Treatment of Severe Diarrhea in Pediatric Patients

Initial Assessment and Management

The Centers for Disease Control and Prevention recommends assessing dehydration severity immediately by examining mental status, perfusion status, skin turgor, respiratory pattern, and body weight, in pediatric patients with severe diarrhea 1, 2
Severe dehydration is defined as ≥10% fluid deficit with signs of shock or near-shock, and requires immediate intravenous rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize, as recommended by the Centers for Disease Control and Prevention 1, 2, 3
The American Academy of Pediatrics recommends monitoring continuously for improvement in vital signs and perfusion during intravenous rehydration 1

The World Health Organization recommends using oral rehydration solution (ORS) containing 50-90 mEq/L of sodium to complete the remaining fluid deficit, after initial intravenous rehydration 1, 2
The Centers for Disease Control and Prevention recommends administering the remaining estimated deficit by mouth over the next several hours, using ORS 1
The American Academy of Pediatrics recommends giving small volumes (5-10 mL) of ORS every 1-2 minutes, using a spoon, syringe, or medicine dropper, for children with vomiting, gradually increasing as tolerated 3

The Centers for Disease Control and Prevention recommends replacing ongoing fluid losses with 10 mL/kg of ORS for each watery or loose stool, and 2 mL/kg of ORS for each episode of vomiting, during both rehydration and maintenance phases 1, 4
The World Health Organization recommends continuously replacing ongoing fluid losses to prevent dehydration, in pediatric patients with severe diarrhea 1, 4

The American Academy of Pediatrics recommends continuing breastfeeding throughout the entire episode without interruption, for breastfed infants with severe diarrhea 3, 5
The Centers for Disease Control and Prevention recommends resuming full-strength formula immediately upon rehydration, for bottle-fed infants with severe diarrhea 1, 3
The American Academy of Pediatrics recommends resuming age-appropriate diet during or immediately after rehydration is completed, including starches, cereals, yogurt, fruits, and vegetables, and avoiding foods high in simple sugars and fats 3

The American Academy of Pediatrics recommends that antimotility drugs (loperamide) are absolutely contraindicated in all children <18 years of age, due to risks of respiratory depression and serious cardiac adverse reactions 3
The Centers for Disease Control and Prevention recommends that ondansetron may be given to children >4 years of age, to facilitate oral rehydration when vomiting is present, but only after adequate hydration is achieved 3
The World Health Organization recommends zinc supplementation to reduce diarrhea duration, in children 6 months to 5 years of age who reside in countries with high zinc deficiency prevalence or show signs of malnutrition 3, 6