Lay Summary

What is diarrhea?
Diarrhea describes stools (also known as bowel movements or "poo") that are frequent and loose or watery. It is a common cause of illness and death in children worldwide, and is often associated with poor sanitation and contaminated water or food sources. Diarrhea has many causes, including infection (infectious gastroenteritis), toxins (food poisoning), food intolerance or other dietary factors (for example, lactose intolerance), and medical problems (for example, Inflammatory Bowel Disease IBD). The commonest causes of diarrhea in developed countries are viruses causing infectious gastroenteritis ("stomach flu"). The viruses, including rotavirus and Norovirus (formerly Norwalk or Norwalk-like virus) cause similar symptoms, including crampy abdominal pain, diarrhea, vomiting, decreased apetite, and sometimes fever. Stomach flu can lead to complications such as dehydration, malnutrition, weight loss and even death in extreme cases. Acute diarrhea usually lasts less than one week, in contrast to chronic diarrhea that lasts weeks to months. Causes of acute diarrhea include the above viral infections, or it can occur as a side effect of antibiotics (antibiotic-associated diarrhea) or it can be acquired in a hospital (nosocomial diarrhea).

How is diarrhea treated conventionally?
Treatment of diarrhea depends on the cause. Diagnosis of medical problems such as IBD (Crohn's disease or Ulcerative Colitis) or Celiac disease requires assessment and treatment by medical specialists, especially if there is poor weight gain, chronic or severe symptoms, or bloody diarrhea. Avoidance of specific causes or risk factors may be of benefit in other situations, such as eliminating dairy products in lactose-intolerant individuals, or drinking only from safe water sources in places with poor sanitation. Careful handwashing after using the toilet and especially before handling food is very important for prevention of infectious diseases. "Toddler's diarrhea" is a transient and benign cause of diarrhea in young children that does not affect apetite, growth or behaviour, does not cause pain, and does not require treatment.

Uncomplicated viral gastroenteritis gets better without medications, and usually runs its course within one week. Although over-the-counter medications are available for vomiting, diarrhea and pain, they are not effective in children and some have potentially harmful side effects. Prevention of dehydration is the best treatment, so infected children and adults are encouraged to drink and eat a variety of fluids and solid foods. If vomiting is severe, fluids should be given in small and frequent amounts, and can include oral rehydration liquids such as Pedialyte and Gastrolyte , milk or formula, and soup, as well as water. Restriction of dairy products, breast milk, baby formula, and solid food is unnecessary since it limits the diet and potentially delays recovery. Also, studies have shown no significant benefit of such restrictions in most healthy individuals with stomach flu. Similarly, the "BRAT" diet of bananas, rice, apple juice and tea or toast has been found to be unhelpful. Factors that can worsen diarrhea include antibiotics and sugary foods such as juice, soft drinks and fruit. Besides viruses, infectious gastroenteritis may also be caused by bacteria or parasites, some of which may require medications. Stool tests may be able to determine the type of infection. All causes of stomach flu are very contagious and easily spread to family members, so careful handwashing can help limit the spread of disease.

What is Complementary and Alternative Medicine (CAM)?
Complementary and alternative medicine (CAM) is a group of diverse health care systems, practices and products that are not presently considered to be part of conventional medicine. (NCCAM. What is Complementary and Alternative Medicine. Health Information. 2002) Examples of CAM practices include massage therapy and acupuncture. Examples of CAM products (also known as natural health products) include Echinacea and St. John's wort.

What kinds of CAM are used to treat diarrhea?
There are many CAM therapies used to treat diarrhea. Many treatments have not been well studied in children, especially regarding effectiveness and safety. There are very few high-quality studies, and this can make it difficult to give good evidence-based advice. The information presented here is based on published research, a lot of which is based in developing countries where diarrhea is a serious and common problem. In particular, randomized, controlled trials (RCTs) of commonly used CAM and studies involving children were searched. The following 3 kinds of CAM used to treat infectious, acute or persistent diarrhea were reviewed:
- Natural health products (NHPs)
- Homeopathy
- Traditional Chinese Medicine (TCM)

Natural Health Products (NHPs)
NHPs are widely used for prevention and treatment of various conditions and to maintain health. Examples include herbals, homeopathic remedies, vitamins, minerals, probiotics, amino acids, and traditional medicines. Dosing and quality of products can vary significantly. NHPs that have been used to treat diarrhea include probiotics, vitamin A, zinc, guar gum, and supplementation with nucleotides or glutamine.

Probiotics
Probiotics are live microorganisms, usually bacteria, that are consumed as dietary supplements or added to foods such as yogurt. There are many different types (species or strains) of bacteria used, and they are thought to promote a healthy combination of bacteria in the gut (large intestines) that can help prevent or treat certain conditions and maintain general wellness.

