Treatment of diarrhoea
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"diarrhea" AND "treatment" AND "oral rehydration"
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WHO diarrhoea treatment guidelines 2024 ORS zinc antibiotics
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Treatment of Diarrhoea
Regardless of the causative agent, age of patient, or country, the sheet anchor of treatment is Oral Rehydration Therapy (ORT). As many as 90-95% of all cases of cholera and acute diarrhoea can be treated by oral fluids alone. The goals are to prevent dehydration, correct existing deficits, maintain nutrition, and address any underlying cause.
1. Oral Rehydration Therapy (ORT)
Reduced Osmolarity ORS (WHO/UNICEF Recommended since 2004)
The current standard replaces the old sodium-bicarbonate-based formula with a reduced osmolarity ORS (245 mOsm/L), which:
- Reduces need for IV therapy by 33%
- Reduces stool output by 20%
- Reduces vomiting by 30%
| Component | grams/litre | mmol/litre |
|---|---|---|
| Sodium chloride | 2.6 | - |
| Glucose (anhydrous) | 13.5 | - |
| Potassium chloride | 1.5 | - |
| Trisodium citrate, dihydrate | 2.9 | - |
| Total weight | 20.5 g | Osmolarity: 245 mOsm/L |
| Sodium | - | 75 |
The packet is dissolved in 1 litre of drinking water, prepared fresh daily, and used within 24 hours. It should not be boiled or sterilized.
Home Fluids (when ORS unavailable)
A simple substitute: 1 level teaspoon salt + 6 level teaspoons sugar in 1 litre of drinking water. Acceptable home fluids include rice water, unsalted soup, yoghurt drinks, green coconut water, and weak tea (add ~3 g/L salt to unsalted fluids).
Fluids to avoid: carbonated beverages, commercial fruit juices, sweetened tea (cause osmotic diarrhoea and hypernatraemia); coffee and diuretic teas.
2. Dehydration Assessment and Treatment Plans
WHO uses a three-plan system based on dehydration severity:
| Plan | Signs | Treatment |
|---|---|---|
| Plan A (No dehydration) | No signs of dehydration | Increased fluids at home, continue feeding, zinc |
| Plan B (Some dehydration) | 2 or more signs: restlessness, sunken eyes, poor skin turgor, drinks eagerly | ORS 75 ml/kg over 4 hours in health facility |
| Plan C (Severe dehydration) | Signs of severe dehydration + shock | IV rehydration immediately |
Intravenous Rehydration (Plan C / Severe cases)
Reserved for severely dehydrated patients in shock or those unable to drink.
Preferred IV solutions (WHO):
- Ringer's Lactate (Hartmann's solution) - best choice; corrects acidosis and replaces potassium
- Diarrhoea Treatment Solution (DTS) - polyelectrolyte solution (Na-Cl 4 g, Na-acetate 6.5 g, KCl 1 g, glucose 10 g per litre)
- Normal saline - only if nothing else available; does not correct acidosis or replace potassium
Dosing: 100 ml/kg total IV fluid, divided as:
| Age | First: 30 ml/kg in | Then: 70 ml/kg in |
|---|---|---|
| Infants (<12 months) | 1 hour | 5 hours |
| Older children/adults | 30 minutes | 2.5 hours |
Once the patient can drink, switch to ORS ~5 ml/kg/hour.
3. Maintenance Therapy (After Rehydration)
| Severity | Oral Fluid |
|---|---|
| Mild (<1 stool every 2 hrs, or <5 ml/kg/hr) | 100 ml/kg/day until diarrhoea stops |
| Severe (>1 stool every 2 hrs, or >5 ml/kg/hr) | Replace stool volume for volume; if unmeasurable, give 10-15 ml/kg/hour |
4. Appropriate Feeding ("Rest the gut" is WRONG)
The current evidence firmly rejects the old practice of withholding food:
- Infant's usual diet of cereals, vegetables, and other foods should be continued during diarrhoea and increased afterwards
- Food should never be withheld and should never be diluted
- Breastfeeding should continue through the episode - it significantly reduces severity and mortality
- Appetite returns after dehydration is corrected in watery diarrhoea; children with bloody diarrhoea should be encouraged to resume feeding as soon as possible
5. Zinc Supplementation
WHO and UNICEF recommend zinc for all children with acute diarrhoea:
- <6 months: 10 mg/day for 10-14 days
- >6 months: 20 mg/day for 10-14 days
Benefits: reduces duration and severity of the current episode; lowers incidence of diarrhoea over the following 2-3 months.
(Recent evidence: A 2024 systematic review and meta-analysis [PMID 39641334] confirms low-osmolarity ORS remains superior to standard ORS in childhood diarrhoea management.)
6. Selective Use of Antibiotics
Antibiotics are not recommended for most acute watery diarrhoea. They are indicated in:
| Condition | Drug of Choice |
|---|---|
| Cholera | Doxycycline, tetracycline, TMP-SMX, azithromycin; fluoroquinolones |
| Shigella (bloody diarrhoea/dysentery) | Ciprofloxacin (Shigella is usually resistant to ampicillin and TMP-SMX) |
- Give antibiotics after vomiting has stopped (usually after 3-4 hours of ORT)
- Injectable antibiotics offer no special advantage over oral
7. Medicines That Should NOT Be Used
WHO explicitly advises against the following in diarrhoea treatment:
| Drug/Class | Reason |
|---|---|
| Neomycin | Damages intestinal mucosa, causes malabsorption |
| Purgatives | Worsen diarrhoea and dehydration |
| Tincture of opium / atropine | Dangerous for children and dysentery patients (decreased intestinal transit) |
| Cardiotonics (e.g. Coramine) | Shock must be corrected with IV fluids, not vasopressors |
| Steroids | Useless and cause adverse effects |
| Kaolin, pectin, bismuth, charcoal | No clinical value |
| Mexaform | No value and potentially dangerous |
8. Special Considerations
- Vitamin A supplementation is a key preventive measure reducing diarrhoea-related mortality by 19-54% in children
- Persistent diarrhoea (>14 days) requires specific investigation and nutritional rehabilitation
- Travellers' diarrhoea in adults: a short course of ciprofloxacin or azithromycin is acceptable when symptom burden is significant
Summary: The WHO 4-pillar approach is: (1) ORS / rehydration, (2) continued feeding + breastfeeding, (3) zinc 10-14 days, (4) selective antibiotics only for bloody diarrhoea or confirmed bacterial cause. Antidiarrhoeal and antimotility drugs are not recommended.
- Park's Textbook of Preventive and Social Medicine, pp. 267-269 (Block 4)
- WHO Diarrhoea Treatment Guidelines
- WHO/UNICEF Joint Statement on Clinical Management of Acute Diarrhoea
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