Oral versus intravenous rehydration therapy in severe gastroenteritis

ESPNIC clinical practice guidelines: intravenous maintenance fluid therapy in acute and critically ill children- a systematic review and meta-analysis

PURPOSE

Intravenous maintenance fluid therapy (IV-MFT) prescribing in acute and critically ill children is very variable among pediatric health care professionals. In order to provide up to date IV-MFT guidelines, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) undertook a systematic review to answer the following five main questions about IV-MFT: (i) the indications for use (ii) the role of isotonic fluid (iii) the role of balanced solutions (iv) IV fluid composition (calcium, magnesium, potassium, glucose and micronutrients) and v) and the optimal amount of fluid.

METHODS

A multidisciplinary expert group within ESPNIC conducted this systematic review using the Scottish Intercollegiate Guidelines Network (SIGN) grading method. Five databases were searched for studies that answered these questions, in acute and critically children (from 37 weeks gestational age to 18 years), published until November 2020. The quality of evidence and risk of bias were assessed, and meta-analyses were undertaken when appropriate. A series of recommendations was derived and voted on by the expert group to achieve consensus through two voting rounds.

RESULTS

56 papers met the inclusion criteria, and 16 recommendations were produced. Outcome reporting was inconsistent among studies. Recommendations generated were based on a heterogeneous level of evidence, but consensus within the expert group was high. "Strong consensus" was reached for 11/16 (69%) and "consensus" for 5/16 (31%) of the recommendations.

CONCLUSIONS

Key recommendations are to use isotonic balanced solutions providing glucose to restrict IV-MFT infusion volumes in most hospitalized children and to regularly monitor plasma electrolyte levels, serum glucose and fluid balance.

The Cutting Edge of Gastroenteritis: Advances in Understanding of Enteric Infection

ABSTRACT

In recent years, multiple advances have been made in the care, diagnosis, and mechanistic understanding of acute gastroenteritis (AGE). In this review, we discuss the current state of the art of diagnosis and management, as well as how changes in practice can improve care and decrease costs. We will discuss present study demonstrating the effect of AGE on the microbiome and how that may be linked to secondary effects or long-term changes. We will explore the use of novel technologies to further our capacity to understand how gastrointestinal infections occur and promulgate. Finally, will discuss advances in our understanding of how gastrointestinal infections capacitate other changes such as post-viral motility or other post viral intestinal dysfunction.

Acute Infectious Gastroenteritis in Infancy and Childhood

BACKGROUND

Despite the introduction of vaccination against rotavirus, and even though it can often be treated on an outpatient basis, acute infectious gastroenteritis is nevertheless the second most common non-traumatic cause of emergency hospitaliza - tion in children aged 1 to 5 years, accounting for approximately 9% of cases (39 410 cases in 2017). The most common path - ogens are viruses (47% rotavirus, 29% norovirus, and 14% adenovirus).

METHODS

This review is based on publications retrieved by a selective search in PubMed employing the terms "acute gastro - enteritis children" AND "dehydration" OR "rehydration" OR "prevention," and by manual searching (based, for example, on reference lists and expert knowledge), with subsequent evaluation including consideration of the relevant guidelines.

RESULTS

The degree of dehydration can be judged from weight loss and other clinical findings. In 17 randomized controlled trials conducted on a total of 1811 children with mild or moderate dehydration, oral rehydration with oral rehydration solution was just as effective as intravenous rehydration with respect to weight gain, duration of diarrhea, and fluid administration, and was associated with shorter hospital stays (weighted mean difference, -1.2 days; 95% confidence interval [-2.38; -0.02]). Oral rehydration therapy failed in 4% of patients [1; 7]. In children who are vomiting or who refuse oral rehydration solution, continuous nasogastric application is just as effective as intravenous rehydration and is the treatment of first choice.

