History

Fact Explanation
The features of acute gastroenteritis occurring in epidemics. The Adenovirus strains (group F, types 40 and 41) [1] [2] are usually transmitted via the feco-oral route by contamination of a common water source.[2] [3] [4] [5]. There is a strong association with infantile diarrhea [1] [6] [7] and diarrheal outbreaks in young children [2] [7]. It also has been noted to be transmitted from child to child. [7]
Asymptomatic infection Some patients can have an asymptomatic infection. [8]
Incubation period of 3-10 days the Adenovirus strains that infect the intestinal mucosa has an incubation period of 3-10 days. [2]
Watery diarrhea Adenoviral gastroenteritis causes a mild [9] and self limiting [10] [11] watery diarrhea that lasts for one to two weeks. [7] Diarrhea has been reported in more than 80% of the adenoviral gastroenteritis. [12] Serotype 41 has a shorter duration of diarrhea. [13]
Vomiting Sudden onset [143] vomiting co-existing with diarrhea are the salient features of viral gastroenteritis. [15] [16] Vomiting has been reported in about 80% of the cases. [12]
Abdominal pain Abdominal pain has been reported in 76% of the cases in some studies. [12] [14]
Fever Mild low-grade fever has been reported in above 90% of the cases. due to inflammatory response to the gastroenteritis. [12] [14]
References
  1. TSOU TP et al. Community Outbreak of Adenovirus, Taiwan, 2011. [web] [viewed 27 May 2014] Available at http://wwwnc.cdc.gov/eid/article/18/11/12-0629_article.htm
  2. CARTER M.J.. Enterically infecting viruses: pathogenicity, transmission and significance for food and waterborne infection. [online] 2005 June, 98(6):1354-1380 [viewed 27 May 2014] Available from: doi:10.1111/j.1365-2672.2005.02635.x
  3. RODRIGUEZ-DIAZ J., QUERALES L., CARABALLO L., VIZZI E., LIPRANDI F., TAKIFF H., BETANCOURT W. Q.. Detection and Characterization of Waterborne Gastroenteritis Viruses in Urban Sewage and Sewage-Polluted River Waters in Caracas, Venezuela. Applied and Environmental Microbiology [online] December, 75(2):387-394 [viewed 27 May 2014] Available from: doi:10.1128/AEM.02045-08
  4. LECLERC H., SCHWARTZBROD L., DEI-CAS E.. Microbial Agents Associated with Waterborne Diseases. Critical Reviews in Microbiology [online] 2002 January, 28(4):371-409 [viewed 27 May 2014] Available from: doi:10.1080/1040-840291046768
  5. MENA KD and GERBA CP. Waterborne adenovirus. Rev Environ Contam Toxicol. [online] 2009;198:133-67. [viewed 27 May 2014] Available at doi: 10.1007/978-0-387-09647-6_4.
  6. CHIBA SHUNZO, NAKAMURA IZUMI, URASAWA SHOZO, NAKATA SHUJI, TANIGUCHI KOHKI, FUJINAGA KEI, NAKAO TOORU. Outbreak Of Infantile Gastroenteritis Due To Type 40 Adenovirus. The Lancet [online] 1983 October, 322(8356):954-957 [viewed 27 May 2014] Available from: doi:10.1016/S0140-6736(83)90463-4
  7. RICHMOND SHIRLEYJ., CAUL E.O., DUNN S.M., ASHLEY C.R., CLARKE SUZANNEK.R., SEYMOUR N.R.. An Outbreak Of Gastroenteritis In Young Children Caused By Adenoviruses. The Lancet [online] 1979 June, 313(8127):1178-1180 [viewed 27 May 2014] Available from: doi:10.1016/S0140-6736(79)91853-1
  8. ZHANG SHUWAN, CHEN TSUN-HSUAN, WANG JUAN, DONG CHANGXIN, PAN JINGJING, MOE CHRISTINE, CHEN WEI, YANG LIHONG, WANG XIAOQIN, TANG HELEN, LI XU, LIU PENGBO. Symptomatic and asymptomatic infections of rotavirus, norovirus, and adenovirus among hospitalized children in Xi'an, China. J. Med. Virol. [online] December, 83(8):1476-1484 [viewed 27 May 2014] Available from: doi:10.1002/jmv.22108
