Oral Rehydration Therapy Protocol in Pediatric Dehydration

Aka: Oral Rehydration Therapy Protocol in Pediatric Dehydration, Dehydration Management in Children with Oral Replacement, Pediatric Diarrhea Fluid Replacement, Mild to Moderate Pediatric Dehydration Management

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II. Indications

  1. Mild to moderate Pediatric Dehydration
  2. Mild to moderate Pediatric Diarrhea

III. Precautions

  1. Use Oral Rehydration Solution (ORS, e.g. Pedialyte or Enfalyte) as this most closely mirrors Diarrhea related losses
    1. Sodium: 50 mEq/L (WHO ORS contains 75 mEq/L, older formulations were 90 mEq/L)
    2. Dextrose: 25 g/L (WHO ORS contains 13.5 g/L or 75 mmol/L)
    3. Potassium: 20-25 mEq/L
    4. Bicarbonate: 30 mEq/L
    5. Osmolality: 20-250 mmol/L
  2. In mild cases, half strength apple juice has been used safely and effectively
    1. Was followed by preferred fluids and resulted in better oral intake than with ORS
    2. However half strength apple juice has far different components than Oral Rehydration Solution
      1. Sodium 1 meq/L
      2. Dextrose: 60 g/L
      3. Potassium: 16 mEq/L
      4. Bicarbonate: 0 mEq/L
      5. Osmolality: 365 mmol/L
    3. Freedman (2016) JAMA 315(18): 1966-74 [PubMed]
  3. Avoid other solutions that do not adequately replace Sodium, bicarbonate, Potassium and Glucose
    1. Avoid hypoosmolar fluids (water, sodas, juices) due to Hyponatremia risk
    2. Avoid adult ORS solutions and Sports Drinks due to risk of Hypernatremia risk

IV. Protocol

  1. Uses Oral Rehydration Solution (e.g. Pedialyte, WHO-ORS)
    1. Only one in 25 treated with ORS will require IV fluids
    2. Hartling (2006) Cochrane Database Syst Rev (3):CD004390 [PubMed]
  2. Consider Ondansetron (Zofran) to aid starting Oral Rehydration Therapy (see below)
    1. Give 15-30 minutes prior to initiation of oral rehydration
  3. Delivery of fluids
    1. Use a syringe (infants)
    2. Spoon or cup (children)
    3. Nasogastric Tube (if unable to take orally)
      1. Safe, effective, and less expensive than Intravenous Fluids
      2. Nager (2002) Pediatrics 109(4): 566-72 [PubMed]
  4. Conversions
    1. One teaspoon: 5 ml
    2. One ounce: 30 ml (2 tbs)

