diarrhea treatment an  updated protocol for  infants

Dehydration symptoms sunken eyes, low urine output, dry mucous membranes, decreased skin turgor, acute weight loss NO Protocol  A YES child is awake and drinks lethargic child, drinks poorly or refuses   PREVENT DEHYDRATION Protocol  B Protocol  C offer fluids often sugar - salts mixture  10 ml / kg after each liquid stool  oral  rehydration   (for 4 to 6 hours) intravenous  rehydration FEEDING sugar-salts mixture  10-25 ml / kg / hour *  breast - fed breast feeding  : don't stop continue  breast -feeding  more often *   bottle - fed bottle feeding  :  stop  transiently the child  does not  vomit offer the  usual  formula at  normal concentration the child vomits start formula  at  1/3  of normal concentration, as cold as possible vomiting stops one bottle at 2/3 of  normal concentration vomiting  does not resume regular formula, normal concentration Persisting diarrhea  (>  5 to 7 days) : cow's milk intolerance (allergy)     ? secondary lactose intolerance ? review dehydration status after 4-6 hours - semi-elementary   formula - soy  or  milk-based formula  without  lactose    -                     + <-----------------------> hospitalisation and / or   persistent vomiting *   Solid   foods present  a  normal  diet allow the child decide how much he/she  takes avoid hypocaloric fat-free  diet (chronic diarrhea) Oral rehydration mixtures contain sugar and various salts. Their composition aims at compensating the often massive fluid losses and correct or prevent imbalances associated with severe diarrhea (acidosis, hypo or hypernatremia, hypokalemia...). The available preparations (in pharmacy) include ORS, Gastrolyte,  GES 45, Alhydrate.  Slightly different formulas such as Soparyx or Carolyt associate rice or carrots. They are less recommended in severe cases.  These rehydration salts are used primarily as an attack treatment. It is best not to extend this phase beyond  necessity, to avoid undernutrition, a cause of slow recovery  and "starvation stools" (green with mucus) often seen wrongly as evidence of treatment failure.  Semi-elementary formulas are predigested,  hypoallergenic and contain no lactose. They include Nutramigen, Pregestimil, Alfaré,  Pepti-junior, Neocate.     The main reason to prescribe soy based formulas is that they don't contain lactose either. But soy is potentially allergenic, just like cow's milk. Other lactose free formulas are milk-based  Aptamil care,  Nan sensitive or Diarinova. The rationale for using those  formulas is the common  transient  lactose intolerance  following many infectious diarrheas. This may require the use of a lactose free or poor  formula  for several weeks, until the  gut surface has recovered its ability to digest lactose. Whenever the child vomits, fluids must be offered as cold as possible, even chilled if the infant  accepts them. Ice creams can be used in older children if they are able to take them.  Cold  tends to open the pyloric sphincter, a  ring muscle separating the gut from the stomach.  The latter can then more easily empty into the gut, instead of upwards.  Anti - vomiting medications such as domperidone (Motilium) are sometimes useful, but rather less effective than this dietary approach.  A soon as possible, a  yeast (saccharomyces boulardii)  sold under the name Entérol  (Ultralevure in France) in packets or capsules,  at the dosage of  2  x  100 mg a day, should be taken, mixed with food. This speeds up recovery, even in viral diarrheas, by far the most frequent. A commercial preparation (Antedia duo) associates this yeast to  a  lactobacillus  probiotic and could be  slightly more effective.   --------------------------------------------- Antibiotics and gut antiseptics are seldom useful, even if it is cautious to leave a stool sample at the laboratory as early as possible, for analysis and culture. Stool cultures grow slowly. In some diarrheas it  may take a week or more to have a result, and a diagnosis.  Sometimes antibiotics with delay the healing process, without bringing any significant benefit. In infectious diarrheas, the symptom is an essential component of the healing process, each stool eliminating billions of germs from the body.   It is also why medications such as loperamide (Imodium), prescribed to adults in order to slow down the intestinal transit and reduce stool volume are not much used in children. They can cause  infected stools accumulations in the gut and mask  dehydration more than prevent or alleviate  it. Their use is held responsible for some fatalities in feverish  young children with severe diarrhea.      --------------------------------------------- In case of  fever, paracetamol (called acetaminophen in North America), for instance as Perdolan or Dafalgan syrups, or as Tylenol,  is preferable to ibuprofen (Junifen, Motrin). Ibuprofen may irritate the stomach and increase the risk of vomiting. Suppositories are not recommended in diarrheas, since they are likely to be rejected too quickly.   ----------------------------------------------- Adsorbing preparations (Carbobel,  Barexal, Carbolactanose,  Tanalone) are sometimes prescribed but  not adapted to severe diarrheas during the acute phase, and when the child is improving, it is dubious that they can make  a significant difference  over   "constipating"  foods (rice, cooked carrots, bananas, grated apples or apple sauce...).