Management of an 11-Year-Old Boy with Uncomplicated Acute Diarrhea
The correct answer is B: nutritional and rehydration therapy, as this child has no signs of dehydration and should proceed directly to maintenance therapy with oral rehydration solution (ORS) and continued age-appropriate diet. 1, 2
Rationale for This Approach
Skip the Rehydration Phase
- For patients with acute diarrhea but without signs of dehydration, the rehydration phase should be omitted and maintenance therapy started immediately. 1
- This 11-year-old is active with no sunken eyes, indicating he is not dehydrated and does not require aggressive fluid replacement 2, 3
Maintenance Therapy Protocol
- Replace ongoing stool losses with 10 mL/kg of ORS for each watery or loose stool (approximately 100-200 mL per stool for older children) 1, 2, 4
- With 4 episodes of diarrhea per day, this translates to roughly 400-800 mL of ORS daily in addition to normal fluid intake 4
- The child should continue his usual age-appropriate diet including starches, cereals, yogurt, fruits, and vegetables while avoiding foods high in simple sugars and fats 1
Why Not Admission and IV Fluids (Option A)?
- IV rehydration is reserved for severe dehydration (≥10% fluid deficit) with shock or near-shock, or for patients who fail oral rehydration therapy 1, 2, 5
- This child has no clinical indicators for IV therapy: he is active, has normal eye appearance, and shows no signs of circulatory compromise 3, 6
- Oral rehydration is safer, more physiologic, and avoids risks of phlebitis and IV infiltrates 1
Why Not Stool Culture (Option C)?
- Antibiotics and stool cultures are not routinely indicated for acute diarrhea unless specific criteria are met 1, 2
- Stool cultures should be considered only when: dysentery (bloody diarrhea) is present, high fever occurs, watery diarrhea persists beyond 5 days, or epidemic setting suggests a specific treatable pathogen 1
- This child has none of these indications, making empirical stool culture unnecessary and not cost-effective 7, 6
Common Pitfalls to Avoid
- Do not withhold food or practice "gut rest" - fasting reduces enterocyte renewal and worsens nutritional outcomes, while early feeding reduces stool output and duration of diarrhea by approximately 50% 1
- Do not use antidiarrheal agents - these are unnecessary and potentially risky in children with acute diarrhea 7
- Do not delay oral rehydration - waiting for laboratory results or admission when the child can be managed at home delays appropriate therapy 2, 6
Monitoring and Follow-Up
- Reassess hydration status if symptoms worsen - watch for decreased urine output, lethargy, sunken eyes, or dry mucous membranes indicating progression to dehydration 2, 3
- Consider medical re-evaluation if diarrhea persists beyond 5 days, fever develops, or bloody stools appear - these warrant investigation for bacterial pathogens 1, 2