"We can not guarantee cure, but what we can guarantee is an 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
[email protected]
[email protected]
www.takvanidr.multiply.com
11/01/201723 June, 2010
Takvani
1
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.
11/01/2017
Takvani
2
Why to talk on diarrhea?
• Use of antiemetics
• Antibiotics often- Nor-metro, Oflo-ornida,
Inj.Amikacin.
• Un-necessary probiotics
• Racecadotril.
11/01/2017
Takvani
3
IAP Consensus Statement
• Highlights several important developments.
• Aims that benefits of new knowledge reach
affected.
• Wants that new products are not
inappropriately used.
11/01/2017
Takvani
next
4
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.
11/01/2017
Takvani
5
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.
11/01/2017
back
Takvani
6
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.
11/01/2017
Takvani
7
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.
11/01/2017
Takvani
8
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 be used.
11/01/2017
Takvani
back
9
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 different.
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 (namely L.
acidophilus, Lactic Acid Bacteria) available in
the Indian market. To recommend a particular
species it will have to be first evaluated in
randomized controlled trials in Indian
children.
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,
Sacc. Bul. and Lacto-bacillus.
11/01/2017
Takvani
15
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.
11/01/2017
Takvani
16
Racecadotril
Not enough evidence:
• Safety.
• Efficacy.
• There is no data from our settings.
• Methodology of studies questionable.
• No routine use
back
11/01/2017
Takvani
17
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.
11/01/2017
Takvani
18
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.
11/01/2017
Takvani
19
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.
11/01/2017
Takvani
20
Acute Diarrhea in the Young Infant (< 2 mth)
• Third generation cephalosporins, intra-venous
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.
11/01/2017
Takvani
21
Acute Diarrhea in the Young Infant (> 2 mth)
• For assessment, IMNCI, No, 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.
11/01/2017
Takvani
22
home available fluids
11/01/2017
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)
Takvani
NEXT
23
Antibiotic in Acute Diarrhoea
Indicated only for :
• Acute bloody diarrhea with gross blood
• Shigella positive culture,
• Cholera,
• Associated systemic infection
• Severe malnutrition. (Septicemia)
11/01/2017
Takvani
24
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
11/01/2017
Takvani
25
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.
11/01/2017
Takvani
26
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 required- personal)
11/01/2017
Takvani
27
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.
11/01/2017
Takvani
28
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.
11/01/2017
Takvani
29
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.
11/01/2017
back
Takvani
30
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.
11/01/2017
Takvani
31
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.
11/01/2017
Takvani
32
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).
11/01/2017
Takvani
33
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
11/01/2017
Takvani
34
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.
back
11/01/2017
Takvani
35
I conclude ….
• Prescribe ORS for all ages.
• Continue Breast feeding and diet.
• Explain danger signals.
• 20 mg/10 mg of elemental zinc
11/01/2017
Takvani
36
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)
11/01/2017
Takvani
37
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, IAP-UNICEF Program on
Evidence-based Management of
Diarrhea. http://indianpediatrics.net/mar2010/mar-215-217.htm
11/01/2017
Takvani
38
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
[email protected]
www.takvanidr.multiply.com
11/01/2017
Takvani
39