Practice Parameter: The Management of Acute Gastroenteritis in Young

Children

Provisional Committee on Quality Improvement, Subcommittee on Acute Gastnoentenitis

This practice parameter formulates recommenda- This practice parameter is not intended as a sole
tions for health care providers about the manage- source of guidance in the treatment of acute gastro-
ment of acute diarrhea in children ages 1 month to enteritis in children. It is designed to assist pedia-
5 years. It was developed through a comprehensive tnicians by providing an analytic framework for the
search and analysis of the medical literature. Expert evaluation and treatment of this condition. It is not
consensus opinion was used to enhance or formu- intended to replace clinical judgment or to estab-
late recommendations where data were insuffi- lish a protocol for all patients with this condition. It
cient. rarely will provide the only appropriate approach
The Provisional Committee on Quality Improve- to the problem. A technical report describing the
ment of the American Academy of Pediatrics (AAP) analyses used to prepare this parameter and a pa-
selected a subcommittee composed of pediatricians tient education brochure are available through the
with expertise in the fields of gastroenterology, Publications Department of the AAP.
infectious diseases, pediatric practice, and epidemi-
ology to develop the parameter. The subcommittee, BACKGROUND
the Provisional Committee on Quality Improve-
Although most children with gastroentenitis who
ment, a review panel of practitioners, and other
live in developed countries have mild symptoms and
groups of experts within and outside the AAP re-
little or no dehydration, a substantial number will
viewed and revised the parameter. Three specific
have more severe disease. In the United States, an
management issues were considered: (1) methods
average of 220 000 children younger than 5 years are
of rehydration, (2) refeeding after rehydration, and
hospitalized each year with gastroentenitis, account-
(3) the use of antidiarrheal agents. Main outcomes
ing for more than 900 000 hospital days. Approxi-
considered were success or failure of rehydration,
mately 9% of all hospitalizations of children younger
resolution of diarrhea, and adverse effects from
than 5 years are because of diarrhea.1 In addition,
various treatment options. A comprehensive bibli-
approximately 300 children younger than 5 years die
ography of literature on gastroenteritis and diar-
each year of diarrhea and dehydration (R. I. Glass,
rhea was compiled and reduced to articles amena-
written communication, February 1995). Clinicians
ble to analysis.
should be aware that young infants who were pre-
Oral rehydration therapy was studied in depth;
mature and children of teenaged mothers who have
inconsistency in the outcomes measured in the
not completed high school, had little or no prenatal
studies interfered with meta-analysis but allowed
care, and belong to minority groups are at higher risk
for formulation of strong conclusions. Oral rehy-
of death caused by diarrhea (R. I. Glass, written
dration was found to be as effective as intravenous
communication, February 1995).
therapy in rehydrating children with mild to mod-
In the United States, the incidence of diarrhea in
erate dehydration and is the therapy of first choice
children younger than 3 years has been estimated to
in these patients. Refeeding was supported by
be 1.3 to 2.3 episodes pen child per year; rates in
enough comparable studies to permit a valid meta-
children attending day care centers are higher.2 Hos-
analysis. Early refeeding with milk or food after
pitalization and outpatient care for pediatric diar-
rehydration does not prolong diarrhea; there is ev-
nhea result in direct costs of more than $2.0 billion
idence that it may reduce the duration of diarrhea
per year.5 There are also indirect costs to families.
by approximately half a day and is recommended
Surveys show that many health cane providers do
to restore nutritional balance as soon as possible.
not follow recommended procedures for manage-
Data on antidiarrheal agents were not sufficient to
ment of this disorder.6 This practice parameter is
demonstrate efficacy; therefore, the routine use of
intended to present current knowledge about the
antidiarrheal agents is not recommended, because
optimal treatment of children with diarrhea.
many of these agents have potentially serious ad-
verse effects in infants and young children.
Children Covered by the Parameter
In this practice parameter, acute gastroentenitis is
The recommendations in this statement do not indicate an exclusive course defined as dianrheal disease of rapid onset, with on
of treatment or serve as a standard of medical care. Variations, taking into
without accompanying symptoms and signs, such as
account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright © 1996 by the American Acad- nausea, vomiting, fever, or abdominal pain. Al-
emy of Pediatrics. though the emphasis of this parameter is on diar-

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rhea, vomiting can be an important component of after evaluation for relevance and validity, 230 anti-
gastroenteritis and is addressed specifically below. des were selected for complete review.
These recommendations apply to children I month Sufficient randomized trials with similar outcomes
to 5 years of age who live in developed countries and performed in developed countries were available on
who have no previously diagnosed disorders, in- early nefeeding to allow the combining of results for
cluding immunodeficiency, affecting major organ meta-analysis. Many controlled studies on oral rehy-
systems. Episodes of diarrhea lasting longer than 10 dration therapy (ORT) in developed countries were
days, diarrhea accompanying failure to thrive, and available, but the outcomes of these studies varied; it
vomiting with no accompanying diarrhea are not was not possible to combine their results quantita-
addressed. Although most patients meeting the cni- tively. Many trials on ORT performed in developing
tenia of this parameter will have viral on self-limited countries were available but were not included in
bacterial diarrhea, children with bacterial dysentery this analysis. Few studies on specific antidiarrheal
or protozoal disease can be treated according to the agents were available, although the committee exam-
principles presented herein but may benefit from med reports on drug therapy from developing as
specific antimicrobial therapy. well as developed countries. Recommendations have
been drawn from analysis of available literature and
Outcomes Studied have been augmented by expert consensus opinion.
The major outcomes studied in this analysis of The sources and validity of data underlying the com-
management options were success or failure of rehy- mittee’s conclusions are indicated. Further details on
dration, resolution of diarrhea, and adverse effects of the literature review and analysis are available in the
antidiarrheal agents. technical report. An abstract of the technical report
follows this practice parameter.
Target Audience and Settings Other clinical decisions must be addressed when
This parameter was designed to aid physicians, treating children with gastroentenitis, eg, when to
nurse practitioners, physician assistants, nurses, and obtain stool cultures, the appropriate use of antibiot-
other health cane providers who care for children ics, and the prevention of diarrhea. Extensive evalu-
with acute diarrheal disease in outpatient and inpa- ation of these issues has not been included as part of
tient settings. It is meant to guide treatment of such this parameter. For additional information, the
children; clinical judgment guided by the special reader is referred to the general review articles that
circumstances of each situation will determine the address many of these issues in detail.
ultimate cane of any individual child and may vary
from the management outlined herein.
REHYDRATION AND REFEEDING: SCIENTIFIC
Sources of Information BACKGROUND