  9. GONÇALVES G., GOUVEIA E., MESQUITA J. R., ALMEIDA A., RIBEIRO A., ROCHA-PEREIRA J., SÃO JOSÉ NASCIMENTO M.. Outbreak of acute gastroenteritis caused by adenovirus type 41 in a kindergarten. Epidemiol. Infect. [online] December, 139(11):1672-1675 [viewed 27 May 2014] Available from: doi:10.1017/S0950268810002803
  10. JALAL H., BIBBY D. F., TANG J. W., BENNETT J., KYRIAKOU C., PEGGS K., CUBITT D., BRINK N. S., WARD K. N., TEDDER R. S.. First Reported Outbreak of Diarrhea Due to Adenovirus Infection in a Hematology Unit for Adults. Journal of Clinical Microbiology [online] December, 43(6):2575-2580 [viewed 27 May 2014] Available from: doi:10.1128/JCM.43.6.2575-2580.2005
  11. GRAY GC and CHORAZY ML. Adenovirus. [web] [viewed 27 May 2014] Available on http://www.antimicrobe.org/new/v01.asp
  12. JARECKI-KHAN K, TZIPORI SR, UNICOMB LE. Enteric adenovirus infection among infants with diarrhea in rural Bangladesh. J Clin Microbiol [online] 1993 Mar, 31(3):484-9 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8458940
  13. UHNOO I, OLDING-STENKVIST E, KREUGER A. Clinical features of acute gastroenteritis associated with rotavirus, enteric adenoviruses, and bacteria. Arch Dis Child [online] 1986 Aug, 61(8):732-8 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3017237
  14. UHNOO I, WADELL G, SVENSSON L, JOHANSSON ME. Importance of enteric adenoviruses 40 and 41 in acute gastroenteritis in infants and young children. J Clin Microbiol [online] 1984 Sep, 20(3):365-72 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6092424
  15. AKAN HüLYA, İZBıRAK GüLDAL, GüROL YESIM, SARıKAYA SEZGIN, GüNDüZ TEHLILE S, YıLMAZ GüLDEN, HAYRAN OSMAN, VITRINEL AYCA. Rotavirus and adenovirus frequency among patients with acute gastroenteritis and their relationship to clinical parameters: a retrospective study in Turkey. Array [online] 2009 December [viewed 27 May 2014] Available from: doi:10.1186/1447-056X-8-8
  16. GARY GW JR, HIERHOLZER JC, BLACK RE. Characteristics of Noncultivable Adenoviruses Associated with Diarrhea in Infants: A New Subgroup of Human Adenoviruses J Clin Microbiol [online] 1979 Jul, 10(1):96-103 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC273101

Examination

Fact Explanation
Mild fever There can be a mild fever due to the inflammatory response in the gut mucosa in almost all the cases. [1] [2]
Prolonged skinfold Feature of mild-moderate dehydration as can be seen in most adenoviral gastroenteritis, especially in infants. [1] [3] [4] [5] It appears at 3-4% of dehydration in children. [6]It is one of the features that co-relates best with the percentage of dehydration in infants. [7] It's a quantitative assessment for the degree of dehydration. [8] [9]
Dry mucous membranes Even though not a quantitative assesment tool in dehydration [6], still a first sign to appear.
Sunken eyes Again not a quantitative assessment [6] but important in initial assessment of the children. [8] [10]
Prolonged capillary refilling time Due to circulatory collapse. An important feature in initial assessment. [7] [10] The time of capillary refilling can indicate the degree of dehydration.
