What is the management for acute diarrhea?

Management of Acute Diarrhea

The cornerstone of acute diarrhea management is oral rehydration therapy (ORS) tailored to the degree of dehydration, with immediate resumption of age-appropriate feeding after rehydration, while avoiding unnecessary antibiotics in typical watery diarrhea. 1

Initial Assessment

Assess dehydration severity using clinical signs:

• Mild dehydration (3-5% fluid deficit): Slightly dry mucous membranes, normal mental status, normal skin turgor 1
• Moderate dehydration (6-9% fluid deficit): Dry mucous membranes, sunken eyes, decreased skin turgor, reduced urine output 1
• Severe dehydration (≥10% fluid deficit): Severe lethargy or altered consciousness, prolonged skin tenting (>2 seconds), cool extremities, decreased capillary refill, rapid deep breathing indicating acidosis 1

Key clinical indicators: Prolonged skin retraction time, decreased perfusion, and rapid deep breathing are more reliable predictors of dehydration than sunken fontanelle or absence of tears 1

Measure body weight to quantify fluid deficit and monitor response to therapy 1

Stool cultures are indicated only for dysentery (bloody diarrhea), not for routine watery diarrhea in immunocompetent patients 1

Rehydration Protocol by Severity

Mild Dehydration (3-5% deficit)

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

Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours using the same small-volume technique 1
• Reassess frequently and continue until clinical signs of dehydration resolve 1

Severe Dehydration (≥10% deficit)

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

No Dehydration

• Skip rehydration phase and proceed directly to maintenance therapy 1

Replacement of Ongoing Losses

During both rehydration and maintenance phases, replace ongoing losses:

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

Dietary Management

Infants

• Breastfed infants: Continue nursing on demand without interruption 1
• Bottle-fed infants: Resume full-strength, lactose-free or lactose-reduced formula immediately upon rehydration 1
• If lactose-free formulas are unavailable, use full-strength lactose-containing formula under supervision 1
• True lactose intolerance is diagnosed only by exacerbation of diarrhea upon reintroduction of lactose, not by stool pH <6.0 or reducing substances >0.5% alone 1

Older Children

• Resume age-appropriate normal diet immediately after rehydration 1
• Early feeding is safer and more effective than delayed feeding, promoting intestinal cell renewal and preventing nutritional consequences 1
• Fasting reduces enterocyte renewal and increases intestinal permeability 1

Pharmacological Considerations

Antibiotics are NOT indicated for typical acute watery diarrhea 2

Loperamide:

• FDA-approved for acute nonspecific diarrhea in patients ≥2 years of age 3
• However, do NOT use loperamide in children under 18 years per pediatric guidelines 2
• In adults, may use loperamide 2 mg cautiously for symptom relief 2
• Contraindicated if fever or bloody diarrhea develops, as this suggests bacterial or inflammatory etiology with risk of complications 2

Critical Pitfalls to Avoid

Do not assume typical viral gastroenteritis if:

• Child presents with jelly-like stools (consider intussusception, especially in infants 6-36 months) 4
• Child has concurrent hypertension (requires nephrology evaluation for underlying renal pathology) 5

Do not use standard isotonic saline protocols in children with hypertension and dehydration, as this may worsen hypernatremia in renal concentrating defects 5

Do not delay specialist consultation when red flags are present (severe dehydration with shock, inability to protect airway, failed oral rehydration despite adequate trial) 4

Do not withhold ORS based solely on high purging rate, as most patients respond well with adequate replacement fluid 1

Do not diagnose glucose malabsorption based on stool reducing substances alone—this requires dramatic increase in stool output with ORS administration 1