Ideally, medical information and recommenda- ORT

tions are derived from well-designed, properly ana- Recommendation. ORT is the preferred treatment
lyzed scientific studies. When such data are not of fluid and electrolyte losses caused by diarrhea in
available on a given subject, consensus may be ob- children with mild to moderate dehydration (based
tamed from experts in the field. In this parameter, on evaluation of controlled clinical trials document-
three specific topics have received in-depth analysis: ing the effectiveness of ORT; an explanation of what
rehydration, reintroduction of feeding, and the use of constitutes a recommendation can be found in the
medications designed to influence diarrhea and to technical report).
provide symptomatic relief. These issues were cho- Replacement of fluid and electrolyte losses is the
sen because of their importance in the management critical central element of effective treatment of acute
of diarrhea, because there is evidence that practitio- diarrhea. Beginning with initial studies conducted
nens need more information in these areas, and be- 150 years ago, investigators have demonstrated that
cause data are available for study. stool losses of water, sodium, potassium, chloride,
In researching these key aspects of the manage- and base must be restored to ensure effective rehy-
ment of acute gastroentenitis, references were identi- Approximately 60 years ago, intravenous
fied through MEDLINE searches using the terms (IV) therapy became the first successful routine
gastroenteritis, diarrhea, and diarrhea, infantile to pro- method of administration of fluid and electrolytes
vide an initial, broad database of articles. In addition, and was widely accepted as the standard form of
specific MEDLINE searches were conducted for van- nehydration therapy.12 The treatment of diarrhea was
ious antidiarnheal agents. To supplement the MED- advanced further in the mid-1960s with the discov-
LINE results, articles also were obtained from a num- ery of coupled transport of sodium and glucose (or
ben of other sources, including personal files of other small, organic molecules), providing scientific
subcommittee members, bibliographies of articles justification for ORT as an alternative to IV therapy.’2
identified through the computer search, the Centers ORT has obvious potential advantages over IV
for Disease Control and Prevention report on man- therapy; it is less expensive and can be administered
agement of acute diarrhea in children,7 the Federal in many settings, including at home by family mem-
Register notice,8 and a petition to the Food and Drug bers. The first studies comparing oral glucose-elec-
Administration from the consumer group Public Cit- trolyte solutions with standard IV therapy were con-
izen (written communication, January 1993). More ducted successfully in patients with cholera in
than 4000 articles were included on the original list; Bangladesh and India in the late 1960s.’3”4 The solu-

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PEDIATRICS 425
tions used were similar to the oral nehydnation salt tration of glucose and glucose polymers and is used
solution recommended by the World Health Ongani- inappropriately in some parts of the United States,
zation and the United Nations Children’s Fund that non are they the same as a commercial product that
has been used successfully throughout the world for derives its carbohydrates from glucose polymers pu-
more than 20 years. nified from nice. Cereal-based ORT can reduce stool
During the past decade, a series of studies from volume by more than 30% in children with toxico-
developed countries has proved the effectiveness of genic diarrhea and by close to 20% in those with
ORT compared with IV therapy in children with nontoxicogenic diarrhea? Cereal- or rice powder-
diarrhea from causes other than cholera.19 These based solutions are not presently available commen-
studies evaluated glucose-electrolyte ORT solutions cially; early refeeding, however, can provide similar
with sodium concentrations ranging from 50 to 90 benefits (see below).
mmol/L compared with rapidly administered IV Hypo-osmolan solutions containing glucose poly-
therapy. These ORT solutions successfully rehy- mens to supply transport molecules also have been
drated more than 90% of dehydrated children and developed (Table 1). These solutions have shown no
had lower complication rates than those for IV ther- appreciable additional benefit compared with the
apy.’ The cost of ORT, when hospitalization can be standard glucose-electrolyte oral solution.23
spared, is substantially less than that of IV therapy,’7
but the frequency of stools, duration of diarrhea, Early Feeding of Appropriate Foods
and rate of weight gain are similar with both thera- Recommendation. Children who have diarrhea and
pies.’19 are not dehydrated should continue to be fed age-
A variety of oral solutions are available in the appropriate diets. Children who require rehydra-
United States (Table 1). Those most readily available tion should be fed age-appropriate diets as soon as
commercially and used most commonly have so- they have been rehydrated (based on evaluation of
dium concentrations ranging from 45 to 50 mmol/L, controlled clinical studies documenting the benefits
which is at or just less than the lower concentration of early feeding of liquid and solid foods).
of the solutions studied. Although these products are Optimal oral therapy regimens have incorporated
best suited for use as maintenance solutions, they can early feeding of age-appropriate foods as an integral
rehydrate satisfactorily otherwise healthy children component. When used with glucose-electrolyte
who are mildly on moderately dehydrated.’5”6’2#{176} Glu- ORT, early feeding can reduce stool output as much
cose-electrolyte solutions such as these, which are as cereal-based ORT can.24’25 A variety of early feed-
formulated on physiologic principles, must be dis- ing regimens have been studied, including human
tinguished from other popular but nonphysiologic milk,2629 diluted and full-strength animal milk and
liquids that have been used inappropriately to treat animal milk formulas,26’27’293’ diluted and full-
children with diarrhea (Table 2). These beverages strength lactose-free formulas,26’32’33 and staple food
have inappropriately low electrolyte concentrations diets with milk.28’30’31’37 These studies have demon-
for ORT use and are hypertonic, owing to their high strated that unrestricted diets do not worsen the
carbohydrate content.6 Parents should be discour- course or symptoms of mild diarrhea27’28 and can
aged from using nonphysiologic solutions to treat decrease stool output32’36’37 compared with ORT or IV
children with diarrhea. therapy alone. The literature from developed coun-
Although glucose-electrolyte ORT is extremely ef- tries on early refeeding27’32’M’35 allows for meta-anal-
fective in replacing fluid and electrolyte losses, it has ysis, which shows that the duration of diarrhea may
no effect on stool volume or the duration of diarrhea. be reduced by 0.43 days (95% confidence interval,
To address this limitation, investigators have admin- -0.74 to -0.12). Although these beneficial effects are
istered cereal-based solutions that include naturally modest, of major importance is the added benefit of
occurring food polymers from stanch, simple pro- improved nutrition with early feeding.32’33
teins, and a variety of other substrates. Stanch and A meta-analysis was performed to evaluate the use
simple proteins provide more cotransport molecules of lactose-containing feedings in children with diar-
with little osmotic penalty, thus increasing fluid and rhea and concluded that 80% on more of children
electrolyte uptake by entenocytes and reducing stool with acute diarrhea can tolerate full-strength milk
losses.2” The best studied of these solutions contain safely.38 Although reduction in intestinal brush-bon-
rice, 50 g/L, instead of glucose. These solutions are den lactase levels is often associated with diarrhea,39
not the same as rice water, which has a low concen- most infants with decreased lactase levels will not

