Otitis media is a middle ear infection associated with effusion, rapid
symptom development, and evidence of middle ear inflammation.
Options for therapy include antibiotic management and watchful waiting,
the choice of which depends on the age of the child and severity of
disease. Amoxicillin (or amoxicillin/clavulanate) remains the antibiotic of
choice despite the high incidence of penicillin nonsusceptible
Acute pharyngitis may be caused by respiratory viruses or bacteria, most
commonly Streptococcus pyogenes. Treatment goals for bacterial
pharyngitis include resolution of symptoms and prevention of rheumatic
heart disease. Amoxicillin is the antibiotic of choice for bacterial
Children represent more than 25% of the population and receive an average of three
prescription medications before 5 years of age. According to the Slone Survey,
between 1998 and 2007, 56% of children younger than 12 years of age had taken at
least one medication in the previous week.
1 Prescription medications accounted for
only 20% of cases; thus, the use of over-the-counter (e.g., nonprescription)
medications was most prevalent. The most predominant over-the-counter medications
used were acetaminophen, pseudoephedrine, ibuprofen, dextromethorphan,
antihistamines, and iron. The most prevalent prescription medications were
amoxicillin and albuterol. The prevalence of chronic medication use for
dyslipidemia, hypertension, type 2 diabetes, and attention deficit hyperactivity
disorder has increased in recent years, illustrating that chronic disease management
is becoming more important in pediatric medicine.
medication use in children, it is essential that health care providers be prepared to
educate families and children on the appropriate use of over-the-counter and
ADMINISTERING MEDICATION TO CHILDREN
these medications should be recommended?
The administration of oral medications to a young child or infant often requires two
adults: one to gently restrain the child while the other rapidly and accurately
administers the medication. If only one adult is available, one can restrain the arms
and legs of the child in a swaddling blanket or large towel as depicted in Figure 104-
making sure the baby swallows.
The administration device (syringe, dropper, or dosing spoon) that generally
accompanies a liquid medication product provides the most accurate measurement of
the desired dose. For infants, liquid medications are most easily administered to the
back cheek in 1- to 2-mL amounts with an oral syringe. Household teaspoons should
not be used to measure medications because teaspoons are of variable sizes and hold
3 to 8 mL of a liquid. Other considerations involve the unit of measurement. To
decrease errors and improve precision of drug delivery, it is recommended to use
milliliter-based dosing exclusively while prescribing and administering liquid
4 Regarding unique delivery devices, studies have shown that parents have
more difficulty accurately delivering doses using dosing cups than other devices.
In some situations, crushed tablets or capsule contents mixed in small amounts (1–
2 teaspoons) of food (e.g., chocolate pudding, applesauce, ice cream, jelly, and
chocolate syrup) offer an alternative to liquid formulations. The taste of liquid
dosage formulations is generally improved by refrigeration and flavoring agents, and
“chasers” (i.e., popsicle, chocolate syrup, or a flavored drink after a dose) are also
helpful. Although medications can be delivered in small amounts (10–15 mL) of
liquid in a bottle (juice, milk, and formula), doses should not be diluted into an entire
scheduled feeding or prepared ahead of time in batches in anticipation of future
administration. Limiting the volume more likely facilitates delivery of the entire
dose, and adding the medication to a feeding bottle immediately before delivery
minimizes the potential of drug instability. Drug interactions with foods and dairy
products should also be considered before drugs are added to feeding formulas. Most
children are able to swallow tablets at 5 to 8 years of age. Duplicate supplies of
medication should be provided to the caregiver, when midday doses are required for
children who attend school or childcare in the event a dose is dropped. Children of
all ages should be encouraged and praised for their cooperation in taking their
medicine. Rewards and positive reinforcements can be useful to gain cooperation in
For M.B.’s amoxicillin, the parents should be given a dosing syringe and shown
how to measure 5 mL. If M.B. is uncooperative with medication administration, she
may need to be restrained and the medication delivered in 1- to 2-mL increments.
