Diarrhea and Dehydration in Children Traveling Abroad

Scott J. Cohen, M.D.

General Treatment of Travelers' Diarrhea in Children

The overwhelming majority of cases of traveler's diarrhea in children resolve spontaneously without medications. Laboratory diagnosis is often difficult to obtain while traveling abroad, and generally unnecessary. Hydration is the mainstay of treatment. Parents should be comfortable with oral rehydration solution (ORS) and rehydration techniques able to recognize and treat the signs of dehydration, and able to deal with severe dehydration. For children with mild to moderate dehydration, ORS should be given. If the child is not vomiting and shows clinical signs of good hydration, parents can resume feeds with starches and bananas as soon as the child is ready to eat.

Pre-travel instructions can help parents make difficult decisions when children do not respond to simple treatments and there are no medical facilities, or there are language barriers, for example. Ideally, parents should seek medical care in the capital city, or the closest large town where there likely is a pediatric hospital, and physicians may speak their language. ORS should be continued en route. If immediate treatment is essential, the parents should take the child to the nearest health clinic. Warning signs of severe dehydration that parents should be aware of include:

• A very ill appearing child, decreased activity
• Decreased urine output, no tears with crying, and dry mouth
• Persistent vomiting after repeated attempts to give small amounts of ORS
• Child's refusal to take oral fluids
• Persistent bloody stools with fevers.

Oral Rehydration Solutions (ORS)

Parents should carry appropriate ORS. These are available in packets of powder, and can be carried from home or purchased from pharmacies in most countries. Packets from WHO are available worldwide. Parents can also make their own solutions. Obviously, solutions must be made/mixed with disinfected water.

HOME MADE OPTION #1:
1 liter disinfected water
1 teaspoon salt
2½ tablespoons sugar
½ cup of orange juice, or coconut milk, or mashed banana for potassium additive.

HOME MADE OPTION #2:
1 liter disinfected water
2 tablespoons sugar
¼ teaspoon salt,
¼ teaspoon of baking soda
½ cup of orange juice, or coconut milk, or mashed banana for potassium additive.

If sugar is unavailable, honey may be substituted if the child is over 1 year of age. In addition, 1 liter of water from boiled rice is an acceptable substitute for sugar.

As a last option, parents can use sports drinks, often available in powder form. These are increasingly available but have drawbacks. They should be mixed to half-strength. Full-strength sport drinks are hypertonic in children, and offer less absorption from the gut.

Treatment for mild to moderate dehydration

FIRST 4 HOURS:

• Give 50 - 100cc/kg of ORS
• Give 1 teaspoonful (5cc) for children less than 2 years of age every 1-2 minutes.
• Frequent sips from a cup for older children.
• Fluids should be given slowly initially, until children demonstrate that they will tolerate them without vomiting; then the volume of fluids can be liberalized.
• If children vomit, wait 10-20 minutes, and resume fluids slowly.

REMAINING HOURS AND DAYS:

• Ideal intake should be at least 100cc/kg/day. This is in addition to the initial bolus given during the first 4 hours
• Breastfed children should be encouraged to breastfeed in addition to ORS.
• As soon as the child feels ready to eat, they should do so; avoid dairy products, meats, or greasy foods.

Medications

A 3-day course of antibiotics may be helpful when children have bloody diarrhea lasting longer than 3 days, or if there is a prolonged course of non-bloody diarrhea in an ill-appearing child. This strategy addresses both Shigella species as well as Enterotoxic E. coli (ETEC), two of the more common causes of traveler's diarrhea. Ciprofloxacin is very effective against both organisms but is presently only recommended in adults. In children, sulfamethoxazole/trimethoprim (SMZ-TMP) or azithromycin may be used but resistance to them is increasing; Azithromycin may be the better of the two. They can be prescribed prior to departure, with clear instructions as to when and how to use. In addition, bismuth subsalicylate can be used to shorten the course of diarrhea, and as a preventive medication. Antiperistaltic agents such as loperamide are not recommended, especially with bloody diarrhea.

Water Purification Techniques

Although safe bottled water is available in most countries, parents should be familiar with disinfecting techniques for emergency situations. Tap water is not safe for drinking anywhere in the developing world. There are many options for water disinfection:

Boiling. This is the most effective method. Enteric parasites such as Giardia lamblia and cysts such as Entamoeba histolytica and Cryptosporidium are killed within 3 minutes of exposure to boiling water and enteric viruses and bacteria, within seconds. The drawbacks of boiling are the need for fuel, a stove and a pot, and waiting for the water to cool prior to drinking.

Filtration. Water filters are available in stores and websites for campers and travelers. The filters have various pore sizes, and most are small enough to filter out enteric bacteria, which are smaller than parasites and cysts. No pores are small enough to filter out viruses. Filters should be bought that are impregnated with iodine, which kills viruses.