Restlessness Due to altered neurological status. [6]
Acute weight loss Due to acute dehydration. [10]
References
  1. JARECKI-KHAN K, TZIPORI SR, UNICOMB LE. Enteric adenovirus infection among infants with diarrhea in rural Bangladesh. J Clin Microbiol [online] 1993 Mar, 31(3):484-9 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8458940
  2. UHNOO I, WADELL G, SVENSSON L, JOHANSSON ME. Importance of enteric adenoviruses 40 and 41 in acute gastroenteritis in infants and young children. J Clin Microbiol [online] 1984 Sep, 20(3):365-72 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6092424
  3. DEY SHUVRA KANTI, SHIMIZU HIDEAKI, PHAN TUNG GIA, HAYAKAWA YUKO, ISLAM ABUL, SALIM ABUL FAIZ MOHAMMAD, KHAN ANISUR RAHMAN, MIZUGUCHI MASASHI, OKITSU SHOKO, USHIJIMA HIROSHI. Molecular epidemiology of adenovirus infection among infants and children with acute gastroenteritis in Dhaka City, Bangladesh. Infection, Genetics and Evolution [online] 2009 July, 9(4):518-522 [viewed 27 May 2014] Available from: doi:10.1016/j.meegid.2009.02.001
  4. AMINU M, AHMAD AA, UMOH JU, DE BEER MC, ESONA MD, STEELE AD. Adenovirus infection in children with diarrhea disease in Northwestern Nigeria. Ann Afr Med [online] 2007 Dec, 6(4):168-73 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18354941
  5. AKAN HüLYA, İZBıRAK GüLDAL, GüROL YESIM, SARıKAYA SEZGIN, GüNDüZ TEHLILE S, YıLMAZ GüLDEN, HAYRAN OSMAN, VITRINEL AYCA. Rotavirus and adenovirus frequency among patients with acute gastroenteritis and their relationship to clinical parameters: a retrospective study in Turkey. Array [online] 2009 December [viewed 27 May 2014] Available from: doi:10.1186/1447-056X-8-8
  6. MACKENZIE ANGELA, BARNES GRAEME, SHANN FRANK. Clinical Signs Of Dehydration In Children. The Lancet [online] 1989 September, 334(8663):605-607 [viewed 27 May 2014] Available from: doi:10.1016/S0140-6736(89)90723-X
  7. STEINER MICHAEL J.. Is This Child Dehydrated?. JAMA [online] 2004 June [viewed 28 May 2014] Available from: doi:10.1001/jama.291.22.2746
  8. FRIEDMAN JEREMY N., GOLDMAN RAN D., SRIVASTAVA RAJENDU, PARKIN PATRICIA C.. Development of a clinical dehydration scale for use in children between 1 and 36 months of age. The Journal of Pediatrics [online] 2004 August, 145(2):201-207 [viewed 28 May 2014] Available from: doi:10.1016/j.jpeds.2004.05.035
  9. FAYOMI O, MACONOCHIE I, BODY R. Is skin turgor reliable as a means of assessing hydration status in children?. Emergency Medicine Journal [online] 2007 February, 24(2):124-125 [viewed 28 May 2014] Available from: doi:10.1136/emj.2006.045229
  10. CHURGAY CA, AFTAB Z. Gastroenteritis in children: Part 1. Diagnosis. Am Fam Physician [online] 2012 Jun 1, 85(11):1059-62 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22962877

Differential Diagnoses

Fact Explanation
Other viral diarrheas The commonest causative agents of acute gastroenteritis are viruses, of them, Rotavirus and Norvovirus are commoner than the others. [1] Others are adenovirus, astrovirus and calicivirus. [2] All viral gastroenteritis types are characterized by acute watery diarrhea, vomiting and fever, while some of them can be asymptomatic. [3] [4] [5] [6] [7] [8] As management of all viral diarrheas is similar, distinction based on organism is only of academic interest. Polymerase Chain Reaction (PCR) is the investigation of choice for species identification. [9]
