The efficacy of bismuth subsalicylate in the treatment of acute diarrhoea and the prevention of persistent diarrhoea

A controlled, randomized, double-blind study in Bangladeshi children (ages 4-36 mo) with acute diarrhoea was undertaken to determine whether bismuth subsalicylate (BSS) would prevent the development of persistent diarrhoea (PD) in young children. The children were randomized to two groups: 226 were given liquid oral BSS, (as Pepto-Bismol), 100 mg/kg/d for 5 d; 225 were given placebo of identical appearance. On admission to the study, the two groups were comparable both clinically and microbiologically. Rotavirus was found in 56% of all the children, and enterotoxigenic E. coli in 31% of a subsample studied. Children treated with BSS had less severe and less prolonged illness than those treated with placebo (p = 0.057). There was, however, no difference in the development of PD between the two groups (8% and 11%). Unexpectedly, patients treated with BSS gained significantly more weight (2.3%) than those treated with placebo (0.5%; p < 0.001) during the course of the study. No toxicity of BSS was detected. Conclusion: Treatment with BSS had a modest therapeutic effect on acute diarrhoea, as has been previously demonstrated, but with no suggestion of a therapeutic effect on the prevention of persistent diarrhoea in this group of patients.     

Clinical characteristics of transient glucose intolerance during acute diarrhoea

Transient glucose intolerance (TGI) is an important cause of WHO G-ORS (Glucose-Oral Rehydration Solution) treatment failure and hospitalization in dehydrated children during acute diarrhoea. This retrospective case-control study was designed to determine some risk and predictive factors for developing TGI among moderately dehydrated patients with acute diarrhoea while under G-ORS therapy. Among moderately dehydrated patients, files of 22 patients with TGI and 66 other dehydrated patients without intolerance were reviewed. Patients with TGI were younger (9.7+/-10.5 mo and 11.6+/-7.8 mo, respectively, p < 0.05), the median age being 6 mo in the TGI group and 10 mo in non-TGI group. There was no difference between groups for sex, admission season, history of fever or vomiting, frequency of vomiting, presence of blood, mucous or leukocyte in stool, presence of associated disease and duration of diarrhoea on admission. The admission haemoglobin, white blood cell, blood pH, sodium and potassium levels were similar in both groups. The mean serum chloride level (116.8+/-6.9, 109.6+/-7.9 mEq/l, respectively, p<0.05) was higher in the TGI group and the bicarbonate level was lower (12.9+/-3.8, 15.3+/-6.0, respectively, p < 0.05). Stool frequency was also higher in patients with TGI (11.2+/-5.3/24 h, 5.9+/-4.4/24 h, respectively, p < 0.05). No difference was found between the nutritional status of children in both groups. More children were breastfed in the group without TGI (34/56, 61%, 6/18, 33% respectively, p=0.079, OR=0.32, 95% CI [0.09-1.11]). It was concluded that patients with TGI are younger and have high stool frequency. Although statistical significance could not be shown, breastfeeding seems to protect children from TGI, as it protects from diarrhoea.     

Efficacy of Lactobacillus rhamnosus GG in acute watery diarrhoea of Indian children: a randomised controlled trial

AIM: To evaluate the role of Lactobacillus rhamnosus GG (LGG) as probiotic in acute watery diarrhoea (AWD). SETTING: Hospital-based study. DESIGN: Randomised, controlled, blinded trial. PATIENTS AND METHOD: All patients of AWD (n = 684) admitted over 1-year period were invited to participate in the study as per predefined inclusion and exclusion criteria and were randomised to intervention and control groups. After adequate rehydration the intervention group (n = 330) received ORS with probiotic powder containing 60 million cells of LGG, while the control group (n = 332) received ORS alone twice daily for a minimum period of 7 days or till diarrhoea ceased. During the study period all patients received ORS and/or IV fluids for ongoing losses, and nutritional supplementation. None of them received any antibiotic or antidiarrhoeal medication. After exclusion of 16 patients, 646 (323 in each arm) patients completed the study. The daily frequency and total duration of diarrhoea and vomiting and the length of hospital stay were studied. Data were analysed by SPSS-10 software. Statistical significance was calculated by Student's t-test and chi2-test. RESULTS: Rotavirus was isolated in 75.85%. There was no significant difference between treatment groups in the daily frequency or duration of diarrhoea or vomiting or in the length of hospital stay. No complication was observed from the use of LGG. CONCLUSION: LGG supplementation does not decrease the frequency and duration of diarrhoea and vomiting in children with AWD, and does not reduce hospital stay in these patients.     

