Persistent Diarrhea in Children: India Academy of Pediatrics Guidelines

Diarrhea is the second most common cause of death in children. There are about 6 billion episodes of diarrhea every year in the world with 2 million deaths. Diarrhea is a condition characterized by a change in the consistency and frequency of stools compared to the normal bowel habit of the child. The vast majority of cases of diarrhea subside within 7 days—this is known as acute diarrhea.

The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Persistent Diarrhea in Children. The lead author for these guidelines on Persistent Diarrhea in Children is Dr. NC Gowrishankar along with co-author Dr. Javeed Iqbal and Dr. Krishna Mohan Gulla. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT, and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.

Following are the major recommendations of guidelines:

Persistent Diarrhea (PD):

An episode of diarrhea of presumed infectious etiology, which starts acutely but lasts for more than 14 days, and excludes chronic or recurrent diarrheal disorders such as celiac disease, tropical sprue, or other congenital, biochemical or metabolic disorders, leading to a deterioration in nutritional status and a substantial risk of death.

About 60% of PD occurs before 6 months and 90% below 1 year of age. According to WHO, PD accounts for only 10% of diarrheal episodes, but as much as 35% of diarrheal deaths in children below 5 years are due to it.

Chronic Diarrhea:

Chronic diarrhea has an insidious onset unlike PD, lasts more than 2 weeks, and is usually due to non-infectious causes. These children need a complete workup for underlying malabsorption. Factors that contribute to PD:

Secondary lactose intolerance

Fungal superinfection

Primary malnutrition leading to enteropathy

Other bacterial infections such as urinary tract infections, otitis media, etc. Chronic Diarrhea Antibiotic-associated diarrhea

Natural History of Diarrhea:

Pathophysiology of PD:

Management of PD:

The common features in all children with PD are small bowel mucosal damage which affects the absorption of nutrients and infections including small intestinal bacterial overgrowth (SIBO). The cornerstone of the management of PD is to break the above chain as mentioned in the pathophysiology. There are three principles of management:

1. Control of diarrhea and its consequences

2. Treatment of infections, if any

3. Nutritional rehabilitation and correction of malnutrition

Steps in Management:

Fluid resuscitation:

Low osmolality ORS is effective

IV fluids may be necessary if the child has severe dehydration

Correction of electrolyte imbalance

Correction of hypoglycemia

Identify infections and treat with antimicrobials or antifungals as appropriate:

A thorough clinical examination for a chest infection, otitis media, or signs of sepsis

Examination of the perineum and oral cavity for superadded fungal infection

CBC, CRP, total protein and albumin, blood sugar, electrolytes, blood and urine cultures, and chest radiograph

Stool routine examination and culture usually have no role in the management

Stools for opportunistic infections such as fungal hyphae, cryptosporidium, and an assay of Clostridium difficile toxins A and B in the appropriate clinical settings are advisable.

Start antibiotics: Quinolones/oral third-generation cephalosporins in the presence of gross blood in stools parenteral ampicillin and aminoglycosides in sepsis, children< 3 months of age or associated extra-gut infections, and HIV

Start antifungals fluconazole 6 mg/kg/dose for 4–6 weeks if there is oral thrush, or the perineum showed fungal infection

Dietary management (Tables 1 and 2)

Home-made, culturally acceptable, and age-appropriate diet to be started.

Total calories should be approximately 100 cal/kg/day.

If the child has features of lactose intolerance, then the diet should be modified as mentioned below. Lactose intolerance should be considered when the child has explosive stools with perianal redness and stool pH<6.5. Keeping the child fasting for 24 hours and diarrhea will be reduced significantly which implies osmotic diarrhea.

Treatment of Lactose Intolerance:

Always start with Diet A (low lactose diet) for 7 days. This is based on the fact that secondary lactose intolerance is common in children with PD and malnutrition. To reduce lactose concentration in animal milk, it should be mixed with cereals, but not diluted with water as that reduces the caloric content.

If there is no response after a week, then start Diet B—milk (lactose) free and provide carbohydrates as a mixture of cereals and glucose. Milk protein is replaced by chicken, egg, or protein hydrolysate. The starch content is reduced and partially substituted by glucose.

A small number of children with PD who do not respond to diet A/B are given diet C for 7 days. It contains only glucose and a protein source as egg white or chicken or commercially available protein hydrolysates. Energy density is increased by adding oil to the diet.

If there is no response after a week, then an elemental diet such as hydrolyzed or amino acid formula may be started. If there is still no response after a week, the child may require total parenteral nutrition, and hence he may be referred to a pediatric gastroenterologist.

Green Banana Diet:

The Green (unripe) banana diet is gaining acceptance for the treatment of PD. The amylase-resistant starch present in this is not digested in the small intestine and reaches the colon. Colonic bacteria ferment this to shyort chain fatty acids which have trophic effects on the colon and increase the absorption of salt and water.

A dose of parenteral Vitamin K should be given at admission. After the infant has begun to improve and is gaining weight, 3 mg/kg/day of iron is added.

There are no published data to recommend the use of empiric antibiotics directed against enteric pathogens, probiotics, racecadotril, steroids, or drugs that alter intestinal motility, including loperamide, codeine, and paregoric.

The failure to respond to treatment may be due to severe systemic infections, unusual enteropathogens, sucrase/isomaltase deficiency, and severe glucose malabsorption.

Strategies to prevent PD include promotion of exclusive breastfeeding, safe complementary feeding practices, promotion of safe drinking water, low osmolality ORS, zinc supplementation, avoiding unnecessary antibiotics, and continued feeding during diarrhea.

Concerns in the Management of PD:

The management of infants below 6 months of age continues to be a problem as they cannot be given most food recommended for older children. They may need extensively hydrolyzed 100% bovine casein infant formulas and elemental amino acid formulas which are very expensive and are not freely available in our country.

Many hospitals are not able to manage children with PD who do not respond to the usual treatments described above. Hence, IAP should take up the initiative to set up regional centers which can manage such refractory cases.

Parent education and uniform protocols of management should be followed by all pediatricians in India.

References:

• Chen RY, Kung VL. Das S, et al. Linking the duodenal microbiota to stunting in a cohort of undernourished Bangladeshi children with enteropathy. N Engl J Med 2020;383:321.
• Gopalan S. Persistent diarrhea. IAP Specialty Series on Pediatric Gastroenterology, Vol. 5 and 6; 2008. pp. 42-76.
• Matthai J, Raju B, Bavdekar A, Pediatric Gastroenterology Chapter, Indian Academy of Pediatrics. Chronic and persistent diarrhea in infants and young children: status statement. Indian Pediatr 2011; 48:37.
• Sarangi G. Persistent and chronic diarrhea in children.In: Parthasarathy A, Menon PSN. Eds. IAP Textbook of Pediatrics, 5th ed. Jaypee Publishers, New Delhi. 2013 518-522.

• Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis 2017; 65:e45.

• The guidelines can be accessed on the official site of IAP:https://iapindia.org/standard-treatment-guidelines/