Persistent Diarrhoea
Description General and supportive measures Medicine treatment 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
Description
General and supportive measures
Medicine treatment
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 3 days to protect nutritional state.
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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 below. 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. Day 8-13: - Semi-elemental formula: sucrose- and lactose-free, protein hydrolysate, medium chain triglyceride. If Giardia is not excluded: - Metronidazole, oral, 7.5 mg/kg/dose 8 hourly for 5 days. In HIV-infected children: Cystoisospora belli and Cyclospora cayetanensis: - 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.
For G. lamblia:
- Metronidazole, oral, 7.5 mg/kg/dose 8 hourly for 5–7 days.
For Y. enterocolitica:
- Ceftriaxone, IV, 100 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 Cystoisospora belli:
- Co-trimoxazole, oral, 5 mg/kg/dose of trimethoprim component 12 hourly for 10.
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)
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, 10 mg/day.
Provide nutritional support.
Standard Treatment Guidelines and Essential Medicines List for South Africa Paediatric Hospital _2023, 5th edition_Updated July 2024
Chapter 2: Alimentary Tract, 2.2 Gastrointestinal Disorders, 2.2.5 Persistent Diarrhoea