Use of Oral Gentamicin, Metronidazole, and Cholestyramine in the Treatment of

Severe Persistent Diarrhea in Infants

Ivor D. Hill, Michael D. Mann, Keith C. Househam and Malcolm D. Bowie
Pediatrics 1986;77;477

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/77/4/477

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1986 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on July 11, 2012

Use of Oral Gentamicin,

Metronidazole,
and
Cholestyramine
in the Treatment
of Severe
Persistent
Diarrhea in Infants
Ivor D. Hill, MD, FCP, Michael D. Mann,
Keith C. Househam,
FCP, and Malcolm
From

the Institute of Child Health, Red Cross

Republic
of South Africa

M Med, PhD,
D. Bowie, MD, FRCP

War Memorial

Childrens

Hospital,

Rondebosch,

ABSTRACT. Oral gentamicin,

tyramine

were given

combinations

either

to infants

metronidazole,
as single agents

who still required

seven days in the hospital

for persistent
effect of these drugs and the interactions
were assessed
by comparing
daily stool
treatment

effect

with

that

of the drugs

in the

and cholesor in various

treatment

pretreatment

on apparent

nitrogen

tion was also studied.

On the first day
presence
of cholestyramine
was associated
icantly
greater
decrease
in stool output.

after

diarrhea.
The
between
them
output
during
period.

The

and fat absorpof treatment

the
with a signifThis effect ap-

peared to be largely due to an interaction

with gentamicm. Thereafter,
only gentamicin
produced
a significantly
greater decrease
in stool weight. At no stage was metronidazole of benefit. Gentamicin
and cholestyramine
also
indirectly
improved apparent
nitrogen
and fat absorption
by reducing
stool output. The combination
of oral gentamicin
and cholestyramine
is recommended
as a safe
and effective way of treating
infants with severe persistent

diarrhea

following

1986;77:477-481;

acute

persistent

gastroenteritis.
diarrhea,

Pediatrics

gentamicin,

choles-

tyramine.

Because
the losses of nutrients
from the bowel are
directly
related
to stool
weight,
maintenance
of
nutrition
by the oral route
is usually
not possible
in infants
with fecal losses
exceeding
this value.2
Termination
of the diarrhea
is crucial
in preventing
the vicious
cycle of gastroenteritis
and malnutrition.
A previous,
uncontrolled
trial demonstrated
that
a combination
of oral gentamicin,
metronidazole,
and cholestyramine
therapy
was effective
in stopping persistent
diarrhea
in the majority
of cases.3
The present
study was undertaken
to test this in a
controlled
fashion
and to determine
which
of the
drugs used singly or in combination
was most effective. The effect
of individual
drugs
and combinations of drugs
was assessed
by comparing
the decrease
in stool output
following
the institution
of
treatment.
The effect of individual
drugs on apparent
was

nitrogen
and
also evaluated.

PATIENTS
Most children
admitted
to Red Cross
War Memona!
Childrens
Hospital
in Cape Town with gastroenteritis
have
a self-limiting
illness,
and the
diarrhea
diminishes
after
a few days.
In 10% to
15% of patients,
severe
diarrhea
continues
and requires
therapy
for more than seven days.
Persistent diarrhea
is defined
as a continuing
daily stool
output
exceeding
30 g/kg of body weight
for seven
days after
commencement
of hospital
treatment.

AND

fat

absorption

during

METHODS

Infants
between
the ages of 6 weeks and 1 year
requiring
admission
to the hospital
for dehydrating
diarrhea
were
assessed.
Only
boys were
studied
because
of the ease in separating
urine
and stool
collections.
Infants
with a history
of diarrhea
for
more than 72 hours and any with a history
of having
had diarrhea
or receiving
antibiotics
in the 2 weeks
preceding
the present
illness
were excluded.
None
had kwashiorkor,
marasmic
kwashiorkor,
or any
skin

lesions

associated

with

nutritional

Received
for publication
Jan 31, 1985; accepted
Aug 1, 1985.
Reprint
requests
to (M.D.B.)
Institute
of Child Health,
Red
Cross War Memorial
Childrens
Hospital,
Rondebosch,
7700,

The day of admission

to hospital
day 0, and initial
treatment
was

Republic of South Africa.

PEDIATRICS
(ISSN 0031

cases.

American

Academy

of Pediatrics.

