What is the management of acute dysentery in a pediatric patient?

Management of Acute Dysentery in Pediatric Patients

For pediatric patients with acute dysentery (bloody diarrhea), immediately assess dehydration severity and initiate oral rehydration therapy (ORS) while considering antimicrobial therapy, as dysentery is one of the specific indications where antibiotics should be considered. 1, 2

Initial Assessment and Dehydration Classification

Rapidly assess dehydration severity using clinical examination:

• Capillary refill time is the most reliable predictor of dehydration 1
• Examine skin turgor (prolonged tenting >2 seconds indicates severe dehydration), mucous membranes, mental status, pulse, and perfusion 1
• Obtain accurate body weight to calculate fluid deficit 1
• Classify dehydration:
  • Mild: 3-5% fluid deficit (increased thirst, slightly dry mucous membranes) 1
  • Moderate: 6-9% fluid deficit (loss of skin turgor, dry mucous membranes) 1
  • Severe: ≥10% fluid deficit (severe lethargy/altered consciousness, prolonged skin tenting, cool poorly perfused extremities, rapid deep breathing) 1

Rehydration Protocol by Severity

Severe Dehydration (≥10% deficit)

• Administer 20 mL/kg boluses of Ringer's lactate or normal saline IV immediately until pulse, perfusion, and mental status normalize 1
• Monitor continuously for improvement in vital signs 1
• Once circulation is restored, transition to ORS for remaining deficit 1

Moderate Dehydration (6-9% deficit)

• Administer 100 mL/kg of ORS over 2-4 hours 1, 2
• Use nasogastric administration if oral intake is not tolerated 1
• For vomiting patients, give 5-10 mL of ORS every 1-2 minutes using a teaspoon, syringe, or medicine dropper 2

Mild Dehydration (3-5% deficit)

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

Ongoing Loss Replacement

• Replace each watery or bloody stool with 10 mL/kg of ORS 1, 2
• Replace each vomiting episode with 2 mL/kg of ORS 1, 2

Antimicrobial Therapy for Dysentery

Unlike uncomplicated watery diarrhea, dysentery (bloody diarrhea) is a specific indication for considering antimicrobial therapy:

• Antibiotics should be considered when dysentery or high fever is present 2
• Do not delay rehydration while awaiting stool culture results 2
• Obtain stool cultures to guide specific antimicrobial selection 2
• For amebic dysentery (if confirmed or highly suspected):
  • Metronidazole 35-50 mg/kg/24 hours divided into three doses orally for 10 days (pediatric dosing) 3
  • Adult dosing: 750 mg orally three times daily for 5-10 days for acute amebic dysentery 3

Nutritional Management

• Resume age-appropriate diet immediately upon rehydration 1, 2
• Include starches, cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars and fats during rehydration 1
• Continue breastfeeding throughout the entire episode without interruption 1, 2
• Do not delay feeding—there is no justification for "bowel rest" 1

Adjunctive Therapy

• Consider ondansetron if vomiting prevents adequate oral intake, as it reduces vomiting rate, improves ORS tolerance, and reduces need for IV rehydration 1, 2

Monitoring and Reassessment

• Reassess hydration status after 2-4 hours of rehydration therapy 1, 2
• If rehydrated, transition to maintenance phase with ongoing loss replacement 1

Critical Contraindications and Pitfalls

Absolutely contraindicated interventions:

• Antimotility drugs (loperamide) are absolutely contraindicated in all children <18 years due to risks of respiratory depression and serious cardiac adverse reactions 1, 2
• Do not use cola drinks or soft drinks for rehydration—they contain inadequate sodium and excessive osmolarity that worsens diarrhea 1
• Do not use hypotonic solutions for initial rehydration in severe dehydration 1

Indications for Hospitalization

Admit patients with:

• Severe dehydration (≥10% deficit) or signs of shock 1, 2
• Failure of ORS therapy despite proper technique 2
• Altered mental status 2
• Stool output exceeding 10 mL/kg/hour 2

Return Precautions

Instruct caregivers to return immediately if:

• Many watery or bloody stools continue 1
• Fever develops 1
• Increased thirst or sunken eyes appear 1
• Condition worsens 1
• Intractable vomiting occurs 1
• High stool output (>10 mL/kg/hour) persists 1