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Despite promising developments such as the new rotavirus vaccine, acute diarrhea won't disappear from pediatric practice any time soon. This straightforward strategy for office management rests on the cornerstones of oral rehydration and continued feeding.
Despite promising developments such as the new rotavirusvaccine, acute diarrhea won't disappear from pediatric practice any timesoon. This straightforward strategy for office management rests on the cornerstonesof oral rehydration and continued feeding.
Imagine that you are a pediatrician living in Milwaukee when one of thelargest water-borne diarrhea outbreaks in United States history occurs,infecting more than 200,000 people with Cryptosporidium. Or that you area nurse in Lima, Peru, when cholera outbreaks sweep across the country.Or that you are an emergency medicine physician in hurricane-ravaged southFlorida where clean water sources are scarce. Or--and for this you won'tneed your imagination--that you are an office-based pediatrician in a healthmaintenance organization that, for every 1,000 children enrolled, will seemore than 500 children with acute diarrhea by 5 years of age.1
What these scenarios have in common is that they require the health-careprovider to have expertise in fluid, electrolyte, and nutritional managementof infants and children with acute diarrhea. The unique aspects of children'smetabolic and physiologic functions were seminal observations made by thefounders of modern day pediatrics. It seems especially appropriate thereforefor pediatricians to advocate and practice scientifically sound and evidenced-basedmanagement of acute diarrhea.2 We will highlight several of theseprinciples, emphasizing practical, office-based care of children with acutediarrhea.
Parents manage most cases of acute diarrhea at home, with or withoutconsulting a medical professional. They often phone their pediatrician foradvice, especially if they feel that the child is only mildly ill. Mostof the many available telephone management protocols and algorithms aretoo detailed and lengthy to be useful to the busy clinician. The office-basedpediatrician needs to assess the problem quickly with the following questionsin mind:
Is an office visit required? Most cases of acute gastroenteritis areviral, self-limited, and well tolerated. The most serious complication isdehydration caused by excessive stool losses, vomiting, or inadequate oralfluid intake. Patients whom the pediatrician suspects may be dehydratedshould be evaluated promptly in the office or, if severe dehydration issuspected, in the emergency department. Patients with little or no dehydrationcan usually be managed at home.
Determining hydration status by telephone, however, is difficult at best.The best method is by history: Ask parents about the presence or absenceof tears when the child cries, dry mucous membranes, and decreased urineoutput. Fewer than six wet diapers per day or no urine output for more thansix to eight hours in an infant (12 hours in an older child) suggests atleast some dehydration and warrants an evaluation in the office.3Other reasons besides dehydration for an office visit are listed in Table1.
How should the child be managed at home? If the telephone history suggestsminimal or no dehydration, advice should center on appropriate fluid andnutritional therapy. Children with diarrhea but without dehydration shouldbe offered more than the usual amount of dietary fluids, including moretimes at the breast for nursing infants or more bottles of infant formula.Patients with voluminous stools (and concomitant fluid and electrolyte losses)should be given a commercially available oral rehydration solution (ORS)to maintain hydration. A rough guide for ORS administration for so-calledmaintenance therapy is 4 to 8 oz for every loose or watery stool until diarrhearesolves. A Parent Guide summarizing these recommendations appears below.
Because fluids with high concentrations of simple carbohydrates suchas sweetened fruit drinks and soft drinks have a high osmolarity (more than300 mOsm/L), they can worsen gastrointestinal fluid losses and are not recommendedfor fluid therapy in acute diarrhea. Table 2 lists other fluids that arenot recommended for diarrhea management either because of high osmolarityor inappropriate amounts of sodium.
What should a child with acute diarrhea eat? Adequate nutrition is acrucial aspect of home therapy for acute diarrhea. Many clinical trials,and a wide variety of indirect evidence, have demonstrated the advantagesof continued feeding during diarrhea.46 Continued feedingreduces the duration of illness and improves weight gain, compared to gradualreintroduction of food.
In considering the benefits of continued feeding, it is important toremember that GI epithelia derive nutrients from both the bloodstream andthe lumen of the GI tract. Starvation during an infection denies these cellsan important energy source precisely when they need it for replication andrepair. Moreover, several of digestive enzymes of the GI mucosa are inducible--theircapacity for activity increases with increased substrate. Reducing dietarysubstrates through starvation may therefore contribute to mucosal atrophy.