Iodine and Chlorine tablets. These tablets are effective against all enteric pathogens except Cryptosporidium. Product instructions must be followed carefully. Generally, chlorine tablets should be in contact with water for about one hour to ensure killing pathogens. Iodine tablets require only about 30 minutes contact time.

If tablets are unavailable, iodine solution from a personal medical kit is an effective substitute. Add 5 to 10 drops of 2% iodine tincture solution to a liter of water. Alternatively, add 10 to15 drops of 10% providone-iodine solution. Both methods reliably disinfect water. Iodine should not be used by people with thyroid conditions, pregnant women, or people with a known allergy to iodine. Iodine should never be used for more than a few months at a time to prevent thyroid problems. Vitamin C, sugar, and other flavors improve the taste of water disinfected with iodine and chlorine.

Organisms Generally Causing Non-bloody Diarrhea

Enterotoxic E. coli

• The most common cause of diarrhea in travelers, accounting for 50 to 80% of cases.
• Quick onset and lasting 2 - 4 days; generally self-limited.
• Diarrhea is watery and voluminous; sometimes associated with nausea and vomiting.
• Hydration alone is normally sufficient.
• For prolonged cases, children may be given a trial of azithromycin or (SMZ/TMP). However, ETEC is becoming increasingly resistant to SMZ/TMP.

Viral Infections

• Includes Rotavirus, Norwalk virus, and enteric adenovirus.
• Rotavirus is the second most common cause of diarrhea in child travelers, after ETEC.
• Vomiting common early in the course, followed by watery stools with colicky abdominal pain.
• Antibiotics not effective. Hydration.

Enterotoxin-producing Staphylococcal Aureus

• Onset within 1- 6 hours of exposure.
• Intense vomiting followed by watery diarrhea.
• Very short-lived course that resolves within several hours.
• Hydration only. Antibiotics play no role.

Giardiasis

• Accounts for 3 - 5% of traveler's diarrhea.
• Most patients recover within 2 - 4 weeks.
• Watery diarrhea, steatorrhea, bloating, nausea, and sulfurous burps.
• Diagnosis on clinical grounds or by stool examination.
• Furazolidone is first-line therapy in children. Metronidazole if furazolidone is unavailable.

Cryptosporidiosis

• Protozoan infection from water contaminated with lamb or calf feces.
• Results in chronic diarrhea of greater than 5 months duration.
• No drugs available

Organisms that Generally Causing Bloody Diarrhea

Organisms invading the intestinal mucosa with resultant blood in the stool cause approximately 10 - 15% of traveler's diarrhea. Although hydration is the mainstay of treatment, antibiotics may be considered in any child whose bloody diarrhea persists for longer than 2 or 3 days.

Shigella

• Most common cause of bloody diarrhea in travelers.
• Rapid onset of symptoms with frequent, voluminous, bloody and mucoid stools.
• Fever, tenesmus, and sometimes seizures from toxin.
• Wide range of complications
• Mild to severe disease.
• Severe complications are rare
• Hydration alone is normally adequate. Consider SMZ/TMP, azythromycin, or cephalosporins for ill-appearing children and/or if bloody diarrhea persists longer than 2 - 3 days.

Campylobacter

• Self-limiting course lasting 5 - 7 days.
• Complications rare.
• Hydration. Consider erythromycin or azithromycin in severe cases.

Yersinia

• Rare cause of diarrhea in travelers.
• Fever, bloody stools, and abdominal pain.
• Nausea, vomiting, headache and pharyngitis are common.

Salmonella (non-typhoid and typhoid types)

• Typhoid vaccine is helpful, but not fully protective.
• Nausea, vomiting, fever, and abdominal pain.
• Voluminous watery stools progressing to bloody mucoid stools with pain.
• Most cases self-limiting.
• Approximately 8% of Salmonella cases progress to bacteremia, with fever, rigors, and toxicity.
• Severe extra-intestinal complications rare. Seen with Salmonella typhoid.
• Hydration. Antibiotic for patients with bacteremia, immunosuppression, clinically toxic appearing, and less than 3 months of age.

Amoebic Dysentery

• Only 10% of cases are symptomatic.
• Associated with abdominal discomfort and bloody mucoid stools.
• Hydration. Metronidazole (trophozoicide) followed by a course of Diloxanide (luminal amoebicide to eradicate cysts).

References

Committee on Infectious Diseases, American Academy of Pediatrics; 2000 Red Book; Report of the Committee on Infectious Diseases. American Academy of Pediatrics. 25^th Edition. 2000

Eddleston, Michael; Pierini, Stephen; Oxford Handbook of Tropical Medicine. Oxford University Press. First Edition. 1999

Auerbach, Paul; Donner, H; Weiss, E; Field Guide to Wilderness Medicine. Mosby, Inc. First Edition. 1999

Gilbert, David; Moellwring, Robert; Sande, Merle; The Sanford Guide to Antimicrobial Therapy. Jeb C. Sanford, Publisher. 31^st edition. 2001.