TABLE 1. Composition of Representative G lucose-Electrolyte Solutions*

Solution CHO, mmol/L Na, mmol/L K, mmol/L Base, mmol/L Osmolality

Naturalyte (unlimited beverage) 140 45 20 48 265

Pediatric electrolyte (NutraMax) 140 45 20 30 250
Pedialyte (Ross) 140 45 20 30 250
Infalyte (formerly Ricelyte; Mead Johnson) 70 50 25 30 200
Rehydralyte (Ross) 140 75 20 30 310
WHO/UNICEF oral rehydration saltsf 111 90 20 30 310
* Adapted from Snyder J. The continuing evolution of oral therapy for diarrhea. Semiti Pediatr Infect Dis. 1994;5:231-235. CHO,
carbohydrate; Na, sodium; K, potassium; WHO, World Health Organization; UNICEF, United Nations Children’s Fund.
t Available from Jaianas Bros Packaging Co. 2533 SW Blvd. Kansas City, MO 64108.

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TABLE 2. Composition of Representative Clear Liquids Not Appropriate for Oral Rehydration Therapy*

Liquid CHO, mmol/L Na, mmol/L K, mmol/L Base, mmol/L Osmolality

Cola 700(F,G) 2 0 13 750

Apple juice 690 (F,G,S) 3 32 0 730
Chicken broth 0 250 8 0 500
Sports beverage 255 (S,G) 20 3 3 330
* Adapted from Snyder J. The continuing evolution of oral therapy for diarrhea. Semin Pediatr Infect Dis. 1994;5:231-235. CHO,
carbohydrate; F, fructose; G, glucose; K, potassium; Na, sodium; 5, sucrose.

have clinical signs on symptoms of malabsorption.7’39 sections. These recommendations are presented in
Infants fed human milk can be nursed safely during schematic form in the algorithm.
episodes of diarrhea.26 Full-strength animal milk on
animal milk formula usually is well tolerated by General Considerations
children who have mild, self-limited diarrhea.27’38
Evaluation of Dehydration
The combination of milk with staple foods, such as
Available published data have provided rigorous
cereal, is an appropriate and well-tolerated regimen
justification for the principles of ORT for diarrhea.
for children who are weaned.28’30’3437 In the past, the
Successful implementation of ORT starts with an
American Academy of Pediatrics (AAP) necom-
evaluation of the child’s degree of dehydration.
mended gradual reintroduction of milk-based for-
mulas or cow’s milk in the management of acute Guidelines for assessment of dehydration and nehy-
dration are listed in Table 3. If an accurate recent
diarrhea, beginning with diluted mixtures.4#{176} This nec-
weight is available, determination of the percentage
ommendation has been reevaluated in light of recent
of weight lost is an objective measure of dehydration.
data. If children are monitored to identify the few in
whom signs of malabsorption develop, a regular age- Capillary refill time can be a helpful adjunctive mea-
appropriate diet, including full-strength milk, can be sure to determine the degree of dehydration.41 Al-
used safely. though refill can be affected by fever, ambient tem-
perature, and age,42 the clinician should consider
The question of which foods are best for refeeding
delayed capillary refill to be a sign of significant
has been an issue of continuing study. Although
agreement is not universal, clinical experience based dehydration until proven otherwise. Urinary output
and specific gravity are helpful measures to confirm
on controlled clinical trials suggests that certain
the degree of dehydration and to determine that
foods, including complex carbohydrates (rice, wheat,
nehydration has been achieved. Parents should be
potatoes, bread, and cereals), lean meats, yogurt,
fruits, and vegetables, are better tolerated.24’25’36’37 taught the natural history of diarrhea and the signs
of dehydration.
Fatty foods or foods high in simple sugars (including
tea, juices, and soft drinks) should be avoided.7 Note
that this is not the classic BRAT diet, which consists Electrolyte Measurement
of bananas, rice, applesauce, and toast. Although Most episodes of dehydration caused by diarrhea
these foods can be tolerated, this limited diet is low are isonatremic, and serum electrolyte detenmina-
in energy density, protein, and fat. tions are unnecessary. Electrolyte levels should be
measured in moderately dehydrated children whose
REHYDRATION AND REFEEDING: MANAGEMENT histories or physical findings are inconsistent with
GUIDELINES straightforward diarrheal episodes and in all se-
The following therapeutic recommendations are verely dehydrated children. Clinicians should be
based on the evaluation of available literature aug- aware of the features of hypernatremic dehydration,
mented by expert opinion, as described in previous which can lead to neurologic damage and which