CONCLUSION

In Germany, children with mild or moderate dehydration are often hospitalized for intravenous rehydration therapy, despite the good evidence supporting ambulatory oral rehydration. Obstacles to intersectoral care, the nursing shortage, and inadequate reimbursement must all be overcome in order to reduce unnecessary hospitalizations and thereby lessen the risk of nosocomial infection.

Disidratazione acuta da gastroenterite nei lattanti

Il bambino sotto 1 anno e, soprattutto, di meno di 6 mesi è ad alto rischio di disidratazione, la cui causa principale è una gastroenterite acuta, soprattutto di origine virale. La gestione di una disidratazione da gastroenterite ha due componenti: la sua correzione e il rapido ripristino della normale perfusione tissutale e il mantenimento dei fabbisogni di acqua e di nutrienti, per limitare al massimo il deficit energetico. La valutazione della gravità della disidratazione è l’elemento chiave che guiderà la terapia. La perdita di peso, espressa in percentuale di peso corporeo prima dell’episodio di disidratazione, è il metodo di riferimento, ma è spesso difficile o impossibile da ottenere. Inoltre, i segni clinici, come l’alterazione dell’aspetto generale, l’allungamento del tempo di riempimento capillare, il riconoscimento di una plica cutanea persistente, gli occhi infossati, una secchezza delle mucose e la mancanza di lacrime, sono i principali elementi che permettono di valutare la gravità della disidratazione. Il trattamento si basa sulla rapida correzione del deficit del settore extracellulare. Un’espansione volemica di 20 ml/kg di una soluzione isotonica somministrata per via endovenosa o intraossea può essere necessaria nella fase iniziale nei casi più gravi (disidratazione > 10%). In tutti gli altri casi, la reidratazione per via orale per correggere il deficit di acqua in 4-6 ore è la tecnica di scelta, che si è dimostrata efficace, sicura e veloce. Essa utilizza delle soluzioni di reidratazione adattate che soddisfano criteri specifici. Il loro utilizzo precoce è la prevenzione più efficace delle forme gravi. L’allattamento al seno non deve essere interrotto e l’alimentazione artificiale deve essere ripresa da 4 a 6 ore dopo l’inizio della reidratazione. La vaccinazione contro i rotavirus prima dei 6 mesi è fortemente raccomandata.

Reducing the burden of diarrhea among children under five years old: lessons learned from oral rehydration therapy corner program implementation in Northern Nigeria

BACKGROUND

In Nigeria, diarrhea remains one of the leading causes of death among children under five years old. Oral Rehydration Therapy (ORT) corners were introduced to health facilities in Bauchi and Sokoto states to serve as points of treatment for sick children and equip caregivers with necessary skills in case management of diarrhea and diarrhea prevention.

OBJECTIVES

The operations research study examined the effect of facility-based ORT corners on caregivers' knowledge and skills in management of simple and moderate diarrhea at home, as well as caregivers' and service providers' perceived facilitators and barriers to utilization and delivering of ORT corner services. It also examined whether ORT activities were conducted according to the established protocols.

METHODS

This quantitative study relied on multiple sources of information to provide a complete picture of the current status of ORT corner services, namely surveys with ORT corner providers (N = 21), health facility providers (N = 23) and caregivers (N = 229), as well as a review of service statistics and health facility observations. Frequency distribution and binary analysis were conducted.

RESULTS

The study revealed that ORT corner users were more knowledgeable in diarrhea prevention and management and demonstrated better skills for managing diarrhea at home than ORT corner non-users. However, the percentage of knowledgeable ORT users is not optimal, and providers need to continue to work toward improving such knowledge. ORT corner providers identified a lack of supplies as the major barrier for providing services. Furthermore, the study revealed a lack of information, education and communication materials, supportive supervision, and protocols and guidelines for delivering ORT corner services, as well as inadequate documentation of services provided at ORT corners.

RECOMMENDATIONS

Recommendations for ORT corners program planners and implementers include ensuring all ORT corners have oral rehydration salt (ORS) packages and salt, sugar, and zinc tablets in stock, a secured commodity supply chain to avoid stockouts, and adequate policies and procedures in place.

