What is the recommended treatment for a pediatric patient presenting with acute diarrhea and vomiting?

Treatment of Pediatric Acute Diarrhea and Vomiting

The first-line treatment for pediatric patients with acute diarrhea and vomiting is oral rehydration therapy with reduced osmolarity oral rehydration solution (ORS), accompanied by continued age-appropriate feeding. 1

Rehydration Therapy

Assessment of Dehydration

• Assess dehydration level:
  • Mild (3-5%): Increased thirst, slightly dry mucous membranes
  • Moderate (6-9%): Loss of skin turgor, dry mucous membranes
  • Severe (≥10%): Severe lethargy, altered consciousness 1

Oral Rehydration

• For mild to moderate dehydration:

  • Use reduced osmolarity ORS containing 65-70 mEq/L sodium and 75-90 mmol/L glucose 1
  • Standard preparation: 3.5g NaCl, 2.5g NaHCO₃, 1.5g KCl, and 20g glucose per liter of clean water 1
  • Continue ORS until clinical dehydration is corrected 1
  • Children who can tolerate at least 20-25 mL/kg of ORS during initial treatment are more likely to succeed with oral rehydration at home 2

• For severe dehydration:

  • Intravenous fluids required for severe dehydration, shock, altered mental status
  • Use isotonic fluids (lactated Ringer's or normal saline) until pulse, perfusion, and mental status normalize 1

Dietary Management

• Continue breastfeeding throughout the diarrheal episode 1
• Resume age-appropriate diet during or immediately after rehydration 1
• For older children:
  • Continue regular diet with emphasis on starches, cereals, yogurt, fruits, and vegetables
  • BRAT diet (bread, rice, applesauce, toast) may be helpful
  • Avoid foods high in simple sugars and fats, lactose-containing products, high-osmolar supplements, spices, coffee, and alcohol 1

Medication Therapy

Antiemetics

• Ondansetron may be given to patients >4 years of age to facilitate oral rehydration 1
  • Only after adequate hydration has begun
  • Should not substitute for fluid and electrolyte therapy
  • Pediatric dosing (for chemotherapy-induced nausea/vomiting, which can guide dosing):
    • 12-17 years: 8 mg 30 minutes before chemotherapy, then 8 mg 8 hours later, then 8 mg twice daily for 1-2 days
    • 4-11 years: 4 mg 30 minutes before chemotherapy, then 4 mg at 4 and 8 hours, then 4 mg three times daily for 1-2 days 3
  • Ondansetron has been shown to reduce vomiting episodes and decrease the need for IV rehydration 4

Antidiarrheals

• Loperamide can be used for non-severe cases in adults but is generally not recommended for young children 1

Antibiotics

• Generally not indicated unless there is:
  • Dysentery (bloody diarrhea)
  • High fever
  • Watery diarrhea lasting >5 days
  • Specific identified pathogen requiring treatment 1
• When indicated, azithromycin is preferred (single dose 500 mg for adults, adjust for children) 1

Supplementation

• Zinc supplementation is beneficial for children 6 months to 5 years with malnutrition 1
• Probiotics may reduce symptom severity and duration in immunocompetent patients 1

Warning Signs Requiring Immediate Medical Attention

• Bloody diarrhea
• Persistent vomiting
• Signs of severe dehydration
• Altered mental status
• High fever
• Symptoms persisting >5 days despite treatment 1

Common Pitfalls to Avoid

1. Delaying rehydration therapy - ORS should be started immediately
2. Using inappropriate fluids - Sports drinks, sodas, and juices are not suitable replacements for ORS due to inappropriate electrolyte and glucose content
3. Withholding food - Early reintroduction of appropriate foods speeds recovery
4. Overreliance on IV fluids - Most cases of mild to moderate dehydration can be managed with ORS, which is safer and more cost-effective 5
5. Using high osmolarity solutions - These can worsen diarrhea and increase the risk of hypernatremia 6, 7

Providing ORS at the time of initial evaluation has been shown to increase compliance and reduce unscheduled follow-up visits 5, making it a cost-effective intervention for pediatric gastroenteritis.