4005).

Copyright

1986

by

the

treatment

Routine

investigations

deficiencies.

was designated
the same
in all

included

examination
of stool and urine specimens
asites and stool and urine cultures.
Blood

microscopic

for parspecimens

PEDIATRICS
Vol. on
77July
No.11,
4 2012
April 1986
Downloaded from pediatrics.aappublications.org at Indonesia:AAP
Sponsored

477

were

cultured

and

measured

for

serum

electrolytes

the drug

and acid-base
status.
An inadequate
circulating
blood volume,
detected
clinically
by poor peripheral
capillary
perfusion,
was corrected
by rapid infusion
of a plasma
volume
expander
(Haemaccel).
Thereafter, the patients
were managed
in the same way
as

those

without

this

sign.

< 7.20) was parsodium

bicarbon-

Severe
metabolic
acidosis
(pH
tially corrected
with intravenous
ate

administration.

nously

to

All

those

circulating

fluid

without

administered

signs

intrave-

of an

inadequate

blood

rows

solution

lated

volume

volume
was
half-strength
Dardextrose
in water.
The calcuof fluid for rehydration
was based
on

in 5%

the clinical
assessment
of dehydration
(ie, 50 mL/
kg if 5% dehydrated
and 100 mL/kg
if 10% dehydrated).
This, together
with a maintenance
volume
of 120 mL/kg/d,
was given at a constant
rate during
24 hours.

Oral

half-strength

Darrows

solution

with

dextrose
was given at three-hourly
intervals
starting three
to 12 hours
after
admission,
and the
intravenous
fluid rate was decreased
as necessary.
The

infants

were

requirements

frequently

reassessed

recalculated

according

and

fluid

to their

prog-

ress. About
24 hours
after
admission,
the oral halfstrength
Darrows
solution
was replaced
with cows
milk formula
feedings.
If the diarrhea
persisted
and
intravenous
fluids were required
to maintain
hydration

on day

based

4, the

formula

feedings

(Isomil)

were
given

changed
in

to a soya-

a volume

of

120

mL/kg/d
equally
divided
into three-hourly
feedings.
On day 5, those infants
still requiring
intravenous
fluid administration
to maintain
hydration
were
selected
for further
study.
From day 5 to 11, they
were nursed
on balance
beds, and stool and urine
were collected
separately.
Stool weight
and apparent

fat

daily.

and

nitrogen

Those

weight

who

greater

than

still

absorption

were

had

diarrhea

30 g/kg

severe
of body

(stool
per

day)

on day 7 were selected

for inclusion
into the study.
They
were
randomly
allocated
to receive
one of
eight treatment
combinations
from days 8 to 1 1. If
the

initial

have
na!

bacteriologic

a urinary
stool

pathogen

was excluded
studied

was

screen

tract
from
allocated

infection,
or parasite,

the

study.
to the

showed

a patient

a recognized
next

treatment

drug

478

levels

of each

(capital

letters

TREATMENT

factor

were

the

G, M, or C) or the

OF SEVERE

plus

cholestyramine

metronidazole

eight

possible

gentamicin

(GMC),

(GMc),

(3)

plus

(2) gen-

gentamicin

plus cholestyramine
(GmC),
(4) metronidazole
plus
cholestyramine
(gMC),
(5) gentamicin
(Gmc),
(6)
metronidazole
(gMc), (7) cholestyramine
(gmC),
(8)
no drugs (gmc).
Gentamicin
was given in a dosage
of 50 mg/kg/d
(maximum
360 mg/d)
in six divided
doses for three
days. The dose of cholestyramine
was 1 g every six
hours
and that of metronidazole
was 100 mg every
eight
hours
for
the cholestyramine

five

days.
Care
was taken
to
at least
one
hour
before

give
the

gentamicin
or metronidazole
to avoid possible
binding of the antibacterial
agents.
The nutritional
status of each infant was assessed
by expressing
the fully rehydrated
weight
as a percentage
of expected
weight
for age. The groups were
compared
with respect
to age and nutritional
status
and in the pretreatment
period
(days 5 to 7) with
respect
to daily stool weight
per kilogram
of body
weight
by analysis
of variance.
The effects
of the
drugs
and the interactions
between
them
on the
severity

