This document provides guidance on assessing and managing acute diarrhea in children. It describes how to take a thorough patient history and conduct a physical exam to evaluate dehydration. Three treatment plans are outlined for: no dehydration (plan A involving oral rehydration), some dehydration (plan B with oral and intravenous rehydration), and severe dehydration (plan C requiring intravenous therapy). The document provides details on oral rehydration solution composition and administration guidelines for rehydration based on a patient's age, weight, and degree of dehydration.

1. Acute Diarrheal Disease
Management.
Dr John P George

2. ASSESSMENT OF THE CHILD WITH DIARRHEA
1. History
• Ask the mother or other caretaker about:
• duration of diarrhea,
• number of watery stools per day,
• type of stool.
• presence of blood in the stool;
• number of episodes of vomiting;
• Abdominal Distention

3. ASSESSMENT OF THE CHILD WITH DIARRHEA
• pre-illness feeding practices; ? Bottle feeding
• type and amount of fluids (including breast
milk) and food taken during the illness;
• drugs or other remedies taken;
• immunization history
• socioeconomic history- water source

4. ASSESSMENT OF THE CHILD WITH DIARRHEA
2. Physical examination
• First, check for signs and symptoms of
dehydration.
• Look for these signs:
• General condition: is the child alert; restless
or irritable; lethargic or unconscious?
• Are the eyes normal or sunken?
• Are tears present in the eyes?

5. ASSESSMENT OF THE CHILD WITH DIARRHEA
• Whether the tongue moist or not
• When water or ORS solution is offered to
drink, is it taken normally or refused, taken
eagerly, or is the child unable to drink owing
to lethargy or coma?
• Is the child malnourished? Look for signs of
malnutrition .

6. ASSESSMENT OF THE CHILD WITH DIARRHOEA
• Feel the child to assess:
• Skin turgor . When the skin over the
abdomen is pinched and released, does it
flatten immediately, slowly, or very slowly
(more than 2 seconds)
• Take the child's temperature:
• Fever may be caused by severe dehydration,
or by a non-intestinal infection such as malaria
or pneumonia.

7. Estimate the fluid deficit
Assessment Fluid deficit as % of body
weight
Fluid deficit in ml/kg body
weight
Assessment Fluid deficit as % of body
weight
Fluid deficit in ml/kg body
weight
No signs of dehydration <5% in an infant
<3% in older child
<50 ml/kg
Some dehydration 5-10% in an infant
3-6% in older child
50-100ml/kg
Severe dehydration >10% in an infant
>6% in older child
>100ml/kg

8. Determine the degree of dehydration
Assessment of diarrhoea patients for dehydration
A B C
LOOK AT:
CONDITION
EYES
THIRST
Well, alert
Normal
Drinks normally, not
thirsty
Restless, irritable
Sunken
Thirsty, drinks eagerly
Lethargic or unconscious
Sunken
Drinks poorly, or not able
to drink
FEEL:
SKIN PINCH
Goes back quickly Goes back slowly Goes back very slowly
DECIDE The patient has
NO SIGNS OF
DEHYDRATION
If the patient has two or
more signs in B, there is
SOME DEHYDRATION
If the patients has two or
more signs in C, there is
SEVERE DEHYDRATION
TREAT Use Treatment Pan A Weigh the patient, if
possible, and use
Treatment Plan B
Weigh the patient and use
Treatment Plan C
URGENTLY

9. MANAGEMENT OF ACUTE DIARRHEA
The objectives of treatment are to:
• prevent dehydration, if there are no signs of
dehydration;
• treat dehydration, when it is present;
• prevent nutritional damage, by feeding during
and after diarrhoea.
• Prevent spread of the enteropathogen

10. MANAGEMENT OF ACUTE DIARRHEA
• In select cases, determine the etiologic agent
and provide specific therapy if indicated.
• reduce the duration and severity of
diarrhoea, and the occurrence of future
episodes, by giving supplemental zinc

11. Treatment Plan A
• home therapy to prevent dehydration and
malnutrition
• Give the child more fluids than usual, to prevent
dehydration
• Most fluids that a child normally takes can be
used. It is helpful to divide suitable fluids into two
groups:
• Fluids that normally contain salt, such as:
• ORS solution
• salted drinks (e.g. salted rice water or a salted
yoghurt drink)
• vegetable or chicken soup with salt.

