diarrhoea master final 2011

Guidelines on the management of

2011

i

COLLEGE OF PAEDIATRICS, ACADEMY OF MEDICINE OF MALAYSIA | MALAYSIAN PAEDIATRIC ASSOCIATION

Committee Members

The following are members of the Guidelines Committee:

Professor Lee Way Seah (Chair) – Professor of Paediatrics and Consultant Paediatric Gastroenterologist and Hepatologist, University of Malaya Medical Centre, Kuala Lumpur; President, College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP)

Datuk Dr. Zulkifli Ismail – Consultant Paediatrian and Paediatric Cardiologist, KPJ Selangor Specialist Hospital, Shah Alam; President Elect, Asia Pacific Pediatric Association (APPA); Past President, Malaysian Paediatric Association (MPA)

Dr. Nur Atiqah Ng Abdullah – Consultant Paediatrician and Paediatric Gastroenterologist, Pantai Hospital, Bukit Pantai, Kuala Lumpur

Dr. Oon Meng Kar – Consultant Paediatrician, Klinik Kanak-kanak Oon, Cheras, Kuala Lumpur

Dr. Chai Pei Fan – Consultant Paediatrician and Paediatric Gastroenterologist and Hepatologist, Pantai Hospital, Bukit Pantai, Kuala Lumpur

©2011 College of Paediatrics, Academy of Medicine of Malaysia and Malaysian Paediatric Association

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THE MANAGEMENT OF ACUTE DIARRHOEA IN CHILDREN 2011

Terms of Reference

Target audience: This guidelines aim to cater mainly for paediatricians, primary care physicians and other frontline healthcare providers involved in providing care for children.

Format:This guidelines consist of easy-to-read information with appropriate flow charts. All facts are evidence-based as far as possible. Where evidence is not currently available, the combined and consensus opinion of the members with adequate consultation with senior colleagues prevailed.

1. The full guidelines on the management of acute diarrhoea in children may be obtained from the following websites:

• CollegeofPaediatrics,AcademyofMedicineofMalaysia(AMMCOP) http://www.acadmed.org.my/

• MalaysianPaediatricAssociation(MPA) http://www.mpaweb.org.my/

• MeadJohnsonNutritionMalaysia http://www.meadjohnsonasia.com.my/home.aspx

2. A pocket reference guide which is a summary of the recommendations for the management of acute diarrhoea in children may be obtained from AMMCOP, MPA or Mead Johnson Nutrition Malaysia.

3. A wall poster consisting of a flow chart on the management of acute diarrhoea in children may be obtained from AMMCOP, MPA or Mead Johnson Nutrition Malaysia.

Content:The committee members have the sole right to determine the content of the suggested guidelines. The sponsor did not influence any part of the content at any time.

Disclosure:No conflict of interest declared by any of the committee members.

Sourceoffunding:This guidelines was made possible by an unrestricted educational grant from Mead Johnson Nutrition Malaysia.

Disclaimer:The content / guidelines is based solely on currently available scientific evidence or best clinical practice. Healthcare professionals are expected to utilise the information contained within this guidelines when exercising their clinical judgement. However, this guidelines should not replace the individual responsibility of the user to make decisions appropriate to the circumstances of the individual patient and informed by the current indications and accuracy of the drug they are considering.

Copyrightownership:Copyright of the document remains with the College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP) and Malaysian Paediatric Association (MPA). No part of this publication may be reproduced in any form without the prior written permission of the authors.

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Contents

01 Introduction 1

02 Summary of the Guidelines 2

03 Scope of the Guidelines 3

04 Definition of Diarrhoea 3

05 Clinical Types of Diarrhoeal Diseases 4

06 Important Causative Agents of Gastroenteritis 5

07 Assessment of Acute Diarrhoea 7

08 Management of Childhood Acute Diarrhoea 11

09 Prevention of Childhood AGE 23

10 Special Considerations 25

11 Part I: Algorithm for Managing Acute Gastroenteritis in Children 26

12 Part II: Algorithm for Managing Acute Gastroenteritis in Children 27

13 Summary of Established Guidelines 28

References 29

Appendix A 34

Appendix B 35

1


01 Introduction

The first Guidelines on Childhood Acute Gastroenteritis (AGE) in Malaysia were published in 2001 by the College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP). Since then there has been a proliferation of publications and new findings in this area in the literature.

Over the last few years, there has been publication of a few guidelines on the management of childhood AGE. The new WHO Guidelines on the ‘Treatment of Diarrhoea’ (2005) caters mainly for the need of developing countries with a limited health care resources,1

while other guidelines such as those from the Center for Disease Control (CDC) and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) cater mainly for North America and the European countries, respectively.2-5 Therefore there is an urgent need to have a local guidelines catering to the specific need for Malaysia.

2


02 Summary of the Guidelines

Acute diarrhoea is the second most important cause of childhood mortality worldwide.6

It is estimated that each year, approximately 1.9 million children younger than 5 years of age dies of acute diarrhoea.7 At present, there is no detailed epidemiological study on the burden of acute diarrhoea in children from Malaysia. However, it was estimated that 1.3% of all medically certified and uncertified deaths (or 69 deaths per year) among children younger than 5 years of age were due to acute gastroenteritis.8

There are four clinical types of diarrhoea, namely acute watery diarrhoea, acute bloody diarrhoea, persistent diarrhoea and diarrhoea with severe malnutrition.1 The main causes of childhood AGE are various enteric viruses and bacteria, although parasites are important in certain specific setting.9 Various studies, based mainly on hospital admission studies, showed that rotavirus is the most common cause of dehydrating diarrhoea in young children requiring hospital care in Malaysia.10-20 Important bacterial pathogens include non-typhoidal Salmonella and E. coli.21

Proper clinical assessment is required to correctly diagnose the condition, in particular the severity of dehydration of the child, to provide the appropriate management. Every child with AGE should be carefully assessed for dehydration and other complications. Criteria for hospital care include moderate-to-severe dehydration, persistent vomiting or worsening diarrhoea even in the absence of dehydration, uncertainty about diagnosis, presence of unfavourable socio-economic factors, or presence of other complications.

In most cases of uncomplicated acute diarrhoea with no significant dehydration, no laboratory investigation is necessary. A careful history and detailed physical examination to assess the state of hydration is often all that is necessary.

In most instances with uncomplicated AGE, oral rehydration therapy is the treatment of choice and is sufficient in a majority of cases. Drug therapy is unnecessary in most cases, and may even be contraindicated or dangerous.

