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North American Journal of Medical Sciences 2010 November, Volume 2. No. 11.

Original Article

OPEN ACCESS

Management of acute gastroenteritis in healthy children

in Lebanon - A national survey
Aouni Alameddine, MD., Sawsan Mourad, MD., Nahida Rifai, MD.
Department of Pediatrics, Makassed General Hospital, Beirut, Lebanon.

Citation: Alameddine A, Mourad S, Rifai N. Management of acute gastroenteritis in healthy children in Lebanon - A
national survey. North Am J Med Sci 2010; 2: 512-517.
Doi: 10.4297/najms.2010.2512
Availability: www.najms.org
ISSN: 1947 2714

Abstract
Background: Acute gastroenteritis remains a common condition among infants and children throughout the world. In 1996,
The American Academy of Pediatrics (AAP) revised its recommendations for the treatment of infants and children with
acute gastroenteritis. Aim: The purpose of this survey was to determine how closely current treatment among Lebanese
pediatricians compares with the AAP recommendations and to determine the impact of such management on the healthcare
system. Patients and Methods: The outline of the study was based on a telephone questionnaire that addressed the
management of healthy infants and children below five years of age with acute gastroenteritis complicated by mild to
moderate dehydration. In addition, the costs of medical treatment and requested laboratory studies were calculated. Results:
A total of 238 pediatricians completed the questionnaire. Most pediatricians prescribed Oral Rehydration Solutions (ORS)
for rehydration (92.4%), advised breastfeeding during acute gastroenteritis (81.5%), and avoided parenteral rehydration for
mild to moderate dehydration (89.1%). In addition to ORS, oral fluids such as soda, juices, and rice water were allowed for
rehydration by 43.7% of pediatricians. Thirty-one percent of pediatricians delayed re-feeding for more than 6 hours after
initiation of rehydration. Only 32.8% of pediatricians kept their patients on regular full-strength formulas, and only 21.8%
permitted full-calorie meals for their patients. 75.4% of pediatricians did not order any laboratory studies in cases of mild
dehydration and 50.4% did not order any laboratory studies for moderate dehydration. Stool analysis and culture were
ordered by almost half of the pediatricians surveyed. Seventy-seven percent prescribed anti-emetics, 61% prescribed
probiotics, 26.3% prescribed antibiotics systematically and local antiseptic agents, 16.9% prescribed zinc supplements, and
11% percent prescribed antidiarrheal agents. Conclusion: Pediatricians in Lebanon are aware of the importance of ORS
and the positive role of breastfeeding in acute gastroenteritis. However, they do not follow optimal recommendations from
the AAP concerning nutrition, laboratory examinations and drug prescriptions. Consequently, this poses significant
financial losses and economic burden.
Keywords: Acute gastroenteritis, Lebanese pediatricians, laboratory studies in acute gastroenteritis in children, oral
rehydration solutions.
Correspondence to: Aouni Alameddine, MD., Department of Pediatrics, Makassed General Hospital, Beirut, Lebanon.
Tel. : 009613597298, Email: aouni.alameddine@gmail.com

routine laboratory testing is no longer necessary. However,

it may be beneficial for individual patients, when oral
replacement therapy was unsuccessful or for patients who
are receiving parenteral hydration [1]. Treatment of acute
gastroenteritis is primarily directed toward preventing or
treating dehydration. When possible, age-appropriate diet
and fluids should be continued [2]. Breastfeeding should
not be discontinued, even during the rehydration phase.
Diet should be increased as soon as it is tolerated to

Introduction
Acute gastroenteritis is a common and costly clinical
condition in children. Over the past two decades, pediatric
acute gastroenteritis has been the subject of considerable
worldwide attention. In the past, a number of laboratory
studies were used to evaluate children with acute vomiting
and/or diarrhea. Since oral rehydration therapy has
become the preferred method of treating dehydration,
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North American Journal of Medical Sciences 2010 November, Volume 2. No. 11.

compensate for lost caloric intake during acute illness.

