What is the management approach for acute diarrhea?

Management of Acute Diarrhea

The cornerstone of acute diarrhea management is oral rehydration therapy (ORT) with early feeding, which is safer and more effective than intravenous therapy for most cases. 1, 2

Assessment of Dehydration

Dehydration severity guides treatment approach:

• Mild dehydration (3-5% fluid deficit):

  • Administer 50 mL/kg of ORS containing 50-90 mEq/L sodium over 2-4 hours 1
  • Start with small volumes (1 teaspoon) and gradually increase 1
  • Reassess after 2-4 hours and proceed to maintenance therapy if rehydrated 1

• Moderate dehydration (6-9% fluid deficit):

  • Administer 100 mL/kg of ORS over 2-4 hours using same approach as mild dehydration 1
  • Patients who can tolerate approximately 25 mL/kg of ORS during initial treatment are more likely to succeed with home management 3

• Severe dehydration (≥10% fluid deficit):

  • Medical emergency requiring immediate IV rehydration 1
  • Administer 20 mL/kg boluses of Ringer's lactate or normal saline until perfusion and mental status normalize 1
  • Switch to oral rehydration once consciousness returns 1

Replacement of Ongoing Losses

• Replace ongoing stool losses with 10 mL/kg ORS for each watery stool 1
• Replace vomiting losses with 2 mL/kg ORS per episode 1
• For measured stool output, replace gram-for-gram with ORS 1

Dietary Management

• Continue feeding during diarrhea rather than fasting - early feeding reduces stool output and shortens illness duration 1
• Breastfed infants: continue nursing on demand 1
• Bottle-fed infants: use full-strength, lactose-free formulas immediately after rehydration 1
• When lactose-free formulas are unavailable, use full-strength lactose-containing formulas with supervision 1
• Older children: continue regular diet with emphasis on starches, cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars and fats 1

Pharmacological Management

• Antibiotics are not routinely indicated for acute diarrhea 1, 2
• Consider antibiotics only for:
  • Dysentery (bloody diarrhea) or high fever 1, 4
  • Watery diarrhea lasting >5 days 1
  • Positive stool cultures for treatable pathogens 1, 5
• Loperamide may be used for symptomatic relief in adults and children over 2 years with non-specific watery diarrhea 6, 5
• Avoid antimotility agents in patients with bloody diarrhea 5

Home Management

• Families should keep ORS at home for early intervention 1
• For mild cases without dehydration, start maintenance therapy immediately 1
• For vomiting patients, administer small volumes (5-10 mL) of ORS every 1-2 minutes and gradually increase 1
• Zinc supplementation can reduce severity and duration of diarrhea, especially in children 4
• Probiotics may shorten illness duration 4, 5

Indications for Medical Attention/Hospitalization

• Severe dehydration or shock 4
• Persistent vomiting unresponsive to small-volume ORS administration 1, 4
• Bloody diarrhea (dysentery) 1, 4
• Infants under 3 months of age 4
• Severe malnutrition 4
• Toxic appearance or suspected surgical abdomen 4

Prevention

• Hand hygiene, safe food preparation, and access to clean water 4, 5
• Education of parents about safe weaning practices 4