Bacterial gastroenteritis The common organismas that cause intestinal infections are Vibrio parahaemolyticus, Samonella spp, Plesiomonas spp, Campylobacter spp, Aeromonas spp and Shigella spp. Even though otherwise expected, most patients with bacterial gastroenteritis do not present with high fever, bloody diarrhoea, or persistent diarrhoea, but generally have quite severe diarrhoea lasting for 2-3 days. Stool cultures do not change management for most patients. [10] [11] Travelers diarrhea is a special entity where the patient has not developed immunological tolerance to the E.coli in the water. [12] [13]
Protozoal infections Protozoal infestations cause rather a persistent and complicated form of gastropathy than simple viral diarrheas. Some cause a bloody diarrhea, some cause malabsorption syndromes, and most cause persistent diarrhea. The commonest organisms are Giardia lamblia, Entamoeba histolytica and Cryptosporidium. [14] [15] [16] Parasites can cause acute travelers' diarrhea as well. [17]
Lactose intolerance A common cause of childhood diarrhea. Usually a chronic form, and not-responding to conventional methods of treatment. It should be taken into consideration in an infant who fails to respond to management in two weeks, and specially when a precipitating factor can be identified. [18] [19]
References
  1. GRANT LINDSAY, VINJé JAN, PARASHAR UMESH, WATT JAMES, REID RAYMOND, WEATHERHOLTZ ROBERT, SANTOSHAM MATHURAM, GENTSCH JON, O’BRIEN KATHERINE. Epidemiologic and Clinical Features of Other Enteric Viruses Associated with Acute Gastroenteritis in American Indian Infants. The Journal of Pediatrics [online] 2012 July, 161(1):110-115.e1 [viewed 28 May 2014] Available from: doi:10.1016/j.jpeds.2011.12.046
  2. DOMíNGUEZ ANGELA, TORNER NúRIA, RUíZ LAURA, MARTíNEZ ANA, BARRABEIG IRENE, CAMPS NEUS, GODOY PERE, MINGUELL SOFIA, PARRóN IGNASI, PUMARéS ANALíA, SALA MARIA ROSA, BARTOLOMé ROSA, PéREZ UNAI, DE SIMóN MERCEDES, MONTAVA REBECA, BUESA JAVIER. Aetiology and epidemiology of viral gastroenteritis outbreaks in Catalonia (Spain) in 2004–2005. Journal of Clinical Virology [online] 2008 September, 43(1):126-131 [viewed 28 May 2014] Available from: doi:10.1016/j.jcv.2008.03.016
  3. WU TZEE-CHUNG, LIU HSIOA-HUI, CHEN YANN-JANG, TANG REN-BIN, HWANG BE-TAU, YUAN HAN-CHIH. Comparison of Clinical Features of Childhood Norovirus and Rotavirus Gastroenteritis in Taiwan. Journal of the Chinese Medical Association [online] 2008 November, 71(11):566-570 [viewed 28 May 2014] Available from: doi:10.1016/S1726-4901(08)70170-9
  4. ANDREASI MARCIA SUELI ASSIS, CARDOSO DIVINA DAS DORES DE PAULA, FERNANDES SONIA MARIA, TOZETTI INES APARECIDA, BORGES ANA MARIA TAVARES, FIACCADORI FABíOLA SOUZA, SANTOS RODRIGO ALESSANDRO TôGO, SOUZA MENIRA. Adenovirus, calicivirus and astrovirus detection in fecal samples of hospitalized children with acute gastroenteritis from Campo Grande, MS, Brazil. Mem. Inst. Oswaldo Cruz [online] 2008 November, 103(7):741-744 [viewed 28 May 2014] Available from: doi:10.1590/S0074-02762008000700020
  5. WIEGERING VERENA, KAISER JAN, TAPPE DENNIS, WEIßBRICH BENEDIKT, MORBACH HENNER, GIRSCHICK HERMANN J.. Gastroenteritis in childhood: a retrospective study of 650 hospitalized pediatric patients. International Journal of Infectious Diseases [online] 2011 June, 15(6):e401-e407 [viewed 28 May 2014] Available from: doi:10.1016/j.ijid.2011.02.006
  6. ZHANG SHUWAN, CHEN TSUN-HSUAN, WANG JUAN, DONG CHANGXIN, PAN JINGJING, MOE CHRISTINE, CHEN WEI, YANG LIHONG, WANG XIAOQIN, TANG HELEN, LI XU, LIU PENGBO. Symptomatic and asymptomatic infections of rotavirus, norovirus, and adenovirus among hospitalized children in Xi'an, China. J. Med. Virol. [online] December, 83(8):1476-1484 [viewed 28 May 2014] Available from: doi:10.1002/jmv.22108
