II. Management: General
- Goal
- Prevent Dehydration
- Stay ahead of Diarrhea
- Maintain oral hydration
- Rehydration protocol
- Rapidly initiate rehydration protocol at the onset of illness (within first 4-5 hours)
- Gastrointestinal rest is a dangerous myth
- Delaying drinking risks further Dehydration
-
Probiotics
- Preparations: Lactobacillus, Saccharomyces bouladii
- Efficacy:
- New larger study shows Lactobacillus does not appear to reduce Diarrhea in Children
- Original studies suggested that it may reduce Diarrhea by 1 day
- Effect requires continued use (eliminated within 2 hours of ingestion)
- Antiinflammatory effect and degrades dietary Antigens
- Antidiarrheals (avoid in general)
- Loperamide (Imodium)
- Has been used in older children and adults, but with only limited supporting evidence
- Contraindicated under age 2 years and not routinely recommended overall in children
- Lomotil
- Do not use at any age due to potential risks
- Loperamide (Imodium)
-
Antibiotics
- Not indicated in most cases
- Trend toward use of Antibiotics in adult Diarrhea is not mirrored in children
- Antibiotics may not only worsen Diarrhea, but also risk complications (e.g. STEC induced HUS)
- Age restrictions on many Antimicrobial Agents used for Diarrhea
- Avoid Fluoroquinolones under age 18 years
- Avoid Septra under age 2 months
- Avoid Tetracycycline under age 9 years
- Avoid Bismuth Subsalicylate (Pepto Bismol) under age 12 years
- Contains Aspirin and increases risk of Reye's Syndrome
III. Management: Diarrhea in infants
- See Pediatric Diarrhea Fluid Replacement
- Avoid supplementing with water (risk of Hyponatremia)
- Formula fed infants
- Continue full strength, standard milk-based formula
- Half-strength formula is unlikely to offer an advantage over full strength formula
- Soy Formula (e.g. Isomil) is unlikely to offer an advantage over standard milk-based formula
-
Breast fed infants
- Consider supplementing with Oral Rehydration Solution between Breast feeds
- Continue Breast Feeding through the Diarrhea
- Avoid stopping Breast Feeding for mild or moderate Diarrhea
- Consult physician if considering discontinuing Breast Feeding
IV. Management: Diarrhea in Children over age 6 months
- Increase clear fluid intake
- Unrestricted diets are generally tolerated
- BRAT diet is based on the use of tolerated, constipating foods
- However it is considered too limiting and not recommended by AAP
- Applesauce
- Rice
- Bananas or carrots (strained for infants)
- Some foods may potentially worsen Diarrhea (may continue, but observe for adverse effects)
- Milk products, although historically avoided, typically require no restriction (see lactase below)
- Raw fruits and vegetables (fructose)
- Bran and beans
- Spices
- Juices with high sugar content
- If Watery stools recur after Diarrhea had been improving
- Recovering child normally has 2-3 mushy stools per day
- Consider using constipating solids on BRAT diet
- Consider avoiding milk products for a few additional days
- BRAT diet is based on the use of tolerated, constipating foods
- Risk of transient Lactase Deficiency with Diarrhea
- Usually no need to avoid lactose
- Observe for signs of Lactose Intolerance
- Large, foamy, explosive stools
- Stools with acid pH and reducing substances
- Sample menu of well tolerated foods after Diarrhea (however restrictions typically not needed)
- Day 1
- Saltines
- White toast with jelly
- Rice
- Applesauce
- Bland soups
- Day 2
- Lean meats
- Soft boiled eggs
- Noodles
- Day 3
- Soft fruits and vegetables
- Pears
- Carrots
- Potatoes
- Cheese
- Cottage cheese
- Yogurt
- Soft fruits and vegetables
- Day 4
- Regular diet
- Consider delaying milk and ice cream introduction for several days
- Day 1
V. Prevention
- Pediatric Diarrhea is very contagious
- Wash hands after each diaper change
- Avoid mess
- Close diapers tightly
- Cover diapers with plastic pants
VI. Complications: Other
- See Pediatric Dehydration
- See Diaper Rash
VII. Resources
- The Treatment of Diarrhea (WHO)