What is the recommended treatment for diarrhea in a pediatric patient?

Treatment of Diarrhea in a 10-Year-Old Child

For a 10-year-old with diarrhea, assess dehydration status first, then provide oral rehydration solution (ORS) at 50 mL/kg over 2-4 hours for mild dehydration or 100 mL/kg for moderate dehydration, resume normal age-appropriate diet immediately upon rehydration, and never use antimotility drugs like loperamide which are absolutely contraindicated. 1

Initial Assessment

Evaluate dehydration severity through focused physical examination:

• Check capillary refill time as the most reliable predictor of dehydration in this age group 1
• Assess skin turgor, mucous membranes, mental status, and pulse 1, 2
• Obtain accurate body weight to calculate fluid deficit 1, 2
• Look for rapid deep breathing (indicating acidosis), prolonged skin retraction time, and decreased perfusion—these are more reliable than sunken fontanelle or absent tears 3, 2

Dehydration Classification:

• Mild: 3-5% fluid deficit 3, 1
• Moderate: 6-9% fluid deficit 3, 1
• Severe: ≥10% fluid deficit with shock or near-shock 3, 1

Rehydration Protocol

For Mild Dehydration (3-5% deficit):

• Administer 50 mL/kg of ORS containing 50-90 mEq/L sodium over 2-4 hours 3, 1
• Start with small volumes using a teaspoon or syringe, then gradually increase as tolerated 3
• Reassess hydration status after 2-4 hours 1

For Moderate Dehydration (6-9% deficit):

• Administer 100 mL/kg of ORS containing 50-90 mEq/L sodium over 2-4 hours 3, 1
• Use the same small-volume technique, gradually increasing amounts 2
• Consider nasogastric administration if oral intake is not tolerated 1

For Severe Dehydration (≥10% deficit):

• This is a medical emergency requiring immediate IV rehydration 3, 1
• Give 20 mL/kg boluses of Ringer's lactate or normal saline IV until pulse, perfusion, and mental status normalize 1, 2
• May require two IV lines or alternate access sites 3
• Once consciousness returns, transition to ORS for remaining deficit 1, 2

For No Dehydration:

• Skip rehydration phase and proceed directly to maintenance therapy 3

Replacement of Ongoing Losses

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

• Give 10 mL/kg of ORS for each watery or loose stool 3, 1, 2
• Give 2 mL/kg of ORS for each vomiting episode 3, 1, 2
• If losses can be measured accurately, provide 1 mL of ORS for each gram of diarrheal stool 3, 2

Nutritional Management

Resume age-appropriate diet immediately upon rehydration—there is no justification for "bowel rest": 1, 2

• Include starches, cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars and fats during rehydration 1, 2
• Continue any breastfeeding throughout the entire episode without interruption 1, 2
• For formula-fed infants, resume full-strength formula immediately 2

Monitoring and Red Flags

Reassess hydration status after 2-4 hours of rehydration 1. Instruct caregivers to return immediately if:

• Many watery stools continue or high stool output (>10 mL/kg/hour) persists 1
• Fever develops 1
• Increased thirst or sunken eyes appear 1
• Condition worsens 1
• Bloody diarrhea develops 1
• Intractable vomiting occurs 1

Critical Contraindications

Antimotility Drugs Are Absolutely Contraindicated:

• Loperamide is contraindicated in all children <18 years due to risks of respiratory depression and serious cardiac adverse reactions 1, 4
• Postmarketing cases of cardiac arrest, syncope, and respiratory depression have been reported in pediatric patients 4
• Pediatric patients may be more sensitive to CNS effects including altered mental status, somnolence, and respiratory depression 4

Other Contraindicated Interventions:

• Avoid cola drinks or soft drinks for rehydration—they contain inadequate sodium and excessive osmolality that worsens diarrhea 1, 2
• Do not use hypotonic solutions for initial rehydration in severe dehydration 1
• Antimicrobial therapy is not indicated unless stool cultures show a specific pathogen requiring treatment or diarrhea persists >5 days 1

Laboratory Studies

Stool cultures are indicated for dysentery (bloody diarrhea) but are not needed for typical acute watery diarrhea 3. Serum electrolytes can be measured when clinical signs suggest abnormal sodium or potassium concentrations 3.

Common Pitfalls to Avoid

• Do not delay feeding—early refeeding prevents nutritional deterioration 1, 2
• Do not underestimate dehydration severity in a 10-year-old who may mask symptoms better than younger children 1
• Do not use antimotility agents even if parents request them—explain the serious cardiac and respiratory risks 1, 4
• Do not interrupt breastfeeding if applicable 1, 2