Health care provider and caregiver preferences regarding nasogastric and intravenous rehydration

OBJECTIVE

Despite evidence supporting its use, nasogastric rehydration is rarely used in North America. We conducted a prospective, cross-sectional, 3-phase study to evaluate current perspectives.

METHODS

We compared the proportions of respondents in favor of nasogastric (as opposed to intravenous) rehydration, should oral rehydration fail, between clinicians and caregivers. Phase 1: caregivers of children aged 3 to 48 months, who presented to a Canadian pediatric emergency department with symptoms of gastroenteritis, were invited to complete a survey. Phase 2: phase 1 participants administered intravenous or nasogastric rehydration had the procedure observed and outcome data recorded. Phase 3: pediatric emergency medicine physicians, fellows, and nurses completed a survey.

RESULTS

Four hundred thirty-five children-parent dyads and 113 health care providers participated. If oral rehydration were to fail, 10% (47 of 435) of caregivers and 14% (16 of 113) of clinicians would choose nasogastric rehydration (difference = 3.4%; 95% confidence interval: -2.8 to 11.4). Caregivers were more familiar with the term intravenous than nasogastric rehydration (80% vs 20%; P < .001). Sixty-four children (15%) received intravenous rehydration; none received nasogastric rehydration. Participating nurses have inserted 90 (interquartile range: 25-150) intravenous cannulas compared with 4 (interquartile range: 2-10) nasogastric tubes during the preceding 6 months (P < .001). After a brief educational intervention, the proportion recommending nasogastric rehydration increased to 27% (117 of 435) among caregivers (P < .001) and 43% (49 of 113) among health care providers (P < .001).

CONCLUSIONS

In keeping with caregiver desires, health care providers in a Canadian emergency department employ intravenous rehydration when oral rehydration fails. Enhanced change management strategies will be required for nasogastric rehydration to become adopted in this environment.

The challenges of managing severe dehydrating diarrhoea in a resource-limited setting

Diarrhoea remains one of the most common causes of childhood deaths worldwide despite the widespread use of oral rehydration solution (ORS). The vast majority of the nearly 2 million diarrhoeal deaths occurring annually in children under five years of age are in south Asia and sub-Saharan Africa. Signs of critical illness in severely dehydrated children are poorly recognised, and although considerable efforts have gone into establishing the management of diarrhoeal disease in general, there is surprisingly little understanding of the aetiology, metabolic processes and risk factors for the very high mortality associated with severe dehydrating diarrhoea (SDD). We suggest that in many resource-poor settings, the degree of fluid requirement as well as the prevalence of electrolyte disturbances are seriously under-recognised and may be contributing significantly to mortality. The heterogeneity of children with SDD renders the generic 'one size fits all' approach to fluid and electrolyte management in these critically ill children inadequate. In this review we will highlight SDD as an important target for research in resource-limited settings, and emphasise the need to re-evaluate the efficacy of prevailing intravenous fluid protocols in well conducted multi-centre interventional trials.

The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality

Background Most diarrhoeal deaths can be prevented through the prevention and treatment of dehydration. Oral rehydration solution (ORS) and recommended home fluids (RHFs) have been recommended since 1970s and 1980s to prevent and treat diarrhoeal dehydration. We sought to estimate the effects of these interventions on diarrhoea mortality in children aged <5 years.

Methods We conducted a systematic review to identify studies evaluating the efficacy and effectiveness of ORS and RHFs and abstracted study characteristics and outcome measures into standardized tables. We categorized the evidence by intervention and outcome, conducted meta-analyses for all outcomes with two or more data points and graded the quality of the evidence supporting each outcome. The CHERG Rules for Evidence Review were used to estimate the effectiveness of ORS and RHFs against diarrhoea mortality.

Results We identified 205 papers for abstraction, of which 157 were included in the meta-analyses of ORS outcomes and 12 were included in the meta-analyses of RHF outcomes. We estimated that ORS may prevent 93% of diarrhoea deaths.