Children who require rehydration should continue to be breastfed or formula-fed. Food should not be withdrawn for longer than 4 – 6 hours after the onset of rehydration. For children who are formula-fed; formula dilution, gradual reintroduction of feeding and switching to lactose-free, soy or hydrolysate formulae are not recommended.

Breastfeeding is the best measure for the prevention of AGE in young infants. Rotavirus is the commonest viral pathogen causing severe dehydrating diarrhoea in the world over. Rotavirus vaccines are not part of the national immunisation schedule in Malaysia. However, it is recommended that vaccination should be considered as part of prevention of rotavirus diarrhoea. Currently there are two rotavirus vaccines available in Malaysia. Both are safe and highly effective in preventing severe dehydrating diarrhoea.22

When the duration of diarrhoea persists for more than 14 days following an episode of AGE, lactose intolerance and food protein allergy (most commonly cow milk or soy protein) complicating AGE, repeated or persistent bacterial or parasitic infections should be excluded. In these cases, consultation with or referral to a specialist with expertise in this area should be considered.

3


03 Scope of the Guidelines The present guidelines are intended to be used in the following settings in Malaysia:

• Primary care settings (out-patient clinic, emergency room)• In-patient care

The guidelines focus mainly on acute diarrhoea in children. It will include various management aspects including office management of AGE such as:

• Clinical assessment• Rehydration management• Drugs (antibiotics, anti-diarrhoeal, and anti-emetics)• Probiotics and prebiotics• Nutrition management (manipulation of feeding practices, special formulae) • Vaccines (rotavirus vaccines)

04 Definition of Diarrhoea

Diarrhoea is defined as the passage of unusually loose or watery stools, usually at least 3 times in a 24-hour period. It is the consistency of the stools that is most important, rather than the frequency. Frequent passing of formed stools is not considered as diarrhoea. Similarly, breastfed babies pass loose, 'pasty' stools sometimes up to 6 to 7 times a day which should not be considered as diarrhoea.1

The main problem with acute diarrhoea is its ability to cause rapid fluid loss through stools in addition to electrolytes loss. The volume of fluid loss can vary from 5ml/kg body weight/day to ≥ 200 ml/kg body weight/day. Dehydration and electrolyte losses associated with untreated diarrhoea are the main causes of morbidity and mortality of childhood AGE.

Diarrhoea can also be the initial signs of non-gastrointestinal tract illness, including meningitis, bacterial pneumonia, otitis media, intussusception and urinary tract infection. In addition, vomiting without diarrhoea can be the first symptom of a host of diverse surgical and metabolic conditions as well.2

4


05 Clinical Types of Diarrhoeal Diseases 1

Acute Watery Diarrhoea

Acute Bloody Diarrhoea(dysentery)

Persistent diarrhoea

Diarrhoea with severe malnutrition

Lasts for several hours or days. The main concern is dehydration. Weight loss can also occur if feeding is being withheld for too long.

Should be considered when blood and mucous are present in the stools. The main dangers are damage to the intestinal mucosa, sepsis and malnutrition. Dehydration, although not as common as in acute watery diarrhoea, may also occur.

Defined as diarrhoea that lasts 14 days or longer. It may lead to malnutrition and serious infection with or without dehydration.

A serious condition and warrants special attention to exclude severe systemic infection, dehydration, severe electrolytes imbalance, heart failure, and vitamin and mineral deficiencies.

5


06 Important Causative Agents of Gastroenteritis

Rotavirus is the main cause of virus-induced gastroenteritis in both developed and developing countries. Other enteric viruses include norovirus, adenovirus, astrovirus and calicivirus.9

In developed countries, enteric viruses are more important than bacterial pathogens in causing childhood diarrhoea.9 In the developing countries, on the other hand, bacterial pathogens, such as E. coli, non-typhoidal Salmonella, Shigella species, and Campylobacter species are important pathogens, in addition to enteric viruses.9

Developed Countries Developing Countries

RotavirusUnknownParasitesBacteriaAdenovirusAstrovirusCalicivirusOther BacteriaToxigenic Escherichia coli

Adapted from Estes MK and Kapikian AZ . In: Fields Virology. 5th ed. Philadelphia: Lippincott, Williams, and Wilkins; 2007:Page 1917-19749

It is also useful to classify important aetiological agents according to age group and nature of stools (Table 1):

Table 1: Important causative agents of gastroenteritis by age group and nature of stool worldwide 4

Rotavirus, astrovirus, calicivirus, enteric adenovirus, enteropathogenic Escherichia coli (EPEC), enterotoxigenic Escherichia coli (ETEC), Vibrio cholerae

≤ 2 years

Enterotoxigenic Escherichia coli (ETEC), rotavirus, Shigella, Vibrio cholerae

2-5 years

Watery

Shigella, shiga-toxin producing Escherichia coli (STEC), Campylobacter jejuni

≤ 2 years

Shigella, shiga-toxin producing Escherichia coli (STEC), non-typhoidal Salmonella, E. histolytica

2-5 years

Mucousy / bloody

6


Table 2: Important causative agents of childhood acute gastroenteritis in Malaysia 10, 12, 14, 19, 20, 23

a includes enteropathogenic and enterotoxigenic E. colib as a mixed infectionNT Not tested

In Malaysia, major enteric viruses causing childhood AGE are rotavirus, norovirus, and enteric adenovirus (Table 2). For bacterial gastroenteritis, the most important causative agent is the non-typhoidal Salmonella, followed by Campylobacter, Shigella and E.coli.21

Among the hospitalised children, 40 to 50% of cases are caused by rotavirus and patients demonstrated severe vomiting and diarrhoea and severe dehydration.

As for outpatient, the main causative agent is non-typhoidal Salmonella. Only 10% of the cases are caused by rotavirus.12 However, the above figure was based on only one study in Malaysia which was performed in a private outpatient clinic in Klang Valley with a relatively small number of patients.

