What are the guidelines for managing pediatric diarrhea?

Guidelines for Managing Pediatric Diarrhea

The cornerstone of pediatric diarrhea management is oral rehydration therapy (ORT) with appropriate fluid replacement based on dehydration severity, followed by early nutritional support and replacement of ongoing losses. 1

Assessment of Dehydration

• Clinically evaluate the degree of dehydration by examining:

  • Skin turgor and tenting
  • Mucous membrane moisture
  • Mental status
  • Pulse rate
  • Capillary refill time 2

• Categorize dehydration severity:

  • Mild (3-5% fluid deficit): increased thirst, slightly dry mucous membranes 2
  • Moderate (6-9% fluid deficit): loss of skin turgor, tenting of skin when pinched, dry mucous membranes 2
  • Severe (≥10% fluid deficit): severe lethargy or altered consciousness, prolonged skin tenting (>2 seconds), cool extremities, decreased capillary refill 2

• Measure the patient's body weight to establish a baseline for monitoring treatment effectiveness 2

Rehydration Therapy

• For mild dehydration (3-5% fluid deficit):

  • Administer 50 mL/kg of oral rehydration solution (ORS) containing 50-90 mEq/L of sodium over 2-4 hours 2
  • Start with small volumes (e.g., one teaspoon) using a teaspoon, syringe, or medicine dropper, gradually increasing as tolerated 2
  • Reassess hydration status after 2-4 hours 2

• For moderate dehydration (6-9% fluid deficit):

  • Administer 100 mL/kg of ORS over 2-4 hours using the same approach as for mild dehydration 2

• For severe dehydration (≥10% fluid deficit, shock or near shock):

  • Immediate IV rehydration is required as a medical emergency 2
  • Administer boluses (20 mL/kg) of Ringer's lactate solution, normal saline, or similar solution until pulse, perfusion, and mental status normalize 2
  • Once consciousness returns to normal, remaining deficit can be replaced orally 2

• For patients without signs of dehydration:

  • Skip rehydration phase and proceed directly to maintenance therapy 2

Replacement of Ongoing Losses

• During both rehydration and maintenance phases:
  • Replace each gram of diarrheal stool with 1 mL of ORS (if losses can be measured) 2
  • Alternatively, administer 10 mL/kg of ORS for each watery/loose stool and 2 mL/kg for each episode of vomiting 2
  • Ongoing losses can be replaced with either low-sodium ORS (40-60 mEq/L sodium) or standard ORS (75-90 mEq/L sodium) 2
  • When using higher sodium ORS, provide additional low-sodium fluids (breast milk, formula, or water) 2

Nutritional Management

• For breastfed infants:

  • Continue nursing on demand throughout the diarrheal episode 2

• For bottle-fed infants:

  • Resume full-strength, lactose-free, or lactose-reduced formulas immediately upon rehydration 2
  • If specialized formulas are unavailable, use full-strength lactose-containing formulas under supervision 2
  • Monitor for signs of lactose intolerance (worsening diarrhea upon introduction of lactose-containing formula) 2

• For older children:

  • Resume age-appropriate diet during or immediately after rehydration 1

Home Management and Education

• Early administration of ORS at home should follow the same principles as clinical management 2
• Parents should be educated about diarrhea management during newborn and well-baby visits 2
• ORS should be available in every household, and a 24-hour supply should be provided to parents of children with diarrhea during clinic visits 2
• Parents should be instructed to seek medical attention if the child becomes irritable or lethargic, has decreased urine output, develops intractable vomiting, or has persistent diarrhea 2

Adjunctive Therapies

• Zinc supplementation may reduce diarrhea duration in children 6 months to 5 years of age with signs of malnutrition 1
• Avoid antimotility drugs in children under 18 years of age 1
• Ondansetron may be considered to facilitate oral rehydration in children >4 years with vomiting, but only after adequate hydration is achieved 1
• Probiotic preparations may help reduce symptom severity and duration in infectious or antimicrobial-associated diarrhea 1