Conclusions ORS is effective against diarrhoea mortality in home, community and facility settings; however, there is insufficient evidence to estimate the effectiveness of RHFs against diarrhoea mortality.

The management of children with gastroenteritis and dehydration in the emergency department

BACKGROUND

Acute gastroenteritis is characterized by diarrhea, which may be accompanied by nausea, vomiting, fever, and abdominal pain.

OBJECTIVE

To review the evidence on the assessment of dehydration, methods of rehydration, and the utility of antiemetics in the child presenting with acute gastroenteritis.

DISCUSSION

The evidence suggests that the three most useful predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern. Studies are conflicting on whether blood urea nitrogen (BUN) or BUN/creatinine ratio correlates with dehydration, but several studies found that low serum bicarbonate combined with certain clinical parameters predicts dehydration. In most studies, oral or nasogastric rehydration with an oral rehydration solution was equally efficacious as intravenous (i.v.) rehydration. Many experts discourage the routine use of antiemetics in young children. However, children receiving ondensetron are less likely to vomit, have greater oral intake, and are less likely to be treated by intravenous rehydration. Mean length of Emergency Department (ED) stay is also less, and very few serious side effects have been reported.

CONCLUSIONS

In the ED, dehydration is evaluated by synthesizing the historical and physical examination, and obtaining laboratory data points in select patients. No single laboratory value has been found to be accurate in predicting the degree of dehydration and this is not routinely recommended. The evidence suggests that the majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy. Ondansetron (orally or intravenously) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for i.v. hydration, and preventing the need for hospital admission in those receiving i.v. hydration.

Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children

BACKGROUND

Dehydration associated with gastroenteritis is a serious complication. Oral rehydration is an effective and inexpensive treatment, but some physicians prefer intravenous methods.

OBJECTIVES

To compare oral with intravenous therapy for treating dehydration due to acute gastroenteritis in children.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (March 2006), CENTRAL (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to March 2006), EMBASE (1974 to March 2006), LILACS (1982 to March 2006), and reference lists. We also contacted researchers, pharmaceutical companies, and relevant organizations.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials comparing intravenous rehydration therapy (IVT) with oral rehydration therapy (ORT) in children up to 18 years of age with acute gastroenteritis.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed quality using the Jadad score. We expressed dichotomous data as a risk difference (RD) and number needed to treat (NNT), and continuous data as a weighted mean difference (WMD). We used meta-regression for subgroup analyses.

MAIN RESULTS

Seventeen trials (1811 participants), of poor to moderate quality, were included. There were more treatment failures with ORT (RD 4%, 95% confidence interval (CI) 1 to 7, random-effects model; 1811 participants, 18 trials; NNT = 25). Six deaths occurred in the IVT group and two in the ORT groups (4 trials). There were no significant differences in weight gain (369 participants, 6 trials), hyponatremia (248 participants, 2 trials) or hypernatremia (1062 participants, 10 trials), duration of diarrhea (960 participants, 8 trials), or total fluid intake at six hours (985 participants, 8 trials) and 24 hours (835 participants, 7 trials). Shorter hospital stays were reported for the ORT group (WMD -1.20 days, 95% CI -2.38 to -0.02 days; 526 participants, 6 trials). Phlebitis occurred more often in the IVT group (NNT 50, 95% CI 25 to 100) and paralytic ileus more often in the ORT group (NNT 33, 95% CI 20 to 100, fixed-effect model), but there was no significant difference between ORT using the low osmolarity solutions recommended by the World Health Organization and IVT (729 participants, 6 trials).

AUTHORS' CONCLUSIONS

Although no clinically important differences between ORT and IVT, the ORT group did have a higher risk of paralytic ileus, and the IVT group was exposed to risks of intravenous therapy. For every 25 children (95% CI 14 to 100) treated with ORT one would fail and require IVT.

Oral rehydration versus intravenous therapy for treating dehydration due to gastroenteritis in children: a meta-analysis of randomised controlled trials

BACKGROUND

Despite treatment recommendations from various organizations, oral rehydration therapy (ORT) continues to be underused, particularly by physicians in high-income countries. We conducted a systematic review of randomised controlled trials (RCTs) to compare ORT and intravenous therapy (IVT) for the treatment of dehydration secondary to acute gastroenteritis in children.

METHODS

RCTs were identified through MEDLINE, EMBASE, CENTRAL, authors and references of included trials, pharmaceutical companies, and relevant organizations. Screening and inclusion were performed independently by two reviewers in order to identify randomised or quasi-randomised controlled trials comparing ORT and IVT in children with acute diarrhea and dehydration. Two reviewers independently assessed study quality using the Jadad scale and allocation concealment. Data were extracted by one reviewer and checked by a second. The primary outcome measure was failure of rehydration. We analyzed data using standard meta-analytic techniques.

RESULTS

The quality of the 14 included trials ranged from 0 to 3 (Jadad score); allocation concealment was unclear in all but one study. Using a random effects model, there was no significant difference in treatment failures (risk difference [RD] 3%; 95% confidence intervals [CI]: 0, 6). The Mantel-Haenzsel fixed effects model gave a significant difference between treatment groups (RD 4%; 95% CI: 2, 5) favoring IVT. Based on the four studies that reported deaths, there were six in the IVT groups and two in ORT. There were no significant differences in total fluid intake at six and 24 hours, weight gain, duration of diarrhea, or hypo/hypernatremia. Length of stay was significantly shorter for the ORT group (weighted mean difference [WMD] -1.2 days; 95% CI: -2.4,-0.02). Phlebitis occurred significantly more often with IVT (number needed to treat [NNT] 33; 95% CI: 25,100); paralytic ileus occurred more often with ORT (NNT 33; 95% CI: 20,100). These results may not be generalizable to children with persistent vomiting.

CONCLUSION

There were no clinically important differences between ORT and IVT in terms of efficacy and safety. For every 25 children (95% CI: 20, 50) treated with ORT, one would fail and require IVT. The results support existing practice guidelines recommending ORT as the first course of treatment in appropriate children with dehydration secondary to gastroenteritis.

Intravenous therapy

Intravenous administration of fluids, drugs, and nutrition is very common in hospitals. Although insertion of peripheral and central cannulae and subsequent intravenous therapy are usually well tolerated, complications that prolong hospitalisation, and in some cases cause death, can arise on occasions. Additionally, many cannulae are inserted unnecessarily. This article seeks to review this area and to outline good medical practice.

The impact of presenting problem based guidelines for children with medical problems in an accident and emergency department

AIMS

To evaluate the impact of presenting problem based guidelines in managing children with either diarrhoea (with or without vomiting) or seizure (with or without fever).

METHODS

This prospective observational study with an intervention was based on a paediatric accident and emergency (A&E) department in Nottingham. All patients (either GP or self referred) were acute attenders aged 0-15 years, with a medical presenting problem during 4 months in the spring of 1997 and 1999. Five hundred and thirty-one diarrhoea attendances (292 before guideline implementation and 239 after) and 411 seizure attendances (212 before guideline implementation and 199 after) were recorded. Evidence based and consensus ratified guidelines developed for the study were implemented using care pathway documentation. Process (documentation, time in the department, investigations, treatment) and outcome (admission to hospital, returns to A&E) data were collected from case notes.

RESULTS

The percentage of children investigated with blood tests fell significantly (haematology requests in diarrhoea presentations from 11% to 4%, biochemistry in seizure presentations from 29% to 17%). Intravenous infusions in diarrhoea presenters fell (9% to 1%), and more appropriate oral fluids were used. Management time in A&E was reduced (diarrhoea presenters: median of 55-40 minutes, seizure presenters: 80-55 minutes, but remained static for other presenting problems). Marked improvements in documentation were seen. Admission rates for diarrhoea attenders increased (27% to 34%) but remained the same for seizure (69% v 73%).

CONCLUSIONS

The implementation of a presenting problem based guideline as a care pathway was associated with improvements in the quality of care by: improved documentation; reduced invasive investigations; more appropriate treatment, and reduced time spent in A&E.

Patterns of use of oral rehydration therapy in Srinagar (Garhwal), Uttaranchal, India

A study was conducted to assess the knowledge of preparing packet oral rehydration solution (ORS) and home-made salt-sugar solution (SSS) among mothers in Srinagar (Garhwal), Uttaranchal. Two hundred and twenty-five mothers were interviewed. Only a small proportion recognized the ORS packets (18.66%) and only 17.77% mentioned the correct method of preparing a solution from a packet (even after reading the instructions on the packet). Homemade SSS was adequately discussed by only 6.22% mothers and they were taught to correctly prepare and administer ORS and home-made SSS. After the educational programme, significant (P < 0.001) improvement in their knowledge was found. Eighty-six per cent knew the correct method of preparing packet ORS and 80.88% the correct method of preparing homemade SSS (P < 0.001). Interventions of this kind should be carried out to improve the knowledge and skills of mothers in treating childhood diarrhoea.

Clinical pathway using rapid rehydration for children with gastroenteritis

OBJECTIVE

To determine in the Emergency Department (ED) the efficacy of a clinical pathway using rapid rehydration for children moderately dehydrated as a result of acute gastroenteritis.

METHODS

This was a prospective study using historical controls, set in the ED of the Children's Hospital at Westmead, NSW, Australia. Subjects were aged from 6 months to 16 years presenting with vomiting and diarrhoea for <48 h who were mildly or moderately dehydrated. The intervention was a clinical pathway involving rapid rehydration using N/2 saline + 2.5% dextrose intravenously at 20 mL/kg per h for 2 h, or Gastrolyte R (Aventis Pharma, Lane Cove, NSW, Australia) via nasogastric tube at the same rate. There were 145 children in the prospective intervention group and 170 in the historical control group. The outcome measures were admission rate, percentage of patients discharged from the ED in 8 h or less, rate of re-presentations within 48 h requiring admission, and rate of procedures with intravenous cannula or nasogastric tube.

RESULTS

In the moderately dehydrated children, significant reductions were observed in the admission rate and the number discharged in 8 h or less in the intervention group compared with the control group, with no significant difference in the rate of re-presentation and the rate of procedures. In the moderately dehydrated children in the intervention group, the admission rate was 29 of 52 (55.8%) compared with the controls 26 of 27 (96.3%) (P < 0.001) and the number discharged in 8 h or less was 23 of 52 (44.2%) compared with 1 of 27 (3.7%) in the controls (P < 0.01).

CONCLUSION

The clinical pathway utilizing rapid rehydration in children moderately dehydrated from gastroenteritis is effective in reducing admission rates and lengths of stay in the ED.

Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration

OBJECTIVE

To assess the safety, efficacy, and cost-effectiveness of rapid nasogastric hydration (RNG) and rapid intravenous hydration (RIV) administered in the emergency department (ED) to young children suffering with uncomplicated, acute moderate dehydration.

METHODS

Ninety-six children aged 3 to 36 months, who presented with signs and symptoms of uncomplicated, acute moderate dehydration caused by vomiting and/or diarrhea, presumed to be caused by viral gastroenteritis, were randomly assigned to receive either RNG with a standard oral rehydration solution or RIV with normal saline. Each solution was administered at a rate of 50 mL/kg of body weight, delivered over a 3-hour period in our urban pediatric ED. All participants were weighed pretreatment and posttreatment and underwent initial and final measurements of their serum electrolytes, blood urea nitrogen, creatinine, and glucose levels, along with urine chemistry and urine specific gravity. Telephone follow-up by completion of a standardized questionnaire was obtained approximately 24 hours after discharge from the ED.

RESULTS

Ninety-two of 96 enrolled patients completed the study. Three patients failed treatment (2 RIV and 1 RNG) and were excluded and hospitalized because of severe, intractable vomiting, and 1 patient was withdrawn secondary to an intussusception. Among 92 evaluable patients, 2 were found to be severely dehydrated (>10% change in body weight) and were excluded from analysis, leaving 90 patients (RNG: N = 46 and RIV: N = 44), who completed the study. Both RNG and RIV were found to be a safe and efficacious means of treating uncomplicated, acute moderate dehydration in the ED. Determinations of electrolytes, blood urea nitrogen, creatinine, or glucose were not found to be of value on an intent-to-treat basis in the care of these patients. The urine specific gravity and incidence of ketonuria declined from levels commensurate with moderate dehydration in the RNG group, but not as consistently so in the RIV group. Both RNG and RIV were substantially less expensive to administer than standard care with intravenous fluid deficit therapy in-hospital, and RNG was more cost-effective to administer over RIV in the outpatient setting.

CONCLUSION

RNG and RIV administered in the ED are safe, efficacious, and cost-effective alternatives to the standard treatment for uncomplicated, acute moderate dehydration in young children. RNG is as efficacious as RIV, is no more labor intensive than RIV, and is associated with fewer complications. In addition, we found that most routine laboratory testing is of little value in these patients and should be avoided, except when clearly clinically indicated.

An evidence and consensus based guideline for acute diarrhoea management

OBJECTIVE

To develop an evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (with or without vomiting), a common problem representing 16% of all paediatric medical attenders at an accident and emergency department. Clinical assessment, investigations (biochemistry and stool culture in particular), admission, and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home.

EVIDENCE

A systematic review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendation were generated.

CONSENSUS

An anonymous, postal Delphi consensus process was used. A panel of 39 selected medical and nursing staff were asked to grade their agreement with the generated statements. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panelists' responses. Consensus was predefined as 83% of panelists agreeing with the statement.

RECOMMENDATIONS

Clinical signs useful in assessment of level of dehydration were agreed. Admission to a paediatric facility is advised for children who show signs of dehydration. For those with mild to moderate dehydration, estimated deficit is replaced over four hours with oral rehydration solution (glucose based, 200-250 mOsm/l) given "little and often". A nasogastric tube should be used if fluid is refused and normal feeds started following rehydration. Children at high risk of dehydration should be observed to ensure at least maintenance fluid is tolerated. Management of more severe dehydration is detailed. Antidiarrhoeal medication is not indicated.

VALIDATION

The guideline has been successfully implemented and evaluated in a paediatric accident and emergency department.

Mothers' skills in preparing oral rehydration salt solution

This was a community based thirty cluster survey, carried out in rural Chittagong district, Bangladesh during 1996 with the objective to assess the skill of mothers in preparing packet ORS solution. A total of 420 mothers whose children had been suffering from acute diarrhoea were investigated. There were 377 (89.8%) mothers who demonstrated the preparation of ORS and 43 (10.2%) mothers never ever prepared the solution and were unable to demonstrate the preparation. One hundred and forty (33.3%) mothers were able to demonstrate the preparation correctly and the rest 237 (56.4%) demonstrated the preparation incorrectly. The incorrect preparation was found to be associated significantly with the refusal of ORS solution by the children (p < 0.01). None of the maternal factors were found to be associated with the correctness of preparation of ORS solution except previous exposure of the mother to the demonstration of ORS solution preparation (p < 0.000). Therefore, demonstration of preparation of ORS solution to the mothers should be in built in the health education package of oral rehydration therapy for diarrhoeal diseases.

