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## Complete Summary

#### GUIDELINE TITLE

Managing acute gastroenteritis among children: oral rehydration,
maintenance, and nutritional therapy.

#### BIBLIOGRAPHIC SOURCE(S)

King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis
among children: oral rehydration, maintenance, and nutritional therapy.
MMWR Recomm Rep 2003 Nov 21;52(RR-16):1-16. \[114 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14627948)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute gastroenteritis including acute diarrhea and dehydration

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Gastroenterology\
Infectious Diseases\
Nutrition\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Dietitians\
Nurses\
Physician Assistants\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

-   To update the 1992 Centers for Disease Control and Prevention (CDC)
    recommendations on the management of acute diarrhea in children

-   To provide a review of the historical background and physiologic
    basis for using oral rehydration therapy (ORT)

-   To provide recommendations for assessing and managing children with
    acute diarrhea, including those who have become dehydrated

#### TARGET POPULATION

Infants and children presenting with symptoms of acute diarrhea and/or
dehydration

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Home Management of Acute Diarrhea**

1.  Initiation of therapy with oral rehydration solutions (ORS)

2.  Parental/caregiver education to recognize signs of illness and
    determine need for medical intervention

3.  Referral for evaluation (usually by telephone)

**Clinical assessment**

1.  Detailed history

2.  Physical examination

3.  Dehydration assessment

4.  Laboratory evaluations including:

    -   Serum electrolytes

    -   Stool, urine, and blood cultures

    -   Complete blood counts

**Treatment/Management**

1.  Acute gastroenteritis therapy based on degree of dehydration
    consisting of:

    -   Rehydration therapy

    -   Replacement of losses

    -   Appropriate nutrition

2.  Maintenance dietary therapy

3.  Pharmacologic therapy

    -   Antimicrobial agents

    -   Nonantimicrobial drug therapies (considered but not recommended)

4.  Supplemental zinc therapy (considered but not recommended)

5.  Functional foods (considered but not recommended)

    -   Probiotics

    -   Prebiotics

#### MAJOR OUTCOMES CONSIDERED

-   Mortality

-   Incidence, severity, and duration of diarrheal disease

-   Number of clinic/emergency department visits

-   Hospitalization rates

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases\
Searches of Unpublished Data

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Relevant literature was identified through an extensive MEDLINE search
by using related terms. Articles were then reviewed for their relevance
to pediatric practice, with emphasis on United States populations.
Unpublished references were sought from the external consultants and
other researchers.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review\
Review of Published Meta-Analyses

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Comparison with Guidelines from Other Groups\
External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

*Recommendations of Others*: Recommendations related to oral rehydration
therapy from the following groups were discussed: the World Health
Organization; the American Academy of Pediatrics and the United Nations
Children\'s Fund.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[Home Management of Acute Diarrhea]{.underline}**

Treatment with oral rehydration solution (ORS) is simple and enables
management of uncomplicated cases of diarrhea at home, regardless of
etiologic agent. As long as caregivers are instructed properly regarding
signs of dehydration or are able to determine when children appear
markedly ill or appear not to be responding to treatment, therapy should
begin at home.

**Initiation of Therapy**

In all cultures, treatment of diarrhea usually begins at home. All
families should be encouraged to have a supply of ORS in the home at all
times and to start therapy with a commercially available ORS product as
soon as diarrhea begins. Although producing a homemade solution with
appropriate concentrations of glucose and sodium is possible, serious
errors can occur; thus, standard commercial oral rehydration
preparations should be recommended where they are readily available and
attainable. The most crucial aspect underlying home management of
diarrhea is the need to replace fluid losses and to maintain adequate
nutrient intake. Regardless of the fluid used, an age-appropriate diet
should also be given. Infants should be offered more frequent breast or
bottle feedings, and older children should be given more fluids.

**Severity Assessment**

Caregivers should be trained to recognize signs of illness or treatment
failure that necessitate medical intervention. Infants with acute
diarrhea are more prone to becoming dehydrated than are older children,
because they have a higher body surface-to-volume ratio, a higher
metabolic rate, relatively smaller fluid reserves, and they are
dependent on others for fluid. For this reason, parents of infants with
diarrhea should promptly seek medical evaluation as soon as the child
appears to be in distress (see Box 1 in the original guideline
document).

