What is the best course of action for a 1-year-old child presenting with profuse and bloody stools, vomiting, and risk of severe dehydration?

Immediate Medical Evaluation Required for Bloody Diarrhea

A 1-year-old child with profuse bloody stools and vomiting requires immediate medical care, as bloody diarrhea (dysentery) indicates potential bacterial or parasitic infection requiring antimicrobial therapy and cannot be managed with oral rehydration therapy alone. 1

Critical Assessment Priorities

Immediate Evaluation for Life-Threatening Conditions

• Assess for severe dehydration signs: prolonged skin tenting (>2 seconds), cool/poorly perfused extremities, decreased capillary refill, severe lethargy or altered consciousness, rapid deep breathing (acidosis) 1
• Obtain accurate body weight to guide fluid replacement calculations 1
• Check for shock or near-shock: these children require immediate IV isotonic fluids (lactated Ringer's or normal saline) rather than oral therapy 1, 2

Why Bloody Diarrhea Demands Different Management

• Bloody diarrhea suggests invasive bacterial pathogens (Shigella, Salmonella, Campylobacter) or parasites causing mucosal damage 1
• Stool cultures must be obtained to identify the causative organism before initiating antimicrobial therapy 1
• White blood cells on methylene blue stain of stool further confirms invasive bacterial infection 1

Rehydration Strategy Based on Dehydration Severity

For Moderate Dehydration (6-9% fluid deficit)

• Administer 100 mL/kg of oral rehydration solution (ORS) over 2-4 hours 2
• Replace ongoing losses: give 10 mL/kg ORS for each bloody stool and 2 mL/kg for each vomiting episode 2
• For vomiting children, give 5-10 mL every 1-2 minutes using a teaspoon or syringe to prevent overwhelming the stomach 1, 2

For Severe Dehydration (≥10% fluid deficit) or Shock

• Switch immediately to IV isotonic fluids (lactated Ringer's or normal saline) 2
• Do not attempt oral rehydration in children with altered mental status, signs of shock, or inability to tolerate oral fluids 1

Antimicrobial Therapy Considerations

When Antibiotics Are Indicated

• Bloody diarrhea is a clear indication for antimicrobial therapy once the organism is identified 1
• Do not delay stool cultures while initiating supportive care 1
• Empiric antibiotics may be considered in children who appear toxic, have high fever, or show signs of sepsis while awaiting culture results 2

Critical Medications to AVOID

• Never give antimotility agents (loperamide) to children <18 years with bloody diarrhea—these can cause severe complications including ileus, abdominal distention, and death 1, 2
• Avoid antidiarrheal adsorbents (kaolin-pectin) as they do not reduce fluid losses and may worsen electrolyte imbalances 1

Management of Concurrent Vomiting

Technique for Vomiting Child

• Administer ORS in very small volumes (5 mL) every minute using a spoon or syringe under close supervision 3
• Gradually increase volume as tolerated rather than allowing ad libitum drinking from a cup 1
• Consider ondansetron (0.2 mg/kg orally, maximum 4 mg) if persistent vomiting prevents adequate oral intake, though only after initial hydration attempts 3, 4

Nutritional Management During Illness

Feeding Recommendations

• Continue breastfeeding on demand throughout the illness 2, 5
• Resume age-appropriate diet immediately after rehydration is achieved—early feeding improves outcomes 2
• Offer starches (rice, potatoes), cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars (soft drinks, undiluted apple juice, presweetened cereals) as these worsen diarrhea through osmotic effects 1

When to Escalate Care

Indications for Hospitalization and IV Therapy

• Severe dehydration (≥10% deficit) or shock 1, 2
• Failure of oral rehydration therapy despite proper technique 2
• Altered mental status or severe lethargy 2
• Stool output exceeding 10 mL/kg/hour 1
• Intractable vomiting not responding to small-volume ORS administration 1

Common Pitfalls to Avoid

• Do not delay seeking medical care for bloody diarrhea—this is not simple viral gastroenteritis and requires specific antimicrobial treatment 1
• Do not restrict diet during or after rehydration—prolonged use of restricted diets (like BRAT diet alone) can result in inadequate nutrition 1
• Do not allow thirsty children to drink large volumes rapidly—this perpetuates vomiting 1
• Do not prescribe empiric antibiotics for watery diarrhea, but bloody diarrhea is the exception requiring antimicrobial evaluation 2