What is the treatment for pediatric diarrhea?

Treatment of Pediatric Diarrhea

The first-line treatment for children with diarrhea is oral rehydration therapy (ORT) using reduced osmolarity oral rehydration solution (ORS), with immediate resumption of age-appropriate diet and continued breastfeeding throughout the illness. 1

Assessment of Dehydration

Assess dehydration severity based on clinical signs:

• Mild dehydration: <3% weight loss
• Moderate dehydration: 3-9% weight loss
• Severe dehydration: >9% weight loss, altered mental status, poor perfusion 1

Treatment Algorithm

1. Mild to Moderate Dehydration

• First-line treatment: Oral Rehydration Solution (ORS)

  • Use commercially available ORS with reduced osmolarity (45-75 mEq/L sodium) 1, 2
  • Target fluid intake: Children should consume approximately 25 mL/kg of ORS during initial rehydration phase 3
  • If oral intake is not tolerated, consider nasogastric administration 1

• Dietary Management

  • Resume age-appropriate diet immediately after initial rehydration (within 4-6 hours) 1
  • Continue breastfeeding throughout the entire illness 1
  • Avoid foods high in simple sugars and fats 1

2. Severe Dehydration

• Immediate IV fluid resuscitation
  • Use isotonic solutions (lactated Ringer's or normal saline) 1
  • Initial fluid bolus: 20 mL/kg 1
  • Continue rapid infusion until clinical signs of hypovolemia improve
  • Once circulation is restored, transition to ORT 1, 2

3. Special Considerations

• For children with ketonemia: Initial IV hydration may be needed before oral rehydration can be tolerated 1
• For children with severe acidosis: Consider physiological dose of bicarbonate to correct blood pH to 7.25 2

Medication Management

• Antimotility agents (e.g., loperamide)

  • DO NOT use in children <18 years with acute diarrhea 1
  • Avoid especially in bloody diarrhea or suspected inflammatory conditions 1

• Antibiotics

  • Only indicated for specific bacterial pathogens:
    • Shigella: Azithromycin (first-line) or TMP-SMX (if susceptible) 1
    • Campylobacter: Azithromycin (first-line) or Erythromycin 1
    • Enterotoxigenic E. coli (ETEC): TMP-SMX (if susceptible) or Azithromycin 1
  • DO NOT use antibiotics for E. coli O157:H7 or other Shiga toxin-producing E. coli (STEC) as they may increase the risk of hemolytic uremic syndrome 1

• Antiemetics, antidiarrheals, and spasmolytics

  • Generally unnecessary and potentially risky in children with acute diarrhea 4

Monitoring and Follow-up

• Monitor for warning signs requiring medical attention:

  • Worsening symptoms despite treatment
  • Development of bloody stools
  • Fever
  • Abdominal distention
  • Symptoms persisting >48 hours 1

• Monitor hydration status:

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

Prevention

• Proper hand hygiene after toilet use and before food preparation 1
• Continue breastfeeding as it provides protection against diarrheal illness 1

High-Risk Populations

• Immunocompromised children: At risk for severe, prolonged, and potentially fatal diarrhea 1
• Premature infants: Increased risk for hospitalization 1
• Malnourished children: At risk for cycle of diarrhea and malnutrition 1

Common Pitfalls to Avoid

1. Overuse of IV fluids: Many children with mild to moderate dehydration can be successfully managed with ORT alone 3, 5

2. Delaying reintroduction of food: Resume age-appropriate diet immediately after initial rehydration 1

3. Inappropriate use of antimotility agents: These should never be used in children under 18 years 1

4. Unnecessary antibiotic use: Most cases of pediatric diarrhea are viral and do not require antibiotics 1, 4

5. Inadequate ORS volume: Children who successfully tolerate approximately 25 mL/kg of ORS during initial rehydration have better outcomes 3