Indian Academy of Pediatrics National Task Force for framing Guidelines on Management of Diarrhea has made several recommendations from 2003-2006.

The focus has been on oral rehydration solutions, zinc and probiotics in acute diarrhea, drug treatment of dysentery and management of diarrhea in young infant and severely malnourished subjects.

The recommendations are largely based on pooled data or meta-analysis of randomized placebo controlled trials.

Oral Rehydration Solution (ORS)
WHO Task Force in July 2001 recommended that reduced ORS with 75 mEq/L of sodium and 75 mmol/L of glucose is effective in adults and children with cholera and that reduced osmolarity ORS solution with 60 mEq/L of sodium does not seem to be significantly better than reduced osmolarity ORS solution containing 75 mEq/L of sodium.

IAP Recommendations on ORS use in diarrhea

	IAP Recommendations  August 2003	IAP  Recommendations  May 2006
Age	All ages	Same as before
Types of diarrhea	All types	Same as before
ORS Adults & Children  More suited for  children	Sodium - 75 mmol/L  Glucose - 75 mmol/L  Osmolarity - 245 mosm/L  Sodium - 60 mmol/L  Glucose - 84 mmol/L  Osmolarity - 224 mosm/L	Sodium - 75 mmol/L  Glucose - 75 mmol/L  Osmolarity - 245  mosm/L  -
Packet Size	1 liter of solution with spoon  measure for 200ml	Same as before
Additives (Probiotics,  Minerals)	Not recommended	Same as before

IAP recommendations are based on following pooled data:

	1.		Bhatnagar S, Bhandari N, Mouli UC, Bhan MK. Consensus statement of IAP National Task Force: Status Report on Management of acute diarrhea. Indian Pediatrics 2004;41:335-348.
	2.		Reduced osmolarity oral rehydration salts (ORS) formulation. A report from a meeting of experts jointly organized by UNICEF and WHO. UNICEF House, New York, USA, 18 July 2001, WHO/FCH/CAH/0.1.22
	3.		Hahn SK, Kim YJ, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration due to diarrhea in children: systematic review. BMJ. 2001;323:81-88.

Government of India Recommendation on ORS (2004)
A single universal ORS solution containing sodium 75 mmol/L and glucose 75 mmol/L, Osmolarity 245 mosm/L was acceptable for all ages and all types of diarrhea.

Role of Zinc in treatment of Acute Diarrhea
Its role has been based on randomized controlled trials of zinc during acute diarrhea. Recommendations are based on pooled analysis of following studies:

	-		Zinc Investigators Collaborative Group. Bhutta ZA, Bird SM, Black RE, Brown KH, Gardner JM, Hidayat A et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials. Am J Clin Nutr 2000; 72: 1516-1522.
	-		Bhatnagar S, Bahl R, Sharma PK, Kumar GK, Saxena SK, Bhan MK. Zinc treatment with oral rehydration therapy reduces stool output and duration of diarrhea in hospitalized children; a randomized controlled trial. J Pediatr Gastroenterol Nutr 2004; 38: 34-40.
	-		Strand TA, Chandyo RK, Bahl R, Sharma PR, Adhikari RK, Bhandari N, et al. Effectiveness and efficacy of zinc for the treatment of acute diarrhea in young children. Pediatrics. 2002 May;109: 898- 903.
	-		Bahl R, Bhandari N, Saksena M, Strand T, Kumar G.T, Bhan MK et al. Efficacy of zinc fortified oral rehydration solution in 6-35 month old children with acute diarrhea. J Pediatr 2002;141:677-682.
	-		Roy SK, Tomkins AM, Akramuzzaman SM, Behrens RH, Haider R, Mahalanabis D et al. Randomized controlled trial of zinc supplementation in malnourished Bangladeshi children with acute diarrhoea. Arch Dis Child 1997;77: 196-200.
	-		Dutta P, Mitra U, Datta A, Niyogi SK, Dutta S, Manna B et al. Impact of zinc supplementation in malnourished children with acute diarrhoea. J Trop Pediatr 2000; 46: 259-263.
	-		Baqui AH, Black RE, El Arifeen S, Yunus M, Chakraborty J, Ahmed S et al. Effect of zinc supplementation started during diarrhoea on morbidity and mortality in Bangladeshi children: Community randomized trial. BMJ 2002;325(7372):1059.
	-		Effect of zinc supplementation on clinical course of acute diarrhoea. Report of a Meeting, New Delhi, 7-8 May 2001. J Health Popul Nutr 2001;19: 338- 346.
	-		Baqui AH, Black RE, El Arifeen S, Yunus M, Zaman K, Begum N, et al. Zinc therapy for diarrhoea increased the use of oral rehydration therapy and reduced the use of antibiotics in Bangladeshi children. J Health Popul Nutr. 2004;22: 440-442.
	-		INCLEN Childnet Zinc Effectiveness for Diarrhea (IC-ZED) Group. Zinc supplementation in acute diarrhea is acceptable, does not interfere with oral rehydration, and reduces the use of other medications: a randomized trial in five countries. J Pediatr Gastroenter Nutr 2006;42: 300-305.
	-		Bhandari N, Mazumder S, Taneja S, Dube B, Black RE, Fontaine O et al . A pilot test of the addition of zinc to the current case management package of diarrhea in a primary health care setting. J Pediatr Gastroenterol Nutr. 2005;41: 685-687.

	1.		Zinc supplementation at twice recommended daily allowance (RDA) at 20 mg/day for children more than 6 months and 10 mg/day for younger than 6 months for 14 days is efficacious in significantly reducing severity as well as duration of diarrhea.
	2.		Recommended studies to determine strategies to deliver zinc, assess feasibility, sustainability and cost effectiveness as well as effect of zinc supplementation in young infants.

IAP recommendations for zinc in diarrhea

	IAP recommendations August 2003	IAP recommendations May 2006
Use	Adjunct to oral rehydration	Same as before
Dose	20 mg during diarrhea and  for 7 days after cessation of  diarrhea	20 mg during diarrhea for total 14 days  in children older than 6 months. 10 mg  for total 14 days in children between 2-6  months
Age	3 months and above	2 months and above
Formulations	Zinc sulphate, gluconate or  acetate	Same as before
Precaution	Not to be used with iron	Same as before

Government of India Recommendations on use of Zinc in Diarrhea (2007):
Same as IAP recommendations (2006)

IAP recommendations on Probiotics (2006)
There is insufficient evidence to recommend probiotics in treatment of acute diarrhea in our settings.

IAP recommendation on Antisecretory Drugs (2006)
There is insufficient evidence on either safety or efficacy of antisecretory drugs like racecadotril for it's routine use in the treatment of diarrhea.

Further Reading
IAP Guidelines 2006 on Management of Acute Diarrhea. Indian Pediatrics, 2007; 44:380-389.