No guidelines have established a specific age under which evaluation is
mandated, but usually, the smaller the child, the lower the threshold
for health-care provider assessment. When fever is present, infants and
children should be evaluated to rule out other serious illnesses (e.g.,
sepsis and meningitis). Underlying conditions, including premature
birth, metabolic and renal disorders, immune compromise, or recent
recovery from surgery, might prompt early evaluation, as might
concurrent illness, including a concurrent respiratory tract infection.
Children with dysentery (blood or mucus in stool) or prolonged diarrhea
(lasting \>14 days) should be evaluated because stool cultures and
antimicrobial therapy might be indicated.

Reports from parents or other caregivers of dehydration can indicate the
need for immediate health-care provider evaluation. Reports of changing
mental status are of particular concern. When the child´s condition is
in doubt, immediate evaluation by a health-care professional should be
recommended. Clinical examination of the child provides an opportunity
for physical assessment, including vital signs, degree of dehydration,
and a more detailed history, and for providing better instructions to
the caregivers.

**Referral for Evaluation**

In developed countries, the decision whether to bring a child to an
office or emergency department (ED) setting for evaluation is usually
made after consultation with a physician or other health-care provider
by telephone. Questions should focus on those factors putting a child at
risk for dehydration. Whenever possible, quantification is helpful. The
clinician should determine how many hours or days the child has been
ill, the number of episodes of diarrhea or vomiting, and the apparent
volume of fluid output. The child´s mental status should be determined.
Parents and other caregivers might not mention underlying conditions
without prompting; therefore, questions from the healthcare provider
regarding past medical history are essential.

**[Clinical Assessment]{.underline}**

Diarrhea is characterized by the passage of loose or watery stools; a
common case definition of acute diarrhea is [\>]{.underline}3 loose or
watery stools/day. The volume of fluid lost through stools can vary from
5 mL/kg body weight/day (approximately normal) to [\>]{.underline}200
mL/kg body weight/day. Dehydration and electrolyte losses associated
with untreated diarrhea cause the primary morbidity of acute
gastroenteritis. Diarrhea can be among the initial signs of
nongastrointestinal tract illnesses, including meningitis, bacterial
sepsis, pneumonia, otitis media, and urinary tract infection. Vomiting
alone can be the first symptom of metabolic disorders, congestive heart
failure, toxic agent ingestion, or trauma. To rule out other serious
illnesses, a detailed history and physical examination should be
performed as part of the evaluation of all children with acute
gastroenteritis.

**History**

The clinical history should assess the onset, frequency, quantity, and
character (i.e., the presence of bile, blood, or mucus) of vomiting and
diarrhea. Recent oral intake, including breast milk and other fluids and
food; urine output; weight before illness; and associated symptoms,
including fever or changes in mental status, should be noted. The past
medical history should identify underlying medical problems, history of
other recent infections, medications, and human immunodeficiency virus
(HIV) status. A relevant social history can include the number and
nature of caregivers, which can affect instructions regarding follow-up
care.

**Physical Examination**

As part of the physical examination, an accurate body weight must be
obtained, along with temperature, heart rate, respiratory rate, and
blood pressure. When recent premorbid weight is unknown but a previous
growth curve is available, an estimate of fluid loss can be obtained by
subtracting current weight from expected weight as determined on the
basis of the previous weight-for-age percentile. The quality of this
estimate will vary, depending on the number and variability of prior
data points, differences among scales, and other factors. The general
condition of the patient should be assessed, with special concern given
to infants and children who appear listless, apathetic, or less
reactive. The appearance of the eyes should be noted, including the
degree to which they are sunken and the presence or absence of tears.
The condition of the lips, mouth, and tongue will yield critical clues
regarding the degree of dehydration, even if the patient has taken fluid
recently. Deep respirations can be indicative of metabolic acidosis.
Faint or absent bowel sounds can indicate hypokalemia. Examination of
the extremities should be included because general perfusion and
capillary refill can help in assessment of dehydration. An especially
valid sign is the presence of prolonged skin tenting. Visual examination
of stool can confirm abnormal consistency and determine the presence of
blood or mucus.

