para>Scoring: 0: no dehydration, 3%, 1 " 4: some dehydration: 3 " 6%, 5 " 8: moderate dehydration: >6%.
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- Most with diarrhea-induced mild dehydration do not need lab tests (2).
- For some with moderate dehydration and all with severe dehydration, obtain Na+ (hypernatremia), potassium (hyperkalemia), bicarbonate (decreased), chloride, glucose (increased), BUN (increased), and creatinine (increased) (2)[C].
TREATMENT
GENERAL MEASURES
- The composition of oral rehydration solution (ORS) according to the WHO and UNICEF recommendations from 2002 include the following:
- Total osmolality: 245 mmol/L
- Equimolar concentrations of glucose and Na
- Glucose: 1.35%
- Na+ concentration: 75 mEq/L
- Potassium concentration: 20 mEq/L
- Citrate concentration: 10 mmol/L
- Chloride concentration: 65 mEq/L (1)[A]
- See Table 2 for composition of common solutions (1).
- ORS is not to be diluted.
- Begin feeding as soon as rehydration is achieved. After rehydration is complete, ORT should not continue as the only fluid intake because the high Na content may lead to hypernatremia (4)[C].
- Effective at all ages
- If child refuses because of taste, flavor with a commercial flavoring such as sugar-free grape-flavored drink mix and use ~1/4 tsp to 4 oz ORS, although it does not lead to increased intake (5)[B].
Table 2Comparison of Effective Oral Dehydration ProductsView LargeTable 2Comparison of Effective Oral Dehydration ProductsSolutionOsmolality mOsm/kg H2O)Na+ (mEq/L)K+ (mEq/L)HCO3 (mEq/L)Carbohydrate (g/L)WHO24575201013.5Pedialyte25045202525Enfalyte20050253430Rehydralyte31075203025
MEDICATION
First Line
- ORT can be used for both rehydration and maintenance hydration.
- The overall approach is to perform initial rehydration over 3 to 4 hours, followed by maintenance hydration.
- Initial rehydration requirements (5)[C]
- Mild dehydration (3 " 5% weight loss): 50 mL/kg
- Moderate dehydration: (6 " 9%): 100 mL/kg
- Severe: (>10% estimated): IV hydration, then 100 mL/kg ORS once tolerating
- In the rehydration phase, ORT should be given as frequent, small amounts by spoon or syringe (4)[C].
- 5 mL every 1 to 2 minutes is often well tolerated and supplies 150 to 300 mL/hr.
- During the maintenance hydration stage, the fluid goals are as follows (4)[C]:
- First 0- to 10-kg body weight: 4 mL/kg/hr
- Next 10- to 20-kg: additional 2 mL/kg/hr
- Additional body weight >20 kg: additional 1 mL/kg/hr
- In addition to the standard volumes of hydration provided, in both rehydration and maintenance phases, ongoing losses should be additionally replaced with 10 mL/kg body weight of ORT for each watery/loose stool or each episode of emesis (4)[C].
- Example: An 18-kg child who has moderate dehydration would require the following:
- Rehydration phase: 100 mL/kg = 1,800 mL over 3 to 4 hours = 450 to 600 mL/hr = ~15 to 20 mL every 2 minutes
- Maintenance phase: 56 mL/hr [(10 kg 4 mL/hr) + (8 kg 2 mL/hr)] = ~15 mL every 15 minutes
- The child should receive additional ORT for any ongoing losses.
- Contraindications
- Conditions predisposing to risk of aspiration
- Significantly depressed level of consciousness, seizure activity
- Severe dehydration, for which IV fluids should be started
- Underlying disorders of intestinal absorption
- Precautions
- The ingredients should be provided in premixed packets to avoid iatrogenic errors in mixing. In the United States, Pedialyte premixed powder packets are to be diluted in 8 oz (240 mL) of water. Many comparable generic formulations are available.
- If water contamination is a concern, it should be boiled/treated for purification.
- Discard the solution after 12 hours if held at room temperature or 24 hours if refrigerated.
- Risks
- Symptomatic hyponatremia: rare, <1%
- Hyperglycemia in diabetics
- Fluid overload if overcorrect in at-risk patients
- Failure (requiring IVF): 4% (5)[B]
Second Line
- For inability to drink adequate amounts of ORS
- Nasogastric (NG) administration of ORS has similar efficacy as IVF for moderate dehydration. Failure rates (requiring IVF) is around 2% (6)[A].
- IV fluids if ORS and NG have failed (6)[A]
- WHO recommends supplementation zinc for 10 to 14 days in developing countries, which shortens the course of diarrhea and lessens costs; 20 mg PO daily for >6 months old, 10 mg for <6 months (5)[A]
- For children with vomiting, ondansetron (0.1 to 0.15 mg/kg) decreases vomiting, allows easier administration of ORT, and decreases the need for IV fluids. Ondansetron ODT can be particularly effective based on its ease of administration and tolerance in the vomiting child (2)[A].
- Probiotics have been shown to shorten diarrhea by about 1 day, decreasing amount of ORS needed (4)[A].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Caregivers who are unable to adequately administer ORS at home may encounter intractable vomiting, poor ORS intake by mouth or NG in ER, profuse diarrhea, unusual irritability or drowsiness, or failure to improve with 24 hours of ORS at home (4).
