Diarrhea Treatment & Management

In 2003 the Center for Disease Control (CDC) put forth new recommendations for the management of acute pediatric diarrhea in both the outpatient and inpatient settings including indication for referral.^[2]

Indications for medical evaluation of children with acute diarrhea include the following:

• Older than 3 months
• Weight of more than 8 kg
• History of premature birth, chronic medical conditions, or concurrent illness
• Fever of 38ºC or higher in infants younger than 3 months or 39ºC or higher in children aged 3-36 months
• Visible blood in the stool
• High-output diarrhea
• Persistent emesis
• Signs of dehydration as reported by caregiver, including sunken eyes, decreased tears, dry mucous membranes, and decreased urine output
• Mental status changes
• Inadequate responses to oral rehydration therapy (ORT) or caregiver unable to administer ORT

The report also includes information on assessment of dehydration and what steps should be taken to adequately treat acute diarrhea.

Treatment of dehydration due to diarrhea includes the following:

• Minimal or no dehydration

  • Rehydration therapy - Not applicable
  • Replacement of losses
    • Less than 10 kg body weight - 60-120 mL oral rehydration solution for each diarrhea stool or vomiting episode
    • More than 10 kg body weight - 120-140 mL oral rehydration solution for each diarrhea stool or vomiting episode
• Mild-to-moderate dehydration

  • Rehydration therapy - Oral rehydration solution (50-100 mL/kg over 3-4 h)
  • Replacement of losses
    • Less than 10 kg body weight - 60-120 mL oral rehydration solution for each diarrhea stool or vomiting episode
    • More than 10 kg body weight - 120-140 mL oral rehydration solution for each diarrhea stool or vomiting episode
• Severe dehydration

  • Rehydration therapy - Intravenous lactated Ringer solution or normal saline (20 mL/kg until perfusion and mental status improve), followed by 100 mL/kg oral rehydration solution over 4 hours or 5% dextrose (half normal saline) intravenously at twice maintenance fluid rates
  • Replacement of losses
    • Less than 10 kg body weight - 60-120 mL oral rehydration solution for each diarrhea stool or vomiting episode
    • More than 10 kg body weight - 120-140 mL oral rehydration solution for each diarrhea stool or vomiting episode
    • If unable to drink, administer through nasogastric tube or intravenously administer 5% dextrose (one fourth normal saline) with 20 mEq/L potassium chloride

ORT is the cornerstone of treatment, especially for small-bowel infections that produce a large volume of watery stool output. ORT with a glucose-based oral rehydration syndrome must be viewed as by far the safest, most physiologic, and most effec­tive way to provide rehydration and maintain hydration in children with acute diarrhea worldwide, as recommended by the WHO; by the ad hoc committee of European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN); and by the American Academy of Pediatrics.^[3] However, the global use of ORT is still insufficient. Developed countries, in particular the United States, seem to be lagging behind despite studies that demonstrate beyond doubt the efficacy of ORT in emergency care settings, in which intravenous rehydration unduly continues to be widely privileged.

Not all commercial ORT formulas promote optimal absorption of electrolytes, water, and nutrients. The ideal solution has a low osmolarity (210-250) and a sodium content of 50-60 mmol/L. Administer maintenance fluids plus replacement of losses. Educate caregivers in methods necessary to replace this amount of fluid. Administer small amounts of fluid at frequent intervals to minimize discomfort and vomiting. A 5-mL or 10-mL syringe without a needle is a very useful tool. The syringe can be quickly used to place small amounts of fluid in the mouth of a child who is uncooperative. Once the child becomes better hydrated, cooperation improves enough to take small sips from a cup. This method is time intensive and requires a dedicated caregiver. Encouragement from the physician is necessary to promote compliance. Oral rehydration is now universally recommended to be completed within 4 hours.

The addition of zinc to oral rehydration solution has been proven effective in children with acute diarrhea in developing countries and is recommended by the WHO.^[4] However, no evidence suggests efficacy in children living in developed countries, in which the prevalence of zinc deficiency is assumed to be extremely low.

The composition of almost all other beverages (carbonated or not) that are commercially available and frequently used in children with diarrhea is completely inadequate for rehydration or for maintaining hydration, considering the sodium content, which is invariably extremely low, and osmolarity that is often dangerously elevated. For instance, Coca-Cola, Pepsi-Cola, and apple juice have an osmolarity of 493, 576, and 694-773, respectively.