Author

Iyngkaran et al 10

Koe et al 12

Lee et al 14

Poo and Lee19

Tan20

Kahar-Bador & Lee23

NumberTested

300

97

228

288

261

568

Rota-virus

19

9

29

30

54

28

Noro-virus

9

Adeno-virus

4

NT

4

NT

NT

2

Salmonella

11

26

10

9

6

Shigella

6

2

0.4b

0

0.4

E. Coli a

10

1

0.4

1

0.4

Campylo-bacter jejuni

0

3

0

0

0

No organism

50

59

56

60

39

49

Percentage of aetiological agent (%)

7


07 Assessment of Acute Diarrhoea 1-5

• Identify the presence of, the degree of, and type of dehydration• Identify the aetiological agent, if indicated and possible • Identify co-morbidity and complications • To assess nutritional status• To ascertain the most appropriate mode of treatment

The following aspects should be covered:• Assess the onset, frequency, quantity and character of both vomiting (presence of bile, blood) and diarrhoea (presence of blood or mucous)• Recent oral intake (including breast milk and other fluids and food)• Urine output• Weight before illness (if available)• Associated symptoms (fever, change in mental status)• Past medical history (underlying medical problems, history of other recent infections, medications, immune compromised states)• Social history

7.1 Assessment:

History

The following aspects should be covered:• Accurate body weight• Vital signs (temperature, heart rate, respiratory rate, blood pressure)• General conditions• Eyes: sunken eyes, presence / absence of tears• Mucous membrane – moist or dry• Respiratory pattern• Bowel sounds• Extremities (perfusion, capillary filling time)• Skin turgor (anterior abdominal wall)• Inspection of stool (presence of blood or mucous)

7.2 Assessment:

Physical Examination (see Appendix A)

Classification into severity of dehydration is essential for appropriate fluid management. The best measure of dehydration is by the percentage loss of body weight.1 However, the actual weight is often not available. It should also be emphasised that clinical signs for dehydration are imprecise.4, 24 Therefore, repeated assessment is often necessary.

Most useful signs for significant dehydration are:4, 25

• Prolonged capillary refill time (normal < 2 seconds)• Reduced skin turgor• Abnormal respiratory pattern

7.3 Assessment:

Dehydration

Aims of assessment

8


Table 3: Simplified ways of classifying the degree of dehydration

This is generally defined as a serum sodium concentration of ≥ 150 mmol/L. Important causes of hypernatraemic dehydration in childhood acute diarrhoea include young infants who were predominantly breastfed and were given inadequate breastfeeding, or given inappropriately prepared infant formula. Very little evidence-based guidelines on this condition have been published recently. An excellent review on this topic can be found elsewhere.26

Signs and symptoms of hypernatremia largely reflect central nervous system dysfunction and are prominent when the increase in the serum sodium concentration is large or occurs rapidly (i.e., over a period of hours). Common symptoms in infants include:26

• hyperpnoea• muscle weakness• restlessness• a characteristic high-pitched cry• insomnia• lethargy• and even coma• convulsions are typically absent except in cases of inadvertent sodium loading or aggressive rehydration

Hypernatraemic dehydration complicating AGE is uncommon nowadays. In a one-year prospective study on 393 children admitted with AGE to a teaching hospital, the incidence of hypernatraemia was 1.2%, while that of hyponatraemia was 1.0%.19

7.4 Hypernatraemic Dehydration

Classification

No signs of dehydration

Some signs of dehydration

Severe dehydration

Fluid deficit as % of body weight

< 3%

3-9%

>9%

Fluid deficit in ml/kg of body weight

< 30 ml/kg

30 – 90 ml/kg

> 90 ml/kg

Adapted from: WHO 20051

9


Generally, in patients with high fever (>39°C), overt faecal blood, abdominal pain, central nervous system involvement such as irritability, apathy, seizures or coma suggest bacterial aetiology.27, 28 Patients presenting with more significant vomiting and respiratory symptoms suggest viral aetiology.29 Rotavirus causes more severe vomiting and dehydration. However, it should be emphasised that the clinical features of both viral and bacterial aetiology overlap considerably.27

7.6 Bacterial or Viral Cause?

It is always useful to keep in mind the possibility that the diagnosis of AGE may be incorrect. Although gastroenteritis consists of the triad of vomiting, diarrhoea and fever, other conditions can present with the above symptoms as well. These include:

• Acute appendicitis• Strangulated hernia• Intussusception or other causes of bowel obstruction• Urinary tract infection• Meningitis and other types of sepsis• Any cause of raised intracranial pressure• Diabetic ketoacidosis• Inborn error of metabolism • Haemolytic uraemic syndrome• Inflammatory bowel disease

Always consider another diagnosis in the presence of any of the following warning signs:23

• Abdominal distension • Bile-stained vomiting• Blood in vomitus or stool (in appropriate clinical setting)• Severe abdominal pain• Vomiting in the absence of diarrhoea• Headache

7.5 Differential Diagnoses 23

10


In the majority of children with uncomplicated AGE with no signs of dehydration, laboratory investigations are unnecessary.4

It should also be noted that laboratory assessment for severity of dehydration are imprecise. The only laboratory measurement that appears to be useful in decreasing the likelihood of > 5% dehydration is serum bicarbonate (presence of a normal serum bicarbonate).23 Electrolytes should be measured in moderately dehydrated children whose history and physical examination findings are inconsistent with a straight-forward diarrhoeal illness, and in all severely dehydrated children.4 Electrolytes should also be measured in all children requiring intravenous therapy, and during therapy to monitor the presence of hyper- and hyponatraemia, and other electrolyte imbalances.4

• Routine stool culture is not indicated as it is expensive and does not alter the management in the vast majority of patients4

• Stools culture is mandatory if profuse watery stools (cholera), blood and mucous in stool (bacterial dysentery)• Virus – usually not indicated• Parasites – only if clinically indicated• Reducing substances (only in watery stool)

Indications for stool culture are shown in Table 4.

• Bloody diarrhoea (consider dysentery)• Severe watery stools (consider cholera)• Severe and prolonged diarrhoea• Immune-compromised child

7.7 Diagnostic Workup 1, 4

7.7.1 Stool:

• Specific gravity – may be helpful in the monitoring of response to therapy in children with severe dehydration undergoing rehydration therapy• Urine microscopy – should not be performed routinely because of possibility of contamination of urine samples during acute diarrhoea

7.7.2 Urine:

• Urea, Na+, K+, pH, HCO3 -

• Complete blood count– if bacterial sepsis is suspected• Consider glucose monitoring (girls younger than 5 years with vomiting)• (± Ca2+, Mg2+ in young infants)

7.7.3 Blood:

Table 4: Indications for stool culture and sensitivity 4

The incidence of hypoglycaemia in children with AGE has been estimated to be between 1.9 – 9.2%.30-32 The risk factors for developing hypoglycaemia are female gender, signs of neuroglycopenia, and frequent vomiting.32

11


08 Management of Childhood Acute Diarrhoea 1-5

Important points to be considered:

• Identification of children at risk of severe disease or at risk of developing complications

