What is the treatment for a pediatric patient with watery, smelly, greenish diarrhea?

From the Guidelines

The primary treatment for a pediatric patient with watery, smelly, greenish diarrhea is oral rehydration therapy using a reduced osmolarity oral rehydration solution (ORS) as the first-line therapy, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1. This approach is crucial for managing mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause. The use of ORS is based on the principle that the coupled transport of sodium and glucose across the intestinal brush border remains intact during diarrhea, leading to enhanced water absorption and enabling oral rehydration 1. Key points to consider in the management of pediatric patients with watery, smelly, greenish diarrhea include:

• Starting with oral rehydration solution (ORS) such as Pedialyte, giving small amounts frequently (5-15 mL every 5-10 minutes) and increasing as tolerated.
• Continuing the child's regular diet, avoiding only high-sugar foods and beverages.
• Considering antimicrobial therapy if bacterial infection is suspected, with options including metronidazole for suspected Giardia, and azithromycin or ciprofloxacin for suspected bacterial pathogens, although empiric antibiotic therapy is not recommended in most cases without recent international travel or specific risk factors 1.
• Avoiding antimotility agents in children due to the risk of adverse events such as ileus, abdominal distension, and lethargy 1.
• Considering probiotics like Lactobacillus GG or Saccharomyces boulardii to help reduce duration, and zinc supplementation to reduce severity and duration, particularly in malnourished children. The greenish color and foul smell of the diarrhea often indicate infection with organisms like Giardia, Salmonella, or other enteric pathogens that disrupt normal intestinal flora and cause malabsorption of fats, leading to the characteristic appearance and odor of the stool. In cases of severe dehydration, shock, or altered mental status, isotonic intravenous fluids such as lactated Ringer’s and normal saline solution should be administered 1. Maintenance fluids should be administered after rehydration, replacing ongoing losses in stools with ORS until diarrhea and vomiting are resolved 1. It is essential to follow the guidelines and recommendations from reputable sources, such as the Infectious Diseases Society of America, to ensure the best possible outcomes for pediatric patients with watery, smelly, greenish diarrhea.

From the FDA Drug Label

Antidiarrheal LOPERAMIDE Solution 10ml (58670-000-10) The FDA drug label does not answer the question.

From the Research

Treatment for Pediatric Patients with Watery, Smelly, Greenish Diarrhea

• The treatment for pediatric patients with watery, smelly, greenish diarrhea primarily involves oral rehydration therapy (ORT) and, in severe cases, intravenous fluids 2, 3, 4, 5, 6.
• According to the study by 2, children with mild-to-moderate dehydration are best treated with ORT using commercially available oral solutions containing 45-75 mEq/l of Na(+).
• For children with severe dehydration, intravenous fluids (60-100 ml/kg of 0.9% saline) should be administered in the first 2-4 hours to restore circulation, followed by ORT to replace losses of water and Na(+) over 6-8 hours 2.
• The addition of 20 mEq/l K(+) to rehydration solutions can help repair cellular K(+) deficits without the risk of hyperkalemia 2.
• A study by 4 found that an ORS tolerance test can be effective in determining the volume of ORS a child with diarrhea and moderate dehydration needs to tolerate to be successfully managed at home.
• The use of oral rehydration solutions depends on an appreciation of the physiological mechanisms of diarrheal illness, and newer formulations using starches, cereals, and/or amino acids may make ORT even more efficacious and acceptable 3.
• It is also important to integrate nutritional management, including electrolytes and glucose, into programs for diarrhea control 3.
• Waiting room oral rehydration has been shown to be a simple yet successful intervention that can reduce the need for intravenous fluids and hospital admissions in children presenting with symptoms of acute gastroenteritis 6.

Key Considerations

• The type of dehydration (isonatremic, hyponatremic, or hypernatremic) should be considered when determining the appropriate treatment strategy 2.
• Age-appropriate diet should be started as soon as tolerated 2.
• Maintenance hydration is best treated with 5% dextrose in 0.2% saline containing 20 mEq/l KCl 2.

Oral Rehydration Therapy

• ORT is the mainstay of treatment for acute watery diarrhea, but it is often underutilized in hospital settings 3, 4, 6.
• The 'standard' oral replacement solution recommended by the World Health Organization has the advantage of wide experience, demonstrated safety and effectiveness, and wide availability 3.