It is well recognized that patients with an acute infection commonlysuffer anorexia, and the argument for continued feeding should not be interpretedas a recommendation to force feed. They should continue their regular dietas much as possible during convalescence, however. Appropriate foods includefresh fruits, vegetables, yogurt, complex carbohydrates, and lean meats.Foods high in fat may not be well absorbed since steatorrhea has been describedfor several days after the improvement of symptoms. Foods and drinks highin simple sugars also may be poorly absorbed because of their high osmoticloads. Most important, advise parents to avoid highly restricted diets toprevent a cycle of weight loss and persistent diarrhea.
Most children with acute diarrhea can safely drink undiluted cow's milkand cow's milk-based formulas, although some have clinically significantlactose intolerance resulting from temporary lactase deficiency. Childrenwith malnutrition or severe dehydration are at higher risk of lactose intoleranceand probably benefit from reduced lactose intake.7 Other childrenwhose stool outputs increase significantly while ingesting lactose-containingfoods may also be placed on a lactose-free diet. Adding soy polysaccharideto infant formula increases stool consistency but does not decrease nutrientor water loss in the stool.8
When has home management failed? Parents should be taught the signs andsymptoms of dehydration and other signs of worsening illness, includingpoor oral intake, persistent vomiting, high fever, bloody stools, abdominalpain, lethargy, and irritability. Instruct them to call at once if theynotice any of these. Also tell them to call if diarrhea persists for morethan two weeks or more than one week without significant improvement insymptoms.
For decades, pediatricians have relied on several "tried and true"symptoms and signs of dehydration. Many of these, however, must be judgedsubjectively--making them prone to large interobserver variability--or havedebatable validity because of their questionable association with intravasculardepletion.9 How "sunken" do a child's eyes need tobe in order to qualify as "sunken," for example? How much doesambient temperature affect capillary refill time (apparently a great deal)?10How well does a sunken fontanel correlate with hydration status (not verywell)?11 Our studies and experience suggest that the most reliableand valid signs of dehydration are the following:
General status. Is the child irritable? Easy to engage? Can one eliciteye contact or a smile? A child's general appearance is among the most helpfulsigns of hydration status.
Body weight. It is axiomatic that acute changes in body weight are causedby shifts in body water. In the otherwise healthy child with acute diarrhea,changes in intravascular water are of major concern, and the most accuratemeasure of hydration change over time is therefore serial body weights.Obtain nude body weights on a scale accurate to at least 10 g for all childrenseen in the office for acute diarrhea. This will help you:
n judge hydration status by comparing current weight against previousknown weights
n make recommendations concerning fluid intake
n establish a baseline weight in case you (or a partner) are asked tosee the patient again during the illness. Documenting weight changes inacute diarrhea also makes good medico-legal sense.
Mucous membranes. The state of the tongue and oral mucosa as determinedby palpation (not just inspection of the labial mucosa) is an importantsign in assessing dehydration. Examination is best done at least a few minutesafter the child has last had some oral fluid (beware teeth!). Normally,infants and children have very moist oral mucosa. A "sandpapery"or dry feel suggests dehydration.
Skin elasticity. We have found that this sign correlates best with thedegree of dehydration.12 Have the child lie supine with her armsat rest beside her rather than extended upward, which stretches the skin.Firmly grasp the skin and subcutaneous tissue along the midaxillary linebetween your thumb and finger, hold the skinfold for two seconds, and thenrelease. The skin should retract immediately. Any prolongation ("tenting")of the skinfold suggests a degree of dehydration, and tenting for more thantwo seconds suggests extreme dehydration or hypernatremia.
