50 Years Ago in The Journal of Pediatrics:

Article Outline

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Levin S. J Pediatr 1958;52:227-44

At the beginning of the 20^th century, gastroenteritis and its consequent dehydration were a major cause of childhood mortality. Not surprisingly, investigations into the causes and management of diarrheal dehydration consumed many of the founders of our specialty.

By the middle of the 20^th century, mortality from diarrhea had plummeted, and many of the management principles on which we base current practice had been established. In this extensive review, Levin, from Johannesburg, South Africa, provides us with a glimpse into the “state of the art” 50 years ago. A few things have changed, but much of what Levin stressed then remains useful advice today.

The review begins with a discussion of “medication” for childhood diarrhea. Levin’s general dismissal of most agents should ring true today, although we still see children being treated with kaolin and opiate preparations, both of which were singled out for avoidance. Interestingly, in light of our current interest in “probiotics,” he noted that yogurt was frequently used despite the lack of “really good evidence” of its efficacy. The modern reader may find his discussion of oral antibiotics quite dated; however, keep in mind that the viral etiology of most childhood gastroenteritis had yet to be established.

Levin next moves to a discussion of intravenous therapy for dehydration, an intervention just coming into its own at the time of the review. Unfortunately, this section reflects the somewhat obfuscated state of this particular topic in 1958. The commentary recognizes the possibility of seizures occurring during the course of treatment, yet equivocates on the optimal initial fluid for rehydration. In balance, however, Levin stresses the body’s remarkable homeostatic ability to correct metabolic derangements, given the adequate provision of substrate. He also reminds the reader that no fluid plan for a severely dehydrated child can be written with a long time horizon; frequent reevaluations and recalculations are necessary.

Finally, Levin reminds us that “starvation” and “bowel rest” are inappropriate strategies in the management of childhood diarrhea. Although this concept is now a part of widely accepted practice guidelines, it needs frequent reinforcement.