Lactose restriction is usually not necessary, although it
might be helpful in cases of chronic malnutrition or in
children with severe enteropathy; changes in formula are
usually unnecessary. Full-strength formula is typically
well tolerated and allows for a more rapid return to full
energy intake [3].Antiemetic and antidiarrheal medications
are generally not indicated and may contribute to
complications. However, the use of antibiotics remains
controversial [1].

insertion for hydration, oral fluids administration, special

formula, antimotility agents, antiemetics, antibiotics, zinc
supplements, probiotics and antiseptics) was calculated
(Table 2). Table 3 shows the average cost of laboratory
parameters and medical treatments.

Despite the growing body of evidence supporting the

safety and efficacy of oral rehydration solutions, they
remain underutilized, and the management of
gastroenteritis continues to vary considerably. Common
management errors include using oral rehydration
solutions in children with little or no dehydration,
administering intravenous rehydration therapy to children
with only moderate dehydration and inappropriately
withholding oral rehydration solutions or other feeding in
children with vomiting [4]. For this reason, the American
Academy of Pediatrics revised its recommendations
concerning the treatment of acute gastroenteritis in healthy
children. Therefore, the aim of our study was to determine
how closely current treatment of acute gastroenteritis in
children among Lebanese pediatricians compared with the
AAP recommendations and to observe the impact of such
management on healthcare costs.

Table 1 Demographic data of pediatricians and their mean scores

of practice.
Number of Mean Score
Pediatricians
SD(a)
P (b)
(%)
Graduation ( Year)
1970s
12 (5.0)
10.33 (3.28)
NS(c)
1980s
44 (18.5)
11.18 (2.90)
1990s
90 (39.5)
11.31 (2.43)
2000s
88 (37.0)
11.25 (2.90)
Graduation ( Country)
Lebanon
90 (38.7)
11.90 (2.23)
<.001
West Europe
56 (24.4)
10.14 (2.5)
France
54 (22.7)
12.70 (2.53)
East Europe
26 (10.9)
8.38 (2.09)
North America
6 (2.5)
8.66 (2.25)
Arab
2 (0.8)
12.00 (0.00)
Practice
Community Hospitals
144 (60.5)
10.8 (2.48)
0.01
Teaching Hospitals
52 (22.7)
12.03 (2.93)
Ambulatory/Private
38 (16.8)
11.6 (3.15)
Clinics
Region
Urban
152 (64.7)
11.6 (2.62)
<.001
Rural
82 (35.3)
10.36 (2.77)
(a) Values are given as mean standard deviation (SD)
(b) A P value less than 0.05 is considered significant
(c) NS: not significant

Statistical Analysis
Data were collected and statistically evaluated with the
analysis of variance test using the SPSS version 16
statistical software package.

Patients and Methods

Prior to the survey, the Institutional Review Board (IRB)
committee of the Makassed General Hospital in Beirut
granted ethical approval. We then conducted a
telephone-based, anonymous questionnaire survey of
Lebanese pediatricians concerning the management of
acute gastroenteritis in healthy children between 1 month
and 5 years in age with mild or moderate dehydration.
Lebanese pediatricians who were registered in the
Lebanese Order of Physician were included in our survey.
We divided the 22-item questionnaire into two sections
(Appendix 1). In the first section, we asked the
pediatricians to provide their year and country of
graduation as a pediatrician, and the region and type of
practice (teaching hospital, community hospital,
ambulatory and private practice, or a combination). The
second section included 18 questions about the
management of acute gastroenteritis in healthy children
aged less than five years with mild or moderate
dehydration. For each of these 18 questions, a score of
zero was given for answers that did not concur with AAP
recommendations and a 1 for answers that were
compatible with the recommendations. The highest score
was 18. We calculated the score for each pediatrician and
then compared scores according to the year, country of
graduation of the pediatrician, the region and the type of
practice (Table 1). The cost of laboratory investigations
requested by the pediatricians including complete blood
count and differential (CBCD), serum electrolytes, stool
analysis and culture was calculated. In addition, the cost of
medical treatment (intravenous line or nasogastric tube