• Prevention / correction of dehydration and electrolyte imbalance• Prevention and treatment of complications such as invasive disease, severe

electrolyte imbalance, metabolic and other complications, malnutrition• Drug(s) treatment, which may have a supplementary role• Provision of adequate and appropriate nutrition

8.1 ReferralforHospitalCare

In the majority of cases of uncomplicated childhood AGE with no significant dehydration, outpatient assessment and subsequent home management is all that is necessary.1, 4, 5 The presence of the following warning signs is helpful in deciding whether the child needs further assessment and possible hospital care:

Table 5: Criteria for Hospital Care 4

• Severe dehydration (> 9% of body weight), shock• Neurological abnormalities (lethargy, seizures, etc.)• Persistent or bilious vomiting (even if no dehydration)• Treatment failure with oral rehydration salts (ORS)• Presence of systemic illness (high fever, toxic looking)• Underlying medical conditions (heart failure, significant

neurodevelopment disabilities)• Caregivers unable to provide adequate care at home or

other social/logistic concerns• Suspected surgical condition, uncertain about diagnosis• Uncertain about degree of dehydration (obese children)

However, it should be emphasised that at present, there are no established, evidence-based criteria for the hospital admission of childhood AGE.4

12


8.2 RehydrationinAcuteDiarrhoea

Generalprinciples: Generally, oral rehydration should be used as first-line therapy for the management of children with AGE.1-5 When oral rehydration is not feasible, enteral rehydration via the naso-gastric route is as effective if not better than intravenous rehydration.1-5, 33 Oral or enteral rehydration is associated with significantly fewer major complications and a shorter hospital stay compared with intravenous therapy and is successful in most children.

• If no excessive vomiting, home management is usually sufficient• If breastfeeding, continue breastfeeding• If formula-fed, continue usual feeding and offer extra water• For older children: continue normal diet with extra fluids

8.2.1 No signs of dehydration (< 3%)

• If no excessive vomiting and in the absence of adverse social circumstances, may still consider outpatient therapy• ORS 30-90ml/kg within 2-3 hours• After every diarrhoea episode: ORS 10ml/kg• Small and frequent feeds with regular assessment• Hospital referral for admission for IV fluid if there is persistent vomiting, worsening dehydration despite adequate therapy

8.2.2 Some signs of dehydration (3-9%)

• Resuscitation (normal saline / Ringer’s lactate)• Frequent monitoring• Immediate referral to hospital for admission

8.2.3 Severe dehydration (> 9%)

8.2.4 Selection of oral rehydration salts (ORS) Table 6 shows the electrolyte content of stool samples obtained from patients with cholera, rotavirus and enteropathogenic Escherichia coli. It is more appropriate to use the original WHO ORS in situations where cholera is likely. In other situations, a reduced osmolality ORS is preferred. Table 6: Mean Stool Na+ and K+ (mmol/L) According to Duration of Diarrhoea Before Admission

Adapted from Molla AM et al, 199134

Duration (h)

0 – 12

13 – 24

25 – 48

48+

Na(mmol/L)

98

83

63

46

K(mmol/L)

29

37

28

65

EPEC

Na(mmol/L)

67

55

44

44

K(mmol/L)

37

38

26

37

Rotavirus

Na(mmol/L)

53

42

32

34

K(mmol/L)

46

42

28

43

Cholera

13


Table 7 shows the electrolyte content of various ORS preparations available in Malaysia. Fluids that are not suitable as substitute for ORS include 100 Plus (Table 8).

Table 7: Electrolytes Composition, Osmolality of Various ORS Preparations

Adapted from Santosham M, 199735; Lee WS, 200936

# 1 molecule of citrate is metabolised into 3 molecules of bicarbonate in the body.

Table 8: Fluids Not Appropriate to be Used in Rehydration Therapy

Adapted from Santosham M, 199735; Lee WS, 200936

NA Not available

Standard WHO (1975)

Reduced-Osmolality WHO (2002)

Ministry of Health

ORS Plus (per sachet)

Upha E-Lyte (per sachet)

Weewa ORS (per sachet)

Na(mmol/L)

90

75

56

75

75

90

K(mmol/L)

20

20

20

20

20

21

Cl(mmol/L)

80

65

56

65

65

81

HCO3(mmol/L)

30

30

20

Glucose (mmol/L)

111

75

137.5

75

75

110

Citrate #(mmol/L)

10

10

10

Osmolality (mmol/kg)

311

245

290

245

245

312

Coca cola

Apple juice

Chicken broth

Tea

100 Plus

Na(mmol/L)

2

3

250

0

21

K(mmol/L)

0

20

8

0

3.5

Cl(mmol/L)

NA

NA

NA

NA

20

HCO3(mmol/L)

NA

0

0

0

3

Glucose (mmol/L)

616

600 – 900

0

0

NA

Osmolality (mmol/kg)

618

260

330

14


8.3 SpecialConsideration

8.3.1 Hypernatraemic dehydration

Hypernatraemic dehydration is defined as serum sodium concentration of more than 145 mEq/L. Generally patients with hypernatraemic dehydration respond well to oral rehydration therapy.2 Those with severe dehydration should first receive intravenous fluid therapy for resuscitation. The principal of subsequent rehydration should be the use of isotonic solution (normal saline) administered at a slower rate, i.e. over 48 hours. Subsequent rehydration can also be achieved with ORS. ORS might be safer than intravenous fluid because it is less likely to lead to a precipitous increase in intracellular water associated with seizures and raised intracranial pressure.2

8.4 AdjunctiveTherapyforAcuteDiarrhoea

8.4.1 Antibiotics 1-5

With only a few exceptions, antibiotic therapy should not be given routinely to children with diarrhoea. Such therapy is ineffective and may be harmful.1-5 Majority of gastroenteritis cases in children are viral in origin (rotavirus, norovirus, adenovirus). Thus, antibiotics are only needed for specific pathogens or defined clinical settings.

