Pediatric Nutrition in Practice

Reducing the Burden of Acute and Prolonged Childhood Diarrhea 169

3

Interventions for Diarrhea Prevention and
Management

Recent evidence suggests that if a range of exist-
ing interventions are scaled up, diarrhea burden
can be significantly reduced. These include EBF
up to 6 months of age, the promotion of comple-
mentary feeding, rotavirus vaccinations, use of
oral rehydration solution (ORS) and zinc in diar-
rhea, improved case management, antibiotics for
dysentery, as well as water, sanitation and hygiene
(WASH) strategies. Table  1 summarizes the ef-
fects of the preventive and therapeutic interven-
tions for diarrhea.
Among the diarrhea prevention interven-
tions, breastfeeding promotion interventions in
developing countries can significantly increase
EBF rates by 43% at day 1, 30% at <1 month, and
90% at 1–5 months, with reductions in rates of
no breastfeeding by 32% at 1 day, 30% at <1
month, and 18% at 1–5 months [4]. Vaccinations
for rotavirus and cholera can reduce rotavirus-
specific mortality by 74% and the cholera inci-
dence by 52%, respectively [5]. WASH strategies
are pivotal for the prevention of diarrheal dis-
eases, as interventions for water quality, sani-
tation, and hygiene can reduce diarrhea mor-
bidity in children by 42, 37, and 31%, respec-
tively [6].
Since the immediate cause of death in most
cases of diarrhea is dehydration, deaths are al-
most entirely preventable if dehydration is pre-
vented or treated. ORS, zinc, and continued
feeding are the recommended treatments for
acute diarrhea among young children. The use of
ORS in developing-country settings can reduce
diarrhea-specific mortality by 69% and results in
a treatment failure rate of 0.2% [7]. Since 2004,
the WHO and United Nations International
Chi ld ren’s Emergenc y Fu nd (U N ICEF) have rec-
ommended zinc for the treatment of diarrhea,
which can reduce all-cause mortality by 46% and
diarrhea-related hospital admissions by 23% [8].
Although the WHO program for the control of

diarrheal disease began in 1978, the global ORS

use has remained stagnant. Interventions per-

taining to ORS promotion, including co-promo-

t ion of zi nc a nd OR S , socia l ma rket i ng , a nd ma ss

media strategies, are effective in improving ORS

usage and should be utilized to improve coverage

of this lifesaving and simple intervention. There

is evidence to recommend antibiotics use for the

reduction of morbidity and mortality due to

cholera, Shigella , and Cryptosporidium. Howev-

er, t his a rea requires more clinica l t ria ls to eva lu-

ate the efficacy and safety of the drugs currently

in use for the treatment of diarrhea and dysen-

tery in both developing and developed countries

[9]. Another major challenge in diarrhea treat-

ment is the vomiting associated with acute gas-

troenteritis, which limits the success of ORS,

leading to an increased use of intravenous rehy-

dration, prolonged emergency department stay,

and hospitalization. Although, antiemetics are

not routinely recommended, recent evidence

suggests that their use can significantly reduce

the incidence of vomiting, hospitalization, and

intravenous f luid requirements and may have

the potential to decrease morbidity and mortal-

ity burden due to diarrhea; however, further evi-

dence is required before universal recommenda-

tion [10].

These preventive and therapeutic interven-

tions, if implemented at current coverage rates

in the 75 low- and middle-income countries

(Countdown countries), could avert 54% of di-

arrhea deaths by 2025 at a cost of USD 3.8 bil-

lion. However, if the coverage of these key evi-

dence-based interventions were scaled up to at

least 80%, and that of immunizations to at least

90%, virtually all diarrhea deaths in children

younger than 5 years could be averted by 2025 at

a cost of USD 6.715 billion [11]. In their recent

report [1 2] , the Federation of International Soci-

eties of Pediatric Gastroenterology, Hepatology,

and Nutrition (FISPGHAN) working group pri-

oritized interventions that could contribute

greatly to achieving Millennium Development

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 168–172
DOI: 10.1159/000367878