NEWER TRENDS IN DIARRHEA MANAGEMENT
Dr. MALATHI SATHIYASEKARAN*
CHENNAI. *
Diarrheal disease is still a problem posing a threat to mankind. This disease is largely preventable. Potential goals in the management of diarrhea are correction of dehydration and electrolyte imbalance, reduction of diarrheal dehydration and stool output, prevention of recurrence, prevention of malnutrition related complications, improvement of mucosal barrier and maximization of nutrient availability. This article summarizes four new trends in the management of diarrhea:
  1. Improved ORS:
  2. Although the standard ORS recommended by the WHO and UNICEF more than twenty-five years ago is safe, cost effective, easy to prepare and has a good shelf-life, it does not decrease the volume of diarrhea, its severity or frequency. Also, increase in stool output caused by hypernatremia is a cause for concern. Therefore, over the last 2 decades, extensive work has been done to develop an 'Improved ORS'. This ORS had to be effective and safe in all types of diarrhea, reduce the stool output and have beneficial clinical effects, compared to standard ORS. Studies on Rice based ORS revealed a reduction in purge rate and stool in children with cholera. However, it was not found to be superior to standard ORS in children with non-cholera diarrhea. Studies done with Reduced Osmolarity ORS showed a reduction in steel output and duration of diarrhea in both cholera and non-cholera diarrhea. Need for unscheduled intravenous infusion was found to be consistently reduced. However, there was a tendency for mild hyponatremia. WHO has recommended a single ORS containing Na 75, glucose 75 and Osmolality of 245 mmoL/L for all ages. Two more methods to improve standard ORS are Amylase resistant starch in ORS and Zinc ORS. The former was found to increase the absorptive efficacy of standard ORS as the undigested starch is broken down by colonic bacteria to short chain fatty acids which stimulate salt and water absorption. However, Zinc supplements are preferred to Zinc ORS.

  3. Zinc Supplements:
  4. Zinc is an essential micronutrient with a catalytic role in many metabolic processes. It also plays a role in perpetuation of genetic material. Zinc deficiency impairs T Killer cell activity, thymic hormone activity brush border permeability and CD4 response to Th1 activity. Zinc supplementation during diarrhea, reduces the severity and duration of diarrhea. WHO task force recommends Zinc in the dose of 10-20 mg/day for 14 days.

  5. Anti-secretory Drugs:
  6. Enteric Nervous System (ENS) is involved in promoting intestinal secretory processes. The receptors in ENS are potential targets for antisecretory drugs. These include 5HT receptor antagonists (e.g.). Grandensetron, Sigma agonists (e.g.). Igmesine, Somatostatin analogues like Octreotide and Encephalinase inhibitors. Encephalins are neurotransmitters present in the entire GIT, mediating absorption and are cleaved by enkephalinases. Racecadotril is an enkephalinase inhibitor. It reduces stool output and duration of diarrhea. Hypokalemia and headache may be its side effects. Dosage is 1.5 mg/kg 8th hourly. IAP task force has not included this drug in regular management of diarrhea.

  7. Probiotics & Prebiotics:
  8. Probiotics are live microbial food supplements or live micro organisms that improve the endogenous microbial flora. (e.g.). Bifidobacterium, Streptococcus thermophilus. Prebiotics are part of bacteria that stimulate colonic bacteria. Probiotics compete with pathogenic organisms for receptor sites and nutrition, cause immuno modulation and acidification of the colon and increase anti inflammatory cytokines. They are effective in antibiotic associated diarrhea, Rota virus diarrhea, Clostridium difficile diarrhea and HIV related diarrhea. They are quite safe. IAP task force has not recommended their use in acute diarrhea. To conclude, reduced Osmolality ORS and Zinc supplements have scientifically documented benefits in diarrhea. Similar research is required for probiotics and Racecadotril.

KEY MESSAGE:
  • Reduced Osmolality ORS reduces stool output and duration in both cholera and non cholera diarrhea.
  • Zinc supplementation during diarrhea reduces the stool output and duration of diarrhea.
  • More studies are needed on anti secretory agents, probiotics and prebiotics before recommending their general use in pediatric practice.
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