Folic acid in the treatment of acute watery diarrhoea in children: a double-blind, randomized, controlled trial

One-hundred and six male children aged 6-23 months with a history of acute watery diarrhoea of less than 72 h duration were randomized to receive either folic acid in a dose of 5 mg at 8-h intervals or placebo for 5 d. There were 54 children in the folic acid group and 52 in the placebo group. The admission characteristics were comparable between the two groups. No significant differences were observed in the intake of oral rehydration solution or stool output between the groups. The mean ± SD of total stool output (g kg⁻¹) was 532 ± 476 vs 479 ± 354 and the duration (h) of diarrhoea was 108 ± 68 vs 103 ± 53 in the folic acid vs placebo group, respectively. The findings, therefore, should have a positive influence on preventing the inappropriate use of folic acid in acute diarrhoea.     

Double-blind, randomized, controlled trial of zinc or vitamin A supplementation in young children with acute diarrhoea

In a double-blind, controlled trial with a factorial design, 684 patients (aged 6 months to 2 y; excludes 6 early dropouts) with acute watery diarrhoea of 3 d or less and some dehydration, who were attending a hospital, were randomly assigned to 4 groups to receive: (a) vitamin A 4500 microg retinol equivalent daily for 15 d; (b) 14.2 mg elemental zinc as acetate for the first 417 patients and 40 mg of the remaining 273 patients randomized to this group for 15 d; (c) both vitamin A 4500 microg retinol equivalent and zinc at the above doses daily for 15 d; or (d) placebo mixtures for 15 d. Patients were observed in the hospital for 24 h and followed up at home for 15 d. All received ascorbic acid 30 mg with each dose of medicine or placebo. Zinc supplementation was associated with a reduced duration of diarrhoea (13%, p = 0.03) and markedly reduced rate (43%, p = 0.017) of prolonged diarrhoea (>7 d). Vitamin A supplementation was associated with a nonsignificant trend for reduced rate of prolonged diarrhoea (p = 0.089). In conclusion, zinc supplementation as adjunct therapy had a substantial impact on the rate of prolonged diarrhoea and some impact on duration and may be beneficial in children with diarrhoea in developing countries.     

Effects of Saccharomyces boulardii in children with acute diarrhoea

AIM: Certain probiotic agents, e.g. Lactobacillus GG, have shown efficacy in clinical trials for the treatment of acute childhood diarrhoea, but few studies have examined the effect of Saccharomyces boulardii. We evaluated the effect of S. boulardii in children with acute diarrhoea. METHODS: Two hundred children were randomized to receive S. boulardii in a granulated form in a daily dose of 250 mg (S. boulardii group) or placebo (placebo group) for 5 d. Clinical and demographic characteristics on admission were similar between the study groups. RESULTS: The medians of the average stool frequency after the second day of the treatment were significantly lower in the S. boulardii group than in the placebo group (p = 0.003). The duration of diarrhoea significantly reduced in the S. boulardii group compared with the placebo group (4.7 vs 5.5 d, p = 0.03). The effect of S. boulardii on watery diarrhoea became apparent after the second day of the treatment. The duration of hospital stay was shorter in the S. boulardii group than in the placebo group (2.9 vs 3.9 d, p < 0.001). Four children from the placebo group versus only one child from the S. boulardii group had persisting diarrhoea. CONCLUSION: The placebo-controlled study suggested that S. boulardii significantly reduced the duration of acute diarrhoea and the duration of hospital stay. S. boulardii seems to be a promising agent for the amelioration of the course of acute diarrhoea in children when used therapeutically.     