At completion of hydration, resumption of feeding is strongly recommended. In fact, many studies convincingly demonstrate that early refeeding hastens recovery. Also, robust evidence suggests that, in the vast majority of episodes of acute diarrhea, refeeding can be accomplished without the use of any special (eg, lactose-free or soy-based) formulas.

Antimotility agents are not indicated for infectious diarrhea, except for refractory cases of Cryptosporidium infection. Antimicrobial therapy is indicated for some nonviral diarrhea because most is self-limiting and does not require therapy.

Therapies recommended for some nonviral diarrheas include the following:

• Aeromonas species: Use cefixime and most third-generation and fourth-generation cephalosporins.
• Campylobacter species: Erythromycin shortens illness duration and shedding.
• C difficile: Discontinue potential causative antibiotics. If antibiotics cannot be stopped or this does not result in resolution, use oral metronidazole or vancomycin. Vancomycin is reserved for the child who is seriously ill.
• C perfringens: Do not treat with antibiotics.
• Cryptosporidium parvum: Administer paromomycin; however, effectiveness is not proven. Nitazoxanide, a newer anthelmintic, is effective against C parvum.
• Entamoeba histolytica: Metronidazole followed by iodoquinol or paromomycin is administered in symptomatic patients. Asymptomatic carriers in nonendemic areas should receive iodoquinol or paromomycin.
• E coli: Trimethoprim-sulfamethoxazole (TMP-SMX) should be administered if moderate or severe diarrhea is noted; antibiotic treatment may increase likelihood of hemolytic-uremic syndrome (HUS). Parenteral second-generation or third-generation cephalosporin is indicated for systemic complications.
• G lamblia: Metronidazole or nitazoxanide can be used.
• Plesiomonas species: Use TMP-SMX or any cephalosporin.
• Salmonella species: Treatment prolongs carrier state, is associated with relapse, and is not indicated for nontyphoid-uncomplicated diarrhea. Treat infants younger than 3 months and high-risk patients (eg, immunocompromised, sickle cell disease). TMP-SMX is first-line medication; however, resistance occurs. Use ceftriaxone and cefotaxime for invasive disease.
• Shigella species: Treatment shortens illness duration and shedding but does not prevent complications. TMP-SMX is first-line medication; however, resistance occurs. Cefixime, ceftriaxone, and cefotaxime are recommended for invasive disease.
• V cholerae: Treat infected individuals and contacts. Doxycycline is the first-line antibiotic, and erythromycin is second-line antibiotic.
• Yersinia species: TMP-SMX, cefixime, ceftriaxone, and cefotaxime are used. Treatment does not shorten disease duration; reserve for complicated cases.

• Surgeon

  • Certain organisms cause abdominal pain and bloody stools.
  • Symptoms resembling appendicitis, hemorrhagic colitis, intussusception, or toxic megacolon may be appreciated.
  • If the infectious etiology in individuals with such symptoms is not certain, seek consultation with a surgeon.
• Infectious-disease specialist: Consider consultation with an infectious-disease specialist for any patient who is immunocompromised because of HIV infection, chemotherapy, or immunosuppressive drugs because atypical organisms are more likely, and complications can be more serious and fulminate.

Breastfed infants with acute diarrhea should be continued on breast milk without any need for interruption. In fact, breastfeeding not only has a well-known protective effect against the development of enteritis, it also promotes faster recovery and provides improved nutrition. This is even more important in developing countries, where with­drawal of breastfeeding during diarrhea has been shown to have a deleterious effect on the development of dehydra­tion in infants with acute watery diarrhea.

• Bananas, rice, applesauce, and toast diet

  • A banana, rice, applesauce, and toast (BRAT) diet was introduced in the United States in 1926 and has enjoyed vast popularity. However, no evidence shows that this diet is useful, and its poor protein content may be a contraindication; therefore, it is not recommended.
  • A strong body of evidence now suggests that resuming the prediarrhea diet is perfectly safe and must be encouraged, obviously respecting any (usually temporary) lack of appetite.
• Lactose ingestion

  • Although rotavirus can cause secondary transient lactose intolerance, this finding is believed to be generally not clinically relevant; use lactose-containing formulas in all individuals with diarrhea.
  • In an incident of worsening of diarrhea proven to be secondary to a clinically important lactose malabsorption in infants positive for rotavirus, a very transient use of lactose-free formulas (5-6 d) can be considered.