Table 2 Estimated costs of the most commonly prescribed

medications and laboratory investigations in acute gastroenteritis.
Medication / Laboratory
Estimated cost
Investigation
(L.P.)(1) /(USD)
Oral Fluids(2)
3,000/2.00
Formula(3)
15,000/10.00
IV line insertion(4)
50,000/33.33
NG tube insertion(5)
10,000 /6.66
Blood Studies(6)
32,000/21.33
Stool Microscopy
10,000 /6.66
Stool Culture
15,000/10.00
Antimotility
9,000/6.00
Antiemetic
4,000/2.66
Antibiotic
4,000/2.66
Zinc Supplements
13,000/8.66
Probiotics
10,000/6.66
Antiseptic
9,000/6.00
(1)L.P. Lebanese Pound (USD 1 = L.P. 1500), (2) Oral fluids
include water, rice water, soda and fruit juice, (3) Lactose-free or
hydrolyzed formula, (4) Intravenous line, (4) Nasogastric tube,
(5)Blood studies include complete blood count and differential in
addition to serum sodium, potassium, chloride and bicarbonate.
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North American Journal of Medical Sciences 2010 November, Volume 2. No. 11.

Table 3 Mean Cost of Treatment of Acute Gastroenteritis in

Children with Acute Gastroenteritis with Mild to Moderate
Dehydration.
Number of
Mean Cost
Pediatricians SD(a) L.P.(b)
Graduation
( Year)
1970s
1980s
1990s
2000s
Graduation
( Country)
Lebanon
W. Europe
France
E. Europe
N. America
Arab
Practice
Community
Hospitals
Teaching
Hospitals

Mean Cost
SD(a) USD

P(c)

12 (5.0)
44 (18.5)
90 (39.5)
88 (37.0)

84,833 (46,700)
69,500 (42,109)
58,800 (31,765)
63,386 (39,269)

56.55 (31.13) 0.97

46.33 (28.07)
39.2 (21.17)
42.25 (26.17)

90 (38.7)
56 (24.4)
54 (22.7)
26 (10.9)
6(2.5)
2 (0.8)

57,978 (34,289)
80,821 (34,412)
39,185 (25,244)
91462 (36,844)
109,330 (41,321)
26,000 (0)

38.65 (22.85) <.001

53.88 (22.94)
26.12 (16.82)
60.97 (24.56)
72.88 (27.54)
17.33 (0)

144 (60.5)

68,958 (37,930) 45.97 (25.28) 0.02

52 (22.7)

52,654 (33,627) 35.10 (22.41)

surveyed, 89% avoided parenteral hydration for mild and

moderate dehydration as compared to all of the
pediatricians who worked in teaching hospitals. Sixty-nine
percent of pediatricians resumed early feeding as
recommended by the AAP; 33% of teaching hospital
practitioners did not follow this practice, while the
practitioners who worked in rural areas tended to allow
early feeding more often (73.8%). Eighteen percent of
pediatricians still discontinued breastfeeding during acute
gastroenteritis, with higher rates among community
hospitals practitioners (20.8%). Seventy-eight of the 238
pediatricians (32.8%) continued human or regular-strength
formula; while 52.8% prescribed lactose-free formula,
13.4% a diluted one, and 1% a hydrolyzed formula.

Ambulatory
and Private
38 (16.8)
59,947 (39,914) 39.96 (26.60)
Clinics
Region
Urban 152 (64.7) 57,789 (37,057) 38.52 (27.7) <.001
Rural 82 (35.3)
75,146 (36,817) 50.09 (24.54)
(1) SD: Standard Deviation, (2) L.P. Lebanese pound (USD 1 =
L.P. 1500), (3) A P value less than 0.05 is considered significant.

Results

Fig. 1 Percentages of irrational medical acts.

(a) Oral fluids besides ORS including juices, soda, rice water,
mineral water, (b) Intravenous hydration, (c) Nasogastric
hydration, and (d) Laboratory studies for mild and moderate
dehydration include complete blood count and differential in
addition to serum sodium, potassium, chloride and bicarbonate.

