What is the management of diarrhea?

Management of Diarrhoea

Oral rehydration solution (ORS) is the first-line treatment for diarrhoea with mild to moderate dehydration, and should be initiated immediately using reduced osmolarity ORS (<250 mmol/L) containing 50-90 mEq/L sodium. 1, 2

Initial Assessment

Evaluate dehydration severity using clinical signs:

• Mild dehydration (3-5% fluid deficit): Slightly dry mucous membranes, normal mental status, adequate perfusion 1, 3
• Moderate dehydration (6-9% fluid deficit): Dry mucous membranes, decreased skin turgor, prolonged capillary refill, sunken eyes 1
• Severe dehydration (≥10% fluid deficit): Shock or near-shock, altered mental status, poor perfusion, rapid deep breathing (acidosis) 1

Obtain body weight to guide fluid replacement calculations and monitor treatment response 1, 3

Rehydration Protocol

Mild Dehydration

• Administer 50 mL/kg of ORS over 2-4 hours 1, 2, 4
• Use small volumes initially (one teaspoon) and gradually increase as tolerated 1
• Reassess hydration status after 2-4 hours 1, 3

Moderate Dehydration

• Administer 100 mL/kg of ORS over 2-4 hours 1, 2, 4
• Follow the same gradual administration approach 1
• If still dehydrated after reassessment, reestimate deficit and restart rehydration 1, 4

Severe Dehydration

• Intravenous rehydration is mandatory - this is a medical emergency 1
• Administer boluses of 20 mL/kg of lactated Ringer's or normal saline until pulse, perfusion, and mental status normalize 1
• Once consciousness returns and patient can tolerate oral intake, switch to ORS for remaining deficit 1

Replacement of Ongoing Losses

• Replace each watery stool with 10 mL/kg of ORS 1, 2, 3
• Replace each vomiting episode with 2 mL/kg of ORS 1, 2, 4
• Continue replacement throughout both rehydration and maintenance phases 1

Nutritional Management

• Continue breastfeeding throughout the illness without interruption 1, 2, 4
• Resume age-appropriate normal diet immediately after rehydration is complete - do not withhold food 1, 2
• For infants, continue usual formula without dilution 1
• Offer food every 3-4 hours during maintenance phase 1

Medications

Antimotility Agents (Loperamide)

• Do NOT use in children under 18 years of age 2
• Contraindicated in children under 2 years due to risk of respiratory depression and cardiac adverse reactions 5
• In adults, use only for symptomatic relief of acute nonspecific diarrhoea, but avoid in bloody diarrhoea, high fever, or suspected infectious colitis 5
• Never exceed recommended dosages - higher doses increase risk of QT prolongation, cardiac arrhythmias, and sudden death 5

Antiemetics

• Ondansetron may be considered in children over 4 years with severe vomiting to facilitate oral rehydration 2

Antibiotics

• Not routinely indicated for acute watery diarrhoea 6, 7
• Consider when: bloody diarrhoea present, high fever, watery diarrhoea persists >5 days, or treatable pathogen identified on stool culture 1, 3
• Azithromycin is preferred first-line when antibiotics are indicated 7

Critical Pitfalls to Avoid

• Do not delay ORS administration while awaiting diagnostic tests - start rehydration immediately 3
• Do not use apple juice, Gatorade, or commercial soft drinks for rehydration - these lack appropriate sodium content and have excessive sugar 1
• Do not use antidiarrheal agents in children or when bloody diarrhoea/fever present - risk of toxic megacolon and serious complications 2, 5
• Do not withhold food after rehydration - early feeding improves nutritional outcomes 1, 2
• Do not use diluted formula - full-strength formula is well-tolerated and provides better nutrition 1

When to Seek Urgent Medical Attention

• Inability to tolerate oral fluids despite ORS attempts 2
• Worsening signs of dehydration 2
• Bloody stools develop 2, 3
• Significant fever increase 2
• Altered mental status or signs of severe dehydration 1
• Abdominal distention or signs of ileus 1, 5