What is the recommended treatment for pediatric diarrhea?

Treatment of Pediatric Diarrhea

The primary treatment for pediatric diarrhea is oral rehydration therapy (ORT) with appropriate fluid replacement based on the degree of dehydration, followed by early reintroduction of age-appropriate nutrition. 1

Assessment of Dehydration

First, assess the degree of dehydration:

• Mild dehydration (3-5% fluid deficit):

  • Signs: Increased thirst, slightly dry mucous membranes
  • Treatment: Oral rehydration

• Moderate dehydration (6-9% fluid deficit):

  • Signs: Loss of skin turgor, skin tenting when pinched, dry mucous membranes
  • Treatment: Oral rehydration (preferred) or IV if unable to tolerate oral

• Severe dehydration (≥10% fluid deficit):

  • Signs: Lethargy, altered consciousness, prolonged skin tenting (>2 seconds), cool extremities, decreased capillary refill
  • Treatment: Immediate IV rehydration as medical emergency 1

Rehydration Protocol

For Mild Dehydration (3-5% fluid deficit):

• Administer ORS containing 50-90 mEq/L sodium
• Volume: 50 mL/kg over 2-4 hours
• Start with small volumes (1 teaspoon) and gradually increase
• Reassess after 2-4 hours 1

For Moderate Dehydration (6-9% fluid deficit):

• Administer ORS using same approach as mild dehydration
• Volume: 100 mL/kg over 2-4 hours
• ORT has been shown to be as effective as IV fluids for moderate dehydration 2

For Severe Dehydration (≥10% fluid deficit):

• Immediate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline
• Continue until circulation, perfusion, and mental status normalize
• When consciousness returns, transition to oral rehydration 1

Replacement of Ongoing Losses

During both rehydration and maintenance phases:

• Replace each watery stool with 10 mL/kg of ORS
• Replace each episode of emesis with 2 mL/kg of ORS
• Use either low-sodium ORS (40-60 mEq/L) or standard ORS (75-90 mEq/L) 1

Nutritional Management

• Breastfed infants: Continue nursing on demand
• Bottle-fed infants: Resume full-strength formula immediately after rehydration
  • Consider lactose-free formulas if available
  • Monitor for signs of lactose intolerance (worsening diarrhea with formula)
• Older children: Continue regular diet with emphasis on:
  • Starches, cereals, yogurt, fruits, vegetables
  • Avoid foods high in simple sugars and fats 1

Medication Considerations

• Antibiotics: Not routinely indicated for acute diarrhea

  • Consider only for:
    • Dysentery (bloody diarrhea)
    • High fever
    • Watery diarrhea lasting >5 days
    • Specific pathogens identified by stool culture 1, 3

• Antidiarrheal agents: Not recommended for children

  • Loperamide is contraindicated in children under 2 years due to risks of respiratory depression and cardiac adverse reactions 4
  • Antiemetics, antidiarrheals, and spasmolytics are unnecessary and potentially risky 3

Management of Vomiting

• For children with vomiting, administer small, frequent volumes of ORS (5 mL every minute)
• Use spoon or syringe with close supervision
• Gradually increase volume as tolerated
• Correction of dehydration often reduces vomiting frequency 1

Home Management

• Provide clear instructions to parents on:
  • How to administer ORS (volume and frequency)
  • Signs of worsening that require medical attention
  • Importance of continuing feeding
  • Replacing ongoing losses 1

Key Pitfalls to Avoid

1. Delaying oral rehydration: ORT should be initiated promptly, as children who can tolerate at least 20-25 mL/kg of ORS during initial assessment are more likely to be successfully managed at home 5

2. Using inappropriate fluids: Avoid sports drinks, sodas, juices, or plain water which have improper electrolyte composition

3. Withholding food: Early reintroduction of age-appropriate nutrition is essential for recovery

4. Unnecessary use of medications: Avoid antibiotics and antidiarrheal agents unless specifically indicated

5. Underestimating dehydration: Pay close attention to clinical signs, particularly in infants who dehydrate more rapidly 1