What is the management for a patient with diarrhea and dehydration, following Philippines guidelines?

Management of Diarrhea with Dehydration Following Philippines Guidelines

Initiate oral rehydration solution (ORS) immediately as first-line treatment for mild to moderate dehydration, using reduced osmolarity ORS at 50-100 mL/kg over 2-4 hours depending on dehydration severity. 1

Assess Dehydration Severity

Determine the degree of fluid deficit to guide treatment intensity:

• Mild dehydration (3-5% fluid deficit): Administer 50 mL/kg of ORS over 2-4 hours 1
• Moderate dehydration (6-9% fluid deficit): Administer 100 mL/kg of ORS over 2-4 hours 1, 2
• Severe dehydration (≥10% fluid deficit, shock, altered mental status): Initiate intravenous fluids with 60-100 mL/kg of 0.9% saline or lactated Ringer's in the first 2-4 hours to restore circulation, then transition to ORS 2, 3

Oral Rehydration Protocol

Use reduced osmolarity ORS (total osmolarity <250 mmol/L) as recommended by the World Health Organization 1, 2:

• Give small, frequent amounts if the patient is vomiting 2
• Replace ongoing losses: 10 mL/kg of ORS for each watery stool and 2 mL/kg for each vomiting episode 1, 2
• Continue ORS until clinical dehydration is corrected 2
• If oral intake fails, consider nasogastric administration of ORS for patients too weak to drink 2

A practical ORS tolerance test can predict success: patients who tolerate at least 25 mL/kg of ORS in the first 2-4 hours are likely to succeed with home management 4

Nutritional Management

• Continue breastfeeding throughout the illness without interruption 1, 2
• Resume normal age-appropriate diet immediately after rehydration is completed—do not withhold food 1, 2
• Early feeding improves outcomes and should not be delayed 2

Medications to AVOID

Never administer antimotility drugs (loperamide) to any patient under 18 years of age 1, 5, 2:

• Loperamide causes documented mortality (0.54% death rate), with all deaths occurring in children under 3 years 5
• Risks include ileus, abdominal distension, lethargy, and death 5
• This is a strong recommendation from the Infectious Diseases Society of America and American Academy of Pediatrics 5

Avoid empiric antibiotics for acute watery diarrhea without recent international travel 2:

• Antibiotics promote resistance without benefit in most cases 2
• Never use antibiotics if Shiga toxin-producing E. coli (STEC) is suspected, as this worsens outcomes and can precipitate hemolytic uremic syndrome 2

Adjunctive Medications That MAY Be Used

• Ondansetron: May be given to children over 4 years with severe vomiting to facilitate ORS tolerance 1, 2
• Zinc supplementation: Reduces diarrhea duration in children 6 months to 5 years in areas with high zinc deficiency or malnutrition 2
• Probiotics: May be offered to reduce symptom severity and duration (weak recommendation) 2

Home Management Criteria

Patients suitable for home management with ORS must be 1:

• Alert and able to take oral fluids
• No signs of severe dehydration
• No altered mental status
• Tolerating adequate ORS volumes (ideally ≥25 mL/kg during observation) 4

Warning Signs Requiring Immediate Medical Attention

Instruct caregivers to return immediately if 1:

• Patient becomes unable to tolerate oral fluids
• Signs of dehydration worsen
• Diarrhea becomes bloody
• Fever increases significantly
• Lethargy or altered mental status develops

Critical Pitfalls to Avoid

• Do not use sport drinks, juice, soft drinks, or chicken broth as ORS substitutes—these lack appropriate sodium and osmolarity 6
• Do not restrict diet during or after rehydration—this delays recovery 2
• Do not give antimotility agents to children—this is the most dangerous error with documented mortality 5
• Do not delay ORS while waiting for IV access in mild-moderate dehydration—ORS prevents 93% of diarrhea deaths and is as effective as IV therapy 7