3. Diarrheal Illnesses

3.4. Management of Persistent Diarrhea

Persistent diarrhea is an episode of diarrhea, with or without blood, which begins acutely and lasts at least 14 days. It accounts for up to 15% of all episodes of diarrhea but is associated with 30% to 50% of deaths. Persistent diarrhea is usually associated with weight loss and often with serious non-intestinal infections. Many children who develop persistent diarrhea are malnourished, greatly increasing their risk of death. Persistent diarrhea almost never occurs in infants who are exclusively breastfed.

All children with diarrhea for 14 days or more should be classified based on the presence or absence of any dehydration (Table 2):

  • Children with severe persistent diarrhea who also have any degree of dehydration require special treatment and should not be managed at the outpatient facility. Referral to a hospital is required. As a rule, treatment of dehydration should be initiated first, unless there is another severe classification.
  • Children with persistent diarrhea and no signs of dehydration can be safely managed in the outpatient clinic, at least initially. Proper feeding is the most important aspect of treatment for most children with persistent diarrhea. The goals of nutritional therapy are to:
    • temporarily reduce the amount of animal milk (or lactose) in the diet; 
    • provide a sufficient intake of energy, protein, vitamins, and minerals to facilitate the repair process in the damaged gut mucosa and improve nutritional status; 
    • avoid giving foods or drinks that may aggravate the diarrhea; and
    • ensure adequate food intake during convalescence to correct any malnutrition.

Table 2. Classification of Children with Persistent Diarrhea Has the Child Had Diarrhea for 14 Days or More?

Assess signs Classify Treatment
With dehydration Severe persistent diarrhea
  • Treat dehydration before and during the child’s transfer, unless the child has another severe condition
  • Refer to hospital
Without dehydration Persistent diarrhea
  • Teach the mother how to feed the child with persistent diarrhea*
  • Tell the mother which signs require immediate medical attention
  • Give multivitamin and minerals (including zinc) for 14 days
  • Follow-up in 5 days

*Recommend that the mother temporarily reduce the amount of animal milk to 50 mL/kg/day, if animal milk is already part of the child’s usual diet, and to continue breast-feeding. If the child is older than 6 months, appropriate complementary food should be given in small, frequent amounts, at least 6 times a day.

Proper feeding is the most important aspect of treatment for most children with persistent diarrhea

Routine treatment of persistent diarrhea with antimicrobials is not effective. Some children, however, have nonintestinal (or intestinal) infections that require specific antimicrobial therapy. The persistent diarrhea of such children will not improve until these infections are diagnosed and treated.