What is the initial treatment for persistent diarrhea in a pediatric patient?

Treatment of Persistent Diarrhea in a 10-Year-Old Child

For a 10-year-old with persistent diarrhea, begin immediate oral rehydration therapy with oral rehydration solution (ORS) containing 50-90 mEq/L sodium, administering 50-100 mL/kg over 2-4 hours depending on dehydration severity, while simultaneously resuming an age-appropriate diet without delay. 1, 2

Initial Assessment

First, assess the degree of dehydration by examining:

• Capillary refill time (most reliable predictor in this age group) 1
• Skin turgor and mucous membranes 3, 1
• Mental status and perfusion 1, 2
• Obtain body weight to calculate fluid deficit 1, 2

Classify dehydration severity:

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

Rehydration Protocol

For Mild Dehydration (3-5% deficit)

• Administer 50 mL/kg of ORS over 2-4 hours 1
• Use small volumes initially (teaspoon, syringe, or dropper), gradually increasing as tolerated 3

For Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours 1, 2
• Consider nasogastric administration if oral intake is not tolerated 1

For Severe Dehydration (≥10% deficit)

• This is a medical emergency requiring immediate IV boluses of 20 mL/kg Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 1, 2
• Once stabilized, transition to ORS for remaining deficit 2

Ongoing Loss Replacement

During both rehydration and maintenance phases:

• Replace 10 mL/kg of ORS for each watery stool 1, 2
• Replace 2 mL/kg of ORS for each vomiting episode 1, 2

Nutritional Management

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

• Include starches, cereals, yogurt, fruits, and vegetables 1, 2
• Avoid foods high in simple sugars and fats 1, 2
• Continue normal feeding without interruption 1

Reassessment and Monitoring

• Reassess hydration status after 2-4 hours of rehydration therapy 1
• If still dehydrated, reestimate fluid deficit and restart rehydration 3
• If rehydrated, transition to maintenance phase with ongoing loss replacement 1

Critical Contraindications and Pitfalls

Antimotility drugs (loperamide) are absolutely contraindicated in all children under 18 years due to risks of respiratory depression and serious cardiac adverse reactions 1, 2, 4. This is an FDA black box warning that applies to your 10-year-old patient 4.

Additional contraindications:

• Avoid cola drinks or soft drinks for rehydration—they contain inadequate sodium and excessive osmolality that worsens diarrhea 1
• Do not use hypotonic solutions for initial rehydration 1
• Antimicrobial therapy is not indicated unless specific pathogens are identified or diarrhea persists beyond 5 days 1

When to Seek Immediate Care

Instruct caregivers to return immediately if:

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