**Dehydration Assessment**

Certain clinical signs and symptoms can quantify the extent of a
patient\'s dehydration (see below). Assessment of the anterior fontanel
might be helpful in selected instances, but it can be unreliable or
misleading. Among infants and children, a decrease in blood pressure is
a late sign of dehydration that heralds shock and can correspond to
fluid deficits \>10%. Increases in heart rate and reduced peripheral
perfusion can be more sensitive indicators of moderate dehydration,
although both can be difficult to interpret because they can vary with
the degree of fever. Decreased urine output is a sensitive but
nonspecific sign. Urine output might be difficult to measure for infants
with diarrhea; however, if urinalysis is indicated, a finding of
increased urine specific gravity can indicate dehydration.

The goal of assessment is to provide a starting point for treatment and
to conservatively determine which patients can safely be sent home for
therapy, which ones should remain for observation during therapy, and
which ones should immediately receive more intensive therapy.

**Symptoms associated with dehydration**:

*Minimal or no dehydration (\<3% loss of body weight)*:

-   Mental status - Well, alert

-   Thirst - Drinks normally; might refuse liquids

-   Heart rate - Normal

-   Quality of pulses - Normal

-   Breathing - Normal

-   Eyes - Normal

-   Tears - Present

-   Mouth and tongue - Moist

-   Skin fold - Instant recoil

-   Capillary refill - Normal

-   Extremities - Warm

-   Urine output - Normal to decreased

*Mild to moderate dehydration (3%--9% loss of body weight)*:

-   Mental status -- Normal, fatigued or restless, irritable

-   Thirst - Thirsty; eager to drink

-   Heart rate - Normal to increased

-   Quality of pulses - Normal to decreased

-   Breathing - Normal; fast

-   Eyes - Slightly sunken

-   Tears - Decreased

-   Mouth and tongue - Dry

-   Skinfold -- Recoil in \<2 seconds

-   Capillary refill -- Prolonged

-   Extremities -- Cool

-   Urine output - Decreased

*Severe dehydration (\>9% loss of body weight)*:

-   Mental status - Apathetic, lethargic, unconscious

-   Thirst - Drinks poorly; unable to drink

-   Heart rate - Tachycardia, with bradycardia in most severe cases

-   Quality of pulses - Weak, thready, or impalpable

-   Breathing - Deep

-   Eyes - Deeply sunken

-   Tears - Absent

-   Mouth and tongue - Parched

-   Skinfold -- Recoil in \>2 seconds

-   Capillary refill -- Prolonged; minimal

-   Extremities -- Cold; mottled; cyanotic

-   Urine output - Minimal

***Sources**: Adapted from Duggan C, Santosham M, Glass RI. The
management of acute diarrhea in children: oral rehydration, maintenance,
and nutritional therapy. MMWR 1992;41(No. RR-16):1--20; and World Health
Organization. The treatment of diarrhoea: a manual for physicians and
other senior health workers. Geneva, Switzerland: World Health
Organization, 1995.*

**Utility of Laboratory Evaluation**

Supplementary laboratory studies, including serum electrolytes, to
assess patients with acute diarrhea usually are unnecessary. Stool
cultures are indicated in cases of dysentery but are not usually
indicated in acute, watery diarrhea for the immunocompetent patient.
However, certain laboratory studies might be important when the
underlying diagnosis is unclear or diagnoses other than acute
gastroenteritis are possible. For example, complete blood counts and
urine and blood cultures might be indicated when sepsis or urinary tract
infection is a concern.

**[Acute Gastroenteritis Therapy Based on Degree of
Dehydration]{.underline}**

Seven basic principles guide optimal treatment of acute gastroenteritis
(see below).

1.  Oral rehydration solutions (ORS) should be used for rehydration.

2.  Oral rehydration should be performed rapidly (i.e., within 3--4
    hours).

3.  For rapid realimentation, an age-appropriate, unrestricted diet is
    recommended as soon as dehydration is corrected.

4.  For breastfed infants, nursing should be continued.

5.  If formula-fed, diluted formula is not recommended, and special
    formula usually is not necessary.

6.  Additional ORS should be administered for ongoing losses through
    diarrhea.

7.  No unnecessary laboratory tests or medications should be
    administered.

***Source**: Adapted from Sandhu BK. Practical guidelines for the
management of gastroenteritis in children. J Pediatr Gastroenterol Nutr
2001;33(Suppl 2):S36--9.*

More specific recommendations for treating different degrees of
dehydration have been recommended by the Centers for Disease Control and
Prevention (CDC), the World Health Organization (WHO), and the American
Academy of Pediatrics (AAP) (see Table 2 in the original guideline
document).