Probiotics, in the form of supplements, have been extensively studied in infants, children, and adults for both treatment and prevention of diarrhea. Probiotics have mostly, but not always, been found to be effective in decreasing severity and duration of acute diarrhea, either on their own or in combination with oral rehydration liquids. The difference in length of illness is generally ½ to 1 day. Probiotics have also been shown to prevent acute diarrhea, decreasing the risk by about half.

Species in the studies have included Lactobacillus acidophilus, Lactobacillus bulgaris, Lactobacillus GG, Lactobacillus reuteri, Bifidobacterium bifidum, Streptococcus thermophilus, and Saccharomyces boulardii, either alone or in various combinations. Study doses range from 5 to 40 billion colony forming units (CFUs) per day.

Safety of probiotics
While probiotics are likely safe in healthy people, consumers should be mindful that they are ingesting live organisms. There are case reports of severe and potentially life-threatening bacterial infections in children and adults with underlying medical problems including weakened immune systems.

Vitamin A
Vitamin A affects immune function, and is used to treat and prevent diarrhea. Only one randomized controlled study (RCT), published in 2000, looked at treatment of acute diarrhea in children, and it found that one high dose of vitamin A had no effect in Turkish infants. Results of vitamin A for prevention of diarrhea are mixed. While some prevention trials have found a protective effect of vitamin A in children, others have not, and there may be a slightly increased risk of developing respiratory problems. In a Tanzanian study published in 2000, vitamin A was associated with decreased risk of diarrhea in malnourished infants and children, but increased risk of cough and fast breathing.

Safety of vitamin A
While vitamin A supplementation is beneficial for those who are malnourished or deficient in vitamin A, it may not make any difference in healthy children with diarrhea and may even cause respiratory problems. Water-soluble vitamins such as vitamin C can be passed out of the body in the urine, but vitamin A is fat-soluble, so the body tends to retain it if excessive amounts are ingested. Large doses can cause hypervitaminosis A, which includes nausea and vomiting, fatigue, skin and hair problems, bone and joint pains, and in severe cases, damage to the liver and kidney. Because it can cause increased pressure on the brain, hypervitaminosis A can also lead to headaches, double vision, dizziness, lethargy, and in children, irritability, softening of the skull, bulging of the soft spot (fontanelle) on the skull, and poor weight gain. In pregnant women, high doses of vitamin A may cause birth defects in the fetus.

Zinc
Zinc is an essential mineral that is involved in immune functioning. In various doses and forms, it has been extensively studied in trials for prevention and treatment of acute diarrhea in children, and most results have been positive. Daily zinc has been found to be effective in preventing diarrhea, improving the acute illness, and even in treating chronic diarrhea and reducing risk of death in children living in developing countries.

2 RCTs showed no benefit of zinc supplementation in childhood diarrhea compared to placebo or oral rehydration liquids. One study published in 1999 looked at persistent diarrhea in hospitalized malnourished Pakistani infants, and the other, from 2006, involved otherwise healthy Turkish children with diarrhea.

Safety of zinc
2 of the studies found that zinc supplementation was associated with increased vomiting. Many of the studies were conducted in developing countries where health factors such as diet, malnourishment and disease have potential effects on zinc metabolism, compared to developed nations. Long-term effects are unknown, but zinc may potentially affect iron and copper metabolism.

Zinc and vitamin A
Several studies have looked at the combination of zinc and vitamin A for treatment of childhood diarrhea. The trials have conflicting results that do not make it possible to recommend such therapy at this time.

Nucleotide supplements
An older study published in 1994 looked at prevention of diarrhea. It found that healthy Chilean infants drinking formulas supplemented with nucleotides were better protected from diarrhea compared to those drinking regular formula. However, there were concerns about the quality of the study.

Safety of nucleotide supplements
Safety is unknown. No information regarding side effects was provided in the above study.

Glutamine supplements
In a 2004 Turkish RCT, daily glutamine supplements given for one week were better than placebo in decreasing the duration of acute diarrhea in otherwise healthy infants up to 2 years old.

Safety of glutamine supplements
Safety is unknown. No side effects were reported in the above study.

Hydrolyzed guar gum
Guar gum is a water-soluble fibre derived from the guar bean. It has many uses, including industrial, medical and nutritional. It is widely used as a thickener, emulsifier and bulking agent in commercial foods. It is thought to help diarrhea by absorbing toxins.

In 2005, an RCT published in Bangladesh looked at infants up to 2 years old who were fed a diet supplemented with hydrolyzed guar gum. The diet was better than placebo at treating chronic diarrhea.

Safety of guar gum
No side effects were reported in the above study, and guar gum is generally considered to be safe, specifically at doses used as a food additive. Because it can absorb many times its weight in water, it can cause stomach upset, bloating and gas. There have been reports of intestinal blockage (obstruction), including one death, in adults using large doses for weight loss purposes. Also, guar gum may potentially interfere with some medications and nutrients.

Homeopathy
The principle that "like cures like" means that substances that cause symptoms at normal or high doses can cure them when given in small, highly diluted amounts.

