Wong

Therapeutic Management
The major goals in the management of acute diarrhea include (1) assessment
of fluid and electrolyte imbalance, (2) rehydration, (3) maintenance fluid
therapy, and (4) reintroduction of an adequate diet. Infants and children with
acute diarrhea and dehydration should be treated first with oral
rehydration therapy (ORT). ORT is one of the major worldwide health care
advances of the past decade. It is more effective, safer, less painful, and less
costly than intravenous (IV) rehydration. The American Academy of
Pediatrics, World Health Organization, and Centers for Disease Control and
Prevention all recommend ORT as the treatment of choice for most cases of
dehydration caused by diarrhea (Nappert and others, 2000; American
Academy of Pediatrics, 1996; Gastanaduy and Begue, 1999). Oral rehydration
solutions (ORS) enhance and promote the reabsorption of sodium and water,
and studies indicate that these solutions greatly reduce vomiting, volume loss
from diarrhea, and the duration of the illness. Oral replacement solutions are
available in the United States as commercially prepared solutions and are
successful in treating the majority of infants with isotonic, hypotonic, or
hypertonic dehydration. Guidelines for rehydration recommended by the
American Academy of Pediatrics are included in Box 24-3.

BOX 24-3 Model for Rehydration

Rehydration solution should consist of 75 to 90 mEq of sodium (Na+) per
liter.
Give 40 to 50 mL/kg of rehydration solution over 4 hours.
Replacement and maintenance solution should consist of 40 to 60 mEq of
Na+ per liter.
Reevaluate the need for further rehydration; initiate maintenance therapy
using maintenance formulations, with daily volumes not to exceed 150
mL/kg/day.
In children with diarrhea without significant dehydration, the maintenance
phase may be initiated without the need for rehydration solution (Acra and
Ghishan, 1996).
If additional fluids are needed, use low-salt fluids such as breast milk or
water.

Modified from American Academy of Pediatrics, Provisional Committee on

Quality Improvement, Subcommittee on Acute Gastroenteritis: Practice
parameter: the management of acute gastroenteritis in young children,
Pediatrics 97(3):424435, 1996.
After rehydration, ORS may be used during maintenance fluid therapy by
alternating the solution with a low-sodium fluid such as water, breast milk,
lactose-free formula, or half-strength lactose-containing formula. In older
children ORS can be given and a regular diet continued. Ongoing stool losses
should be replaced on a 1:1 basis with ORS. If the stool volume is not known,
approximately 10 mL/kg (4 to 8 ounces) of ORS should be given for each
diarrhea stool.
Solutions for oral hydration are useful in most cases of dehydration, and
vomiting is not a contraindication. A child who is vomiting should be given an
ORS at frequent intervals and in small amounts. In young children the fluid
may be given with a spoon or small syringe in 5- to 10-mL increments every 1
to 5 minutes by the caregiver. An ORS may also be given via nasogastric or
gastrostomy tube infusion. Infants without clinical signs of dehydration do not
need ORT. They should, however, receive the same fluids recommended for
infants with signs of dehydration in the maintenance phase and for ongoing
stool losses.

! NURSING ALERT
Diarrhea is not managed by encouraging intake of clear fluids by
mouth, such as fruit juices, carbonated soft drinks, and gelatin.
These fluids usually have a high carbohydrate content, a very low
electrolyte content, and a high osmolality (Lasche and Duggan,
1999). Caffeinated soda is avoided, because caffeine is a mild
diuretic and may lead to increased loss of water and sodium.
Chicken or beef broth is not given, because it contains excessive
sodium and inadequate carbohydrate. A BRAT diet (bananas, rice,
applesauce, and toast or tea) is contraindicated for the child and
especially for the infant with acute diarrhea, because this diet has
little nutritional value (low in energy and protein), is high in
carbohydrates, and is low in electrolytes.
Early reintroduction of nutrients is desirable and is gaining more widespread
acceptance. Continued feeding or early reintroduction of a normal diet has no
adverse effects and actually lessens the severity and duration of the illness
and improves weight gain when compared with the gradual reintroduction of
foods (Lasche and Duggan, 1999). Infants who are breast-feeding should

continue to do so, and ORS should be used to replace ongoing losses in these
infants.
The use of nonhuman milk for infants and children with diarrhea remains
controversial. Cow's milk and cow's milk formulas are of concern because
poor digestion of lactose can occur in children with infectious diarrhea.
However, some studies indicate that well-hydrated infants may resume fullstrength nonhuman milk feeding immediately without adverse reactions
(Hugger, Harkless, and Rentschler, 1998).
Many infants and children are safely managed with a diet containing cow's
milk. Some practitioners advocate the use of a lactose-free formula only if
milk or regular formula is not tolerated. In older children a regular diet can
generally be offered after rehydration has been achieved. In toddlers there is
no contraindication to continuing soft or pureed foods. A diet of easily
digestible foods such as cereals, cooked vegetables, and meats is adequate
for the older child.
In cases of severe dehydration and shock, IV fluids are initiated whenever the
child is unable to ingest sufficient amounts of fluid and electrolytes to (1)
meet ongoing daily physiologic losses, (2) replace previous deficits, and (3)
replace ongoing abnormal losses. Patients who usually require IV fluids are
those with severe dehydration, those with uncontrollable vomiting, those who
are unable to drink for any reason (e.g., extreme fatigue, coma), and those
with severe gastric distention.
The IV solution is selected on the basis of what is known regarding the
probable type and cause of the dehydrationusually a saline solution
containing 5% dextrose in water. Sodium bicarbonate may be added, because
acidosis is usually associated with severe dehydration. Although the initial
phase of fluid replacement is rapid in both isotonic and hypotonic
dehydration, it is contraindicated in hypertonic dehydration because of the
risk of water intoxication, especially in the brain cells.
After the severe effects of dehydration are under control, specific diagnostic
and therapeutic measures are begun to detect and treat the cause of the
diarrhea. Because of the self-limiting nature of vomiting and its tendency to
improve when dehydration is corrected, the use of antiemetic agents is not
recommended. The use of antibiotic therapy in children with acute
gastroenteritis is controversial. Antibiotics may shorten the course of some
diarrheal illnesses (e.g., those caused by Shigella). However, most bacterial
diarrheas are self-limiting, and the diarrhea often resolves before the
causative organism can be determined. Antibiotics may prolong the carrier
period for bacteria such as Salmonella. Antibiotics may be considered,
however, in patients with immunosuppression, severe symptoms or

persistent disease, or patients who have had transplantation (Jabbar and

Wright, 2003; Burkhart, 1999) (see Intestinal Parasitic Diseases, Chapter 14).