Overview of Childhood Acute Diarrhoea in Europe: Implications for Oral Rehydration Therapy

Guandalini, S. (Department of Pediatrics, University of Naples, Naples, Italy). Overview of childhood acute diarrhoea in Europe: Implications for oral rehydration therapy. Acta Paediatr Scand Suppl 364: 5, 1989.
Infant mortality from acute diarrhoea has sharply declined in the last few decades throughout Europe. However, acute diarrhoea is still a very common occurrence in European children, who experience, in their first 3 years of life, approximately 1 episode/year. The commonest agent responsible for infectious diarrhoeas appears to be rotavirus, followed by campylo-bacter. Although water loss may be high, the mean sodium Loss is close to 40 mmol/l of stool in rotaviral diarrhoea, and to 60 mmol//l in diarrhoeas due to invasive pathogens such as campylobacter and salmonella. Larger fluid losses but a somewhat lower sodium loss accompanies non-cholera secretory diarrhoeas, which appear to be commoner in infants than in older children. This evidence indicates that an ORS for European children should have a sodium concentration lower than 90 mmol/l which was primarily intended for use in developing countries. Clearly, the glucose concentration is crucial, as it is now evident that concentrations higher than the recommended 110 mmol/l may lead, particularly in rotaviral enteritis, to worsening of diarrhoea and development of hypernatraemia. Finally, it appears that in Europe the use of commercially available ORS is strikingly low, so that infants and children are often given a variety of "clear fluids", generally inadequate to ensure proper rehydration or maintenance of hydration. Thus an effort should he made not only to devise the "ideal" solution, but also to effectively implement its use.     

Acute pancreatitis in paediatric systemic lupus erythematosus

Acute pancreatitis (AP) rarely complicates the clinical course of systemic lupus erythematosus (SLE). AP as the initial manifestation of SLE is exceptional, but its outcome is often fatal. Corticosteroids have been suspected to play a role in the development of AP, but the therapeutic benefit seems to be far above the risk of exacerbation of pancreatic lesions. We report a 13-y-old girl presenting with arthralgia and malaise, followed by abdominal pain, generalized oedema and haemodynamic instability. Increased CRP (325 ng/ml), serum amylase (14,000 IU/l) and lipase (2500 IU/l) levels suggested AP. Acute anuric renal failure required haemodialysis. Multiorgan involvement suggested SLE, which was confirmed 3 d later by increased anti-ds-DNA levels. Three methylprednisolone pulses were administered promptly, followed by oral prednisone (1.5 mg/kg/d) and six pulses of cyclophosphamide (500 mg/1.73 m2/2 wk). Mycophenolate mofetil was introduced for long-term disease control. Amylase and lipase levels decreased over 4 wk. Renal function was normal after 3 wk and proteinuria negative after 6 wk.This case suggests that steroid pulse therapy should be promptly administered if clinical and biochemical investigations suggest SLE to be responsible for AP. Aggressive treatment may be life saving.     

Randomized, controlled, clinical trial of rice versus glucose oral rehydration solutions in infants and young children with acute watery diarrhoea

A randomized clinical trial was carried out to compare a packaged ready-to-mix rice oral rehydration solution (ORS) to the standard glucose ORS for the treatment of childhood diarrhoea. Children were of either gender, aged 3–35 months, presenting with a history of watery diarrhoea for 72 h or less. The main outcomes examined were stool output, ORS intake, duration of diarrhoea and nutritional recovery during follow-up at 16 d of illness. Stool output in the first 24 h (106 vs 107 g kg^-1), ORS intake in clinic (93 vs 102 ml per motion) and duration of diarrhoea (88 h vs 81 h) were similar in the two treatment groups. The few episodes that became persistent were similar (2%) in the two groups. The weight gain during follow-up was similar in the two ORS groups.     