Because assessing signs of dehydration is inherently imprecise and thesigns tend to be more apparent in hypertonic dehydration, it is probablyunrealistic to expect precise differentiation between "mild" and"moderate" dehydration. The World Health Organization has, infact, suggested that hydration status be judged as "none" (nodehydration), "some" (including mild to moderate dehydration),or "severe" (properly reserved for children with shock or impendingshock).13 The vast majority of children with acute diarrhea seenin offices or clinics in the US have "some" or "no"dehydration. Gorelick and colleagues recently evaluated the sensitivityand specificity of several common signs of dehydration (Table 3).14
Routine laboratory evaluation of the child with acute diarrhea and mildto moderate dehydration is usually unnecessary.15 Serum electrolytescommonly disclose a metabolic acidosis, and the risk of significant hypo-or hypernatremia often can be determined by history or physical examination.Serial laboratory evaluation to measure response to rehydration therapyis probably no more reliable than serial physical examinations and bodyweights. Stool culture for bacterial pathogens is indicated for bloody diarrheabut unnecessary in the usual case of acute watery diarrhea in the immunocompetentpatient.
Treatment of acute diarrhea generally follows from hydration assessment(Table 4). Children with mild to moderate dehydration should be rehydratedwith appropriate oral solutions under medical supervision, which can clearlybe done in the office. None of the many objections that have been raisedto office rehydration therapy is insurmountable.16 Key aspectsof successful office rehydration include:
Children with "some" (mild to moderate) dehydration generallyhave fluid deficits of around 3% to 8% of body weight. These patients shouldreceive 60 to 80 mL/kg of fluid over four hours. Years of experience ina variety of settings have identified the following crucial features ofsuccessful ORS administration:
Start slowly. A common error in rehydration therapy is to calculate thefluid deficit, fill an 8- or 12-oz bottle with ORS, and hand the entirecontents to the child. A hungry or thirsty patient often "chugs"the contents of the bottle and promptly vomits from stomach distention or,even more discouraging, throws the bottle on the floor, unpleasantly surprisedby the salty taste of its contents. To avoid these alternatives, use a teaspoon,syringe, or medicine dropper initially to give small amounts (3 to 5 mL)of fluid at 1- to 2-minute intervals. Introducing the solution graduallyallows the child's taste buds to acclimate to the salty taste and has otherbenefits in the vomiting child, as described below.
Steady as it goes. An impressive volume of ORS can be given in smallaliquots over two to four hours. Consider, for example, an 8-kg child withsome dehydration. According to our guidelines, he should be given 480 to640 mL (16 to 21 oz) of ORS over four hours. If the child is given 5 mLevery minute, he will meet that goal in 11/2 to twohours (480 mL divided by 5 mL/minute divided by 60 minutes/hour equals 1.6hours). Since this "slow" rate of administration is adequate toachieve rehydration sooner than recommended, the administration rate canbe even slower if need be.
Customary rates of ORS administration may even surpass the rate of intravenousfluids (IVF). Dehydrated children treated with IVF often are given a bolusof 20 mL/kg. The "bolus" may be delivered over 45 to 60 minutes,however, especially if an IV pump is used to administer the fluid. Small-gaugeangiocatheters can also limit the rate at which IVF can be given. The childdescribed previously would receive 20 mL/kg x 9 kg, or 180 mL, over 45 to60 minutes. A child receiving ORS at 5 mL/min would receive 225 mL to 300mL over the same time period, fully 25% to 67% more fluid.
Re-evaluate the response to therapy regularly. A specially designed flowsheetto monitor patient progress during oral rehydration makes it easier forboth the medical staff and parents to see what progress has been made (Table5). As noted in Table 4, appropriate rehydration includes replacing notjust the estimated deficit based on the extent of dehydration but also ongoinglosses from diarrhea and vomiting. Although it is difficult to measure theseextra fluid losses precisely, even in the hospital, reasonable estimatesare 4 to 8 oz for each watery or loose stool and 5 to 10 mL/kg for eachepisode of vomiting. The volume of emesis is notoriously easy to overestimate,so serial body weights during rehydration should be documented.
Severe dehydration is a medical emergency requiring prompt IV fluid replacement.Intravenous rehydration should take place in a setting such as an emergencydepartment where appropriate monitoring and intensive resuscitation, ifneeded, are available. A role does exist for IV hydration in the office,however, for the minority of patients who do not tolerate oral rehydration,such as those with intractable vomiting and dehydration. Office IV hydrationrequires personnel with the skills to obtain and maintain IV access, properIV administration equipment, STAT lab availability for serum electrolytedetermination, and the ability to monitor the patient closely while he orshe is receiving IV fluids.