of the

ing

decline

the

diarrhea

were

in stool

assessed

weight

from

by determin-

pretreatment

levels.
The daily
stool
weight
per kilogram
weight
on days 8, 9, 10, and 1 1 was subtracted
the mean
of the pretreatment
stool
weight

of body
from
of that

individual.
These
results
were
analyzed
in the
standard
way for a 2 x 2 x 2 factorial
design.4
The effect of the drugs on apparent
nitrogen
and
fat

absorption

was

assessed

on a three-day

balance

(days 9 to 11 inclusive)
using multiple
linear regression.5 The dependent
variable
was the percentage
of nitrogen
or the percentage
of fat absorption.
Stool weight
has a marked
effect on each of these
therefore,

it was

included

as a continu-

ous independent
variable.
The factors
gentamicin,
metronidazole,
and cholestyramine
were included
as categorical
variables
(1 when the drug was given
and 0 when it was not).
RESULTS

he

Details
of the groups
are shown
in Table 1. There
were no differences
between
the groups
with regard
to age or percentage
of weight
for age (P > .05).
There
were no differences
in stool weights
between

infant

to be

group

from

presence

tamicin

plus

(1)

to

which
the infant
had been excluded,
and the trial
continued
until 40 infants
had completed
the study.
The study was analyzed
as a 2 x 2 x 2 factorial
with
five replications
(ie, five infants
in each
group).4
The three
factors
were
gentamicin
(G),
metronidazole
(M), and cholestyramine
(C). The
two

metronidazole

were:

bacte-

or a bacteremia,

The

as g, m, or c). The

combinations

variables,2

measured

weight

(expressed

treatment

of the

absence

PERSISTENT

of

the

groups

in the

pretreatment

nor were
there
significant
group
between
those
days.
diarrhea
with
a stool weight
(mean

(days

5 to 7);

SEM).

The
ment

period

changes
within
each
All infants
had severe
of 105.7 8.5 g/kg/d

mean
levels

DIARRHEA

decrease
on days

in stool

weight

8, 9, 10, and

from

pretreat-

11 in the

presence

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on July 11, 2012

TABLE

1.

Characteristics

of Infants

in Treatment

Groups
Drug

Characteristic

GMC

Gmc

gMC

gMc

gmC

gmc

Age (mo)
Mean
Range

4.33

3.98

3.50

4.64

5.12

3.62

4.62

1.50-7.40

1.90-5.40

1.80-8.40

2.30-7.60

1.50-9.50

2.30-5.50

1.60-9.60

SEM

0.98

0.66

1.24

1.46

1.68

0.59

1.05

% expected
wt
for age
Mean
Range

73.9

64.4-88.6

65.1-100.8

G, gentamicin;

5.6

4.3

5.9

letters

M, metronidazole;

C, cholestyramine.

G, M, or C and the absence

TABLE

by the

in Stool

Weights

of a drug

Decrease

2.

Day
47.2

small

(GMC

5.3

3.3

in Infants

on Different

11.5

63.1

9.3

64.4

38.7

15.3

63.3 16.4

11

98.8

49.1

are

13.8

expressed

receiving

the

drug.

as

15.3

the

65.7

mean

to 7) levels
G, gentamicin;

in Table
2. On
treatment
was
The decrease
in
in those infants
compared
with
effects

and

GmC)

compared

with

The

results

on

days

16.7

decrease

76.9

86.1

82.7

91.5

in

14.2

stool

TABLE

weights

15.2

g/kg/d

1 1 were

similar
to those on day 9. The effect of metronidazole treatment
was not significant,
but in those
patients
receiving
metronidazole
(GMC,
GMc, gMc
and gMC) on day 11, the stool weight
was 17.0 g/

3.

15.9

(g/kg/d)

of

Nitrogen

21.5
50.7
51.1

8.7
9.9
15.0

56.5

absence

Stool

14.3

SEM

from

(lower

case

Weight

and

Drug

% Nitrogen

% Fat
Absorption

Absorption

84.19
-.43 (.06)

(stool wt)

(gentamicin)

-3.61

(metronidazole)
(cholestyramine)

R
The partial

Regimen

and Fat Absorption*

B1
B,
B,
B4

capital

13.2
15.0

Effect

on Apparent

of genta-

10 and

12.6

73.8 14.6

in the presence
(capital
letter)
and
M, metronidazole;
C, cholestyramine.

