Wednesday, March 6, 2013

Review Article: The Management of Acute Gastroenteritis in Children

M. Pieścik-Lech, R. Shamir, A. Guarino, H. Szajewska
Aliment Pharmacol Ther. 2013;37(3):289-303. 

Abstract and Introduction


Background In 2008, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society of Paediatric Infectious Disease (ESPID) developed evidence-based guidelines for the management of acute gastroenteritis (AGE) in children in Europe.
Aim To summarise data published subsequently to the ESPGHAN/ESPID guidelines.
Methods MEDLINE and The Cochrane Library were searched in August 2012 for randomised controlled trials (RCTs) or their meta-analyses published after 2008.
Results Efforts to improve the taste and/or efficacy of oral rehydration solution (ORS) continue, and some interventions are promising. While standard (over 24 h) nasogastric rehydration is still being used, new evidence confirms that rapid (over 4 h) rehydration is also effective. For intravenous rehydration, new evidence is available regarding rapid or ultrarapid and large-volume vs. standard-volume rehydration; as the new evidence is not consistent, until more data are available, the administration of 20 mL/kg seems appropriate. Convincing evidence has accumulated showing that ondansetron reduces the risk for vomiting; however, a clearance on safety in children is needed. New evidence has reconfirmed that in Europe, where zinc deficiency is rare, there is no benefit from the use of zinc. New data, although mainly from outside of Europe, have reconfirmed that either smectite or racecadotril is an effective adjunctive therapy to oral rehydration. There is a clear effect of using certain probiotics, such as Lactobacillus GG or S. boulardii.
Conclusions The update of current ESPGHAN/ESPID recommendations is warranted.


Acute gastroenteritis (AGE), characterised by the sudden onset of diarrhoea with or without vomiting, is one of the most common infectious diseases of childhood. In Europe, it is estimated that the incidence of diarrhoea ranges from 0.5 to 1.9 episodes per child per year in children up to 3 years of age.[1] In low- and middle-income countries, while the incidence of acute diarrhoea has declined from 3.4 episodes/child year in 1990 to 2.9 episodes/child year in 2010, the incidence of AGE remains high, especially in infants aged 6–11 months (4.5 episodes/child year).[2] Moreover, worldwide diarrhoea remains one of the leading causes of mortality among children younger than 5 years.[3]
In 2008, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society of Paediatric Infectious Diseases (ESPID) developed evidence-based guidelines for the management of AGE for practitioners at all levels of health care – primary care physicians, paediatricians and family physicians – practising in Europe.[1] In addition, a number of national guidelines have been developed, although their quality varies.[4] Perhaps the best known among them are those developed by the National Institute for Health and Clinical Excellence (NICE).[5]
Both ESPGHAN/ESPID and the NICE guidelines largely agree on key issues in the management of AGE. Oral rehydration therapy with a hypotonic solution remains central to the management of AGE. Fast oral rehydration with rapid return to regular food is recommended. The routine use of special or diluted formulas is unjustified. Continuation of breastfeeding is strongly recommended. The guidelines recommend against the routine use of antibiotics in otherwise healthy children presenting with AGE. Regarding drugs, both sets of guidelines recommend against the use of antiemetics, but they strongly emphasise the need for further research. Compared with the NICE guidelines, the ESPGHAN/ESPID guidelines make a stronger recommendation for the use of probiotics for the management of AGE, particularly those with documented efficacy such as Lactobacillus GG and Saccharomyces boulardii. The ESPGHAN/ESPID guidelines state that treatment with racecadotril (an enkephalinase inhibitor) may be considered in the management of AGE. Both sets of guidelines state that there is evidence suggesting that smectite (a natural hydrated aluminomagnesium silicate that binds to digestive mucus and has the ability to bind endotoxins and exotoxins, bacteria and rotavirus) is an effective antidiarrhoeal agent, but only the ESPGHAN/ESPID guidelines recommend that the use of smectite may be considered in the management of AGE.
The objective of this review was to summarise the more recent data on the management of AGE published subsequently to the ESPGHAN/ESPID document, and to find out whether this added information justifies revision of the guidelines. We searched MEDLINE and The Cochrane Database of Systematic Reviews in August 2012 for randomised controlled trials (RCTs) or their meta-analyses (considered the best study design for answering questions about the effectiveness of an intervention) published in the last 5 years related to the management of AGE in the paediatric population. No limit was imposed regarding the language of publication. In particular, we searched for studies on the use of enteral (oral or nasogastric) and intravenous rehydration therapy, antiemetics and antidiarrhoeal drugs [such as probiotics, (dio)smectite, zinc, racecadotril] compared with placebo or no intervention in children (for summary of evidence, see Table 1). Studies related to the use of antimicrobials are not covered in this review. We focused primarily, although not exclusively, on studies performed in high-income populations. In the case of diarrhoeal diseases, consideration of the study location is important, as factors such as pathogens, access to clean water and sanitation, or comorbidities may have an impact on outcomes.

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