12. Treatment Plan A
• Fluids that do not contain salt, such as:
• plain water
• water in which a cereal has been cooked (e.g.
unsalted rice water)
• unsalted soup
• yoghurt drinks without salt
• green coconut water
• weak tea (unsweetened)
• unsweetened fresh fruit juice.

13. Treatment Plan A:
• Unsuitable fluids
• A few fluids are potentially dangerous and should
be avoided during diarrhoea. Especially
important are drinks sweetened with sugar,
which can cause osmotic diarrhoea and
hypernatraemia. Some examples are:
• commercial carbonated beverages
• commercial fruit juices
• sweetened tea.

14. Treatment Plan A
• How much fluid to give
• The general rule is: give as much fluid as the
child wants until diarrhoea stops. As a guide,
after each loose stool, give:
• children under 2 years of age: 50-100 ml (a
quarter to half a large cup) of fluid; give a
teaspoon every 1-2 mins

15. Treatment Plan A
• children aged 2 up to 10 years: 100-200 ml (a
half to one large cup);
• older children and adults: as much fluid as
they want.
• For an older child, give frequent sips from a
cup
• If the child vomits, wait for 10 mins. Then
continue but more slowly ( e.g every 2-3 mins)

16. Treatment Plan A
• Take the child to a health worker if there are signs
of dehydration or other problems
• The mother should take her child to a health worker
if the child:
• starts to pass many watery stools;
• has repeated vomiting;
• becomes very thirsty;
• is eating or drinking poorly;
• develops a fever;
• has blood in the stool; or
• the child does not get better in three days

17. Oral Rehydration Solution
Composition of reduced (low) osmolarity ORS solution.
Grams/Litre Mmol/litre
Sodium chloride 2.6 Sodium 75 (mmol/L)
Glucose, anhydrous 13.5 Chloride 65
Potassium chloride 1.5 Glucose,anhydrous 75
Trisodium citrate,
dihydrate
2.9 Potassium 20
Citrate 10
Total Osmolarity 245

18. Treatment Plan B:
• oral rehydration therapy for children with some
dehydration
• Needs admission for observation in hospital
• ORS + Zinc(10-20mg/day)
• Amount of ORS needed for rehydration-
Weight x 75 ml given in first 4 hours
• When rehydration is complete, maintenance
therapy should be started.
• Patients with mild diarrhoea usually can then be
treated at home using 100 mL of ORS/kg/24 hr
until the diarrhoea stops

19. Treatment Plan B:
• Supplementary ORS is given to replace
ongoing losses from diarrhoea or
emesis.10ml/kg of ORS to be given for each
loose stool
• Breast-feeding should be allowed after
rehydration in infants who are breast-fed; in
other patients, their usual formula, milk, or
feeding should be offered after rehydration

20. Guidelines for treating children and adults with
some dehydration
Approximate Amount Of ORS to be given in 4 hours
Age Less than 4
months
4-11
Months
12-23
Months
2-4 Years 5-14 Years 15 years or
older
Weight Less than 5
Kg
5-7.9 Kg 8-10.9 kg 11-15.9Kg 16-29.9 Kg 30 kg or more
Volume
(ml)
200-400 400-600 600-800 800-1200 1200-2200 2200-4000
Reference-THE TREATMENT OF DIARRHOEA-A manual for physicians and other senior health workers by WHO

21. Monitoring the progress of oral rehydration
therapy
• If there are no signs of dehydration, the child
should be considered fully rehydrated. When
rehydration is complete:
• - the skin pinch is normal;
• - thirst has subsided;
• - urine is passed;
• - the child becomes quiet, is no longer irritable
and often falls asleep.
• change to Plan A of Treatment

22. Monitoring the progress of oral rehydration
therapy
• If the child still has signs indicating some
dehydration, continue oral rehydration
therapy by repeating Treatment Plan B.
• At the same time start to offer food, milk and
other fluids, as described in Treatment Plan A
• continue to reassess the child frequently.

23. Monitoring the progress of oral rehydration
therapy
• If signs of severe dehydration have appeared,
intravenous (IV) therapy should be started
following Treatment Plan C.
• This is very unusual, however, occurring only
in children who
• drink ORS solution poorly and
• pass large watery stools frequently during the
rehydration period
• frequent, severe vomiting.

