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Three Part Question

In [children with acute diarrhoea] is [the use of smectite with oral rehydration solution better than oral rehydration solution alone] at [shortening the duration of diarrhoea] ?

Clinical Scenario

A 12-month-old boy with acute diarrhea is brought to the emergency department by his parents. He tolerates oral rehydration solution well but his parents still worry very much about his frequent loose stools. You wonder if the use of smectite would provide any additional benefit.

Search Strategy

Medline 1966-August 2005, Embase 1966-August 2005, and The Cochrane Library, Issue 3, 2005.
Medline: {(dioctahedral$.mp OR smect$.mp) AND (exp diarrhea OR exp gastroenteritis OR diarrh$.mp)} LIMIT to human AND English. Embase: {(diactahedral* OR smect*) AND ('diarrhea'/exp OR 'gastroenteritis'/exp OR diarrh*)} LIMIT to human AND English. Cochrane Library: "smectite".

Search Outcome

Altogether 21 papers were found, of which five were considered to be original research of high quality (randomised controlled trials) and relevant to the topic of interest. These five paper are shown in the table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Narkeviciute et al, 2002 Lithuania	54 patients (age 6-48 months) with acute diarrhoea randomised to dioctahedral smectite (DS)+oral rehydration solution (ORS) or ORS	PRCT	Duration of diarrhoea (hours)	Significantly shorter duration of diarrhoea in the DS+ORS group (42.3±24.7 vs. 61.8±33.9, p=0.019)	Small number of patients Randomisation by birthday No blinding
Guarino et al, 2001 Italy	804 patients (age 3months–5year) with acute diarrhoea randomised to DS+ORS or ORS	PRCT	Duration of diarrhoea (hours)	Significantly shorter duration of diarrhoea in the DS+ORS group (96±21 vs. 119±23, p<0.001)	Incomparable baseline data No intention-to-treat analysis No blinding
Lexomboon et al, 1994 Thailand	66 patients (age 1-24 months) with acute diarrhoea randomised to DS+ORS or ORS	PRCT	Cure rate at 72 hours	Significantly higher cure rate in the DS+ORS group at 72 hours after the treatment (71% vs. 34%, p<0.01)	Small number of patients Unclear randomisation No blinding
Madkour et al, 1993 Egypt	90 boys (age 3-24 months) with acute diarrhoea randomised to DS+ORS or ORS	PRCT	Duration of diarrhoea (hours)	Significantly shorter duration of diarrhoea in the DS+ORS group (54.1±2.35 vs. 72.9±1.98, p<0.001)	Small number of patients
			Total number of diarrhoeal stools	Significant smaller number of total diarrhoeal stools in the DS+ORS group (11.3±0.48 vs. 13.8±0.45, p<0.001)
Vivatvakin et al, 1992 Lithuania	62 patients (age 1-24 months) with acute diarrhoea randomised to DS+ORS or ORS	PRCT	Duration of diarrhoea (hours)	Significantly shorter duration of diarrhoea in the DS+ORS group (43.3±25.1 vs. 84.7±48.5, p=0.005)	Small number of patients Unclear randomisation No blinding

Comment(s)

Dioctahedral smectite is a natural adsorbent clay formed of fine sheets of aluminomagnesium silicate. Smectite has been found to adsorb viruses, bacteria, bacterial toxins, thus protecting the intestinal mucosa. Most clinical studies were relatively small and only one was obviously blinded. However, they consistently showed the efficacy of smectite in reducing the duration of diarrhoea. In children with acute diarrhoea rehydrated with oral rehydration solution, smectite may shorten the duration of diarrhoea by about 20% to 50%. There was no significant side effects observed. Considering safety, tolerance and antidiarrhoeal activity of smectite, it's worth a try to use smectite in the treatment of acute diarrhoea in children.

Clinical Bottom Line

Oral smectite appears to be effective at shortening the duration of diarrhoea in children with acute diarrhoea rehydrated with oral rehydration solution.

References

1. Narkeviciute I, Rudzeviciene O, Leviniene G, Mociskiene K, Eidukevicius R. Management of Lithuanian children's acute diarrhoea with Gastrolit solution and dioctahedral smectite. Eur J Gastroenterol Hepatol 2002; 14:419-24.
2. Guarino A, Bisceglia M, Castellucci G, et al. Smectite in the treatment of acute diarrhea: a nationwide randomized controlled study of the Italian Society of Pediatric Gastroenterology and Hepatology (SIGEP) J Pediatr Gastroenterol Nutr 2001;32:71-5.
3. Lexomboon U, Harikul S, Lortholary O. Control randomized study of rehydration/rehydration with dioctahedral smectite in ambulatory Thai infants with acute diarrhea. Southeast Asian J Trop Med Public Health 1994;25:157-62.
4. Madkour AA, Madina EM, el-Azzouni OE, Amer MA, el-Walili TM, Abbass T. Smectite in acute diarrhea in children: a double-blind placebo-controlled clinical trial. J Pediatr Gastroenterol Nutr 1993;17:176-81.
5. Vivatvakin B, Jongpipatvanich S, Harikul S, Eksaengri P, Lortholary O. Control study of oral rehydration solution (ORS)/ORS + dioctahedral smectite in hospitalized Thai infants with acute secretory diarrhea. Southeast Asian J Trop Med Public Health 1992;23:414-9.