The parents should be ready to provide M.B. with something that tastes good
immediately after administering the medication.
Otic, ophthalmic, and nasal medications usually need to be administered to infants
and young children in a different manner than adults. Otic medications should be
instilled by pulling the auricle down and out in infants and young children, whereas
older children should have the auricle of the ear held up and back to straighten the
ear canal. During the instillation of nose and eye drops, position infants and toddlers
with their head lower than the rest of the body because gravity assists in dispersing
the medication. This can be achieved by laying the infant across a bed with the
shoulders projecting over the edge of the bed. Restraining the infant often is required
during the administration of ophthalmic formulations. When administering the eye
medication (Fig. 104-2), the caregiver must be cautious to avoid injury to the eye
caused by sudden movements of the infant. The technique of placing the hand, which
holds the eye medication on the forehead of the infant during administration, can help
to minimize eye injury because the hand holding the eye dropper will move when the
To minimize fear and improve cooperation during instillation of eye, nose, or ear
drops, the procedure should be explained to the child as simply as possible. It is best
to warm the medication in your hand for a few minutes before administration because
medications can feel cold inside the ears or nose even when stored at room
If ear drops were to be administered to M.B., she should be lying down with the
affected ear up. The auricle should be pulled down and out, and the ear drops placed
in the ear canal. She should remain in that position for at least 1 minute.
Diaper dermatitis is commonly encountered in pediatric practice, occurring in up to
35% of infants at any given time. Although the pathogenesis of diaper dermatitis is
not well defined, a number of factors (e.g., chemical irritants, friction, and bacteria)
have been associated with skin inflammation in the diaper area. In particular, skin
wetness and pH have been implicated in diaper dermatitis, and wetness appears to
have greater influence than that of pH. Overhydration of the skin increases the
permeability of low-molecular-weight compounds and exacerbates the effects of
6 Cloth diapers covered with plastic pants or disposable diapers with plastic
outer linings decrease air circulation and increase moisture in the diaper area and
7 Residual chemicals or laundry detergents in the diaper (cloth or
disposable), as well as soaps, medications, or lotions that have been applied directly
to the infant’s skin, also have roles in the development of diaper rash.
Four clinical presentations of dermatitis are associated with diaper wear:
A mild, scaling rash in the perianal area
A sharply demarcated confluent erythema
Ulceration distributed through the diaper area
A beefy red confluent erythema with satellite lesions, vesiculopustular lesions, and
diffuse involvement of the genitalia
K.G.’s rash is consistent with a candidal infection, which typically is beefy red
and associated with vesicular satellite lesions. The presence of a rash for longer than
3 days and the diffuse involvement of the genitalia and inguinal folds are also
characteristic of this form of diaper rash. K.G.’s rash can be treated with 1%
clotrimazole or 2% miconazole cream applied to the inflamed area four times daily
until it has resolved. Nystatin (100,000 units/g) ointment can be applied, but often is
not as effective as the imidazole antifungals because of increasing resistance of
CASE 104-2, QUESTION 2: What steps would you recommend for K.G.’s mother to treat her diaper rash
The removal of stool and urine from the diaper area by gentle rinsing with plain
water and more frequent diaper changes often help to alleviate diaper rashes. Wiping
the baby with diaper wipes that contain alcohol can sting, further irritating the
involved area, and should be avoided until the rash has resolved. A good protective
agent containing zinc oxide or petrolatum (e.g., Desitin) can be applied with each
diaper change to create a barrier to irritants and seal out moisture. Powdered
protective agents (e.g., cornstarch and talc) can minimize friction caused by diapers,
but should be used cautiously because the infant can aspirate powder particles and
8 When used, powders should be shaken into the
diaper or applied close to the body, away from the baby’s face. Other prevention and
treatment measures appropriate for K.G. include the following:
Change the diaper as soon as it is wet or at least every 2 to 4 hours during the day.
Keep the diaper area clean (e.g., nightly baths until resolved).
Use superabsorbent disposable diapers at night.
Expose the diaper area to air as often as possible.
