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Am Fam Physician. 2000;62(9):1965-1967

to the editor: The excellent article by Dr. Burkhart1 summarized the evaluation of children with the common problem of acute gastroenteritis and reaffirmed the usefulness of simple treatments in uncomplicated cases. However, the article contains a few niggling inconsistencies, including an endorsement of foods such as “yogurt, fruit” for children with acute gastroenteritis without dehydration (page 2559 under the subheading entitled “No Dehydration”) and an admonition against foods such as “juices and soft drinks” on the basis of their high sugar content.
One look at food labels demonstrates little difference in the sugar content among whole fruit, fruit juice and soft drinks. Fruit-flavored yogurt may also have a substantial content of simple sugar per serving.
This admonition against foods with a high content of simple sugars is confusing because foods with a similar content of simple sugars appear on the list of endorsed foods and the list of foods to avoid. In addition, no reason is given as to why foods with a high content of simple sugars are to be avoided in children with acute gastroenteritis without dehydration.
The article then states that the antidiarrheal medications, including yogurt, are generally not indicated “because of lack of evidence that they are effective and because of concerns that adverse effects may outweigh any benefits” (page 2562 under the subheading “Management of Symptoms”).1 This, too, is confusing because the text endorses yogurt as a food for children with acute gastroenteritis (page 2559) and later advises against yogurt for children with acute gastroenteritis with diarrhea.
to the editor: I would like to point out an error in the article1 on acute gastroenteritis in children. Dr. Burkhart states that “Antidiarrheal medications … [e.g., Pepto-Bismol] … are generally not indicated in children with acute gastroenteritis because of the lack of convincing evidence that they are effective and because of concerns that adverse effects may outweigh any benefits.”
Contrary to this advice, two well-designed studies,2,3 both conducted in South America (a challenging environment for the treatment of children with gastroenteritis), found that bismuth subsalicylate (Pepto-Bismol) at a dosage of 1.14 mL per kg every four hours decreased stool output and the duration of symptoms.
Moreover, results of a placebo-controlled, randomized trial2 involving 275 infants (mean age of 13.5 months) revealed that stool output, duration of diarrhea and hospital stay were significantly decreased in patients treated with bismuth subsalicylate versus placebo, with no observed adverse reactions. That study concluded that bismuth subsalicylate is “a safe and effective adjunct to oral rehydration therapy for infants and young children with watery diarrhea.”

editor's note: These letters were sent to the author of “Management of Acute Gastroenteritis in Children,” who did not reply.

Email letter submissions to afplet@aafp.org. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Letters may be edited to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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