Evidence based Medicine on Acute Diarrhea in Children

1. Evidence based Medicine on Acute Diarrhea in Children Dr.H.K.Takvani, MD Ped., FIAP IPP, NNF, Gujarat State Chapter 2009-2010National Executive Board Member. IAP 4 termsPresident IAP, Gujarat State Branch, 2001 President IMA Jamnagar City Branch 2008-09Children Hospital and Neonatal Care Centre JAMNAGAR-361008, Gujarat, Indiadrtakvani@gmail.comdrtakvani@rediffmail.comwww.takvanidr.multiply.com "We can not guarantee cure, but what we can guarantee is an honest and transparent effort". Takvani

2. Why to talk on diarrhea? Prescription Surveys says….. • No ORS. IVF where ORS works well or better • No advice on continuing, increasing BF, (unnecessary stoppage of BF), diet or hygiene • No zinc. Takvani

3. Why to talk on diarrhea? • Use of antiemetics • Antibiotics often- Nor-metro, Oflo-ornida, Inj.Amikacin. • Un-necessary probiotics • Racecadotril. Takvani

4. IAP Consensus Statement • Highlights several important developments. • Aims that benefits of new knowledge reach affected. • Wants that new products are not inappropriately used. next Takvani

5. ORS in diarrhea ORS for all ages and all types of diarrhea. Low osmolarity ORS recommended, WHO Sodium 75 mmol/L and glucose 75 mmol/l, osmolarity 245 mosmol/L Continue Breast feeding and routine normal diet and energy dense feeds. Takvani

6. Why Reduced osmolarity ORS? 39% reduction in need for IVF 19% reduction in stool output 29% lower incidence of vomiting Risk of hyponatremia not significant in any type of diarrhea. back Takvani

7. Zinc in Diarrhea Based on studies in India and other developing countries there is sufficient evidence to recommend zinc in the treatment of acute diarrhea as adjunct to oral rehydration. Takvani

8. Zinc in Diarrhea • Zinc has an additional modest benefit • Reduces stool volume. • Reduces duration of diarrhea. • Oral rehydration therapy must remain the main stay of treatment. Takvani

9. Zinc in Diarrhea • Dose: Elemental Zinc 20 mg/day for 6months and older for 14 days 10 mg/day Between 2-6 months. • Any of zinc salts e.g., sulphate, gluconate or acetate may be used. back Takvani

10. Recommendations of the IAP National Task Force for Use of Probiotics • The group recommended that based on analysis of studies there is presently insufficient evidence to recommend probiotics in the treatment of acute diarrhea in our settings

11. Recommendations of the IAP National Task Force for Use of Probiotics • Almost all the studies till now were done in developed countries except for one very small study from Pakistan. It may not be possible to extrapolate the findings of these studies to our setting where the breast feeding rates are high and the microbial colonization of the gut is different.

12. Recommendations of the IAP National Task Force for Use of Probiotics • The effect of probiotics is strain related and there is paucity of data to establish the efficacy of the probiotic species (namely L. acidophilus, Lactic Acid Bacteria) available in the Indian market. To recommend a particular species it will have to be first evaluated in randomized controlled trials in Indian children.

13. Recommendations of the IAP National Task Force for Use of Probiotics • The earlier studies have documented a beneficial effect on rotavirus diarrhea which was present in >75% of cases in studies from the west. Rotavirus constitutes about 15% to 25% in India.

14. Recommendations of the IAP National Task Force for Use of Probiotics • The primary outcome analyzed in all the studies was the duration of diarrhea. The more objective parameter of stool output was not evaluated.

15. What are Probiotics ?? Nonpathogenic micro-organisms. Exert a positive influence on the health or physiology of the host. They consist of either yeast or bacteria, Sacc. Bul. and Lacto-bacillus. Takvani

16. Probiotics in the Treatment of Diarrhea Mechanisms: Protect the intestine by competing with pathogens for attachment. Strengthening tight junctions between enterocytes 3. Enhancing the mucosal immune response to pathogens. Takvani

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

18. Acute Diarrhea in the Young Infant (< 2 mth) • For assessment, recommendations by the IMNCI which is an adapted version of IMCI for India, should be followed. • See if child is sick or well child. • Management is different for sick and well. Takvani

19. Acute Diarrhea in the Young Infant (< 2 mth) Infants who are breastfed and have no dehydration do not need ORS and mothers should be advised to increase breast feeds more often and for longer duration. Takvani

20. Acute Diarrhea in the Young Infant (< 2 mth) • Young infants with dehydration should be treated as has been recommended for other children with dehydration by ORS or IVF as per dehydration. Takvani

21. Acute Diarrhea in the Young Infant (< 2 mth) • Third generation cephalosporins, intra-venous ceftriaxone and amikacin if the child is sick looking, ?septicemia. • Where hospitalization is not possible, Oral Cefixime with Inj. Amikacin may be tried after explaining the nature of disease and risk. Takvani

22. Acute Diarrhea in the Young Infant (> 2 mth) • For assessment, IMNCI, No, some,sever dehy. • Management is as per grades of dehydration. • In cases of No & some dehydration when orally acceptable ORS- ZINC- home available fluids- increase BF. IVF in Severe Dehydration. Takvani

