MAIN RECOMMENDATIONS FOR TREATING DIARRHEA IN CHILDREN UNDER 10 YEARS OLD ACCORDING TO THE TREATMENT GUIDELINES OF THE WORLD HEALTH ORGANIZATION (WHO)

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1. Treatment of Diarrhea and Use of Antibiotics in Children Under 10 Years Old

Recommendations:

– For children under 10 years old with acute watery diarrhea (regardless of the cause), WHO recommends not using antibiotics (Conditional recommendation, low evidence).

– For children under 10 years old with persistent diarrhea (regardless of the cause), WHO does not provide recommendations regarding the use of antibiotics (due to lack of evidence).

Summary of Evidence:

– A systematic review was conducted based on 5 studies related to acute watery diarrhea (13,114 participants, including children over 5 years old), in low- and middle-income countries (Egypt, India). No studies related to persistent diarrhea were found. The antibiotics used were nitazoxanide and azithromycin. Conclusion: low-quality evidence suggests increased recovery rates, reduced duration of diarrhea, no clear difference in mortality. Very low evidence on increased microbiological recovery rates and the need for IV fluid administration.

– Additional evidence: A new study evaluated azithromycin added to the WHO standard regimen for children aged 2–23 months. The results showed no improvement.mortality within 180 days, clinical improvement only slightly improved and no difference in antibiotic resistance status.

Evidence-based decision:

– No clear mortality benefit from antibiotic use.

– Risks from antibiotics (side effects, drug resistance) outweigh uncertain benefits.

– High costs and unclear benefits => WHO does not recommend the use of antibiotics.

 2. Treatment of bloody diarrhea in children under 10 years old

Recommendation: In children under 10 years old with diarrhea accompanied by blood in the stool, WHO recommends treatment with antibiotics compared to not using antibiotics (Strong recommendation, moderate to low-quality evidence).

Note:

– Preferred choice: Ciprofloxacin 15 mg/kg/dose, twice daily for 3 days.

– Alternative choice: Ceftriaxone 50–80 mg/kg/day for 3 days.

Summary of evidence: Based on a previous Cochrane review on antibiotics in the treatment of Shigella dysentery, WHO has made a strong recommendation for the use of antibiotics when results show that untreated children may face serious complications. At the same time, healthcare providers should refer to local antibiotic resistance patterns and the WHO AWARE list.

3.Treatment of Diarrhea with Zinc in Children Under 10 Years Old

Recommendations:

– For children with acute watery diarrhea: WHO recommends oral zinc supplementation(3) (Strong recommendation, moderate evidence).

– For children with persistent diarrhea: WHO recommends oral zinc supplementation (Strong recommendation, moderate evidence).

– For all forms of diarrhea: WHO suggests a dose of 5 mg of zinc/day (Conditional recommendation, low evidence).

Note: Zinc gluconate causes less vomiting than other forms, treatment duration: 10–14 days. A low dose (5 mg) causes less vomiting and is equally effective as a high dose.

Summary of Evidence: A systematic review based on the results of 38 major clinical trials (43 articles), including both high and low-income countries. The analysis results show that the recovery rate increased by 75% (RR 1.75), the average duration of diarrhea decreased by 26.29 hours, and there was no difference in mortality rates. From this, it is concluded that the use of zinc may help reduce the need for antibiotics. Additionally, zinc is inexpensive, accessible, familiar to the public, and the healthcare system.

 4. Treatment of Diarrhea with Probiotics in Children Under 10 Years Old

Recommendations:

-Children with acute watery diarrhea: WHO recommends not using probiotics (Conditional recommendation, low evidence).

– Children with prolonged diarrhea: WHO does not provide a recommendation (lack of evidence).

Note: There are many issues related to the use of probiotics such as: high cost, difficulty in storage, and unclear regulation. Although there is potential for prolonged diarrhea, further research is needed.

Summary of evidence: Results are summarized from 99 studies (mainly RCTs), on various types of probiotics. For acute watery diarrhea: the clinical recovery rate slightly increased (RR 1.23; CI 95%: [1,01–1,49]); the mortality rate decreased (RR: 0.17, but not due to diarrhea); the average duration of diarrhea decreased by 7.2 hours. The results showed no significant differences in adverse clinical outcomes, increased side effects, or serious side effects between the groups. For prolonged diarrhea (2 studies), the results indicated that the average duration of diarrhea decreased by 96.45 hours.

5. Treatment of diarrhea accompanied by dehydration with low-osmolarity rehydration solution

Recommendation: Children under 10 years old with acute watery diarrhea accompanied by dehydration: WHO recommends the use of low-osmolarity rehydration solution (LORS)(5) (Strong recommendation, moderate evidence)

Summary of evidence: A systematic review was conducted based on 9 RCTs involving 1942 children, primarily from low- and middle-income countries (Bangladesh, India, Egypt…) and children under 5 years old comparing LORS and standard ORS. The results showed that in the group using LORS, the average duration of diarrhea decreased, the amount of electrolyte solution needed to drink decreased, the rate of intravenous fluid administration decreased (but not significantly), and there was no clear difference in the number of children recovered after 5 days. From this, WHOstrongly recommends the use of LORS for all children under 10 years old with acute diarrhea accompanied by dehydration, due to its equivalent or better effectiveness compared to regular ORS, less need for intravenous fluids, lower cost, and safety.

References: WHO (2024), Guideline on management of pneumonia and diarrhea in children up to 10 years of age, access link: https://www.who.int/publications/i/item/9789240103412

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