TABLE 3. Assessme nt of Dehydration*

Variable Mild, 3%-5% Moderate, 6%-9% Severe, 10%

Blood pressure Normal Normal Normal to reduced

Quality of pulses Normal Normal or slightly decreased Moderately decreased
Heart rate Normal Increased Increasedt
Skin turgor Normal Decreased Decreased
Fontanelle Normal Sunken Sunken
Mucous membranes Slightly dry Dry Dry
Eyes Normal Sunken orbits Deeply sunken orbits
Extremities Warm, normal capillary refill Delayed capillary refill Cool, mottled
Mental status Normal Normal to listless Normal to lethargic or comatose
Urine output Slightly decreased <1 mL/kg/h <<1 mL/kg/h
Thirst Slightly increased Moderately increased Very thirsty or too lethargic to indicate
* Adapted from Duggan et al.7 See text regarding hypernatremic dehydration. The percentages of body weight reduction that correspond
to different degrees of dehydration will vary among authors. The critical factor in assessment is the determination of the patient’s
hemodynamic and perfusion status. If a clinician is unsure of the category into which a patient falls, it is recommended that therapy for
the more severe category be used.
t Bradycardia may appear in severe cases.

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PEDIATRICS 427
requires special nehydration techniques. This condi- should be given more fluids than usual during an
tion can result from ingestion of hypertonic liquids episode of diarrhea.
(boiled milk and homemade solutions to which salt Some practical techniques exist to induce reluctant
is added) or the loss of hypotonic fluids in the stool children to drink glucose-electrolyte solutions. Ad-
or urine. Irritability and fever may be present, and a ministering the solution in small amounts at first
doughy feel to the skin is a distinctive feature. The may allow the child
to get accustomed to the taste.
typical loose skin and tenting of the skin associated Some commercial solutions have flavors added that
with the more common isotonic and hypotonic de- do not alter their basic composition but may make
hydration may not be present. In children receiving them more palatable. Glucose-electrolyte solutions
Iv therapy, electrolyte levels should be measured can be frozen into an ice-pop form, which may ap-
initially and as therapy progresses. ORT can be used peal to some children.
effectively in the treatment of both hypennatnemic
and hyponatremic dehydration, as well as isonatre-
mic dehydration. IV Therapy
Clinical studies strongly emphasize ORT; yet the
Vomiting clinician must know when and how to administer IV
Vomiting occurs frequently in the course of acute therapy, which maintains an important role in the
gastroenteritis and sometimes may be the only man- treatment of children with diarrhea. All children
ifestation. Almost all children who have vomiting who are severely dehydrated and in a state of shock
and dehydration can be treated with ORT.7 The key or near shock require immediate and vigorous IV
to therapy is to administer small volumes of a glu- therapy. Children who are moderately dehydrated
cose-electrolyte solution frequently. Studies have in- and who cannot retain oral liquids because of pen-
dicated that therapy can be initiated with 5-mL (1- sistent vomiting also should receive fluids by the IV
teaspoon) aliquots given every 1 to 2 minutes. route, as should children who are unconscious on
Although this technique is labor intensive, it can be have ileus. Administration of ORT is labor intensive,
done by a parent and will deliver 150 to 300 mL/h. requiring cane givers who can administer small
As dehydration and electrolyte imbalance are con- amounts of fluid at frequent intervals. If such per-
rected by the repeated administration of small sonnel are not available, IV therapy is indicated.
amounts of the solution, vomiting often decreases in Clinicians must evaluate a child’s condition in
frequency. As the vomiting lessens, larger amounts light of the circumstances. If staff are skilled in IV
of the solution can be given at longer intervals. When administration and are unable to devote time to oral
nehydration is achieved, other fluids, including milk, nehydration, and if reliable parents are not available,
as well as food, may be introduced. insertion of an IV line will be more expedient. Facil-
The use of a nasogastric tube is another option in a ity in IV therapy should not lead automatically to its
child with frequent vomiting; continuous rather than use. Because children may show considerable im-
bolus infusion of ORT solution can result in im- provement after periods of IV therapy, a child who is
proved absorption of fluid and electrolytes. Nasogas- not severely dehydrated may be able to go home and
tric infusion also can be used as a temporary expe- complete rehydnation orally, if proper follow-up is
dient while IV access is being sought; however, available, after receiving IV fluids for several hours
nasogastric infusion should not be used in a coma- in an emergency department or a similar facility.
tose patient or in a child who may have ileus on an The committee emphasizes the need for clinicians
intestinal obstruction. to recognize the advantages and disadvantages of
The committee did not evaluate the use of anti- both ORT and IV therapy in selecting the best treat-
emetic drugs. Consensus opinion is that antiemetic ment for an individual patient in a specific setting.
drugs are not needed. Physicians who feel that anti-
emetic therapy is indicated in a given situation
should be aware of potential adverse effects. Costs
If vomiting continues despite efforts to administer The major factor affecting the cost of rehydnating a
an oral rehydrating solution, IV hydration is mdi- child is the setting in which therapy occurs, with the
cated, with return to the oral route when vomiting expense increasing as one moves from home to office
abates. to emergency department or hospital wand. Oral re-
hydration is better suited to less-intensive levels of
Refusal to Take an Oral Rehydrating Solution care, but clinicians must be certain that adequate
Experience gained from more than 25 years of ORT assistance and supervision are available to provide
use indicates that children who are dehydrated effective therapy. If appropriate assistance is not
rarely refuse ORT; however, those who are not de- available, a child may require hospital care for ORT.
hydrated may refuse the solution because of its salty Clinicians should document the requirements of
taste. Children with mild diarrhea and no dehydra- these patients to justify the need for such services to
tion should be fed regular diets and do not require insurers.
glucose-electrolyte solutions. As long as it is clear to
the physician and parents that the child is not dehy-
drated and is in stable condition or showing im- Specific Therapy
provement, special solutions need not be added to The treatment of a child with diarrhea is directed
the regular feeding routine; however, young children primarily by the degree of dehydration present.

