What is the recommended treatment for a pediatric patient with 3 days of diarrhea and vomiting?

Treatment of Pediatric Diarrhea with Vomiting

Oral rehydration solution (ORS) is the first-line treatment for pediatric patients with 3 days of diarrhea and vomiting, with the degree of dehydration determining the specific rehydration volume and approach. 1, 2

Initial Assessment

Evaluate dehydration severity by examining:

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

Categorize dehydration as:

• Mild: 3-5% fluid deficit 1, 2
• Moderate: 6-9% fluid deficit 1, 2
• Severe: ≥10% fluid deficit with shock or altered mental status 1

Rehydration Strategy by Severity

Mild Dehydration (3-5% deficit)

• Administer 50 mL/kg of reduced osmolarity ORS over 2-4 hours 1, 2
• Use small volumes initially (5-10 mL every 1-2 minutes) with gradual increases 2
• Critical pitfall: Avoid allowing thirsty children to drink large volumes ad libitum, as this worsens vomiting 2

Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours 1, 2
• Consider nasogastric administration if oral intake is not tolerated 1, 3

Severe Dehydration (≥10% deficit)

• Immediate IV rehydration is mandatory with 20 mL/kg boluses of lactated Ringer's or normal saline until pulse, perfusion, and mental status normalize 1, 3
• May require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous) 1
• Once consciousness returns, transition to ORS for remaining deficit 1, 3

Ongoing Loss Replacement

After initial rehydration:

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

Nutritional Management

• Continue breastfeeding throughout the entire episode without interruption 1, 2
• Resume age-appropriate diet immediately after rehydration (or during rehydration for mild cases) 1, 2
• Recommended foods include starches, cereals, yogurt, fruits, and vegetables 2, 3
• Avoid foods high in simple sugars and fats 2, 3
• There is no justification for "bowel rest" 3

Adjunctive Therapies

Antiemetics

• Ondansetron may be given to children >4 years of age to facilitate oral rehydration when vomiting is present, but only after adequate hydration is achieved 1, 2
• Increases ORT success rates and reduces need for IV therapy 2

Absolutely Contraindicated

• Antimotility drugs (loperamide) are absolutely contraindicated in ALL children <18 years of age due to risks of respiratory depression and serious cardiac adverse reactions 1, 2, 4
• Postmarketing cases of cardiac arrest, syncope, and respiratory depression have been reported in pediatric patients 4

Probiotics

• May be offered to reduce symptom severity and duration in immunocompetent children 1, 2

Zinc Supplementation

• Recommended for children 6 months to 5 years of age in countries with high zinc deficiency prevalence or with signs of malnutrition 1, 2
• Reduces duration of diarrhea 1, 2

Reassessment and Monitoring

• Reassess hydration status after 2-4 hours of rehydration 1, 2, 3
• If still dehydrated, reestimate fluid deficit and restart rehydration 1, 5
• If rehydrated, transition to maintenance phase with ongoing loss replacement 2, 3

Warning Signs Requiring Immediate Medical Attention

• Bloody diarrhea (dysentery) 2
• Intractable vomiting preventing successful oral rehydration 2, 3
• High stool output (>10 mL/kg/hour) 2, 3
• Decreased urine output, lethargy, or irritability 2
• Signs of worsening dehydration despite treatment 2

Antimicrobial Considerations

• Antibiotics are NOT routinely indicated for acute gastroenteritis 2
• Consider only when: dysentery is present, high fever occurs, watery diarrhea persists >5 days, or stool cultures indicate a treatable pathogen 2
• Stool cultures are indicated for dysentery but not needed for typical acute watery diarrhea 1