Children with the isotonic dehydration most commonly seen with viralgastroenteritis should receive isonatremic IV solutions such as normal salineand lactated Ringer's solution. Obtain serum electrolytes as indicated beforeand after fluid administration. Also obtain an initial complete blood count,blood urea nitrogen, serum creatinine, urinalysis, and, of course, baselineweight and vital signs. Calculate the approximate fluid deficit based onthe child's previous weight or clinical observation. The fluid deficit fora typical moderately dehydrated candidate for office IV rehydration wouldlikely be in the 60 to 80 mL/kg range (corresponding to 6% to 8% dehydration).
A reasonable IV infusion rate in the office would be 20 mL/kg over thefirst 20 to 30 minutes followed by reassessment and additional fluids at10 to 20 mL/kg/h over the next 30 to 60 minutes. Remember that the goalof IV rehydration in the office is not necessarily to completely rehydratethe child but rather to rehydrate the child to the point where oral rehydrationis feasible. As soon as the child can tolerate an ORS, it should be usedto complete rehydration.
Both parents and physicians commonly regard the child with protractedvomiting as the most challenging clinical situation. Indeed, truly intractablevomiting (along with ileus and altered consciousness) is one of the fewcontraindications to oral rehydration therapy. Nevertheless, a vast amountof experience in a variety of settings has underlined the fact that slow,steady administration of oral fluids is often the key to success in patientswith vomiting.
Giving ORS at low rates reduces the chances of vomiting by both preventingoverdistention of the stomach and helping to correct acidosis. Since commerciallyavailable oral solutions contain citrate or other base salts, their usecan promptly correct acidosis from bicarbonate loss in diarrheal stools.Administering ORS by nasogastric tube is cheaper and associated with shorterhospital stays than management with IVF.17
Several oral rehydration products are available in the US (Table 6).They generally include premixed water and electrolyte solutions, althoughtwo companies sell pouches containing the rehydration salts for mixing withwater. The latter are especially helpful for families with children travelingoverseas, camping, or in other situations that prohibit the bulk and weightof premixed solutions.
The composition, osmolarity, and sodium-to-glucose ratio of commercialforms of ORS continue to provoke much scientific debate. Although stoolsodium losses in various kinds of acute diarrhea vary widely,18it has been clearly shown that ORS containing 60 to 90 mEq/L of sodium cancorrect both dehydration and electrolyte abnormalities.19
Perhaps more important than the absolute amount of sodium and carbohydratein a given ORS (within these ranges) is the molar ratio between the twocomponents. Since the physiologic principle behind ORS is the co-transportof one molecule of sodium with one of glucose at the epithelial cell level,the optimal ratio is 1:1. Previously, commercial ORS in the US had lessthan 40 mEq/L Na and contained excessive amounts of carbohydrate.
More recently, however, appropriate rehydration and maintenance solutionshave been marketed. Recent data also suggest that solutions with lower osmolaritythat preserve an optimal sodium: glucose ratio could have benefits for childrenwith acute, noncholera diarrhea.20
As with many infectious diseases, increasing the rate of breastfeedingcould go a long way toward preventing many cases of diarrhea. Once infectionoccurs, however, preventing its spread becomes important, especially inday-care facilities and preschools. Hand washing is the most important preventivemeasure. Staff members should wash their hands and exposed arms with soapand warm water before starting work, after changing infants' and toddlers'diapers, and at all other times that would help to break the route of fecal-oraltransmission. Fingernails should be kept clean and trimmed.
Children should be taught to practice good hygiene, especially when usingthe toilet.21 Toileting and diapering areas must be kept separatefrom the food preparation area. Floor and surface walls should be easy toclean and cleaned routinely. An effective and inexpensive cleaning solutioncan be made by adding 1/4 cup of household bleach(5.25% sodium hypochlorite) to one gallon of water. The solution shouldbe made fresh daily and kept safely out of the reach of children. In addition,local and state health agency guidelines and regulations for infection controlin day-care and preschool settings should be followed.
Most exclusion policies for school or day care state that an infant orchild with acute viral diarrhea cannot return until he or she is asymptomatic.Some more tolerant policies allow a child to return if the stool can becontained within the diaper or if a toilet-trained child is not incontinent.More stringent policies apply to bacterial or protozoal infections suchas Escherichia coli O157:H7, Shigella, and Giardia lamblia than to viralinfections. Exclusion is enforced until follow-up cultures are negativefor the organism. Local and state health regulations guide the exclusionpolicies of schools and day-care centers.