24. Cascade for acute, mild/moderate, watery diarrhoea:
with mild/moderate dehydration.
High
↑
Resources
↓
Low
Level 1
Intravenous fluids (consider) + ORT
Level 2
Nasogastric tube ORS—if persistent, vomiting
Level 3
ORT
Level 4
Home-made oral fluid: salt, sugar, and clean water
Reference: World Gastroenterology Organisation Global Guidelines Acute diarrhoea in adults
and children: a global perspective

25. Treatment Plan C
• for patients with severe dehydration
• preferred treatment for children with severe
dehydration is rapid intravenous rehydration
• Children who can drink, even poorly, should be
given ORS solution by mouth until the IV drip is
running.

26. Treatment Plan C
• In addition, all children should start to receive
some ORS solution (about 5 ml/kg/h) when
they can drink without difficulty, which is
usually within 3-4 hours (for infants) or 1-2
hours (for older patients).
• This provides additional base and potassium,
which may not be adequately supplied by the
IV fluid.

27. Indication for IV fluids;
• Severe Dehydration with or without shock
• Persistent Vomiting
• Failure to correct or worsening of dehydration
on ORT
• High purge rate
• Failure of Acceptance of ORS in dehydrated
child
• Altered Sensorium/Seizures

28. IV Fluid Therapy
• Preferred solutions
• Ringer's Lactate Solution is the best commercially
available solution.
• The concentration of potassium is low and there is no
glucose to prevent hypoglycaemia
• Ringer's Lactate Solution with 5% dextrose has the added
advantage of providing glucose to help prevent
hypoglycaemia. If available, it is preferred to Ringer's
Lactate Solution without dextrose

29. IV Fluid Therapy
Maintenance Fluids
• >6Yrs-12 years-%DN/2 with KCl 20 Meq/l
• >1 months-6 years- 5%DN/4 with KCl 20meq/l
• <1months 5%DN/6 with KCl 20meq/l

30. IV Fluid Therapy
Acceptable solution
• Normal saline (0.9% NaCl; also called isotonic or
physiological saline) is often available.
• It does not contain a base to correct acidosis and
does not replace potassium losses.

31. IV Fluid Therapy
• Unsuitable solution
• Plain glucose (dextrose) solution should not
be used since it does not contain electrolytes
• and thus does not correct the electrolyte
losses or the acidosis. It does not effectively
correct hypovolaemia.

32. WHO Guidelines for intravenous treatment of
children and adults with severe dehydration
Start IV fluids immediately. If the patient can drink, give ORS by mouth until the drip
is set up.
Give 100 ml/kgRinger's Lactate Solution divided as follows:
Age First Give 30ml/kg in Then give 70ml/kg in:
Infants 1 hour(b) 5 hours
Older 30 minutes(b) 21/2 hours
Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip
more rapidly.
• After six hours (infants) or three hours (older patients), evaluate the patient using
the assessment chart.
Then choose the appropriate Treatment Plan (A, B or C) to continue treatment.
a If Ringer's Lactate Solution is not available, normal saline may be used).
b Repeat once if radial pulse is still very weak or not detectable.

33. IV Fluid Therapy
Guideline for the total amount of fluid to be replaced in some and severe dehydration
Usual Fluid
Deficit(ml/Kg)
Deficit Fluid
Replaced(ml/kg)
Maintenance
fluid required in 8
hrs(ml/kg)
Total amount of
fluid for correction
of dehydration to
be given in 8 hours
Some
Dehydration
70-100ml 50 50 100
Severe
Dehydration
120-180ml
(>100<200)
100 50 150

34. Cascade for acute, severe, watery diarrhoea:
cholera-like, with severe dehydration.
High
↑
Resources
↓
Low
Level 1
Intravenous fluids + antibiotics + diagnostic tests:
stool microscopy/culture
Based on tests: tetracycline, fluoroquinolone
Level 2
Intravenous fluids + antibiotics
Empirical: tetracycline, fluoroquinolone, or other
Level 3
Intravenous fluids + ORT
Level 4
Nasogastric tube ORS—if persistent, vomiting
Level 5
ORT
Level 6
Home-made oral fluid: salt, sugar, and clean water
Reference: World Gastroenterology Organisation Global Guidelines Acute diarrhoea in adults
and children: a global perspective.

