Pocket Guide - Academy of Medicine of Malaysia

Transcription

Guidelines on the management of
2011
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
i
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:
• College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP)
http://www.acadmed.org.my/
• Malaysian Paediatric Association (MPA)
http://www.mpaweb.org.my/
• Mead Johnson Nutrition Malaysia
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.
Source of funding:
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.
Copyright ownership:
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.
ii
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
iii
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.
1
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.
2
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
3
05 Clinical Types of Diarrhoeal Diseases 1
Acute Watery Diarrhoea
Lasts for several hours or days. The main concern
is dehydration. Weight loss can also occur if
feeding is being withheld for too long.
Acute Bloody Diarrhoea
(dysentery)
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.
Persistent diarrhoea
Defined as diarrhoea that lasts 14 days or longer.
It may lead to malnutrition and serious infection
with or without dehydration.
Diarrhoea with
severe malnutrition
A serious condition and warrants special attention to
exclude severe systemic infection, dehydration, severe
electrolytes imbalance, heart failure, and vitamin and
mineral deficiencies.
4
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
Rotavirus
Unknown
Parasites
Bacteria
Adenovirus
Astrovirus
Calicivirus
Other Bacteria
Toxigenic
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
Watery
≤ 2 years
Rotavirus, astrovirus, calicivirus, enteric adenovirus,
enteropathogenic Escherichia coli (EPEC), enterotoxigenic
Escherichia coli (ETEC), Vibrio cholerae
2-5 years
Enterotoxigenic Escherichia coli (ETEC), rotavirus, Shigella,
Vibrio cholerae
Mucousy / bloody
≤ 2 years
Shigella, shiga-toxin producing Escherichia coli (STEC),
Campylobacter jejuni
2-5 years
Shigella, shiga-toxin producing Escherichia coli (STEC),
non-typhoidal Salmonella, E. histolytica
5
Table 2: Important causative agents of childhood acute gastroenteritis
in Malaysia 10, 12, 14, 19, 20, 23
Percentage of aetiological agent (%)
Author
Iyngkaran et al 10
Number Rota- NoroTested virus virus
Adeno- Salmonella Shigella E. Coli a
Campylovirus
bacter jejuni
No
organism
300
19
4
11
6
10
0
50
Koe et al 12
97
9
NT
26
2
1
3
59
Lee et al 14
228
29
4
10
0.4b
0.4
0
56
Poo and Lee 19
288
30
NT
9
0
1
0
60
Tan 20
261
54
NT
6
0.4
0.4
0
39
Kahar-Bador
& Lee 23
568
28
9
2
49
a
includes enteropathogenic and enterotoxigenic E. coli
as a mixed infection
NT Not tested
b
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.
6
07 Assessment of Acute Diarrhoea 1-5
Aims of assessment
• 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
7.1 Assessment:
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
7.2 Assessment:
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)
History
Physical Examination
(see Appendix A)
7.3 Assessment:
Dehydration
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
7.4 Hypernatraemic
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
Table 3: Simplified ways of classifying the degree of dehydration
Classification
Fluid deficit as % of body weight
Fluid deficit in ml/kg of body weight
No signs of dehydration
< 3%
< 30 ml/kg
Some signs of dehydration
3-9%
30 – 90 ml/kg
Severe dehydration
>9%
> 90 ml/kg
Adapted from: WHO 2005 1
8
7.5 Differential
Diagnoses 23
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
7.6 Bacterial
or
Viral Cause?
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
9
7.7 Diagnostic
Workup 1, 4
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 hyperand hyponatraemia, and other electrolyte imbalances.4
7.7.1
Stool:
• Routine stool culture is not indicated as it is expensive
and does not alter the management in the vast majority
of patients 4
• 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.
Table 4: Indications for stool culture and sensitivity 4
•
•
•
•
Bloody diarrhoea (consider dysentery)
Severe watery stools (consider cholera)
Severe and prolonged diarrhoea
Immune-compromised child
7.7.2
Urine:
• 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
7.7.3
Blood:
• Urea, Na+, K+, pH, HCO3 • Complete blood count– if bacterial sepsis is suspected