One of the more vexing issues for parents is what to do with a childwho has chronic nonspecific diarrhea of childhood (toddler's diarrhea),a state of symptomatic diarrhea that can last for weeks to many months.Since this is, by definition, a noninfectious diarrheal illness, these childrendo not need to be excluded from day care or school. A letter from the child'spediatrician will usually suffice to gain re-entry.
Managing acute diarrhea has always been and will continue to be a stapleof pediatric office practice. New developments in the field may lessen theburden of diarrheal diseases, however. Perhaps the most exciting of theseis the 1998 approval and release of an effective vaccine for rotavirus,22discussed in the article that begins on page 105. Studies have shown thistetravalent vaccine to significantly decrease clinic visits and hospitalizationsfor rotavirus diarrhea. A second promising new development is the use ofprobiotic compounds, such as lactobacillus, which may help prevent or modulatesome GI infections.
Although rotavirus accounts for the majority of viral diarrhea in infantsand young children requiring hospitalization for acute diarrhea, it accountsfor only about 10% of mild diarrhea in community surveys.23 Therefore,acute diarrhea in children will not disappear overnight. The cornerstoneof excellent diarrhea management for the office-based pediatrician remainsappropriate fluid, electrolyte, and nutritional therapy. With the basic,time-honored skills of pediatrics, including telephone and triage expertise,and the superb track record of ORS, a proven and effective therapy for morethan 30 years (see "Does the US really need ORS?" above), pediatricianstoday are well prepared to manage acute gastroenteritis.
DR. LASCHE is Chief of Pediatrics, Harvard Vanguard MedicalAssociates, West Roxbury, MA, and Instructor in Pediatrics, Harvard MedicalSchool, Boston.
DR. DUGGAN is Assistant Professor of Pediatrics, Divisionof GI/Nutrition, Children's Hospital and Harvard Medical School, Boston.
1. Parashar U, Holman R, Bresee J, et al: Epidemiology of diarrheal diseaseamong children enrolled in four west coast health maintenance organizations.Pediatr Infect Dis J 1998;17:605
2. Harrison H: Contribution of American pediatricians to treatment ofdiarrheal dehydration. Pediatr Res 1990;27:S62
3. Baker R, Schmidt B: Pediatric Telephone Advice. Boston, Little, Brown,and Co, 1997, p 40
4. Santosham M, Foster S, Reid R, et al: Role of soy-based, lactose-freeformula during treatment of acute diarrhea. Pediatrics 1985;76:292
5. Brown KH, Gasta§aduy AS, Saavedra JM, et al: Effect of continuedoral feeding on clinical and nutritional outcomes of acute diarrhea in children.J Pediatr 1988;112:191
6.Duggan C, Nurko S: Feeding the gut: The scientific basis for continuedenteral nutrition duing acute diarrhea. J Pediatr 1997;131:801
7. Brown K, Peerson J, Fontaine O: Use of nonhuman milks in the dietarymanagement of young children with acute diarrhea: A meta-analysis of clinicaltrials. Pediatrics 1994;93:17
8. Brown K, Perez F, Peerson J, et al: Effect of dietary fiber (soy polysaccharide)on the severity, duration, and nutritional outcome of acute, watery diarrheain children. Pediatrics 1993;92:241
9. Liebelt E: Clinical and laboratory evaluation and management of childrenwith vomiting, diarrhea, and dehydration. Curr Opin Pediatr 1998;10:461
10. Gorelick M, Shaw K, Baker M: Effect of ambient temperature on capillaryrefill in healthy children. Pediatrics 1993;92:699
11. MacKenzie A, Barnes G, Shann F: Clinical signs of dehydration inchildren. Lancet 1989;2:605
12. Duggan C, Refat M, Hashem M, et al: How valid are clinical signsof dehydration in infants? J Pediatr Gastroenterol Nutr 1996;22:56
13. World Health Organization, Division of Child Health and Development.Integrated Management of Childhood Illness. WHO/CDD/995.14, 1995
14. Gorelick M, Shaw K, Murphy K: Validity and reliability of clinicalsigns in the diagnosis of dehydration in children. Pediatrics 1997;99:E6,http://www.pediatrics.org/cgi/content/ full/99/5/e6
15. Teach SJ, Yates EW, Feld LG: Laboratory predictors of fluid deficitin acutely dehydrated children. Clin Pediatr 1997;36:395