Recommendations:

Antibiotics are indicated in the following situations:

• Shigella dysentery - in cases presenting as bloody diarrhoea, these should be treated with an antimicrobial effective for Shigella

• When cholera is suspected• When diarrhoea is associated with another acute infection such as pneumonia

and urinary tract infection• May be indicated for Salmonella gastroenteritis in very young babies

(< 3 months), immune-compromised, immuno-suppressed, systemically ill, achlorhydia

15


Table 9: Recommended Antibiotics for Acute Diarrhoea 4

Pathogen

Shigellosis 4

SalmonellaGastroenteritis (in high risk children) A

Campylobacterdysentery

Cholera

Antibiotics

Azithromycin

Ceftriaxone

Trimethoprim-sulfamethoxazole

Amoxicillin

Ceftriaxone

Trimethoprim-sulfamethoxazole

Ciprofloxacin

Erythromycin

Azithromycin

Doxycycline B

Azithromycin

Total daily doses

Day 1: 12 mg/kgDay 2-5: 6 mg/kg

50 mg/kg

10/50 mg/kg( TM/SMZ )

40-50 mg/kg

50 mg/kg

10/50 mg/kg

5-10 mg/kg PO

4-7 mg/kg IV

30-50 mg/kg

4-7 mg/kg IV

>8 kg: 4.4 mg/kg(300 mg as a single

dose in adult)

Day 1: 12 mg/kgDay 2-5: 6 mg/kg

No. of Doses/day

1

1

2

3

1

2

2

2

2

2

1

1

Duration

5 days

2-5 days

5 days

5 days

2-5 days

5 days

5 days

5 days

5 days

5 days

Single dose

3 days

Note:

A: High risk children include those with underlying immune deficiency, anatomical and functional asplenia, corticosteroid or immunosuppressive therapy, inflammatory bowel disease, achlorhydria, and neonates and young infants.4

B: World Health Organization (WHO) does not recommend the use of doxycycline in children with cholera.

16


8.4.2 Anti-emetics

Anti-emetics include drugs such as dimenhydrinate, metoclopromide, domperidone and promethazine. These may cause sedation that can interfere with oral rehydration therapy. Due to this reason, anti-emetics are not routinely indicated in children with diarrhoea.1-5

In addition, anti-emetics may decrease vomiting but increase frequency of diarrhoea. This will lead to retention of fluid and toxin that would have been eliminated through vomiting.4, 37 Therefore, it is recommended that children with persistent vomiting be given small frequent feeds.

Recommendations:

• Not recommended

8.4.3 Anti-diarrhoeal agents and other therapies

Anti-diarrhoeal agents are generally not indicated in childhood AGE.

Various anti-diarrhoeal agents and other therapies are available in the market, and they can be divided into the following categories:

Table 10: Anti-diarrhoeal Agents and Other Therapies Commonly Used in Childhood Acute Diarrhoea, According to Efficacy on Diarrhoea and Safety Profile

No. Categories Examples

1 No effect on diarrhoea or not safe in young children Loperamide Activated charcoal

2 Possible effects on diarrhoea but not licensed to be used in young children

Kaolin-pectin Cholestyramine Bismuth-salt

3 Uncertain or some effects, but generally safe Diosmectite Certain probiotics

4 Safe and licensed in children with useful / positive effects in childhood diarrhoea

Zinc Certain probiotics Racecadotril

17


8.4.3.1 Anti-motility(intestinaltransitinhibitor;opiateagonists)

(i) Loperamide (Imodium®)

• decrease frequency and duration of diarrhoea but have serious side effects (lethargy and death) especially in young children (< 3 years).38 In this meta-analysis, 8 out of 972 children with loperamide had lethargy/death compared to none from the placebo group.38

Recommendations:

• Not recommended38

(ii) Diphenoxylate HCl (Lomotil®)

• anti-peristaltic, mask water loss, prolong intestinal transit time• increases direct contact between intestinal epithelium and noxious agents• usage in Shigella – invasive illness, prolonged fever, prolonged excretion of

Shigella• has narrow therapeutic range, hence risk of overdose and severe side effects

Recommendations:

• Not recommended

18


8.4.3.2 Intraluminal agents(adsorbents,bulk-forming,etc.)

(i) Silicates - kaolin/pectin39

• binds microorganisms or their products• increase stool consistency but not losses of water and electrolytes• not very effective• may decrease intestinal nutrient or drug absorption

Recommendations:

• Not recommended39

(i) Silicates – diosmectite (Smecta®)

• binds selected bacterial pathogens and rotavirus• restore integrity of damaged intestinal epithelium• reduce stool output and duration of diarrhoea• shown to be effective in rotavirus diarrhoea• maybe used as adjunctive to ORS• A meta-analysis published in 2006 showed that diosmectite is a useful adjunctive

therapy to childhood acute gastroenteritis.40 A total of six randomised-controlled trials showed that as compared to placebo, diosmectite significantly reduced the duration of diarrhoea by approximately 22.7 hours, and the chance of a cure on intervention day 3 was significantly increased in diosmectite vs. the control group (RR 1.64, 95% CI: 1.36-1.98).40 A more recent randomised controlled trial showed that diosmectite reduced stool output in children with acute watery diarrhoea, especially those who were rotavirus-positive.41

• No side effects 4, 40

Recommendations:

• Can be considered as an adjunctive therapy4, 40

19


8.4.3.3 Anti-secretory

(i) Enkephalinaseinhibitors(racecadotril*)

• enkephalinase-inhibitor, preserving endogenous enkephalinase• significantly reduces stool output (~50%) by 48 hour• well tolerated• no side effects42, 43

One of the major drawbacks on racecadotril is that most randomised-controlled trials previously were mainly industry-sponsored.42, 43

Recommendations:

• Can be considered as an adjunctive therapy42, 43

* Not commercially available in Malaysia at the time of publication of this guideline.

Table 11: Recommendation on The Use of Anti-emetics and Anti-diarrhoeal Agents on Childhood Acute Gastroenteritis 4

Agents Recommendation

Anti-emetics Dimenhydrinate, Metoclopromide, Domperidone, Promethazine

Not recommended

Anti-motility Loperamide Diphenoxylate HCl

Not recommended Not recommended

Intramural agents Silicates-kaolin / pectin Diosmectite

Not recommended Can be considered as adjunctive

Anti-secretory Racecadotril

Can be considered as adjunctive

Though commonly used, most of the anti-diarrhoeal agents and other therapies have no practical benefits and are never indicated for the treatment of acute diarrhoea in children. In fact, some are harmful to children.1-5

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8.4.4 Probiotics and prebiotics

Certain strains of probiotics may be an effective adjunct to the management of diarrhoea.4 The effects of probiotics are strain-specific and dose specific. Not all probiotics are equivalent in terms of efficacy and the efficacy of a specific strain cannot be generalised. Even the most studied strain like Lactobacillus GG show efficacy results that are not always consistent. In fact, there is no evidence of efficacy for many available commercial preparations. Products with multiple strains should also have efficacy studies. Adding additional strains to an effective strain may not necessarily have a synergistic effect or increase in efficacy.