Treatment should include two phases: rehydration and maintenance. In the
rehydration phase, the fluid deficit is replaced quickly (i.e., during
3--4 hours) and clinical hydration is attained. In the maintenance
phase, maintenance calories and fluids are administered. Rapid
realimentation should follow rapid rehydration, with a goal of quickly
returning the patient to an age-appropriate unrestricted diet, including
solids. Gut rest is not indicated. Breastfeeding should be continued at
all times, even during the initial rehydration phases. The diet should
be increased as soon as tolerated to compensate for lost caloric intake
during the acute illness. Lactose restriction is usually not necessary
(although it might be helpful in cases of diarrhea among malnourished
children or among children with a severe enteropathy), and changes in
formula usually are unnecessary. Full-strength formula usually is
tolerated and allows for a more rapid return to full energy intake.
During both phases, fluid losses from vomiting and diarrhea are replaced
in an ongoing manner. Antidiarrheal medications are not recommended for
infants and children, and laboratory studies should be limited to those
needed to guide clinical management.

**Minimal Dehydration**

For patients with minimal or no dehydration, treatment is aimed at
providing adequate fluids and continuing an age-appropriate diet.
Patients with diarrhea must have increased fluid intake to compensate
for losses and cover maintenance needs; use of ORS should be encouraged.
In principle, 1 mL of fluid should be administered for each gram of
output. In hospital settings, soiled diapers can be weighed (without
urine), and the estimated dry weight of the diaper can be subtracted.
When losses are not easily measured, 10 mL of additional fluid can be
administered per kilogram body weight for each watery stool or 2 mL/kg
body weight for each episode of emesis. As an alternative, children
weighing \<10 kg should be administered 60--120 mL (2--4 ounces) ORS for
each episode of vomiting or diarrheal stool, and those weighing \>10 kg
should be administered 120--240 mL (4--8 ounces). Nutrition should not
be restricted (see Dietary Therapy).

**Mild to Moderate Dehydration**

Children with mild to moderate dehydration should have their estimated
fluid deficit rapidly replaced. These updated recommendations include
administering 50--100 mL of ORS/kg body weight during 2--4 hours to
replace the estimated fluid deficit, with additional ORS administered to
replace ongoing losses. Using a teaspoon, syringe, or medicine dropper,
limited volumes of fluid (e.g., 5 mL or 1 teaspoon) should be offered at
first, with the amount gradually increased as tolerated. If a child
appears to want more than the estimated amount of ORS, more can be
offered. Although administering ORS rapidly is safe, vomiting might be
increased with larger amounts. Nasogastric (NG) feeding allows
continuous administration of ORS at a slow, steady rate for patients
with persistent vomiting or oral ulcers. Clinical trials support using
NG feedings, even for vomiting patients. Rehydration through an NG tube
can be particularly useful in ED settings, where rapid correction of
hydration might prevent hospitalization. Although rapid intravenous (IV)
hydration can also prevent hospital admission, rapid NG rehydration can
be well-tolerated, more cost-effective, and associated with fewer
complications. In addition, a randomized trial of ORS versus IV
rehydration for dehydrated children demonstrated shorter stays in EDs
and improved parental satisfaction with oral rehydration.

Certain children with mild to moderate dehydration will not improve with
ORT; therefore, they should be observed until signs of dehydration
subside. Similarly, children who do not demonstrate clinical signs of
dehydration but who demonstrate unusually high output should be held for
observation. Hydration status should be reassessed on a regular basis,
and might be performed in an ED, office, or other outpatient setting.
After dehydration is corrected, further management can be implemented at
home, provided that the child´s caregivers demonstrate comprehension of
home rehydration techniques (including continued feeding), understand
indications for returning for further evaluation, and have the means to
do so. Even among children whose illness appears uncomplicated on
initial assessment, a limited percentage might not respond adequately to
ORT; therefore, a plan for reassessment should be agreed upon.
Caregivers should be encouraged to return for medical attention if they
have any concerns, if they are not sure that rehydration is proceeding
well, or if new or worsening symptoms develop.

