Persistent diarrhoea

DESCRIPTION

Persistent diarrhoea is a diarrhoeal episode of presumed infectious aetiology that begins acutely but has a prolonged duration lasting more than 14 days.

GENERAL AND SUPPORTIVE MEASURES

Treatment strategy includes a stepwise approach with modification of the diet, which are not mutually exclusive and are applied according to local resources.

  • Monitor hydration, stools, nutritional status, weight gain, growth and other nutritional parameters such as serum proteins.
  • Nutritional support:
  • Aim to provide at least 460 kJ/kg/day orally within three days to protect nutritional state.

STEP-WISE EMPIRIC PROTOCOL FOR MANAGEMENT OF DIARRHOEA

Commence management at the most appropriate step according to previous management – many infants with persistent diarrhoea will already have failed the “day 1-2” stage and will commence management on “day 3-7”.

Day 0 (presentation at Health Care Facility with acute diarrhoea)

  • Rehydration according to figure above. Recommence breast or formula feeds within 4-6 hours, and additional oral rehydration solution (ORS) to maintain hydration.

Day 1-2

  • Continue full-strength feeds with additional ORS as required.

Day 3-7

  • Change to lactose-free feeds if not breastfed.
  • Continue additional oral rehydration as required.
  • If diarrhoea resolves, discharge, but continue with lactose-free feeds for 2 weeks.

Day 8-13

  • Semi-elemental formula: sucrose- and lactose-free, protein hydrolysate, medium chain triglyceride.
  • Continue additional ORS as required.
  • If diarrhoea resolves, discharge if possible on semi-elemental feeds for at least 2 weeks. If this is not possible a trial of lactose free feeds before discharge should be given and if successful, the child should be discharged on this feed.

If giardia is not excluded:

  • Metronidazole, oral, 7.5 mg/kg/dose 8 hourly for 5 days.

In HIV infected children: Isospora belli and Cyclospora :

  • Co-trimoxazole, oral, 5 mg/kg/dose of trimethoprim 12 hourly for 10 days.

If diarrhoea persists the child should be referred for further investigations and/or intravenous alimentation.

  • Where the stepwise approach is not possible:
  • Under 4 months:
    Encourage exclusive breastfeeding if lactose intolerance is not severe. If not exclusive breastfeeding, use breast milk substitutes that are low in lactose, e.g. yoghurt or amasi or specialised formulae or lactose-free milk formula.
  • Children aged 4 months and older:
    Feeding should be restarted as soon as the child can eat, with small meals 6 times a day.
  • Nasogastric feeding may be required in children who eat poorly.
    If the response is good, give additional fruit and well-cooked vegetables to children who are responding well.
    After 7 days of treatment with an effective diet, resume an appropriate diet for age, including milk, which provides at least 460 kJ/kg/day.
    Follow up regularly to ensure recovery from diarrhoea, continued weight gain and adherence to feeding advice.

MEDICINE TREATMENT

CAUTION
Antidiarrhoeal and anti-emetic agents are NOT recommended.

Antibiotic therapy

Antibiotics are only indicated when specific infections are suspected or where they are used in the Step-Wise Based Empiric Protocol for Management of Diarrhoea.

All persistent diarrhoea with blood in stool should be treated as dysentery. See Dysentery .

For campylobacter :

  • Azithromycin, oral, 10 mg/kg/ day for 3 days.

LoE: III[6]

For G. lamblia :

  • Metronidazole, oral, 7.5 mg/kg/dose 8 hourly for 5–7 days.

For Y. enterocolitica :

  • Ceftriaxone, IV, 50 mg/kg/dose once daily.
    OR
  • Cefotaxime, IV, 50 mg/kg/dose 6 hourly.

For Cryptosporidium :

  • No effective treatment available in the presence of HIV related immunosuppression.

For Isospora belli :

  • Co-trimoxazole, oral, 5 mg/kg/dose of trimethoprim component 6 hourly for 10 days then 12 hourly for 3 weeks.

For Cyclospora cayetanensis :

  • Co-trimoxazole, oral, 5 mg/kg/dose of trimethoprim component 6 hourly for 5 days.

For Microsporidia :

  • Albendazole, oral, 7.5 mg/kg 12 hourly. (Specialist supervision)

LoE: III[7]

After success as indicated by weight gain, return of appetite and decrease of diarrhoea, less elemental diets can be judiciously and slowly re-introduced.

Mineral and micronutrient deficiencies

  • Zinc (elemental), oral,
  • If < 10 kg: 10 mg/day.
  • If > 10 kg: 20 mg/day.

Provide nutritional support.