Results comparing homeopathic treatment of acute childhood diarrhea with placebo are conflicting. 3 small trials from Nicaragua and Nepal concluded that individualized homeopathy combined with oral rehydration liquids led to decreased duration of diarrhea by about 1 day in infants and children, but there were concerns about the poor quality of one of the studies. A larger RCT of Honduran infants and children published in 2006 found no difference between placebo and homeopathic tablets containing a combination of Arsenicum album, Calcarea carbonica, Sulphur, Chamomilla, and Podophyllum.

Safety of homeopathy
Homeopathy is considered to be very safe since the preparations are very dilute, but it may be possible to trigger a reaction in an allergic person. Temporary worsening of symptoms, called "aggravation", can last a few hours and happens in 10-20% of patients.

Traditional Chinese Medicine (TCM)
TCM is an ancient Chinese system of medicine that includes meditation, herbal and nutritional therapy, restorative physical exercises, and acupuncture. Regarding acupuncture, it was developed in China over 2000 years ago, and uses a variety of techniques, such as thin needles, lasers and pressure, to stimulate specific anatomical points along meridians through which the body's vital energy, "qi", flows.

Most of the research on the TCM treatment of acute diarrhea in children was written in Chinese. Only 2 older English language studies were identified, both in Chinese journals of traditional medicine. Such journals often include publications of poor quality and with major flaws in methodology. One study from 1995 looked at Chinese herbal medicine and the other study published in 1993 used acupuncture. Both trials found that TCM was better at treating diarrhea than a variety of non-TCM treatments.

Safety of TCM
Chinese herbal medicine:
Some herbal preparations from China have been found to be contaminated with toxins (i.e. heavy metals such as mercury or arsenic) and/or adulterated with prescription medications such as steroids. Reports of allergic reactions, and side effects involving blood, liver, heart and lungs after drinking Chinese teas are well documented.

Acupuncture
Acupuncture is very safe, with risk of complications estimated to be 0.05 per 10 000 treatments (5 in a million). The commonest side effects are needle pain, fatigue, and bleeding from the punctured area. Serious complications are rare, and include fainting, punctured lung (pneumothorax), injury to nerves and other tissues, and infections such as hepatitis.

Conclusions

There is research showing that CAM may help children with diarrhea. However, many of the studies have significant limitations that make it difficult to offer advice with confidence based on their conclusions, whether positive or negative. These limitations include lack of safety information (especially long-term side effects), flaws in methodology, and small numbers of patients recruited. For diarrhea, most of the studies were done on children in developing nations who may not share the same health factors or the same response to therapy, as children from developed countries. Evidence from single studies of a particular therapy should encourage further study and confirmation of conclusions, and the use of such therapies should be supervised with caution by health care providers. Pediatric dosing is often unknown and the quality of some natural health products is unreliable, making safety a further concern. Adults respond to therapies in ways that children may not, therefore assumptions based on adult experience can be inaccurate or even harmful. Products given to prevent, rather than treat, illness are often given every day during susceptible periods. For diarrhea, this means that children may be taking NHPs for many weeks or months at a time. Some therapies and products can be costly and add financial stress for families.

The following figure shows how the evidence for each CAM can be organized according to safety and effectiveness.

Green
Probiotics
Zinc

Blue
Vitamin A
Nucleotide supplements
Glutamine supplements
Hydrolyzed guar gum
Homeopathy

Yellow
Traditional Chinese Medicine

The CAM therapies are organized into colour-coded categories for clarity. Conventional medications can also be categorized similarly. For instance, many over-the-counter medications would fall into the blue area, and many prescription medications would fall into the yellow area. Some pediatric health issues can be potentially serious, especially if the condition is chronic, or multiple therapies, NHPs and medications are used together. The decision to use CAM should be based on each child's health and include discussion with the child's physician.

The natural course of uncomplicated viral gastroenteritis, the commonest cause of acute diarrhea in developed nations, is full recovery in less than one week. Each child is unique, and families must weigh the risks and benefits of all interventions as objectively as possible. This is especially important for therapies and products in which good evidence is limited or unknown. The information provided here is intended to promote discussion among parents and health care providers of children with diarrhea and is not meant to replace medical advice. More high-quality studies are needed to guide recommendations about effectiveness and safety of CAM for treatment of diarrhea, and to assist caregivers and families in making informed decisions about treatment options.

Funding: Partial funding support for this review was received from Passeport Santé.

Lay summaries: For more information in French, please see Passeport Santé.

Clinician summaries: Full scientific review article will be published in Pediatrics in Review.

Disclaimer: The information available on this website is intended to provide general information about complementary and alternative medicine (CAM). This website does not provide specific medical advice and the information provided should not be used as a substitute for seeking medical advice from a registered health practitioner. The opinions expressed on this website are not necessarily reflective of the opinion of the Stollery Children's Hospital, Capital Health Authority,Passeport Santé or Pediatrics in Review.