**Severe Dehydration**

Severe dehydration constitutes a medical emergency requiring immediate
IV rehydration. Lactated Ringer´s (LR) solution, normal saline, or a
similar solution should be administered (20 mL/kg body weight) until
pulse, perfusion, and mental status return to normal. This might require
two IV lines or even alternative access sites (e.g., intraosseous
infusion). The patient should be observed closely during this period,
and vital signs should be monitored on a regular basis. Serum
electrolytes, bicarbonate, blood urea nitrogen, creatinine, and serum
glucose levels should be obtained, although commencing rehydration
therapy without these results is safe. Normal saline or LR infusion is
the appropriate first step in the treatment of hyponatremic and
hypernatremic dehydration. Hypotonic solutions should not be used for
acute parenteral rehydration.

Severely dehydrated patients might require multiple administrations of
fluid in short succession. Overly rapid rehydration is unlikely to occur
as long as weight-based amounts are administered with close observation.
Errors occur most commonly in settings where adult dosing is
administered to infants (e.g., \"500 mL NS \[normal saline\] IV bolus x
2\" would provide 200 mL/kg body weight for an average infant aged 2-- 3
months). Edema of the eyelids and extremities can indicate
overhydration. Diuretics should not be administered. After the edema has
subsided, the patient should be reassessed for continued therapy. With
frail or malnourished infants, smaller amounts (10 mL/kg body weight)
are recommended because of the reduced ability of these infants to
increase cardiac output and because distinguishing dehydration from
sepsis might be difficult among these patients. Smaller amounts also
will facilitate closer evaluation. Hydration status should be reassessed
frequently to determine the adequacy of replacement therapy. A lack of
response to fluid administration should raise the suspicion of
alternative or concurrent diagnoses, including septic shock and
metabolic, cardiac, or neurologic disorders.

As soon as the severely dehydrated patient\'s level of consciousness
returns to normal, therapy usually can be changed to the oral route,
with the patient taking by mouth the remaining estimated deficit. An NG
tube can be helpful for patients with normal mental status but who are
too weak to drink adequately. Although no studies have specifically
documented increased aspiration risk with NG tube use in obtunded
patients, IV therapy is typically favored for such patients. Although
leaving IV access in place for these patients is reasonable in case it
is needed again, early reintroduction of ORS is safer. Using IV
catheters is associated with frequent minor complications, including
extravasation of IV fluid, and with rare substantial complications,
including the inadvertent administration of inappropriate fluid (e.g.,
solutions containing excessive potassium). In addition, early ORS will
probably encourage earlier resumption of feeding, and data indicate that
resolution of acidosis might be more rapid with ORS than with IV fluid.

**[Clinical Management in the Hospital]{.underline}**

Inpatient care is indicated for children if:

-   caregivers cannot provide adequate care at home

-   substantial difficulties exist in administrating ORT, including
    intractable vomiting, ORS refusal, or inadequate ORS intake

-   concern exists for other possible illnesses complicating the
    clinical course;

-   ORS treatment fails, including worsening diarrhea or dehydration
    despite adequate volumes

-   severe dehydration (\>9% of body weight) exists

-   social or logistical concerns exist that might prevent return
    evaluation, if necessary

-   such factors as young age, unusual irritability or drowsiness,
    progressive course of symptoms, or uncertainty of diagnosis exist
    that might indicate a need for close observation

In addition, studies of mortality caused by acute diarrhea in the United
States have identified prematurity, young maternal age, black race, and
rural residence as risk factors for suboptimal outcome; thus, these
factors should also be considered when deciding if hospital care is
required.

**[Limitations of ORT]{.underline}**

Although ORT is recommended for all age groups and for diarrhea of any
etiology, certain restrictions apply to its use. Refer to the
\"Potential Harms\" and \"Contraindications\" fields for more
information.

**[Hypernatremic Dehydration]{.underline}**

Patients with hypernatremic dehydration (i.e., serum sodium
concentration \>145 mEq/L) respond well to ORT. Those with severe
dehydration should first receive IV hydration as previously discussed.
Subsequent hydration should be achieved with ORS. As with isonatremic
dehydration, ORS should be administered to replace the calculated
deficit and ongoing losses. ORS might be safer than IV therapy because
it is less likely to lead to a precipitous increase in intracellular
water associated with seizures and elevated intracranial pressure. For
more detailed recommendations regarding therapy of hypernatremic
dehydration, other sources should be consulted.

