Gastroenteritis in children, treatment

1. The Effectiveness and Safety of
Treatments used for
Acute Diarrhea in Children
Dr Gaby Falakha
Centre Hospitalier du Nord – Zgharta
April 22nd 2016

2.  I have no disclosures

3. Introduction
 Although diarrhea kills about two million people in
developing countries each year, it remains a problem in
developed countries as well
 An average child will have 7-12 episodes of acute diarrhea
up to the age of 5 years
 9% of all hospital admissions below the age of 5 years
 300-500 deaths from acute diarrhea each year in USA

4. Outline
1. ORT
2. Lactose-free milk
3. Smectite
4. Racecadotril
5. Zinc
6. Probiotics
1. Prevalence
2. Morbidity
3. Etiology
4. Diagnosis
5. Prevention

5. The aim of management
1. Maintain or regain hydration
2. Prevent malnutrition

6. 1. Oral Rehydration Solutions
 Primarily designed for the treatment of cholera epidemics in
developing countries
 Secondarily applied for the treatment of diarrhea in
developed countries
 Initially high osmolarity (Na 90 mEq, Osmolarity 311)- 1969
 Modified low osmolarity (Na 75 mEq, Osmolarity 245)-2002
 The recommended treatment of dehydration by WHO,
UNICEF, AAP and ESPGHAN

7. Bulletin of the World Health Organization, 2001, 79 (5)
 Today, more than 20 years later, oral rehydration solution is an
accepted therapy, valued by health workers in developing and
developed countries alike.
 In fact, oral rehydration therapy may be one of the best examples of
a reverse technology transfer as its use spreads throughout the
industrialized world
 More importantly, the diarrhea mortality rate for children under five
years of age has decreased from almost 5 million to 1.8 million a year.

8. Rehydration
Minimal Mild - Moderate Severe
Rehydration Not applicable 50-100 ml/Kg
over 4 hours
Intra-venous followed
by
ORT 100 ml/Kg over 4
hours
Replacement of
losses
50-100 ml for
each diarrheal
stool or vomiting
episode
60-120 ml (< 10 Kg)
120-140 ml (> 10 Kg)
for each diarrheal stool
or vomiting episode
60-120 ml (< 10 Kg)
120-140 ml (> 10 Kg)
for each diarrheal stool
or vomiting episode

9. When to start urgent IV rehydration
1. Resuscitation from shock
2. Severe abdominal distension and ileus
3. An altered level of consciousness
4. Recurrent vomiting
5. Deterioration or lack of improvement after 4
hours of adequate oral fluids

10. What Are the Indications for Nasogastric
Rehydration?
When oral rehydration is not feasible, enteral rehydration
by the nasogastric (NG) route is the preferred method of
rehydration, and should be proposed before IV rehydration

11. Modified ORS
 Added components : Rice, carrots, prebiotics, zinc,
glucose polymers, starch…
 Modified taste : apple, peach, carrots …
 There is insufficient evidence in favor or against the
universal prescription of enriched ORS (II, B) (weak
recommendation, low-quality evidence).

12. Apple (natural) 258
Apple (bottled) 773
Pineapple (bottled) 725
Coke 509
Pepsi 571
Sprite 703
Seven up 650
WHO - ORS 245
Osmolarity of fruit juices and carbonated beverages
Electrolytes, sugar, calories, osmolarity and pH of beverages and coconut water.
Burana Chavalittamrong et al. Southeast J. Trop. Med , Vol.13;nr 3 Sept 1982

13. Enteral vs Intravenous Rehydration Therapy for Children With
Gastroenteritis. A Meta-analysis of Randomized Controlled Trials.
Fonseca et al. Arch Pediatr Adolesc Med. 2004;158:483-490

14. Enteral vs Intravenous Rehydration Therapy for Children With
Gastroenteritis. A Meta-analysis of Randomized Controlled Trials.
Fonseca et al. Arch Pediatr Adolesc Med. 2004;158:483-490

15. Reluctance to use ORT
 Only 33% of children with diarrhea in developing countries
receive ORS to treat their disease
 People do not consider ORT high-tech enough.
 ORT is for the dispensary
 Physicians prefer I/V fluids.
 It takes time (and many phone calls) to educate parents (ORT)
 ORS has no effect on the frequency of bowel movements, the
duration of diarrhea, or associated symptoms such as
abdominal pain
Bulletin of the World Health Organization, vol. 85, no. 1, pp. 42–48, 2007.