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No Dehydration shock syndrome, myocanditis, myocandiopathy, on
ORT. Although ORT has been used to replace on- penicarditis.
going stool losses in children with mild diarrhea and For appropriate guidance in treating these cniti-
no dehydration by giving 10 mL/kg for each stool,7 cally ill patients, the reader is referred to comprehen-
these children are the least likely to take ORT, in pant sive neviews.445
because of the salty taste of the solutions. If the stool ORT. When the patient’s condition has stabilized
output remains modest, a supplemental glucose- and mental status is satisfactory, ORT may be insti-
electrolyte solution may not be required if age-ap- tuted, with the IV line kept in place until it is certain
propniate feeding is continued and fluid consump- that IV therapy is no longer needed.
tion is encouraged. Feeding. When rehydration is complete, feeding
Feeding. Continued age-appropriate feeding, with should be resumed and should follow the guidelines
the foods discussed above and increased fluid intake, given above.
may be the only therapy required if hydration is
normal, which is the case in most US children with
THERAPY WITH ANTIDIARRHEAL COMPOUNDS
diarrhea. Infants should continue to drink human
milk on regular strength formula. Olden children may Drugs are used to alter the course of diarrhea by
continue to drink milk. decreasing stool water and electrolyte losses, short-
ening the course of illness, or relieving discomfort.
Mild Dehydration (3% to 5%) Passage of a formed stool is not in itself a measure of
successful therapy, because water can remain high in
ORT. Dehydration should be connected by giving
formed stools. Such cosmetic changes may give pa-
50 mL/kg ORT plus replacement of continuing
tients or their families a false sense of security, caus-
losses during a 4-hour period.7 Replacement of con-
ing a delay in seeking more effective therapy.
tinuing losses from stool and emesis is accomplished
A variety of pharmacologic agents have been used
by giving 10 mL/kg for each stool;7 also, emesis
to treat diarrhea. These compounds may be classified
volume is estimated and replaced. Reevaluation of
by their mechanisms of action, which include: (1)
hydration and replacement of losses should occur at
alteration of intestinal motility, (2) alteration of se-
least every 2 hours.
cretion, (3) adsorption of toxins or fluid, and (4)
Feeding. As soon as dehydration is corrected, feed-
alteration of intestinal microflora. Some agents may
ing should begin and should follow the guidelines
have more than one mechanism of action. Many of
given above.
the agents have systemic toxic effects that are aug-
mented in infants and children or in the presence of
Moderate Dehydration (6% to 9%)
diarnheal disease; most are not approved for children
ORT. Dehydration is connected by giving 100 younger than 2 on 3 years. Few published data are
mL/kg ORT plus replacement of continuing losses available to support the use of most antidiarnheal
during a 4-hour period. Rapid restoration of the cm- agents to treat acute diarrhea, especially in children.
culating volume helps correct acidosis and improves For the purposes of this review, these drugs have
tissue perfusion, which aids the early refeeding pro- been grouped for analysis by their proposed mech-
cess. At the end of each hour of rehydration, hydra- anisms of action. Agents for which there are suffi-
tion should be assessed, and continuing stool and cient available data are considered individually. Ta-
emesis losses should be calculated with the total ble 4 lists generic and brand names of the drugs
added to the amount remaining to be given. This task commonly used to treat persons with diarrhea.
may be accomplished best in a supervised setting,
Recommendation. As a general rule, pharmaco-
such as an emergency department, urgent-care facil-
ity, on physician’s office. logic agents should not be used to treat acute

Feeding. When nehydration is complete, feeding

should be resumed and should follow the guidelines
TABLE 4. Medications Used to Relieve Symptoms in Patients
given above.
With Acute Diarrhea*

Severe Dehydration (1O%) Alteration of intestinal motility

Opiates
Severe dehydration causes shock or a near-shock Loperamide (Imodium, Imodium-AD, Maalox Antidiarrhea,
condition and is a medical emergency. The key to the Pepto Diarrhea Control)
treatment of the severely dehydrated child is bolus Difenoxin and atropine (Motofen)t
Diphenoxylate and atropine (Lomotil)t
IV therapy with a solution such as normal saline or
Tincture of opium (paregoric)t
Ringer’s lactate. A common recommendation is to
Alteration of secretion
give 20 mL/kg of body weight during a 1-hour pe- Bismuth subsalicylate (Pepto-Bismol)
nod; however, larger quantities and much shorter Adsorption of toxins and water
periods of administration may be required. Attapulgite (Diasorb, Donnagel, Kaopectate, Rheaban)
Alteration of intestinal microflora
Electrolyte levels must be determined in children
Lactobacillus (Pro-Bionate, Superdophilus)
with severe dehydration. Frequent clinical reevalua-
* The actual formulations marketed under these trade names
tion is critical. If the patient does not respond to
change frequently. More changes are anticipated in the near future
rapid bolus rehydration, the clinician should con-
based on Food and Drug Administration rulings. Other medica-
sider the possibility of an underlying disorder, tions with similar mechanisms of action may be available.
including, but not limited to, septic shock, toxic 1 Requires prescription.

