How to manage diarrhea in pediatric patients?

Management of Diarrhea in Pediatric Patients

The cornerstone of managing pediatric diarrhea is oral rehydration therapy (ORS) with reduced osmolarity solutions containing 50-90 mEq/L sodium, stratified by dehydration severity, combined with continued feeding and strict avoidance of antimotility drugs in all children under 18 years. 1

Initial Assessment

Assess dehydration severity immediately by examining:

• Capillary refill time (most reliable predictor) 2
• Skin turgor, mucous membranes, mental status, and pulse 3, 1
• Obtain body weight to calculate fluid deficit and monitor response 3, 2

Categorize dehydration:

• 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 Strategy by Severity

Severe Dehydration (≥10% deficit)

This is a medical emergency requiring immediate IV intervention. 3, 1

• Administer 20 mL/kg boluses of Ringer's lactate or normal saline IV until pulse, perfusion, and mental status normalize 3, 2
• May require two IV lines or alternate access (venous cutdown, femoral vein, intraosseous) 3
• Once consciousness returns, transition to ORS for remaining deficit 3, 1
• Monitor continuously for improvement in vital signs 2

Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours 3, 1
• Use teaspoon, syringe, or medicine dropper to give small volumes initially, then gradually increase 3
• Consider nasogastric administration if oral intake not tolerated 2

Mild Dehydration (3-5% deficit)

• Administer 50 mL/kg of ORS over 2-4 hours 3, 1
• Start with small volumes (one teaspoon) and gradually increase as tolerated 3

No Dehydration

• Skip rehydration phase and proceed directly to maintenance therapy 3

Critical Technique for Vomiting Children

A common pitfall is allowing thirsty children to drink large volumes ad libitum, which worsens vomiting. 1

• Give 5-10 mL of ORS every 1-2 minutes with gradual increases 1
• Use spoon, syringe, cup, or feeding bottle for controlled administration 1
• This technique facilitates successful oral rehydration even with ongoing vomiting 1

Replacement of Ongoing Losses

During both rehydration and maintenance phases, replace ongoing losses continuously: 3

• 10 mL/kg of ORS for each watery/loose stool 3, 1, 2
• 2 mL/kg of ORS for each vomiting episode 3, 1, 2
• Continue until diarrhea and vomiting resolve 1

Nutritional Management

Do not delay feeding—there is no justification for "bowel rest." 2

For Breastfed Infants

• Continue breastfeeding on demand throughout the entire episode without interruption 3, 1, 4

For Bottle-Fed Infants

• Resume full-strength formula immediately upon rehydration 3, 1
• Lactose-free or lactose-reduced formulas preferred, but full-strength lactose-containing formulas acceptable under supervision 3
• True lactose intolerance indicated only by worsening diarrhea with lactose reintroduction, not by stool pH <6.0 or reducing substances >0.5% alone 3

For Older Children

• Resume age-appropriate diet during or immediately after rehydration 1, 2
• Recommended foods: starches, cereals, yogurt, fruits, vegetables 1, 2
• Avoid: foods high in simple sugars and fats 1, 2

Adjunctive Therapies

Ondansetron

• May be given to children >4 years with vomiting to facilitate ORS 1
• Only after adequate hydration 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 in countries with high zinc deficiency or signs of malnutrition 1, 4
• Reduces diarrhea duration 1, 4

Probiotics

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

Absolutely Contraindicated Interventions

Antimotility drugs (loperamide) are absolutely contraindicated in all children <18 years of age due to risks of respiratory depression and serious cardiac adverse reactions including cardiac arrest and syncope. 1, 2, 5

• Postmarketing cases of cardiac arrest, syncope, and respiratory depression reported in children <2 years 5
• Also avoid when inflammatory diarrhea, fever, or risk of toxic megacolon exists 1
• Do not use cola drinks or soft drinks—they contain inadequate sodium and excessive osmolarity that worsens diarrhea 2

Monitoring and Reassessment

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

Warning Signs Requiring Immediate Medical Attention

Instruct caregivers to return immediately if: 1, 2

• Bloody diarrhea (dysentery) 1
• Severe dehydration with shock or near-shock 1
• Intractable vomiting preventing successful ORT 1
• High stool output (>10 mL/kg/hour) 1, 2
• Signs of glucose malabsorption (increased stool output with ORS) 1
• Decreased urine output, lethargy, or irritability 1

Antibiotic Considerations

Antibiotics are not routinely indicated but consider when: 1

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

Prevention

Hand hygiene is critical: after toilet use, diaper changes, before/after food preparation, before eating, and after handling garbage or animals. 1