Dry the diaper area completely before a new diaper is put on.
Apply a barrier cream such as zinc oxide or petrolatum after each diaper change.
For cotton diapers, use a bacteriostatic agent in the diaper pail and rinse water or
use a diaper service to ensure that diapers are sterile.
Apply a low-potency, nonfluorinated topical corticosteroid, such as 0.5% to 1%
hydrocortisone, twice daily for no longer than 2 weeks when severe inflammation
Normal body temperature varies throughout the day, peaking in late afternoon or
early evening. Body temperature can be measured rectally, orally, axillary (under the
arm), temporally (on the forehead), and tympanically. Rectal temperatures are most
reliable in infants younger than 3 months of age. Oral measurements of temperature
are not appropriate in children younger than 3 years of age because it is difficult for
young children to maintain a tight seal around the thermometer.
Although references differ, fever can be defined as an axillary temperature greater
than 37.5°C (99.5°F) or a core temperature
9 Rectal and tympanic measurements are typically
0.3°C to 0.6°C (0.5°F to 1°F) higher than an oral reading, whereas axillary
measurements are lower by the same amount. (Fahrenheit temperatures can be
converted to or from centigrade temperatures by the formula °F = 1.8°C + 32.)
Children with fevers might not have other signs or symptoms of an illness. Any
child younger than 2 months of age who develops a fever requires a complete
evaluation (e.g., blood culture and urinalysis), because clinical manifestations of a
serious infection often are subtle, nonspecific, and not predictive of the extent or
In this situation, antibiotic therapy is usually initiated while
awaiting laboratory results. Children 3 to 36 months of age with a temperature
greater than or equal to 39°C (102.2°F) and white blood cell counts less than 5,000
–1 are at increased risk for bacteremia.
any age with a temperature greater than 41°C should be evaluated not only for
bacteremia, but also for possible meningitis. Blood cultures, lumbar puncture,
urinalysis, and chest radiograph should be considered on an individual basis to help
determine the etiology of infection. Febrile immunocompromised children and febrile
children with functional or anatomic asplenia are at increased risk for sepsis or
fulminant infections (e.g., Streptococcus pneumoniae, Salmonella species, and
Escherichia coli) and should receive prompt antibiotic therapy.
seizures. Is this a valid concern?
Febrile seizures occur in approximately 2% to 4% of children 6 months to 5 years
of age who have temperature elevations greater than 38°C.
pathogenesis are unknown, and there is no evidence that the rate of temperature
13 Genetic predisposition also appears to be a factor because
febrile seizures occur with greater frequency among family members.
seizures are of two types: simple and complex. Simple febrile seizures last less than
15 minutes and do not have significant focal features. Complex febrile seizures have
a longer duration, occur in series, and are associated with focal changes. Typically,
febrile seizures occur within the first 24 hours of a febrile episode.
is in the age group at greatest risk for having a febrile seizure, he has been febrile for
more than 24 hours, and a seizure is unlikely during this illness.
CASE 104-3, QUESTION 2: How should R.B.’s fever be treated?
Acetaminophen is the most common antipyretic agent used in children. The usual
dose, oral or rectal, is 10 to 15 mg/kg/dose administered every 4 to 6 hours as
needed to a maximum of 75 mg/kg/day.
Ibuprofen is administered as 5 to 10
mg/kg/dose orally every 6 to 8 hours as needed to a maximum of 40 mg/kg/day.
Ibuprofen is as effective as acetaminophen as an antipyretic and is similar in safety.
Although renal failure has been reported after ibuprofen use in children, the risk of
renal impairment appears greater in children with dehydration, underlying
cardiovascular or renal disease, or other nephrotoxic drugs, and children <6 months
Acetaminophen 100 to 150 mg every 4 to 6 hours as needed or ibuprofen 50 to 100
mg every 6 to 8 hours as needed should be effective in lowering R.B.’s fever.
Acetaminophen typically has been considered to be a first-line drug in children.