The

54.0 11.2

30.2 10.8

12.1
by the

Regimens*
C

10.3

40.0

Drug

81.1

40.2-113.9

drug is indicated

45.3

87.6 12.1
98.4 12.5

Results

of a particular

g, m, or c.

in those
receiving
gentamicin
but not cholestyramine (Gmc and GMc),
28.8 g/kg/d
in those
given
cholestyramine
but
not
gentamicin
(gMC
and
gmC), and 27.9 g/kg/d
in those given neither
(gMc
and gmc).
On day 9 the effect of gentamicin
treatment
was
significant.
The decrease
in stool weight
was 47.6
g/kg
greater
in those
receiving
gentamicin
than
those
not (F,,32 = 9.95; P < .01). The effects
of
cholestyramine
treatment
(26.2 g/kg; F1,32 = 3.01;
P > .05) and metronidazole
treatment
(1.3 g/kg)
were not significant,
and there were no significant
interactions.

6.6

letters

micin treatment
(18.9 g/kg, F,,32 = 2.05; P > .05)
and metronidazole
treatment
(15.5 g/kg,
F1,32 =
1,31; P > .05) were not significant.
The effect
of
cholestyramine
treatment
on day 8 was largely
due
to a significant
interaction
between
cholestyramine
and gentamicin
(F,,32 = 5.75; P < .05). Stool weight
declined
79.2 g/kg/d
in those
who received
both
drugs

7.4

9
10

and absence
of each drug is shown
day 8, the effect of cholestyramine
significant
(F,,32 = 6.08; P < .05).
stool weight
was 32.5 g/kg greater
receiving
cholestyramine
treatment
not

79.9

70.4-90.8

28.3 8.9

pretreatment
(days
letter) of each drug.

those

79.4

63.0-94.0

Administration

g
11.9

78.5

54.4-89.4

82.5

5.00

3.10-9.00
1.05

59.0-101.7

87.1

79.8

64.2-93.9

SEM
*

GmC

GMc

Regimen*

1.70

-2.44

90.31
-.42 (.06)

(3.94)

-6.65

(4.04)

(3.71)

-1.48

(3.80)

(3.73)

-13.51

(3.82)

.60

regression

.61

coefficients

for the multiple

lin-

Y = A + B1X1 + B,X2 + B,X3 + B4X4,

where Y = % nitrogen
absorption
or % fat absorption,
x1 = stool weight (g/kg/d)
SEM, and X2, X3, and X4
=
categorical
variables
(SEM)
for gentamicin,
metronidazole,
and cholestyramine,
respectively.
When
the
drug was given, the value of the categorical
variable was
1. The
value 0 was allocated
to those patients
who did
ear

regression

not

receive

the

drug.

kg higher
than those who did not
Gmc, gmC, gmc).
Between
days 9 and 11, nitrogen
tion

improved

as

the

stool

receive
and

weight

it (GmC,
fat absorp-

decreased.

In

Table
3, the partial
regression
coefficients
for the
multiple
linear
regression
of percentage
nitrogen
and fat absorption
are shown.
Except
for their
effect
on stool weight,
none of the drugs
directly
affected
nitrogen
absorption,
but the administration of cholestyramine
was associated
with a reduction in fat absorption.

ARTICLES
Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on July 11, 2012

479

gentamicin
treatment
(groups
GMC,
GMc,
GmC,
Gmc) did not have a significantly
greater
decrease
in stool output
in the first 24 hours
of treatment
compared
with those not receiving
gentamicin.
On

DISCUSSION
Prior to treatment,
all of the infants
in this study
had equally
severe
persistant
diarrhea.
The mean
daily stool weight
was more than 100 g/kg of body
weight,
and a previous
study has shown
that at this
magnitude
of diarrhea
nitrogen
and energy
requirements

cannot

be

met

with

oral

nutrient

days

intake.2

Such infants
are in negative
nitrogen
balance
and
apparent
fat absorption
is of the order of 30% of
intake.
Carbohydrate
absorption
is also impaired.6
Termination
of the diarrhea
is essential
if nutrition
is to be maintained.
To assess
the effects
of the drugs,
a 2 x 2 X 2
factorial
method
of analysis
was chosen
to overcome the problem
of having
small numbers
in each
group. Use of this method
allows the main effect of
a particular
drug to be assessed
by comparing
all
patients
receiving
the preparation
with all of those
not receiving
it. In effect, this means
that for each
drug used
in this study
20 patients
receiving
a
particular
drug were compared
with 20 not receiving
it.
During
the first 24 hours
of treatment,
infants
who
received
cholestyramine
treatment
(groups
GMC, GmC, gMC, gmC) had a significantly
greater
decrease
in stool weight
than
those
who did not
receive
the drug (Table
2). Thereafter,
on days 9 to
1 1, although
the

the

difference

decline

was

not

in stool

weight

significant.