**[Dietary Therapy]{.underline}**

Recommendations for maintenance dietary therapy depend on the age and
diet history of the patient. Breastfed infants should continue nursing
on demand. Formula-fed infants should continue their usual formula
immediately upon rehydration in amounts sufficient to satisfy energy and
nutrient requirements. Lactose-free or lactose-reduced formulas usually
are unnecessary. A meta-analysis of clinical trials indicates no
advantage of lactose-free formulas over lactose-containing formulas for
the majority of infants, although certain infants with malnutrition or
severe dehydration recover more quickly when given lactose-free formula.
Patients with true lactose intolerance will have exacerbation of
diarrhea when a lactose-containing formula is introduced. The presence
of low pH (\<6.0) or reducing substances (\>0.5%) in the stool is not
diagnostic of lactose intolerance in the absence of clinical symptoms.
Although medical practice has often favored beginning feedings with
diluted (e.g., half- or quarter-strength) formula, controlled clinical
trials have demonstrated that this practice is unnecessary and is
associated with prolonged symptoms and delayed nutritional recovery.

Formulas containing soy fiber have been marketed to physicians and
consumers in the United States, and added soy fiber has been reported to
reduce liquid stools without changing overall stool output. This
cosmetic effect might have certain benefits with regard to diminishing
diaper rash and encouraging early resumption of normal diet but is
probably not sufficient to merit its use as a standard of care. A
reduction in the duration of antibiotic-associated diarrhea has been
demonstrated among older infants and toddlers fed formula with added soy
fiber.

Children receiving semisolid or solid foods should continue to receive
their usual diet during episodes of diarrhea. Foods high in simple
sugars should be avoided because the osmotic load might worsen diarrhea;
therefore, substantial amounts of carbonated soft drinks, juice, gelatin
desserts, and other highly sugared liquids should be avoided. Certain
guidelines have recommended avoiding fatty foods, but maintaining
adequate calories without fat is difficult, and fat might have a
beneficial effect of reducing intestinal motility. The practice of
withholding food for [\>]{.underline}24 hours is inappropriate. Early
feeding decreases changes in intestinal permeability caused by
infection, reduces illness duration, and improves nutritional outcomes.
Highly specific diets (e.g., the BRAT \[bananas, rice, applesauce, and
toast\] diet) have been commonly recommended. Although certain benefits
might exist from green bananas and pectin in persistent diarrhea, the
BRAT diet is unnecessarily restrictive and, similar to juice-centered
diets, can provide suboptimal nutrition for the patient´s nourishment
and recovering gut. Severe malnutrition can occur after gastroenteritis
if prolonged gut rest or clear fluids are prescribed.

Children in underdeveloped countries often have multiple episodes of
diarrhea in a single season, making diarrhea a contributing factor to
suboptimal nutrition, which can increase the frequency and severity of
subsequent episodes. For this reason, increased nutrient intake should
be administered after an episode of diarrhea. Recommended foods include
age-appropriate unrestricted diets, including complex carbohydrates,
meats, yogurt, fruits, and vegetables. Children should as best as
possible maintain caloric intake during acute episodes, and subsequently
should receive additional nutrition to compensate for any shortfalls
arising during the illness.

**[Pharmacologic Therapy]{.underline}**

**Antimicrobial Agents**

Because viruses (e.g., rotavirus, astrovirus, enteric adenovirus,
norovirus, and sapovirus) are the predominant cause of acute diarrhea in
developed countries, the routine use of antimicrobial agents for
treating diarrhea wastes resources and might lead to increased
antimicrobial resistance. Even when a bacterial cause is suspected in an
outpatient setting, antimicrobial therapy is not usually indicated among
children because the majority of cases of acute diarrhea are
self-limited and not shortened by antimicrobial agents. Exceptions to
these rules involve special needs of individual children (e.g.,
immune-compromised hosts, premature infants, or children with underlying
disorders). Information regarding appropriate antimicrobial therapy of
bacterial and parasitic causes of acute infectious diarrhea is
available.

**Nonantimicrobial Drug Therapies**

Nonspecific antidiarrheal agents (e.g., adsorbents such as
kaolin-pectin), antimotility agents (e.g., loperamide), antisecretory
drugs, and toxin binders (e.g., cholestyramine), are commonly used among
older children and adults, but data are limited regarding their
efficacy. Side effects of these drugs are well-known, in particular
among the antimotility agents, including opiate-induced ileus,
drowsiness, and nausea caused by the atropine effects and binding of
nutrients and other drugs. Because acute diarrhea is a common illness,
cost-effective analyses should be undertaken before routine
pharmacologic therapy is recommended.