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PEDIATRICS 429
diarrhea (based on limited studies and strong com- available to document the efficacy of these agents in
mittee consensus). children with diarrhea. A placebo-controlled trial of
the drug mepenzolate bromide in adults failed to
Drugs That Alter Intestinal Motility demonstrate a positive effect, and many anticholin-
Loperamide engic side effects were reported.63 A dry mouth, the
Loperamide is a piperadine derivative, chemically most frequently observed side effect, may alter the
related to mepenidine, which decreases transit veloc- clinical evaluation of dehydration. Infants and young
ity and may increase the ability of the gut to retain children are especially susceptible to the toxic effects
fluid. Loperamide also may inhibit calmodulin, a of anticholinergic drugs.TM Coma, respiratory depres-
protein involved in intestinal transport. Loperamide sion, and paradoxical hypenexcitability have been
is more specific for the s-opiate receptors of the gut reported.TM
and thus has fewer of the effects on the central ner- Recommendation. Anticholinergic agents are not
vous system associated with other opiates. Under recommended in the management of diarrhea in
certain controlled conditions, it also has been shown
children (based on limited scientific evidence and
to have antisecretory properties, but this effect was
strong committee consensus).
not seen in an adult volunteer model of acute gas-
troentenitis.47 Well-designed clinical trials in both
adults and children have demonstrated some bene- Alteration of Secretion
ficial effects of loperamide in the treatment of acute
Bismuth Subsalicylate
diarnhea.4749 Lopenamide, when used in conjunction
with oral nehydration, reduced the volume of stool Bismuth subsalicylate, as well as bismuth subni-
losses and shortened the course of disease in children trate and bismuth subgallate, has been used as ad-
3 months to 3 years of age. These effects, although junctive therapy for acute diarrhea. The mechanism
statistically significant, were not clinically signifi- of action of these compounds is uncertain, although
cant, and the small number of studies makes it dif- laboratory studies have shown that bismuth subsa-
ficult to combine them in a meaningful way. In ad- licylate inhibits intestinal secretion caused by ente-
dition, many of the studies and case reports rotoxicogenic E coli and cholera toxins.65 Controlled
involving children have shown unacceptably high trials have demonstrated that bismuth subsalicylate
rates of side effects, including lethargy, ileus, nespi- reduced the frequency of unformed stools and in-
ratory depression, and coma, especially in in- creased stool consistency in adults with traveler’s
fants.7’48’5055 Death also has been associated with lop- diarrhea66 and in volunteers receiving the Norwalk
eramide therapy.51 virus.67 A controlled clinical trial in children with
Recommendation. Loperamide is not recom- acute diarrhea demonstrated that the administration
mended to treat acute diarrhea in children (based of bismuth subsalicylate was associated with a de-
on limited scientific evidence that the risks of ad- creased duration of diarrhea and a decreased fre-
verse effects of loperamide outweigh its limited ben- quency of unformed stools.68 A second controlled
efits in reducing stool frequency, and on strong com- trial in children receiving only oral therapy for acute
mittee consensus). diarrhea found that bismuth subsalicylate adminis-
tration was associated with a shorter duration of
Other Opiates diarrhea, decreased total stool output, decreased
Few data support the use of other opiate analogues need for intake of an oral rehydnation solution, and
or opiate and atropine combinations (Table 4) to treat reduced hospitalization,69 although criteria for hos-
diarrhea in children. The potential for toxic side ef- pita! discharge were not standardized in this study.
fects is a major concern.49’5659 Opiates can produce Overall, the beneficial effects have been modest, and
respiratory depression, altered mental status, and
the treatment regimen involves a dose every 4 hours
ileus. These drugs pose an additional danger to in-
for 5 days. Salicylate absorption after ingestion of a
dividuals with fever, toxemia, or bloody stools, be-
bismuth subsalicylate compound has been reported
cause they have been shown to worsen the course of
in adults7#{176}and children.71 Insufficient data exist as to
diarrhea in patients with shigellosis,#{176} antimicrobial-
the risk of Reye syndrome associated with this com-
associated colitis,6’ and diarrhea caused by Esche-
pound; such a risk is of at least theoretical concern.
richia coli 0157:H7.62
Bismuth-associated encephalopathy and other toxic
Recommendation. Opiates as well as opiate and
effects have been reported after the long-term in-
atropine combination drugs are contraindicated in
gestion of high doses of bismuth-containing
the treatment of acute diarrhea in children (based
compounds.72
on limited scientific evidence and strong committee
consensus). Recommendation. The routine use of bismuth sub-
salicylate is not recommended in the treatment of
Anticholinergic Agents children with acute diarrhea (based on limited sci-
Panasympatholytic agents have been used in the entific evidence that the benefit of bismuth subsalicy-
treatment of acute gastroentenitis to decrease the late is modest in most children with diarrhea because
cramping associated with diarrhea. They exert their of concerns about toxic effects, and on committee
effect on gastrointestinal tract smooth muscle by de- consensus; further studies may demonstrate a thera-
creasing motility and reducing tone. Few data are peutic role for this agent).