16. Complications of IV vs ORT
ORT Intravenous Rehydration
3% Paralytic Ileus 2% phlebitis
4% Failures Cost of hospitalization
No difference in weight gain, duration of diarrhea or hypernatremia

17. Nutritional management
 Never stop Breast-feeding
 Lactose-free versus Lactose-containing formulas

18. 2. Lactose-Free Formulas
Cycle of diarrhea if lactose is continued

22. A statistically significant reduction of 47% in the risk of
treatment failure (RR: 0.53; 95%CI: 0.40 to 0.70; p<0.0001)

23. Diosmectite
1. Adsorbent clay mineral
2. Not absorbed following oral ingestion
3. Eliminated unchanged (in approximately 16
hours)

24. Diosmectite
Pharmacological properties
1. Can adsorb bacterial toxins, bacteria, viruses, bile salts
2. Could reduce the production of hydrogen in the colon
during microbial fermentation
3. Have powerful coating properties, it protects the
intestinal epithelium
4. Can suppress the production of IL-8

25. Mean duration of diarrhea (h) in comparative randomised
clinical studies of diosmectite.
Szajewska et al. 2006
International Journal of Pediatrics, Volume 2013
It is important to delineate the groups (out-patient versus in-patient,
older versus younger, viral versus other etiologies of diarrhea) that
derive the greatest clinical benefit from diosmectite therapy

26. Racecadotril
 Racecadotril is an antisecretory agent that can prevent
fluid/electrolyte depletion from the bowel as a result of
acute diarrhea without affecting intestinal motility
 Active only when there is a hypersecretory state
 May be used with ORT
 First licensed in France in 1992, UK 2013, Lebanon 2016
 Demonstrated safety

27. Christophe Faure; International Journal of Pediatrics. Vol 2013

28. Racecadotril
Systematic review: racecadotril in the treatment of acute diarrhoea in children
H. SZAJEWSKA, M. RUSZCZYN´ SKI, A. CHMIELEWSKA & J. WIECZOREK
Aliment Pharmacol Ther 26: 2007, 807–813

29. Racecadotril
Systematic review: racecadotril in the treatment of acute diarrhoea in children H.
SZAJEWSKA, M. RUSZCZYN´ SKI, A. CHMIELEWSKA & J. WIECZOREK
Aliment Pharmacol Ther 26: 2007, 807–813

31. Zinc in the treatment of Diarrhea
 Zinc influences the activity of over 300 enzymes
 At the level of gastrointestinal system, zinc restores
mucosal barrier integrity and enterocyte brush-border
enzyme activity
 In areas where the prevalence of zinc deficiency or the
prevalence of moderate malnutrition is high, zinc may be of
benefit in children aged six months or more.
 The current evidence does not support the use of zinc
supplementation in children below six months of age.

32. Oral zinc for treating diarrhea in children
Lazzerini M, Ronfani L

33. Probiotics

34. A reduction in Diarrhea duration of 0.7 days
A reduction in Diarrhea frequency of 1.6 stools
on day 2
Probiotics

35.  480 infants from 1-28 months diagnosed with Rotavirus G-E
60 Patients Treatment
1 Saccharomyces Boulardi
2 Zinc
3 Lactose free formula
4 Saccharomyces Boulardi + Zinc
5 Saccharomyces Boulardi + L-F formula
6 Zinc + L-F formula
7 S. Boulardi + Zinc + L-F formula
8 Control group

36.  480 infants from 1-28 months diagnosed with Rotavirus G-E
60 Patients Treatment
1 Saccharomyces Boulardi
2 Zinc
3 Lactose free formula
4 Saccharomyces Boulardi + Zinc
5 Saccharomyces Boulardi + L-F formula
6 Zinc + L-F formula
7 S. Boulardi + Zinc + L-F formula
8 Control group
Results: The duration of Diarrhea was significantly reduced
in groups 2 and 4.
A statistically significant shortening of hospitalization in
groups 2 and 4

37. Probiotics

39. The beneficial effects of probiotics in acute diarrhea in children
seem to be moderate, strain-dependent and dose-dependent

40. Efficacy of racecadotril vs. smectite, probiotics or zinc
as an integral part of treatment of acute diarrhea in
children under five years: A meta-analysis of multiple
treatments
Gutiérrez-Castrellón P et al. Gac Med Mex. 2015;151:329-37

41. ORT Nasogastric
(versus IV)
Serum
Electrolytes
Racecadotril Odansetron
France 90% 5% 92% 51% 0%
Belgium 90% 80% 80% 0% 0%
The
Netherlands
90% 100% 43% 0% 14%
Switzerland 90% 86% 29% 0% 36%

42. Why do we need so many treatments for
a self limited disease?
 Patient well being (maintaining or restoring health)
 Client satisfaction
 1 Physician / 300 citizens
 450 annual graduates from national medical faculties
 There are 6 requests for licensure of 6 new medical
faculties pending in the ministry of higher education
 The financial profit is huge : 25,2% of the Lebanese
population is < 14 years of age. If we consider 2
prescriptions/child/year that would sum up to > 2 million
prescriptions/year.

43. Take home message
1. Oral rehydration-solution (safest, most
physiological and most effective)
2. Early refeeding (never stop breast-feeding!)
3. No or limited testing
4. No unnecessary drugs, that may be of benefit
in children with AGE, but there is insufficient
evidence to recommend their routine use

44. Thanks for your attention