How should a child with food poisoning presenting with diarrhea and possible dehydration be managed?

Management of Food Poisoning in Children

For a child with food poisoning presenting with diarrhea and possible dehydration, immediately assess dehydration severity using capillary refill time, skin turgor, and mental status, then administer oral rehydration solution at 50-100 mL/kg over 2-4 hours based on severity while continuing age-appropriate feeding—never use antimotility agents like loperamide, which are absolutely contraindicated in all children under 18 years. 1, 2, 3

Immediate Assessment of Dehydration Severity

The first critical step is establishing the precise degree of dehydration, as this determines all subsequent management:

• Capillary refill time is the most reliable predictor of dehydration in pediatric patients 2
• Examine skin turgor (pinch test), mucous membrane moisture, mental status, and perfusion 1, 2
• Obtain body weight immediately to calculate fluid deficit and monitor response 1, 2

Classification by Severity

• Mild dehydration (3-5% deficit): Increased thirst, slightly dry mucous membranes 2
• Moderate dehydration (6-9% deficit): Loss of skin turgor with skin tenting when pinched, dry mucous membranes 2
• Severe dehydration (≥10% deficit): Severe lethargy or altered consciousness, prolonged skin tenting >2 seconds, cool poorly perfused extremities with delayed capillary refill, rapid deep breathing indicating acidosis 2

Critical pitfall: Do not rely solely on sunken fontanelle or absent tears—these are less reliable than capillary refill, skin turgor, and respiratory pattern 2, 4

Rehydration Protocol Based on Severity

Mild Dehydration (3-5% Deficit)

• Administer 50 mL/kg of oral rehydration solution (ORS) containing 50-90 mEq/L sodium over 2-4 hours 1, 2
• Use commercially prepared pediatric ORS (e.g., Pedialyte)—not sports drinks, juices, or homemade solutions 2
• Give small initial volumes (one teaspoon or 5-10 mL) every 1-2 minutes using a spoon, syringe, or medicine dropper, gradually increasing as tolerated 1, 2

Moderate Dehydration (6-9% Deficit)

• Administer 100 mL/kg of ORS over 2-4 hours using the same small-volume technique 1, 2, 5
• If oral intake is not tolerated, consider nasogastric administration 2

Severe Dehydration (≥10% Deficit)

• This is a medical emergency requiring immediate hospital admission 1
• Initiate intravenous rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline immediately until pulse, perfusion, and mental status normalize 1, 2
• Once circulation is restored, transition to ORS for the remaining deficit 2

Ongoing Loss Replacement

After initial rehydration, replace continuing losses:

• 10 mL/kg of ORS for each watery stool 1, 2, 5
• 2 mL/kg of ORS for each vomiting episode 1, 2

Nutritional Management

Do not delay feeding—there is no justification for "bowel rest" through fasting:

• Resume age-appropriate diet immediately upon rehydration including starches, cereals, yogurt, fruits, and vegetables 1, 2, 5
• Continue breastfeeding without interruption throughout the entire episode 1, 2, 5
• Avoid foods high in simple sugars and fats during the acute phase 1, 2
• For bottle-fed infants, resume full-strength formula immediately 2

Critical evidence: Early feeding improves outcomes and maintains nutritional status—fasting delays recovery 6, 1, 2

Reassessment and Monitoring

• Reassess hydration status after 2-4 hours of rehydration therapy 1, 2, 5
• Examine skin turgor, mucous membranes, mental status, urine output, and weight changes 5
• If still dehydrated, reestimate fluid deficit and continue rehydration 5
• If rehydrated, transition to maintenance phase with ongoing loss replacement and age-appropriate diet 2, 5

Pharmacological Considerations

Absolutely Contraindicated

Antimotility agents (loperamide) are absolutely contraindicated in all children under 18 years due to risks of respiratory depression and serious cardiac adverse reactions 2, 5, 3

May Consider

• Ondansetron (0.15-0.2 mg/kg, maximum 4 mg) may be considered if vomiting prevents adequate oral intake, as it reduces vomiting rate, improves ORS tolerance, and reduces need for IV rehydration 2, 7, 4

Antimicrobial Therapy

• Antibiotics are NOT indicated for routine uncomplicated watery diarrhea 5
• Consider antibiotics only when:
  • Dysentery (bloody diarrhea) or high fever is present 5
  • Watery diarrhea persists >5 days 2, 5
  • Stool cultures indicate a specific pathogen requiring treatment 2, 5
  • Patient is immunocompromised or has clinical features of sepsis 5

Critical pitfall: Do not prescribe empiric antibiotics for uncomplicated watery diarrhea—this promotes resistance without benefit 5

Red Flag Signs Requiring Immediate Medical Evaluation

Instruct caregivers to return immediately if the child develops:

• Severe lethargy or altered mental status 1, 2
• Persistent vomiting preventing fluid intake 1, 2
• High fever 1, 2
• Bloody diarrhea 1, 2
• Sunken eyes or signs of worsening dehydration 1
• Decreased urine output (fewer than 3 wet diapers in 24 hours) 2
• High stool output (>10 mL/kg/hour) 2

Escalation Criteria

Switch to intravenous isotonic fluids if:

• Severe dehydration (≥10% deficit) or shock develops 2, 5
• Altered mental status occurs 5
• ORS therapy fails despite proper technique 5
• Stool output exceeds 10 mL/kg/hour 2

Common Pitfalls to Avoid

• Do not use cola drinks, sports drinks, or homemade salt-sugar solutions for rehydration—they contain inadequate sodium and excessive osmolality that worsens diarrhea 2
• Do not withhold food or impose "bowel rest"—this lacks evidence and delays nutritional recovery 6, 1, 2
• Do not routinely order laboratory tests for mild-moderate dehydration without specific clinical indications 2
• Do not give antimotility agents to any pediatric patient with acute diarrhea 2, 5, 3