What is the best approach to manage diarrhea in pediatric patients?

Management of Pediatric Diarrhea

The cornerstone of managing diarrhea in children is oral rehydration therapy (ORS) with appropriate fluid replacement based on dehydration severity, combined with continued feeding—antimotility drugs like loperamide are absolutely contraindicated in all children under 18 years of age. 1, 2

Initial Assessment

First, assess the degree of dehydration by examining:

• Capillary refill time (most reliable predictor in infants) 3
• Skin turgor 1
• Mucous membranes (dry vs. moist) 1
• Mental status 1
• Pulse quality 1
• Weigh the child to establish baseline and calculate fluid deficit 1

Categorize dehydration severity:

• Mild: 3-5% fluid deficit 4
• Moderate: 6-9% fluid deficit 4
• Severe: ≥10% fluid deficit, shock, or near-shock 4

Rehydration Protocol by Severity

Mild Dehydration (3-5% deficit)

• Administer 50 mL/kg of ORS over 2-4 hours 4, 1
• Use ORS containing 50-90 mEq/L of sodium 4
• Give small volumes initially (one teaspoon) using a spoon, syringe, or medicine dropper, then gradually increase as tolerated 4
• Reassess hydration status after 2-4 hours 4

Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours 4, 1
• Use the same technique as mild dehydration 4
• Reassess after 2-4 hours; if still dehydrated, reestimate deficit and restart rehydration 4

Severe Dehydration (≥10% deficit)

• This is a medical emergency requiring immediate IV rehydration 4, 1
• Administer 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 4, 1
• May require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) 4
• Once consciousness returns to normal, transition to oral rehydration for remaining deficit 4

No Dehydration

• Skip rehydration phase and proceed directly to maintenance therapy 4

Replacing Ongoing Losses

During both rehydration and maintenance phases:

• 10 mL/kg of ORS for each watery or loose stool 4, 1
• 2 mL/kg of ORS for each episode of vomiting 4, 1
• Continue until diarrhea and vomiting resolve 1

Feeding Management

Infants

• Continue breastfeeding on demand throughout the entire episode without interruption 4, 1
• For bottle-fed infants, resume full-strength formula immediately upon rehydration 4, 1
• Use lactose-free or lactose-reduced formulas if available; if not, full-strength lactose-containing formulas under supervision 4
• True lactose intolerance is diagnosed by worsening diarrhea upon reintroduction of lactose-containing foods, not by stool pH or reducing substances alone 4

Older Children

• Resume age-appropriate diet during or immediately after rehydration 1
• Recommended foods: starches, cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars and fats 1

Special Technique for Vomiting Children

A common pitfall is allowing a thirsty child to drink large volumes of ORS ad libitum, which worsens vomiting 1. Instead:

• Administer 5-10 mL of ORS every 1-2 minutes 1
• Gradually increase the amount as tolerated 1
• Use a spoon, syringe, cup, or feeding bottle 1

Adjunctive Therapies

Ondansetron

• May be given to children >4 years of age to facilitate oral rehydration when vomiting is present 1
• Only after adequate hydration is achieved 1
• Increases ORT success rates and reduces need for IV therapy and hospitalization 1

Zinc Supplementation

• Recommended for children 6 months to 5 years of age with signs of malnutrition or living in countries with high zinc deficiency prevalence 1, 5
• Reduces duration of diarrhea 1, 5

Probiotics

• May be offered to reduce symptom severity and duration in immunocompetent children with infectious diarrhea 1

What NOT to Do

Absolutely Contraindicated

• Antimotility drugs (loperamide) are contraindicated in ALL children <18 years of age 1, 2
• Avoid at any age when inflammatory diarrhea, fever, or risk of toxic megacolon exists 1
• Postmarketing cases of cardiac arrest, syncope, and respiratory depression have been reported in pediatric patients 2

Inappropriate Fluids

• Do not use cola drinks or soft drinks—they contain inadequate sodium and excessive osmolality that worsens diarrhea 3, 6

Feeding Errors

• Do not delay feeding until diarrhea stops—there is no justification for "bowel rest" 3
• Never stop breastfeeding during diarrhea or rehydration 3

Warning Signs Requiring Immediate Medical Attention

Return immediately if the child develops:

• Bloody diarrhea (dysentery) 1
• Severe dehydration with shock or near-shock 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
• Decreased urine output, lethargy, or irritability 1

Antibiotic Considerations

Antibiotics are not routinely indicated for acute gastroenteritis 1. Consider antibiotics only when:

• Dysentery is present 1
• High fever occurs 1
• Watery diarrhea persists >5 days 1
• Stool cultures indicate a treatable pathogen 1