430 PRACTICE Downloaded from

PARAMETER pediatrics.aappublications.org at King Fahad National Guard Hosp on March 1, 2015
Adsorption of Fluid and Toxins Other Agents
Adsorbents A variety of drugs not discussed herein are used in
Several antidiarnheal compounds are reported to clinical practice to treat diarrhea. Little evidence ex-
work by adsorbing bacterial toxins and by binding ists regarding their safety or efficacy; therefore, they
water to reduce the number of bowel movements cannot be recommended.
and to improve stool consistency. Kaolin-pectin, fi-
ben, and activated charcoal are classified in this cat- RESEARCH ISSUES
egory, but the only such agent currently used widely In developing this practice parameter, the commit-
is attapulgite. No conclusive evidence is available to tee reviewed a large body of literature, but only a
show that these agents reduce the duration of diar- fraction was amenable to rigorous scientific analysis.
rhea, stool frequency, on stool fluid losses.50 Disad- Only the issue of refeeding was supported by a suf-
vantages include adsorption of nutrients, enzymes, ficient number of comparable studies to allow meta-
and antibiotics in the intestine.73 analysis. The systematic evaluation of the evidence
Recommendation. Adsorbents are not recom- for the remaining questions points to areas that need
mended for the treatment of diarrhea in children more research. In particular, the usefulness of drug
(based on limited scientific evidence and committee therapy for acute gastroenteritis needs to be exam-
consensus; efficacy has not been shown, although med more closely. In developed countries, studies of
major toxic effects are not a concern). ORT that focus on factors such as barriers to imple-
mentation, costs, and acceptability to parents and
health care providers would help facilitate its use.
Alteration of Intestinal Microflora
The practice parameter, “The Management of Acute Gastroen-
Lactobacillus teritis in Young Children,” was reviewed by the appropriate corn-
Lactobacillus is administered to patients with acute mittees and sections of the AAP, including the Chapter Review
Group, a focus group of office-based pediatricians representing
diarrhea to alter the composition of the intestinal
each AAP district: Gene R. Adams, MD; Robert M. Corwin, MD;
flora.74 Normally, saccharolytic bacteria in the intes- Lawrence C. Pakula, MD; Barbara M. Harley, MD; Howard B.
tine ferment dietary carbohydrates that have not Weinblatt, MD; Thomas J. Herr, MD; Kenneth E. Matthews, MD;
been absorbed completely, causing a decrease in pH Diane Fuquay, MD; Robert D. Mines, MD; and Delosa A. Young,
MD. Comments also were solicited from relevant outside medical
that produces short-chain fatty acids and deters in-
organizations. The clinical algorithm was developed by James R.
testinal pathogens. The short-chain fatty acids are Cooley, MD, Harvard Community Health Plan.
absorbed through the colonic mucosa and facilitate
absorption of water. When a patient has diarrhea, the SUBCOMMITTEE ON ACUTE GASTROENTERITIS, 1992 TO

fecal flora are diminished, production of short-chain 1995

Lawrence F. Nazarian, MD, Chair
fatty acids is reduced, and colonic absorption of Wa-
James H. Berman, MD
ten is impaired.75 There is no consistent evidence that
Gail Brown, MD, MPH
administration of Lactobacillus-containing com- Peter A. Margolis, MD, PhD
pounds alters the course of diarrhea.76’ The supple- David 0. Matson, MD, PhD
mentation of infant formula with Bifidobacterium bifi- Juhling McClung, MD
dum and Streptococcus thermophilus has been shown to Larry K. Pickering, MD
reduce the incidence of acute diarrhea and notavirus John D. Snyder, MD
shedding in hospitalized infants.78 Two studies of PRovIsIoNAL COMMITTEE ON QUALITY IMPROVEMENT,
young children demonstrated a reduction in the du- 1993 TO 1995
ration of diarrhea caused by rotavirus associated David A. Bergman, MD, Chair
with the administration of Lactobacillus GG.79’8#{176}Addi- Richard D. Baltz, MD
tional research is needed in the area of bacterial James R. Cooley, MD

interference using Lactobacillus-containing com- John B. Coombs, MD

Lawrence F. Nazarian, MD
pounds7
Thomas A. Riemenschneider, MD
Recommendation . Lactobacillus-containing corn- Kenneth B. Roberts, MD
pounds currently are not recommended in the treat- Daniel W. Shea, MD
ment of acute diarrhea in children (based on limited
LIAIsoN REPRESENTATIVES
scientific evidence and committee consensus; effi- Michael J. Goldberg, MD
cacy has not been shown, although toxic effects are Section Liaison
not a concern). Charles J. Homer, MD, MPH
Section on Epidemiology
Thomas F. Tonniges, MD
Newer Treatments for Diarrhea AAP Board of Directors
Several medications have shown promise in the
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OFMarch 1, 2015
PEDIATRICS 431
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32. Santosham M, Foster 5, Reid R, et al. Role of soy-based, lactose-free ment of acute traveler’s diarrhea. J C/in Gastroenterol. 1983;5:223-227
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muth subsalicylate activity inhibits
of crude toxins of Escherichia co/i and hancement of the circulating antibody secreting cell response in human
Vibrio cholerae. J Infect Dis. 1977;136:693-696 diarrhea by a human Lactobacillus strain. Pediatr Res. 1992;32:141-144
66. DuPont HL, Ericsson CD, Johnson PG. et al. Prevention of traveler’s 81 . Donowitz M, Levine 5, Watson A. New drug treatments for diarrhoea.
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1987;257:1347-1350 82. Schiller LR, Santa Ana CA, Morawski 5G. Fordtran JS. Studies of the
67. Steinhoff MC, Douglas RG Jr. Greenberg HB, Callahan DR. Bismuth antidiarrheal action of clonidine: effects on motility and intestinal ab-
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1495-1499 83. BridgesRJ, Worrell RT, Frizzell RA, Benos DJ. Stilbene disulfonate
68. Soriano-Brucher H, Avendano P, O’Ryan M, et al. Bismuth subsalicylate blockadeof colonic secretory Cl-channels in planar lipid bilayers. Am I
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1991;87:18-27 84. DuPont HL, Ericsson CD, Mathewson JJ, Marani 5, Knellwolf-Cousin
69. Figueroa-Quintanilla D, Salazar-Lmdo E, Sack RB, et al. A controlled AL, Martinez-Sandoval FG. alaride maleate, an intestinal calmodulin
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70. Feldman 5, Chen SL, Pickering LK, Cleary TG, Ericsson CD, Hulse M. 85. Cook DJ, Kelton JG, Stanisz AM, Collins SM. Somatostatin treatment for
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72. Mendelowitz PC, Hoffman RS, Weber S. Bismuth absorption and myo-
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73. Parpia SH, Nix DE, Hejmanowski LG, Goldstein HR. Wilton JH, Schen- MMWR. 1992;41(RR-16):1-20
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79. Isolauri E, Juntunen M, Rautanen T, Sillanaukee P, Koivula T. A human
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PEDIATRICS 433
 ALGORITHM