  7. LORROT M., BON F., EL HAJJE M. J., AHO S., WOLFER M., GIRAUDON H., KAPLON J., MARC E., RAYMOND J., LEBON P., POTHIER P., GENDREL D.. Epidemiology and clinical features of gastroenteritis in hospitalised children: prospective survey during a 2-year period in a Parisian hospital, France. Eur J Clin Microbiol Infect Dis [online] December, 30(3):361-368 [viewed 28 May 2014] Available from: doi:10.1007/s10096-010-1094-9
  8. WALKER-SMITH J. Rotavirus gastroenteritis. Arch Dis Child [online] 1978 May, 53(5):355-362 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1544907
  9. PAWLOWSKI SEAN W., WARREN CIRLE ALCANTARA, GUERRANT RICHARD. Diagnosis and Treatment of Acute or Persistent Diarrhea. Gastroenterology [online] 2009 May, 136(6):1874-1886 [viewed 28 May 2014] Available from: doi:10.1053/j.gastro.2009.02.072
  10. CHAN SS, NG KC, LYON DJ, CHEUNG WL, CHENG AF, RAINER TH. Acute bacterial gastroenteritis: a study of adult patients with positive stool cultures treated in the emergency department. Emerg Med J [online] 2003 Jul, 20(4):335-8 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12835343
  11. UHNOO I, OLDING-STENKVIST E, KREUGER A. Clinical features of acute gastroenteritis associated with rotavirus, enteric adenoviruses, and bacteria. Arch Dis Child [online] 1986 Aug, 61(8):732-8 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3017237
  12. HILL DAVID R, BEECHING NICK J. Travelersʼ diarrhea. Current Opinion in Infectious Diseases [online] 2010 October, 23(5):481-487 [viewed 28 May 2014] Available from: doi:10.1097/QCO.0b013e32833dfca5
  13. ERICSSON CHARLES D. Travellers' diarrhoea. International Journal of Antimicrobial Agents [online] 2003 February, 21(2):116-124 [viewed 28 May 2014] Available from: doi:10.1016/S0924-8579(02)00282-0
  14. ABD EL BAGI MOHAMED E., SAMMAK BASSAM M., MOHAMED ABDULRAHMAN E., AL KARAWI MOHAMED A., AL SHAHED MONA, AL THAGAFI MOHAMED A.. Gastrointestinal parasite infestation. European Radiology Supplements [online] 2004 March, 14(3):1-1 [viewed 28 May 2014] Available from: doi:10.1007/s00330-003-2041-2
  15. JERNIGAN J, GUERRANT RL, PEARSON RD. Parasitic infections of the small intestine. Gut [online] 1994 Mar, 35(3):289-93 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8150333
  16. GENDREL D., TRELUYER J.M., RICHARD-LENOBLE D.. Parasitic diarrhea in normal and malnourished children. Fundam Clin Pharmacol [online] 2003 April, 17(2):189-197 [viewed 28 May 2014] Available from: doi:10.1046/j.1472-8206.2003.00169.x
  17. OKHUYSEN PABLO C.. Traveler's Diarrhea Due to Intestinal Protozoa. CLIN INFECT DIS [online] 2001 July, 33(1):110-114 [viewed 28 May 2014] Available from: doi:10.1086/320894
  18. LARRAMENDI CARLOS H., MARCO FRANCISCO M., GARCíA-ABUJETA JOSé L., MATEO MáXIMA, DE LA VEGA ANA, SEMPERE JOSé M.. Acute allergic reaction to an iron compound in a milk-allergic patient. [online] 2006 May, 17(3):230-233 [viewed 28 May 2014] Available from: doi:10.1111/j.1399-3038.2005.00373.x
  19. HARRISON M, KILBY A, WALKER-SMITH JA, FRANCE NE, WOOD CB. Cows' milk protein intolerance: a possible association with gastroenteritis, lactose intolerance, and IgA deficiency. Br Med J [online] 1976 Jun 19, 1(6024):1501-4 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/776336

Investigations - for Diagnosis

Fact Explanation
Specific investigation is not required in acute watery diarrhea. This is usually self limiting, and resolves without specific treatment. [1]
References
  1. CASBURN-JONES A C. Management of infectious diarrhoea. Gut [online] 2004 February, 53(2):296-305 [viewed 28 May 2014] Available from: doi:10.1136/gut.2003.022103

