What is the treatment for a 5-year-old with diarrhea (loose motion)?

Treatment of Loose Motion (Diarrhea) in a 5-Year-Old Child

The cornerstone of treatment for a 5-year-old with diarrhea is oral rehydration solution (ORS) to prevent and treat dehydration, combined with continued age-appropriate feeding—antibiotics and antimotility drugs play no role in routine management. 1

Immediate Assessment of Hydration Status

First, determine the degree of dehydration by examining:

• Skin turgor (pinch test for tenting)
• Mucous membranes (dry vs. moist)
• Mental status (alert vs. lethargic)
• Capillary refill time
• Pulse quality 2

Categorize dehydration severity:

• Mild (3-5% fluid deficit): Slightly increased thirst, minimally dry mucous membranes 2
• Moderate (6-9% fluid deficit): Loss of skin turgor, dry mucous membranes, decreased urine output 2
• Severe (≥10% fluid deficit): Severe lethargy, prolonged skin tenting, cool extremities, rapid pulse—requires immediate IV fluids 3

Rehydration Phase

For Mild to Moderate Dehydration (Most Common)

• Administer 50 mL/kg of ORS over 2-4 hours for mild dehydration 2
• Administer 100 mL/kg of ORS over 2-4 hours for moderate dehydration 2
• Give ORS in small, frequent amounts (5-10 mL every 1-2 minutes) using a spoon or syringe—not ad libitum from a cup, as this commonly triggers vomiting 1
• If the child vomits, wait 5-10 minutes and resume with smaller, more frequent sips 1

For Severe Dehydration

• Immediate IV rehydration with 20 mL/kg boluses of lactated Ringer's or normal saline until pulse, perfusion, and mental status normalize 2, 3
• Once stabilized, transition to ORS for continued rehydration 1

Maintenance Phase (After Rehydration)

Replace ongoing losses with ORS until diarrhea resolves:

• 10 mL/kg of ORS for each watery stool 2
• 2 mL/kg of ORS for each vomiting episode 2
• Continue this replacement throughout the illness 1

Nutritional Management

Resume age-appropriate diet immediately after rehydration is achieved—do NOT withhold food: 1

• Continue regular meals with normal foods the child usually eats 1
• Avoid prolonged fasting, which worsens nutritional status and prolongs diarrhea 2
• Early refeeding decreases intestinal permeability and reduces illness duration 1
• The commonly recommended BRAT diet (bananas, rice, applesauce, toast) has limited supporting evidence and unnecessarily restricts nutrition 1

What NOT to Do: Critical Pitfalls

Never Give Antimotility Drugs

Loperamide and other antimotility agents are contraindicated in all children under 18 years of age due to risk of:

• Respiratory depression
• Serious cardiac adverse reactions
• Ileus and abdominal distension
• Deaths have been reported in 0.54% of children given loperamide 1, 4

The FDA drug label explicitly states loperamide is contraindicated in pediatric patients less than 2 years and should be avoided in older children with acute diarrhea 4.

Antibiotics Are Not Indicated

Antibiotics play only a limited role in routine childhood diarrhea 1

• Most cases are viral (rotavirus is the most common cause) and self-limiting 1
• Antibiotics are only indicated for specific bacterial infections with high fever, bloody diarrhea, or severe illness 3
• Never use antibiotics if bloody diarrhea is present without ruling out Shiga toxin-producing E. coli (STEC), as antibiotics increase risk of hemolytic uremic syndrome 3

Adjunctive Therapies (Optional)

Antiemetics

• Ondansetron may be given to children over 4 years of age to facilitate oral rehydration if vomiting is prominent 1, 2
• Only use after adequate hydration is achieved 2
• May increase stool volume slightly but reduces need for hospitalization 1

Probiotics

• May be offered to reduce symptom severity and duration in immunocompetent children 1, 2
• Evidence is moderate quality; specific strains and dosages vary 1

Zinc Supplementation

• Reduces duration of diarrhea in children 6 months to 5 years in countries with high zinc deficiency prevalence or signs of malnutrition 1, 2
• Less relevant in well-nourished children in developed countries 1

Home Management and Prevention

Parents should keep ORS at home at all times and start treatment as soon as diarrhea begins 1

Hand hygiene is critical:

• Wash hands after using the toilet, changing diapers, before preparing food, and before eating 1, 2
• Use soap and water (alcohol-based sanitizers are less effective against some pathogens like norovirus) 5

When to Seek Medical Care

Refer immediately if:

• Severe dehydration (lethargy, prolonged skin tenting, cool extremities) 3
• Bloody diarrhea (requires evaluation for bacterial pathogens) 3
• High fever with worsening symptoms 3
• Failed oral rehydration (persistent vomiting, inability to drink) 3
• Age under 3 months with suspected bacterial infection 3

Expected Clinical Course

• Most children improve within 48 hours with proper ORS and feeding 1
• Diarrhea typically resolves within 5-7 days for viral gastroenteritis 1
• Successful home management with ORS prevents the majority of hospitalizations and deaths 1