Dosing errors have occurred, when teaspoonful quantities of acetaminophen infant
drops (80 mg/0.8 mL) were given instead of the liquid formulation (160 mg/5 mL) or
when regular-strength tablets (325 mg) have been substituted for chewable children’s
tablets (80 and 160 mg). To reduce the risk for dosing errors, in 2011, the Consumer
Healthcare Products Association (a group of leading manufacturers and distributors
of nonprescription medications) voluntarily converted to a single 160 mg/5 mL
acetaminophen concentration. In addition, in 2017 manufacturers began transitioning
to a single strength of children’s chewable acetaminophen tablets (160 mg).
However, providers should continue to question caregivers about the dosage form of
acetaminophen they have at home, concurrent use of any other products containing
acetaminophen, and whether cumulative doses are within the recommended range.
Recent data have suggested that ibuprofen may be a more effective alternative to
acetaminophen for R.B. and should be used first.
formulations (infant drops, 40 mg/mL; children’s suspension, 100 mg/5 mL) and a
chewable tablet (100 mg). Adverse effects are limited when ibuprofen is used in
recommended doses for short-term antipyresis. Some data suggest that combination
therapy with acetaminophen every 4 to 6 hours and ibuprofen every 6 to 8 hours may
be more effective in reducing time with fever in the first 24 hours.
combination therapy may be associated with medication errors,
suggest an increased risk of acute kidney injury may occur with this combination.
Aspirin therapy is not recommended for treatment of fever in children or adolescents
with chickenpox, gastroenteritis, or respiratory viral infections because of its link
Another common diagnosis in children is viral upper respiratory infection or the
common cold. Preschool children generally experience between six and eight colds
20 Children with a cold often present with sore throat, nasal congestion,
rhinorrhea, sneezing, cough, and irritability.
CLINICAL PRESENTATION AND TREATMENT
which cold medications would be appropriate to manage J.K.’s symptoms.
A cool-mist humidifier can increase the amount of moisture in room air and
decrease irritation in the upper airway when humidity is low. Saline nose drops
followed by bulb suctioning can help to clear the nasal passages in J.K. who is
younger than 6 months of age. It is especially important to do this before feedings. A
decongestant, however, should not be prescribed for J.K. because of her age and the
potential for adverse effects. If J.K. was older and a topical nasal decongestant was
needed, phenylephrine would be preferred over oxymetazoline and xylometazoline
because of its lesser association with toxicity (e.g., sedation, convulsions, insomnia,
and coma) in children younger than 6 years of age.
antitussives, nor guaifenesin should be recommended for J.K.
because there is no evidence of their efficacy, and unintentional overdoses are
common in this age group. Antihistamines are not effective for rhinorrhea caused by
the common cold and should not be recommended. Antitussives are likely not
effective and should not be used if the child’s cough is productive. Expectorants,
such as guaifenesin, are also not effective, and evidence is insufficient to support the
use of vitamin C, zinc, or echinacea in children for treatment or prevention of the
Several hundred over-the-counter medications for upper respiratory symptoms are
available, and over 1 billion units of these products are sold each year in the United
23 Nevertheless, the safety and effectiveness of these cough and cold
medications in children have yet to be proved.
24 The Centers for Disease Control and
Prevention (CDC) reported that 1,519 children younger than 2 years of age were
admitted to emergency departments in 2004 to 2005 because of overdoses and other
problems associated with cough and cold medicines. Furthermore, according to the
US Food and Drug Administration (FDA), 54 deaths in children were linked to the
use of decongestants (e.g., pseudoephedrine, phenylephrine, and ephedrine) and 69
deaths to antihistamines (e.g., diphenhydramine, brompheniramine, and
chlorpheniramine) from 1969 to September 13, 2006. Most of these deaths occurred
in children younger than 2 years of age, and some of the fatalities occurred in
children who received overdoses that might have been the result of inadvertent
administration of multiple medications containing the same ingredient.