Quantitative determination of single serum proteins during acute hepatitis in childhood

Fifteen serum proteins were estimated by linear immunodiffusion in blood samples from children with acute hepatitis.Blood was drawn at the beginning of the disease and three weeks later. The results were compared with results obtained from a group of age-matched normal children.At the beginning of the disease prealbumin and beta-2-glycoprotein I were depressed, whereas alpha-1-acid-glycoprotein, alpha-1-antitrypsin, ceruloplasmin and alpha-2-HS-glycoprotein were found to be elevated.Alpha-2-macroglobulin, transferrin and beta-lipoprotein showed a significant elevation after three weeks. Beta-1-A/C, IgM and IgG remained elevated during the time of observation.Albumin, haptoglobin and IgA were similar in patients and controls and did not change during the period of observation.Dedicated to Prof. Dr. H. Bickel on the occasion of his 60th birthdaySupported by Deutsche ForschungsgemeinschaftThis work is part of the M.D. thesis of C.M. and was presented in part at the 26th congress of the Süddeutschen Kinderärzte, Stuttgart, June 1977     

Enteric infections,cow's milk intolerance and parenteral infections in 118 consecutive cases of acute diarrhoea in children

One hundred and eighteen consecutive cases of childhood acute diarrhoea (mean age: 10.5 months) were studied after admission to our Pediatric Unit in Naples over a 13-month period. A diagnosis was established in 92 patients (78%): 55% of patients were found to have an infectious enteritis (among them, 5 had ETEC infections and 1 had an ST-producing Klebsiella infection), 12% a parenteral infection, 11% cow's milk intolerance. The occurrence of gross blood (P<0.01), leukocytes, and reducing substances in the stools was more commonly associated with infectious enteritis than with diarrhoea due to all other causes. In 14 patients (8 of whom were malnourished), diarrhoea ran a prolonged course. In all, the eventual outcome was favourable.Our findings, while confirming that infectious enteritides account for most of acute diarrhoeas in children, stress the importance of parenteral infections and cow's milk intolerance in this condition. Also, the need for an accurate search for enterotoxigenicity of enterobacteria before ruling out their pathogenetic role is stressed.Abbreviations ETEC enterotoxigenic Escherichia coli - ESR erythrocyte sedimentation rate - CMPI cow's milk protein intolerance - UTI urinary tract infection This work was supported by the 1982 grant 82.02295.56 from the National Research Council (C. N. R.)     

降钙素原和C-反应蛋白对儿童全身和局部细菌感染的诊断价值

目的 探讨降钙素原（PCT）和C-反应蛋白（CRP）对诊断全身和局部细菌感染的价值。方法 检索2011年1月至2012年6月在深圳市儿童医院住院病史系统中感染性疾病患儿的资料,分为全身细菌感染组（血培养阳性的严重脓毒症和败血症）,局部细菌感染组（急性化脓性扁桃体炎、泌尿系感染及化脓性骨关节炎）,病毒感染组（传染性单核细胞增多症和手足口病）。比较各组PCT、CRP水平和阳性率的差异。绘制受试者工作曲线（ROC）,计算曲线下面积（AUC）,评估PCT和CRP对全身和局部细菌感染的诊断价值。结果 148例患儿进入分析,全身细菌感染组19例,局部细菌感染组55例,病毒感染组74例。①CRP水平(mg·L-1)、PCT水平(μg·L-1)和PCT阳性率局部细菌感染组低于全身细菌感染组（CRP：21.35 vs 76.0,P＝0.001;PCT:0.10 vs 28.09, 32.7% vs 100%,P均<0.001）;CRP水平和阳性率局部细菌感染组高于病毒感染组（21.35 vs 4.0, 73.1% vs 27.0%, P均<0.001), PCT水平和阳性率局部细菌感染组与病毒感染组差异无统计学意义。3组WBC计数差异无统计学意义;WBC阳性率全身细菌感染组高于病毒感染组（84.5% vs 54.0%,P=0.017）,局部细菌感染组与全身细菌感染组、病毒感染组差异无统计学意义。②PCT水平和阳性率局部细菌感染合并全身炎症反应综合征（SIRS）患儿显著高于不合并SIRS者（0.40 vs 0.08,P＝0.002;60.0% vs 17.1%, P＝0.001）,CRP水平和阳性率无显著差异。③PCT和CRP诊断全身细菌感染的ROC AUC分别为0.99和0.84;诊断局部细菌感染的ROC AUC分别为0.54和0.78。结论 PCT是识别全身细菌感染和监测局部细菌感染进展而合并SIRS的敏感指标。鉴别局部细菌感染时,CRP较PCT敏感。     

