What is the management for dysentery and vomiting in children?

Management of Dysentery and Vomiting in Children

Oral rehydration therapy (ORT) is the cornerstone of management for children with dysentery and vomiting, with antibiotics reserved only for specific cases of dysentery with high fever or prolonged symptoms.

Assessment of Dehydration

• Assess degree of dehydration based on clinical signs including skin turgor, mucous membrane moisture, lethargy, and capillary refill time 1
• Mild dehydration (3-5% fluid deficit): sunken eyes, dry mouth, thirsty, normal to slightly decreased skin turgor 2
• Moderate dehydration (6-9% fluid deficit): previous signs plus tachycardia, irritability/lethargy, decreased skin turgor 2
• Severe dehydration (≥10% fluid deficit): previous signs plus shock or near shock, significantly altered mental status 2

Rehydration Approach

For Mild to Moderate Dehydration

• For mild dehydration: administer 50 mL/kg of oral rehydration solution (ORS) over 2-4 hours 2
• For moderate dehydration: administer 100 mL/kg of ORS over 2-4 hours 2
• Replace ongoing losses with additional ORS: 10 mL/kg for each watery stool and 2 mL/kg for each episode of vomiting 2

For Severe Dehydration

• Begin immediate IV rehydration with boluses (20 mL/kg) of Ringer's lactate or normal saline until vital signs normalize 2
• Once stabilized, transition to oral rehydration to complete fluid replacement 2

Managing Vomiting

• For children with vomiting, administer small volumes (5 mL) of ORS every minute using a spoon or syringe under close supervision 2, 1
• Gradually increase the volume as tolerated 2
• Simultaneous correction of dehydration often lessens the frequency of vomiting 2
• Studies show that >90% of children with vomiting can be successfully rehydrated orally when small volumes are administered frequently 1

Nutritional Management

• Breastfed infants should continue nursing on demand 2, 1
• For bottle-fed infants, continue with full-strength formula immediately upon rehydration 2
• If formula intolerance is suspected, consider lactose-free or lactose-reduced formulas 2
• For older children on solid foods, continue their usual diet during episodes of dysentery and vomiting 2
• Recommended foods include starches, cereals, yogurt, fruits, and vegetables 2
• Avoid foods high in simple sugars and fats 2

Medication Considerations

For Dysentery (Bloody Diarrhea)

• Antibiotics should be considered when dysentery (bloody diarrhea) is present, especially with high fever 2
• Antibiotics are also indicated when watery diarrhea lasts >5 days or when stool cultures indicate a specific bacterial pathogen 2
• WHO-recommended antibiotics for dysentery include ciprofloxacin, ceftriaxone, and pivmecillinam, which have shown >99% cure rates 3

For Vomiting

• Antiemetics should only be considered after adequate hydration is established 1
• Ondansetron may be considered for children >4 years with persistent vomiting to improve tolerance of oral rehydration 1, 4
• Children receiving ondansetron are less likely to vomit, have greater oral intake, and are less likely to need IV rehydration 4

Medications to Avoid

• Antimotility drugs (e.g., loperamide) should NOT be given to children with acute diarrhea and vomiting 1, 5
• Loperamide is contraindicated in children less than 2 years of age due to risks of respiratory depression and serious cardiac adverse reactions 5

Home Management

• Parents should be instructed to offer small, frequent sips of ORS rather than large volumes 2
• A 24-hour supply of ORS should be provided to parents of children with diarrhea upon clinic visits 2
• Parents should be taught to monitor for signs of worsening dehydration (decreased urine output, lethargy, persistent vomiting) 2
• Return for medical care if the child becomes irritable or lethargic, has decreased urine output, develops intractable vomiting, or has persistent symptoms 2

When to Seek Emergency Care

• Bilious vomiting (green color) requires emergency evaluation 1
• Projectile vomiting that persists requires emergency evaluation 1
• Signs of severe dehydration not responding to oral rehydration require emergency care 1
• Bloody diarrhea with high fever or signs of toxicity 2

Common Pitfalls and Caveats

• A frequent mistake is allowing a thirsty child to drink large volumes of ORS at once, which can worsen vomiting 2
• Patients with intestinal ileus should not be given oral fluids until bowel sounds are audible 2
• ORT has been proven effective in over 90% of children with vomiting, even those with concurrent diarrhea 1
• Unnecessary use of IV fluids when oral rehydration would be sufficient increases healthcare costs and patient discomfort 6
• Children with a serum bicarbonate concentration of ≤13 mEq/L may be less likely to tolerate oral rehydration and may require IV fluids 7