Recommendations:

• probiotic strain or strains with proven efficacy and in appropriate doses • commercial probiotic products with viability studies

Several meta-analyses and systemic reviews have shown a statistically significant effect and moderate clinical benefit of selected probiotic strains in the treatment of acute watery diarrhoea.44, 45, 46

The most studied probiotic strains are Lactobacillus GG, lactobacillus acidophilus and Saccharomyces boulardii. The designs of the studies are different, using different strains and some a combination of different strains. The studies also have different aims and measured different end points.

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Table 12: Summary of Randomised Controlled Trials (RCT) of The Four Commonest Strains on Acute Gastroenteritis in Children

Strain Total number of RCT

Efficacy (number of studies)

Efficacy (number of studies)

Lactobacillus Rhamnosus GG 47-56

10 • Reduce duration of diarrhoea (5/10)• Reduce by 8 to 37 hours • Reduce stool frequency (5/10)• Effective only for rotavirus positive patients (2/10)

1.2x1010 to 2x1013 CFU3 to 7 days

Lactobacillus acidophilus 57-62

6 • Reduce duration of diarrhoea (5/6)• Reduce by 6.6 to 31 hours • Reduce stool frequency (1/6)

1x109 to 6x109 CFU3 to 5 days

Saccharomyces boulardii 63-67

5 • Reduce duration of diarrhoea (4/5)• Reduce by 24 to 38 hours

3 x 109 CFU5 to 6 days

Lactobacillus reuteri 68, 69, 70

3* • Reduce duration of diarrhoea (2/3)• Reduce by 30 to 40 hours

1x1010 CFU 5 days

* 2 studies with added Lactobacillus rhamnosus

Currently there is no role for prebiotics in the treatment of AGE.

Recommendations:

• Not recommended

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8.5 NutritionalTherapy/SpecialInfantFormula

Children who require rehydration should continue to be fed. Food should not be withdrawn for longer than 4 – 6 hours after the onset of rehydration. Breastfeeding should be continued during acute gastroenteritis. For children who are formula-fed, formula dilution and gradual reintroduction of feeding are not recommended.3, 4, 71, 72

8.5.1 Undiluted vs. diluted formula

A meta-analysis (1994) identified 16 studies (9 randomised controlled trials) that investigated the practice of diluting formula 2- to 6-fold for periods ranging from 1 to 6 days.72

Children given undiluted formula has a slight increase in stool frequency (p = 0.046) as compared to those fed with diluted formula, but there was no difference in the duration of diarrhoea. Children fed with undiluted formula resulted in a significant body weight catch-up (p = 0.002) as compared to those fed with diluted formula.72

Recommendations:

• In children who are on infant formula, no dilution of formula is recommended

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8.5.2 Soy-based or cow milk-based lactose-free formula

The vast majority of young children with acute gastroenteritis can safely continue to receive lactose-containing milk formula because the number of treatment failures is negligible compared to children with acute diarrhoea on a lactose-free diet.4, 71, 72, 73

In a meta-analysis on randomised controlled trials comparing lactose-free versus lactose-containing formula after AGE, overall, 22% (95% CI 18-27%) of children who consumed lactose had therapeutic failure compared to 12% (95% CI 9% - 15%) in children who did not. However, the results were widely heterogeneous.72

However, only 4 out of 14 trials provided information on stool frequency and outputs. Lactose-containing formula caused marginally greater stool outputs than lactose-free formula.72 Nine trials reported data on the duration of diarrhoea after the initiation of therapy. Pooled results were widely heterogeneous.72 The effects on weight gain cannot be reliably assessed as very few studies reported data on weight gain.72

Thus, there is at present no sufficient, evidence-based data to support the routine need to switch from a cow milk-based formula to a soy or hydrolysate formula in a baby with acute gastroenteritis.4

There is also no advantage for soy formula over cow milk formula over severity and duration of diarrhoea, duration of hospitalisation, or treatment failure.74, 75

In addition, the incidence of secondary lactose intolerance after AGE in Malaysian infants is generally low, about 3% (see section 10.1).

Recommendations:

• In the absence of clinical evidence suggestive of lactose intolerance (please refer to 10.2), a routine change to lactose-free formula (either soy-based or cow milk-based) after an episode of acute diarrhoea is not recommended.

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Table 12: Locally Available Soy-based and Lactose-free Formulae (in Alphabetical Order)

Nature Locally available brand Age range Manufacturer

Cow milk-based lactose-free

• Dulac® Lactose Free

• Enfalac A+ LactoFree®

• Mamex® Gold Lactose Free

• Nan AL 110

• NL33

• Novalac AD

• Similac® LF

0 – 12 months

Infancy and beyond

Infancy and beyond

Infancy and beyond

Infancy and beyond

Infancy and beyond

0 – 12 months

Danone Dumex

Mead Johnson

Danone Dumex

Nestle

Morinaga

UP International

Abbott Nutrition

Soy-based • Enfalac A+ ProSobee®

• Isomil®

• Isomil® Plus

• Mamex® Gold Soya Step 1

• Mamex® Gold Soya Step 2

• Nursoy®

Infancy and beyond

0 – 12 months

> 12 months

0 – 6 months

7 months and beyond

Infancy and beyond

Mead Johnson

Abbott Nutrition

Abbott Nutrition

Danone Dumex

Danone Dumex

Pfizer

8.5.4 Zinc

UNICEF and WHO recommend zinc supplementation (10mg below 6 months of age, 20mg in older infants and children for 10-14 days) as a universal treatment for children with diarrhoea.76 There is no proven benefit of the use of zinc in children without severe malnutrition, with acute gastroenteritis.77 Thus, zinc should only be given to malnourished children.4

Recommendations:

• Zinc can be considered to be given to malnourished children with acute diarrhoea

8.5.5 Others

Homeopathy: Although homeopathy continues to be widely used, there is insufficient evidence to recommend its use for the treatment of acute gastroenteritis in children.4

HerbalMedicine: There is insufficient evidence to recommend in favour or against the use of herbal medicine for the treatment of acute gastroenteritis in children.4

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09 Prevention of Childhood AGE

9.1 GeneralMeasures

General measures of preventing childhood AGE are effective in certain circumstances.4

The best measure is the promotion of breastfeeding, while others include the use of safe drinking water, and an improvement of environmental hygiene.

