What is the recommended treatment for pediatric diarrhea?

Pediatric Diarrhea Treatment

Immediate Assessment and Rehydration Strategy

The cornerstone of pediatric diarrhea management is oral rehydration therapy (ORS) with reduced osmolarity solutions containing 50-90 mEq/L sodium, stratified by dehydration severity, while continuing age-appropriate feeding throughout treatment. 1

Clinical Assessment of Dehydration Severity

Accurately categorize dehydration by examining:

• Skin turgor and capillary refill time (most reliable predictors—prolonged skin retraction >2 seconds and decreased perfusion indicate significant dehydration) 2
• Mental status and level of consciousness 2
• Mucous membrane moisture 2
• Pulse quality and perfusion 1
• Body weight (essential baseline for monitoring treatment effectiveness) 2, 1

Dehydration categories:

• Mild (3-5% fluid deficit): Increased thirst, slightly dry mucous membranes 2
• Moderate (6-9% fluid deficit): Loss of skin turgor, skin tenting, dry mucous membranes 2
• Severe (≥10% fluid deficit): Severe lethargy/altered consciousness, prolonged skin tenting, cool/poorly perfused extremities, rapid deep breathing (acidosis sign) 2

Rehydration Protocol by Severity

Mild Dehydration (3-5% deficit)

• Administer 50 mL/kg of ORS over 2-4 hours 2, 1
• Use small volumes initially (one teaspoon) via spoon, syringe, or medicine dropper, gradually increasing as tolerated 2
• Reassess hydration status after 2-4 hours—if still dehydrated, reestimate deficit and restart rehydration 2, 1

Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours using the same technique 2, 1
• For vomiting children: Give 5-10 mL every 1-2 minutes, gradually increasing 1
• Critical pitfall to avoid: Do NOT allow ad libitum drinking of large ORS volumes in thirsty children—this worsens vomiting 1

Severe Dehydration (≥10% deficit)

• This is a medical emergency requiring immediate IV rehydration 2, 1
• Administer 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 2, 1
• May require two IV lines or alternate access (venous cutdown, femoral vein, intraosseous infusion) 2
• Once consciousness returns, transition to oral rehydration for remaining deficit 2

Replacement of Ongoing Losses

During both rehydration and maintenance phases:

• Replace 10 mL/kg of ORS for each watery/loose stool 2, 1
• Replace 2 mL/kg of ORS for each vomiting episode 2, 1
• Continue replacement until diarrhea and vomiting resolve 1

Nutritional Management

Feeding During Illness

• Continue breastfeeding on demand throughout the entire diarrheal episode 1, 3
• Resume age-appropriate diet immediately upon rehydration or during rehydration—early refeeding prevents nutritional deterioration 1, 4
• For formula-fed infants, resume full-strength formula immediately after rehydration 3

Adjunctive Therapies

Zinc Supplementation

• Recommended for children 6 months to 5 years with signs of malnutrition or in zinc-deficient populations—reduces diarrhea duration 1, 3

Ondansetron

• May be given to children >4 years to facilitate oral rehydration when vomiting is present, but only after adequate hydration is achieved 1

Contraindicated Medications

Antimotility drugs (including loperamide) are absolutely contraindicated in children under 18 years of age due to risks of respiratory depression, cardiac adverse reactions, and paralytic ileus 1, 5

Additional medications to avoid:

• Do NOT routinely use antibiotics, antiemetics, antidiarrheals, or spasmolytics 1, 6
• Antibiotics are beneficial only for specific pathogens: cholera, shigellosis (bloody diarrhea/dysentery), confirmed amebiasis, or giardiasis 2, 7

Laboratory Testing

• Stool cultures indicated for dysentery (bloody diarrhea) 2
• Not needed for typical acute watery diarrhea in immunocompetent patients 2
• For diarrhea persisting >5-7 days, obtain stool cultures and consider parasitic causes requiring targeted antimicrobial therapy 4
• Serum electrolytes only when clinical signs suggest abnormal sodium/potassium concentrations 2

Warning Signs Requiring Immediate Medical Attention

• Bloody diarrhea (dysentery) 1
• Intractable vomiting preventing successful oral rehydration 1
• High stool output (>10 mL/kg/hour) 1
• Signs of glucose malabsorption (increased stool output with ORS administration) 1
• Severe dehydration with shock or near-shock 1
• Persistent lethargy, irritability, or decreased urine output 4