**[Supplemental Zinc Therapy]{.underline}**

A number of trials have supported zinc supplementation as an effective
agent in treating and preventing diarrheal disease. Further research is
needed to identify the mechanism of action of zinc and to determine its
optimal delivery to the neediest populations. The role of zinc
supplements in developed countries needs further evaluation.

**[Functional Foods]{.underline}**

Functional foods can be defined as foods that have an effect on
physiologic processes separate from their established nutritional
function. Probiotics have been defined as live microorganisms in
fermented foods that promote optimal health by establishing an improved
balance in intestinal microflora. Because dietary supplements (e.g.,
probiotics) are usually not regulated by the federal government,
potential exists for great variability among them, providing a challenge
to the prescribing physician to make an informed recommendation
regarding their use.

Prebiotics differ from probiotics in that they are complex carbohydrates
rather than organisms used to preferentially stimulate the growth of
health-promoting intestinal flora. Specific recommendations regarding
their use should await further well-controlled human trials.

**[Specific Clinical Scenarios]{.underline}**

Oral rehydration therapy is critical in managing specific types of
diarrheal diseases.

**Acute Bloody Diarrhea (Dysentery)**

Dysentery is defined as acute bloody diarrhea caused by invasive
microbial infection. This does not include occult blood (detected by
guaiac card only) or streaks of blood on the surface of formed stool.
The treatment of dehydration in dysentery follows the same principles as
treatment of acute watery diarrhea. The child with bloody diarrhea is at
higher risk for complications, including sepsis and other systemic
diseases; therefore, the threshold for admission of such children to the
hospital for close observation is lower. Stool cultures are indicated in
the setting of acute bloody diarrhea and are helpful for guiding
therapy. Food should not be withheld for children with dysentery any
more than in other cases of diarrhea. More frequent, smaller meals might
be better tolerated, and higher protein intakes have proven beneficial
among children recovering from dysentery.

In the majority of cases, empiric antimicrobial agents should not be
administered while awaiting culture results, because antimicrobial
therapy might not be indicated even when culture results are positive.
Amoebiasis is an unusual cause of bloody diarrhea in young children,
even in less-developed countries. Treatment for amoebiasis should be
reserved for those cases in which trophozoites are detected on
microscopic examination of the stools. Recommendations for therapy of
specific enteric pathogens associated with bloody diarrhea are available
elsewhere.

**Persistent Diarrhea and Diarrhea with Severe Malnutrition**

These clinical entities are critical, especially among children of
developing countries. Therapy should include oral rehydration when
indicated, although the specifics of the evaluation, and fluid,
electrolyte, and nutritional management differ and are beyond the scope
of this review. The reader is referred to other sources for information
regarding these conditions.

**[Choice of ORS]{.underline}**

On the basis of recent clinical research, the United Nations Children\'s
Fund (UNICEF) and WHO organized a consultation on oral rehydration that
recommended a reduced osmolarity solution for global use. In May 2002,
WHO announced a new ORS formulation consistent with these
recommendations, with 75 mEq/L sodium, 75 mmol/L glucose, and total
osmolarity of 245 mOsm/L (see Table 3 in the original guideline
document). The newer hypotonic WHO-ORS is also recommended for use in
treating adults and children with cholera, although postmarketing
surveillance is under way to confirm the safety of this indication. The
composition of commonly available oral rehydration solutions is distinct
from other beverages frequently used inappropriately for rehydration.

**New Solutions**

Recipes to improve ORS have included adding substrates for sodium
co-transport (e.g., the amino acids glycine, alanine, and glutamine) or
substituting complex carbohydrates for the glucose (rice and other
cereal-based ORS).The amino acid preparations have not been demonstrated
to be more effective than traditional ORS, and they are more costly.
Rice-based ORS can be recommended where training is adequate and home
preparation is preferable, and it can be particularly effective in
treating dehydration caused by cholera. Nevertheless, given the
simplicity and safety of ORS packets in developing countries and of
commercially available ORS in developed countries, these remain the
first choice for the majority of clinicians.

