What is the management protocol for diarrhea in children?

Management Protocol for Diarrhea in Children

Oral rehydration therapy (ORT) with low-osmolarity ORS is the cornerstone of management for children with acute diarrhea, and should be the first-line treatment for mild to moderate dehydration. 1

Classification of Dehydration

Assess the degree of dehydration based on clinical signs:

• Mild dehydration (3-5% fluid loss): Slightly dry mucous membranes, increased thirst
• Moderate dehydration (6-9% fluid loss): Dry mucous membranes, sunken eyes, decreased skin turgor, decreased urine output
• Severe dehydration (≥10% fluid loss): Very dry mucous membranes, deeply sunken eyes, poor skin turgor, lethargy/altered mental status, rapid pulse, hypotension

Rehydration Protocol

Step 1: Initial Rehydration

• Mild to Moderate Dehydration:

  • Administer low-osmolarity ORS: 50-100 mL/kg over 3-4 hours 1
  • Children should tolerate at least 25 mL/kg of ORS during initial rehydration to be successfully managed at home 2
  • Commercial ORS options include Pedialyte, CeraLyte, and Enfalac Lytren 1

• Severe Dehydration:

  • Begin with IV rehydration using isotonic fluids (lactated Ringer's or normal saline) 1
  • Administer 20 mL/kg boluses until circulation is restored
  • Transition to ORS once the child is stabilized 1

Step 2: Ongoing Maintenance

• Replace ongoing losses with 5-10 mL/kg ORS after each loose stool
• Continue breastfeeding throughout the diarrheal episode 1
• Resume age-appropriate diet during or immediately after rehydration 1
• Early feeding reduces stool output and diarrhea duration by approximately 50% 1

Nutritional Management

• DO NOT restrict food during diarrheal episodes
• DO continue breastfeeding throughout the illness
• Recommended foods:
  • BRAT diet (Bananas, Rice, Applesauce, Toast) 1
  • Age-appropriate regular diet
• Avoid:
  • Foods high in simple sugars
  • High-fat foods 1

Medication Guidelines

• Antibiotics: Generally NOT indicated for most cases of acute gastroenteritis 1

  • Exceptions:
    • 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

• Antiemetics: Ondansetron may be used if vomiting prevents ORS intake 1

• NOT recommended:

  • Antimotility drugs (e.g., loperamide) in children under 18 years 1
  • Intestinal antiseptics 3
  • Spasmolytics 3
  • Probiotics (conditional recommendation for North America) 1

Monitoring and Warning Signs

Monitor for:

• Urine output (target ≥0.5 mL/kg/h)
• Vital signs, especially blood pressure and heart rate
• Electrolytes, particularly sodium levels 1

Warning signs requiring immediate medical attention:

• Persistent vomiting preventing ORS intake
• High stool output (>10 mL/kg/hour)
• Bloody diarrhea
• Worsening dehydration despite treatment
• Lethargy or altered mental status 1

Prevention and Infection Control

• Proper hand hygiene
• Food and water safety
• Rotavirus vaccination 1
• Educate caregivers on infection prevention measures

Special Considerations

• 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 initial observation have a higher success rate with home management 2
• Low-osmolarity ORS (245 mOsm/L) reduces the need for unscheduled IV therapy by approximately 33% compared to standard WHO ORS 4
• Nasogastric administration of ORS should be considered for children who cannot tolerate oral intake or are too weak to drink adequately 1