How to manage a diarrhea-like situation?

Management of Diarrhea

The most effective approach to managing diarrhea is to focus on rehydration therapy based on the degree of dehydration, followed by appropriate dietary management and replacement of ongoing fluid losses. 1

Assessment of Dehydration

• Assess the degree of dehydration by examining clinical signs and symptoms 1:

  • Mild dehydration (3-5% fluid deficit): Increased thirst, slightly dry mucous membranes
  • Moderate dehydration (6-9% fluid deficit): Loss of skin turgor, tenting of skin when pinched, dry mucous membranes
  • Severe dehydration (≥10% fluid deficit): Severe lethargy or altered mental status, prolonged skin tenting (>2 seconds), cool and poorly perfused extremities, decreased capillary refill

• Weigh the patient to establish a reference point for monitoring treatment effectiveness 2

Rehydration Strategy

Based on Severity of Dehydration

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

  • Administer 50 mL/kg of oral rehydration solution (ORS) over 2-4 hours 1
  • Start with small volumes (e.g., one teaspoon) and gradually increase as tolerated 1
  • Reassess hydration status after 2-4 hours 1

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

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

• For severe dehydration (≥10% fluid deficit):

  • This is a medical emergency requiring immediate IV rehydration 1
  • Administer boluses (20 mL/kg) of Ringer's lactate solution or normal saline until pulse, perfusion, and mental status normalize 1
  • Once consciousness returns to normal, transition to oral rehydration 1

• For patients without signs of dehydration:

  • Skip rehydration phase and start maintenance therapy immediately 1

Replacement of Ongoing Fluid Losses

• During both rehydration and maintenance therapy, replace ongoing fluid losses 1:
  • Administer 10 mL/kg of ORS for each watery stool passed 1, 2
  • Administer 2 mL/kg of fluid for each episode of vomiting 1, 2
  • Use either low-sodium ORS (40-60 mEq/L of sodium) or standard ORS (75-90 mEq/L of sodium) 1
  • When using higher sodium ORS, provide additional low-sodium fluids (e.g., water, breast milk) 1

Dietary Management

• Dietary recommendations depend on age and dietary history 1:

• For infants:

  • Continue breastfeeding on demand throughout the diarrheal episode 1, 2
  • For bottle-fed infants, resume full-strength, lactose-free, or lactose-reduced formulas immediately upon rehydration 1
  • If lactose-free formulas are unavailable, use full-strength lactose-containing formulas under supervision 1

• For older children and adults:

  • Continue regular diet during diarrhea 1
  • Recommended foods include starches, cereals, yogurt, fruits, and vegetables 1
  • Avoid foods high in simple sugars and fats 1, 3
  • Resume age-appropriate usual diet during or immediately after rehydration 1

Medication Considerations

• Antibiotics are not usually indicated for acute diarrhea 1

  • Consider antibiotics only for specific conditions: dysentery, high fever, watery diarrhea lasting >5 days, or when specific pathogens are identified 1

• Antidiarrheal agents (e.g., loperamide):

  • Not recommended for children under 2 years due to risk of respiratory depression and cardiac adverse reactions 4
  • For adults and children ≥13 years: Initial dose 4 mg followed by 2 mg after each loose stool, maximum 16 mg/day 4
  • For children 6-12 years: 2 mg two to three times daily (based on weight) 4
  • For children 2-5 years: Use liquid formulation, 1 mg three times daily 4
  • Monitor for adverse effects including constipation, dizziness, and cardiac events 4

Special Considerations

• For patients with vomiting:

  • Start with small, frequent volumes of fluid (e.g., 5 mL) and gradually increase as tolerated 1
  • Administer fluids slowly to prevent triggering more vomiting 1

• For high-risk patients:

  • Patients with bloody stools, weight loss, or persistent fever require urgent medical referral 5
  • Immunocompromised patients may need more aggressive evaluation and treatment 1

• Avoid commercial soft drinks, fruit juices, and sports drinks for rehydration as they have high osmolarity and low electrolyte content 6, 1

Warning Signs Requiring Medical Attention

• Severe dehydration signs (altered mental status, poor perfusion) 1
• Bloody diarrhea 1
• Persistent fever 1
• Diarrhea lasting more than 5 days 1
• Inability to maintain hydration with oral fluids 1