What is the treatment for pediatric diarrhea?

Treatment of Pediatric Diarrhea

The cornerstone of pediatric diarrhea management is oral rehydration therapy (ORT) with reduced osmolarity oral rehydration solution (ORS) as first-line treatment for mild to moderate dehydration, while continuing age-appropriate feeding throughout the illness. 1

Rehydration Therapy

Assessment of Dehydration

• Mild to moderate dehydration: Use oral rehydration therapy
• Severe dehydration: Start with intravenous fluids before transitioning to oral rehydration

Oral Rehydration Therapy (First Line)

• Use reduced osmolarity ORS containing 45-75 mEq/L sodium 1, 2
• Recommended ORS composition:
  • 65-70 mEq/L sodium
  • 75-90 mmol/L glucose 1
  • Can be prepared by mixing 3.5g NaCl, 2.5g NaHCO₃, 1.5g KCl, and 20g glucose per liter of clean water 1
• For children who cannot tolerate oral intake, consider nasogastric administration of ORS 1

Intravenous Rehydration (For Severe Dehydration)

• Use isotonic fluids (lactated Ringer's or normal saline) at 60-100 ml/kg in the first 2-4 hours 1, 2
• Ringer's lactate is preferred as it better corrects metabolic acidosis 1
• Continue until pulse, perfusion, and mental status normalize 1
• Transition to oral rehydration once the patient is stable 1

Nutritional Management

• Continue breastfeeding throughout the diarrheal episode (strong recommendation) 1
• Resume age-appropriate diet during or immediately after rehydration 1
• Consider a bland/BRAT diet (Bananas, Rice, Applesauce, Toast) 1
• Avoid spicy foods, foods high in simple sugars and fats 1
• For children 6 months to 5 years with signs of malnutrition or in areas with high zinc deficiency, provide zinc supplementation 1

Antimicrobial Therapy

• Empiric antimicrobial therapy is NOT recommended for most cases of acute watery diarrhea 1
• Consider antimicrobial therapy only in specific cases:
  • Infants <3 months with suspected bacterial etiology
  • Immunocompetent patients with fever, abdominal pain, and bloody diarrhea
  • Recent international travelers with fever ≥38.5°C or signs of sepsis 1
• For children requiring antimicrobials:
  • Infants <3 months or those with neurologic involvement: third-generation cephalosporin
  • Other children: azithromycin 1
• Avoid antimicrobials in cases of STEC O157 and other Shiga toxin 2-producing E. coli 1

Medications to Avoid

• Loperamide is contraindicated in children less than 2 years of age due to risks of respiratory depression and serious cardiac adverse reactions 3
• Avoid antimotility agents in inflammatory diarrhea 1
• Antiemetics, antidiarrhetics, and spasmolytics are unnecessary and potentially risky 4

Adjunctive Therapies

• Probiotics may be offered to reduce symptom severity and duration (weak recommendation) 1
• For oliguric patients with severe acidosis, consider physiological dose of bicarbonate to correct blood pH to 7.25 2

Monitoring and Follow-up

• Reassess hydration status regularly until corrected 1
• Evaluate patients after 48-72 hours of treatment 1
• Monitor electrolytes in patients with underlying conditions 1
• If no improvement occurs, consider alternative diagnoses 1
• For persistent symptoms (≥14 days), reassess fluid and electrolyte balance, nutritional status, and consider noninfectious causes 1

Prevention and Education

• Implement proper hand hygiene practices 1
• Educate patients and caregivers about food and water safety 1
• Asymptomatic contacts should not receive preventive therapy 1

Clinical Pearls

• An ORS tolerance test can help determine if a child can be managed at home. Children who can tolerate approximately 25 ml/kg of ORS during a 2-4 hour observation period are more likely to be successfully managed at home 5
• Both glucose-based and rice syrup solids-based ORS are effective for rehydration in infants with mild to moderate dehydration 6
• The addition of 20 mEq/L potassium to rehydration solutions helps repair cellular potassium deficits without risk of hyperkalemia 2