- Persistent diarrhoea
Persistent diarrhoea is diarrhoea, with or without blood, that begins acutely
and lasts for ≥ 14 days. When there is some or severe dehydration, persistent
diarrhoea is classifi ed as ‘severe - Treatment
Give fl uids according to treatment plan B or C, as appropriate - children, however, may have impaired glucose absorption, and ORS solution
may not be as effective. When these children are given ORS, their stool volume
increases markedly, thirst increases, signs of dehydration develop or worsen,
and the stools contain a large amount of unabsorbed glucose. These children
require IV rehydration until ORS solution can be taken without causing the
diarrhoea to worsen.
Routine treatment of persistent diarrhoea with antibiotics is not effective and
should not be done. Some children, however, have non-intestinal or intestinal
infections that require specifi c antibiotic therapy.
■ Examine every child with persistent diarrhoea for non-intestinal infections
such as pneumonia, sepsis, urinary tract infection, oral thrush and otitis
media, and treat appropriately.
Give micronutrients and vitamins as shown - Supplementary multivitamins and minerals
Give all children with persistent diarrhoea daily supplementary
multivitamins and minerals for 2 weeks. These should provide as broad
a range of vitamins and minerals as possible, including at least two
recommended daily allowances of folate, vitamin A, zinc, magnesium and
copper.
As a guide, one recommended daily allowance for a child aged 1 year is:
■ folate, 50 μg
■ zinc, 10 mg
■ vitamin A, 400 μg
■ iron, 10 mg
■ copper, 1 mg
■ magnesium, 80 mg
Treat persistent diarrhoea with blood in the stools with an oral antibiotic
effective for Shigella, Give an oral antibiotic (for 5 days) to which most local strains of Shigella
are sensitive.
– Give ciprofl oxacin at 15 mg/kg twice a day for 3 days if antibiotic sensitivity
is unknown. If local antimicrobial sensitivity is known, follow
local guidelines.
– Give ceftriaxone IV or IM at 50–80 mg/kg per day for 3 days to severely
ill children or as second-line treatment.
Give oral metronidazole at 10 mg/kg three times a day for 5 days only if:
– microscopic examination of fresh faeces reveals trophozoites of Entamoeba
histolytica within red blood cells; or
– trophozoites or cysts of giardia are seen in the faeces, or
– two different antibiotics that are usually effective for Shigella locally have
been given without clinical improvement.
– if stool examination is not possible, when diarrhoea persists for > 1 month - Careful attention to feeding is essential for all children with persistent diarrhoea.
Breastfeeding should be continued for as often and as long as the child wants.
Other food should be withheld for 4–6 h only for children with dehydration who
are being rehydrated following treatment plan B or C.
Hospital diet
Children treated in hospital require special diets until their diarrhoea lessens
and they are gaining weight. The goal is to give a daily intake of at least 110
calories/kg. -
Infants aged < 6 months
• Encourage exclusive breastfeeding. Help mothers who are not breastfeeding
exclusively to do so. - • If the child is not breastfeeding, give a breast milk substitute that is low in
lactose, such as yoghurt, or is lactose-free. Use a spoon or cup; do not use
a feeding bottle. Once the child improves, help the mother to re-establish
lactation.
• If the mother is not breastfeeding because she is HIV-positive, she should
receive appropriate counselling about the correct use of breast milk substitutes.
Children aged ≥ 6 months
Feeding should be restarted as soon as the child can eat. Food should be given
six times a day to achieve a total intake of at least 110 calories/kg per day.
Many children will eat poorly, however, until any serious infection has been
treated for 24–48 h. These children may require nasogastric feeding initially.
Two recommended diets
If there are signs of dietary failure
(see below) or if the child is not improving after 7 days of treatment, the fi rst
diet should be stopped and the second diet given for 7 days.
Successful treatment with either diet is characterized by:
■ adequate food intake
■ weight gain
■ fewer diarrhoeal stools
■ absence of fever.
The most important criterion is weight gain. Weight should increase for at least
three successive days before weight gain can be assumed.
Give additional fresh fruit and well-cooked vegetables to children who are
responding well. After 7 days of treatment with the effective diet, they should
resume an appropriate diet for their age, including milk, which provides at least
110 calories/kg per day. Children may then return home but must be followed up
regularly to ensure continued weight gain and compliance with feeding advice.
Dietary failure is indicated by:
■ an increase in stool frequency (usually to > 10 watery stools a day), often with
a return of signs of dehydration (usually shortly after a new diet is begun), or
■ failure to establish daily weight gain within 7 days. - First diet for persistent diarrhoea: a starch-based, reduced-milk
(low-lactose) diet
The diet should contain at least 70 calories/100 g, provide milk or yoghurt as a
source of animal protein, but no more than 3.7 g lactose/kg per day and should
provide at least 10% of calories as protein. The following example provides 83
calories/100 g, 3.7 g lactose/kg per day and 11% of calories as protein:
■ full-fat dried milk (or whole liquid milk: 85 ml) 11 g
■ rice 15 g
■ vegetable oil 3.5 g
■ cane sugar 3.0 g
■ water to make up 200 ml
Second diet for persistent diarrhoea: a reduced-starch (cereal)
no-milk (lactose-free) diet
The 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 up 200 ml
Finely ground, cooked chicken (12 g) can be used in place of egg to give a diet
providing 70 calories/100 g
Dr. Jayaprakash
Superintendent, ICH.
Institute of Child Health.
Gov. Medical College Kottayam.
Kerala, India.