V. Management: Oral Protocol

  1. See Pediatric Dehydration
  2. Mild Dehydration (standard replacement)
    1. Total ORS: 50 ml/kg over 4 hours by syringe, spoon or cup
    2. Give 1 ml/kg of ORS by syringe every 5 minutes for 4 hours or
    3. Give 3 ml/kg of ORS every 15 minutes for 4 hours
  3. Moderate Dehydration (accelerated replacement)
    1. Total ORS: 100 ml/kg over 4 hours or WHO age and weight specific recommendations
      1. Weight <5 kg (age <4 months): 200 to 400 ml in 4 hours (50-100 ml/h or 2-3 oz/h)
      2. Weight 5-8 kg (age 5-12 months): 400 to 600 ml in 4 hours (100-150 ml/h or 3-5 oz/h)
      3. Weight 8-11 kg (age 12-24 months): 600 to 800 ml in 4 hours (150-200 ml/h or 5-7 oz/h)
      4. Weight 11 to 16 kg (age 2 to 5 years): 800 to 1200 ml in 4 hours (200-300 ml/h or 7-10 oz/h)
      5. Weight 16 to 30 kg (age 5 to 15 years): 1200 to 2200 ml in 4 hours (300-550 ml/h or 10-18 oz/h)
      6. Weight >30 kg (age >15 years): 2200 to 4000 ml in 4 hours (550-1000 ml/h or 18-33 oz/h)
    2. Infant Example: 200 to 400 ml in 4 hours
      1. Give >50 ml (~2 oz) per hour of ORS
      2. Give 5-10 ml (1-2 tsp) every 5 minutes
    3. Toddler Example (age 2): 600 to 800 ml in 4 hours
      1. Give >150 ml (5 oz) per hour of ORS
      2. Give 15-30 ml (0.5-1 oz or 1-2 tbs) every 5-10 minutes
    4. Preschool Child Example (age 4): 800 to 1200 ml in 4 hours
      1. Give >200 ml (~7 oz) per hour of ORS
      2. Give 30-45 ml (1-1.5 oz or 2-3 tbs) every 5-10 minutes
  4. Severe Dehydration failing oral rehydration with reassessment every 1-2 hours (WHO protocol)
    1. Caution, this WHO Protocol is very high volume (adjust per clinical situation, illness severity)
    2. Age <12 months: LR 30 ml/kg IV over 1 hour, then 70 ml/kg IV over 5 hours
    3. Age >12 months: LR 30 ml/kg IV over 30 min, then 70 ml/kg IV over 2.5 hours
  5. Ongoing losses (added replacement per stool or Emesis)
    1. Method 1: Give an additional 10 ml/kg per stool or 2 ml/kg per Emesis or
    2. Method 2: Give an additional one-half to one cup ORS per stool (older children)
    3. Method 3: Replace for each episode of Diarrhea or Vomiting
      1. Age <2 years or weight <22 pounds: Give 60-120 ml (2-4 oz)
      2. Age 2-10 years or weight >22 pounds: Give 120-240 ml (4-8 oz)
      3. Age >10 years may drink as much as they wish up to 20 ml/kg/hour total
      4. (2017) Presc Lett 24(1): 5
  6. Vomiting
    1. Pause feeding for 30-60 minutes if Vomiting occurs
    2. Give 5-10 ml every 5 minutes
    3. May resume above Diarrheal replacement after no Vomiting for 30-60 minutes
    4. Consider Ondansetron (Zofran) 4 mg ODT tablets
      1. See Ondansetron for dosing, precautions
      2. Weight 8-15 kg (17-33 lb): Ondansetron 2mg (half tab)
      3. Weight 15-30 kg (33-66 lb): Ondansetron 4 mg (one tab)
      4. Weight >30 kg (>66 lb): Ondansetron 4-8 mg (4 mg is typically sufficient)
      5. Freedman (2006) N Engl J Med 354:1698-705 [PubMed]

VI. Management: Disposition

  1. Emergency Department
    1. May be discharged home if initial replacement is successful and ongoing losses are not severe
  2. Home
    1. Parents reassess every 2 hours
    2. Indications to return to emergency department
      1. Losses (Diarrhea, Vomiting) exceed 25% of hourly fluid requirements
      2. Unable to maintain fluids orally
    3. Home Diet
      1. Breast Feeding may continue
      2. Children may eat a regular diet and foods that they like as tolerated
        1. No longer recommend BRAT Diet (Bananas, rice, applesauce, toast) which is too limiting
  3. Admission Indications
    1. Severe Dehydration
    2. Intractable Vomiting
    3. Bilious Vomiting
    4. Profuse Diarrhea that is difficult to maintain adequate oral intake to replace
    5. Secondary causes (e.g. Diabetic Ketoacidosis, Sepsis, Inborn Errors of Metabolism, Pyelonephritis)
    6. Significant Electrolyte abnormalities (e.g. Hyponatremia, Hypernatremia, Hypokalemia)
    7. Hypoglycemia
    8. Age <6 months with ongoing losses

VII. Management: Severe Dehydration

  1. See Dehydration Management

VIII. Resources

  1. The Treatment of Diarrhea (WHO)
    1. https://www.who.int/maternal_child_adolescent/documents/9241593180/en/
  2. Vega and Bhimji (2017) Pediatric Dehydration in Stat Pearls
    1. https://www.ncbi.nlm.nih.gov/books/NBK436022/

IX. References

  1. Walton (2020) Crit Dec Emerg Med 34(6): 3-9
  2. Canavan (2009) Am Fam Physician 80(7): 692-6 [PubMed]
  3. Churgay (2012) Am Fam Physician 85(11): 1066-70 [PubMed]
  4. Hartman (2019) Am Fam Physician 99(3): 159-65 [PubMed]
  5. King (2003 MMWR Recomm Rep 52(RR-16):1-16 [PubMed]

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