• Consider glucose monitoring (girls younger
than 5 years with vomiting)
• (± Ca 2+, Mg2+ in young infants)
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
10
08 Management of Childhood Acute Diarrhoea 1-5
Important points to be considered:
•
•
•
•
•
8.1
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
Referral for Hospital Care
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
11
8.2
Rehydration in Acute Diarrhoea
General principles: 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.
8.2.1
No signs of
dehydration
• 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
(< 3%)
8.2.2
Some signs of
dehydration
• 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
(3-9%)
8.2.3
Severe dehydration
• Resuscitation (normal saline / Ringer’s lactate)
• Frequent monitoring
• Immediate referral to hospital for admission
(> 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
Cholera
Duration
Na
EPEC
K
Na
Rotavirus
K
Na
K
(h)
(mmol/L)
(mmol/L)
(mmol/L)
(mmol/L)
(mmol/L)
(mmol/L)
0 – 12
98
29
67
37
53
46
13 – 24
83
37
55
38
42
42
25 – 48
63
28
44
26
32
28
48+
46
65
44
37
34
43
12
Adapted from Molla AM et al, 199134
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
Na
K
Cl
(mmol/L)
(mmol/L)
(mmol/L)
HCO3
Glucose
Standard WHO (1975)
90
20
80
30
111
311
Reduced-Osmolality WHO (2002)
75
20
65
30
75
245
Ministry of Health
56
20
56
20
137.5
290
ORS Plus (per sachet)
75
20
65
75
10
245
Upha E-Lyte (per sachet)
75
20
65
75
10
245
Weewa ORS (per sachet)
90
21
81
110
10
312
(mmol/L)
Citrate #
Osmolality
(mmol/L)
(mmol/L)
(mmol/kg)
Adapted from Santosham M, 1997 35; Lee WS, 2009 36
#
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
Na
(mmol/L)
(mmol/L)
(mmol/L)
(mmol/L)
HCO3
Glucose
Osmolality
Coca cola
2
0
NA
NA
616
618
Apple juice
3
20
NA
0
600 – 900
250
8
NA
0
0
Tea
0
0
NA
0
0
100 Plus
21
3.5
20
3
NA
Chicken broth
K
Cl
(mmol/L)
(mmol/kg)
260
330
Adapted from Santosham M, 1997 35; Lee WS, 2009 36
NA Not available
13
8.3
Special Consideration
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
Adjunctive Therapy for Acute Diarrhoea
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
14
Table 9: Recommended Antibiotics for Acute Diarrhoea 4
Pathogen
Shigellosis
4
Salmonella
Gastroenteritis
(in high risk children) A
Campylobacter
dysentery
Cholera
Antibiotics
Total daily doses
No. of Doses/day
Duration
Azithromycin
Day 1: 12 mg/kg
Day 2-5: 6 mg/kg
1
5 days
Ceftriaxone
50 mg/kg
1
2-5 days
Trimethoprimsulfamethoxazole
10/50 mg/kg
( TM/SMZ )
2
5 days
Amoxicillin
40-50 mg/kg
3
5 days
Ceftriaxone
50 mg/kg
1
2-5 days
Trimethoprim
-sulfamethoxazole
10/50 mg/kg
2
5 days
Ciprofloxacin
5-10 mg/kg PO
2
5 days
4-7 mg/kg IV
2
5 days
Erythromycin
30-50 mg/kg
2
5 days
Azithromycin
4-7 mg/kg IV
2
5 days
Doxycycline B
>8 kg: 4.4 mg/kg
(300 mg as a single
dose in adult)
1
Single dose
Azithromycin
Day 1: 12 mg/kg
Day 2-5: 6 mg/kg
1
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.
15
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
16
8.4.3.1 Anti-motility (intestinal transit inhibitor; opiate agonists)
(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 metaanalysis, 8 out of 972 children with loperamide had lethargy/death compared to
none from the placebo group.38
Recommendations:
•
(ii) Not recommended 38
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
17
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:
•
(i) Not recommended 39
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 therapy 4, 40
18
8.4.3.3 Anti-secretory
(i) Enkephalinase inhibitors (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 therapy 42, 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
19
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.
20
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)
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)
Efficacy
(number of studies)
Lactobacillus
Rhamnosus GG 47-56
10
•
•
•
•
Lactobacillus
acidophilus 57-62
6
• Reduce duration of diarrhoea (5/6)
• Reduce by 6.6 to 31 hours
• Reduce stool frequency (1/6)
1x10 9 to 6x109 CFU
3 to 5 days
Saccharomyces
boulardii 63-67
5
• Reduce by 24 to 38 hours
3 x 109 CFU
5 to 6 days
Lactobacillus
reuteri 68, 69, 70
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
21
1.2x1010 to 2x1013 CFU
3 to 7 days
8.5
Nutritional Therapy / Special Infant Formula
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
22
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 lactosecontaining 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.
