What is the treatment for diarrhea in pediatric patients?

Treatment of Diarrhea in Pediatric Patients

The cornerstone of treatment for pediatric diarrhea is oral rehydration therapy using reduced osmolarity oral rehydration solution (ORS), not antimotility drugs which are contraindicated in children under 18 years. 1

Assessment of Dehydration

• Evaluate the degree of dehydration by examining skin turgor, mucous membranes, mental status, pulse, and capillary refill time 1, 2
• Categorize dehydration as:
  • Mild (3-5% fluid deficit)
  • Moderate (6-9% fluid deficit)
  • Severe (≥10% fluid deficit, shock, or pre-shock) 1, 3
• Weighing the child is essential to establish a baseline for monitoring treatment effectiveness 2, 3

Rehydration Strategy Based on Dehydration Severity

Mild Dehydration (3-5% fluid deficit)

• Administer 50 mL/kg of ORS over 2-4 hours 4, 1
• Initially provide small volumes (e.g., one teaspoon) and gradually increase as tolerated 4

Moderate Dehydration (6-9% fluid deficit)

• Administer 100 mL/kg of ORS over 2-4 hours 4, 1
• Use the same administration technique as for mild dehydration 4

Severe Dehydration (≥10% fluid deficit)

• Immediate IV rehydration with boluses (20 mL/kg) of Ringer's lactate solution or normal saline until pulse, perfusion, and mental status normalize 4, 3
• May require two IV lines or alternate access sites in emergency situations 4
• Once the child's level of consciousness returns to normal, transition to oral rehydration for the remaining deficit 3

No Dehydration

• Skip rehydration phase and start maintenance therapy immediately 4

Replacement of Ongoing Fluid Losses

• During both rehydration and maintenance phases, replace ongoing losses: 4, 1
  • 10 mL/kg of ORS for each watery stool
  • 2 mL/kg of ORS for each episode of vomiting
• For measurable losses in a healthcare facility: 1 mL of ORS for each gram of diarrheal stool 4
• Use either low-sodium ORS (40-60 mEq/L sodium) or standard ORS (75-90 mEq/L sodium) with additional low-sodium fluid source (breast milk, formula, water) 4

Nutritional Management

• Continue breastfeeding throughout the diarrheal episode 1, 2
• For bottle-fed infants, resume age-appropriate formula immediately upon rehydration 4, 2
• Preferably use lactose-free or lactose-reduced formulas when available 4
• If using standard lactose-containing formulas, monitor for signs of lactose intolerance (worsening diarrhea) 4
• Resume age-appropriate diet during or immediately after rehydration 1

Adjunctive Therapies

• Zinc supplementation is recommended for children 6 months to 5 years of age who live in countries with high zinc deficiency prevalence or who show signs of malnutrition 1, 2
• Ondansetron may be given to children >4 years of age with vomiting to facilitate oral rehydration, but only after adequate hydration is achieved 1
• Antimotility drugs like loperamide are contraindicated in pediatric patients less than 2 years of age due to risks of respiratory depression and serious cardiac adverse reactions 5

Monitoring and Follow-up

• Reassess hydration status after 2-4 hours of rehydration 4, 1
• If the child remains dehydrated, reassess the fluid deficit and restart rehydration 2
• Monitor for signs of improvement or deterioration 1

Common Pitfalls to Avoid

• Avoid using hypotonic solutions for initial rehydration in severe dehydration 3
• Do not use popular beverages like apple juice, sports drinks, or commercial soft drinks for rehydration 3
• Avoid antimotility medications in children under 2 years 5
• Do not delay transitioning to oral rehydration once the child is alert and able to drink 3