A total of 863 pediatricians were registered in the 2010

logbook of the Lebanese Order of Physicians. From this
logbook, 440 pediatricians were randomly chosen by the
computer and contacted for the survey. However, only 238
pediatricians answered our questionnaire (27.6%).
Therefore, data from the participating 238 pediatricians
were analyzed.

Laboratory studies for mild dehydration, including CBCD,

and serum electrolytes, were requested by 24.6% of
pediatricians; whereas these studies were ordered by
49.6% in patients with moderate dehydration. Fifty-eight
percent of pediatricians requested microscopic stool
analysis and fifty percent ordered a stool culture.

The majority of the pediatricians surveyed graduated in

the 1990s (39.5%) and 2000s (37%). Among them, 38.7%
graduated from Lebanese university hospitals, 24% from
West Europe excluding France, 22% from France and 11%
from East Europe. Fifty-four pediatricians (22.7%) worked
in teaching hospitals, while 40 practiced in private clinics
(16.8%). Of the 238 pediatricians, 152 were employed in
urban areas and major cities while 82 pediatricians worked
in rural areas (64.7% versus 35.3%, respectively). The
highest score among surveyed pediatricians was 17/18 and
the lowest was 6/18. Table 1 summarizes the mean score
in the different groups of pediatricians and Figure 1 shows
the percentages of irrational medical acts.

Eleven percent of Lebanese pediatricians prescribed

antimotility medications. On the other hand, 77% of
pediatricians prescribed antiemetic agents. In regard to
antibiotic prescription, more than 26% of pediatricians
preferred to treat acute gastroenteritis with antimicrobial
agents. The rate of antibiotic use was higher in
pediatricians working in rural areas or in an ambulatory
setting(45.2% versus 40% respectively). Zinc supplements
were prescribed by 16.8% of pediatricians and probiotics
by 60%.

Concerning rehydration, oral rehydration solutions (ORS)

were prescribed alone by 49% of pediatricians and in
combination with other fluids such as juice, soda, water
and/or rice water by 43%. Among all pediatricians

The estimated mean cost of irrational management was

63,872 Lebanese Pound (L.P.), which was equal to USD
42.58, for each patient. Table 3 summarizes the mean cost
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North American Journal of Medical Sciences 2010 November, Volume 2. No. 11.

of treatment in relation to the different groups of

pediatricians.

than 32% of pediatricians used a lactose-containing

formula after successful rehydration. This result was
comparable to that of a European survey [8].Although
medical practice has often favored beginning feeding with
diluted (e.g. half or quarter-strength) formula, controlled
clinical trials have demonstrated that this practice is
unnecessary and is associated with prolonged symptoms
and delayed nutritional recovery [12, 13]. However, 13.4%
of Lebanese pediatricians still preferred to dilute the
formula.

Discussion
The results of our questionnaire revealed that two thirds of
the pediatricians in Lebanon usually followed the AAP
recommendations with a mean score of 11/18.
Pediatricians who graduated in the last two decades and
those working in teaching hospitals and/or in urban areas
were more likely to adhere to the AAP guidelines than the
other groups. A similar study done in Israel in 1998
showed that 60% of pediatricians followed these
guidelines [6].

Supplementary laboratory studies, including serum

electrolytes to assess patients with acute diarrhea usually
are unnecessary [14, 15]. Stool cultures are indicated in
cases of dysentery but are not usually indicated in acute
watery diarrhea for the immune-competent patient [3].
However, certain laboratory studies might be important
when the underlying diagnosis is unclear or when
diagnoses other than acute gastroenteritis are possible.
Laboratory studies such as CBCD and serum electrolytes
were largely requested by pediatricians in our survey.
More than half of pediatricians working in rural areas
tended to request stool analysis and culture; this may be
due to the higher prevalence of parasitic and/or bacterial
gastrointestinal infections in these areas.