23
Table 12: Locally Available Soy-based and Lactose-free Formulae (in Alphabetical Order)
Nature
Locally available brand
Cow milkbased
lactose-free
Age range
• Dulac® Lactose Free
0 – 12 months
Danone Dumex
• Enfalac A+ LactoFree ®
Infancy and beyond
Mead Johnson
• Mamex Gold Lactose Free
Infancy and beyond
Danone Dumex
• Nan AL 110
Infancy and beyond
Nestle
• NL33
Infancy and beyond
Morinaga
• Novalac AD
Infancy and beyond
UP International
• Similac LF
0 – 12 months
Abbott Nutrition
• Enfalac A+ ProSobee ®
Infancy and beyond
Mead Johnson
• Isomil
®
®
Soy-based
Manufacturer
0 – 12 months
Abbott Nutrition
• Isomil® Plus
> 12 months
Abbott Nutrition
®
• Mamex Gold Soya Step 1
0 – 6 months
Danone Dumex
• Mamex® Gold Soya Step 2
7 months and beyond
Danone Dumex
• Nursoy
Infancy and beyond
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
Herbal Medicine: There is insufficient evidence to recommend in favour or against the
use of herbal medicine for the treatment of acute gastroenteritis in children.4
24
09 Prevention of Childhood AGE
9.1 General Measures
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.
®
25
9.3 Probiotics and prebiotics
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
26
10 Special Considerations
10.1 Persistent Diarrhoea
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 Lactose Intolerance
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.
27
10.3 Cow Milk Protein Allergy
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.
28
11 Part I: Algorithm for Managing Acute
Gastroenteritis in Children
Child with diarrhoea
(> 3 times in a 24 hour period)
Do the following:
1. History and physical examination
2. Assess presence, degree and type of dehydration
3. Assess if stools are watery and if blood and mucous
are present
4. It should be emphasised that by just inspecting the
appearance of the stool, it is impossible to differentiate
with certainty viral from bacterial gastroenteritis
5. Assess nutritional status
6. 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:
Watery without
blood and mucous
Blood and mucous
Consider the following:
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 possibility
2. Rehydrate as necessary
1. Exclude bacterial pathogens
2. 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
29
• 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
12 Part II: Algorithm for Managing Acute
Gastroenteritis in Children
No signs of dehydration
Some signs of dehydration
Severe dehydration
(<3% loss of body weight)
(3-9% loss of body weight)
(>9% 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
• 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
• 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
No admission
if no excessive vomiting
No admission
if no excessive vomiting
Immediate referral to hospital
for admission
• 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
Stable
Unstable
Hospital referral for admission
for IV fluid if persistent
vomiting/worsening dehydration
30
• Resuscitation
(normal saline/Ringer’s lactate)
• Frequent monitoring
Consider intensive care
if not resolved
Unresolved
13 Summary of Established Guidelines
Setting
CDC 2003 2
WHO 2005 1
ESPGHAN
2008 4
New South
Wales Health
2010 5
AMMCOP/MPA
2011
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 strainspecific 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.
31
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36
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 2005 1, CDC 2003 2
37
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
Not tested
Yes
Yes
Yes
Does not
interfere
with ORS
Adapted from Edelman et al, 198593 and Salazar-Lindo E. 2010 94
38
The sponsor of this educational material was not involved in the
development of this publication and in no way influenced its content.
The full guidelines on the management of acute diarrhoea in children
may be obtained from the following websites:
•College of Paediatrics, Academy of Medicine of Malaysia (AMMCOP)
http://www.acadmed.org.my/
•Malaysian Paediatric Association (MPA) http://www.mpaweb.org.my/
•Mead Johnson Nutrition Malaysia http://www.meadjohnsonasia.com.my/home.aspx
©2011 College of Paediatrics, Academy of Medicine of Malaysia and Malaysian Paediatric Association

Pocket Guide - Academy of Medicine of Malaysia

Transcription

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