What is the first line of treatment for managing diarrhea and vomiting?

Management of Diarrhoea and Vomiting

Oral rehydration solution (ORS) administered in small, frequent volumes is the first-line treatment for managing diarrhea and vomiting in both children and adults. 1

Initial Assessment and Rehydration Approach

For Children:

• Administration technique:
  • Start with 5-10 ml of ORS every 1-2 minutes using a spoon, syringe, cup, or bottle 1
  • Gradually increase the amount as tolerated
  • Avoid allowing a thirsty child to drink large volumes at once (common mistake)
  • For vomiting children, administer via slow nasogastric infusion if necessary 2

For Adults:

• Similar principles apply but with larger volumes
• Administer ORS in small, frequent amounts initially

Replacement of Fluid Losses:

• Administer 10 ml/kg of ORS for each liquid stool 1
• Administer 2 ml/kg for each episode of vomiting 1
• Patients who can tolerate at least 20-25 ml/kg of ORS during initial rehydration are more likely to succeed with home management 3

Dietary Recommendations During Illness

For Infants:

• Continue breastfeeding throughout the episode 1
• For formula-fed infants, consider lactose-free formulas if lactose malabsorption is suspected 1
• Full-strength, lactose-free formulas can be safely introduced immediately after rehydration 1

For Children and Adults:

• Resume age-appropriate diet during or immediately after rehydration 1
• Offer food every 3-4 hours 1
• Prioritize starches, cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars and fats 1

When to Seek Medical Attention

Immediate medical evaluation is needed for:

• Bloody diarrhea (possible bacterial or parasitic infection requiring antimicrobial treatment) 2, 1
• Signs of severe dehydration (>10% weight loss in infants) 1
• Intractable vomiting not responding to small-volume ORS administration 2
• No improvement within 48 hours 1
• Worsening symptoms 1
• Development of warning signs (severe vomiting, persistent fever, abdominal distension) 1

Pharmacological Management

Antimotility Agents:

• Not recommended for children under 18 years 1, 4
• For adults with non-bloody diarrhea, loperamide may be considered after adequate hydration 1
  • Initial dose: 4 mg followed by 2 mg every 4 hours (not to exceed 16 mg/day) 1
  • Contraindicated in cases of bloody diarrhea, fever, or suspected inflammatory diarrhea 1, 4
  • Avoid in patients with cardiac risk factors due to risk of QT prolongation and arrhythmias 4

Probiotics:

• May be considered for symptom management in adults and children 1
• Options include Saccharomyces boulardii, Lactobacillus rhamnosus, or combination probiotics 1
• Use with caution in immunocompromised patients 1

Prevention and Control

• Proper hand hygiene (washing with soap and water):
  • After using toilet
  • After changing diapers
  • Before preparing food 1
• Contact precautions with gloves and gowns for C. difficile infections 1
• Rotavirus vaccination to prevent rotavirus gastroenteritis 1

Special Considerations

Severe Cases:

• Intravenous rehydration is indicated for:
  • Severe dehydration with shock or near-shock 2
  • Intestinal ileus (until bowel sounds return) 2
  • Failed oral rehydration therapy 1

Home Management:

• All families should be encouraged to have a supply of ORS at home 2
• Educate caregivers on proper administration techniques
• Emphasize the importance of increased fluid intake and maintaining caloric intake 2

Pitfalls to Avoid:

• Allowing dehydrated children to drink large volumes of ORS at once (increases risk of vomiting) 2, 1
• Using antimotility agents in children or in cases of bloody diarrhea 1, 4
• Delaying reintroduction of appropriate foods 1
• Neglecting to replace ongoing losses from continued diarrhea or vomiting 1

The reduced osmolarity ORS formulation recommended by WHO has been shown to reduce the need for unscheduled IV fluid, lower stool volume, and decrease vomiting compared to previous formulations 5, making it the preferred choice for rehydration therapy.