Management - General Measures

Fact Explanation
Oral rehydration therapy The viral gastroenteritis rarely require medications. The best proven management option is oral re-hydration therapy. [1] The special hypo-osmolar Oral Re-hydration Salt Solution has the best prognosis. [2] [3] [4] Dehydration occurs more quickly in infants and young children and therefore early administration of an oral re-hydration solution prevents dehydration and acidosis. [1]
Assuring adequate nutrition Use of nutrient-rich food during the phase of illness is advisable to compensate with the loss, and in the case of children, to secure adequate growth. [5] [6]
Zinc supplementation Zinc supplementation with ORS solution has been proven to reduce the morbidity from acute diarrhea in developing countries. [7] Zinc deficiency has been associated with higher incidence of diarrhea so there is a compelling body of clinical data that Zn is likely to be effective both in the treatment of acute diarrhea and in its prophylaxis. The indicated dose is 10 to 30 mg per day. [7] [8]
Prevention strategies The general gastroenteritis prevention strategies should be applied. The usual implications are breast-feeding, water supply and sanitation improvements, promotion of personal and domestic hygiene and weaning education/food hygiene. [9] [10]
References
  1. CASBURN-JONES A C. Management of infectious diarrhoea. Gut [online] 2004 February, 53(2):296-305 [viewed 28 May 2014] Available from: doi:10.1136/gut.2003.022103
  2. MUNOS M. K., WALKER C. L. F., BLACK R. E.. The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality. International Journal of Epidemiology [online] December, 39(Supplement 1):i75-i87 [viewed 28 May 2014] Available from: doi:10.1093/ije/dyq025
  3. ISLAM A, MOLLA AM, AHMED MA, YAMEEN A, THARA R, MOLLA A, ISSANI Z, HENDRICKS K, SNYDER JD. Is rice based oral rehydration therapy effective in young infants? Arch Dis Child [online] 1994 Jul, 71(1):19-23 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1029905
  4. HAHN S, KIM S, GARNER P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. Cochrane Database Syst Rev [online] 2002:CD002847 [viewed 28 May 2014] Available from: doi:10.1002/14651858.CD002847
  5. BROWN KH. Dietary management of acute diarrheal disease: contemporary scientific issues. J Nutr [online] 1994 Aug, 124(8 Suppl):1455S-1460S [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8064403
  6. WHELAN KEVIN, SCHNEIDER STéPHANE M. Mechanisms, prevention, and management of diarrhea in enteral nutrition. Current Opinion in Gastroenterology [online] 2011 March, 27(2):152-159 [viewed 28 May 2014] Available from: doi:10.1097/MOG.0b013e32834353cb
  7. TELMESANI ABDULWAHABMA. Oral rehydration salts, zinc supplement and rota virus vaccine in the management of childhood acute diarrhea. J Fam Community Med [online] 2010 December [viewed 28 May 2014] Available from: doi:10.4103/1319-1683.71988
  8. GOLDMAN RD. Zinc supplementation for acute gastroenteritis. Canadian Family Physician [online] April 2013 [viewed 28 May 2014] vol. 59 no. 4 363-364
  9. ANDERSON EVAN J. Prevention and treatment of viral diarrhea in pediatrics. Expert Review of Anti-infective Therapy [online] 2010 February, 8(2):205-217 [viewed 28 May 2014] Available from: doi:10.1586/eri.10.1
  10. HUTTLY SR, MORRIS SS, PISANI V. Prevention of diarrhoea in young children in developing countries. Bull World Health Organ [online] 1997, 75(2):163-74 [viewed 28 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9185369