What is the management approach for a child with abdominal pain and diarrhea for 1 week?

Management of Abdominal Pain with Diarrhea in Children for 1 Week

A child with abdominal pain and diarrhea persisting for 7 days requires immediate hydration status assessment, oral rehydration therapy initiation, and stool pathogen investigation since diarrhea beyond 5 days warrants testing for infectious agents that may require targeted antimicrobial treatment. 1

Immediate Assessment

Evaluate hydration status by examining:

• Skin turgor and capillary refill time (prolonged skin retraction and decreased perfusion are the most reliable indicators) 2, 3
• Mucous membrane moisture 1, 3
• Mental status and perfusion 1, 3
• Urine output (decreased output indicates significant dehydration) 2
• Respiratory pattern (rapid, deep breathing suggests moderate-to-severe dehydration) 2, 3
• Body weight to establish baseline for monitoring 1

Rehydration Protocol Based on Severity

Mild Dehydration (3-5% fluid deficit)

• Administer 50 mL/kg of oral rehydration solution (ORS) containing 50-90 mEq/L sodium over 2-4 hours 1, 3
• Start with small volumes (one teaspoon) using a spoon, syringe, or medicine dropper, gradually increasing as tolerated 2, 1
• Use commercially available low-osmolarity ORS such as Pedialyte, CeraLyte, or Enfalyte 2, 3

Moderate Dehydration (6-9% fluid deficit)

• Administer 100 mL/kg of ORS over 2-4 hours using the same gradual technique 2, 1
• If vomiting occurs, give small volumes every 1-2 minutes rather than stopping rehydration 1
• For infants unable to drink, nasogastric tube administration at 15 mL/kg/hour is an effective alternative 2

Severe Dehydration (≥10% fluid deficit)

• This is a medical emergency requiring immediate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 1, 3
• Once stabilized, transition to ORS for remaining deficit replacement 3

Replace Ongoing Losses

• Administer 10 mL/kg of ORS for each watery/loose stool 2, 1
• Administer 2 mL/kg of ORS for each vomiting episode 2, 1
• For infants <10 kg, provide 60-120 mL ORS per diarrheal stool or vomiting episode, up to ~500 mL/day 2
• Children <2 years should receive 50-100 mL after each stool; older children should receive 100-200 mL 2

Nutritional Management

• Breastfed infants must continue nursing on demand throughout the illness 2, 1, 3
• Formula-fed infants should resume full-strength, lactose-free or lactose-reduced formula immediately after rehydration 2, 1, 3
• Older children should resume age-appropriate diet immediately upon rehydration, as early refeeding prevents nutritional deterioration 1, 3
• Offer age-appropriate foods every 3-4 hours as tolerated for children >4-6 months 2

Critical: Investigation for Persistent Diarrhea

Since diarrhea has persisted for 7 days (beyond the 5-day threshold), specific pathogen investigation is mandatory: 1

• Obtain stool cultures and microscopy 1
• Consider parasitic causes (Giardia, Entamoeba histolytica) that may require antiparasitic therapy 1, 4
• Test for bacterial pathogens (Shigella, Salmonella, Campylobacter) that may need antimicrobial therapy 1, 4

Adjunctive Therapy

• Zinc supplementation is recommended for children 6 months to 5 years with signs of malnutrition or in zinc-deficient populations, as it reduces diarrhea duration 1, 4

Critical Pitfalls to Avoid

• DO NOT allow ad libitum drinking of large ORS volumes in thirsty children, as this worsens vomiting 1
• DO NOT use antimotility drugs (loperamide is contraindicated in children <2 years and should be avoided in all pediatric gastroenteritis) 1, 5, 6
• DO NOT routinely use antibiotics, antiemetics, antidiarrheals, or spasmolytics 1, 6, 4
• DO NOT use soft drinks for rehydration due to high osmolality 3
• DO NOT "rest the bowel" through fasting 3

Warning Signs Requiring Immediate Medical Attention

• Bloody diarrhea 1
• Intractable vomiting 1
• High stool output 1
• Persistent lethargy or altered mental status 1
• Decreased urine output 1
• Signs of severe dehydration or shock 1, 3

Monitoring Response

• Reassess hydration status after 2-4 hours; if still dehydrated, reestimate fluid deficit and restart rehydration therapy 2, 3
• Monitor weight changes, stool frequency and consistency, and clinical signs including skin turgor and mental status 2, 3
• If ORS therapy fails, progression to severe dehydration occurs, or altered mental status develops, switch immediately to IV rehydration 2, 3