Management of a 2-Year-Old with Diarrhea and Ileus
A 2-year-old with diarrhea and ileus requires immediate intravenous fluid resuscitation with isotonic fluids (lactated Ringer's or normal saline) and must not receive oral fluids until bowel sounds return. 1
Immediate Management: Fluid Resuscitation
The presence of ileus is an absolute contraindication to oral rehydration therapy, regardless of dehydration severity. 1
Intravenous Fluid Protocol
Administer isotonic IV fluids (lactated Ringer's or normal saline) immediately upon recognition of ileus, as oral fluids will not be absorbed and may worsen distension. 1
Continue IV rehydration until clinical parameters normalize: pulse rate, perfusion, mental status, and the child awakens with no aspiration risk. 1
Most critically, do not give oral fluids until bowel sounds are audible on physical examination, as this indicates resolution of the ileus. 1
Assessment of Dehydration Severity
While initiating IV fluids, assess the degree of dehydration to guide total fluid requirements:
Mild dehydration (3-5% fluid deficit): Slightly dry mucous membranes, normal mental status, sunken eyes, increased thirst. 2, 3
Moderate dehydration (6-9% fluid deficit): Previous signs plus tachycardia, decreased skin turgor (>2 seconds), reduced urine output, irritability or lethargy. 2, 3
Severe dehydration (≥10% fluid deficit): Previous signs plus shock or near-shock, significantly altered mental status, cool extremities, prolonged capillary refill. 2, 3, 4
Critical Pitfall to Avoid
The most common and dangerous error is attempting oral rehydration in a child with ileus. This guideline-based contraindication exists because the paralyzed bowel cannot absorb fluids, leading to progressive distension, potential aspiration risk, and delayed appropriate treatment. 1
Transition to Oral Rehydration
Once bowel sounds return and ileus resolves:
Transition to oral rehydration solution (ORS) to complete remaining fluid deficit replacement. 1
Start with small volumes (5 mL every 1-2 minutes) using a spoon or syringe, gradually increasing as tolerated. 1, 3
Use low-osmolarity ORS (sodium 75-90 mEq/L) such as Pedialyte, CeraLyte, or Enfalac Lytren—never use apple juice, Gatorade, or soft drinks. 1, 2
Nutritional Management After Ileus Resolution
Continue breastfeeding throughout if the child is breastfed, even during the ileus phase (though intake will be minimal until resolution). 1, 3
Resume age-appropriate diet immediately after rehydration is complete—do not delay feeding. 1
Use full-strength formula for bottle-fed infants; diluted formula provides no benefit. 1
Focus on starches, cereals, yogurt, fruits, and vegetables for older children; avoid high-sugar and high-fat foods. 3
Medications to Avoid
Never give antimotility drugs (loperamide) to any child under 18 years with diarrhea, as they can precipitate or worsen ileus and cause serious complications including toxic megacolon. 1, 4
Avoid antiemetics until adequate hydration is established via IV route in this case. 3
Red Flags Requiring Surgical Consultation
While managing the ileus medically, watch for signs that suggest mechanical obstruction rather than functional ileus:
Bilious (green) vomiting suggests intestinal obstruction or malrotation with volvulus and requires emergency surgical evaluation. 3, 4
Bloody diarrhea with high fever or signs of toxicity may indicate a surgical abdomen. 3
Progressive abdominal distension despite IV fluids and bowel rest may indicate mechanical obstruction. 5
Failure of ileus to resolve within 24-48 hours of conservative management warrants imaging and surgical consultation. 5