was

Infants

greater,
receiving

9 to 11, the

administration

of gentamicin

those

receiving

gentamicin

without

cholestyramine

(groups
GMc
and Gmc)
or neither
drug
(groups
gMc and gmc). The effect on stool weight
of infants
receiving
both
gentamicin
and
cholestyramine
(GMC
and GmC)
compared
with those
receiving
neither
(gMc and gmc) is illustrated
in the Figure.
Metronidazole
treatment
appears
to have little effect on stool weight
either
alone or in combination
with the other drugs.
The
factors
responsible
for the persistence
of
severe
diarrhea
are not entirely
clear. None of the
infants
included
in this study
had a recognized
bacterial
pathogen
in their stools.
A previous
study
using the same criteria
for patient
selection
demonstrated
a grossly
abnormal
overgrowth
of microorganisms
in the small bowel of infants
with diarrhea
persisting
for seven
days
after
admission.7

20

C
H
A
N

G
E
20

_40
S

0
0

6O

80
G

H
I

-100

g
_120

10

d
DAY

OF

HOSPITAL

TREATMENT

Decrease
in stool weight from pretreatment
levels in infants receiving
a combiof gentamicin
and cholestyramine
(-)
and those receiving neither of these drugs
-). Horizontal
line at 0 represents
the mean daily stool weight
(g/kg of body weight!

Figure.

nation
(-

d) of each

480

TREATMENT

group

before

OF SEVERE

starting

treatment.

PERSISTENT

was

accompanied
by a significantly
greater
decrease
in
stool weight
in comparison
to those
not receiving
the drug (Table
2). It appears
that the effect
of
cholestyramine
on day 8 is largely
due to an interaction
with gentamicin.
During
the first 24 hours
of treatment,
the decrease
in stool weight
of infants
receiving
cholestyramine
but
not
gentamicin
(groups
gMC and gmC) was similar
to the effect in

DIARRHEA

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on July 11, 2012

Although
the duodenal
microflora
of the infants
in
this study was not investigated,
there is no reason
to believe
it should
be any different
from those
in
the previous
study.
We believe
the bacterial
overgrowth
plays a role in the pathogenesis
of persistent
diarrhea.
The microorganisms
may be directly
involved
by damaging
the intestinal
mucosa.8
Alternatively,
or in addition,
they
may be indirectly
involved
by the elaboration
of toxins
or by deconjugating
and dehydroxylating
the bile salts.8
The
early beneficial
effect noted with the use of cholestyramine
treatment
supports
the indirect
mechanism as a cause
of persistent
diarrhea.
The dominant
role of gentamicin
noted
after
the first 24
hours
of treatment
supports
the view that elimination
of the bacterial
overgrowth
is most important in controlling
ongoing
diarrhea.
As has been noted in a previous
study, the greater
the stool weight
the poorer
is apparent
nitrogen
and fat absorption.2
Nitrogen
and fat absorption
decreased
by about
0.4% with each gram per kilogram of body weight
increase
in stool output
(Table
3). Gentamicin
treatment
had a major
effect
on
stool weight
and indirectly
on apparent
nitrogen
and fat absorption.
As the stool weight
decreased,
apparent
nitrogen
and fat absorption
improved.
No
direct
effect of gentamicin
was noted.
In contrast,
metronidazole
treatment
did not produce
a decrease
in stool
weight;
therefore,
no indirect
effect
on
apparent
nitrogen
and fat absorption
occurred.
Neither was a direct effect noted.
By reducing
stool weight
(Table
2), cholestyramine indirectly
improved
nitrogen
absorption,
but
no direct effect was demonstrated.
The decrease
in
stool weight
also improved
fat absorption,
but the
drug directly
impaired
uptake
of fats (Table
3).
This is not surprising
because
cholestyramine
is a
bile salt-binding
resin. The net effect on fat absorption is a balance
between
the improvement
derived
from the reduction
of stool weight
and the direct
effect
of cholestyramines
impairment
of fat absorption.
By calculation,
a decrease
in stool weight
exceeding
32 g/kg of body weight
per day would
offset
the reduction
in fat absorption
associated
with cholestyramine
treatment.
Between
days 9 and
11, infants
receiving
cholestyramine
had a mean
reduction
in daily stool weight
that was 32 g/kg of
body weight
greater
than
those
not receiving
the
drug (Table
2). On average,
cholestyramine
treatment alone neither
improved
nor impaired
fat absorption.
The overall
effect of gentamicin
and cho-