25 Later that year, the Consumer Healthcare Products Association announced that
many manufacturers would voluntarily modify their labels to exclude
recommendations for children younger than 4 years of age.
toxicity and death related to over-the-counter cough and cold products, the CDC has
recommended that caregivers avoid giving these products to children younger than 2
years of age unless advised by a clinician.
If deemed necessary by a physician for
older children, nonprescription cough and cold medications containing single
ingredients should be selected to minimize the potential for adverse effects and
administration of multiple products with similar ingredients. Of note, parents often
misunderstand labeling of over-the-counter products, placing the child at risk for
It is critical that health care providers educate caregivers on the
proper use and administration of these medications to children. Treatment of J.K.’s
symptoms should include the use of a cool-mist humidifier in the room and saline
nasal drops followed by suctioning before feedings.
Chronic constipation is defined as delay or difficulty in stooling for at least 2 weeks’
It accounts for 3% of annual visits to pediatrician offices, and up to a
quarter of referrals to gastroenterologists.
30 Beyond the neonatal period, constipation
is most commonly idiopathic or functional and may be related to a diet low in fiber,
lack of time or routine for toileting, or passage of a painful stool resulting in a fear of
defecating. Other causes of constipation include anatomic (fissures), neurogenic
(Hirschsprung disease), hypotonic (cerebral palsy), and endocrine (cystic fibrosis
and hypothyroidism) disorders.
30 Medications such as opioids, antacids, and
anticonvulsants, among others, can also contribute to constipation. It is important that
constipation be managed appropriately because it can have negative effects on
growth and development, has been linked to gastrointestinal distress, and adversely
In addition, constipation in childhood can remain a problem
CLINICAL PRESENTATION AND TREATMENT
Before maintenance therapy can be initiated, disimpaction of the patient is
necessary. Although no controlled studies compare efficacy of the oral and rectal
routes, oral therapy (mineral oil, polyethylene glycol, and bisacodyl) is preferred
because it is less invasive and might lead to better adherence than rectal therapy
(phosphate soda enemas, mineral oil enemas, glycerin suppositories in infants, and
bisacodyl suppositories in older children).
30 After disimpaction, a combination of
behavioral, dietary, and pharmacologic therapies should be initiated to promote
regular stool production and prevent reimpaction. Dietary interventions include
adequate fluid and fiber intake. The impact of cow’s milk on constipation is still
controversial. Some data suggest no link,
30 although other recent literature hints at
causation through an immune-mediated mechanism.
polyethylene glycol 3350, mineral oil, lactulose, and sorbitol should be titrated to
produce one to two soft stools daily. Stimulant laxatives might be needed
intermittently in certain cases. Although no clear recommendation for one
maintenance medication has been given over others, recent data suggest that
polyethylene glycol may be the most effective and best tolerated in children.
recommended dosing of medications for treatment of constipation is listed in Table
104-1. Appropriate initial therapy for R.J. could include eliminating or limiting milk
intake, behavioral techniques, and polyethylene glycol 0.5 to 1.5 g/kg/day (7.5–15 g).
Practically, this would be half to one 17-g packet administered daily in 4 to 8 ounces
Vomiting and diarrhea, two commonly encountered complaints in pediatric practice,
are usually self-limiting, but severe cases can result in serious complications such as
dehydration, metabolic disturbances, and even death. Infants and young children are
particularly susceptible to the more severe complications.
PATHOGENESIS AND PRESENTATION OF VOMITING
Vomiting or emesis is defined as forceful expulsion of gastrointestinal (GI) contents
through the mouth or nose, while nonforceful expulsion of GI contents is considered
regurgitation. In newborns, regurgitation of small amounts of breast milk or formula
after feeding, especially when burping, is common. In most cases, regurgitation
usually resolves by 1 to 2 years of age and rarely causes problems.
evaluation of regurgitation is not needed in a child who is growing well. Other
causes of vomiting during the newborn period include pyloric stenosis,
gastroesophageal reflux (GER), overfeeding, food intolerance, and GI obstruction.
Beyond the neonatal period, the most common cause of vomiting is infection.
