What is the treatment for severe diarrhea in pediatric patients?

Treatment of Severe Diarrhea in Pediatric Patients

Severe dehydration (≥10% fluid deficit, shock or near-shock) is a medical emergency requiring immediate intravenous rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize, followed by transition to oral rehydration therapy to complete fluid replacement. 1, 2

Initial Assessment and Recognition

Assess dehydration severity immediately by examining:

• Mental status and level of consciousness (severe lethargy or altered consciousness indicates severe dehydration) 1
• Perfusion status: capillary refill time >2 seconds, cool extremities, weak pulse 1
• Skin turgor: prolonged skin tenting and retraction time >2 seconds 1
• Respiratory pattern: rapid, deep breathing suggests acidosis 1
• Body weight if pre-illness weight is known 1

Severe dehydration is defined as ≥10% fluid deficit with signs of shock or near-shock. 1

Emergency Intravenous Rehydration Protocol

Begin IV rehydration immediately without delay for laboratory studies. 1

• Administer 20 mL/kg boluses of Ringer's lactate solution or normal saline 1, 2
• Repeat boluses until pulse, perfusion, and mental status return to normal 1
• Use two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) if needed for rapid fluid delivery 1
• Monitor continuously for improvement in vital signs and perfusion 1

The goal is to restore circulation and reverse shock as rapidly as possible. 1

Transition to Oral Rehydration

Once the patient's level of consciousness returns to normal and circulation is restored, transition to oral rehydration solution (ORS) to complete the remaining fluid deficit. 1, 2

• Use ORS containing 50-90 mEq/L of sodium 1
• Administer the remaining estimated deficit by mouth over the next several hours 1
• For children with vomiting, give small volumes (5-10 mL) every 1-2 minutes using a spoon, syringe, or medicine dropper, gradually increasing as tolerated 2

Critical pitfall to avoid: Do not allow a thirsty child to drink large volumes of ORS ad libitum, as this worsens vomiting. 2

Replacement of Ongoing Losses

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

• 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

Nutritional Management

Continue breastfeeding throughout the entire episode without interruption. 2, 3

For bottle-fed infants, resume full-strength formula immediately upon rehydration. 1, 2

Resume age-appropriate diet during or immediately after rehydration is completed. 2 Recommended foods include starches, cereals, yogurt, fruits, and vegetables; avoid foods high in simple sugars and fats. 2

Adjunctive Therapies and Contraindications

Antimotility drugs (loperamide) are absolutely contraindicated in all children <18 years of age. 2, 4 The FDA label specifically states loperamide is contraindicated in pediatric patients less than 2 years of age due to risks of respiratory depression and serious cardiac adverse reactions. 4

Ondansetron may be given to children >4 years of age to facilitate oral rehydration when vomiting is present, but only after adequate hydration is achieved. 2

Zinc supplementation reduces diarrhea duration in children 6 months to 5 years of age who reside in countries with high zinc deficiency prevalence or show signs of malnutrition. 2, 5

Warning Signs Requiring Immediate Return

Instruct caregivers to return immediately if the child develops: 2, 3

• Bloody diarrhea (dysentery) 2
• Intractable vomiting preventing oral rehydration 2
• High stool output (>10 mL/kg/hour) 2
• Signs of worsening dehydration 3
• Decreased urine output, lethargy, or irritability 2

Reassessment

Reassess hydration status frequently during treatment. 1 If the patient remains dehydrated after initial therapy, reestimate the fluid deficit and restart appropriate rehydration. 1