23. home available fluids Takvani

24. Antibiotic in Acute Diarrhoea Indicated only for : Acute bloody diarrhea with gross blood Shigella positive culture, Cholera, Associated systemic infection Severe malnutrition. (Septicemia) Takvani

25. Antibiotic in Acute Dysentery • Indiscriminate use of antibiotics • Increasing incidence of resistance. • Cotrimoxazole has been recommended as the first line drug for acute bloody diarrhea. • High resistance of shigella to cotrimoxazole Takvani

26. Antibiotic in Acute Dysentery Resistance rates to cotrimoxazole exceed 30% Cefixime 20mg/kg/day 5-7 days should be used instead of quinolones looking to safety and medico legal aspects. No response to cefixime in 3 days Ceftriaxone 50-100mg/kg od for 2-5 days. Takvani

27. Antibiotic in Acute Dysentery Antibiotics are not indicated if • No visible blood in stools • Pus cells on stool microscopy because of poor specificity of the test. • Routine stool examination or stool cultures have no useful role. (except to show that antibiotics are not required- personal) Takvani

28. Antibiotic in Acute Dysentery Entamoeba histolytica and helminths rarely ever cause acute diarrhea in children. Metronidazole and antihelminthics therefore have no role in the routine management of acute bloody diarrhea. Takvani

29. Antibiotic in Acute Dysentery Metronidazole/Tinidazole should be used when cases of acute dysentery fail to respond to second line drugs for dysentery such as cefixime or when a stool examination has confirmed trophozoites of Entamoeba hystolitica. Takvani

30. Antibiotics in Acute Dysentery Aminoglycosides like gentamicin and amikacin have a poor spectrum of activity against shigella species and therefore they are ineffective in the management of acute bloody diarrhea. back Takvani

31. Antiemetics in Acute Diarrhea Vomiting, common associated symptom. Distressing to the parent, antiemetics. Overdose due to haste/improper preparation like domperidone 10mg/1ml instead of 1mg/1ml in sone (Domstal Baby and Motinorn) and round the clock prescrition like TDS leads to side effects. Takvani

32. Antiemetics in Acute Diarrhea • Low osmolarity ORS reduces vomiting. • Stop for 10 minutes and than restart giving ORS in small sips. • Most can be managed by frequent small sips (5-10 ml) of ORS with sips of simple water and breast feeding in between without force feeding ORS. Takvani

33. Antiemetics in Acute Diarrhea Antiemetics should be reserved for children in whom the vomiting is severe, recurrent and interferes with ORS intake (more than 3 per hour). Takvani

34. Antiemetics in Acute Diarrhea • A single dose of domperidone/?ondansetron in children with severe vomiting. • Continued use is not recommended. • Dose of 0.1-0.3 mg/kg/dose. • Single dose only Takvani

35. Antiemetics in Acute Diarrhea • In view of serious side effects metoclopramide is not recommended. • Personal experience: Single dose of Inj.Metoclopramide 0.2mg/kg stops vomiting and improves ORS intake and avoids IV fluids in many cases without a single case of side effect. Not validated by IAP. back Takvani

36. I conclude …. Prescribe ORS for all ages. Continue Breast feeding and diet. Explain danger signals. 20 mg/10 mg of elemental zinc Takvani

37. I conclude…. • No probiotics, may be as a placebo • Causious approach infants <2 mo/PEM as it can be a part of Septicemia. • Judicious use of antibiotics for dysentery and systemic infections • No antimotility agents….strictly. (seen deaths) Takvani

38. If interested… Indian Pediatrics Statement Consensus statement of IAP National Task Force: Status report on management of acute diarrhea Shinjini Bhatnagar,Nita Bhandari, U.C. Mouli , M.K. Bhan. Indian Pediatrics : Apr 2004;41:335 - 348 Statement National seminar on importance of zinc in human health Ms. Rekha Sinha. Indian Pediatrics : Dec 2004;41:1213 - 1217  Editorial The role of zinc in child health in developing countries: Taking the science where it matters Zulfiqar A. Bhutta. Indian Pediatrics : May 2004;41:429 - 433  Brief Reports Outcome of Nutritional Rehabilitation with and without Zinc SupplementationK.E. Elizabeth, P. Sreedevi and S. Noel Narayanan. Indian Pediatrics : Jun 2000;37:650 – 655 Management of Acute Diarrhea: From Evidence to PolicyShinjini Bhatnagar, Seema Alam* and Piyush Gupta* National Co-ordinator, and *Joint National Co-ordinators, IAP-UNICEF Program on Evidence-based Management of Diarrhea.http://indianpediatrics.net/mar2010/mar-215-217.htm Takvani

39. Friends…. Please Share your views Dr.H.K.TakvaniMD (Pediatrics), FIAP Children Hospital and Neonatal Care Centre ValkeshwariNagari IndiraMarg JAMNAGAR-361008, Gujarat, India drtakvani@gmail.com www.takvanidr.multiply.com Takvani