Vomiting in infants and children can also be caused by central nervous system (CNS)
disease (e.g., intracranial tumors), metabolic disease (e.g., urea cycle disorder),
inflammatory bowel disease, and ulcers. Conditions causing emesis in older infants
and children range from viral gastroenteritis to more severe illnesses, such as bowel
obstruction or head injury, which require immediate medical attention.
vomiting can also result from medication or toxic ingestions. In teenagers, migraine,
pregnancy, and psychological disorders, such as bulimia, have been associated with
Medications for the Treatment of Constipation
Medication Initial Dosage Comments
Polyethylene glycol 3350 0.2–0.8 g/kg/day 0.5 g/kg initial dose; titrate to effect; do not
Lactulose 1–2 g/kg/day divided once or twice
1.5–3 mL/kg/day; do not exceed 60 mL/day
Sorbitol 1–3 mL/kg/day once or twice daily Less expensive than lactulose
Barley malt extract 2–10 mL/240 mL of milk or juice daily Useful for infants drinking from a bottle
Magnesium hydroxide 1–3 mL/kg/day using 400 mg/5 mL Infants are at risk for hypermagnesemia
Phosphate enema ≥2 years of age: 6 mL/kg up to 135
Electrolyte abnormalities more common in
children with renal failure or Hirschprung
disease. Avoid in children <2 years
Mineral oil >1 year of age: Disimpaction: 15–30
mL/year of age up to 240 mL daily
Better tolerated if chilled. Avoid in children
<1 year. Lipoid pneumonia may occur if
Maintenance: 1–3 mL/kg/day Maximum daily dose: 90 mL/day
Senna 2–6 years of age: 2.5–5 mg/day Not recommended for chronic use
6–12 years of age: 7.5–10 mg/day
Bisacodyl 3–10 years: 5 mg/day Not recommended for chronic use
Glycerin suppositories 2–5 years: 1 pediatric suppository per
Preferred stimulant for children <2 years of
≥6 years: 1 adult suppository per dose
PATHOGENESIS AND PRESENTATION OF DIARRHEA
Diarrhea refers to an increase in frequency, volume, or liquidity of stool when
compared with normal bowel movements. In developing countries, diarrhea is a
common cause of death in children younger than 5 years of age. In the United States,
gastroenteritis accounts for approximately 1 to 2 million physician visits, more than
200,000 hospitalizations, and about 300 deaths each year.
Acute diarrhea in infants and children is generally abrupt in onset, lasts a few
days, and is most commonly caused by viruses. (see Chapter 69, Infectious Diarrhea
for infectious diarrhea of other origins.) Diarrhea is considered chronic if it is longer
than 2 weeks in duration. Chronic diarrhea can be caused by malabsorption,
inflammatory disease, infection, alteration of intestinal flora, milk or protein
intolerance, drugs, and other causes.
Infants and children are at high risk for morbidity and mortality secondary to
diarrhea for several reasons. Dehydration can occur easily because acute net
intestinal fluid losses are relatively much greater in young children than in adults.
This may result from inefficient transport systems in the developing intestine. In
addition, the percentage of total body water in children is higher than in adults; thus,
they are more susceptible to body fluid shifts. Total body water changes from 80% of
total body weight in premature infants to 70% in term infants and 60% in adults.
Finally, the renal capacity to compensate for fluid and electrolyte imbalances in the
infant is limited compared with that of adults.
experiencing vomiting, diarrhea, and low-grade temperatures. How should J.R.’s vomiting be treated?