lestyramine
together
was a marked
reduction
in
daily stool output
and an improvement
in nitrogen
and fat absorption.
It is a minority
of infants
with acute gastroenteritis who go on to have persistent
diarrhea
of the
severity
of the infants
in this study.
In patients
such as these, maintenance
of nutrition
via the oral
route
is not possible
because
of the large
stool
nitrogen
and energy
losses.
Termination
of the
diarrhea
and reduction
of these
losses is essential.
This study has shown
the use of a combination
of
oral gentamicin
and cholestyramine
to be an effective and rapid
means
of achieving
this. It is also
safe and, except for a mild metabolic
acidosis
during
the administration
of cholestyramine,
no complications
have been encountered
in 8 years of using
this treatment.
Measurements
of serum gentamicin
levels in a number
of similar
infants
receiving
oral
gentamicin
in the dose prescribed
have shown
absorption
to be insignificant
(unpublished
data).
It
is recommended
that oral gentamicin
and cholestyramine
be given to infants
with severe,
persistent,
dehydrating
diarrhea
who show
no signs
of improvement
after seven days of hospital
treatment.

ACKNOWLEDGMENTS
This
Research

work was
Council.

supported

We thank the Mobil

nical assistance.

by the

Research

South

African

Medical

Associateship

for tech-

REFERENCES
1. Bowie
atrics

2. Mann

3.

MD,

Mann

MD,

MD,

Hill

ID, Peat

tion
in prolonged
1982;57:268-273
Hill ID, Mann
MD,
persistent
diarrhoea
243

4. Snedecor
Ames,

Hill

GW,
Iowa,

Iowa

GM,

diarrhoea

7.

bowel

et al: Protein
in

Bowie
MD:
in infants.

Cochrane
State

infancy.
Successful
S Afr Med

WG:
University
JH: Applied

5. Bottenberg
RA, Ward
sian.
Lackland
AF Base, TX.
Laboratory,
Aerospace
Medical
TDR-63-6,
1963
6.

ID: The

cocktail.

Pedi-

1981;67:920-921

Statistical
Press,
Multiple

and

fat absorp-

Arch

Dis

management
J 1980;58:241Methods,
1967
Linear

6570th
Personnel
Division,
report

Mann
MD,
Hill
ID, Moore
L, et al: Xylose
infants
with
severe
prolonged
diarrhoea.
180;58:598-599
Hill ID, Mann
MD, Moore L, et al: Duodenal
infants
with
acute
and persistent
diarrhoea.

1983;58:330-334
8. Lifshitz
F: The enteric
flora in childhood
rhoea. Am J Clin Nutr
1977;50:1511-1516

of

ed

6.

Regres-

Research
No. PRL-

absorption
S

Afr

in

Med

microflora
in
Arch Dis Child
disease-diar-

ARTICLES

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on July 11, 2012

Child

481

Use of Oral Gentamicin, Metronidazole, and Cholestyramine in the Treatment of

Severe Persistent Diarrhea in Infants
Ivor D. Hill, Michael D. Mann, Keith C. Househam and Malcolm D. Bowie
Pediatrics 1986;77;477
Updated Information &
Services

including high resolution figures, can be found at:

http://pediatrics.aappublications.org/content/77/4/477

Permissions & Licensing

Information about reproducing this article in parts (figures, tables)

or in its entirety can be found online at:
http://pediatrics.aappublications.org/site/misc/Permissions.xhtml

Reprints

Information about ordering reprints can be found online:

http://pediatrics.aappublications.org/site/misc/reprints.xhtml

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1986 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on July 11, 2012