In a systematic review of RCTs comparing lower-concentration oral rehydrating solution with standard World Health Organization solution, lower-concentration solution showed superior efficacy. These resulted in fewer unscheduled infusions of IV fluids (OR=0.59; 95% CI, 0.45–0.79) and less stool output without increasing the incidence of hyponatremia.8
Unrestricted diets may reduce the duration of diarrhea compared with oral or IV fluids alone, and age-appropriate diets should be resumed immediately after hydration (based on a review of variable-quality RCTs and prospective trials or case series).2 No studies supported the effectiveness of BRAT (bananas, rice cereal, applesauce, toast) diets over the infant’s usual diet.2,4 A meta-analysis of variable-quality RCTs demonstrated no significant difference in stool frequency between lactose-containing and lactose-free diets.9 Comparisons of undiluted lactose-milk with diluted milk or delayed reintroduction of milk revealed no significant differences in treatment failure or duration of diarrhea, although stool output increased slightly with the undiluted diet. However, undiluted milk was superior for restoring body weight.9
Multiple RCTs showed that Lactobacillus supplementation shortened the duration of diarrhea for infants and young children10,11 and reduced the risk of diarrhea persisting more than 3 days (relative risk [RR]=0.43; 95% CI, 0.34–0.53; P<.001; number needed to treat [NNT]=4).11 This probiotic can be reconstituted in oral rehydrating solution and administered 1 to 8 times daily, depending on the formulation.
Antidiarrheal agents are not recommended (based on limited reviews and consensus reports).2-4,12
TABLE
Evaluative strategies and therapeutic interventions for infant diarrhea
| Routine diarrhea* | Complicated diarrhea† | SOR | ||||
|---|---|---|---|---|---|---|
| Recommended | Not recommended | Recommended | Not recommended | |||
| Evaluation | Serology | X | X | B1, C2-3 | ||
| Stool culture | X | X | C2-3 | |||
| Intervention | WHO ORS (Osm 311 mmol/L) | X | X‡ | A8 | ||
| ORS (Osm 250 mmol/L) | X | X | A8 | |||
| Age-appropriate diet after hydration | X | X | C2 | |||
| Continued breast-feeding | X | X | B6,7 | |||
| BRAT diet | X | X | C2,4 | |||
| Lactose-free or dilute lactose diet | X | X | B9 | |||
| Lactobacillus (probiotic) | X | X | A10,11 | |||
| Antidiarrheal agents | X | X | C2,4,12 | |||
| * Mild to moderate dehydration, diarrhea of short duration without bloody stools, severe systemic illness, suspected food poisoning, or recent foreign travel. | ||||||
| † Severe dehydration, prolonged diarrhea, or diarrhea with bloody stools, severe systemic illness, suspected food poisoning, or recent foreign travel. | ||||||
| ‡ Recommended for treatment of cholera. | ||||||
| ORS, oral rehydration solution; SOR, strength of recommendation; BRAT, bananas, rice cereal, applesauce, and toast. | ||||||
Recommendations from others
The Centers for Disease Control and Prevention (CDC) recommends oral rehydrating solution for mild to moderate dehydration, and boluses of normal saline or Lactated Ringer’s (20 cc/kg) for severe dehydration. For frail or malnourished infants, boluses of 10 cc/kg should be given until hydrated.
The CDC also recommended against nutrition containing simple sugars (soft drinks, juice, gelatin desserts) due to high osmotic loads, but noted that diets containing some fats may have a beneficial effect on intestinal motility. They also recommended age-appropriate use of complex carbohydrates, meats, yogurt, fruits and vegetables. Zinc supplementation may also be beneficial (SOR: C).12
CLINICAL COMMENTARY
Exam should note fever, weight loss, abdominal tenderness, blood in the stool
Lettie Carter, MD
North Shore University Hospital at Glen Cove, Glen Cove, NY
The evaluation and management of an infant with diarrhea as always, begins with history. The length and severity of the illness, sick contacts, oral intake, travel, and characteristics of the stool are all important factors to consider. The physical exam should note presence of fever, weight loss, abdominal tenderness, and blood in the stool. Laboratory studies such as electrolytes, stool culture, and Wright stain are really only indicated if the child is severely dehydrated, unable to maintain hydration with oral intake and requires IV fluids, or if the episode is unusually protracted or the stool bloody.
A regular age-appropriate diet is essential, but parents should be counseled to avoid adding too much juice to the diet in an effort to rehydrate.