9.2 Vaccines

Rotavirus is the commonest viral pathogen causing severe dehydrating diarrhoea in the world over. Two rotavirus vaccines, RotaTeq® and Rotarix®, both safe and highly efficacious, are available in Malaysia.78, 79 Vaccines for other enteric pathogens are currently not available on a routine basis. Rotavirus vaccines are part of routine universal vaccination programme in many countries in the world. First dose of primary vaccination should be given between the age of 6 and 12 weeks, and the full schedule (RotaTeq® 3 doses and Rotarix® 2 doses) should be completed by the age of 8 months for RotaTeq® and 6 months for Rotarix®.80 Both have been proven to be very safe and are highly effective in preventing severe dehydrating diarrhoea.80

Rotavirus vaccines are not part of the National Immunisation Program (NIP) in Malaysia. However, it is recommended that vaccination should be considered as part of prevention of rotavirus diarrhoea.

Recommendations:

• Rotavirus vaccine should be considered as a part of prevention of rotavirus diarrhoea in Malaysian children.

Table 13: Rotavirus Vaccines Available in Malaysia

Drug Dosage Dosing interval

Rotateq®

(Pentavalent Rotavirus vaccine)

PO x 3 doses up to age 32 weeks

1st dose administered at 6-12 weeks of age. Subsequent 2 doses administered at 4-10 weeks’ interval. 3rd dose should be completed before 32 weeks of age.

Rotarix® (Monovalent human attenuated Rotavirus vaccine)

PO x 2 doses up to age 24 weeks

1st dose between 6-14 weeks of age. 2nd dose between 14-24 weeks of age. Interval between 2 doses should not be < 4 weeks.

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9.3 Probioticsandprebiotics

There are studies on the use of probiotics in preventing antibiotic associated diarrhoea (AAD) in children and adults. Studies in children have shown certain strains like Bifidobacterium lactis, Streptococcus thermophilus, Saccharomyces boulardii, Lactobacillus rhamnosus are able to reduce the risk of AAD (relative risk [RR] between 0.3 to 0.45).81, 82, 83 A meta-analysis on use the use of probiotics to prevent AAD concluded that treating 7 children at risk of developing AAD will only prevent 1 case of AAD.84 Another meta-analysis noted that the potential protective effects of probiotics to prevent AAD in children did not withstand intention-to-treat analysis.85

There are also studies that looked at using probiotics supplements to prevent acute diarrhoea in children or use of formula with added probiotics with or without prebiotics to prevent acute diarrhoea in children.86, 87 Not all studies showed beneficial effects.88, 89

Prebiotics are defined as non-digestible food compounds that beneficially affect the host by selectively stimulating the growth and/or activity of one or of a limited number of bacteria in the large intestine, thereby improving the health of the host. Not all types of prebiotics are the same or have similar effect. There is very little evidence that prebiotics may be used as a preventive measure to the management of diarrhoea.90, 91

27


10 Special Considerations

10.1 PersistentDiarrhoea

Approximately 3-14% of children with acute gastroenteritis developed persistent diarrhoea.22, 92

In Malaysia, approximately 3% of children with AGE developed persistent diarrhoea (duration > 14 days).22, 92 Bacterial infections, lactose intolerance and food protein allergy (cow milk and soy protein) are the three most important causes of persistent diarrhoea following AGE in Malaysia.22, 92

10.2 LactoseIntolerance

Clinical features of lactose intolerance include:92

• Abdominal pain• Nausea• Persistent diarrhoea• Watery stools• Abdominal distension• ± Perianal excoriation

Secondary lactose intolerance should be suspected when acute diarrhoea fails to resolve with the presence of the above clinical features.

In children with lactose intolerance without malnutrition, a temporary change to lactose-free formula, either cow milk-based or soy protein-based, is often adequate. A change to either extensively hydrolysed formula or elemental formula is unnecessary. In malnourished children with persistent diarrhoea, consultation with or referral to an appropriate expert is indicated.

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10.3 CowMilkProteinAllergy

Food protein allergy is a potentially serious complication following acute gastroenteritis. Children suspected with cow milk protein allergy should be referred to a specialist with expertise in this area.

Recommendations:

• In children with lactose intolerance with normal nutritional status, a temporary change to lactose-free formula, either cow milk-based or soy protein-based, is adequate. A change to either extensively hydrolysed formula or elemental formula is not indicated. Soy formula is generally not recommended in infants younger than 6 months of age.

• In a malnourished child with persistent diarrhoea, consultation with or referral to a specialist with expertise in this area is advisable.

• In a child with persistent diarrhoea where food protein allergy is suspected, consultation with or referral to a specialist with special expertise in this area is advisable.

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11 Part I: Algorithm for Managing Acute Gastroenteritis in Children

Child with diarrhoea(> 3 times in a 24 hour period)

Watery without blood and mucous

Do the following:

1. History and physical examination2. Assess presence, degree and type of dehydration3. Assess if stools are watery and if blood and mucous are present4. It should be emphasised that by just inspecting the appearance of the stool, it is impossible to differentiate with certainty viral from bacterial gastroenteritis5. Assess nutritional status6. Consider other diagnoses in the presence of warning signsa

7. Always consider differential diagnosesb

a. Warning signs:

• Abdominal distension • Bile-stained vomiting• Blood in vomitus or stool • Severe abdominal pain• Vomiting in the absence of diarrhoea• Headache

b. Differential diagnoses:

• Acute appendicitis• Strangulated hernia• Intussusception or other causes of bowel obstruction• Urinary tract infection• Meningitis and other types of sepsis• Any cause of raised intracranial pressure• Diabetic ketoacidosis• Inborn error of metabolism • Haemolytic uraemic syndrome• Inflammatory bowel disease

Consider the following:

1. Stool hanging drop test for V. cholerae or culture if the diarrhoea is profuse and watery in nature or fishy odour, should consider cholera as a possibility2. Rehydrate as necessary

Blood and mucous

Consider the following:

1. Exclude bacterial pathogens2. Stool studies for dysentery (Shigella, Campylobacter jejuni, STEC, non-typhoidal Salmonella, E. histolytica)3. Treatment with antibiotic for the specific pathogen (see Guideline above)4. Rehydrate as necessary

Criteria for hospital admission:

• severe dehydration (> 9% of body weight), shock• neurological abnormalities (lethargy, seizures, etc.)• persistent or bilious vomiting (even if no dehydration)• treatment failure with oral rehydration salts (ORS)• presence of systemic illness (high fever, toxic looking)• underlying medical conditions (heart failure, significant neurodevelopment disabilities)• caregivers unable to provide adequate care at home or other social/logistic concerns• suspected surgical condition, uncertain about diagnosis• uncertain about degree of dehydration (obese children)

