What is the best course of treatment for a 1.5-year-old child presenting with diarrhea?

Management of Diarrhea in a 1.5-Year-Old Child

The cornerstone of treatment is oral rehydration therapy (ORS) with continued feeding—assess hydration status immediately, administer ORS based on dehydration severity, and avoid antibiotics and antimotility drugs in routine cases. 1

Immediate Assessment of Hydration Status

Evaluate the child's hydration level by examining:

• Skin turgor and tenting (prolonged tenting indicates moderate-to-severe dehydration) 2
• Mucous membranes (dry indicates dehydration) 2
• Mental status (lethargy or irritability suggests significant dehydration) 2
• Capillary refill time (>2 seconds indicates poor perfusion) 2
• Pulse quality and perfusion of extremities 2

Categorize dehydration severity:

• Mild (3-5% fluid deficit): Increased thirst, slightly dry mucous membranes 2
• Moderate (6-9% fluid deficit): Loss of skin turgor, dry mucous membranes, tenting of skin 2
• Severe (≥10% fluid deficit): Severe lethargy, prolonged skin tenting, cool extremities, decreased capillary refill, signs of shock 2

Rehydration Protocol Based on Severity

For Mild Dehydration (Most Common Scenario)

• Administer 50 mL/kg of ORS over 2-4 hours 1
• Use small, frequent volumes initially (5-10 mL every 1-2 minutes) with a spoon or syringe 1
• Gradually increase the amount as tolerated 2
• Reassess hydration status after 2-4 hours 1

For Moderate Dehydration

• Administer 100 mL/kg of ORS over 2-4 hours 1
• Follow the same small-volume, frequent administration technique 1
• Reassess after 2-4 hours and continue rehydration if still dehydrated 2

For Severe Dehydration (Medical Emergency)

• Immediate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 3
• May require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) 2
• Transition to oral ORS once consciousness returns to complete fluid replacement 3

Replacement of Ongoing Losses

Throughout treatment, continuously replace ongoing losses:

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

Nutritional Management During Illness

Do not withhold food—continue feeding throughout the illness:

• If breastfed: Continue nursing on demand without interruption 1
• If formula-fed: Resume full-strength formula immediately upon rehydration 1
• For solid foods: Continue age-appropriate diet with starches, cereals, yogurt, fruits, and vegetables 2
• Avoid foods high in simple sugars and fats 2

The common pitfall of "resting the bowel" through fasting is not justified and can worsen nutritional status 2

Managing Vomiting

If the child is vomiting:

• Administer very small volumes of ORS (5 mL) every minute 1
• Use a spoon, syringe, or medicine dropper for controlled administration 2
• Avoid allowing the thirsty child to drink large volumes ad libitum, as this worsens vomiting 1
• Simultaneous correction of dehydration often lessens vomiting frequency 2

When Antibiotics Are NOT Indicated

Antibiotics and antimotility drugs are not routinely indicated for acute diarrhea in this age group 2. The 2017 IDSA guidelines specifically recommend against empiric antimicrobial therapy for watery diarrhea in immunocompetent children 2.

When to Consider Antibiotics

Consider antibiotics only in specific circumstances:

• Bloody diarrhea (dysentery) with high fever documented in a medical setting 2
• Infants <3 months of age with suspected bacterial etiology 2
• Watery diarrhea persisting >5 days 2
• Stool cultures indicating a treatable pathogen 2

For empiric therapy in children when indicated, azithromycin or a third-generation cephalosporin are appropriate choices depending on local susceptibility patterns 2

Critical Warning Signs Requiring Immediate Medical Attention

Parents should return immediately if the child develops:

• Decreased urine output 1
• Lethargy or severe irritability 1
• Intractable vomiting preventing oral rehydration 1
• Bloody stools 1
• Signs of severe dehydration or shock 1
• High stool output (>10 mL/kg/hour) 1

Key Pitfalls to Avoid

• Do not use plain water, juice, or sports drinks for rehydration—these lack appropriate sodium concentration 3
• Do not give antimotility drugs (loperamide)—these are absolutely contraindicated in children <18 years of age 1
• Do not delay rehydration while awaiting diagnostic results—start ORS immediately 3
• Do not withhold food or "rest the bowel"—continue age-appropriate feeding 2

Adjunctive Therapies (Limited Role)

• Zinc supplementation may reduce diarrhea duration in children 6 months to 5 years with malnutrition or in areas with high zinc deficiency 1
• Probiotics may reduce symptom severity and duration in immunocompetent children 1
• These are adjuncts only—ORS and continued feeding remain the primary treatment 1