Routine use of antiemetics for acute vomiting in children is not recommended
because masking of symptoms may delay diagnosis of a treatable illness. In addition,
the safety and efficacy of the antiemetics, including metoclopramide, promethazine,
trimethobenzamide, and dimenhydrinate, have not been demonstrated.
promethazine is contraindicated in children younger than 2 years of age because of
the risk of fatal respiratory depression. Ondansetron does decrease vomiting,
increases oral intake and decreases the need for intravenous (IV) rehydration;
however, the utility of ondansetron in gastroenteritis needs consideration because this
effect may not be sustained, and the drug has not been shown to decrease consistently
Parents should be taught the signs and symptoms of gastroenteritis and vomiting
that are sufficiently serious to warrant medical attention. The child’s primary-care
provider should be contacted if the child is toxic appearing, exhibits unusual
behavior, exhibits signs of an ear infection, experiences abdominal pain or
distension, has red or black vomitus or stool, or if there is a history or suspicion of
toxic ingestion or head trauma. Medical evaluation is also necessary for infants
younger than 6 months of age, when persistent vomiting or high-volume diarrhea is
chronic medical conditions or prematurity is involved. Because fever can
accompany vomiting in viral gastroenteritis, any fever occurring in a neonate
warrants medical attention. Fever in older infants and children warrants medical
attention, when it becomes prolonged or changes in pattern.
When communicating with a health care provider about a vomiting child, it is
helpful if the parents have knowledge of the child’s fluid intake, and the frequency
and volume of vomiting and urination. The amount of vomitus can be estimated by the
Vomiting associated with gastroenteritis usually resolves in 24 to 48 hours. Infants
are particularly susceptible to the development of fluid and electrolyte abnormalities;
therefore, fluid and electrolyte replacements are critically important.
J.R., who is early in the course of gastroenteritis, must receive sufficient fluids to
prevent dehydration. Oral hydration therapy can be successful when given in small
volumes, even if J.R. is still vomiting. For example, 5 to 10 mL can be administered
every 5 to 10 minutes, with gradual increases in volume as tolerated. Volumes equal
to estimated fluid deficit (usually 50–100 mL/kg) should be given over the course of
2 to 4 hours. For each diarrheal stool, an additional 10 mL/kg of oral electrolyte
solution should be given. If diarrhea or vomiting recurs, 10 mL/kg and 2 mL/kg of an
oral rehydration solution (ORS) can be administered for each stool or emesis,
46 J.R.’s clinical condition should continue to be monitored by his
caregiver. If stool output exceeds 10 mL/kg/hour, ORS might not be sufficient, and
the health care provider should be contacted. ORS should only be abandoned in
children with intractable vomiting, loss of consciousness, bowel obstruction, or if the
child is in shock. Most infants will tolerate oral hydration when small amounts are
given frequently. As dehydration is corrected, the frequency of vomiting typically
decreases. Once rehydration has been achieved, fluids other than ORS and a diet
appropriate for age may be started.
46 Breast milk or formula should be given as
increased in frequency and water content. How can the severity of J.R.’s diarrhea be assessed?
To determine the severity of dehydration and whether hospitalization may be
needed, consider the following questions:
Does the child have any of the following signs and symptoms of severe
dehydration: deeply sunken eyes, parched mucous membranes, significantly
prolonged capillary refill; cool, mottled extremities; crying without tears; oliguria
or anuria; weak or thready pulses; lethargy; poor oral intake; deep respirations;
history of seizures or convulsions; a fever without perspiration; or thirst?
Are a large number of copious stools still being produced (>10 mL/kg/hour)? Is
bowel obstruction a possibility?
Is there a risk of dehydration from inadequate monitoring, or is the parent unable to
care for the child? Specific inquiries should be made about the number and
consistency of stools in children with diarrhea.
Estimating the degree of dehydration is particularly valuable in assessing the
patient with diarrhea, and weight loss is a good criterion. A 3% to 9% weight loss is
considered mild to moderate dehydration, whereas more than 9% is considered
(see Chapter 103, Pediatric Fluid, Electrolytes, and Nutrition,
for information about IV replacement therapy in children with 10% or more
The goal of J.R.’s treatment should be focused on the prevention of dehydration
and the restoration and maintenance of adequate fluid and electrolyte balance. Mild
to moderate diarrhea without dehydration is generally managed at home by continued
solutions at home; however, frequent errors in the preparation of these solutions
resulted in exacerbation of problems with fluid and electrolyte balance.
