Editing Diarrhea (section)

==Management==
In many cases of diarrhea, replacing lost fluid and salts is the only treatment needed. This is usually by mouth – [[oral rehydration therapy]] – or, in severe cases, [[intravenously]].<ref name=WHO2010a/> Diet restrictions such as the [[BRAT diet]] are no longer recommended.<ref>{{cite journal | vauthors = King CK, Glass R, Bresee JS, Duggan C | title = Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy | journal = MMWR. Recommendations and Reports | volume = 52 | issue = RR-16 | pages = 1–16 | date = November 2003 | pmid = 14627948 | url = https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm | df = dmy-all | archive-url = https://web.archive.org/web/20141028174056/http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm | author5 = Centers for Disease Control Prevention | url-status = live | archive-date = 28 October 2014 }}</ref> Research does not support the limiting of milk to children as doing so has no effect on duration of diarrhea.<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=1728 |title=BestBets: Does Withholding milk feeds reduce the duration of diarrhoea in children with acute gastroenteritis? |url-status=live |archive-url=https://web.archive.org/web/20090504105749/http://www.bestbets.org/bets/bet.php?id=1728 |archive-date=4 May 2009 }}</ref> To the contrary, WHO recommends that children with diarrhea continue to eat as sufficient nutrients are usually still absorbed to support continued growth and weight gain, and that continuing to eat also speeds up recovery of normal intestinal functioning.<ref name=WHOtreatmentdiarrhoea2005/> CDC recommends that children and adults with cholera also continue to eat.<ref name = CDCmanualCholera/> There is no evidence that early refeeding in children can cause an increase in inappropriate use of intravenous fluid, episodes of vomiting, and risk of having persistent diarrhea.<ref>{{cite journal | vauthors = Gregorio GV, Dans LF, Silvestre MA | title = Early versus Delayed Refeeding for Children with Acute Diarrhoea | journal = The Cochrane Database of Systematic Reviews | issue = 7 | pages = CD007296 | date = July 2011 | volume = 2011 | pmid = 21735409 | pmc = 6532715 | doi = 10.1002/14651858.CD007296.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref>

Medications such as [[loperamide]] (Imodium) and [[bismuth subsalicylate]] may be beneficial; however they may be [[contraindicated]] in certain situations.<ref name="pmid18192963">{{cite journal | vauthors = Schiller LR | title = Management of diarrhea in clinical practice: strategies for primary care physicians | journal = Reviews in Gastroenterological Disorders | volume = 7 | issue = Suppl 3 | pages = S27-38 | year = 2007 | pmid = 18192963 }}</ref>

===Fluids===
{{See also|Management of dehydration}}
[[File:Cholera rehydration nurses.jpg|thumb|A person consuming oral rehydration solution]]
[[Oral rehydration therapy|Oral rehydration solution (ORS)]] (a slightly sweetened and salty water) can be used to prevent dehydration. Standard home solutions such as salted rice water, salted yogurt drinks, vegetable and chicken soups with salt can be given. Home solutions such as water in which cereal has been cooked, unsalted soup, green coconut water, weak tea (unsweetened), and unsweetened fresh fruit juices can have from half a teaspoon to full teaspoon of salt (from one-and-a-half to three grams) added per liter. Clean plain water can also be one of several fluids given.<ref name=WHOtreatmentdiarrhoea2005/> There are commercial solutions such as [[Pedialyte]], and relief agencies such as [[UNICEF]] widely distribute packets of salts and sugar. A WHO publication for physicians recommends a homemade ORS consisting of one liter water with one teaspoon salt (3 grams) and two tablespoons sugar (18 grams) added<ref name=WHOtreatmentdiarrhoea2005/> (approximately the "taste of tears"<ref name=2010WorldCupTravellersGuide>[https://www.who.int/topics/test/food_safety/safe_food_travel.pdf A Guide on Safe Food for Travellers] {{webarchive|url=https://web.archive.org/web/20120709034248/http://www.who.int/topics/test/food_safety/safe_food_travel.pdf |date=9 July 2012 }}, Welcome to South Africa, Host to the 2010 FIFA World Cup (bottom left of page 1).</ref>). Rehydration Project recommends adding the same amount of sugar but only one-half a teaspoon of salt, stating that this more dilute approach is less risky with very little loss of effectiveness.<ref name=RehydrationProject>Rehydration Project, {{cite web |url=http://rehydrate.org/ |title=Diarrhoea, Diarrhea, Dehydration, Oral Rehydration, Mother and Child Nutrition, Water, Sanitation, Hygiene – Rehydration Project |access-date=22 June 2015 |url-status=live |archive-url=https://web.archive.org/web/20150608064953/http://rehydrate.org/ |archive-date=8 June 2015 }} Homemade Oral Rehydration Solution Recipe.</ref> Both agree that drinks with too much sugar or salt can make dehydration worse.<ref name=WHOtreatmentdiarrhoea2005/><ref name=RehydrationProject/>

Appropriate amounts of supplemental zinc and potassium should be added if available. But the availability of these should not delay rehydration. As WHO points out, the most important thing is to begin preventing dehydration as early as possible.<ref name=WHOtreatmentdiarrhoea2005/> In another example of prompt ORS hopefully preventing dehydration, CDC recommends for the treatment of cholera continuing to give Oral Rehydration Solution during travel to medical treatment.<ref name=CDCmanualCholera>[https://www.cdc.gov/haiticholera/pdf/chw_trainingmaterialsforcholera.pdf Community Health Worker Training Materials for Cholera Prevention and Control] {{webarchive|url=https://web.archive.org/web/20111020070810/http://www.cdc.gov/haiticholera/pdf/chw_trainingmaterialsforcholera.pdf |date=20 October 2011 }}, CDC, slides at back are dated 17 November 2010. Page 7 states "...{{nbsp}} Continue to breastfeed your baby if the baby has watery diarrhea, even when traveling to get treatment. Adults and older children should continue to eat frequently."</ref>

Vomiting often occurs during the first hour or two of treatment with ORS, especially if a child drinks the solution too quickly, but this seldom prevents successful rehydration since most of the fluid is still absorbed. WHO recommends that if a child vomits, to wait five or ten minutes and then start to give the solution again more slowly.<ref name=WHOtreatmentdiarrhoea2005/>

Drinks especially high in simple sugars, such as [[soft drinks]] and fruit juices, are not recommended in children under five as they may ''increase'' dehydration. A too rich solution in the gut draws water from the rest of the body, just as if the person were to drink sea water.<ref name=WHOtreatmentdiarrhoea2005/><ref name=NICE2009>{{cite web|title=Management of acute diarrhoea and vomiting due to gastroenteritis in children under 5|url=http://guidance.nice.org.uk/CG84|work=National Institute of Clinical Excellence|date=April 2009|url-status=live|archive-url=https://web.archive.org/web/20090802094158/http://guidance.nice.org.uk/CG84|archive-date=2 August 2009}}</ref> Plain water may be used if more specific and effective ORT preparations are unavailable or are not palatable.<ref name=NICE2009/> Additionally, a mix of both plain water and drinks perhaps too rich in sugar and salt can alternatively be given to the same person, with the goal of providing a medium amount of sodium overall.<ref name=WHOtreatmentdiarrhoea2005/> A [[nasogastric tube]] can be used in young children to administer fluids if warranted.<ref name=Webb2005>{{cite journal | vauthors = Webb A, Starr M | title = Acute gastroenteritis in children | journal = Australian Family Physician | volume = 34 | issue = 4 | pages = 227–31 | date = April 2005 | pmid = 15861741 }}</ref>

===Eating===
The WHO recommends a child with diarrhea continue to be fed. Continued feeding speeds the recovery of normal intestinal function. In contrast, children whose food is restricted have diarrhea of longer duration and recover intestinal function more slowly. The WHO states "Food should ''never'' be withheld and the child's usual foods should ''not'' be diluted. Breastfeeding should ''always'' be continued."<ref name=WHOtreatmentdiarrhoea2005/> In the specific example of cholera, the CDC makes the same recommendation.<ref name = CDCmanualCholera/> Breast-fed infants with diarrhea often choose to breastfeed more, and should be encouraged to do so.<ref name=WHOtreatmentdiarrhoea2005/> In young children who are not breast-fed and live in the developed world, a lactose-free diet may be useful to speed recovery.<ref>{{cite journal | vauthors = MacGillivray S, Fahey T, McGuire W | title = Lactose avoidance for young children with acute diarrhoea | journal = The Cochrane Database of Systematic Reviews | volume = 2013 | issue = 10 | pages = CD005433 | date = October 2013 | pmid = 24173771 | pmc = 4276385 | doi = 10.1002/14651858.CD005433.pub2 }}</ref>
Eating food containing [[soluble fibre]] may help, but insoluble fibre might make it worse.<ref>{{cite web |url=https://www.webmd.com/digestive-disorders/chronic-diarrhea-16/diarrhea-more-fiber |title=The Facts About Fiber |access-date=25 January 2020 |archive-date=27 July 2020 |archive-url=https://web.archive.org/web/20200727012104/https://www.webmd.com/digestive-disorders/chronic-diarrhea-16/diarrhea-more-fiber |url-status=deviated }}</ref>

===Medications===
{{Main article|Antidiarrhoeal}}
Antidiarrheal  agents  can  be  classified  into  four  different groups: antimotility, antisecretory, adsorbent, and anti-infectious.<ref name=Diosmectite2009>{{cite journal | vauthors=Guarino A, Lo Vecchio A, Pirozzi MR |s2cid=56519371 |title=Clinical role of diosmectite in the management of diarrhea. |journal=Expert Opin Drug Metab Toxicol |date=2009 |volume=5 |issue=4 |pages=433–440 |doi=10.1517/17425250902865594|pmid=19379128 }}</ref> While [[antibiotic]]s are beneficial in certain types of acute diarrhea, they are usually not used except in specific situations.<ref>{{cite journal | vauthors = Dryden MS, Gabb RJ, Wright SK | title = Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin | journal = Clinical Infectious Diseases | volume = 22 | issue = 6 | pages = 1019–25 | date = June 1996 | pmid = 8783703 | doi = 10.1093/clinids/22.6.1019 | doi-access = free }}</ref><ref name=CE08/> There are concerns that antibiotics may increase the risk of [[hemolytic uremic syndrome]] in people infected with [[Escherichia coli O157:H7]].<ref>{{cite journal | vauthors = Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI | title = The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections | journal = The New England Journal of Medicine | volume = 342 | issue = 26 | pages = 1930–6 | date = June 2000 | pmid = 10874060 | pmc = 3659814 | doi = 10.1056/NEJM200006293422601 }}</ref> In resource-poor countries, treatment with antibiotics may be beneficial.<ref name=CE08>{{cite journal | vauthors = de Bruyn G | title = Diarrhoea in adults (acute) | journal = BMJ Clinical Evidence | volume = 2008 | pages = 0901 | date = March 2008 | pmid = 19450323 | pmc = 2907942 }}</ref> However, some bacteria are developing [[antibiotic resistance]], particularly ''Shigella''.<ref>{{cite web |url=https://www.who.int/vaccine_research/diseases/diarrhoeal/en/index6.html |title=Diarrhoeal Diseases |date=February 2009 |work=World Health Organization |url-status=dead |archive-url=https://web.archive.org/web/20081215123745/http://www.who.int/vaccine_research/diseases/diarrhoeal/en/index6.html |archive-date=15 December 2008 }}</ref> Antibiotics can also cause diarrhea, and [[antibiotic-associated diarrhea]] is the most common adverse effect of treatment with general antibiotics.

While bismuth compounds ([[Pepto-Bismol]]) decreased the number of bowel movements in those with travelers' diarrhea, they do not decrease the length of illness.<ref>{{cite journal | vauthors = DuPont HL, Ericsson CD, Farthing MJ, Gorbach S, Pickering LK, Rombo L, Steffen R, Weinke T | title = Expert review of the evidence base for self-therapy of travelers' diarrhea | journal = Journal of Travel Medicine | volume = 16 | issue = 3 | pages = 161–71 | year = 2009 | pmid = 19538576 | doi = 10.1111/j.1708-8305.2009.00300.x | doi-access = free }}</ref> Anti-motility agents like [[loperamide]] are also effective at reducing the number of stools but not the duration of disease.<ref name=NEJM2014/> These agents should be used only if bloody diarrhea is not present.<ref>{{cite journal | vauthors = Pawlowski SW, Warren CA, Guerrant R | title = Diagnosis and treatment of acute or persistent diarrhea | journal = Gastroenterology | volume = 136 | issue = 6 | pages = 1874–86 | date = May 2009 | pmid = 19457416 | pmc = 2723735 | doi = 10.1053/j.gastro.2009.02.072 }}</ref>

[[Diosmectite]], a natural aluminomagnesium silicate clay, is effective in alleviating symptoms of acute diarrhea in children,<ref>{{cite journal | vauthors = Dupont C, Vernisse B | title = Anti-diarrheal effects of diosmectite in the treatment of acute diarrhea in children: a review | journal = Paediatric Drugs | volume = 11 | issue = 2 | pages = 89–99 | date = 2009 | pmid = 19301931 | doi = 10.2165/00148581-200911020-00001 | pmc = 7100234 }}</ref> and also has some effects in chronic functional diarrhea, radiation-induced diarrhea, and chemotherapy-induced diarrhea.<ref name="pmid26576135"/> Another absorbent agent used for the treatment of mild diarrhea is [[kaopectate]].

[[Racecadotril]] an antisecretory medication may be used to treat diarrhea in children and  adults.<ref name=Diosmectite2009/> It has better tolerability than [[loperamide]], as it causes less [[constipation]] and [[flatulence]].<ref name="Arzneistoff-Profile">{{cite book|title=Arzneistoff-Profile| year = 1982 | veditors = Dinnendahl V, Fricke U |publisher=Govi Pharmazeutischer Verlag|location=Eschborn, Germany|isbn=978-3-7741-9846-3|language=de}}</ref> However, it has little benefit in improving acute diarrhea in children.<ref>{{cite journal | vauthors = Liang Y, Zhang L, Zeng L, Gordon M, Wen J | title = Racecadotril for acute diarrhoea in children | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | pages = CD009359 | date = December 2019 | issue = 12 | pmid = 31858591 | pmc = 6923519 | doi = 10.1002/14651858.CD009359.pub2 | collaboration = Cochrane Infectious Diseases Group }}</ref>

[[Bile acid sequestrants]] such as [[cholestyramine]] can be effective in chronic diarrhea due to [[bile acid malabsorption]]. Therapeutic trials of these drugs are indicated in chronic diarrhea if bile acid malabsorption cannot be diagnosed with a specific test, such as [[SeHCAT]] retention.<ref>{{cite journal | vauthors = Wilcox C, Turner J, Green J | title = Systematic review: the management of chronic diarrhoea due to bile acid malabsorption | journal = Alimentary Pharmacology & Therapeutics | volume = 39 | issue = 9 | pages = 923–39 | date = May 2014 | pmid = 24602022 | doi = 10.1111/apt.12684 | s2cid = 12016216 | doi-access = free }}</ref>

===Alternative therapies===
Zinc supplementation may benefit children over six months old with diarrhea in areas with high rates of malnourishment or zinc deficiency.<ref>{{cite journal | vauthors = Lazzerini M, Wanzira H | title = Oral zinc for treating diarrhoea in children | journal = The Cochrane Database of Systematic Reviews | volume = 12 | issue = 12 | pages = CD005436 | date = December 2016 | pmid = 27996088 | pmc = 5450879 | doi = 10.1002/14651858.CD005436.pub5 }}</ref> This supports the World Health Organization guidelines for zinc, but not in the very young.

A Cochrane Review from 2020 concludes that [[probiotic]]s make little or no difference to people who have diarrhea lasting 2 days or longer and that there is no proof that they reduce its duration.<ref name="pmid33295643">{{cite journal | vauthors = Collinson S, Deans A, Padua-Zamora A, Gregorio GV, Li C, Dans LF, Allen SJ | title = Probiotics for treating acute infectious diarrhoea | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 12| pages = CD003048 | date = December 2020 | pmid = 33295643 | pmc = 8166250 | doi = 10.1002/14651858.CD003048.pub4 }}</ref> The [[probiotic]] [[lactobacillus]] can help prevent [[antibiotic-associated diarrhea]] in adults but possibly not children.<ref>{{cite journal | vauthors = Kale-Pradhan PB, Jassal HK, Wilhelm SM | title = Role of Lactobacillus in the prevention of antibiotic-associated diarrhea: a meta-analysis | journal = Pharmacotherapy | volume = 30 | issue = 2 | pages = 119–26 | date = February 2010 | pmid = 20099986 | doi = 10.1592/phco.30.2.119 | s2cid = 21836205 }}</ref> For those with [[lactose intolerance]], taking digestive [[enzyme]]s containing [[lactase]] when consuming dairy products often improves symptoms.