IV Fluids
To be used for initial resuscitation in severe cases or for ORS failure
Nursing
If vomiting occurs, small amounts of ORS given frequently are usually effective.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Primarily outpatient
- Designed to be administered by family members
DIET
- For breastfeeding infants, the mother should continue nursing.
- For bottle-fed babies, there should be an early institution of formulas. Lactose-free formulas rarely are required.
- Age appropriate
- Complex carbohydrate-rich (e.g., rice, bread, potato, cereal), low-fat foods should be offered as soon as the dehydration deficit is replaced.
- Cow 's milk can be added to diet after several days.
PATIENT EDUCATION
- Awareness and availability of ORT markedly diminishes morbidity from gastroenteritis.
- Early use of ORT at home for children with diarrhea reduces outpatient visits, hospitalizations, and costs.
- Travelers concerned with severe diarrhea should carry ORT packets on trips.
PROGNOSIS
- Rapid clinical improvement despite continuing diarrhea is the usual course.
- The overall complication rate for oral rehydration is similar to that for parenteral rehydration in cases of mild and moderate dehydration.
COMPLICATIONS
Change to IV hydration if the patient has increasing weight loss (fluid deficit), clinical deterioration, or intractable vomiting.
REFERENCES
11 Suh JS, Hahn WH, Cho BS. Recent advances of oral rehydration therapy (ORT). Electrolyte Blood Press. 2010;8(2):82 " 86.22 Niescierenko M, Bachur R. Advances in pediatric dehydration therapy. Curr Opin Pediatr. 2013;25(3):304 " 309.33 Jauregui J, Nelson D, Choo E, et al. External validation and comparison of three pediatric clinical dehydration scales. PLoS One. 2014;9(5):e95739.44 Churgay CA, Aftab Z. Gastroenteritis in children: part II. Prevention and management. Am Fam Physician. 2012;85(11):1066 " 1070.55 Atia AN, Buchman AL. Oral rehydration solutions in non-cholera diarrhea: a review. Am J Gastroenterol. 2009;104(10):2596 " 2604.66 Rouhani S, Meloney L, Ahn R, et al. Alternative rehydration methods: a systematic review and lessons for resource-limited care. Pediatrics. 2011;127(3):e748 " e457.
ADDITIONAL READING
- Alhashimi D, Al-Hashimi H, Fedorowicz Z. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2009;(2):CD005506.
- American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice parameter: the management of acute gastroenteritis in young children. Pediatrics. 1996;97(3):424 " 435.
- Bryce J, Boschi-Pinto C, Shibuya K, et al. WHO estimates of the causes of death in children. Lancet. 2005;365(9465):1147 " 1152.
- Canani RB, Cirillo P, Terrin G, et al. Probiotics for treatment of acute diarrhoea in children: randomised clinical trial of five different preparations. BMJ. 2007;335(7615):340.
- Duggan C, Fontaine O, Pierce NF, et al. Scientific rationale for a change in the composition of oral rehydration solution. JAMA. 2004;291(21):2628 " 2631.
- Fonseca BK, Holdgate A, Craig JC. Enteral vs intravenous rehydration therapy for children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med. 2004;158(5):483 " 490.
- Hahn S, Kim S, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. Cochrane Database Syst Rev. 2002;(1):CD002847.
- Hartling L, Bellemare S, Wiebe N, et al. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database Syst Rev. 2006;(3):CD004390.
- Lazzerini M, Ronfani L. Oral zinc for treating diarrhoea in children. Cochrane Database Syst Rev. 2008;(3):CD005436.
- Murphy C, Hahn S, Volmink J. Reduced osmolarity oral rehydration solution for treating cholera. Cochrane Database Syst Rev. 2004;(4):CD003754.
- Santosham M, Keenan EM, Tulloch J, et al. Oral rehydration therapy for diarrhea: an example of reverse transfer of technology. Pediatrics. 1997;100(5):E10.
- Spandorfer PR, Alessandrini EA, Joffe MD, et al. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics. 2005;115(2):295 " 301.
- Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA. 2004;291(22):2746 " 2754.
- Victora CG, Bryce J, Fontaine O, et al. Reducing deaths from diarrhoea through oral rehydration therapy. Bull World Health Organ. 2000;78(10):1246 " 1255.
- World Health Organization. Reduced osmolarity oral rehydration salts (ORS) formulation. New York, NY: UNICEF House; 2001. http://apps.who.int/iris/bitstream/10665/67322/1/WHO_FCH_CAH_01.22.pdf
CODES
ICD10
- E86.0 Dehydration
- A09 Infectious gastroenteritis and colitis, unspecified
- K52.9 Noninfective gastroenteritis and colitis, unspecified
ICD9
- 276.51 Dehydration
- 009.0 Infectious colitis, enteritis, and gastroenteritis
- 558.9 Other and unspecified noninfectious gastroenteritis and colitis
SNOMED
- dehydration (disorder)
- Infectious gastroenteritis (disorder)
- Oral rehydration therapy
- Noninfectious gastroenteritis (disorder)
CLINICAL PEARLS
- ORT is as effective as less costly than IV hydration for mild and moderate dehydration, yet it is underused in the developed world.
- ORT should not be diluted.
- The addition of ondansetron can augment the effectiveness of ORT.