Oral rehydration therapy using a commercial pediatric oral

rehydration solution was the preferred approach to mild or
moderate dehydration and was accepted as the standard of
care for the clinically efficacious and cost-effective
management of acute gastroenteritis [2]. The French
survey of pediatricians in 2004 showed that 63% allowed
rehydration using ORS as compared to 16% of
pediatricians in a multi-center European study conducted
in 2000, 87% of Israeli pediatricians in 1998, and 30% of
US pediatricians in 1991 [6-9]. In our survey, 92% of
Lebanese pediatricians recommended ORS at the
beginning of treatment for rehydration. The results were
similar to those obtained in 2001 that involved Hungarian
pediatricians [10]. However, almost half of the
pediatricians in our survey used ORS in combination with
other oral fluids such as soda, juices, mineral water or rice
water. This practice, by far, tended to increase the severity
of diarrheal illness by increasing the intraluminal
osmolarity of the intestines when using soda or juices and,
therefore, exacerbating the course of the disease.
Conversely, mineral and rice water do not contain the
sufficient amount of electrolytes required to compensate
their fecal losses.

Since viruses are the predominant cause of acute

gastroenteritis in developed countries [16], the routine use
of antibiotics may lead to increased antimicrobial
resistance. Even when a bacterial cause is suspected in an
outpatient setting, antimicrobial treatment usually should
not be initiated because the majority of cases are
self-limited.
An
exception
may
be
for
immune-compromised children and those with an
underlying disease [3]. However, the pediatricians
worldwide variably prescribed antimicrobials. Two percent
of pediatricians in Bahrain prescribed an antibiotic for
patients with acute gastroenteritis [17] as compared to
81% in a French population after performing a stool
culture [7]. In our survey, more than 26% of pediatricians
considered acute gastroenteritis in our country to be
parasitic or bacterial in origin and, therefore, prescribed
antibiotics systematically as a part of treatment. In
addition, pediatricians working in rural areas tended to
prescribe antibiotics more often. Nonspecific antidiarrheal
agents (e.g. adsorbents such as kaolin-pectin), antimotility
agents (e.g. loperamide), antisecretory drugs, and toxin
binders (e.g. cholestyramine) are commonly used among
older children and adults, however, data are limited
regarding their efficacy. Side effects of these drugs are
well-known, in particular among the antimotility agents,
including opiate-induced ileus, drowsiness, and nausea
caused by the atropine effects and binding of nutrients and
other drugs [3]. Almost all French pediatricians prescribed
at least one drug in managing children with acute
gastroenteritis [7]. In our survey, antiemetics were the
most commonly used medication by three-quarters of
pediatricians, followed by probiotics, which were
prescribed by 60% of pediatricians. Their efficacy has not
been proven in the literature.

Breastfeeding should be continued at all times, even

during the initial rehydration phase in children with acute
gastroenteritis [3]. In our survey, 82% of pediatricians
continued breastfeeding compared to 84% in the
Hungarian and 77% in the European surveys, respectively
[8,10].The AAP recommended continuing a non-restrictive
diet promptly after an episode of gastroenteritis in children
to compensate for lost caloric intake during acute illness
[2].It was unfavorable that three quarters of the
pediatricians in our survey prescribed an antidiarrheal diet
and one third delayed the introduction of feeding until 24
hours after the oral rehydration. Noted that this practice
remains frequent worldwide; 66% of French pediatricians
prescribed a dietary regimen and only 10% of Hungarian
pediatricians suggested early reintroduction of normal
feeding after oral rehydration [7, 10]. Lactose-free or
lactose-reduced formulas usually are unnecessary. A
meta-analysis of clinical trials indicated no advantage of
lactose-free formulas over lactose-containing formulas for
the majority of infants, although certain infants with
malnutrition or severe dehydration recovered more quickly
when given lactose-free formulas [11]. In our survey, more
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North American Journal of Medical Sciences 2010 November, Volume 2. No. 11.

To our knowledge, this is the first survey that evaluated

the impact of management of patients with acute
gastroenteritis on the healthcare system. The costs
resulting from irrational management of acute
gastroenteritis in our survey was surprisingly elevated for
each patient. Therefore, this might contribute to the
increased financial burden on the healthcare system.

