Red Flags
- Severe dehydration (lethargy, sunken eyes, very slow skin pinch, unable to drink) — emergency IV fluid resuscitation with Ringer's lactate; admission[1]
- Persistent vomiting, severe abdominal pain, bilious vomiting, blood in stool, or convulsions — investigate other cause; admit[1]
- Suspected cholera (rice-water stool, rapid dehydration, outbreak setting) — IV fluid + antibiotic; notify public health; isolate where possible[1]
- Persistent diarrhoea ≥14 days, weight loss, or failure to thrive — investigate for chronic infection, malabsorption, intolerance, immunodeficiency[1]
First-line treatment
Interventions
- Plan A — no dehydration (home)[1]Continue breastfeeding and age-appropriate feeding (do not stop or dilute milk); extra ORS after each loose stool (50–100 mL <2 years, 100–200 mL ≥2 years); zinc 14 days
- Plan B — some dehydration (clinic)[1]Low-osmolarity ORS 75 mL/kg over 4 hours; reassess at 4 h. If improved, continue at home with Plan A. If unchanged, repeat. If worse, escalate to Plan C
- Plan C — severe dehydration (admission)[1]Ringer's lactate IV: <12 months 30 mL/kg over 1 h then 70 mL/kg over 5 h. ≥12 months 30 mL/kg over 30 min then 70 mL/kg over 2.5 h. Reassess after each bolus
- Continue feeding throughout illness[1]Breastfeeding continues uninterrupted. Older infants and children should resume normal diet as soon as tolerated; lactose-free formula not routinely needed except in protracted post-enteritis intolerance
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Low-osmolarity ORS[1] | Oral rehydration salt | Not applicable — paediatric guideline | Plan A: 50–100 mL <2 years, 100–200 mL ≥2 years after each stool. Plan B: 75 mL/kg over 4 h | Sodium 75 mEq/L, glucose 75 mmol/L, osmolarity 245 mOsm/L; continue with feeds, do not dilute or boil; replaces electrolytes and prevents dehydration |
| Zinc supplementation[1] | Trace element | Not applicable — paediatric guideline | ≥6 months: 20 mg PO daily × 14 days. <6 months: 10 mg PO daily × 14 days | Reduces severity, duration, and recurrence of diarrhoea; given as dispersible tablet; continue full 14 days even after diarrhoea stops |
| Ringer's lactate (IV)[1] | Balanced isotonic crystalloid | Not applicable — paediatric guideline | Severe dehydration weight-based per IMNCI Plan C | Preferred over normal saline for severe dehydration; avoid over-hydration in malnourished children (different ORS scheme — ReSoMal — and slower rehydration) |
| Ciprofloxacin or azithromycin (selective)[1] | Fluoroquinolone or macrolide | Not applicable — paediatric guideline | Ciprofloxacin 15 mg/kg BD × 3 days for shigellosis; azithromycin 10 mg/kg single dose for cholera | Only for visible blood in stool (probable shigellosis), suspected cholera, or culture-proven bacterial enteritis; avoid for non-specific diarrhoea (AMR) |
| Metronidazole (for amoebiasis or giardiasis)[1] | Nitroimidazole | Not applicable — paediatric guideline | Amoebiasis: 35–50 mg/kg/day in 3 divided doses × 5–10 days. Giardiasis: 15 mg/kg/day × 5 days | Prolonged or persistent diarrhoea with confirmed amoebic or Giardia parasites on stool; not for routine use |
| DO NOT use anti-motility agents (loperamide) in children[1] | Anti-motility agent — contraindicated | Not applicable | Contraindicated in children with diarrhoea | Risks paralytic ileus, sepsis, and delayed pathogen clearance; avoid antiemetics other than ondansetron in selected ED settings |
Low-osmolarity ORS[1]
Oral rehydration salt
- Adult
- Not applicable — paediatric guideline
- Paediatric
- Plan A: 50–100 mL <2 years, 100–200 mL ≥2 years after each stool. Plan B: 75 mL/kg over 4 h
Sodium 75 mEq/L, glucose 75 mmol/L, osmolarity 245 mOsm/L; continue with feeds, do not dilute or boil; replaces electrolytes and prevents dehydration
Zinc supplementation[1]
Trace element
- Adult
- Not applicable — paediatric guideline
- Paediatric
- ≥6 months: 20 mg PO daily × 14 days. <6 months: 10 mg PO daily × 14 days
Reduces severity, duration, and recurrence of diarrhoea; given as dispersible tablet; continue full 14 days even after diarrhoea stops
Ringer's lactate (IV)[1]
Balanced isotonic crystalloid
- Adult
- Not applicable — paediatric guideline
- Paediatric
- Severe dehydration weight-based per IMNCI Plan C
Preferred over normal saline for severe dehydration; avoid over-hydration in malnourished children (different ORS scheme — ReSoMal — and slower rehydration)
Ciprofloxacin or azithromycin (selective)[1]
Fluoroquinolone or macrolide
- Adult
- Not applicable — paediatric guideline
- Paediatric
- Ciprofloxacin 15 mg/kg BD × 3 days for shigellosis; azithromycin 10 mg/kg single dose for cholera
Only for visible blood in stool (probable shigellosis), suspected cholera, or culture-proven bacterial enteritis; avoid for non-specific diarrhoea (AMR)
Metronidazole (for amoebiasis or giardiasis)[1]
Nitroimidazole
- Adult
- Not applicable — paediatric guideline
- Paediatric
- Amoebiasis: 35–50 mg/kg/day in 3 divided doses × 5–10 days. Giardiasis: 15 mg/kg/day × 5 days
Prolonged or persistent diarrhoea with confirmed amoebic or Giardia parasites on stool; not for routine use
DO NOT use anti-motility agents (loperamide) in children[1]
Anti-motility agent — contraindicated
- Adult
- Not applicable
- Paediatric
- Contraindicated in children with diarrhoea
Risks paralytic ileus, sepsis, and delayed pathogen clearance; avoid antiemetics other than ondansetron in selected ED settings
Safety-net
- Continue breastfeeding and feeding through the illness — withholding food prolongs diarrhoea and worsens nutrition[1]
- Return same-day if child cannot drink, vomits everything, becomes lethargic, develops blood in stool, persistent fever, or fewer wet nappies than usual[1]
- Hand hygiene, safe drinking water, exclusive breastfeeding for 6 months, and rotavirus + measles vaccination prevent most childhood diarrhoea[1]
Referral criteria
- Severe dehydration, persistent vomiting, suspected sepsis, severe acute malnutrition with diarrhoeaPaediatric admission[1]
- Persistent diarrhoea ≥14 days or chronic diarrhoea with weight lossPaediatric review for malabsorption, immunodeficiency, post-enteritis enteropathy[1]
- Visible blood in stool with high fever or systemic illnessPaediatric admission for IV antibiotic and supportive care[1]
- Cluster of cases (suspected outbreak — cholera, rotavirus)Public health notification; contact tracing and water/sanitation review[1]
Clinical summary
Triage of dehydration, low-osmolarity ORS, zinc, and selective antibiotic use in acute diarrhoeal disease in children under 5.