Written by Timothy Okooboh (Pharm.D).
The demand for Flagyl® antibiotic (Metronidazole) by concerned mothers and other caregivers in treating almost every occurrence of diarrhoea in children is bad practice yet understandable. This is because they are not healthcare professionals.
But the use of antibiotics or anti-diarrhoeal agents (loperamide) by a healthcare provider as first line medicines in treating almost every case of diarrhoea in children is not only bad practice but disappointing.
This article provides a simple summary of the WHO recommended treatment guideline for diarrhoea in children. This guideline has helped to adequately treat diarrhoea by correcting or preventing dehydration and malnutrition, which are issues that arise with poorly treated diarrhoea in children. Therefore, it has helped to reduce the number of diarrhoea-associated deaths in children, especially those below 5 years.
Treatment Objectives for Diarrhoea in Children
Diarrhoea is the passage of loose or watery stools at least three times within a 24 hour period. Dehydration and malnutrition are the two main issues that can arise from diarrhoea in children. Therefore, the main goals of therapy for treating diarrhoea in children are:
- Prevent dehydration if it has not occurred.
- Correct dehydration if it has occurred.
- Reduce the severity and duration of diarrhoea.
- Reduce the chance of the child developing diarrhoea for the next two to three months.
- Prevent malnutrition.
- Correct malnutrition if it has occurred.
These treatment goals are very easy to achieve. To actualize them, there are five main components of diarrhoea treatment. They are:
- Oral rehydration salts (ORS) (helps to achieve the first and second goals of therapy listed above).
- Zinc supplementation (helps to achieve the third and fourth goals of therapy listed above).
- Continued feeding of the child (can help to achieve the fifth goal of therapy listed above).
- Antibiotics for those with bloody diarrhoea (dysentery) or cholera.
- Addressing macro and micro nutrient deficiencies for persistent diarrhoea (helps to achieve the sixth goal of therapy listed above).
Oral Rehydration Therapy
The immediate treatment of diarrhoea is to replace lost fluid and electrolytes. ORS is given by mouth to prevent or correct dehydration. The child should be given as much fluid he/she can tolerate till diarrhoea stops. If the child has severe dehydration and cannot drink or is unconscious, referral to the hospital is necessary as intravenous hydration will be required. See how to assess a child with diarrhoea to determine the level of dehydration.
Some important things to consider
- Vomiting often occurs during the first hour or two of treatment, especially when the child drinks the solution too quickly. If vomiting occurs, the mother or caregiver can wait for 5-10 minutes and start giving ORS again, but more slowly (e.g. a spoonful every 2-3 minutes).
- During rehydration with ORS, over hydration may occur. This is shown by a puffy or swollen eyelid of the child. The caregiver must be informed about this. If over hydration occurs, the caregiver should stop giving ORS solution, but continue to give breast milk or plain water and food. A diuretic should not be given. When the puffiness of the eyelid is gone, ORS can be resumed.
WHO and UNICEF recommend that a child with diarrhoea should be given 10-20mg of Zinc supplement daily for 10 to 14 days (even if diarrhoea stops before then). Research has shown that this will:
- Reduce the severity and duration of diarrhoea. That is, diarrhoea that would have taken five days to resolve could take just one to three days to resolve if zinc supplement is given together with ORS solution.
- Reduce the chance of the child coming down with diarrhoea for the next two to three months.
- Replace lost zinc and prevent micronutrient deficiency.
NB: Children less than 6 months of age should receive 10mg Zinc supplement. Children who are 6 months and above should receive 20mg Zinc supplement.
Continued Feeding of the Child
Diarrhoea causes malnutrition and malnutrition further worsens diarrhoea. Therefore, all children with diarrhoea should be fed as usual. Feeding decreases the volume and frequency of passing out loose stool, speeds up recovery, and stimulates intestinal wall renewal.
Some important things to consider
- Sweet tea, sweetened fruit drinks or soft drinks should not be given to children with diarrhoea.
- In general, foods suitable for a child with diarrhoea are the same as those required by healthy children. But food should be offered more frequently in smaller portions.
- After diarrhoea stops, the same energy rich foods should be continued and increased for at least two weeks.
An appropriate antibiotic is indicated for treating bloody diarrhoea (dysentery) or cholera. Blood in diarrhoea indicates infection by bacteria such as shigella, E.coli, and salmonella, that cause destruction of the intestinal wall. Not all cases of diarrhoea is caused by bacteria. Viruses such as rotavirus can also cause diarrhoea. Therefore, antibiotics should not be used routinely or as first line medicines for children with diarrhoea. Routine use can lead to spread of antibiotic resistance.
Persistent diarrhoea can lead to Malnutrition. Feeding the child as usual during diarrhoea can help to prevent malnutrition. Children with malnutrition can also be treated with ready-to-use therapeutic foods (RUTF) which are energy-densed and micro nutrient-enriched foods.
Do probiotics have a role to play in diarrhoea treatment?
There are healthy bacteria in the intestine that synthesize vitamins such as biotin and folic acid, and facilitate absorption of dietary minerals such as magnesium, calcium, and iron. In addition to loss of fluid and electrolytes, persistent diarrhoea can lead to disruption of this healthy intestinal flora. Hence, probiotics which are live bacteria that confer a benefit to health, can also be given to children with diarrhoea, as they can help to prevent malnutrition and reduce severity of diarrhoea. Probiotics are available in pharmacy outlets.
Do anti-motility drugs such as loperamide have a role to play for treatment of diarrhoea in children?
The goal of treatment for diarrhoea is to replace lost fluid and electrolytes and to prevent or correct malnutrition. Anti-motility drugs do not help to achieve any of those. Therefore, in addition to their side effects, they are not recommended for treating diarrhoea in children less than five years of age.
Prevention Strategies of Diarrhoea in Children
Prevention is always better than cure! Diarrhoea in children can be prevented by good hygiene, clean water supply, proper sanitation, and breast feeding. Mothers must wash their hands with soap and water after changing their baby’s diaper. Regular hand washing by mothers, other caregivers, and children, can greatly reduce the incidence of paediatric diarrhoea.
Putting it all together
Treatment of diarrhoea in children is targeted at preventing or resolving dehydration and malnutrition. Therefore, a child with diarrhoea should be given more fluids at home by the caregiver using oral rehydration salts solution. 10-20mg Zinc supplement should be given for 10 to 14 days. The child should be fed as usual, usually more frequently in smaller portions. If dysentery or cholera occurs, the healthcare provider should give an appropriate antibiotic based on antimicrobial sensitivity test. However, antibiotics should not be used routinely. Anti-motility drugs such as loperamide should be avoided in children less than 5 years. Probiotics can help to prevent malnutrition and reduce severity of diarrhoea. Diarrhoea in children can be prevented by good hygiene, clean water supply, sanitation, and breast feeding. If symptoms of diarrhoea do not resolve within two to three days, the child should be referred to the health centre.
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