10. Arat A, Bodnszky H, Bense T, Veres G, Sznyi L.

Treatment of infants with acute diarrhea in Hungary.
Orv Hetil 2001; 142:115-159.
11. Brown KH, Peerson J, Fontaine O. Use of nonhuman
milks in the dietary management of young children
with acute diarrhea: a meta-analysis of clinical trials.
Pediatrics 1994; 93:17-27.
12. Santosham M, Foster S, Reid R, et al. Role of
soy-based, lactose-free formula during treatment of
acute diarrhea. Pediatrics 1985; 76:292-298.
13. Brown KH, Gastanaduy AS, Saavedra JM, et al.
Effect of continued oral feeding on clinical and
nutritional outcomes of acute diarrhea in children. J
Pediatr 1988; 112:191-200.
14. Teach SJ, Yates EW, Feld LG. Laboratory predictors
of fluid deficit in acutely dehydrated children. Clin
Pediatr 1997;36:395-400.
15. Nager AL, Wang VJ. Comparison of nasogastric and
intravenous methods of rehydration in pediatric
patients with acute dehydration. Pediatrics
2002;109:566-572.
16. Pang XL, Honma S, Nakata S, Vesikari T. Human
caliciviruses in acute gastroenteritis of young
children in the community. J Infect Dis 2000;
181:S288-294.
17. Ismaeel AY, Al Khaja KA, Damanhori AH, Sequeira
RP, Botta GA. Management of acute diarrhea in
primary care in Bahrain: self-reported practices of
doctors. J Health Popul Nutr 2007; 25:205-211.

Conclusion
The results from our survey suggested that, with the
exception of recommending ORS for rehydration and
continuation of breastfeeding during acute diarrhea, only a
minority of pediatricians followed AAP recommendations
for optimal management of acute gastroenteritis.
Consequently, significant financial losses and economic
burden may ensue. These findings suggested that effective
healthcare policies are needed to implement the
recommendations and to reduce the unnecessary medical
costs on the healthcare system in our country.

Acknowledgement
We would like to thank Fouad Ziade, PhD. for his support
and assistance in data analysis.

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Appendix 1
Management of acute gastroenteritis in healthy children aged 1 month - 5 years
with mild to moderate dehydration - A national survey

1.
2.
3.
4.
5.

Title of doctor:
Pediatrician
Pediatric Gastroenterologist
Year of graduation:
Country:
Practice:
University Hospital Private clinic
Region of practice:
Rural
Urban
Management of acute gastroenteritis:
a.

6.

Rehydration:
i. Discontinuation of breast feeding:
ii. ORS
iii. Use of gaseous drinks:
iv. Other
v. IV hydration: immediate
vi. Nasogastric tube insertion for hydration:
Refeeding:
a.
Time:

b.

Type:
i.
ii.

Yes
No
Frequency:
Yes
No
Frequency:
Yes
No
Yes
No

Duration:
Duration:
Duration:

After 6 hrs from ORS hydration

After 12 hrs
After 24 hrs
Yes
No
Yes
No
Diluted
Normal concentration

Continuation of breast milk

Regular milk formula:

Yes
No
Duration:
Yes
No
Duration:
Diluted
Normal concentration

iii. Lactose free formula:

iv. Hydrolyzed milk formula:

Regular
Anti-diarrheal diet Specify:
Duration:

v. Food:

6. Laboratory studies:
Mild dehydration:
Moderate dehydration:
CBCD
Electrolytes
7. Stools analysis:
Stools culture:

Yes
No
Yes
No
Yes
No
Others (specify):
Yes
No
Yes
No

8. Medical treatment:
Drugs that alter intestinal motility
Anti-emetics
ATB
Zn supplement
Probiotics
Intestinal antiseptics

Yes
Yes
Yes
Yes
Yes
Yes

517

No
No
No
No
No
No

Specify:
Specify:
Specify:
Specify:
Specify: