January 1, 2022

Oral Rehydration Therapy

Wake Med University Hospital ED, Raleigh, North Carolina. Submitted by Courtney Mann, MD.

Definition

Oral rehydration therapy (ORT) is a specific procedure intended to rehydrate the moderately dehydrated infant or toddler. Its advantages over parenteral therapy include fewer complications, lower cost, lower hospitalization rate, and minimizing the risk of iatrogenic hypernatremia or hyponatremia. Parents and staff embarking on ORT must be highly motivated and committed to performing the procedure properly.

Evaluation

Defining Characteristics of Degrees of Dehydration

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Characteristic

Min. or None

Moderate

Severe

Condition

Well, alert

Restless, irritable

Lethargic, floppy

Eyes

Normal

Sunken

Very sunken

Tears

Present

Absent

Absent

Mouth and Tongue

Moist

Dry

Very dry

Thirst

Not thirsty

Drinks eagerly

Unable to drink

Skin pinch

Goes back immediately

Slowly

Very slowly

The appropriate patients for ORT are those with mild to moderate dehydration (classically defined as 3-9%).

Indications

  • Children between 3 months and 5 years of age with acute diarrheal illness with or without vomiting
  • Children with mild to moderate dehydration
  • Patient is able to tolerate oral intake
  • Normal bedside glucose
  • Parental ability and willingness to comply with procedure.

Contraindications

  • Shock
  • Altered mental status
  • Severe dehydration
  • Parental limitations
  • Excessive vomiting
  • Abdominal distention or absent bowel sounds
  • Abnormal bedside glucose
  • (Adjusted) Age 3 months or less
  • Unreliable home situation
  • Uncontrolled diarrhea
  • Complicated medical history (prematurity, cardiac anomalies, AIDS, etc.)

Treatment

  • Assess for indications and contraindications
  • Bedside glucose
  • Consider Ondansetron (Zofran) 0.2 mg/kg po
  • For mild dehydration, have parent administer 50-60 cc/kg of Rehydralyte over a four hour time period.
  • For moderate dehydration, parent will administer 80-100 cc/kg over four hours. May administer with a spoon or syringe every minute or two. If the rehydration is going well, may consider discharge after 2 hours and the parent will continue the remainder at home.
  • Add additional 10 cc/kg to the total for every diarrheal stool in the Emergency Department.
  • Some vomiting is not a contraindication and not an indication of failure of ORT
  • If successfully rehydrated, discharge patient home with rapid reinstitution of age appropriate normal diet within 4 to 6 hours.
  • If failed procedure, consider:Admission
  • A single 30 cc/kg normal saline bolus, labs (Chem 7) and reattempt ORT
  • Nasogastric tube administration of Rehydralyte

References

  1. American Academy of Pediatrics. Practice parameter: The management of acute gastroenteritis in young children. Pediatrics, 1996; 97: 424-436.
  2. Baker SS, Davis AM. Hypocaloric oral therapy during an episode of diarrhea and vomiting can lead to severe malnutrition. J Ped Gastro and Nutrition, 1998; 27: 1-5.
  3. Brown KH, et.al. Effect of continued oral feeding on clinical and nutritional outcomes of acute diarrhea in children. J Pediatr, 1988; 112: 191-200.
  4. Casteel HB, Fiedorek SC. Oral rehydration therapy. Ped Clin N Amer, 1990; 37: 295-311.
    Gavin N, Merrick N, et.al. Efficacy of glucose-based oral rehydration therapy. Pediatrics, 1996; 98: 45-51.
  5. Gerardi MJ. Managing fluid and electrolyte therapy without a calculator-handout from presentation at American College of Emergency Physicians, 1998; Scientific assembly October 11-14, 1998, San Diego CA.
  6. Meyers A. Fluid and electrolyte therapy for children. Curr Opin Ped, 1994; 6: 303-309.
  7. Merrick N, Davidson B, Fox S, et.al. Treatment of acute gastroenteritis: Too much and too little care. Clin Ped, 1996; 35 (9): 429-435.
  8. Watkins SL. The Basics of fluid and electrolyte therapy. Pediatric Annals, 1995; 24 (1): 16-22.
    Lance Brown, 1999 Revised Courtney Mann, 2004
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