Oral rehydration therapy

Oral rehydration therapy (ORT) with glucose-electrolyte solutions has been considered to be one of the greatest therapeutic advances of this century. ORT is effective in acute diarrheal disease of diverse etiology. The most widely used oral rehydration solution (ORS) worldwide is that recommended by the World Health Organisation (Na 90, K 20, glucose 111 and citrate 10 mmol/L). Attempts to improve the efficacy of ORS have been made by using complex substrates (rice and other cereals) in place of glucose, and by reducing osmolality by decreasing glucose and sodium concentrations in monomeric ORS. ORS may have wider applications in the management of patients with the short bowel syndrome and in post-surgical patients.

Transient renal acidification defect during acute infantile diarrhea: the role of urinary sodium

We studied urinary acidification daily during the hospital course of 16 infants with acute gastroenteritis and metabolic acidosis. Urine pH value on admission was higher than 5.5 in 14 (87%) patients. We hypothesized that inappropriate urinary acidification was due to sodium deficiency and inadequate sodium delivery to the distal nephron. Forty-one urinary samples were collected during metabolic acidosis. The mean pH of 24 urine samples with sodium concentration less than 10 mmol/L was significantly higher than the pH of 17 samples with sodium concentration greater than 10 mmol/L (6.04 +/- 0.06 vs 5.19 +/- 0.1; p less than 0.001). The urine ratios of titratable acid to creatinine and of total acidity to creatinine were significantly higher in urine samples containing more sodium (p less than 0.02), whereas the ammonium/creatinine ratio was not. After administration of furosemide or correction of the sodium deficit, appropriate acidification was observed. We conclude that impaired urinary acidification is frequently found during metabolic acidosis in infants with acute gastroenteritis and results from a sodium deficit rather than from transient distal renal tubular acidosis.

Clinical presentation and management of acute gastro-enteritis in in-patient children at King Khalid University Hospital, Riyadh, Saudi Arabia

In a retrospective survey, case notes of all children with acute gastro-enteritis (AGE) admitted to our hospital between 1984 and 1988 were reviewed. The total number of cases was 300. The mean age was 14 months (range 1-60 mths): 67% of cases were boys and 33% girls. Eleven per cent were exclusively breastfed. The clinical presentation was diarrhoea and vomiting in 81%, diarrhoea alone in 15%, and vomiting primarily in 4%. All children had good nutritional status, i.e. both their height and weight were between the 5th and 90th percentile for their age and none showed signs of marasmus or kwashiorkor. Forty-six per cent of the children had AGE without dehydration. Mild, moderate and severe dehydration was present in 41%, 10% and 3% of cases, respectively. Isotonic, hypotonic and hypernatraemic dehydration was present in 95%, 3% and 2% of cases of dehydration, respectively. Sixty-five per cent of cases were given intravenous (IV) fluids. The mean duration of IV administration was 1 day, with a range of 1-7 days. Twenty-two per cent of the children were given oral rehydration solution (ORS) initially, and 13% were given IV plus ORS. None of the children died of gastro-enteritis. It is concluded that there was excessive use of IV fluids, and that there is an urgent need to encourage the use of ORS.

Optimising oral rehydration solution composition for the children of Europe: clinical trials

Clinical trials testing different oral rehydration solutions (ORS) are reviewed. The effects of individual components and their concentrations are analysed in order to establish margins of safety for the composition of the ideal ORS for children in Europe. Glucose is the solute of choice for ORS and concentrations of 70-140 mmol/l are adequate. Glucose may be replaced by sucrose or glucose polymers. "Low" sodium concentrations (35-60 mmol/l) are advised for rehydration and maintenance in acute non-cholera diarrhoea, for children of all ages, including neonates, and for any degree of dehydration except shock. Although intended for children who are not malnourished, the European ORS should have an adequate potassium concentration (20-30 mmol/l), namely the same concentration as found in WHO-ORS. Chloride concentration depends upon other constituents of ORS, namely sodium and potassium, but the range of 30-90 mmol/l is considered to be adequate. Base or base precursors are not required for correction of acidosis except in the severe cases that always need intravenous replacement. A relatively low osmolality seems advisable.