Commercially available oral glucose–electrolyte formulations, such as Pedialyte, are
designed to enhance glucose and sodium absorption and should be used in infants and
young children. Carbonated beverages and fruit juices do not contain sufficient
sodium to replace diarrheal losses and should not be used. Rehydration and
maintenance solutions can be made more palatable with sugar-free flavorings (e.g.,
The World Health Organization (WHO) formerly promoted use of an oral
replacement solution (WHO formula) containing sodium (90 mEq/L), potassium (20
mEq/L), bicarbonate (30 mEq/L), chloride (80 mEq/L), and 2% glucose for the
widespread management of acute diarrhea in third-world countries. The WHO
formula, which had a 90% successful rehydration rate for the management of
diarrhea, contained a high concentration of sodium. Although commercially available
ORS contain less sodium than the WHO formulation, these preparations were equally
effective as the WHO formula, even when used to treat the high-sodium losses
associated with cholera. Furthermore, these lower sodium-containing formulations
were associated with less vomiting, lower stool output, and reduced need for IV
infusions in non–cholera-associated gastroenteritis. As a result, the WHO, in 2002,
promoted a new formulation that consists of 75 mEq/L sodium and a total osmolarity
43,45 Glucose is added to oral electrolyte solutions to enhance
glucose-coupled sodium transport; however, concentrations greater than 3% can
impair sodium absorption because the glucose-coupled sodium transport system
becomes saturated at this concentration and any additional glucose acts as an
osmotically active solute in the bowel lumen. The electrolyte content of commonly
used ORS is provided in Table 104-2. Assuming J.R.’s fluid deficit is 50 to 100
mL/kg, he should receive 500 to 1,000 mL of ORS in the course of approximately 4
hours. In addition, he should receive an extra 100 mL for each diarrheal stool and 20
mL for each emesis that occurs. If stool output continues at a pace that cannot be
matched with oral replacement, or signs and symptoms of severe dehydration occur,
J.R. should be referred to his pediatrician again.
REINSTITUTION OF ORAL FEEDINGS
Previously, feeding during an episode of viral gastroenteritis has been delayed
because of the malabsorption that typically occurs during and after these bouts. The
malabsorption, however, is self-limiting, and substantial amounts of carbohydrate,
protein, and fat can still be absorbed. The reinstitution of a regular diet, therefore,
should not adversely affect mild diarrhea and can be beneficial.
encouraged to continue feeding their children using age-appropriate diet while
avoiding simple sugars, which can increase osmotic load and worsen diarrhea.
Continuation of oral feeding, despite diarrheal episodes, minimizes the development
of protein and energy deficits, facilitates the maintenance and repair of intestinal
mucosa, promotes recovery of brush border membrane disaccharidases, decreases
the duration of illness, and improves nutritional status.
intolerance can occur with viral gastroenteritis, most children with mild diarrhea can
tolerate full-strength animal milk, animal milk-based formula, and breast milk. If the
child becomes lactose intolerant during this illness, a lactose-free formula may be
substituted for 2 to 6 weeks until GI lactase production returns to normal. Specific
diets are often recommended during diarrhea (e.g., BRAT [bananas, rice, applesauce,
toast]). Although these diets can be occasionally useful, the nutritional value of these
foods is relatively low, and they do not provide optimal nutrition compared with
complete diets with fats and proteins.
45,46 Once J.R. has been adequately rehydrated,
he may resume his normal diet. However, the caregivers must take care to avoid
juices and other foods with simple sugars, which may worsen diarrhea.
WHO formula (1975) 90 20 111 311
WHO formula (2002) 75 20 75 245
WHO, World Health Organization.
Medications play a minor role in the treatment of acute infantile diarrhea because
most episodes are self-limiting. Antibiotics are recommended when systemic
bacteremia is suspected, when immune defenses are compromised, when a persistent
enteric infection is sensitive to antibiotics, or when Shigella, Campylobacter, Vibrio
cholerae, Clostridium difficile, and certain Escherichia coli strains are isolated.
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