16. Reis EC, Goepp JG, Katz S, et al: Barriers to use of oral rehydrationtherapy. Pediatrics 1994;93:708
17. Gremse D: Effectiveness of nasogastric rehydration in hospitalizedchildren with diarrhea. J Pediatr Gastroenterol Nutr 1995;21:145
18. Molla A, Rahaman M, Sarker S, et al: Stool electrolyte content andpurging rates in diarrhea caused by rotavirus, enterotoxigenic E coli, andV cholerae in children. J Pediatr 1981;98:835
19. Santosham M, Daum R, Dillman L, et al: Oral rehydration therapy ofinfantile diarrhea: A controlled study of well-nourished children hospitalizedin the United States and Panama. N Engl J Med 1982;306:1070
20. International Study Group on Reduced-Osmolarity ORS Solutions: Multicentreevaluation of reduced-osmolarity oral rehydration salts solution. Lancet1995;345:282
21. Health in Day Care: A Manual for Professionals. Elk Grove Village,IL, American Academy of Pediatrics, 1987
22. Bernstein DI, Glass RI, Rodgers G, et al: Evaluation of rhesusrotavirusmonovalent and tetravalent reassortant vaccines in US children. US RotavirusVaccine Efficacy Group. JAMA 1995;273:1191
23. Bartlett AVD, Reves RR, Pickering LK: Rotavirus in infant-toddlerday-care centers: Epidemiology relevant to disease control strategies. JPediatr 1988;113:435
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25. Gavin N, Merrick N, Davidson B: Efficacy of glucose-based oral rehydrationtherapy. Pediatrics 1996;98:45
Diarrhea is common in children and usually lasts from three to seven days. The main danger from diarrhea is that children can lose a great deal of fluid and salt in the frequent stools and become dehydrated. If dehydration is severe, the child may need to be hospitalized for fluid replacement. You can prevent dehydration fairly easily when your child has diarrhea. Here's how:
Give liquids as soon as diarrhea starts. The best liquid to give is an oral rehydration solution. These solutions replace the water and salts lost to diarrhea. You can buy them at the grocery story or drug store. You do not need a prescription. Do not give plain water since drinking only water can be harmful. You can give a small amount of water along with the oral rehydration solution if your child wants it.
DO NOT GIVE the following liquids, which contain a lot of sugar or sweetener and can make diarrhea worse: Juices, cola or other soft drinks, sports drinks such as Gatorade, and drinks such as Kool-Aid. Also avoid tea, chicken broth, boiled skim milk, and homemade solutions to which salt is added.
Give 1/2 cup (4 oz) of rehydration solution for every watery stool, using a small spoon, if your child is under 2 years of age. If your child is over 2 years, give 1/2 cup to one cup (8 oz) for every watery stool. Give the solution until the diarrhea stops. If your child is vomiting, give one teaspoon of the solution every two to three minutes until the vomiting stops, then gradually return to the regular amount.
Continue to feed your child. Eating is important to maintain health. If your child is nursing, continue to breastfeed. If he is taking formula, continue with the same formula.
If your child is eating solid foods, continue with the regular diet. Good foods to give include cooked cereal, bananas, cooked meat, noodles, crackers, rice, vegetables, potatoes, and yogurt. Avoid foods with a lot of sugar (such as Jello, ice cream, and sweetened cereals) and fried, fatty foods.
Do not give medication without consulting your child's doctor. Most children with diarrhea get better without medication. Some over-the-counter medicines for diarrhea can even be harmful. Remember that food and fluids are the most important treatment for diarrhea.
Take steps to prevent the spread of infection. Hand washing is the most important means of preventing diarrhea from spreading. Wash your hands and exposed arms with soap and warm water after caring for your child, especially after diaper changes. Keep your fingernails clean and trimmed. Teach your child to wash her hands before eating and, especially, after using the toilet.
Call your child's doctor if:
No tears when crying
Unusual drowsiness or fussiness
Managing acute diarrhea: What every pediatrician needs to know.