35. Drug Therapy in Diarrhea.
• Definitive Indications
• Shigella Dysentry, giardiasis, infection with
E.Hystolitica
• Cholera
• Septicemia, Diarrhea with systemic illness
• Moderate to severe PEM
• Immunocompromised Situations.

36. Drug Therapy in Diarrhea
• In dysentery, begin empirical therapy with
cotrimoxazole (TMP-SMX) or ampicillin for 5
days
↓
If no improvement (disappearance of fever, less
blood in stools, fewer stools, return to normal
activity) after 48 hours, change to Nalidixic
acid for 5 days

37. Cascade for acute bloody diarrhoea—
with mild/moderate dehydration.
High
↑
Resources
↓
Low
Level 1
ORT + antibiotics + diagnostic tests: stool microscopy/culture
Consider causes: S. dysenteriae, E. histolytica,
severe bacterial colitis
Level 2
ORT + antibiotics
Empirical antibiotics for moderate/severe illness
Level 3
ORT
Level 4
Home-made oral fluid: salt, sugar, and clean water
Reference: World Gastroenterology Organisation Global Guidelines Acute diarrhoea in adults
and children: a global perspective.

38. Drug Therapy in Diarrhea
Cause Antibiotics of Choice Alternatives
Cholera Doxycycline
Single dose of 6mg/kg PO
or
Tetracycline
Children: 12.5 mg/kg
4 times a day x 3 days
Erythromycin
Children: 12.5 mg/kg
4 times a day x 3 days
Shigella dysentery Ciprofloxacin
Children: 15 mg/kg
2 times a day x 3 days
Pivmecillinam
Children: 20 mg/kg
4 times a day x 5 days
Ceftriaxone
Children: 50-100 mg/kg
once a day IM x 2 to 5 day

39. Drug Therapy in Diarrhea
Cause Antibiotics of Choice Alternatives
Amoebiasis Metronidazole
Children: 10 mg/kg
3 times a day x 5 days (10
days for severe disease)
Giardiasis Albendazole
Children: 400 mg
once a day x 5 days
Metronidazole
15 mg/kg/24 hr divided tid
PO for 5 days

40. Zinc Therapy
• Zinc has been identified to play a critical role
in metalloenzymes, polyribosomes, the cell
membrane, and cellular function, leading to
the belief that it also plays a central role in
cellular growth and in the function of the
immune system.
• Intestinal zinc losses during diarrhea
aggravate pre existing zinc deficiency.

41. Probiotics
• commonly used probiotic bacteria
include Lactobacillus, Bifidobacteria and the
yeast Saccharomyces boullardii.
• probiotics offer innumerable benefits to the
host by alleviating symptoms of lactose
intolerance.

42. Probiotics
Uses if Probiotics:
• They are also known to prevent
• acute diarrhea,
• traveler’s diarrhea,
• antibiotic associated diarrhea,
• Rotaviral diarrhea
• probiotics don’t work the same in everyone.
Probiotics may be more effective in older
people than in younger ones.

43. Probiotics
• Conclusions of the IAP National Task Force for use of
probiotics in diarrhea, May 2006
• The group recommended that there is presently
insufficient evidence to recommend probiotics in the
treatment of acute diarrhea in our settings as:
• Almost all the studies till now were done in developed
countries.
• It may not be possible to extrapolate the findings of
these studies to our setting where the breast feeding
rates are high and the microbial colonization of the gut
is different

44. AntiSecretory Drugs.
• Rececodotil -Enkephalinase inhibitor
preventing the breaking down of endogenous
encephalins in GI tract. It decreases intestinal
hypersecretion but not motility.
• Currently not indicated for acute diarhoeal
disease.
• It should await more evidence from well
designed RCT done in our settings.

45. Antidiarrhoeal
Drugs
• These agents, though commonly used, have
no practical benefit and are never indicated
for the treatment of acute diarrhoea in
children.
• Adsorbents -e.g. kaolin, activated charcoal,
cholestyramine
• Antimotility drugs e.g. loperamide
hydrochloride, tincture of opium, codeine.

46. References
• Nelson Textbook of Pediatrics 19th edition
• IAP text Book of Peadiatrics
• THE TREATMENT OF DIARRHOEA-A manual for
physicians and other senior health workers by WHO
• IAP Guidelines 2006 on Management of Acute
Diarrhea
• World Gastroenterology Organisation Global
Guidelines
• Acute diarrhea in adults and children: a global
perspective February 2012.