Pediatric Diarrhea Treatment: Oral Rehydration Therapy and Antidiarrheals
Oral rehydration solution (ORS) is the first-line treatment for pediatric diarrhea, while antimotility drugs like loperamide should not be given to children under 18 years of age. 1
Rehydration Management Algorithm
Step 1: Assess Dehydration Status
- Mild dehydration (3-5%): Minimal electrolyte disturbances, thirst, slightly dry mucous membranes
- Moderate dehydration (6-9%): Higher risk of electrolyte abnormalities, decreased skin turgor, dry skin
- Severe dehydration (≥10%): Severe electrolyte disturbances, lethargy, prolonged skin retraction, cold extremities 2
Step 2: Select Appropriate Rehydration Method
For Mild to Moderate Dehydration:
- First-line: Reduced osmolarity ORS with sodium concentration 65-90 mEq/L 1, 2
- Dosing:
- Mild dehydration: 50 mL/kg over 2-4 hours
- Moderate dehydration: 100 mL/kg over 2-4 hours 2
- Administration technique: Administer small volumes (5-10 mL) every 1-2 minutes, gradually increasing amount 1
- Avoid allowing thirsty children to drink large volumes at once
- Use spoon, syringe, cup, or feeding bottle for controlled administration
For Severe Dehydration:
- First-line: Isotonic intravenous fluids (lactated Ringer's or normal saline) 1
- Transition: Switch to ORS when pulse, perfusion, and mental status normalize, patient awakens, has no risk factors for aspiration, and no evidence of ileus 1
Step 3: Maintenance and Ongoing Losses
- Once rehydrated, replace ongoing losses with ORS until diarrhea resolves 1
- After each loose stool: Administer 10 mL/kg of ORS
- After each vomiting episode: Administer 2 mL/kg of fluid 2
Nutritional Management
- Continue breastfeeding throughout the diarrheal episode 1, 2
- Resume age-appropriate diet during or immediately after rehydration 1
- Recommended foods: Starches, cereals, yogurt, fruits, and vegetables
- Avoid foods high in simple sugars and fats 2
- For formula-fed infants: Consider lactose-free or reduced-lactose formulas after rehydration 2
Pharmacological Management
Antimotility Agents
- Loperamide (Imodium) should NOT be given to children under 18 years of age 1
- Rationale: Risk of serious adverse events (ileus, lethargy, death) outweighs benefits in children 3, 4
- Studies show serious adverse events occurred in 0.9% of children receiving loperamide, with all cases occurring in children younger than 3 years 3
Antiemetics
- Ondansetron may be given to children >4 years and adolescents to facilitate ORS tolerance when vomiting is present 1
Other Adjunctive Therapies
- Zinc supplementation reduces diarrhea duration in children 6 months to 5 years in countries with high zinc deficiency prevalence 1
- Probiotics may be considered to reduce symptom severity and duration 1
Special Considerations and Cautions
When ORS May Not Be Sufficient
- Bloody diarrhea: May require antimicrobial treatment; seek medical care immediately 1
- Intractable vomiting: Consider nasogastric administration of ORS 1
- High stool output (>10 mL/kg/hour): Still attempt ORS, but may have lower success rate 1
- Glucose malabsorption: Suspect if stool contains glucose/reducing substances AND stool output increases dramatically with ORS 1
Warning Signs Requiring Medical Attention
- Persistent symptoms >48 hours
- Signs of severe dehydration
- Bloody diarrhea
- High fever
- Refusal to feed 2
Common Pitfalls to Avoid
- Using inappropriate fluids like sports drinks, juices, or sodas which have improper electrolyte composition 2
- Improper mixing of ORS packets resulting in solutions too concentrated or dilute 2
- Allowing dehydrated children to drink large volumes of ORS at once 1
- Using antimotility medications in children under 18 years 1
ORS therapy has been shown to significantly reduce hospitalizations and complications in children with acute diarrhea when properly administered in primary care settings 5, making it the cornerstone of pediatric diarrhea management.