Other potential additives to ORS include substances capable of
liberating short-chain fatty acids (e.g., amylase-resistant starch
derived from corn) and partially hydrolyzed guar gum. The presumed
mechanism of action is the enlistment of increased colonic sodium uptake
coupled to short-chain fatty acid transport. Other possible future ORS
composition changes include addition of probiotics, prebiotics, zinc, or
protein polymers.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

If the principles of therapy outlined in this report are accepted by all
levels of the medical community and if education of parents includes
teaching them to begin oral rehydration therapy (ORT) at home, numerous
deaths and unnecessary clinic visits and hospitalizations can be
avoided. ORT is suitable for use among children throughout the world.

#### POTENTIAL HARMS

**Limitations of Oral Rehydration Therapy (ORT)**

-   Stool output in excess of 10 mL/kg body weight/hour has been
    associated with a lower rate of success of oral rehydration;
    however, children should not be denied ORT simply because of a high
    purging rate, because the majority of children will respond well if
    administered adequate replacement fluid.

-   A limited percentage of infants (\<1%) with acute diarrhea
    experience carbohydrate malabsorption. This is characterized by a
    dramatic increase in stool output after intake of fluids containing
    simple sugars (e.g., glucose), including oral rehydration solutions
    (ORS). Patients with true glucose malabsorption also will have an
    immediate reduction in stool output when intravenous (IV) therapy is
    used instead of ORS. However, the presence of stool-reducing
    substances alone is not sufficient to make this diagnosis, because
    this is a common finding among patients with diarrhea and does not
    in itself predict failure of oral therapy.

-   Certain patients with acute diarrhea have concomitant vomiting.
    However, the majority can be rehydrated successfully with oral
    fluids if limited volumes of ORS (5 mL) are administered every 5
    minutes, with a gradual increase in the amount consumed.
    Administration with a spoon or syringe under close supervision helps
    guarantee a gradual progression in the amount taken. Often,
    correction of acidosis and dehydration lessens the frequency of
    vomiting. Continuous slow nasogastric (NG) infusion of ORS through a
    feeding tube might be helpful. Even if a limited amount of emesis
    occurs after NG administration of fluid, treatment might not be
    affected adversely. The physician might meet resistance in
    implementing NG rehydration in a vomiting child, but NG rehydration
    might help the initial rehydration and speed up tolerance to
    refeeding, leading to improved patient disposition and quicker
    discharge.

**Overly Rapid Rehydration**

Among patients with severe dehydration, overly rapid rehydration is
unlikely to occur as long as weight-based amounts are administered with
close observation. Errors occur most commonly in settings where adult
dosing is administered to infants (e.g., \"500 mL NS \[normal saline\]
IV bolus x 2\" would provide 200 mL/kg body weight for an average infant
aged 2--3 months).

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Among children in hemodynamic shock, administration of oral solutions
might be contraindicated because airway protective reflexes might be
impaired. Likewise, patients with abdominal ileus should not be
administered oral fluids until bowel sounds are audible. Intestinal
intussusception can be present with diarrhea, including bloody diarrhea.
Radiographic and surgical evaluations are warranted when the diagnosis
of bowel obstruction is in question.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis
among children: oral rehydration, maintenance, and nutritional therapy.
MMWR Recomm Rep 2003 Nov 21;52(RR-16):1-16. \[114 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14627948)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Nov 21

#### GUIDELINE DEVELOPER(S)

Centers for Disease Control and Prevention - Federal Government Agency
\[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Caleb K. King, MD, University of North Carolina, Chapel Hill,
North Carolina; Roger Glass, MD, PhD, Division of Viral and Rickettsial
Diseases, National Center for Infectious Diseases, Centers for Disease
Control and Prevention; Joseph S. Bresee, MD, Division of Viral and
Rickettsial Diseases, National Center for Infectious Diseases, Centers
for Disease Control and Prevention; Christopher Duggan, MD, Children´s
Hospital Boston, Boston, Massachusetts

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### ENDORSER(S)

American Academy of Pediatrics - Medical Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the Centers for Disease Control and
Prevention (CDC) Web site:

-   [HTML Format](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm)

-   [Portable Document Format
    (PDF)](http://www.cdc.gov/mmwr/PDF/rr/rr5216.pdf)

Print copies: Available from the Centers for Disease Control and
Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased
from the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402-9325; (202) 783-3238.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on June 30, 2004.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

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Date Modified: 11/3/2008