What is the treatment for diarrhea in infants less than one year old?

Treatment of Diarrhea in Infants Less Than One Year

Oral rehydration solution (ORS) is the cornerstone of treatment for infants with diarrhea, with the primary goal being prevention and correction of dehydration to reduce morbidity and mortality. 1, 2

Immediate Assessment of Hydration Status

Rapidly assess the infant's hydration status by examining:

• Skin turgor (persistent skin fold indicates severe dehydration)
• Mucous membranes (dry indicates dehydration)
• Mental status (lethargy or irritability are warning signs)
• Pulse and capillary refill time (prolonged >2 seconds indicates poor perfusion)
• Weight loss (most reliable indicator if pre-illness weight is available) 2, 3

Classify dehydration severity:

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

Rehydration Protocol Based on Severity

For Severe Dehydration (≥10% deficit, shock, or altered mental status)

Immediately initiate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline, repeating boluses until pulse, perfusion, and mental status normalize, then transition to ORS to complete rehydration. 1, 2, 3

For Moderate Dehydration (6-9% deficit)

Administer 100 mL/kg of reduced osmolarity ORS over 2-4 hours. 2, 3

For Mild Dehydration (3-5% deficit)

Administer 50 mL/kg of ORS over 2-4 hours. 2, 3

Managing Concurrent Vomiting

If the infant 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, 4

• A common pitfall is allowing a thirsty infant to drink large volumes rapidly, which worsens vomiting 4
• For persistent vomiting despite small-volume administration, consider continuous slow nasogastric infusion 1, 2

Replacing Ongoing Losses After Initial Rehydration

After achieving rehydration, replace ongoing losses with 10 mL/kg of ORS for each liquid stool and 2 mL/kg for each vomiting episode until diarrhea and vomiting resolve. 2, 4, 3

Nutritional Management During Diarrhea

For Breastfed Infants

Continue breastfeeding on demand throughout the entire diarrheal episode without any interruption. 1, 2, 3

For Formula-Fed Infants

Resume full-strength formula immediately upon rehydration—do not dilute the formula. 2, 3

• Older guidelines recommended diluting formula, but current evidence shows this is unnecessary and may prolong diarrhea 1
• For infants >4-6 months, offer age-appropriate foods including cereals, starches, and vegetables 1, 2

Zinc Supplementation

Administer oral zinc supplementation to infants 6 months to 1 year of age, as it reduces the duration of diarrhea, particularly in those with signs of malnutrition. 1, 2, 3

Medications: What to Use and What to Avoid

Absolutely Contraindicated

Do NOT use antimotility drugs (loperamide) in any infant—they are absolutely contraindicated in children under 18 years of age due to risks of respiratory depression and serious cardiac adverse reactions. 1, 2, 3

Do NOT use antiemetics (ondansetron) in infants under 4 years of age. 2, 3

May Consider

Probiotic preparations may be offered to reduce symptom severity and duration in immunocompetent infants with infectious diarrhea. 1, 2

Antibiotics

Do NOT routinely use antibiotics for acute watery diarrhea. 2, 4

Consider antibiotics only when:

• Bloody diarrhea (dysentery) is present
• High fever occurs
• Watery diarrhea persists for more than 5 days
• Stool cultures indicate a specific treatable pathogen 2, 4

Reassessment and Monitoring

Reassess hydration status after 2-4 hours of rehydration. 2, 3

• If the infant remains dehydrated, reassess the fluid deficit and restart the rehydration protocol 2, 3
• If rehydrated, transition to maintenance phase with ongoing loss replacement 2

Warning Signs Requiring Immediate Medical Attention

Instruct caregivers to return immediately if:

• Persistent watery stools continue (>10 mL/kg/hour is high-risk)
• Intractable vomiting develops that prevents oral intake
• Decreased urine output occurs
• Infant becomes lethargic, irritable, or condition worsens
• Bloody diarrhea appears
• Signs of severe dehydration develop (sunken eyes, no tears, very dry mouth) 1, 2, 4

Common Pitfalls to Avoid

• Do not use homemade solutions—use commercially available ORS with appropriate sodium content (75-90 mEq/L for active rehydration) 4, 5
• Do not withhold breastfeeding—this is a critical error that worsens outcomes 2, 3
• Do not dilute formula—resume full-strength immediately 2, 3
• Do not allow rapid, large-volume drinking in vomiting infants—this perpetuates the vomiting cycle 4
• Do not use soft drinks or juices—their high osmolality worsens diarrhea 1

Prevention and Infection Control

Hand hygiene should be performed after diaper changes, before and after food preparation, and before eating to prevent transmission. 1, 2