What is the recommended treatment for a 20-month-old patient with diarrhea?

Treatment of Diarrhea in a 20-Month-Old

Oral rehydration solution (ORS) is the cornerstone of treatment for a 20-month-old with diarrhea, with the primary goal being rapid assessment and correction of dehydration status. 1, 2

Initial Assessment

Rapidly assess hydration status by examining:

• Skin turgor, mucous membranes, mental status, pulse, and capillary refill time 2
• Weight loss (most reliable clinical indicator) 2

Classify dehydration severity:

• Mild (3-5% fluid deficit) 2, 3
• Moderate (6-9% fluid deficit) 2, 3
• Severe (≥10% fluid deficit, shock, or pre-shock) 2, 3

Rehydration Protocol

For Mild Dehydration (3-5% deficit):

• Administer 50 mL/kg of reduced osmolarity ORS over 2-4 hours 1, 2

For Moderate Dehydration (6-9% deficit):

• Administer 100 mL/kg of ORS over 2-4 hours 1, 2

For Severe Dehydration:

• Immediately initiate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize, then transition to ORS 1, 2

Managing Concurrent Vomiting

If the child is vomiting:

• Administer small, frequent volumes of ORS (5 mL every 1-2 minutes) using a spoon or syringe, gradually increasing the amount as tolerated 2, 3
• Avoid allowing the child to drink large volumes ad libitum, as this worsens vomiting 3

Replacing Ongoing Losses

After initial rehydration:

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

Nutritional Management

Breastfeeding:

• Continue breastfeeding on demand throughout the entire diarrheal episode without interruption 1, 2

Formula Feeding:

• Resume full-strength formula immediately upon rehydration (do not dilute formula) 1, 2

Solid Foods:

• Resume age-appropriate diet during or immediately after rehydration is completed 1
• Recommended foods include starches, cereals, yogurt, fruits, and vegetables 3

Zinc Supplementation

• Administer oral zinc supplementation, as it reduces the duration of diarrhea in children aged 6 months to 5 years, particularly those with signs of malnutrition 1, 2, 3

Medications to AVOID

Antimotility Drugs:

• Loperamide is absolutely contraindicated in all children under 18 years of age 1, 3, 4
• The FDA specifically contraindicates loperamide in children under 2 years due to risks of respiratory depression and serious cardiac adverse reactions 4

Antiemetics:

• Ondansetron is not recommended for children under 4 years of age 1, 2

Antibiotics:

• Do not use antibiotics routinely unless bloody diarrhea (dysentery), high fever, or watery diarrhea persisting more than 5 days is present 2, 3

Reassessment and Monitoring

• Reassess hydration status after 2-4 hours of rehydration 2, 3
• If the child remains dehydrated, reassess the fluid deficit and restart the rehydration protocol 2

Warning Signs Requiring Immediate Medical Attention

Return immediately if:

• Persistent watery stools continue 2
• Intractable vomiting develops 2, 3
• Decreased urine output occurs 2, 3
• Child becomes irritable, lethargic, or condition worsens 2, 3
• Bloody diarrhea (dysentery) develops 3
• High stool output (>10 mL/kg/hour) 3

Common Pitfalls to Avoid

• Do not allow ad libitum drinking in vomiting children, as this perpetuates the vomiting cycle 3
• Do not dilute formula, as this provides no benefit and may worsen electrolyte imbalances 1
• Do not use antimotility agents in any child under 18 years—this is a strong contraindication with moderate-quality evidence 1
• Do not withhold breastfeeding at any point during the illness 1, 2