What is the treatment for acute diarrhea with dehydration?

Treatment of Loose Stool with Dehydration

For acute diarrhea with dehydration, oral rehydration solution (ORS) containing 50-90 mEq/L of sodium is the first-line treatment, with the specific volume and approach determined by the severity of dehydration assessed through physical examination.

Assessment of Dehydration Severity

Before initiating treatment, you must categorize the degree of dehydration through physical examination and measure body weight for monitoring 1, 2:

• Mild dehydration (3-5% fluid deficit): Increased thirst, slightly dry mucous membranes 3
• Moderate dehydration (6-9% fluid deficit): Loss of skin turgor, dry mucous membranes, decreased urine output, rapid deep breathing, prolonged skin retraction time, decreased perfusion 2, 3
• Severe dehydration (≥10% fluid deficit): Severe lethargy or altered consciousness, prolonged skin tenting, shock or near-shock state 1, 3

Key clinical indicators: Rapid deep breathing, prolonged skin retraction time, decreased perfusion, and capillary refill time are more reliable than sunken fontanelle or absence of tears 3.

Rehydration Protocol Based on Severity

Mild Dehydration (3-5% fluid deficit)

Administer 50 mL/kg of ORS over 2-4 hours 1, 3:

• Start with small volumes (one teaspoon) using a teaspoon, syringe, or medicine dropper 1, 2
• Gradually increase the amount as tolerated 1, 2
• Reassess hydration status after 2-4 hours 1, 2
• If rehydrated, progress to maintenance therapy; if still dehydrated, reestimate deficit and restart rehydration 1, 2

Moderate Dehydration (6-9% fluid deficit)

Administer 100 mL/kg of ORS over 2-4 hours using the same gradual approach 1, 2, 3:

• Use the same small-volume initiation technique as mild dehydration 1, 2
• Research supports that children tolerating at least 25 mL/kg of ORS during initial observation have significantly better success with home oral rehydration (79.7% success rate) compared to those tolerating less than 11 mL/kg 4
• Reassess after 2-4 hours and adjust accordingly 1, 2

Severe Dehydration (≥10% fluid deficit)

This is a medical emergency requiring immediate IV rehydration 1, 3:

• Administer boluses of 20 mL/kg of Ringer's lactate solution or normal saline until pulse, perfusion, and mental status normalize 1, 3
• May require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) 1
• Once consciousness returns to normal, switch to oral rehydration for remaining deficit 1
• For severe acidosis with oliguria, administer physiological dose of bicarbonate to correct blood pH to 7.25 5

Replacement of Ongoing Losses

During both rehydration and maintenance phases, replace ongoing losses 1, 2:

• 10 mL/kg of ORS for each watery or loose stool 1, 2
• 2 mL/kg of ORS for each episode of vomiting 1, 2
• For infants <10 kg: provide 60-120 mL ORS per diarrheal stool or vomiting episode, up to ~500 mL/day 2
• If losses can be measured accurately, administer 1 mL of ORS for each gram of diarrheal stool 1

Dietary Management

Feeding should begin immediately upon rehydration—do not "rest the bowel" 3:

• Breastfed infants: Continue nursing on demand throughout the illness 1, 2, 3
• Bottle-fed infants: Administer full-strength, lactose-free, or lactose-reduced formulas immediately upon rehydration 1, 2, 3
• When lactose-free formulas are unavailable, full-strength lactose-containing formulas can be used under supervision 1
• True lactose intolerance is diagnosed by exacerbation of diarrhea upon introduction of lactose-containing foods, not merely by low stool pH (<6.0) or reducing substances (>0.5%) 1

ORS Selection

Use low-osmolarity ORS containing 50-90 mEq/L of sodium 1, 2, 3:

• Commercial formulations include Pedialyte, CeraLyte, and Enfalac Lytren 2
• Both glucose-based and rice syrup solids-based ORS are equally effective for rehydration 6

Critical Pitfalls to Avoid

• Do not use soft drinks for rehydration due to high osmolality 3
• Do not use anti-diarrheal agents—they are contraindicated 3
• Do not delay feeding once rehydration is achieved 3
• Switch to IV therapy if there is progression to severe dehydration, shock, altered mental status, or failure of ORS therapy 2

Monitoring Response

Regularly assess clinical signs 2:

• Skin turgor and mucous membrane moisture 2
• Mental status 2
• Stool frequency and consistency 2
• Body weight changes 1