The only effective treatment for diarrhea is hydroelectrolytic replacement using the glucose-electrolyte solution and the methodology for oral administration recommended by PAHO. Antimicrobial drugs should be used only for some diarrheas caused by invasive bacteria or parasites and in cases of cholera.
Antispasmodics are also not recommended. Although they relieve cramps and reduce the number of bowel movements, at the same time they reduce intestinal movements without decreasing the secretion process, causing intestinal stasis. The use of these medications in cases of invasive diarrhea may prolong the duration of the disease; in cases of toxigenic diarrhea, they may cause fluid accumulation.
Nor has it been proven that so-called antidiarrheal drugs produce an important effect, with the exception of bismuth, which must be used in large and repeated doses in order to be effective. It should be kept in mind that diarrhea is a defense mechanism that serves to eliminate microorganisms and their toxic products. Consequently, treatment must be directed toward normalizing the processes of intestinal absorption and secretion, as well as replacing fluids and electrolytes.
PAHO promotes the use of oral rehydration therapy. Most of the time, it achieves good fluid replacement. However, there are some diarrheas in which the rate of fluid and electrolyte loss is greater than the rate at which serum can be administered orally. Only in these cases is it necessary to use either an antidiarrheal medication or intravenous rehydration.
Based on the previous considerations, the following may be stated:
· Oral rehydration therapy should be applied to all children with dehydration due to diarrhea, except when there is shock or pre-shock, paralytic ileus or marked abdominal distension, intense sedation, marked irritability, uncontrollable vomiting, four or more episodes of vomiting in one hour that make oral rehydration impossible, or severe respiratory difficulty. The methodology for treatment and the strategies for its application have been published previously.
· During the first two hours of treatment, it can be determined whether it will be possible to rehydrate the child completely by mouth. In general terms, in 95 to 97% of cases, oral serum is accepted and tolerated, vomiting disappears and a good response is observed, with improvement in the general condition. The child becomes calmer and may even sleep because thirst has decreased.
When a good response is not observed during the first two hours of treatment, it may be that the diarrhea increases markedly or that vomiting is not controlled. In these cases, oral rehydration should be suspended and intravenous rehydration should be used.
In cases of diarrhea without dehydration, oral serum is administered mainly to replace losses of water and electrolytes and to prevent dehydration. The amount of serum is determined according to the child’s age, as well as the frequency and volume of bowel movements.
In general terms, it is recommended to administer a quantity of oral serum after each bowel movement, alternating it with the administration of food, over 24-hour periods.
Feeding the Child with Diarrhea
The current tendency is not to interrupt the administration of food, either during the acute phase of the disease or during the convalescence period. In children with dehydration, a period of oral rehydration lasting approximately six hours is established.
During this period, it is recommended to administer only oral serum. However, breastfed children may receive breast milk after the first two hours of rehydration. At the end of rehydration, the second phase of treatment begins, in which food administration is started and serum continues to be supplied each time the child has a bowel movement. This phase is called the feeding and hydration-maintenance phase.
Whenever possible, the first food offered should be milk. In breastfed children, no problems arise because breast milk is well tolerated. For that reason, it should never be suspended, except during the first 24 hours of rehydration.
Children who are bottle-fed should be given undiluted cow’s milk, in small quantities but more frequently. It is not advisable to give diluted milk, since it has been shown that most children with diarrhea tolerate it when administered in that form. On the other hand, there is a risk of introducing among mothers the idea that sick children should be fed only diluted milk.
When milk is not available, cereal flours may be used. Children older than six months may be given vegetable puree, rice, banana and egg.
However, most physicians and nutritionists fear worsening the diarrhea by providing food, since they do not have a simple clinical or laboratory methodology for diagnosing cases of food intolerance or malabsorption. The presence of reducing substances in the stool, an acidic pH, or the determination of D-xylose malabsorption does not correlate adequately with nutrient absorption.
