Evidence based Medicine on Acute Diarrhea in Children

Dr.H.K.Takvani, MD Ped., FIAP

IPP, NNF, Gujarat State Chapter 2009-2010National Executive Board Member. IAP 4 termsPresident IAP, Gujarat State Branch, 2001 President IMA Jamnagar City Branch 2008-09 Children Hospital and Neonatal Care CentreJAMNAGAR-361008, Gujarat, Indiadrtakvani@gmail.com drtakvani@rediffmail.com www.takvanidr.multiply.com

19/04/2323 June, 2010 Takvani 1

"We can not guarantee cure, but what we can guarantee is an honest and transparent effort".

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. 19/04/23 Takvani 2

Why to talk on diarrhea?

• Use of antiemetics

• Antibiotics often- Nor-metro, Oflo-ornida, Inj.A

mikacin.

• Un-necessary probiotics

• Racecadotril.19/04/23 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. next19/04/23 Takvani 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.

19/04/23 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. back19/04/23 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.

19/04/23 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.19/04/23 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. back19/04/23 Takvani 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. 19/04/23 Takvani 15

Probiotics in the Treatment of Diarrhea

Mechanisms: 1.Protect the intestine by competing with

pathogens for attachment. 2.Strengthening tight junctions between

enterocytes3. Enhancing the mucosal immune

response to pathogens.19/04/23 Takvani 16

RacecadotrilNot enough evidence:Not enough evidence:• Safety.• Efficacy.• There is no data from our settings.• Methodology of studies questionable.• No routine use back

19/04/23 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. 19/04/23 Takvani 18

• 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.

19/04/23 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.

19/04/23 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.

19/04/23 Takvani 21

Acute Diarrhea in the Young Infant (< 2 mth)

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. 19/04/23 Takvani 22

19/04/23Takvani

23

hom

e av

aila

ble

fluid

sacceptable 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) NEXT

Antibiotic in Acute Diarrhoea

Indicated only for : • Acute bloody diarrhea with gross blood• Shigella positive culture, • Cholera, • Associated systemic infection• Severe malnutrition. (Septicemia)19/04/23 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 cotrimoxazole19/04/23 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.19/04/23 Takvani 26

Antibiotic in Acute Dysentery

Antibiotics are not 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)

19/04/23 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.19/04/23 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.

19/04/23 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. back 19/04/23 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.

19/04/23 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.

19/04/23 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).

19/04/23 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

19/04/23 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

19/04/23 Takvani 35

I conclude ….

• Prescribe ORS for all ages.

• Continue Breast feeding and diet.

• Explain danger signals.

• 20 mg/10 mg of elemental zinc

19/04/23 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)

19/04/23 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

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drtakvani@gmail.com www.takvanidr.multiply.com

Dr.H.K.Takvani MD (Pediatrics), FIAPChildren Hospital and Neonatal Care Centre

Valkeshwari NagariIndira Marg

JAMNAGAR-361008, Gujarat, India

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