Page 142 - 15Diarrhoeaandvomiting

Other therapies

Clinical trials on the antimotility agent loperamide had demonstrated a statistically significant
antidiarrhoeal effect in children with gastroenteritis. Loperamide is not licensed for use in young
children with acute diarrhoea in the UK. For that reason, but also given the reported adverse
effects such as drowsiness, abdominal distension and ileus, its use was not recommended.

Recommendation on antidiarrhoeal agents

Do not use antidiarrhoeal medications.

Research recommendation

Is racecadotril (an enkephalinase inhibitor) cost-effective and safe in the treatment of
gastroenteritis in children compared with a placebo?

8.3 Micronutrients and fibre

Zinc is an important trace element in gastrointestinal structure and function. It is involved in
epithelial barrier integrity, tissue repair and immune function. Diarrhoea is associated with
significant zinc loss. 175 In developing countries, zinc deficiency may be common owing to
inadequate food intake, reduced availability in animal food sources, and high phytate content in
the diet resulting in impaired absorption. 176 In 1995, a study from India first reported significant
clinical benefit from zinc therapy in gastroenteritis. The WHO has recommended zinc
177
supplementation in children with gastroenteritis. Vitamin A deficiency has been associated with
an increased mortality rate in patients with gastroenteritis in developing countries. It has therefore
been postulated that supplementation during the acute illness could be of clinical benefit.
Glutamine is an amino acid that acts as an important substrate for rapidly dividing cells, including
enterocytes and lymphocytes. It has therefore been postulated that glutamine supplementation
might be of benefit in gastroenteritis. 178 Folic acid is a water-soluble vitamin with a crucial role in
DNA synthesis. It has been proposed that its administration might be beneficial in gastroenteritis,
promoting mucosal repair and regeneration and enhancing the immune response. 179 Dietary
fibre (soy polysaccharide) supplementation during the illness has been proposed as an effective
adjunctive treatment for the reduction of diarrhoea in children with gastroenteritis.

8.3.1 Zinc

Evidence overview
A Cochrane review 180 was identified that included 18 trials in total. Eight of these trials were
relevant here 175,177,181–186 with the remainder being excluded as they had participants who were
malnourished or who had persistent diarrhoea.
Three of the studies were conducted in India, 177,182,185 two in Bangladesh, 175,184 one in Brazil 181
and one in Nepal. The remaining study was a multicentre trial carried out in Pakistan, India
186
and Ethiopia. 183 Seven studies had two treatment arms and one had three arms. Across the
175
eight studies, 5155 participants suffering from acute diarrhoea (children aged 1–60 months)
were enrolled. Four studies were hospital-based trials, 175,181,182,185 three were community-based
trials 177,177,183 and one study included outpatient participants as well as inpatient. 184
185
All eight trials included in this review were RCTs. In one study the method used to generate
the allocation sequence was unclear but in the other seven trials the method of randomisation
was considered adequate. Five studies assured adequate allocation concealment, 177,182–184,186 but
in the remaining three this was unclear. 175,181,185 The outcome assessor was blinded in seven trials
but allocation concealment was unclear in one. 185 Only five trials reported a sample size power
calculation. 175,177,182–184 Seven trials included more than 90% of the randomised participants in
the analysis. In one study the number of participants lost to follow-up was unclear. 185 Definition
criteria for inclusion of the participants varied between the studies. Dose and duration of the
supplementation, formulation and type of zinc salts administered and follow-up were not uniform
across all the studies.

117