What is the best course of treatment for a child with diarrhea?

Treatment of Diarrhea in Children

Oral rehydration therapy (ORS) is the cornerstone of treatment for children with diarrhea, with the specific approach determined by the severity of dehydration assessed clinically. 1, 2

Immediate Assessment of Dehydration Severity

Rapidly assess the child's hydration status by examining:

• Mental status and level of consciousness 1
• Skin turgor and capillary refill time (>2 seconds indicates severe dehydration) 3, 4
• Mucous membrane moisture 3
• Perfusion status and pulse quality 1
• Respiratory pattern (rapid, deep breathing suggests acidosis) 3
• Body weight (most reliable indicator) 5

Classify dehydration into three categories:

• Mild (3-5% fluid deficit): Increased thirst, slightly dry mucous membranes 3, 2
• Moderate (6-9% fluid deficit): Loss of skin turgor, skin tenting when pinched, dry mucous membranes 3, 2
• Severe (≥10% fluid deficit): Severe lethargy or altered consciousness, prolonged skin tenting, cool/poorly perfused extremities, decreased capillary refill, signs of shock 3, 1

Rehydration Protocol Based on Severity

Mild Dehydration (3-5% Fluid Deficit)

• Administer 50 mL/kg of ORS containing 50-90 mEq/L sodium over 2-4 hours 3, 2
• Use a teaspoon, syringe, or medicine dropper to give small volumes initially (5-10 mL every 1-2 minutes), then gradually increase as tolerated 1, 2
• Reassess hydration status after 2-4 hours 3, 2

Moderate Dehydration (6-9% Fluid Deficit)

• Administer 100 mL/kg of ORS containing 50-90 mEq/L sodium over 2-4 hours 3, 2
• Use the same small-volume, frequent administration technique 1
• If the child is vomiting, give 5 mL every 1-2 minutes using a spoon or syringe—this prevents triggering more vomiting while simultaneously correcting dehydration 5

Critical pitfall to avoid: Do not allow a thirsty child to drink large volumes of ORS ad libitum, as this worsens vomiting 2

Severe Dehydration (≥10% Fluid Deficit, Shock or Near-Shock)

This is a medical emergency requiring immediate action: 3, 1

• Immediately administer 20 mL/kg boluses of Ringer's lactate or normal saline intravenously 3, 1
• Repeat boluses until pulse, perfusion, and mental status normalize 1, 5
• This may require two IV lines or alternate access sites (venous cutdown, femoral vein, intraosseous infusion) 3
• Once the child's level of consciousness returns to normal, transition to ORS to complete the remaining fluid deficit 1, 2

Replacing Ongoing Losses During Both Phases

After initial rehydration is achieved:

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

Nutritional Management

For Breastfed Infants

• Continue breastfeeding on demand throughout the entire diarrheal episode without any interruption 1, 5

For Formula-Fed Infants

• Resume full-strength formula immediately upon rehydration 1, 5
• Use lactose-free or lactose-reduced formula when available; if unavailable, full-strength lactose-containing formula can be used under supervision 5
• True lactose intolerance is indicated only by worsening diarrhea upon reintroduction 5

For Children on Solid Foods

• Resume age-appropriate diet during or immediately after rehydration is completed 1, 2
• Recommended foods include starches, cereals, yogurt, fruits, and vegetables 1, 5
• Avoid foods high in simple sugars and fats 1, 5

Critical pitfall: Do not use "clear liquids" like cola, apple juice, or sports drinks for rehydration—these contain inadequate sodium and excessive sugar, causing osmotic diarrhea and electrolyte imbalance 5

Adjunctive Therapies

Zinc Supplementation

• Administer zinc supplementation to children 6 months to 5 years of age who reside in countries with high zinc deficiency prevalence or show signs of malnutrition 1, 2
• This reduces diarrhea duration 1, 5

Probiotics

• Probiotic preparations may be offered to reduce symptom severity and duration in immunocompetent children 2, 5

Ondansetron (for Vomiting)

• 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
• Do NOT use in children <4 years of age 5

Antimotility Drugs (Loperamide)

• Absolutely contraindicated in ALL children <18 years of age 1, 2, 6
• Risks include respiratory depression and serious cardiac adverse reactions 1, 6
• Postmarketing cases of cardiac arrest, syncope, and respiratory depression have been reported in pediatric patients 6

When to Consider Antibiotics

Antibiotics are NOT routinely indicated for acute watery diarrhea 2, 5

Consider antibiotics only when: 2, 5

• Bloody diarrhea (dysentery) is present
• High fever occurs
• Watery diarrhea persists >5 days
• Stool cultures indicate a treatable pathogen

Warning Signs Requiring Immediate Medical Attention

Instruct caregivers to return immediately if: 2, 5

• Intractable vomiting prevents successful oral rehydration
• High stool output (>10 mL/kg/hour)
• Decreased urine output
• Lethargy, irritability, or worsening mental status
• Signs of glucose malabsorption (increased stool output with ORS administration)
• Persistent watery stools or overall condition not improving

Prevention and Home Management

• Parents should keep ORS sachets at home and begin administration at the first sign of diarrhea 5
• Provide detailed written and oral instructions on mixing ORS from packets to avoid inappropriate dilution 2, 5
• Hand hygiene after toilet use, diaper changes, before and after food preparation, before eating, and after handling garbage or animals 2