What are the recommended medications for treating diarrhea in children?

From the Guidelines

For treating diarrhea in children, oral rehydration therapy (ORT) is the primary recommendation, not medication. ORT solutions like Pedialyte, Infalyte, or homemade solutions (1 liter of clean water with 6 teaspoons of sugar and 1/2 teaspoon of salt) should be given frequently in small amounts. Children should continue their regular diet, avoiding sugary drinks and fatty foods. Zinc supplements (10mg daily for infants under 6 months, 20mg daily for older children) for 10-14 days can reduce severity and duration, as supported by 1. Probiotics like Lactobacillus GG or Saccharomyces boulardii may help shorten illness duration, as suggested by 1. Anti-diarrheal medications such as loperamide (Imodium) are not recommended for children as they can cause serious side effects, according to 1. Antibiotics are only appropriate for specific bacterial infections diagnosed by a doctor. Parents should seek immediate medical attention if the child shows signs of dehydration (decreased urination, dry mouth, no tears when crying), high fever, bloody diarrhea, or if symptoms persist beyond 2-3 days. Rehydration is crucial because diarrhea causes fluid and electrolyte loss that can quickly lead to dangerous dehydration in children. The use of reduced osmolarity oral rehydration solution (ORS) is recommended as the first-line therapy of mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause, as stated in 1 and 1. Nasogastric administration of ORS may be considered in infants, children, and adults with moderate dehydration, who cannot tolerate oral intake, or in children with normal mental status who are too weak or refuse to drink adequately, as mentioned in 1 and 1. It is essential to replace ongoing losses in stools from infants, children, and adults with ORS, until diarrhea and vomiting are resolved, as recommended in 1. In severe dehydration, intravenous rehydration should be continued until pulse, perfusion, and mental status normalize and the patient awakens, has no risk factors for aspiration, and has no evidence of ileus, as stated in 1. Once the patient is rehydrated, maintenance fluids should be administered, as suggested in 1. The safety and efficacy of ORS, in comparison to intravenous rehydration therapy (IVT), was evaluated in a meta-analysis of 17 RCTs involving 1811 patients aged <18 years from high-income and low-income countries, as mentioned in 1. Low-osmolarity ORS can be given to all age groups, with any cause of diarrhea, and is safe in the presence of hypernatremia as well as hyponatremia, as stated in 1. Some commercially available formulations that can be used as ORS include Pedialyte Liters (Abbott Nutrition), CeraLyte (Cero Products), and Enfalac Lytren (Mead Johnson), as mentioned in 1. Popular beverages that should not be used for rehydration include apple juice, Gatorade, and commercial soft drinks, as stated in 1. Breastfed infants should continue nursing throughout the illness, as recommended in 1. After rehydration is complete, maintenance fluids should be resumed along with an age-appropriate normal diet offered every 3–4 hours, as suggested in 1. Children previously receiving a lactose-containing formula can tolerate the same product in most instances, as mentioned in 1. Diluted formula does not appear to confer any benefit, as stated in 1. Isotonic intravenous fluids such as lactated Ringer’s and normal saline solution should be administered when there is severe dehydration, shock, or altered mental status and failure of ORS therapy, as recommended in 1. In people with ketonemia, an initial course of intravenous hydration may be needed to enable tolerance of oral rehydration, as suggested in 1. Infants, children, and adults with mild to moderate dehydration should receive ORS until clinical dehydration is corrected, as stated in 1. Replacement of water, electrolytes, and nutrients lost during diarrhea is essential in the management of diarrhea, as mentioned in 1. Oral rehydration has been credited with saving millions of lives in the management of dehydration in all age groups, regardless of the cause, and is recommended by the WHO as the first line of rehydration, as stated in 1. The coupled transport of sodium and glucose across the intestinal brush border remains intact, and leads to enhanced water absorption, enabling oral rehydration, as mentioned in 1. Phlebitis occurred more often in children receiving IVT, and paralytic ileus occurred more often with ORS, as stated in 1. The model estimated that 4% of children treated with ORS would fail and require IVT, as mentioned in 1. Standard WHO-ORS (osmolarity 311 mmol/L) was the recommended agent for several decades, as stated in 1. Despite its ability to hydrate, WHO-ORS had limitations, including inability to reduce the volume or duration of diarrhea, and concerns that it could lead to hypernatremia, especially in noncholera diarrhea in which salt losses are reduced, as mentioned in 1. In 2002, a hypotonic ORS with total osmolarity <250 mmol/L was recommended by the WHO and subsequently by various other advisory bodies as first-line therapy for mild to moderate dehydration caused by diarrhea of all causes, as stated in 1. A variety of scales are available to grade the severity of dehydration in young children but no single, standard, validated method exists, as mentioned in 1. Note that signs of dehydration may be masked when a child is hypernatremic, as stated in 1. After rehydration is complete, maintenance fluids should be resumed along with an age-appropriate normal diet offered every 3–4 hours, as suggested in 1. Children previously receiving a lactose-containing formula can tolerate the same product in most instances, as mentioned in 1. Diluted formula does not appear to confer any benefit, as stated in 1. Isotonic intravenous fluids such as lactated Ringer’s and normal saline solution should be administered when there is severe dehydration, shock, or altered mental status and failure of ORS therapy, as recommended in 1. In people with ketonemia, an initial course of intravenous hydration may be needed to enable tolerance of oral rehydration, as suggested in 1. Infants, children, and adults with mild to moderate dehydration should receive ORS until clinical dehydration is corrected, as stated in 1. Replacement of water, electrolytes, and nutrients lost during diarrhea is essential in the management of diarrhea, as mentioned in 1. Oral rehydration has been credited with saving millions of lives in the management of dehydration in all age groups, regardless of the cause, and is recommended by the WHO as the first line of rehydration, as stated in 1. The coupled transport of sodium and glucose across the intestinal brush border remains intact, and leads to enhanced water absorption, enabling oral rehydration, as mentioned in 1. Phlebitis occurred more often in children receiving IVT, and paralytic ileus occurred more often with ORS, as stated in 1. The model estimated that 4% of children treated with ORS would fail and require IVT, as mentioned in 1. Standard WHO-ORS (osmolarity 311 mmol/L) was the recommended agent for several decades, as stated in 1. Despite its ability to hydrate, WHO-ORS had limitations, including inability to reduce the volume or duration of diarrhea, and concerns that it could lead to hypernatremia, especially in noncholera diarrhea in which salt losses are reduced, as mentioned in 1. In 2002, a hypotonic ORS with total osmolarity <250 mmol/L was recommended by the WHO and subsequently by various other advisory bodies as first-line therapy for mild to moderate dehydration caused by diarrhea of all causes, as stated in 1. A variety of scales are available to grade the severity of dehydration in young children but no single, standard, validated method exists, as mentioned in 1. Note that signs of dehydration may be masked when a child is hypernatremic, as stated in 1. Some key points to consider when treating diarrhea in children include:

• The use of ORT solutions like Pedialyte, Infalyte, or homemade solutions
• The importance of continuing the regular diet, avoiding sugary drinks and fatty foods
• The potential benefits of zinc supplements and probiotics
• The need to seek immediate medical attention if the child shows signs of dehydration, high fever, bloody diarrhea, or if symptoms persist beyond 2-3 days
• The recommendation to use reduced osmolarity oral rehydration solution (ORS) as the first-line therapy of mild to moderate dehydration
• The consideration of nasogastric administration of ORS in infants, children, and adults with moderate dehydration
• The importance of replacing ongoing losses in stools from infants, children, and adults with ORS, until diarrhea and vomiting are resolved
• The need to continue intravenous rehydration in severe dehydration until pulse, perfusion, and mental status normalize
• The recommendation to resume maintenance fluids and an age-appropriate normal diet after rehydration is complete
• The importance of oral rehydration in the management of dehydration in all age groups, regardless of the cause. It is essential to follow these guidelines to ensure the best possible outcome for children with diarrhea, as supported by 1, 1, 1, and 1.

From the FDA Drug Label

Loperamide hydrochloride is contraindicated in pediatric patients less than 2 years of age due to the risks of respiratory depression and serious cardiac adverse reactions The safety and effectiveness of loperamide hydrochloride in pediatric patients with chronic diarrhea have not been established

The recommended medication for treating diarrhea in children is not explicitly stated in the provided drug label. Loperamide is contraindicated in pediatric patients less than 2 years of age. For children over 2 years old, the label does not provide a clear recommendation for the treatment of diarrhea. 2

From the Research

Recommended Medications for Treating Diarrhea in Children

• Oral rehydration therapy is effective for the treatment of diarrhea of any etiology in patients of any age, as stated in the study 3.
• Optimal management of acute infectious diarrhea includes rapid rehydration using an appropriate glucose-based or cereal-based oral rehydration solution, early refeeding with a mixed diet, and continuation of lactose-containing foods unless clinical signs of lactose intolerance develop 3.
• Loperamide is considered the most potent and safe antidiarrheal drug for use in acute and chronic diarrhea 4.
• Antibiotics are used without hesitation only in invasive diarrhea 4.
• A reduced osmolarity oral rehydration solution combined with early administration of Lactobacillus GG is an effective treatment for acute diarrhea in young children 5.

Oral Rehydration Solutions

• The use of oral rehydration solution (ORS) has revolutionized the management of acute diarrhea, resulting in decreased mortality associated with acute diarrheal illnesses in children 6.
• Various modifications to the standard ORS have been derived, including hypo-osmolar or hyperosmolar solutions, use of rice-based ORS, zinc supplementation, and the use of amino acids 6.
• A single solution can be used for oral rehydration and maintenance therapy of infants with diarrhea and mild to moderate dehydration, as shown in the study 7.

Additional Considerations

• In chronic diarrhea, diagnostic work up must precede therapy, and potentially diarrheogenic drugs or foods have to be eliminated 4.
• Early administration of Lactobacillus GG at the start of oral rehydration can result in the shortest duration of diarrhea, best weight gain, and fastest correction of acidosis 5.