From the Guidelines
Diarrhea in pediatric patients should be managed primarily with oral rehydration therapy using reduced osmolarity oral rehydration solutions (ORS), as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1. The management of diarrhea in pediatric patients involves several key components, including:
- Oral rehydration therapy with reduced osmolarity ORS, which is recommended as the first-line therapy for mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause 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 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 1 Some important considerations in the management of pediatric diarrhea include:
- Continuing breastfeeding or formula feeding during episodes, and introducing a regular diet as soon as tolerated
- Avoiding antimotility agents like loperamide in children under 2 years
- Using antibiotics only when necessary, such as in cases of bloody diarrhea, high fever, or severe illness, and using azithromycin (10 mg/kg on day 1, then 5 mg/kg for 4 days) as a potential treatment option 1
- Monitoring for signs of severe dehydration, bloody stools, persistent vomiting, high fever, or if symptoms last beyond 7 days, and seeking immediate medical attention if any of these occur. The causes of diarrhea in pediatric patients can be varied, but most cases are viral and self-limiting, typically resolving within 5-7 days 1. Dehydration is the primary concern as children have higher body water content and faster metabolic rates than adults, making them more vulnerable to fluid losses 1.
From the FDA Drug Label
Pediatric Use 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 Dehydration, particularly in pediatric patients less than 6 years of age, may further influence the variability of response to loperamide hydrochloride. The safety and effectiveness of loperamide hydrochloride in pediatric patients with chronic diarrhea have not been established
The causes of diarrhea in pediatric patients are not directly addressed in the label. The management of diarrhea in pediatric patients is not explicitly stated, but loperamide hydrochloride is contraindicated in pediatric patients less than 2 years of age. For pediatric patients over 2 years of age, caution is advised due to the potential for CNS effects and dehydration. No therapeutic dose for chronic diarrhea in pediatric patients has been established 2.
From the Research
Causes of Diarrhea in Pediatrics
- Diarrheal illnesses in infants and children can be caused by various viral, bacterial, and parasitic pathogens 3
- Dehydrating diarrhea is a common cause of morbidity and mortality in pediatric patients 4
Management of Diarrhea in Pediatrics
- Oral rehydration therapy is the mainstay of treatment for acute watery diarrhea 4, 5, 6, 7
- The use of oral rehydration solutions (ORS) has revolutionized the management of acute diarrhea, resulting in decreased mortality associated with acute diarrheal illnesses in children 7
- The World Health Organization (WHO) recommends a standard ORS formula, which has been shown to be effective and safe for treating dehydration in pediatric patients 4, 5
- Rapid introduction of full feedings, including milk products, is associated with better weight gain and shorter duration of diarrhea in pediatric patients 5
- Cholestyramine may be used as an adjunct therapy to shorten the duration of diarrhea, but only after adequate rehydration has been achieved 5
- An ORS tolerance test can be used to assess the effectiveness of oral rehydration therapy in pediatric patients with moderate dehydration, and to determine the volume of ORS needed to tolerate for successful management at home 6
Nutritional Management
- Nutritional management, including electrolytes and glucose, is an important part of the management of diarrhea in pediatric patients 4
- Rapid restoration of a normal, age-appropriate diet can help reduce the impact of diarrhea on nutrition in pediatric patients 3
- The use of alternative substrates to glucose, such as starches and proteins, may be beneficial in oral rehydration therapy for pediatric patients 4