Gastroenterology Book


Diarrhea Management in Children

Aka: Diarrhea Management in Children, Management of Mild Diarrhea under age 2 years, Management of Moderate Diarrhea under age 2 years
  1. See Also
    1. Triage of Children with Diarrhea
    2. Pediatric Diarrhea
    3. Pediatric Diarrhea Fluid Replacement
    4. Oral Rehydration Solution
    5. Pediatric Dehydration
    6. Traveler's Diarrhea Management
    7. Traveler's Diarrhea Prophylaxis
    8. Traveler's Diarrhea Prevention
    9. Waterborne Illness
    10. Foodborne Illness
    11. Chronic Diarrhea
    12. Pediatric Vomiting
    13. Diarrhea
  2. Management: General
    1. Goal
      1. Prevent Dehydration
      2. Stay ahead of Diarrhea
    2. Maintain oral hydration
      1. Rehydration protocol
        1. See Pediatric Diarrhea Fluid Replacement
      2. Rapidly initiate rehydration protocol at the onset of illness (within first 4-5 hours)
        1. Gastrointestinal rest is a dangerous myth
        2. Delaying drinking risks further Dehydration
    3. Probiotics
      1. Preparations: Lactobacillus, Saccharomyces bouladii
      2. Efficacy:
        1. New larger study shows Lactobacillus does not appear to reduce Diarrhea in Children
          1. Schnadower (2018) N Engl J Med 379(21):2002-14 [PubMed]
        2. Original studies suggested that it may reduce Diarrhea by 1 day
          1. Effect requires continued use (eliminated within 2 hours of ingestion)
          2. Antiinflammatory effect and degrades dietary Antigens
    4. Antidiarrheals (avoid in general)
      1. Loperamide (Imodium)
        1. Has been used in older children and adults, but with only limited supporting evidence
        2. Contraindicated under age 2 years and not routinely recommended overall in children
      2. Lomotil
        1. Do not use at any age due to potential risks
    5. Antibiotics
      1. Not indicated in most cases
      2. Trend toward use of antibiotics in adult Diarrhea is not mirrored in children
      3. Antibiotics may not only worsen Diarrhea, but also risk complications (e.g. STEC induced HUS)
      4. Age restrictions on many antimicrobial agents used for Diarrhea
        1. Avoid Fluoroquinolones under age 18 years
        2. Avoid Septra under age 2 months
        3. Avoid Tetracycycline under age 9 years
        4. Avoid Bismuth Subsalicylate (Pepto Bismol) under age 12 years
          1. Contains Aspirin and increases risk of Reye's Syndrome
  3. Management: Diarrhea in infants
    1. See Pediatric Diarrhea Fluid Replacement
    2. Avoid supplementing with water (risk of Hyponatremia)
    3. Formula fed infants
      1. Continue full strength, standard milk-based formula
      2. Half-strength formula is unlikely to offer an advantage over full strength formula
      3. Soy Formula (e.g. Isomil) is unlikely to offer an advantage over standard milk-based formula
    4. Breast fed infants
      1. Consider supplementing with Oral Rehydration Solution between Breast feeds
      2. Continue Breast Feeding through the Diarrhea
        1. Avoid stopping Breast Feeding for mild or moderate Diarrhea
        2. Consult physician if considering discontinuing Breast Feeding
  4. Management: Diarrhea in Children over age 6 months
    1. Increase clear fluid intake
      1. See Pediatric Diarrhea Fluid Replacement
    2. Unrestricted diets are generally tolerated
      1. BRAT diet is based on the use of tolerated, constipating foods
        1. However it is considered too limiting and not recommended by AAP
        2. Applesauce
        3. Rice
        4. Bananas or carrots (strained for infants)
      2. Some foods may potentially worsen Diarrhea (may continue, but observe for adverse effects)
        1. Milk products, although historically avoided, typically require no restriction (see lactase below)
        2. Raw fruits and vegetables (fructose)
        3. Bran and beans
        4. Spices
        5. Juices with high sugar content
      3. If Watery stools recur after Diarrhea had been improving
        1. Recovering child normally has 2-3 mushy stools per day
        2. Consider using constipating solids on BRAT diet
        3. Consider avoiding milk products for a few additional days
    3. Risk of transient Lactase Deficiency with Diarrhea
      1. Usually no need to avoid lactose
      2. Observe for signs of Lactose Intolerance
        1. Large, foamy, explosive stools
        2. Stools with acid pH and reducing substances
    4. Sample menu of well tolerated foods after Diarrhea (however restrictions typically not needed)
      1. Day 1
        1. Saltines
        2. White toast with jelly
        3. Rice
        4. Applesauce
        5. Bland soups
      2. Day 2
        1. Lean meats
        2. Soft boiled eggs
        3. Noodles
      3. Day 3
        1. Soft fruits and vegetables
          1. Pears
          2. Carrots
          3. Potatoes
        2. Cheese
        3. Cottage cheese
        4. Yogurt
      4. Day 4
        1. Regular diet
        2. Consider delaying milk and ice cream introduction for several days
  5. Prevention
    1. Pediatric Diarrhea is very contagious
    2. Wash hands after each diaper change
    3. Avoid mess
      1. Close diapers tightly
      2. Cover diapers with plastic pants
  6. Complications: Other
    1. See Pediatric Dehydration
    2. See Diaper Rash
  7. Resources
    1. The Treatment of Diarrhea (WHO)
  8. References
    1. Churgay (2012) Am Fam Physician 85(11): 1066-70 [PubMed]
    2. Hartman (2019) Am Fam Physician 99(3):159-65 [PubMed]
    3. King (2003 MMWR Recomm Rep 52(RR-16):1-16 [PubMed]

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