Management of Toddler Diarrhea
Start oral rehydration solution (ORS) immediately at home, assess for dehydration, and continue normal feeding without delay.
Immediate Home Assessment
Assess dehydration severity by examining:
- Skin turgor (pinch test for tenting) 1
- Mucous membranes (dry vs moist) 1
- Mental status (alert vs lethargic) 1
- Capillary refill time (most reliable predictor in toddlers) 1
Classify dehydration:
- Mild (3-5% deficit): Increased thirst, slightly dry mouth 2
- Moderate (6-9% deficit): Skin tenting, dry mucous membranes 1
- Severe (≥10% deficit): Severe lethargy, prolonged skin tenting >2 seconds, cool extremities, altered consciousness—requires emergency department immediately 1
Rehydration Protocol
For Mild Dehydration (Most Common)
Give 50 mL/kg of ORS over 2-4 hours 1, 2. For a typical 12 kg toddler, this equals approximately 600 mL (about 2.5 cups) spread over 2-4 hours.
Critical technique to prevent vomiting:
- Start with very small volumes: 1 teaspoon (5 mL) every 1-2 minutes using a spoon or syringe 2
- Never let a thirsty child drink large volumes rapidly—this worsens vomiting 2
- Gradually increase volume as tolerated 2
ORS Product Selection
Use commercially available ORS such as:
These products are appropriate for both rehydration and maintenance in typical viral diarrhea 3, 2.
Avoid: Soft drinks, undiluted apple juice, sports drinks—these contain inadequate sodium and excessive sugar that worsens diarrhea by osmotic effects 3, 1
Replace Ongoing Losses
After initial rehydration, give additional ORS for each episode:
For a 12 kg toddler: approximately 120 mL (½ cup) per watery stool and 24 mL (5 teaspoons) per vomit.
Feeding During Illness
Resume normal age-appropriate diet immediately upon rehydration—do NOT withhold food 1, 2. There is no justification for "bowel rest" 1.
Recommended foods:
- Starches: rice, potatoes, noodles, crackers, bananas 3, 1
- Cereals: rice, wheat, oat cereals 3
- Yogurt, vegetables, fresh fruits 3, 1
- Continue breastfeeding without interruption if applicable 3, 2
- Resume full-strength formula immediately (no dilution needed) 3, 2
Avoid during acute phase:
- Foods high in simple sugars (soft drinks, Jell-O, presweetened cereals) 3
- High-fat foods (delay gastric emptying) 3
The "BRAT diet" (bananas, rice, applesauce, toast) is acceptable short-term but should not be prolonged as it provides inadequate calories and protein 3.
Medications: What to AVOID
Loperamide (Imodium) is absolutely contraindicated in all children under 18 years due to risks of respiratory depression and serious cardiac adverse reactions 1, 2, 4. This is an FDA black-box level warning 4.
Antibiotics are NOT indicated for typical viral diarrhea 3, 1. Most toddler diarrhea is viral and self-limited 3.
When to Seek Immediate Medical Care
Go to the emergency department if:
- Bloody diarrhea develops 2
- Severe dehydration signs: severe lethargy, prolonged skin tenting, cool extremities 1
- Intractable vomiting preventing oral intake 2
- Very high stool output (>10 mL/kg/hour, roughly >1 cup/hour for a 12 kg toddler) 2
- Diarrhea persists >5 days 1
- Decreased urine output, sunken eyes, or worsening condition 1
Reassessment
Reassess hydration status after 2-4 hours of ORS therapy 1, 2. If rehydrated (improved skin turgor, moist mouth, normal alertness), transition to maintenance phase with ongoing loss replacement 1.
Common Pitfalls
- Allowing rapid drinking: Thirsty toddlers will gulp ORS, triggering vomiting—always use small frequent volumes 2
- Withholding food: Early feeding reduces severity and duration of diarrhea 3
- Using inappropriate fluids: Juice, soda, and sports drinks worsen diarrhea 3, 1
- Giving antidiarrheal medications: These are dangerous in children and provide no mortality/morbidity benefit 1, 4
- Prolonged restrictive diets: The BRAT diet or diluted formulas beyond 24-48 hours cause malnutrition 3