What is the recommended treatment for diarrhea?

Treatment of Diarrhea

The first-line treatment for diarrhea is oral rehydration therapy with reduced osmolarity oral rehydration solution (ORS), which should be administered based on the degree of dehydration, with appropriate dietary management and selective use of adjunctive therapies. 1

Assessment of Dehydration

Determine the severity of dehydration before initiating treatment:

• Mild to moderate dehydration (3-9% fluid deficit):

  • Signs: Dry mucous membranes, decreased skin turgor, sunken eyes, decreased urine output
  • Treatment: Oral rehydration therapy

• Severe dehydration (≥10% fluid deficit):

  • Signs: Altered mental status, poor perfusion, weak pulse, shock
  • Treatment: Immediate intravenous fluid resuscitation

Rehydration Protocol

Mild to Moderate Dehydration

1. Initial rehydration phase:

   • Administer 50-100 mL/kg of reduced osmolarity ORS over 3-4 hours 1
   • For children <10 kg: 60-120 mL ORS for each diarrheal stool
   • For children >10 kg: 120-240 mL ORS for each diarrheal stool
   • Adults: Up to 2 L/day as needed

2. Administration technique:

   • For vomiting patients: Give small, frequent volumes (5 mL every minute) and gradually increase 1
   • Use spoon or syringe with close supervision for young children

Severe Dehydration

1. Emergency IV rehydration:

   • Administer isotonic fluids (Ringer's lactate or normal saline) in 20 mL/kg boluses until pulse, perfusion, and mental status normalize 1
   • May require multiple boluses or alternate access sites

2. Transition to oral therapy:

   • Once mental status improves and patient can tolerate oral intake, switch to ORS to complete rehydration 1

Maintenance Phase

1. Replace ongoing losses:

   • 10 mL/kg ORS for each watery stool
   • 2 mL/kg ORS for each episode of vomiting 1

2. Dietary management:

   • Continue breastfeeding throughout the diarrheal episode for infants 1
   • Resume age-appropriate diet immediately after rehydration 1
   • For bottle-fed infants: Use full-strength, lactose-free formulas if available
   • For older children: Continue regular diet with emphasis on starches, cereals, yogurt, fruits, and vegetables 1
   • Avoid foods high in simple sugars and fats

Adjunctive Therapies

Antimotility Agents

• Adults: Loperamide may be given for acute watery diarrhea in immunocompetent adults 1
• Children: Antimotility drugs should NOT be given to children <18 years of age 1
• Contraindications: Avoid in inflammatory diarrhea, bloody diarrhea, or diarrhea with fever 1

Antiemetics

• Ondansetron may be given to children >4 years and adolescents to facilitate oral rehydration when vomiting is present 1

Probiotics

• May be offered to reduce symptom severity and duration in immunocompetent patients 1
• Evidence is moderate quality; specific recommendations for strains and dosages should be based on manufacturer guidance

Zinc Supplementation

• Recommended for children 6 months to 5 years in areas with high prevalence of zinc deficiency or signs of malnutrition 1

Antimicrobials

• Not routinely recommended for acute watery diarrhea 1
• Consider only for:
  • Dysentery (bloody diarrhea)
  • High fever
  • Watery diarrhea lasting >5 days
  • Specific identified pathogens requiring treatment
  • Immunocompromised patients

Common Pitfalls to Avoid

1. Inappropriate use of antimotility agents in children - can cause serious complications
2. Routine use of antibiotics - may prolong carrier state and increase antibiotic resistance
3. Using inappropriate fluids - avoid apple juice, sports drinks, and soft drinks as they have improper electrolyte content and osmolarity 1
4. Delaying refeeding - early reintroduction of appropriate diet speeds recovery
5. Overreliance on IV fluids when ORS would be sufficient and safer

Special Considerations

• Vomiting: Start with small volumes of ORS and increase gradually; consider ondansetron for severe cases in appropriate age groups
• Home management: Educate caregivers on proper ORS preparation and administration, warning signs requiring medical attention, and appropriate diet

By following this evidence-based approach to diarrhea management with emphasis on appropriate rehydration therapy, most cases can be managed effectively with reduced morbidity and mortality.