what to do with all that poo

It seems like it is always gastro season in clinic. Teaching conference tomorrow will be about one of the uncommon, but life threatening diagnoses associated with diarrhea in children. Do you know what to do for the masses of children with more mundane, acute viral gastroenteritis? Here’s a quick post to review some common options once you are reassured that a child does not require further workup, for guidance, see the IDSA guidelines. There are many good resources for management, below I reference guidance from the ESPGHAN but the CDC, AAP and others have similar recommendations.

First up, the BRAT diet, bananas – rice – applesauce – toast. This is a classic that I am sure nearly everyone was told to utilize at some point in their life. These foods are 1) fairly benign, 2)contain fiber, and 3) seem like a reasonable choice. Problem is, they doesn’t seem to actually improve duration or amount of diarrhea and may limit important micro-nutrients in a child’s diet that may be helpful. Some kids are picky enough, when they are sick the name of the game should be get in whatever nutrition you can as early and often as possible. Similarly, zinc is often suggested as a possible supplement, though this has really only shown utility in settings where the prevalence of zinc deficiency is quite high – aka not in most places in the US.

What about milk? It is actually possible that, due to a post-viral transient lactase deficiency, some children benefit from reducing the amount of lactose in their diet for a short period. Breastfeeding children should not be switched to anything except more breast milk however. Families could try decreasing the milk intake for older kids, or switching formula fed infants to a non-milk based formula (one of the very few uses for soy formula) for a week or so. In practice, I tell people to only do this if it seems like things aren’t improving or milk causes symptoms. If the child can drink milk, and it doesn’t seem to cause trouble, let them have milk. Remember that too much juice can also worsen diarrhea as well due to the osmotic effects of excessive fructose in the GI tract – aka Toddler’s Diarrhea – a complicating factor for the child who is not eating and drinking 48 ounces a day of apple juice to stay hydrated.

Probiotics? Sigh, this article and this one from Canada, both published in NEJM were quite the buzz-kill in terms of my clinic based gastro management. See this blog post from PEMBlog (pemcincinati.com) for an interview with one of the US study’s authors, Dr. Schnadower. They basically showed that probiotics were no better than placebo in management of acute gastro. Prior to these studies, this was the one thing it seemed we could offer that might help families tame the tide of gastro washing through their homes…

Medication would be nice, but there are good reasons to avoid antibiotics (see this week’s resident led teaching conference on HUS) beyond the fact that they are largely useless. Loperamide, an anti-motility agent is also a big no-no given the risk of adverse effects related to the ileus (toxic megacolon) as well as systemic effects like lethargy.

So what’s a pediatrician to do? It is always helpful to review good hand washing. Be sure to address spread to other family members, especially if there are high risk (young or otherwise ill) members of the household and advise exclusion from daycare or school while a child still has diarrhea, which can (unfortunately) last several days, if not longer, though most gastro is relatively short lived.

Andi L Shane. et. al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea, Clinical Infectious Diseases, Volume 65, Issue 12, 15 December 2017, Pages e45–e80, https://doi.org/10.1093/cid/cix669

Ashkenazi, S., et. al. (2014). Infectious Diseases Evidence-Based Guidelines for the Management of Acute Gastroenteritis in Children in Europe : Update 2014, 59(1), 132–152. https://doi.org/10.1097/MPG.0000000000000375

Freedman et al. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med 2018; 379:2015-2026. DOI: 10.1056/NEJMoa1802597.

Schnadower et al. Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children. NEJM 2018; 379:2002-2014. DOI: 10.1056/NEJMoa1802598.

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