Treatment of Diarrhea in Children

1. Assess dehydration first

• Mental status, thirst, skin turgor, eyes (sunken?), tears, mucous membranes
• Capillary refill, pulse, blood pressure
• Urine output

2. Oral Rehydration Therapy (ORT) - first line

• WHO-recommended low-osmolarity oral rehydration solution (ORS) (sodium ~75 mmol/L) is the standard of care for mild-to-moderate dehydration and is as effective as IV fluids in most cases, with fewer complications - Tintinalli's Emergency Medicine, p. 888.
• Home-made ORS: 1 liter clean water + 6 level teaspoons sugar + 1/2 teaspoon salt, if commercial sachets aren't available.
• Give small, frequent sips (e.g., a teaspoon every 1-2 minutes for a vomiting child); increase as tolerated.
• ORS does not reduce stool output or shorten diarrhea duration, but it corrects and prevents dehydration effectively - Goldman-Cecil Medicine, "Fluid Replacement."
• Routine fasting is not recommended; feeding should resume as soon as vomiting subsides - Rosen's Emergency Medicine, "Oral Rehydration."

3. IV fluids - only when needed

• Severe dehydration or shock
• Intractable vomiting preventing oral intake
• Altered mental status/inability to safely take oral fluids
• Abdominal distension/ileus

4. Zinc supplementation

• 10 mg/day for infants under 6 months
• 20 mg/day for children 6 months and older
• Given for 10-14 days

5. Continued feeding / nutrition

• Continue breastfeeding throughout, including during rehydration.
• Resume an age-appropriate, normal diet as soon as tolerated - no need for routine lactose-free or diluted formula in most children.
• Avoid sugary drinks/juices which can worsen osmotic diarrhea.

6. Antiemetics

• A single dose of oral ondansetron is commonly used in ED settings to reduce vomiting and improve success of oral rehydration, reducing need for IV fluids and hospitalization.

7. Antibiotics - selective, not routine

• Shigella - antibiotics recommended (reduces duration/transmission)
• Campylobacter - azithromycin if early and severe
• Vibrio cholerae - antibiotics indicated
• Salmonella - generally avoided (may prolong carriage) except in infants <3 months, immunocompromised, or invasive disease
• E. coli O157:H7 (suspected hemolytic-uremic syndrome) - antibiotics should be avoided, as they can increase HUS risk

8. Probiotics

9. Medications to avoid

• Loperamide and other antimotility agents are generally avoided in young children, especially with bloody diarrhea or suspected bacterial/invasive infection (risk of toxic megacolon, prolonged bacterial illness).

Red flags requiring urgent medical evaluation

• Signs of severe dehydration or shock
• Bloody diarrhea, high fever, severe abdominal pain
• Persistent vomiting preventing oral intake
• Diarrhea lasting >14 days (persistent diarrhea - needs evaluation for micronutrient deficiency, non-intestinal infection, and possible lactose-free diet)
• Infants under 3 months, or immunocompromised children

Recent evidence check

• Under 1 year: No honey and no over-the-counter cough/cold syrup. Use breastmilk/formula, saline nose drops, and gentle nasal suction.
• Age 1 year or older: Honey is usually the safest option for night cough. Give ½ teaspoon (age 1-5), 1 teaspoon (age 6-11) before bed. Do not give honey to infants under 12 months due to botulism risk.
• Under 4 years: Avoid OTC cough/cold syrups. They can cause dangerous side effects and do not help much.
• Age 4-6 years: Do not use combination cough-and-cold syrups unless a clinician specifically advises it.
• Over 6 years: A doctor or pharmacist can advise a single-ingredient medicine if needed, but avoid combination products and avoid codeine-containing cough syrup in children.