After addressing dehydration, each of the three major classes of diarrhoea need to be treated differently, but WHO guidelines stress that antibiotics and antidiarrhoeal medications should not be routinely administered to children with diarrhoea. Indeed, antibiotics have no effect on the most common cause of diarrhoea (rotavirus), and antidiarrhoeal medications “do not prevent dehydration or improve nutritional status and some have dangerous, sometimes fatal, side-effects,” according to the Pocket Book of Hospital Care for Children (unless otherwise noted, the following section on treatment is condensed from the Pocket Book).27
Acute diarrhoea: for the most part, the clinical management for acute diarrhoea is contained in Treatment Plan A. Some children, however, do have non-intestinal or intestinal infections that require specific antibiotic therapy. For instance, if cholera is the suspected cause of acute diarrhoea, an oral antibiotic should be given that is effective against strains of Vibrio cholerae in the area (possibly tetracycline, doxycycline, cotrimoxazole, or erythromycin).
Dysentery: Children with blood in their diarrhoea are classified as having dysentery, which can also cause abdominal pain, fever, convulsions, lethargy, dehydration and rectal prolapse. Any infant under 2 months of age with dysentery or with severe malnutrition should be hospitalised. Likewise, if the child is lethargic, has abdominal distension and tenderness or convulsions, he or she may be at high risk of sepsis and should be hospitalised.
In young infants (under 2 months) dysentery should be treated with IM/IV ceftriaxone (100 mg/kg) once daily for 5 days. In older children, dysentery should first be treated with an oral antibiotic (for 5 days), to which most local strains of Shigella are sensitive, usually ciprofloxacin, pivmecillinam, and other fluoroquinolones.
If there is no improvement after a couple of days (no fever, fewer stool, less blood), clinicians should look for other conditions, stop the first antibiotic and try a second one. If there is still no response, the recommendations are to continue looking for other conditions, and treat for possible amoebiasis with metronidazole (10 mg/kg, 3 times a day) for 5 days. (Again, it is important to point out that children with HIV can have other causes of infections that can cause bloody diarrhoea or even lesions such as KS — so failure to respond should increase the index of suspicion for an HIV-related condition).
Complications of dysentery: Rectal prolapse should be pushed gently back in using a surgical glove or a wet cloth. Another option is to apply a compress with a warm solution of saturated magnesium sulphate to reduce the prolapse by decreasing the oedema. High fevers should be managed with paracetomol; repeated or prolonged convulsions with IM paraldehyde, and potassium depletion with ORS (when indicated) or foods rich in potassium like bananas (for children eating solid foods). The child should also be encouraged to breastfeed or eat more. Since this may be difficult when he or she lacks an appetite, the child should be encouraged to frequently eat small amounts of his or her preferred foods.
Persistent diarrhoea: According to IMAI guidelines, children with persistent diarrhoea and signs of dehydration should be classified as severe persistent diarrhoea and require hospitalisation — partly to address dehydration, but partly to make certain that the child receives adequate feeding and avoids developing severe malnutrition. (Severely malnourished children with persistent diarrhoea also require hospitalisation, but need specialised care including a cautious approach to feeding (such as low osmolarity/lactose feeds) since the child’s physiological state is fragile).
Children with severe persistent diarrhoea should be examined for non-intestinal infections as well (especially if they are suspected of having HIV) and treated accordingly. Blood in the diarrhoea should be treated with antibiotics as dysentery.
Consider giving treatment for amoebiasis (oral metronidazole: 7.5 mg/kg, 3 times a day, for 5 days) only if laboratory tests reveals trophozoites of Entamoeba histolytica within red blood cells of a fresh stool sample, or if two different antibiotics, which are usually effective for local Shigella strains have been tried without clinical improvement.
Give treatment for giardiasis (metronidazole: 5 mg/kg, 3 times a day, for 5 days) if cysts or trophozoites of Giardia lamblia are seen in the faeces. Note, metronidazole may also be effective for some of the less common infections seen in HIV — however, treatment of C. difficile related diarrhoea typically requires a longer course.28
Again, feeding is very important, and food should only be withheld in children while they are being rehydrated (using plans B and C) for at most four to six hours. Children who are in the hospital need special diets with a daily intake of at least 110 calories per kg to make certain that they gain weight.
