to correct estimated dehydration in 3 to 4 hours (i.e., fast rehydration) (1–5).
- Use of hypoosmolar solution (60 mmol/L sodium, 74–111 mmol/L glucose) (6–12).
- Continuation of breast-feeding throughout (13).
- Early refeeding, i.e., resumption of normal diet (without restriction of lactose intake) after 4 hours rehydration (1–5,14–26).
- Prevention of further dehydration by supplementing maintenance fluids with ORS (10 mmol/kg/watery stool (1–4).
- No unnecessary medication (27–28).
The evidence for this practice has been published piecemeal during the past 10 years and includes the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Working Group's published recommendations for feeding in childhood gastroenteritis (1–2). Although a Working Group study showed that probiotics have beneficial effects (29), a metaanalysis did not support the routine use of probiotics in treating gastroenteritis (30).
The recommendations of the ESPGHAN Working Group are based, in part, on its own studies and are concordant with those issued by the American Academy of Pediatrics (28) and the World Health Organization (WHO) (31), except for the World Health Organization ORS composition (Table 1), which currently is being reappraised (personal communication, O. Fontaine, WHO, July 18, 2001).
PRACTICAL GUIDELINES FOR MANAGEMENT OF ACUTE DIARRHEA
History taking should include questions about duration and severity of diarrhea and vomiting, fluid intake, food intake, urinary output, previous weights, presence of blood in stools, and symptoms of other causes of diarrhea and/or vomiting.
Examination should assess the degree of dehydration (Table 2), weight and height, and presence of pyrexia. If dehydration is less than 5%, the child can be managed at home.
Management at Home
Rehydrate orally using ESPGAN-based ORS. Emphasize the importance of adequate hydration. Recommending use of “clear fluids” is inappropriate (for example, water alone or homemade solutions of sugar and fruit) primarily because they lack adequate sodium. Furthermore, sugar, fruit juices, and cola can worsen diarrhea as they have high osmolar load and little sodium (Table 3)
Calculate the fluid deficit and replace over 4 hours, e.g., for a 10 kg child with 5% dehydration, the deficit is 5% of 10,000 g = 500 mL. Therefore, give 500 mL of ORS in 4 hours, i.e., 125 mL/h. Give sachets of ORS with clear instructions on how to make the solution and how much to give. It is essential to emphasise to the parents the importance of adequate hydration and to give clear instructions on how to make ORS and how much to administer.
If child is breast-fed, continue breast-feeding. If the child was dehydrated, then ideally the child should be reassessed at 4 hours. If rehydrated, start normal feeding including maintenance fluids. Continue to supplement with ORS 10 mL/kg for each watery stool or vomitus until child recovers. Full feeding appropriate for age is well tolerated with no adverse effects, and the practice of withholding food for 24 or more hours is inappropriate. Early feeding may decrease the intestinal permeability changes induced by infection (20).
Management in the Hospital
Indications for hospital admission include 1) patient 5% or more dehydrated; 2) parents unable to manage oral rehydration at home; 3) patient not tolerating oral rehydration (refusing, vomiting, insufficient intake); 4) failure of treatment, e.g., worsening diarrhea and/or dehydration despite ORT; 5) other concerns, e.g., diagnosis uncertain, potential for surgery, child “at risk,” child irritable or drowsy, or child younger than 2 months.
Investigations should include plasma urea and electrolytes (on admission and after initial rehydration), full blood count, and stools analysis for pathogens.
Weigh the patient, calculate fluid deficit, and replace in 4 hours. Give small frequent feeds. If the patient does not tolerate oral rehydration (refuses, vomits, takes insufficient volumes), use a nasogastric tube to give ORS. Review the patient 4 hours later. If the patient is successfully rehydrated, start a normal diet and continue maintenance fluids (150 ml/kg/day for first 6 kg plus 50 ml/kg/day for 7–20 kg plus 20 ml/kg/day for >20 kg.) and supplementary ORS, 10 mL/kg/watery stool. If dehydration persists, continue the same regime but also replace fluid deficit with ORS in the following 4 hours.
If the patient becomes or is more than 10% dehydrated, intravenous rehydration is necessary. Indications for intravenous therapy include 1) shock, 2) >10% dehydrated, or 3) failure of oral replacement therapy.
If the patient is in shock, first resuscitate with 0.8% saline (20 mL/kg). To rehydrate, replace the deficit with 0.45% saline/5% dextrose. Calculate amount using the uncorrected weight (e.g., for 10% dehydration, 8 kg child = 10% of 8000 g = 800 g = 800 mL). Replace 50% during the first 4 hours and the remainder during the following 4 hours. Continue with maintenance therapy: replace with 0.18% saline/5% dextrose. Calculate amount according to age and weight (Table 4). Add 10 mmol KC1 to each 500 mL of IV fluid after urine has been passed.
When the patient has been rehydrated, begin maintenance with ORS, if necessary give nasogastrically. As soon as these are tolerated, have the patient start on a normal diet. Continue to replace ongoing diarrheal losses with ORS 10 mL/kg/watery stool.
A patient with sodium >150 mmol/L requires frequent reassessment: 1) resuscitate with IV therapy as discussed above, and 2) rehydrate. The aim is to reduce the sodium levels slowly because dramatic falls are hazardous.
Oral or nasogastric rehydration using ORS is the method of choice and by far the safest.
Only if this fails is (slow) IV rehydration necessary: Replace the calculated deficit with IV 0.45% saline/5% dextrose over 8 hours. Calculate using uncorrected weight. Repeat plasma sodium at 8 hours. If normonatremic, move on to maintenance, otherwise continue for an additional 8 hours and repeat plasma sodium.
Provide maintenance by replacing deficit with 0.18% saline/5% dextrose. Calculate for 24 hours from end of replacement.
Add 10 mmol KC1 to each 500 mL of IV fluid after the patient has passed urine.
When the patient is rehydrated, start a normal diet including maintenance fluids. Continue to supplement with ORS (10 mL/kg/watery stool) until diarrhea stops.
If diarrhea continues longer than 10 days, advise the parent to return the child for medical reassessment. Check the stool for persistent infection. If diarrhea returns each time milk is introduced, the child may have developed lactose intolerance. Test the stool pH and test for reducing substances using CLINITAB. It is an easy bedside test. If the test reads 1% or more, it is considered positive (0.5% or less is not significant). If the child is weaned, it is advisable to continue the child on solids and give ORS as maintenance fluid for 24 hours. If the diarrhea returns on reintroduction of milk, put the child on a lactose-free formula for 2 weeks and reassess. Most lactose intolerance is temporary and caused by patchy villous damage. The lactase level returns to normal as the gut mucosal cells renew themselves.
If the stool is negative for reducing substances and the diarrhea is related to milk intake, the child may have developed cow's milk–protein intolerance and may require a protein hydrolysate formula. A jejunal biopsy to look for cow's milk–protein enteropathy is advisable for proper diagnosis.
Encourage extra food intake for a few weeks to make up for any weight loss during the diarrheal episode.
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