Travellers' diarrhoea among children returning to the United Kingdom from visits abroad

An evidence and consensus based guideline for acute diarrhoea management

OBJECTIVE

To develop an evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (with or without vomiting), a common problem representing 16% of all paediatric medical attenders at an accident and emergency department. Clinical assessment, investigations (biochemistry and stool culture in particular), admission, and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home.

EVIDENCE

A systematic review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendation were generated.

CONSENSUS

An anonymous, postal Delphi consensus process was used. A panel of 39 selected medical and nursing staff were asked to grade their agreement with the generated statements. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panelists' responses. Consensus was predefined as 83% of panelists agreeing with the statement.

RECOMMENDATIONS

Clinical signs useful in assessment of level of dehydration were agreed. Admission to a paediatric facility is advised for children who show signs of dehydration. For those with mild to moderate dehydration, estimated deficit is replaced over four hours with oral rehydration solution (glucose based, 200-250 mOsm/l) given "little and often". A nasogastric tube should be used if fluid is refused and normal feeds started following rehydration. Children at high risk of dehydration should be observed to ensure at least maintenance fluid is tolerated. Management of more severe dehydration is detailed. Antidiarrhoeal medication is not indicated.

VALIDATION

The guideline has been successfully implemented and evaluated in a paediatric accident and emergency department.

Comparison of milk and maize based diets in kwashiorkor

The dual sugar test of intestinal permeability is a reliable non-invasive way of assessing the response of the small intestinal mucosa to nutritional rehabilitation.

AIM

To compare a local mix of maize-soya-egg to the standard milk diet in the treatment of kwashiorkor.

DESIGN

The diets were alternated three monthly in the sequence milk-maize-milk. There were a total of 533 kwashiorkor admissions of at least five days during the study who received either milk or maize. Intestinal permeability was assessed at weekly intervals by the lactulose-rhamnose test in 100 kwashiorkor cases, including 55 on milk and 45 on the maize diet.

RESULTS

Permeability ratios (95% confidence interval) on the milk diet improved by a mean of 6.4 (1.7 to 11.1) compared with -6.8 (-16.8 to 5.0) in the maize group. The improved permeability on milk occurred despite more diarrhoea, which constituted 34.8% of hospital days (29.8 to 39.8) compared with 24.3% (17.8 to 30.8) in the maize group. Case fatality rates for all 533 kwashiorkor admissions were 13.6% v 20.9%, respectively, giving a relative risk of death in the maize group of 1.54 (1.04 to 2.28). The maize group also had more clinical sepsis (60% v 31%) and less weight gain (2.9 v 4.4 g/kg/day) than the milk group.

IMPLICATIONS

Milk is superior to a local maize based diet in the treatment of kwashiorkor in terms of mortality, weight gain, clinical sepsis, and improvement in intestinal permeability.

Diarrhoeal disease: current concepts and future challenges. Malnutrition and infection

In individual children in developed countries it is possible to follow a sequence of infection of the gastrointestinal tract leading to chronic diarrhoea which, if it long persists, may in turn lead to undernutrition. Both in individuals and epidemiologically in developing countries it is, by contrast, often difficult to be certain whether infection precedes under-nutrition or vice versa. Chronic diarrhoea is heterogeneous and aetiology varies from community to community. Unlike acute diarrhoea, for which there is highly effective unitary therapy (oral rehydration therapy), diverse therapies are required for chronic diarrhoea based on specific diagnoses and so render community strategies difficult. The importance of adequate calorie intake is emphasized but when there is intolerance to food ingested this is counter-productive. The relative importance of post-infective food intolerance remains controversial and in many communities is unknown. Increasing emphasis is now given to the role of infection in pathogenesis of diarrhoea and malnutrition, e.g. the acquired immune deficiency syndrome and Helicobacter pylori. Hospital-based case studies including small intestinal biopsy in individual communities, by virtue of an 'iceberg effect', may prove useful for insights into aetiology and pave the way for interventions, e.g. antibiotics or dietary therapy.

Enteropathogenic Escherichia coli and life threatening chronic diarrhoea

Enteropathogenic Escherichia coli (EPEC) infection is not generally thought to cause severe diarrhoea after the neonatal period. Patients admitted to Queen Elizabeth Hospital for Children over the three years (1984-7) with diarrhoea and EPEC infection were reviewed. Clinical details, features of small intestinal mucosa, and treatment were recorded in those who developed chronic diarrhoea with failure to thrive. Twenty six children with EPEC required hospital admission for diarrhoea and six of these (23%) developed chronic diarrhoea. In contrast only two (5%) of 42 with other serogroups of E coli (p less than 0.01) and 28 (4%) of 764 children without EPEC admitted with acute diarrhoea developed chronic symptoms (p less than 0.01). EPEC serogroups detected in the stool of the six children with chronic diarrhoea were 0128 in three, 0114 in two, and 0119 in one. The patients' clinical characteristics were: previous good health, no significant immunodeficiency, age 4-10 months, foreign travel (three of six), severe life threatening secretory diarrhoea from 0.5 to 1.5 1 per day (four of six), small intestinal enteropathy (five of six) three of whom showed mucosal adherent, non-invasive E coli of the same serotype as that in the stool, in association with microvillous loss and pedestal formation. All were treated with hypoallergenic feeds, two with parenteral nutrition, and three with parenteral antibiotics. All eventually recovered. EPEC infection is a common treatable cause of life threatening chronic diarrhoea in infancy.