For young infants under 6 months, exclusive breastfeeding should be encouraged. If the child is not breastfeeding, a low lactose breast milk substitute such as yoghurt should be used. Children who have moved onto solid foods should be encouraged to start eating again as soon as possible, although, initially, naso-gastric feeding may be necessary.
The Pocket Book recommends the following two diets for children over 6 months of age with severe persistent diarrhoea. The goal should be to achieve weight gain, which needs to occur for at least three consecutive days. Children who are responding well should be given fresh fruit and vegetables if available.
After seven days on an effective diet, the child’s regular diet may resume as long as they are getting at least 110 calories per kg. Children who are sent home should continue to receive regular follow-up however, to make certain that they are continuing to gain weight.
Diet for persistent diarrhoea, first diet: A starch-based, reduced milk concentration (low lactose) diet
Diet should provide at least 70 calories/100 g, use milk or yoghurt as a source of animal protein, but no more than 3.7 g lactose/kg body weight/day, and should provide at least 10% of calories as protein. The following example provides 83 calories/100 g, 3.7 g lactose/kg body weight/day and 11% of calories as protein:
- full-fat dried milk (or whole liquid milk: 85 ml): 11g
- rice:15 g
- vegetable oil: 3.5 g
- cane sugar: 3 g
- enough water to make 200 ml
If the first diet is not successful (there is an increase in diarrhoea) or failure establish a solid weight gain after 7 days, the second diet should be given:
Diet for persistent diarrhoea, second diet: A no-milk (lactose-free) diet with reduced cereal (starch)
The second diet should contain at least 70 calories/100 g, and provide at least 10% of calories as protein (egg or chicken). The following example provides 75 calories/100 g:
- whole egg: 64 g
- rice: 3 g
- vegetable oil: 4 g
- glucose: 3 g
- water to make 200 ml
Finely ground, cooked chicken (12 g) can be used in place of the egg to give a diet providing 70 calories/100 g.
All children with persistent diarrhoea should be given daily supplementary multivitamins and minerals for two weeks, including at least two recommended daily allowances of folate, vitamin A, zinc, magnesium and copper.
Healthcare providers should continue daily monitoring of hospitalized children for weight, diet adherence, temperature and number of diarrhoea stools. As for children who have been sent home, caregivers should bring them in again in five days or sooner if diarrhoea worsens or other problems develop.
Children with persistent diarrhoea that is not as severe should also receive an adequate caloric intake (and supplements), and eat frequent small meals. Caregivers should be advised that the child may have difficulty digesting milk (animal milk) other than breast milk.
Other pragmatic palliative and supportive measures
Palliative care guides make a number of other useful suggestions that could improve outcomes in a child, and help the child’s family manage. In Children’s Palliative Care in Africa, Amery et al recommend using a waterproof plastic undersheet covered with cotton sheet or absorbent material.29 The child’s caregiver should be given counselling about the risks of cross-infection, while the family should be advised regarding nutrition and household hygiene (especially handling the baby’s water and food).
In A Clinical Guide to Supportive and Palliative Care for HIV/AIDS in Sub-Saharan Africa, Barigye et al recommend obtaining “serum electrolytes and a full blood count because anaemia and thrombocytopaenia are relatively frequent complicating factors.” In addition, they recommend giving skin care when diarrhoea or incontinence threaten skin integrity.30 Amery et al suggest using a barrier cream; treating for candidiasis (nappy rash); administering metronidazole rectally if there is an offensive discharge and considering steroid suppositories or retention enema.
For children with HIV who appear to be having diarrhoea due to a side-effect of antiretroviral therapy, consider switching drug regimens if possible, if diarrhoea is caused by an antiretroviral agent.31 Likewise, after excluding serious treatable causes, they recommend trying loperamide, codeine, or low-dose morphine to help with intractable diarrhoea (which may be caused by HIV enteropathy for instance).
This should be done cautiously though. In fact, the Pocket Book advises: “Never give drugs for symptomatic relief of abdominal pain and rectal pain, or to reduce the frequency of stools, as they can increase the severity of the illness.”