Clinician takes history

and examines patient,
aged 1 month to 5 years,
with acute diarrhea

(1) Clinician obtains patient’s current

weight.
OR
(2) Clinician estimates % dehydration,
if no recent weight for comparison
is available. (A)

3
4

Is one or more of the following (1) Hospitalize patient.

present?: (2) Give intravenous fluid therapy with
(1) Patient 10 % dehydrated bolus of normal saline or Ringer’s
(A); lactate, 20-40 mvkg for 1 hour.
Reevaluate and repeat if
(2) Signs of shock; Yes-s necessary.
(3) Begin oral rehydration when patient

: :::r::::t0us;
is stable, as per Box 6.

______________________
(B)

No
5 6
_________________________________

Begin oral rehydration

Is patient 6-9% therapy at 100 mI/kg
Yes
over a 4 hour period, plus
replacement of ongoing losses.
(C)

No
8

Begin oral rehydration

therapy at 50 mI/kg
over a 4 hour period, plus
replacement of ongoing losses. 9 10
(C)
Continue oral

spatien

therapy? oral
erating
ehydration Yes rehydration
hours or for
until 4-6 I
rehydrated.
(E)

No
11 12 $
(1) Institute intravenous
Patient with diarrhea is less therapy.
than 3% dehydrated by weight (2) Consider nasogastric

I loss or clinical
(F)
estimation.

] tube

14
13
(1) Resume breast feeding,
(1) Continue child’s regular diet. formula or milk.
(2) Consider added glucose-electrolyte (2) Resume recommended foods.
solution to replace stool losses, or (3) Replace ongoing losses with
give more usual dietary fluids. glucose-electrolyte solution.
(G) (H)

434 DownloadedPARAMETER
PRACTICE from pediatrics.aappublications.org at King Fahad National Guard Hosp on March 1, 2015
 ANNOTATIONS FOR THE MANAGEMENT OF F. The type and intensity of therapy will vary with
ACUTE GASTROENTERITIS IN YOUNG CHILDREN the individual clinical situation.
Rehydration and Refeeding Algorithm G. Often, a child has diarrhea but remains ade-
quately hydrated. The parent can be reassured but
A. See Table 3 for guidance in the assessment of
should be taught to assess hydration and to identify
the degree of dehydration.
B. Restoration of cardiovascular stability is critical a worsening condition. If the stool output remains
modest, ORT might not be required if early, age-
and is accomplished by giving bolus IV therapy with
normal saline or Ringer’s lactate solution (see text). appropriate feeding is instituted and increased con-
In the patient who does not respond, consider the sumption of usual dietary fluids is encouraged. More
possibility of an underlying disorder, such as myo- significant stool losses can be replaced with an oral
canditis, myocardiopathy, penicanditis, septic shock, nehydrating solution at the rate of 10 mL/kg for each
or toxic shock syndrome. When the patient is in stool.
stable condition and has achieved satisfactory mental H. Bneastfeeding should be resumed. Nonlactose
status, ORT can be used according to the ORT guide- formula, milk-based formula, on milk may be given,
lines. although a small percentage of children will not to!-
C. Solutions containing 45 to 90 mmol/L sodium enate lactose-containing fluids. Lactose-containing
should be given in a volume of 100 mL/kg for mod- solutions seem to be tolerated better when combined
erate dehydration and 50 mL/kg for mild dehydra- with complex carbohydrates in weaned children.
tion. Giving the child these volumes requires pa- Children who are eating foods may resume eating,
tience and persistence, and progress must be although certain foods are tolerated better than oth-
monitored frequently. ens. Recommended foods include complex carbohy-
D. Intractable, severe vomiting, unconsciousness, drates (rice, wheat, potatoes, bread, and cereals), lean
and ileus are contraindications to ORT. Persistent meats, yogurt, fruits, and vegetables. Avoid fatty
refusal to drink may require a trial of IV therapy. foods and foods high in simple sugars (including
E. The rehydration phase usually can be com- juices and soft drinks). Supplement feeding with an
pleted in 4 hours; reevaluation should occur every 1 oral electrolyte solution, 10 mL/kg for each diarrheal
to 2 hours. See text for guidance to decide when stool and the estimated amount vomited for each
rehydnation has been achieved. emesis.

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright © 1996 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
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 Practice Parameter: The Management of Acute Gastroenteritis in Young Children
Pediatrics 1996;97;424

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright © 1996 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

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