Continue and refer to part II: Algorithm for Managing Acute Gastroenteritis in Children

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12 Part II: Algorithm for Managing Acute Gastroenteritis in Children

StableUnstable

Unresolved

No signs of dehydration(<3% loss of body weight)

• Child alert• Drinks normally • Heart rate, quality of pulse, breathing, eyes and capillary refill are normal• Tears present and mouth and tongue are moist• Instant recoil in skin fold• Warm extremities• Normal to decreased urine output

Some signs of dehydration(3-9% loss of body weight)

• Child normal, fatigued, restless or irritable• Thirsty and eager to drink• Heart rate normal to increased, quality of pulse normal to decreased, breathing normal to fast, eyes slightly sunken and capillary refill prolonged • Tears decreased and mouth and tongue are dry• Skin fold recoil in < 2 seconds• Cool extremities• Decreased urine output• If patient has 2 or more signs of the above, there is some dehydration

• Breastfeed or milk feed normally• Formula dilution not recommended• Children may continue on lactose containing milk formula• Continue normal diet in older children• Encourage lots of fluid intake• Offer ORS

Advise to seek medical attention if persist more than

14 days. Consider lactose intolerance and

food protein allergy

• Trial of ORS 30-90 ml/kg (75 ml/kg for moderate cases) within 4 to 6 hours • Every diarrhoea episode: ORS 10 ml/kg• If ORS by mouth is refused/inadequate, try spoon feeding or ORS by nasogastric /oralgastric tube feeding• Breastfeed or milk feed normally• Formula dilution not recommended• Children may continue on lactose containing milk formula• Continue normal diet in older children• Small and frequent feeds with regular assessment

Hospital referral for admissionfor IV fluid if persistent

vomiting/worsening dehydration

Severe dehydration(>9% loss of body weight)

• Child apathetic, lethargic, unconscious • Drinks poorly and unable to drink• Tachycardia with bradycardia in most severe cases, quality of pulse weak and thready or impalpable, breathing deep, eyes deeply sunken and capillary refill prolonged and minimal• Tears absent and mouth and tongue are parched• Skin fold recoil in > 2 seconds• Cold, mottled and cyanotic extremities• Minimal urine output

• Resuscitation (normal saline/Ringer’s lactate)• Frequent monitoring

Consider intensive care if not resolved

No admission if no excessive vomiting

No admission if no excessive vomiting

Immediate referral to hospital for admission

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13 Summary of Established Guidelines

CDC 20032 WHO 20051 ESPGHAN 2008 4

New South Wales Health 20105

AMMCOP/MPA 2011

Setting Paediatric practice, with emphasis on US populations

Developing countries or communities with scarce health resources

European Countries, low diarrhoeal morbidity and mortality

Primary case setting in New South Wales, Australia

Paediatric, primary care and frontline healthcare providers in Malaysia

ORS Yes Yes Yes Yes Yes

Antibiotics Routine use wastes resources & may lead to antimicrobial resistance

Not routinely indicated. Only in selected clinical situations

Do not recommend routine use in otherwise healthy children

Rarely required. Consult paediatric or infectious specialist

Not routinely indicated. Only required for specific pathogens or defined clinical settings

Antiemetics NR NR NR NR NR

Antimotility (Loperamide, Imodium)

NR NR NR NR NR

Antimotility (Diphenoxylate HCL; Lomotil)

NR NR NR NR NR

Adsorbants (Smectite)

- NR May be recommended

- May be considered as an adjunctive

Adsorbants (Kaolin-pectin)

NR NR NR NR NR

Anti-secretory (Racecodotril)

Need more studies

- May be recommended

- May be considered as an adjunctive*

Anti-secretory (Bismuth subsalicylate)

NR NR (Not practical, needs to be given frequently)

NR NR NR

Probiotics Should await further clinical trials

- Strain-specific (Lactobacillus GG, S. boulardii)

Some benefits. Can be given when a normal diet is reintroduced

May be considered as an adjunctive. Should be strain-specific and dose specific.

Prebiotics Should await further clinical trials

- NR - NR

A switch to lactose-free, soy or hydrolysate

NR NR NR NR NR

NR Not recommended * Not commercially available in Malaysia at the time of publication of this guideline.

32


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APPENDIX A

Assessment of dehydration in acute diarrhoea

Symptom No signs of dehydration (< 3% loss of body weight)

Mild to moderate dehydration (3-9% loss of body weight)

Severe dehydration (> 9% loss of body weight)

Mental status Well, alert N, fatigue or restless, irritable

Apathetic, lethargic, unconscious

Thirst Drinks N, might refuse liquids

Thirsty, eager to drink

Drinks poorly, unable to drink

Heart rate Normal Normal to increased Tachycardia, with bradycardia in most severe cases

Quality of pulse

Normal Normal to decreased

Weak, thready, or impalpable

Breathing Normal Normal, fast Deep

Eyes Normal Slightly sunken Deeply sunken

Tears Present Decreased Absent

Mouth and tongue

Moist Dry Parched (very dry)

Skin fold Instant recoil Recoil in < 2 seconds

Recoil in > 2 seconds

Capillary refill Normal Prolonged Prolonged, minimal

Extremities Warm Cool Cold, mottled, cyanotic

Urine output Normal to decreased

Decreased Minimal

Adapted from WHO 20051, CDC 20032

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APPENDIX B

Anti-Diarrhoeal Drugs

Attributes Loperamide Bismuth subsalicylate

Smectide Racecadotril

Reduces secretion

Yes No Yes Yes

Prevents virulence

No No Yes No

Reduce stool output

No Yes Yes Yes

Shorten duration of diarrhoea

No No Yes Yes

Fast acting - No Yes Yes

Constipation as a side effect

Yes No No No

Systemic side effects

Yes Potentially No No

Does not interfere with ORS

Not tested Yes Yes Yes

Adapted from Edelman et al, 198593 and Salazar-Lindo E. 201094

The sponsor of this educational material was not involved in the development of this publication and in no way influenced its content.

The fullguidelines on the management of acute diarrhoea in children may be obtained from the following websites: •CollegeofPaediatrics,AcademyofMedicineofMalaysia(AMMCOP) http://www.acadmed.org.my/ •MalaysianPaediatricAssociation(MPA) http://www.mpaweb.org.my/ •MeadJohnsonNutritionMalaysia http://www.meadjohnsonasia.com.my/home.aspx

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