Treatment of Acute Diarrheal Disease
The cornerstone of treatment for acute diarrheal disease is oral rehydration therapy (ORT) using reduced osmolarity oral rehydration solution (ORS), which should be administered as first-line therapy for mild to moderate dehydration in all age groups. 1
Assessment of Hydration Status
- Evaluate the degree of dehydration clinically by assessing skin turgor, mucous membranes, mental status, pulse, and capillary refill time 1
- Categorize dehydration as:
- Mild: 3-5% fluid deficit
- Moderate: 6-9% fluid deficit
- Severe: ≥10% fluid deficit, shock or near shock 1
- Measure body weight when possible to help quantify fluid losses 1
Rehydration Phase
Mild to Moderate Dehydration
- Administer reduced osmolarity ORS as first-line therapy 1
- For mild dehydration (3-5% deficit): give 50 mL/kg ORS over 2-4 hours 1
- For moderate dehydration (6-9% deficit): give 100 mL/kg ORS over 2-4 hours 1
- Start with small volumes (5-10 mL) every 1-2 minutes and gradually increase as tolerated to prevent vomiting 1
- Nasogastric administration of ORS may be considered for those who cannot tolerate oral intake or refuse to drink adequately 1
Severe Dehydration
- Immediate intravenous rehydration with isotonic fluids (lactated Ringer's or normal saline) is required 1
- Administer IV boluses (20 mL/kg) until pulse, perfusion, and mental status normalize 1
- Once the patient is stabilized, transition to oral rehydration for the remaining deficit 1
- Continue IV rehydration until pulse, perfusion, and mental status normalize, patient awakens, has no risk factors for aspiration, and has no evidence of ileus 1
Maintenance Phase
- After rehydration, administer maintenance fluids and replace ongoing losses 1
- Replace each watery stool with 10 mL/kg of ORS 1
- Replace each episode of emesis with 2 mL/kg of ORS 1
- Continue ORS until diarrhea and vomiting resolve 1
Nutritional Management
- Continue breastfeeding throughout the diarrheal episode in infants 1
- Resume age-appropriate diet during or immediately after rehydration 1
- For bottle-fed infants, use full-strength, lactose-free, or lactose-reduced formulas immediately upon rehydration 1
- Avoid food restriction as it can lead to malnutrition and prolonged recovery 2, 3
Adjunctive Therapies
Antimotility Agents
- Loperamide may be given to immunocompetent adults with acute watery diarrhea 1, 4
- Do not give antimotility drugs to children under 18 years of age 1
- Avoid antimotility agents in cases of inflammatory diarrhea or diarrhea with fever 1
Antiemetics
- Ondansetron may be given to facilitate oral rehydration in children >4 years of age and adolescents with vomiting 1
- Antiemetics should only be considered after adequate hydration is achieved 1
Probiotics
- Probiotic preparations may be offered to reduce symptom severity and duration in immunocompetent adults and children with infectious or antimicrobial-associated diarrhea 1, 3
Zinc Supplementation
- Oral zinc supplementation reduces diarrhea duration in children 6 months to 5 years of age who live in countries with high zinc deficiency prevalence or who show signs of malnutrition 1, 3
Special Considerations
- For bloody diarrhea (dysentery), stool cultures are indicated and antimicrobial therapy may be necessary 1, 2
- Patients with high stool output (>10 mL/kg/hour) may still benefit from ORT but may require more careful monitoring 1
- Home management of diarrhea should include early administration of ORS and appropriate feeding 1
Common Pitfalls to Avoid
- Delaying rehydration therapy while waiting for laboratory results 1
- Allowing dehydrated children to drink large volumes of ORS at once, which can increase vomiting 1
- Using inappropriate fluids like fruit juices, sodas, or sports drinks that have high sugar content and inappropriate electrolyte composition 5
- Restricting food during diarrhea, which can worsen nutritional status 2, 3
- Routine use of antibiotics for uncomplicated acute watery diarrhea 2, 3