Serum Albumin, Retinol-binding Protein, Thyroxin-binding Prealbumin and Acute Phase Reactants as Indicators of Undernutrition in Children with Undue Susceptibility to Acute Infections

ABSTRACT. This study was conducted in order to test the usefulness of measuring the concentrations of selected serum proteins and acute phase reactants in assessing the nutritional status of children with undue susceptibility to acute infections. The concentrations of serum proteins were determined by an immunodiffusion technique in 28 children with undue susceptibility to infections and were compared with those in healthy children. The patients were grouped according to the clinical pattern, i.e. into children with mainly upper respiratory tract infections, with frequent middle ear infections and with lower respiratory tract infections. The total group and all three subgroups of patients had not only significantly lower ( p < 0.001 or p < 0.01) mean serum levels of albumin and retinol-binding protein, but also of the acute phase reactants α₂-macroglobulin and ceruloplasmin ( p < 0.01) than the controls. No differences were observed between the patients and the controls in respect of the acute phase reactant orosomucoid. This study indicates that the concentrations of albumin and RBP along with selected acute phase reactants are rapidly influenced by altered nutritional status in children with undue susceptibility to acute infections.     

Risk factors for development of dehydration in young children with acute watery diarrhoea: a case-control study

In a case-control study to understand the risk factors for development of life-threatening dehydration, a total of 379 children comprising 243 cases (moderate or severe dehydration) and 136 controls (non or mild dehydration) up to 2 years of age suffering from acute watery diarrhoea were studied. By univariate analysis, the presence of vibrios in stool, withdrawal of breast feeding during diarrhoea, not giving fluids, including oral rehydration solution (ORS), during diarrhoea, frequent purging (> 8/ day), vomiting (> 2/day) and undernutrition were identified as risk factors. However, by multivariate analysis after controlling for confounders, withdrawal of breast feeding during diarrhoea (odds ratio (OR) = 6.8, p < 0.00001) and not giving ORS during diarrhoea (OR = 2.1, p < 0.006) were identified as significant risk factors. The confounding variables which also contributed significantly to increasing the risk were age (≤ 12 months; OR = 2.7, p = 0.001), frequent purging (> 8/day; OR = 4.1, p < 0.00001), vomiting (> 2/day; OR = 2.4, p = 0.001) and severe undernutrition (%median <60 weight-for-age of Indian Academy of Paediatrics classification; OR = 3.1, p = 0.001). We feel that these findings will be useful for Global and National Diarrhoeal Diseases Control Programmes for formulating intervention strategies for preventing death due to diarrhoeal dehydration.     

Validation of the verbal autopsy method to ascertain acute respiratory infection as cause of death

The validity of the Verbal Autopsy (VA) in death due to acute respiratory infection (ARI), Was tested in 36 children who died by any acute infectious disease as stated by the necropsy diagnosis, at two public hospitals in Mexico City; the illness started at home. Clinical data obtained through VA were compared with diagnoses of necropsies, which were considered as “gold standard”. The presence of dyspnoea for more than one day showed sensitivity of 0.69 and Specificity of 0.74, while history of coughing showed a sensitivity of 0.61 and a specificity of 0.73. Combination of both clinical data improved specificity (0.83), but decreased sensitivity (0.54). Additional sources of diagnosis (a panel of assessors, the clinical record and the death certificate), also showed good sensitivity (0.69–0.77) and specificity (0.74–7.8). Focus on history of dyspnea and/or cough in children with an infectious syndrome should be emphasized, as a useful epidemiologic tool to determine children’s mortality due to ARI in areas where diagnosis resources are constrained.